AN ACT To provide for a reformation of the United States healthcare system, repealing by means of amendment the Patient Protection and Affordable Care Act and replacing it with an America First solution for the healthcare system of the United States. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, SECTION 1. Short title. This Act may be cited as the “Make America Healthy Again Act of 2025”. Sec. 2. Table of contents. The table of contents of this Act is as follows— Sec. 1. Short title. Sec. 2. Table of contents. Sec. 3. Severability. Sec. 4. Immediate relief. TITLE I—Expenditures Subtitle A—Patient Access to Public Health Programs Sec. 101. The Prevention and Public Health Fund. Sec. 102. Federal payments. Sec. 103. Part D resales. Sec. 104. Exclusion of coverage of advance care planning services under the Medicare program. Sec. 105. Allowing certain individuals with alternative health coverage to choose to opt out of the Medicare part A benefit. Sec. 106. Reform of Title X. Sec. 107. Price negotiation. Sec. 108. Employee Background Check Expansion. Subtitle B—Medicaid Program Enhancement Sec. 111. Repeal of Medicaid provisions. Sec. 112. Repeal of Medicaid expansion. Sec. 113. Elimination of DSH cuts. Sec. 114. Reducing State Medicaid costs. Sec. 115. Safety net funding for non-expansion States. Sec. 116. Providing incentives for increased frequency of eligibility redeterminations. Sec. 117. Work requirement for nondisabled, nonpregnant adults under Medicaid. Sec. 118. Enabling Medicaid payments for conversion therapy. Subtitle C—Per Capita Allotment for Medical Assistance Sec. 121. Per capita allotment for medical assistance. Sec. 122. Revival of Pregnancy Assistance Fund. Subtitle D—Patient Relief and Health Insurance Market Stability Sec. 131. Repeal of cost-sharing subsidy. Sec. 132. Patient and State Stability Fund. Subtitle E—Implementation Funding Sec. 141. American Health Care Implementation Fund. Sec. 142. Repeal of Patient Identification Program. Sec. 143. Parental Rights in Mental Health. Sec. 144. Quotas in Federal Policing. Sec. 145. Defunding sexually suggestive education. Sec. 146. Ban on funding for racist programs. Sec. 147. Deregulation of school lunch. Subtitle F—Research Sec. 151. Stem cell research. Sec. 152. Cosmetic surgery and treatment research. Sec. 153. Inclusivity in research. Sec. 154. Stillbirth research. Sec. 155. Perinatal Pathology Fellowships. Sec. 156. Ectopic Pregnancy Research. Sec. 157. New generic medications research. Subtitle G—Adoption Sec. 161. Religious adoption services. Subtitle H—Medicare Expansion Sec. 171. Freestanding Emergency Centers. Sec. 172. Sole community hospitals. Sec. 173. Chiropractor coverage. Sec. 174. Legalizing discounts for Medicare Part D purchases. Sec. 175. Coverage for obesity medication. Sec. 176. Clinical laboratory tests. Sec. 177. Pharmacist services under Medicare Part B. Sec. 178. Long-term care for Seniors. TITLE II—Revenues Subtitle A—Repeal and Replace of Health-Related Tax Policy Sec. 201. Taxes on certain insurance plans offering luxury coverage. Sec. 202. Corrective excise tax. Sec. 203. Small business tax credit. Sec. 204. Miscellaneous tax repeals. Sec. 205. Reduction tax. Sec. 206. Reform of nonprofit CO-OP insurance. Sec. 207. Reform of health savings accounts. Sec. 208. Reform of Archer MSAs and flexible spending accounts. Sec. 209. Deduction for qualified charity care. Sec. 210. Establishment of a tax credit for medical infrastructure investment. Sec. 211. Restoration of deduction for expenses allocable to Medicare part D subsidy. Sec. 212. Reduction of income threshold for determining medical care deduction. Sec. 213. Repeal of Medicare tax increase. Sec. 214. Refundable tax credit for health insurance coverage. Sec. 215. Maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation. Sec. 216. Allow both spouses to make catch-up contributions to the same health savings account. Sec. 217. Special rule for certain medical expenses incurred before establishment of health savings account. Sec. 218. Expansion of medical expense deduction. Subtitle B—Repeal of Certain Consumer Taxes Sec. 221. Repeal of tax on prescription medications. Subtitle C—Encouragement of Adoption of Domestic Orphans Sec. 231. Encouragement of adoption of domestic orphans. Sec. 232. Child tax deduction. Subtitle D—Remuneration From Certain Insurers Sec. 241. Remuneration from certain insurers. Subtitle E—Repeal of Net Investment Income Tax Sec. 251. Repeal of net investment income tax. TITLE III—Abortion and contraception Subtitle A—Prohibition on abortion. Sec. 301. All humans considered human. Sec. 302. Foreign abortion and sex-related tourism. Sec. 303. Diplomatic provisions. Sec. 304. Import and export regulation to prevent ectopic pregnancies. Sec. 305. Contraceptive regulation. Sec. 306. Control of abortifacient drugs. Sec. 307. Enhancement of Criminal Penalties. Sec. 308. Prohibition of anti-fetal hate crimes. Subtitle B—Technical provisions. Sec. 311. HHS authority. Sec. 312. Role of State, tribal, and local law. Sec. 313. Effective date. Sec. 314. Authorization of appropriations. Subtitle C—Other regulations relating to remains and contraception. Sec. 321. Closing "valuable consideration" loopholes. Sec. 322. Cleaning American water supplies. Sec. 323. Conservatorships prohibited from excessive control over reproduction. Subtitle D—Backup regulations. Sec. 331. Definitions. Sec. 332. Pain-capable unborn child protection. Sec. 333. Abortion statistics and accountability. Sec. 334. Abortion recipient identification. Sec. 335. Abortion provider licensing. Sec. 336. Forced abortion. Sec. 337. Teleabortion prevention. Sec. 338. Born-alive infants protection. Sec. 339. Dismemberment abortion ban. Subtitle E—Further provisions. Sec. 341. Foreign abortion and sex-related tourism. Sec. 342. Safe Crisis Pregnancy Centers. Sec. 343. No charge for failed delivery. Sec. 344. Restriction on HHS. Sec. 345. Release of political prisoners. TITLE IV—Regulations Subtitle A—General Regulation Reduction and Reform Sec. 401. Codification of minimum ages. Sec. 402. Capping out-of-pocket costs of insulin. Sec. 403. Intellectual property of unavailable products. Sec. 404. Act not found. Sec. 405. Constructions. Sec. 406. Right to try reform. Sec. 407. Reducing administrative costs and burdens in health care. Sec. 408. Requirements for cosmetic medical procedures. Sec. 409. Local-level deregulation. Sec. 410. Termination of patient lives. Sec. 411. Indian Healthcare. Sec. 412. Guidelines for medical practice. Sec. 413. Medical supply chain security. Sec. 414. Healthcare lawsuits. Sec. 415. Protection against political discrimination. Sec. 416. Non-invasive diagnostics. Sec. 417. Patient visitation rights. Sec. 418. Abolition of certificates of need. Subtitle B—Regulatory Reform for Health Insurance and Exchanges Sec. 421. Increasing competition in insurance exchange. Sec. 422. Interstate purchasing of health insurance. Sec. 423. Limits on coverage. Sec. 424. Surprise billing prevention. Sec. 425. Health Insurance Anti-Trust. Sec. 426. Limited-duration insurance. Sec. 427. Coverage for preexisting conditions. Subtitle C—Prescription Drugs and Related Provisions Sec. 431. Vaccine injury or death. Sec. 432. Chief Pharmaceutical Trade Negotiator. Sec. 433. Orange Book modernization. Sec. 434. Clarification of Controlled Substances Act. Sec. 435. Biological product patent transparency. Sec. 436. Fast track review for certain generic drugs. Sec. 437. Country of origin of drugs. Sec. 438. FDA Modernization. TITLE V—Pandemics and Epidemics Subtitle A—Pandemic preparedness Sec. 501. Emergency public health emergency construction. Sec. 502. Transportation safety during pandemics. Sec. 503. Public health emergency employment stability. Sec. 504. Evaluation and reported related to ability to seal borders in times of emergency. Sec. 505. Immigration during public health crises. Sec. 506. Public health emergency expanded as including global health emergencies. Sec. 507. Intentional spread of disease. Sec. 508. Defense Production Act amendments. Sec. 509. Waivers for pandemic readiness. Subtitle B—Public Health Service Sec. 511. Conscription into the Public Health Service. Sec. 512. Veterinary care during public health emergencies. Sec. 513. Public access to information regarding epidemics and potential epidemics. Sec. 514. Relationship with State law. Sec. 515. Territorial enforcement. Sec. 516. Eradication of Yersinia pestis. Sec. 517. Limitation on liability for volunteer health care professionals. Subtitle C—Pandemic recovery Sec. 521. Renaming of the COVID-19 pandemic. Sec. 522. Authorization of imposition of sanctions. Sec. 523. Post-lockdown health recovery. Sec. 524. Lockdowns ended. Sec. 525. Investigation of VAERS. Sec. 526. Civil Rights Act Improvement. Sec. 527. Post-Lockdown Education. Sec. 528. Ketogenic diet deregulation. TITLE VI—Veterans Sec. 601. Department of Energy veterans health research and development. Sec. 602. Interagency collaboration. Sec. 603. Pilot program on posttraumatic growth. Sec. 604. Financial assistance to certain entities to provide and coordinate the provision of suicide prevention services for veterans at risk of suicide and veteran families. Sec. 605. Veterinary insurance for veterans. Sec. 606. Cooperation between Department of Veterans Affairs and the Department of the Interior. Sec. 607. Wheelchairs for veterans with service-connected disabilities. Sec. 608. Discharge treatment. Sec. 609. Third-party review of appointees in Veterans Health Administration. Sec. 610. Unionization of the Veteran Health Administration. Sec. 611. Deeming certain State Veterans homes as meeting Medicare skilled nursing facilities conditions and requirements. Sec. 612. Hyperbaric oxygen therapy. TITLE VII—Education Sec. 701. Clarification of Title IX. Sec. 702. Sports rules. Sec. 703. Reduction of regulatory burdens for universities. Sec. 704. Living facility equality under Title IX. Sec. 705. Repeal of SAFRA Act. Sec. 706. High demand skillset education loans. Sec. 707. Improvement of secondary education. Sec. 708. Territorial application. Sec. 709. Clarification of school authority. Sec. 710. Rules regarding seminaries. Sec. 711. Educational status of child sexual mutilation. Sec. 3. Severability. If any provision of this Act, an amendment made by this Act, or the application of such provision or amendment to any person or circumstance is held to be unconstitutional, the remainder of this Act, the amendments made by this Act, and the application of the provisions of such to any person or circumstance shall not be affected thereby. Sec. 4. Immediate relief. Unless otherwise stated, the provisions of this Act shall enter into effect following appropriate regulations issued by the Secretary of Health and Human Services (or any other person designated by the President) or within 60 days. TITLE I—Expenditures Subtitle A—Patient Access to Public Health Programs Sec. 101. The Prevention and Public Health Fund. Subsection (b) of section 4002 of the Patient Protection and Affordable Care Act (42 U.S.C. 300u–11), as amended by section 5009 of the 21st Century Cures Act, is repealed effective the first fiscal year after the enactment of this Act. Of the funds made available by such subsection, the unobligated balance at the time of such repeal is rescinded. Sec. 102. Federal payments. (a) In general.—Notwithstanding any other provision of law, no funding shall be provided for any prohibited entity, defunded activity, or State, local, territorial, district, or other program which provides funding for any defunded activity or prohibited entity. (b) Definitions.—In this section: (1) PROHIBITED ENTITY.—The term “prohibited entity” means an entity, including its affiliates, subsidiaries, successors, and other associates that provides or refers for any defunded activity. (2) DEFUNDED ACTIVITY.—The term “defunded activity” means the following— (A) abortions, other than an abortion in the case where a woman suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death unless an abortion is performed, including a life-endangering physical condition caused by or arising from the pregnancy itself; (B) contraceptive drugs, substances, procedures, barriers, treatments, devices, implants, injections, or sterilizations; (C) tests or treatments for sexually transmitted diseases (excluding sexually transmitted diseases that cause ectopic pregnancy), except in such cases as it may be intended primarily for people to whom such diseases were not transmitted via sexual activity; (D) distribution, advocacy, or use of any illegal, unauthorized, uncertified, marijuana-related, or prostitution-related treatment or substance which is claimed to be medical in nature (with the exception of legitimate advocacy for the legalization of new medicines which are not currently or previously listed under Schedule I of the Controlled Substances Act); (E) illegal immigration (including all funds intended to benefit any person residing unlawfully in the United States, but excluding such circumstances in which emergency room service may be provided without knowledge of a patient's identity); (F) hormonal treatments or cosmetic modifications of persons not for the treatment of a physical medical condition or restoring a person's appearance or curing homosexuality or transsexuality, a paraphilia, or another sexual issue such as infertility, including surgeries which claim to alter the biological sex or race of a person, or intended to accompany a shift in gender identity or other identity; (G) any applicable luxury health plan as defined by 26 U.S.C. 4378 or applicable healthcare associated products as defined by 26 U.S.C. 5892; (H) any "public health emergency" or other emergency which is declared against a belief or system of beliefs which enjoys protection under the United States Constitution and has not started any insurrection against any Federal, State, tribal, territorial (including the District of Columbia), or local government of the United States; and (I) any plan, emergency, law, or ordinance which attempts to benefit or favor a race, including by claiming to support certain races by assigning any priority, affirmative action, lack or presence of healthcare right (including by declaring races to be at-risk groups which warrant any form of healthcare when persons of other races would not be entitled to such care given similar or comparable or near-similar or near-comparable medical background), or other superior of inferior status on the basis of race). (3) EXEMPT ENTITY.—A manufacturer or other user of medical devices used for reconstructive surgeries may be treated as exempt from prohibited entity status if the defunded activity for which such an entity provides or refers would be the use of such medical devices for approved non-reconstructive purposes. (c) Enforcement.—The Department of Health and Human Services and the Social Security Adminitration are tasked with the enforcement of this section and recollection of funds improperly spent with an interest rate not lower than 5%. The Internal Revenue Service, Department of Justice, Department of Homeland Security, and other agencies are obligated to provide assistance whenever the need arises. (d) Retroactivity.—All unspent funds allocated for any prohibited entity or defunded activity are immediately rescinded, except that for the duration of the fiscal year in which this provision went into effect, the President may continue funding as may be necessary to provide notice to any persons who may be affected, ensure that changes do not deviate from regular schedules, and ensure that transactions currently in progress are not cancelled. (e) Price ceiling.—Insofar as it does not fund a defunded activity, payments may be made to prohibited entities in exchange for patented medical products and services that are not otherwise available for patients, pursuant to an agreement which includes a reduction in costs for such products or services by at least 50% relative to prices for which such patented products and services are provided to other persons. (f) Effect on other law.—No law shall be interpreted as requiring any entity to become a prohibited entity, including insofar as State, Territorial, or District law may be preempted by this section. Sec. 103. Part D resales. Section 1395w-102 subsection (e)(2)(A) of Title 42 of the United States Code is amended as follows— “(A) In general” “Such term does not include drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under section 1396r–8(d)(2) of this title, other than subparagraph (E) of such section (relating to smoking cessation agents), other than subparagraph (I) of such section (relating to barbiturates) if the barbiturate is used in the treatment of epilepsy, cancer, or a chronic mental health disorder, and other than subparagraph (J) of such section (relating to benzodiazepines), or under section 1396r–8(d)(3) of this title, as such sections were in effect on December 8, 2003. Such term also does not include a drug when used for contraceptive purposes or for the treatment of sexual or erectile dysfunction, unless such drug were used to treat a condition, other than sexual or erectile dysfunction, for which the drug has been approved by the Food and Drug Administration. Such term also does not include any drug which the beneficiary intends to sell, and any Part D Eligible Individual who has sold a drug prescribed via Medicare must repay all expenditures on drugs which were sold and will no longer be considered a Part D Eligible Individual.” Sec. 104. Exclusion of coverage of advance care planning services under the Medicare program. (a) In general.—Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended— (1) in paragraph (24), by striking the “or” at the end; (2) in paragraph (25), by striking the period and inserting “; or”; and (3) by inserting after paragraph (25) the following new paragraph: “(26) which are advance care planning services, other than under section 1812(a)(5).”. (b) Effective date.—The amendment made by this section shall apply with respect to coverage beginning after December 31, 2027. Sec. 105. Allowing certain individuals with alternative health coverage to choose to opt out of the Medicare part A benefit. (a) In general.—Any individual described in subsection (c) who is otherwise entitled to benefits under part A of title XVIII of the Social Security Act may elect (in such form and manner as may be specified by the Commissioner of Social Security, in consultation with the Secretary of Health and Human Services) to opt out of such entitlement. Notwithstanding any other provision of law, in the case of an individual who makes such an election, such individual— (1) may (in such form and manner as may be specified by the Commissioner, in consultation with the Secretary) subsequently choose to end such election and opt back into such entitlement (in accordance with a process determined by the Commissioner, in consultation with the Secretary) without, subject to subsection (b), being subject to any penalty; (2) shall not be required to opt out of benefits under title II of such Act as a condition for making such election; and (3) shall not be required to repay any amount paid under such part A for items and services furnished prior to making such election. (b) Notification of termination of qualifying alternative health coverage required.— (1) NOTIFICATION.—In the case of an individual who makes an election under subsection (a) and whose enrollment in qualifying alternative health coverage is subsequently terminated, such individual shall notify the Secretary of Health and Human Services of such termination not later than 60 days after the date of such termination. (2) LATE ENROLLMENT PENALTY.—If an individual required to notify the Secretary under paragraph (1) fails to provide such notification within the period specified under such paragraph and subsequently chooses to end the election made by such individual under subsection (a) and opt back into benefits under part A of title XVIII of the Social Security Act, such individual shall be subject to a late enrollment penalty (as determined by the Secretary) in a manner and amount similar to an individual enrolled under such part A pursuant to section 1818 of such Act (42 U.S.C. 1395i–2). (c) Individual described.— (1) IN GENERAL.—For purposes of this section, an individual described in this subsection is an individual who demonstrates (in accordance with a process determined by the Commissioner, in consultation with the Secretary) that the individual is enrolled under qualifying alternative health coverage. (2) QUALIFYING ALTERNATIVE HEALTH COVERAGE.—For purposes of this section, the term “qualifying alternative health coverage” includes a group health plan or health insurance coverage offered in the group or individual market (as such terms are defined in section 2791 of the Public Health Service Act (42 U.S.C. 300gg–91), or other health coverage specified by the Commissioner, in consultation with the Secretary, that provides at least benefits comparable to benefits provided under part A of title XVIII of the Social Security Act. Sec. 106. Crisis Pregnancy Grants. (a) The Public Health Service Act is amended by adding at the end the following: “TITLE XXXIV—AWARENESS FOR EXPECTING MOTHERS “SEC. 3401. WEBSITE AND PORTAL. “(a) Website.—Not later than 1 year after the date of enactment of this section, the Secretary shall publish a user-friendly public website, life.gov, to provide a comprehensive list of Federal, State, local governmental, and private resources available to pregnant women including— “(1) resources to mental health counseling, pregnancy counseling, and other prepartum and postpartum services; “(2) comprehensive information on alternatives to abortion; “(3) information about abortion risks, including complications and failures; and “(4) links to information on child development from moment of conception. “(b) Portal.—Not later than 1 year after the date of enactment of this section, the Secretary shall publish a portal on the public website of the Department of Health and Human Services that— “(1) through a series of questions, will furnish specific tailored information to the user on what pregnancy-related information they are looking for, such as— “(A) Federal, State, local governmental, and private resources that may be available to the woman within her ZIP Code, including the resources specified in subsection (c); and “(B) risks related to abortion (including potential civil and criminal penalties) at all stages of fetal gestation; and “(2) provides for the submission of feedback on how user-friendly and helpful the portal was in providing the tailored information the user was seeking. “(c) Resources.—The Federal, State, local governmental, and private resources specified in this subsection are the following: “(1) Mentorship opportunities, including pregnancy help and case management resources. “(2) Health and well-being services, including women’s medical services such as obstetrical and gynecological support services for women, abortion pill reversal, breastfeeding, general health services, primary care, and dental care. “(3) Financial assistance, work opportunities, nutrition assistance, childcare, and education opportunities. “(4) Material or legal support, including transportation, food, nutrition, clothing, household goods, baby supplies, housing, shelters, maternity homes, tax preparation, legal support for child support, family leave, breastfeeding protections, and custody issues. “(5) Recovery and mental health services, including services with respect to addiction or suicide intervention, intimate partner violence, sexual assault, rape, sex trafficking, and counseling for women and families surrounding unexpected loss of a child. “(6) Prenatal diagnostic services, including disability support organizations, medical interventions for a baby, perinatal hospice resources, pregnancy and infant loss support, and literature on pregnancy wellness. “(7) Healing and support services for abortion survivors and their families. “(8) Services providing care for children, including family planning services and short-term care resources. “(d) Administration.—The Secretary may not delegate implementation or administration of the portal established under subsection (b) below the level of the Office of the Secretary. “(e) Follow-Up.—The Secretary shall develop a plan under which— “(1) the Secretary includes in the portal established under subsection (b), a mechanism for users of the portal to take an assessment through the portal and provide consent to use the user’s contact information; “(2) the Secretary conducts outreach via phone or email to follow up with users of the portal established under subsection (b) on additional resources that would be helpful for the users to review; and “(3) upon the request of a user of the portal for specific information, after learning of the additional resources through the portal, agents of the Department of Health and Human Services make every effort to furnish specific information to such user in coordination with Federal, State, local governmental, and private health care providers and resources. “(f) Resource List Aggregation.— “(1) IN GENERAL.—Pursuant to criteria developed in subsection (e)(2), the Secretary and each State shall provide recommendations of State, local governmental, and private resources under subsection (b)(1)(A) to include in the portal. “(2) CRITERIA FOR MAKING RECOMMENDATIONS.—The Secretary shall develop criteria to provide to the States to determine whether resources recommended as described in paragraph (1) for inclusion in the portal can appear in the portal. Such criteria shall include the requirement that the resource provider is not a prohibited entity and the requirement that the resource provider has been engaged in providing services for a minimum of 3 consecutive years. “(3) GRANT PROGRAM.— “(A) IN GENERAL.—The Secretary may provide grants to States to establish or support a system that aggregates the resources described in subsection (b)(1)(A), in accordance with the criteria developed under paragraph (2), and that may be coordinated, to the extent determined appropriate by the State, by a statewide, regionally-based, or community-based public entity or private nonprofit. “(B) APPLICATIONS.—To be eligible to receive a grant under subparagraph (A), a State shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require, including a plan for outreach and awareness activities, and a list of service providers that would be included in the State system supported by the grant. “(g) Maternal Mental Health Hotline.—The Secretary shall ensure that the Maternal Mental Health Hotline of the Health Resources and Services Administration— “(1) disseminates information regarding, and linkages to, the life.gov website and portal described in subsections (a) and (b); “(2) has the capacity to help families in every State and community in the Nation; and “(3) includes live chat features, 24 hours a day, to connect individuals to the information the portal hosts. “(h) Prohibition Regarding Certain Entities.—The resources listed on the life.gov website, and made available through the portal and hotline established under this section may not include any resource offered by a prohibited entity. “(i) Services In Different Languages.—The life.gov website and hotline shall ensure the widest possible access to services for families who speak languages other than English that are official languages of States. “(j) Reporting Requirements.— “(1) IN GENERAL.—Not later than 180 days after the date on which the life.gov website and portal are established under subsection (a), the Secretary shall submit to Congress a report on— “(A) the traffic of the website and the interactive portal; “(B) user feedback on the accessibility and helpfulness of the website and interactive portal in tailoring to the user’s needs; “(C) insights on gaps in Federal, State, local governmental, and private programming with respect to services for pregnant and postpartum women; and “(D) suggestions on how to improve user experience and accessibility based on user feedback and missing resources that would be helpful to include in future updates. “(2) CONFIDENTIALITY.—The report under paragraph (1) shall not include any personal identifying information regarding individuals who have used the website or portal. “(k) Definitions.—In this section: “(1) ABORTION.—The term ‘abortion’ means the use or prescription of any instrument, medicine, drug, or other substance or device to intentionally— “(A) kill the unborn child of a woman known to be pregnant; or “(B) prematurely terminate the pregnancy of a woman known to be pregnant, with an intention other than to— “(i) increase the probability of a live birth or of preserving the life or health of the child after live birth; or “(ii) remove a dead unborn child. “(2) BORN ALIVE.—The term ‘born alive’ has the meaning given such term in section 8(b) of title 1, United States Code. “(3) PROHIBITED ENTITY.—The term ‘prohibited entity’ has the meaning established by section 102 of the Health Care Act of 2027. “(4) UNBORN CHILD.—The term ‘unborn child’ means an individual organism of the species homo sapiens, beginning at fertilization, until the point of being born alive.”. (b) Reform of Title X.—42 U.S. Code § 300(d) is amended as follows: “(d) Definitions.— “(1) In this Act, the term ‘family planning’ means— “(1) services to improve the efficacy of pregnancy planning, pregnancy spacing, raising children, or fertilization; “(2) adoption services; “(3) abstinence education and information regarding the prevention of birth defects (including congenital conditions) and developmental disorders (including risks associated to delayed pregnancy as well as teen pregnancy); “(4) conversion therapy; “(5) pregnancy emergency preparedness (including to assist in the proper burial of miscarried children); “(6) pregnancy-related medical services including reversal of poisonings intended to ultimately kill unborn children and pregnancy diagnostic services; and “(7) marriage preparation services, provided intercourse between the spouses could result in the conception of a human child.” “(2) In this Act, the term ‘contraceptive development’ means research and development intended to improve the results of family planning. “(3) In this Act, the term ‘abstinence education’ means education intended to teach individuals how to abstain from sexual intercourse, including education intended to teach individuals how to abstain from adultery and fornication. “(4) In this Act, the term ‘conversion therapy’ means therapies intended to treat or cure a paraphilia or gender identity disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Third Edition. “(5) In this Act, the word ‘voluntary’ includes when intended to fulfill a court order, contractual obligation, or other order or obligation.”. Sec. 107. Price negotiation. (a) Notwithstanding the Social Security Act, the Centers for Medicare & Medicaid Services (in this section, "the Centers" or "CMS") may hire price negotiators to reduce expenditures by Medicare and to reduce Federal expenditures on other healthcare programs, including by reducing Federal grants to States. (b) The Secretary of Health and Human Services (in this section, "the Secretary") shall establish relevant guidelines and regulations to ensure that expenditures are reduced by a minimum of 400 billion by 2028, including by establishing guidelines for pay via commission. The Secretary shall also establish conflict-of-interest regulations to ensure that negotiators shall seek the lowest possible prices. (c) Compensation for CMS price negotiators shall be appropriated from such funds that shall go unspent otherwise due to their negotiation work, except that not more than 0.1% or 100 million dollars of such funds shall go to such negotiators. (d) The Centers shall make available to the States and to Medicare Part C plans any benefits which may be possible to extend to State and Part C health plans, provided that such benefits shall not be made available at a loss beyond such an acceptable loss as may be designated by the Secretary or as may exceed 2% of total cost in the case of any benefit provided to a Medicare Part C plan. (e) The Centers shall withhold the issuance of grants to States for State purchases of product or service except in such case that— (1) the State already made such purchase prior to January 2028 and holds applicable proof of purchase, (2) the State is using grants to provide a product or service (other than a defunded activity) which is not ordinarily available to beneficiaries, (3) the State has obtained such product or service at a lower price than would be possible for the Centres and is willing to accept less Federal grant funding as a consequence. Sec. 108. Employee Background Check Expansion. Section 1921(b)(6) of the Social Security Act (42 U.S.C. 1396r–2(b)(6)) is amended— (1) by striking “and other health care entities (as defined in section 431 of the Health Care Quality Improvement Act of 1986)” and inserting “, other health care entities (as defined in section 431 of the Health Care Quality Improvement Act of 1986), providers of services (as defined in section 1861(u)), suppliers (as defined in section 1861(d)), and providers of items or services under a State plan under this title (or a waiver of such a plan)”; and (2) by striking “such hospitals or other health care entities” and inserting “such hospitals, health care entities, providers, or suppliers”. Subtitle B—Medicaid Program Enhancement Sec. 111. Repeal of Medicaid provisions. The Social Security Act is amended— (1) in section 1902 (42 U.S.C. 1396a)— (A) in subsection (a)(47)(B), by inserting “and provided that any such election shall cease to be effective on January 1, 2028, and no such election shall be made after that date” before the semicolon at the end; and (B) in subsection (l)(2)(C), by inserting “and ending December 31, 2029,” after “January 1, 2014,”; (2) in section 1915(k)(2) (42 U.S.C. 1396n(k)(2)), by striking “during the period described in paragraph (1)” and inserting “on or after the date referred to in paragraph (1) and before January 1, 2028”; and (3) in section 1920(e) (42 U.S.C. 1396r–1(e)), by striking “under clause (i)(VIII), clause (i)(IX), or clause (ii)(XX) of subsection (a)(10)(A)” and inserting “under clause (i)(VIII) or clause (ii)(XX) of section 1902(a)(10)(A) before January 1, 2028, section 1902(a)(10)(A)(i)(IX),”. Sec. 112. Repeal of Medicaid expansion. (a) In general.—Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is amended— (1) in section 1902 (42 U.S.C. 1396a)— (A) in subsection (a)(10)(A)— (i) by striking clauses (i)(VIII) and (ii)(XX); (ii) in clause (ii), by adding at the end the following new subclause: “(XXIV) effective immediately upon the passage of the Health Care Act of 2027— “(aa) who are expansion enrollees (as defined in subsection (nn)(1)); or “(bb) who are grandfathered expansion enrollees (as defined in subsection (nn)(2));”; and (B) by adding at the end the following new subsection: “(tt) Expansion enrollees.—In this title: “(1) IN GENERAL.—The term ‘expansion enrollee’ means an individual— “(A) who is under 65 years of age; “(B) who is not pregnant; “(C) who is not entitled to, or enrolled for, benefits under part A of title XVIII, or enrolled for benefits under part B of title XVIII; “(D) who is not described in any of subclauses (I) through (VII) of subsection (a)(10)(A)(i); “(E) who is a veteran, beginning in fiscal year 2031; and “(F) whose income (as determined under subsection (e)(14)) does not exceed 133 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved. “(2) GRANDFATHERED EXPANSION ENROLLEES.—The term ‘grandfathered expansion enrollee’ means an expansion enrollee who— “(A) was enrolled (or in the process of enrollment) under the State plan under this title (or under a waiver of such plan) as of December 31, 2027; and “(B) does not have a break in eligibility for medical assistance under such State plan (or waiver) for more than one month after such date. “(3) APPLICATION OF RELATED PROVISIONS.—Any reference in subsection (a)(10)(G), (k), or (gg) of this section or in section 1903, 1905(a), 1920(e), or 1937(a)(1)(B) to individuals described in subclause (VIII) of subsection (a)(10)(A)(i) shall be deemed to include a reference to expansion enrollees (including grandfathered expansion enrollees).”; and (2) in section 1905 (42 U.S.C. 1396d)— (A) in subsection (y)(1), in the matter preceding subparagraph (A)— (i) by inserting “and that has elected to cover newly eligible individuals before March 1, 2017” after “that is one of the 50 States or the District of Columbia”; and (ii) by inserting after “subclause (VIII) of section 1902(a)(10)(A)(i)” the following: “who, for periods after December 31, 2019, are grandfathered expansion enrollees (as defined in section 1902(nn)(2))”; and (B) in subsection (z)(2)— (i) in subparagraph (A), by inserting after “section 1937” the following: “and, for periods after December 31, 2019, who are grandfathered expansion enrollees (as defined in section 1902(nn)(2))”; and (ii) in subparagraph (B)(ii)— (I) in subclause (VI), by adding “and” at the end; and (II) by inserting “through fiscal year 2027” after “each subsequent year” in subclause (VI); and (III) by inserting the following new subclause: “(VII) 2028 and each subsequent year is 80 percent, decreasing ten percent per year for eight years thereafter.” (b) Sunset of essential health benefits requirement.—Section 1937(b)(5) of the Social Security Act (42 U.S.C. 1396u–7(b)(5)) is repealed. Sec. 113. Elimination of DSH cuts. Section 1923(f) of the Social Security Act (42 U.S.C. 1396r–4(f)) is amended— (1) in paragraph (7)— (A) in subparagraph (A)— (i) in clause (i) by striking “and for each of fiscal years 2028 through 2031”; and (ii) in clause (ii)— (I) in subclause (I), by adding “and” at the end; (II) in subclause (II), by striking the semicolon at the end and inserting a period; and (III) by striking subclauses (III) through (VIII); and (B) by adding at the end the following new subparagraph: “(C) EXEMPTION FROM REDUCTION FOR NON-EXPANSION STATES.— “(i) IN GENERAL.—In the case of a State that is a non-expansion State for a fiscal year, subparagraph (A)(i) shall not apply to the DSH allotment for such State and fiscal year. “(ii) NO CHANGE IN REDUCTION FOR EXPANSION STATES.—In the case of a State that is an expansion State for a fiscal year, the DSH allotment for such State and fiscal year shall be determined as if clause (i) did not apply. “(iii) NON-EXPANSION AND EXPANSION STATE DEFINED.— “(I) The term ‘expansion State’ means with respect to a fiscal year, a State that, as of July 1 of the preceding fiscal year, provides for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) for medical assistance under this title (or a waiver of the State plan approved under section 1115). “(II) The term ‘non-expansion State’ means, with respect to a fiscal year, a State that is not an expansion State.”; and (2) in paragraph (8), by striking “fiscal year 2031” and inserting “fiscal year 2028”. Sec. 114. Reducing State Medicaid costs. (a) Letting States disenroll high dollar lottery winners.— (1) IN GENERAL.—Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended— (A) in subsection (a)(17), by striking “(e)(14), (e)(14)” and inserting “(e)(14), (e)(15)”; and (B) in subsection (e)— (i) in paragraph (14) (relating to modified adjusted gross income), by adding at the end the following new subparagraph: “(J) TREATMENT OF CERTAIN LOTTERY WINNINGS AND INCOME RECEIVED AS A LUMP SUM.— “(i) IN GENERAL.—In the case of an individual who is the recipient of qualified lottery winnings (pursuant to lotteries occurring on or after January 1, 2028) or qualified lump sum income (received on or after such date) and whose eligibility for medical assistance is determined based on the application of modified adjusted gross income under subparagraph (A), a State shall, in determining such eligibility, include such winnings or income (as applicable) as income received— “(I) in the month in which such winnings or income (as applicable) is received if the amount of such winnings or income is less than $80,000; “(II) over a period of 2 months if the amount of such winnings or income (as applicable) is greater than or equal to $80,000 but less than $90,000; “(III) over a period of 3 months if the amount of such winnings or income (as applicable) is greater than or equal to $90,000 but less than $100,000; and “(IV) over a period of 3 months plus 1 additional month for each increment of $10,000 of such winnings or income (as applicable) received, not to exceed a period of 120 months (for winnings or income of $1,260,000 or more), if the amount of such winnings or income is greater than or equal to $100,000. “(ii) COUNTING IN EQUAL INSTALLMENTS.—For purposes of subclauses (II), (III), and (IV) of clause (i), winnings or income to which such subclause applies shall be counted in equal monthly installments over the period of months specified under such subclause. “(iii) HARDSHIP EXEMPTION.—An individual whose income, by application of clause (i), exceeds the applicable eligibility threshold established by the State, may continue to be eligible for medical assistance to the extent that the State determines, under procedures established by the State under the State plan (or in the case of a waiver of the plan under section 1115, incorporated in such waiver), or as otherwise established by such State in accordance with such standards as may be specified by the Secretary, that the denial of eligibility of the individual would cause an undue medical or financial hardship as determined on the basis of criteria established by the Secretary. “(iv) NOTIFICATIONS AND ASSISTANCE REQUIRED IN CASE OF LOSS OF ELIGIBILITY.—A State shall, with respect to an individual who loses eligibility for medical assistance under the State plan (or a waiver of such plan) by reason of clause (i), before the date on which the individual loses such eligibility, inform the individual of the date on which the individual would no longer be considered ineligible by reason of such clause to receive medical assistance under the State plan or under any waiver of such plan and the date on which the individual would be eligible to reapply to receive such medical assistance. “(v) QUALIFIED LOTTERY WINNINGS DEFINED.—In this subparagraph, the term ‘qualified lottery winnings’ means winnings from a sweepstakes, lottery, or pool described in paragraph (3) of section 4402 of the Internal Revenue Code of 1986 or a lottery operated by a multistate or multijurisdictional lottery association, including amounts awarded as a lump sum payment. “(vi) QUALIFIED LUMP SUM INCOME DEFINED.—In this subparagraph, the term ‘qualified lump sum income’ means income that is received as a lump sum from one of the following sources: “(I) Monetary winnings from gambling (as defined by the Secretary and including monetary winnings from gambling activities described in section 1955(b)(4) of title 18, United States Code). “(II) Income received as liquid assets from the estate (as defined in section 1917(b)(4)) of a deceased individual.”; and (ii) by striking “(14) Exclusion” and inserting “(15) Exclusion”. (2) RULES OF CONSTRUCTION.— (A) INTERCEPTION OF LOTTERY WINNINGS ALLOWED.—Nothing in the amendment made by paragraph (1)(B)(i) shall be construed as preventing a State from intercepting the State lottery winnings awarded to an individual in the State to recover amounts paid by the State under the State Medicaid plan under title XIX of the Social Security Act for medical assistance furnished to the individual. (B) APPLICABILITY LIMITED TO ELIGIBILITY OF RECIPIENT OF LOTTERY WINNINGS OR LUMP SUM INCOME.—Nothing in the amendment made by paragraph (1)(B)(i) shall be construed, with respect to a determination of household income for purposes of a determination of eligibility for medical assistance under the State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) (or a waiver of such plan) made by applying modified adjusted gross income under subparagraph (A) of section 1902(e)(14) of such Act (42 U.S.C. 1396a(e)(14)), as limiting the eligibility for such medical assistance of any individual that is a member of the household other than the individual (or the individual’s spouse) who received qualified lottery winnings or qualified lump-sum income (as defined in subparagraph (J) of such section 1902(e)(14), as added by paragraph (1)(B)(i) of this subsection). (b) Repeal of retroactive eligibility.— (1) IN GENERAL.— (A) STATE PLAN REQUIREMENTS.—Section 1902(a)(34) of the Social Security Act (42 U.S.C. 1396a(a)(34)) is amended by striking “in or after the third month before the month in which he made application” and inserting “in or after the month in which the individual made application”. (B) DEFINITION OF MEDICAL ASSISTANCE.—Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended by striking “in or after the third month before the month in which the recipient makes application for assistance” and inserting “in or after the month in which the recipient makes application for assistance”. (2) EFFECTIVE DATE.—The amendments made by paragraph (1) shall apply to medical assistance with respect to individuals whose eligibility for such assistance is based on an application for such assistance made (or deemed to be made) on or after October 1, 2028. (c) Updating allowable home equity limits in Medicaid.— (1) IN GENERAL.—Section 1917(f)(1) of the Social Security Act (42 U.S.C. 1396p(f)(1)) is amended— (A) in subparagraph (A), by striking “subparagraphs (B) and (C)” and inserting “subparagraph (B)”; (B) by striking subparagraph (B); (C) by redesignating subparagraph (C) as subparagraph (B); and (D) in subparagraph (B), as so redesignated, by striking “dollar amounts specified in this paragraph” and inserting “dollar amount specified in subparagraph (A)”. (2) EFFECTIVE DATE.— (A) IN GENERAL.—The amendments made by paragraph (1) shall apply with respect to eligibility determinations made after the date that is 180 days after the date of the enactment of this section. (B) EXCEPTION FOR STATE LEGISLATION.—In the case of a State plan under title XIX of the Social Security Act that the Secretary of Health and Human Services determines requires State legislation in order for the respective plan to meet any requirement imposed by amendments made by this subsection, the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session shall be considered to be a separate regular session of the State legislature. (d) Reducing State and Federal debts incurred by Medicaid, CHIP, and other grant program accounting errors.— (1) IN GENERAL.—The Centers for Medicare & Medicaid Services are required to issue optimal arrangements to prevent states from taking out loans to pay Medicaid expenses before reimbursement by the Federal government, including by way of issuing loans with interest pegged to healthcare inflation which would be automatically forgiven as a means of delivering funding. (2) APPLICATION.—This subsection shall apply to all health programs administered by the Federal government involving states, including the State Children's Health Insurance Program and Medicaid. (3) Medicare PART C.—The Centers for Medicare & Medicaid Services may establish similar practices to ensure minimization of costs for the Medicare program insofar as it is practicable, including as may be li. (4) ENFORCEMENT.—This provision may be enforced via withholding or reduction of funding as well as via other methods available as provided by law. (e) Section 1115(a)(1) of the Social Security Act (42 U.S.C. 1315(a)(1)) is amended— (1) by striking “1602, or 1902” and inserting “or 1602”; and (2) by inserting “and shall waive compliance with section 1902,” after “as the case may be,”. Sec. 115. Safety net funding for non-expansion States. Title XIX of the Social Security Act is amended by inserting after section 1923 (42 U.S.C. 1396r–4) the following new section: “Adjustment in payment for services of safety net providers in non-expansion States “Sec. 1923A. “(a) In general.—Subject to the limitations of this section, for each year during the period beginning with fiscal year 2028 and ending with fiscal year 2032, each State that is one of the 50 States or the District of Columbia and that, as of July 1 of the preceding fiscal year, did not provide for eligibility under clause (i)(VIII) or (ii)(XX) of section 1902(a)(10)(A) for medical assistance under this title (or a waiver of the State plan approved under section 1115) (each such State or District referred to in this section for the fiscal year as a ‘non-expansion State’) may adjust the payment amounts otherwise provided under the State plan under this title (or a waiver of such plan) to health care providers that provide health care services to individuals enrolled under this title (in this section referred to as ‘eligible providers’) so long as the payment adjustment to such an eligible provider does not exceed the provider’s costs in furnishing health care services (as determined by the Secretary and net of payments under this title, other than under this section, and by uninsured patients) to individuals who either are eligible for medical assistance under the State plan (or under a waiver of such plan) or have no health insurance or health plan coverage for such services. “(b) Increase in applicable FMAP.—Notwithstanding section 1905(b), the Federal medical assistance percentage applicable with respect to expenditures attributable to a payment adjustment under subsection (a) for which payment is permitted under subsection (c) shall be equal to— “(1) 100 percent for calendar quarters in fiscal years 2028, 2029, 2030, and 2031; and “(2) 95 percent for calendar quarters in fiscal year 2032. “(c) Annual allotment limitation.—Payment under section 1903(a) shall not be made to a State with respect to any payment adjustment made under this section for all calendar quarters in a fiscal year in excess of the $2,000,000,000 multiplied by the ratio of— “(1) the population of the State with income below 138 percent of the poverty line in 2020 (as determined based the table entitled ‘Health Insurance Coverage Status and Type by Ratio of Income to Poverty Level in the Past 12 Months by Age’ for the universe of the civilian noninstitutionalized population for whom poverty status is determined based on the 2015 American Community Survey 1–Year Estimates, as published by the Bureau of the Census), to “(2) the sum of the populations under paragraph (1) for all non-expansion States. “(d) Disqualification in case of State coverage expansion.—If a State is a non-expansion for a fiscal year and provides eligibility for medical assistance described in subsection (a) during the fiscal year, the State shall no longer be treated as a non-expansion State under this section for any subsequent fiscal years.”. Sec. 116. Providing incentives for increased frequency of eligibility redeterminations. (a) In general.—Section 1902(e)(14) of the Social Security Act (42 U.S.C. 1396a(e)(14)) (relating to modified adjusted gross income), as amended by section 114(a)(1), is further amended by adding at the end the following: “(K) FREQUENCY OF ELIGIBILITY REDETERMINATIONS.—Beginning on October 1, 2027, and notwithstanding subparagraph (H), in the case of an individual whose eligibility for medical assistance under the State plan under this title (or a waiver of such plan) is determined based on the application of modified adjusted gross income under subparagraph (A) and who is so eligible on the basis of clause (i)(VIII) or clause (ii)(XX) of subsection (a)(10)(A), a State shall redetermine such individual’s eligibility for such medical assistance no less frequently than once every 6 months.”. (b) Increased administrative matching percentage.—For each calendar quarter during the period beginning on October 1, 2027, and ending on December 31, 2031, the Federal matching percentage otherwise applicable under section 1903(a) of the Social Security Act (42 U.S.C. 1396b(a)) with respect to State expenditures during such quarter that are attributable to meeting the requirement of section 1902(e)(14) (relating to determinations of eligibility using modified adjusted gross income) of such Act shall be increased by 5 percentage points with respect to State expenditures attributable to activities carried out by the State (and approved by the Secretary) to increase the frequency of eligibility redeterminations required by subparagraph (K) of such section (relating to eligibility redeterminations made on a 6-month basis) (as added by subsection (a)). Sec. 117. Work requirement for nondisabled, nonpregnant adults under Medicaid. (a) Section 1902 of the Social Security Act (42 U.S.C. 1396a), as previously amended, is further amended (effective October 2, 2027) by striking subsection (jj) and inserting the following in its place: “(jj) Work requirement option for nondisabled, nonpregnant adults.— “(1) IN GENERAL.—Beginning October 1, 2028, subject to paragraph (3), a State may elect to condition medical assistance to a nondisabled, nonpregnant individual under this title upon such an individual’s satisfaction of a work requirement (as defined in paragraph (2)). “(2) WORK REQUIREMENT DEFINED.—In this section, the term ‘work requirement’ means, with respect to an individual, the individual’s participation in work activities (as defined in section 407(d) (42 U.S.C. 607(d)) for such period of time as determined by the State, and as directed and administered by the State. “(3) REQUIRED EXCEPTIONS.—States administering a work requirement under this subsection may not apply such requirement to— “(A) a woman who recently gave birth through the end of the month in which the 90-day period beginning on the last day of her pregnancy, as recorded on the birth certificate of the youngest child delivered as a result of such pregnancy; “(B) an individual who is under 18 years of age; “(C) an individual who is the only parent or caretaker relative in the family of a child who has not attained 6 years of age or who is the only parent or caretaker of a child with disabilities necessitating exemption; “(D) an individual who is unable to work due to hospitalization; or “(E) an individual who is married or widowed and has seven or more children living in the home. “(4) FUNDING MODIFICATION.—No funds shall be granted to States for payments made for any individual eligible for hospital insurance under section 226. No funds shall be granted to States for payments made for any medical assistance for any nondisabled, nonpregnant individuals not participating in work activities who are not covered by an exemption under paragraph (3) of this section. “(5) WORK OPPORTUNITY REQUESTS.—Applicants and current Medicaid recipients may submit requests to states for opportunities to fulfill their obligations under this subsection; however, a submission of such a request shall not count as satisfaction of a work requirement under this section.”. Sec. 118. Enabling Medicaid payments for conversion therapy. (a) In general.—Section 1902 of the Social Security Act (42 U.S.C. 1396a), as previously amended, is amended— (1) in subsection (a)— (A) in paragraph (85), by striking “and” at the end; (B) in paragraph (86), by striking the period at the end and inserting “; and”; and (C) by inserting after paragraph (86) the following new paragraph: “(87) provide that, beginning with the first day of the first quarter that begins on or after the date of enactment of this paragraph, payment may be made under the plan with respect to conversion therapy (as defined in subsection (qq)) furnished to an individual enrolled under the plan (or a waiver of such plan).”; and (2) by amending subsection (qq) as follows: “(qq) Conversion therapy; Gender identity; Person; Sexual orientation.—For purposes of subsection (a)(87) and this subsection: “(1) CONVERSION THERAPY.—The term ‘conversion therapy’— “(A) means any practice or treatment by any person that seeks to change another individual’s sexual orientation or gender identity (unless such practice seeks to change a heterosexual or cisgender individual’s sexual orientation or gender identity shall not be treated as conversion therapy), including efforts to change behaviors or gender expressions, or to eliminate or reduce sexual or romantic attractions or feelings toward individuals of the same gender, if such person receives monetary compensation in exchange for any such practice or treatment; and “(B) does not include any practice or treatment, which does not seek to change sexual orientation or gender identity, that— “(i) provides assistance to an individual undergoing a gender transition; or “(ii) provides acceptance, support, and understanding of a client or facilitation of a client’s coping, social support, and identity exploration and development, including sexual orientation-neutral interventions to prevent or address unlawful conduct or unsafe sexual practices. “(2) GENDER IDENTITY.—The term ‘gender identity’ means the gender-related identity, appearance, mannerisms, or other gender-related characteristics of an individual, regardless of the individual’s designated sex at birth. “(3) PERSON.—The term ‘person’ means any individual, partnership, corporation, cooperative, association, or any other entity. “(4) SEXUAL ORIENTATION.—The term ‘sexual orientation’ means homosexuality, heterosexuality, or bisexuality. “(5) CISGENDER.—The term ‘cisgender’ refers to the gender identity which aligns with the binary reality of biological sex and matches the chromosomal and genital reality of the individual.”. (b) Preemption.—Any State law, regulation, or ordinance which may claim to outlaw conversion therapy as defined by the Social Security Act or establish regulations which have the effect of shutting down all conversion therapy providers in a State are hereby preempted. Subtitle C—Reformed payments to States Sec. 121. Per capita allotment for medical assistance. Title XIX of the Social Security Act is amended— (1) in section 1903 (42 U.S.C. 1396b)— (A) in subsection (a), in the matter before paragraph (1), by inserting “and section 1903A(a)” after “except as otherwise provided in this section”; and (B) in subsection (d)(1), by striking “to which” and inserting “to which, subject to section 1903A(a),”; and (2) by inserting after such section 1903 the following new section: “Sec. 1903A. Per capita-based cap on payments for medical assistance. “(a) Application of per capita cap on payments for medical assistance expenditures.— “(1) IN GENERAL.—If a State has excess aggregate medical assistance expenditures (as defined in paragraph (2)) for a fiscal year (beginning with fiscal year 2020), the amount of payment to the State under section 1903(a)(1) for each quarter in the following fiscal year shall be reduced by ¼ of the excess aggregate medical assistance payments (as defined in paragraph (3)) for that previous fiscal year. In this section, the term ‘State’ means only the 50 States and the District of Columbia. “(2) EXCESS AGGREGATE MEDICAL ASSISTANCE EXPENDITURES.—In this subsection, the term ‘excess aggregate medical assistance expenditures’ means, for a State for a fiscal year, the amount (if any) by which— “(A) the amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State and fiscal year; exceeds “(B) the amount of the target total medical assistance expenditures (as defined in subsection (c)) for the State and fiscal year. “(3) EXCESS AGGREGATE MEDICAL ASSISTANCE PAYMENTS.—In this subsection, the term ‘excess aggregate medical assistance payments’ means, for a State for a fiscal year, the product of— “(A) the excess aggregate medical assistance expenditures (as defined in paragraph (2)) for the State for the fiscal year; and “(B) the Federal average medical assistance matching percentage (as defined in paragraph (4)) for the State for the fiscal year. “(4) FEDERAL AVERAGE MEDICAL ASSISTANCE MATCHING PERCENTAGE.—In this subsection, the term ‘Federal average medical assistance matching percentage’ means, for a State for a fiscal year, the ratio (expressed as a percentage) of— “(A) the amount of the Federal payments that would be made to the State under section 1903(a)(1) for medical assistance expenditures for calendar quarters in the fiscal year if paragraph (1) did not apply; to “(B) the amount of the medical assistance expenditures for the State and fiscal year. “(b) Adjusted total medical assistance expenditures.—Subject to subsection (g), the following shall apply: “(1) IN GENERAL.—In this section, the term ‘adjusted total medical assistance expenditures’ means, for a State— “(A) for fiscal year 2028, the product of— “(i) the amount of the medical assistance expenditures (as defined in paragraph (2)) for the State and fiscal year, reduced by the amount of any excluded expenditures (as defined in paragraph (3)) for the State and fiscal year otherwise included in such medical assistance expenditures; and “(ii) the 1903A FY20 population percentage (as defined in paragraph (4)) for the State; or “(B) for fiscal year 2029 or a subsequent fiscal year, the amount of the medical assistance expenditures (as defined in paragraph (2)) for the State and fiscal year that is attributable to 1903A enrollees, reduced by the amount of any excluded expenditures (as defined in paragraph (3)) for the State and fiscal year otherwise included in such medical assistance expenditures and includes non-DSH supplemental payments (as defined in subsection (d)(4)(A)(ii)) and payments described in subsection (d)(4)(A)(iii) but shall not be construed as including any expenditures attributable to the program under section 1928. In applying subparagraph (B), non-DSH supplemental payments (as defined in subsection (d)(4)(A)(ii)) and payments described in subsection (d)(4)(A)(iii) shall be treated as fully attributable to 1903A enrollees. “(2) MEDICAL ASSISTANCE EXPENDITURES.—In this section, the term ‘medical assistance expenditures’ means, for a State and fiscal year, the medical assistance payments as reported by medical service category on the Form CMS-64 quarterly expense report (or successor to such a report form, and including enrollment data and subsequent adjustments to any such report, in this section referred to collectively as a ‘CMS-64 report’) for which payment is (or may otherwise be) made pursuant to section 1903(a)(1). “(3) EXCLUDED EXPENDITURES.—In this section, the term ‘excluded expenditures’ means, for a State and fiscal year, expenditures under the State plan (or under a waiver of such plan) that are attributable to any of the following: “(A) DSH.—Payment adjustments made for disproportionate share hospitals under section 1923. “(B) MEDICARE COST-SHARING.—Payments made for Medicare cost-sharing (as defined in section 1905(p)(3)). “(C) SAFETY NET PROVIDER PAYMENT ADJUSTMENTS IN NON-EXPANSION STATES.—Payment adjustments under subsection (a) of section 1923A for which payment is permitted under subsection (c) of such section. “(D) MISCELLANEOUS EXPENDITURES.—Payments made for any defunded activity or prohibited entity as defined by section 102 of the Health Care Act of 2027. “(4) 1903A FY 20 POPULATION PERCENTAGE.—In this subsection, the term ‘1903A FY20 population percentage’ means, for a State, the Secretary’s calculation of the percentage of the actual medical assistance expenditures, as reported by the State on the CMS–64 reports for calendar quarters in fiscal year 2020, that are attributable to 1903A enrollees (as defined in subsection (e)(1)). “(c) Target total medical assistance expenditures.— “(1) CALCULATION.—In this section, the term ‘target total medical assistance expenditures’ means, for a State for a fiscal year and subject to paragraph (4), the sum of the products, for each of the 1903A enrollee categories (as defined in subsection (e)(2)), of— “(A) the target per capita medical assistance expenditures (as defined in paragraph (2)) for the enrollee category, State, and fiscal year; “(B) the number of 1903A enrollees for such enrollee category, State, and fiscal year, as determined under subsection (e)(4). “(2) TARGET PER CAPITA MEDICAL ASSISTANCE EXPENDITURES.—In this subsection, the term ‘target per capita medical assistance expenditures’ means, for a 1903A enrollee category and State— “(A) for fiscal year 2020, an amount equal to— “(i) the provisional FY22 target per capita amount for such enrollee category (as calculated under subsection (d)(5)) for the State; increased by “(ii) the applicable annual inflation factor (as defined in paragraph (3)) for fiscal year 2020; and “(B) for each succeeding fiscal year, an amount equal to— “(i) the target per capita medical assistance expenditures (under subparagraph (A) or this subparagraph) for the 1903A enrollee category and State for the preceding fiscal year, increased by “(ii) the applicable annual inflation factor for that succeeding fiscal year. “(3) APPLICABLE ANNUAL INFLATION FACTOR.—In paragraph (2), the term ‘applicable annual inflation factor’ means, for a fiscal year— “(A) for each of the 1903A enrollee categories described in subparagraphs (C), (D), and (E) of subsection (e)(2), the percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) from September of the previous fiscal year to September of the fiscal year involved; and “(B) for each of the 1903A enrollee categories described in subparagraphs (A) and (B) of subsection (e)(2), the percentage increase described in subparagraph (A) plus 1 percentage point. “(4) DECREASE IN TARGET EXPENDITURES FOR REQUIRED EXPENDITURES BY CERTAIN POLITICAL SUBDIVISIONS.— “(A) IN GENERAL.—In the case of a State that had a DSH allotment under section 1923(f) for fiscal year 2020 that was more than 6 times the national average of such allotments for all the States for such fiscal year and that requires political subdivisions within the State to contribute funds towards medical assistance or other expenditures under the State plan under this title (or under a waiver of such plan) for a fiscal year (beginning with fiscal year 2028), the target total medical assistance expenditures for such State and fiscal year shall be decreased by the amount that political subdivisions in the State are required to contribute under the plan (or waiver) without reimbursement from the State for such fiscal year, other than contributions described in subparagraph (B). “(B) EXCEPTIONS.—The contributions described in this subparagraph are the following: “(i) Contributions required by a State from a political subdivision that, as of the first day of the calendar year in which the fiscal year involved begins— “(I) has a population of more than 5,000,000, as estimated by the Bureau of the Census; and “(II) imposes a local income tax upon its residents. “(ii) Contributions required by a State from a political subdivision for administrative expenses if the State required such contributions from such subdivision without reimbursement from the State as of January 1, 2027. “(d) Calculation of FY19 provisional target amount for each 1903A enrollee category.—Subject to subsection (g), the following shall apply: “(1) CALCULATION OF BASE AMOUNTS FOR FISCAL YEAR 2020.—For each State the Secretary shall calculate (and provide notice to the State not later than April 1, 2028, of) the following: “(A) The amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2020. “(B) The number of 1903A enrollees for the State in fiscal year 2020 (as determined under subsection (e)(4)). “(C) The average per capita medical assistance expenditures for the State for fiscal year 2020 equal to— “(i) the amount calculated under subparagraph (A); divided by “(ii) the number calculated under subparagraph (B). “(2) FISCAL YEAR 2028 AVERAGE PER CAPITA AMOUNT BASED ON INFLATING THE FISCAL YEAR 2016 AMOUNT TO FISCAL YEAR 2028 BY CPI-MEDICAL.—The Secretary shall calculate a fiscal year 2019 average per capita amount for each State equal to— “(A) the average per capita medical assistance expenditures for the State for fiscal year 2020 (calculated under paragraph (1)(C)); increased by “(B) the percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) from September, 2020 to September, 2027. “(3) AGGREGATE AND AVERAGE EXPENDITURES PER CAPITA FOR FISCAL YEAR 2019.—The Secretary shall calculate for each State the following: “(A) The amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2028. “(B) The number of 1903A enrollees for the State in fiscal year 2019 (as determined under subsection (e)(4)). “(4) PER CAPITA EXPENDITURES FOR FISCAL YEAR 2028 FOR EACH 1903A ENROLLEE CATEGORY.—The Secretary shall calculate (and provide notice to each State not later than January 1, 2028, of) the following: “(A) (i) For each 1903A enrollee category, the amount of the adjusted total medical assistance expenditures (as defined in subsection (b)(1)) for the State for fiscal year 2020 for individuals in the enrollee category, calculated by excluding from medical assistance expenditures those expenditures attributable to expenditures described in clause (iii) or non-DSH supplemental expenditures (as defined in clause (ii)). “(ii) In this paragraph, the term ‘non-DSH supplemental expenditure’ means a payment to a provider under the State plan (or under a waiver of the plan) that— “(I) is not made under section 1923; “(II) is not made with respect to a specific item or service for an individual; “(III) is in addition to any payments made to the provider under the plan (or waiver) for any such item or service; and “(IV) complies with the limits for additional payments to providers under the plan (or waiver) imposed pursuant to section 1902(a)(30)(A), including the regulations specifying upper payment limits under the State plan in part 447 of title 42, Code of Federal Regulations (or any successor regulations). “(iii) An expenditure described in this clause is an expenditure that meets the criteria specified in subclauses (I), (II), and (III) of clause (ii) and is authorized under section 1115 for the purposes of funding a delivery system reform pool, uncompensated care pool, a designated State health program, or any other similar expenditure (as defined by the Secretary). “(B) For each 1903A enrollee category, the number of 1903A enrollees for the State in fiscal year 2028 in the enrollee category (as determined under subsection (e)(4)). “(C) For fiscal year 2020, the State’s non-DSH supplemental and pool payment percentage is equal to the ratio (expressed as a percentage) of— “(i) the total amount of non-DSH supplemental expenditures (as defined in subparagraph (A)(ii)) and payments described in subparagraph (A)(iii) for the State for fiscal year 2020; to “(ii) the amount described in subsection (b)(1)(A) for the State for fiscal year 2020. “(D) For each 1903A enrollee category an average medical assistance expenditures per capita for the State for fiscal year 2019 for the enrollee category equal to— “(i) the amount calculated under subparagraph (A) for the State, increased by the non-DSH supplemental and pool payment percentage for the State (as calculated under subparagraph (C)); divided by “(ii) the number calculated under subparagraph (B) for the State for the enrollee category. “(5) PROVISIONAL FY20 PER CAPITA TARGET AMOUNT FOR EACH 1903A ENROLLEE CATEGORY.—Subject to subsection (f)(2), the Secretary shall calculate for each State a provisional FY20 per capita target amount for each 1903A enrollee category equal to the average medical assistance expenditures per capita for the State for fiscal year 2019 (as calculated under paragraph (4)(D)) for such enrollee category multiplied by the ratio of— “(A) the product of— “(i) the fiscal year 2028 average per capita amount for the State, as calculated under paragraph (2); and “(ii) the number of 1903A enrollees for the State in fiscal year 2028, as calculated under paragraph (3)(B); to “(B) the amount of the adjusted total medical assistance expenditures for the State for fiscal year 2028, as calculated under paragraph (3)(A). “(e) 1903A enrollee; 1903A enrollee category.—Subject to subsection (g), for purposes of this section, the following shall apply: “(1) 1903A ENROLLEE.—The term ‘1903A enrollee’ means, with respect to a State and a month and subject to subsection (i)(1)(B), any Medicaid enrollee (as defined in paragraph (3)) for the month, other than such an enrollee who for such month is in any of the following categories of excluded individuals: “(A) CHIP.—An individual who is provided, under this title in the manner described in section 2101(a)(2), child health assistance under title XXI. “(B) IHS.—An individual who receives any medical assistance under this title for services for which payment is made under the third sentence of section 1905(b). “(C) BREAST AND CERVICAL CANCER SERVICES ELIGIBLE INDIVIDUAL.—An individual who is entitled to medical assistance under this title only pursuant to section 1902(a)(10)(A)(ii)(XVIII). “(D) PARTIAL-BENEFIT ENROLLEES.—An individual who— “(i) is an alien who is entitled to medical assistance under this title only pursuant to section 1903(v)(2); “(ii) is entitled to medical assistance under this title only pursuant to subclause (XII) or (XXI) of section 1902(a)(10)(A)(ii) (or pursuant to a waiver that provides only comparable benefits); “(iii) is a dual eligible individual (as defined in section 1915(h)(2)(B)) and is entitled to medical assistance under this title (or under a waiver) only for some or all of Medicare cost-sharing (as defined in section 1905(p)(3)); or “(iv) is entitled to medical assistance under this title and for whom the State is providing a payment or subsidy to an employer for coverage of the individual under a group health plan pursuant to section 1906 or section 1906A (or pursuant to a waiver that provides only comparable benefits). “(2) 1903A ENROLLEE CATEGORY.—The term ‘1903A enrollee category’ means each of the following: “(A) ELDERLY.—A category of 1903A enrollees who are 65 years of age or older. “(B) BLIND AND DISABLED.—A category of 1903A enrollees (not described in the previous subparagraph) who are eligible for medical assistance under this title on the basis of being blind or disabled. “(C) CHILDREN.—A category of 1903A enrollees (not described in a previous subparagraph) who are children under 19 years of age. “(D) EXPANSION ENROLLEES.—A category of 1903A enrollees (not described in a previous subparagraph) for whom the amounts expended for medical assistance are subject to an increase or change in the Federal medical assistance percentage under subsection (y) or (z)(2), respectively, of section 1905. “(E) OTHER NONELDERLY, NONDISABLED, NON-EXPANSION ADULTS.—A category of 1903A enrollees who are not described in any previous subparagraph. “(3) MEDICAID ENROLLEE.—The term ‘Medicaid enrollee’ means, with respect to a State for a month, an individual who is eligible for medical assistance for items or services under this title and enrolled under the State plan (or a waiver of such plan) under this title for the month. “(4) DETERMINATION OF NUMBER OF 1903A ENROLLEES.—The number of 1903A enrollees for a State and fiscal year, and, if applicable, for a 1903A enrollee category, is the average monthly number of Medicaid enrollees for such State and fiscal year (and, if applicable, in such category) that are reported through the CMS–64 report under (and subject to audit under) subsection (h). “(f) Special payment rules.— “(1) APPLICATION IN CASE OF RESEARCH AND DEMONSTRATION PROJECTS AND OTHER WAIVERS.—In the case of a State with a waiver of the State plan approved under section 1115, section 1915, or another provision of this title, this section shall apply to medical assistance expenditures and medical assistance payments under the waiver, in the same manner as if such expenditures and payments had been made under a State plan under this title and the limitations on expenditures under this section shall supersede any other payment limitations or provisions (including limitations based on a per capita limitation) otherwise applicable under such a waiver. “(2) TREATMENT OF STATES EXPANDING COVERAGE AFTER FISCAL YEAR 2028.—In the case of a State that did not provide for medical assistance for the 1903A enrollee category described in subsection (e)(2)(D) during fiscal year 2016 but which provides for such assistance for such category in a subsequent year, the provisional FY19 per capita target amount for such enrollee category under subsection (d)(5) shall be equal to the provisional FY19 per capita target amount for the 1903A enrollee category described in subsection (e)(2)(E). “(3) IN CASE OF STATE FAILURE TO REPORT NECESSARY DATA.—If a State for any quarter in a fiscal year (beginning with fiscal year 2019) fails to satisfactorily submit data on expenditures and enrollees in accordance with subsection (h)(1), for such fiscal year and any succeeding fiscal year for which such data are not satisfactorily submitted— “(A) the Secretary shall calculate and apply subsections (a) through (e) with respect to the State as if all 1903A enrollee categories for which such expenditure and enrollee data were not satisfactorily submitted were a single 1903A enrollee category; and “(B) the growth factor otherwise applied under subsection (c)(2)(B) shall be decreased by 1 percentage point. “(g) Recalculation of certain amounts for data errors.—The amounts and percentage calculated under paragraphs (1) and (4)(C) of subsection (d) for a State for fiscal year 2020, and the amounts of the adjusted total medical assistance expenditures calculated under subsection (b) and the number of Medicaid enrollees and 1903A enrollees determined under subsection (e)(4) for a State for fiscal year 2020, fiscal year 2028, and any subsequent fiscal year, may be adjusted by the Secretary based upon an appeal (filed by the State in such a form, manner, and time, and containing such information relating to data errors that support such appeal, as the Secretary specifies) that the Secretary determines to be valid, except that any adjustment by the Secretary under this subsection for a State may not result in an increase of the target total medical assistance expenditures exceeding 2 percent. “(h) Required reporting and auditing of CMS–64 data; transitional increase in Federal matching percentage for certain administrative expenses.— “(1) REPORTING.—In addition to the data required on form Group VIII on the CMS–64 report form as of January 1, 2027, in each CMS-64 report required to be submitted (for each quarter beginning on or after October 1, 2018), the State shall include data on medical assistance expenditures within such categories of services and categories of enrollees (including each 1903A enrollee category and each category of excluded individuals under subsection (e)(1)) and the numbers of enrollees within each of such enrollee categories, as the Secretary determines are necessary (including timely guidance published as soon as possible after the date of the enactment of this section) in order to implement this section and to enable States to comply with the requirement of this paragraph on a timely basis. “(2) AUDITING.—The Secretary shall conduct for each State an audit of the number of individuals and expenditures reported through the CMS–64 report for fiscal year 2020, fiscal year 2028, and each subsequent fiscal year, which audit may be conducted on a representative sample (as determined by the Secretary). “(3) TEMPORARY INCREASE IN FEDERAL MATCHING PERCENTAGE TO SUPPORT IMPROVED DATA REPORTING SYSTEMS FOR FISCAL YEARS 2028 AND 2029.—For amounts expended during calendar quarters beginning on or after October 1, 2028, and before October 1, 2029— “(A) the Federal matching percentage applied under section 1903(a)(3)(A)(i) shall be increased by 10 percentage points to 100 percent; “(B) the Federal matching percentage applied under section 1903(a)(3)(B) shall be increased by 25 percentage points to 100 percent; and “(C) the Federal matching percentage applied under section 1903(a)(7) shall be increased by 10 percentage points to 60 percent but only with respect to amounts expended that are attributable to a State’s additional administrative expenditures to implement the data requirements of paragraph (1). “(i) Flexible block grant option for States.— “(1) IN GENERAL.—In the case of a State that elects the option of applying this subsection for a 10-fiscal-year period (beginning no earlier than fiscal year 2028 and, at the State option, for any succeeding 10-fiscal-year period) and that has a plan approved by the Secretary under paragraph (2) to carry out the option for such period— “(A) the State shall receive, instead of amounts otherwise payable to the State under this title for medical assistance for block grant individuals within the applicable block grant category (as defined in paragraph (6)) for the State during the period in which the election is in effect, the amount specified in paragraph (4); “(B) the previous provisions of this section shall be applied as if— “(i) block grant individuals within the applicable block grant category for the State and period were not section 1903A enrollees for each 10-fiscal year period for which the State elects to apply this subsection; and “(ii) if such option is not extended at the end of a 10-fiscal-year-period, the per capita limitations under such previous provisions shall again apply after such period and such limitations shall be applied as if the election under this subsection had never taken place; “(C) the payment under this subsection may only be used consistent with the State plan under paragraph (2) for block grant health care assistance (as defined in paragraph (7)); and “(D) with respect to block grant individuals within the applicable block grant category for the State for which block grant health care assistance is made available under this subsection, such assistance shall be instead of medical assistance otherwise provided to the individual under this title. “(2) STATE PLAN FOR ADMINISTERING BLOCK GRANT OPTION.— “(A) IN GENERAL.—No payment shall be made under this subsection to a State pursuant to an election for a 10-fiscal-year period under paragraph (1) unless the State has a plan, approved under subparagraph (B), for such period that specifies— “(i) the applicable block grant category with respect to which the State will apply the option under this subsection for such period; “(ii) the conditions for eligibility of block grant individuals within such applicable block grant category for block grant health care assistance under the option, which shall be instead of other conditions for eligibility under this title, except that in the case of a State that has elected the applicable block grant category described in— “(I) subparagraph (A) of paragraph (6), the plan must provide for eligibility for pregnant women and children required to be provided medical assistance under subsections (a)(10)(A)(i) and (e)(4) of section 1902; or “(II) subparagraph (B) of paragraph (6), the plan must provide for eligibility for pregnant women required to be provided medical assistance under subsection (a)(10)(A)(i); and “(iii) the types of items and services, the amount, duration, and scope of such services, the cost-sharing with respect to such services, and the method for delivery of block grant health care assistance under this subsection, which shall be instead of the such types, amount, duration, and scope, cost-sharing, and methods of delivery for medical assistance otherwise required under this title, except that the plan must provide for assistance for— “(I) hospital care; “(II) surgical care and treatment; “(III) medical care and treatment; “(IV) obstetrical and prenatal care and treatment; “(V) prescribed drugs, medicines, and prosthetic devices; “(VI) other medical supplies and services; and “(VII) health care for children under 18 years of age. “(B) REVIEW AND APPROVAL.—A plan described in subparagraph (A) shall be deemed approved by the Secretary unless the Secretary determines, within 30 days after the date of the Secretary’s receipt of the plan, that the plan is incomplete or actuarially unsound and, with respect to such plan and its implementation under this subsection, the requirements of paragraphs (1), (10)(B), (17), and (23) of section 1902(a) shall not apply. “(3) AMOUNT OF BLOCK GRANT FUNDS.— “(A) FOR INITIAL FISCAL YEAR.—The block grant amount under this paragraph for a State for the initial fiscal year in the first 10-fiscal-year period is equal to the sum of the products (for each applicable block grant category for such State and period) of— “(i) the target per capita medical assistance expenditures for such State for such fiscal year (under subsection (c)(2)); “(ii) the number of 1903A enrollees for such category and State for fiscal year 2019, as determined under subsection (e)(4); and “(iii) the Federal average medical assistance matching percentage (as defined in subsection (a)(4)) for the State for fiscal year 2019. “(B) FOR ANY SUBSEQUENT FISCAL YEAR.—The block grant amount under this paragraph for a State for each succeeding fiscal year (in any 10-fiscal-year period) is equal to the block grant amount under subparagraph (A) (or this subparagraph) for the State for the previous fiscal year increased by the annual increase in the consumer price index for all urban consumers (all items; U.S. city average) for the fiscal year involved. “(C) AVAILABILITY OF ROLLOVER FUNDS.—The block grant amount under this paragraph for a State for a fiscal year shall remain available to the State for expenditures under this subsection for the succeeding fiscal year but only if an election is in effect under this subsection for the State in such succeeding fiscal year. “(4) FEDERAL PAYMENT AND STATE RESPONSIBILITY.—The Secretary shall pay to each State with an election in effect under this subsection for a fiscal year, from its block grant amount under paragraph (3) available for such fiscal year, an amount for each quarter of such fiscal year equal to the enhanced FMAP described in the first sentence of section 2105(b) of the total amount expended under the State plan under this subsection during such quarter, and the State is responsible for the balance of funds to carry out such plan. “(5) BLOCK GRANT INDIVIDUAL DEFINED.—In this subsection, the term ‘block grant individual’ means, with respect to a State for a 10-fiscal-year period, an individual who is not disabled (as defined for purposes of the State plan) and who is within an applicable block grant category for the State and such period. “(6) APPLICABLE BLOCK GRANT CATEGORY DEFINED.—In this subsection, the term ‘applicable block grant category’ means with respect to a State for a 10-fiscal-year period, either of the following as specified by the State for such period in its plan under paragraph (2)(A)(i): “(A) 2 ENROLLEE CATEGORIES.—Both of the following 1903A enrollee categories: “(i) CHILDREN.—The 1903A enrollee category specified in subparagraph (C) of subsection (e)(2). “(ii) OTHER NONELDERLY, NONDISABLED, NON-EXPANSION ADULTS.—The 1903A enrollee category specified in subparagraph (E) of such subsection. “(B) OTHER NONELDERLY, NONDISABLED, NON-EXPANSION ADULTS.—Only the 1903A enrollee category specified in subparagraph (E) of subsection (e)(2). “(7) BLOCK GRANT HEALTH CARE ASSISTANCE.—In this subsection, the term ‘block grant health care assistance’ means assistance for health-care-related items and medical services for block grant individuals within the applicable block grant category for the State and 10-fiscal-year period involved who are low-income individuals (as defined by the State). “(8) AUDITING.—As a condition of receiving funds under this subsection, a State shall contract with an independent entity to conduct audits of its expenditures made with respect to activities funded under this subsection for each fiscal year for which the State elects to apply this subsection to ensure that such funds are used consistent with this subsection and shall make such audits available to the Secretary upon the request of the Secretary. “(9) FIRST PERIOD.—The first period beginning no earlier than FY2028 as defined by paragraph (1) shall end no later than fiscal year 2034, and shall not be a ten-year period. “(i) DEDUCTION FOR FAILURE TO ADEQUATELY REPORT DEATH.—Any State which does not meet reporting standards for certificates of death which may be established by the Department of Health and Human Services, the Department of the Treasury, and the Social Security Administration shall automatically lose ten percent of any funds to which it would otherwise be entitled under this Act.”. Sec. 122. Revival of Pregnancy Assistance Fund. (a) Section 10214 of the Patient Protection and Affordable Care Act is amended by striking “$25,000,000 for each of fiscal years 2010 through 2019, to carry out this chapter.” and inserting “$2,500,000,000 for each of fiscal years 2026 through 2035, to carry out this chapter.” (b) Section 10213 of the Patient Protection and Affordable Care Act is amended— (1) by inserting “(C) comprehensive assistance and incentives (as well as information about available assistance and incentives) to help women to become mothers.” at the end of subsection (d), (2) by inserting “Territorial and Tribal governments may, at the discretion of the Secretary, be treated as States for the purposes of this chapter.” at the ending of subsection (e), (3) by inserting “(and if appropriate, cash benefits for mothers who attend counseling prior to referral)” after “provide referrals” in subsection (b)(4)(E), (4) by adding at the end of the section a new subsection (f) as follows— “(f) Monitoring.—States receiving grants from the Pregnancy Assistance Fund must submit annual reports to the Secretary for Health and Human Services detailing: “(1) Birth rate outcomes: “(A) The number of births to women receiving any form of benefit under the program. “(B) The state’s Total Fertility Rate (TFR), with particular attention to increases in birth rates among young women (e.g., women under 25) and vulnerable populations. “(C) The teen pregnancy rate and the percentage of out-of-wedlock births, with efforts to reduce out-of-wedlock pregnancies through family formation programs and marriage incentives. “(2) Program utilization rates: “(A) The number of participants accessing prenatal care, postnatal recovery, adoption services, and family counseling. “(B) The participation rates in programs promoting family stability, including marriage counseling and family support services, as well as the percentage of program participants who enter marriage or adopt children. “(C) The number of participants in postpartum recovery services, including those accessing preventative aesthetic treatments for physical recovery and mental health support. “(3) Financial reporting: “(A) States must provide an itemized breakdown of how Federal and State funds are used to support maternal health programs, specifying funding allocations for: “(i) Prenatal/postnatal care (minimum 40% of total funds). “(ii) Adoption incentives and family counseling (up to 20% of total funds). “(iii) Childcare and early education (minimum 10% of total funds). “(iv) Administrative costs, which must not exceed 10% of the total budget. “(v) Outcome-based accountability: States that demonstrate significant increases in birth rates, reductions in abortion rates, and improvements in maternal health outcomes may receive bonus funding. “(4) Impact on abortion rates: “(A) States must track and report the impact of the program on abortion rates, including: “(i) The number of adoption referrals and completed adoptions as a result of the program. “(ii) The number of abortions avoided due to participation in pregnancy support programs, family counseling, or adoption services. “(B) States which prohibit or restrict abortion shall be exempted from this requirement in respect to abortions which are prohibited in such States. “(5) Long-term outcomes for participants and society: “(A) States must report on the long-term success of participants, including: “(i) The percentage of mothers who complete education or transition to employment after receiving assistance. “(ii) Maternal and child health outcomes tracked for a minimum of two years after birth, focusing on both physical and mental health. “(iii) Family stability outcomes, including the percentage of participants who remain in stable relationships or marriages. “(B) Long-term Demographic Tracking: States must submit data on long-term demographic trends, including the impact of the program on: “(i) Overall birth rates in the state, including race, ethnicity, and income-level breakdowns. “(ii) The percentage of children born to married parents and the out-of-wedlock birth rate. “(iii) The impact on college-educated women, specifically tracking how the program influences birth rates among women pursuing higher education.” “(6) Penalties and performance incentives: “(A) The Secretary shall have the authority to set goals for the Pregnancy Assistance Fund. “(B) The Secretary shall have the authority to penalize States which fail to meet goals set for the Pregnancy Assistance Fund by reducing such States' funding via the Pregnancy Assistance Fund. “(C) The Secretary shall have the authority to establish rewards, which shall come from the funds of the Pregnancy Assistance Fund, for States which exceed the goals of the Pregnancy Assistance Fund and to define goal tiers for the purposes of administering such rewards.” Subtitle D—Patient Relief and Health Insurance Market Stability Sec. 131. Repeal of cost-sharing subsidy. (a) In general.—Section 1402 of the Patient Protection and Affordable Care Act is repealed. (b) Effective date.—The repeal made by subsection (a) shall apply to cost-sharing reductions (and payments to issuers for such reductions) for plan years beginning after December 31, 2027. Sec. 132. Patient and State Stability Fund. The Social Security Act (42 U.S.C. 301 et seq.) is amended by adding at the end the following new title: “TITLE XXII—Patient and State Stability Fund “Sec. 2201. Establishment of program. “There is hereby established the ‘Patient and State Stability Fund’ to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the ‘Administrator’), to provide funding, in accordance with this title, to the 50 States during the period, subject to section 2204(c), beginning on January 1, 2028, and ending on December 31, 2035, for the purposes described in section 2202. “Sec. 2202. Use of funds. “(a) In General.—Subject to subsections (b) and (c), a State may use the funds allocated to the State under this title for any of the following purposes: “(1) Helping, through the provision of financial assistance, high-risk individuals who do not have access to health insurance coverage offered through an employer enroll in health insurance coverage in the individual market in the State, as such market is defined by the State (whether through the establishment of a new mechanism or maintenance of an existing mechanism for such purpose). “(2) Providing incentives to appropriate entities to enter into arrangements with the State to help stabilize premiums for health insurance coverage in the individual market, as such markets are defined by the State. “(3) Reducing the cost for providing health insurance coverage in the individual market and small group market, as such markets are defined by the State, to individuals who have, or are projected to have, a high rate of utilization of health services (as measured by cost) and to individuals who have high costs of health insurance coverage due to the low density population of the State in which they reside. “(4) Promoting participation in the individual market and small group market in the State and increasing health insurance options available through such market. “(5) Promoting access to preventive services; dental care services (whether preventive or medically necessary); vision care services (whether preventive or medically necessary); or any combination of such services. “(6) Maternity coverage and newborn care. “(7) Prevention, treatment, or recovery support services for individuals with mental or substance use disorders, focused on either or both of the following: “(A) Direct inpatient or outpatient clinical care for treatment of addiction and mental illness. “(B) Early identification and intervention for children and young adults with serious mental illness. “(8) Providing payments, directly or indirectly, to health care providers for the provision of such health care services as are specified by the Administrator. “(9) Providing assistance to reduce out-of-pocket costs, such as copayments, coinsurance, premiums, and deductibles, of individuals enrolled in health insurance coverage in the State. “(b) Required use of increase in allotment.—A State shall use the additional allocation provided to the State from the funds appropriated under the second sentence of section 2204(a) for each year only for the purposes described in paragraphs (6) and (7) of subsection (a). “(c) Required use of additional increase to certain waiver States to provide financial hardship assistance.—A State shall use the additional allocation provided to the State from the funds appropriated under the last sentence of section 2204(a) only in accordance with such last sentence. “Sec. 2203. State eligibility and approval; Default safeguard. “(a) Encouraging State options for allocations.— “(1) IN GENERAL.—To be eligible for an allocation of funds under this title for a year during the period described in section 2201 for use for one or more purposes described in section 2202, a State shall submit to the Administrator an application not later than six months prior to the beginning of the prior year and in such form and manner as specified by the Administrator and containing— “(A) a description of how the funds will be used for such purposes; “(B) a certification that the State will make, from non-Federal funds, expenditures for such purposes in an amount that is not less than the State percentage required for the year under section 2204(e)(1); and “(C) such other information as the Administrator may require. “(2) AUTOMATIC APPROVAL.—An application so submitted is approved unless the Administrator notifies the State submitting the application, not later than 60 days after the date of the submission of such application, that the application has been denied for not being in compliance with any requirement of this title and of the reason for such denial. “(3) ONE-TIME APPLICATION.—If an application of a State is approved for a year, with respect to a purpose described in section 2202, such application shall be treated as approved, with respect to such purpose, for each subsequent year through 2032. “(4) TREATMENT AS A STATE HEALTH CARE PROGRAM.—Any program receiving funds from an allocation for a State under this title, including pursuant to subsection (b), shall be considered to be a ‘State health care program’ for purposes of sections 1128, 1128A, and 1128B. “(b) Default Federal safeguard.— “(1) IN GENERAL.— “(A) 2028.—For allocations made under this title for 2018, in the case of a State that does not submit an application under subsection (a) by the 45-day submission date applicable to such year under subsection (a)(1) and in the case of a State that does submit such an application by such date that is not approved, subject to section 2204(e), the Administrator, in consultation with the State insurance commissioner, shall use the allocation that would otherwise be provided to the State under this title for such year, in accordance with paragraph (2), for such State. “(B) 2029 THROUGH 2034.—In the case of a State that does not have in effect an approved application under this section for 2019 or a subsequent year beginning during the period described in section 2201, subject to section 2204(e), the Administrator, in consultation with the State insurance commissioner, shall use the allocation that would otherwise be provided to the State under this title for such year, in accordance with paragraph (2), for such State. “(2) REQUIRED USE FOR MARKET STABILIZATION PAYMENTS TO ISSUERS.—Subject to section 2204(a), an allocation for a State made pursuant to paragraph (1) for a year shall be used to carry out the purpose described in section 2202(2) in such State by providing payments to appropriate entities described in such section with respect to claims that exceed $50,000 (or, with respect to allocations made under this title for 2020 or a subsequent year during the period specified in section 2201, such dollar amount specified by the Administrator), but do not exceed $350,000 (or, with respect to allocations made under this title for 2020 or a subsequent year during such period, such dollar amount specified by the Administrator), in an amount equal to 75 percent (or, with respect to allocations made under this title for 2020 or a subsequent year during such period, such percentage specified by the Administrator) of the amount of such claims. “Sec. 2204. Allocations. “(a) Appropriation.—For the purpose of providing allocations for States (including pursuant to section 2203(b)) under this title there is appropriated, out of any money in the Treasury not otherwise appropriated $15,000,000,000 for each year starting FY2026 and ending FY2034. The amount otherwise appropriated under the previous sentence for 2028 shall be increased by $22,000,000,000, to be used and available under subsection (d) only for the purposes described in paragraphs (6) and (7) of section 2202(a). The amount otherwise appropriated under this subsection shall be increased by $10,000,000,000 for the period beginning with 2028 and ending with 2030, to be allocated to non-expansion States. “(b) Allocations.— “(1) PAYMENT.— “(A) IN GENERAL.—From amounts appropriated under subsection (a) for a year, the Administrator shall, with respect to a State and not later than the date specified under subparagraph (B) for such year, allocate, subject to subsection (e), for such State (including pursuant to section 2203(b)) the amount determined for such State and year under paragraph (2). “(B) SPECIFIED DATE.—For purposes of subparagraph (A), the date specified in this subparagraph is— “(i) for 2028, the date that is 45 days after the date of the enactment of this title; and “(ii) for 2029 and subsequent years, January 1 of the respective year. “(2) ALLOCATION AMOUNT DETERMINATIONS.— “(A) FOR 2028 AND 2029.— “(i) IN GENERAL.—For purposes of paragraph (1), the amount determined under this paragraph for 2028 and 2029 for a State is an amount equal to the sum of— “(I) the relative incurred claims amount described in clause (ii) for such State and year; and “(II) the relative uninsured and issuer participation amount described in clause (iv) for such State and year. “(ii) RELATIVE INCURRED CLAIMS AMOUNT.—For purposes of clause (i), the relative incurred claims amount described in this clause for a State for 2018 and 2019 is the product of— “(I) 85 percent of the amount appropriated under subsection (a) for the year; and “(II) the relative State incurred claims proportion described in clause (iii) for such State and year. “(iii) RELATIVE STATE INCURRED CLAIMS PROPORTION.—The relative State incurred claims proportion described in this clause for a State and year is the amount equal to the ratio of— “(I) the adjusted incurred claims by the State, as reported to the Secretary of Health and Human Services based on a process which shall be established by such Secretary; to “(II) the sum of such adjusted incurred claims for all States, as so reported, for such third previous year. “(iv) RELATIVE UNINSURED AND ISSUER PARTICIPATION AMOUNT.—For purposes of clause (i), the relative uninsured and issuer participation amount described in this clause for a State for 2018 and 2019 is the product of— “(I) 15 percent of the amount appropriated under subsection (a) for the year; and “(II) the relative State uninsured and issuer participation proportion described in clause (v) for such State and year. “(v) RELATIVE STATE UNINSURED AND ISSUER PARTICIPATION PROPORTION.—The relative State uninsured and issuer participation proportion described in this clause for a State and year is— “(I) in the case of a State not described in clause (vi) for such year, 0; and “(II) in the case of a State described in clause (vi) for such year, the amount equal to the ratio of— “(aa) the number of individuals residing in such State who for the third preceding year were not enrolled in a health plan or otherwise did not have health insurance coverage (including through a Federal or State health program) and whose income is below 100 percent of the poverty line applicable to a family of the size involved; to “(bb) the sum of the number of such individuals for all States described in clause (vi) for the third preceding year. “(vi) STATES DESCRIBED.—For purposes of clause (v), a State is described in this clause, with respect to 2027 and 2028, if the State satisfies either of the following criterion: “(I) The ratio described in subclause (II) of clause (v) that would be determined for such State by substituting ‘2020’ for each reference in such subclause to ‘the third preceding year’ and by substituting ‘all such States’ for the reference in item (bb) of such subclause to ‘all States described in clause (vi)’ is greater than the ratio described in such subclause that would be determined for such State by substituting ‘2013’ for each reference in such subclause to ‘the third preceding year’ and by substituting ‘all such States’ for the reference in item (bb) of such subclause to ‘all States described in clause (vi)’. “(II) The State has fewer than three health insurance issuers offering qualified health plans through the Exchange for 2027. “(B) FOR 2028 THROUGH 2034.—For purposes of paragraph (1), the amount determined under this paragraph for a year (beginning with 2020) during the period described in section 2201 for a State is an amount determined in accordance with an allocation methodology specified by the Administrator which— “(i) takes into consideration the adjusted incurred claims of such State, the number of residents of such State who for the previous year were not enrolled in a health plan or otherwise did not have health insurance coverage (including through a Federal or State health program) and whose income is below 100 percent of the poverty line applicable to a family of the size involved, and the number of health insurance issuers participating in the insurance market in such State for such year; “(ii) is established after consultation with health care consumers, health insurance issuers, State insurance commissioners, and other stakeholders and after taking into consideration additional cost and risk factors that may inhibit health care consumer and health insurance issuer participation; and “(iii) reflects the goals of improving the health insurance risk pool, promoting a more competitive health insurance market, and increasing choice for health care consumers. “(c) Annual distribution of previous year’s remaining funds.—In carrying out subsection (b), the Administrator shall, with respect to a year (beginning with 2028 and ending with 2034), not later than March 31 of such year— “(1) determine the amount of funds, if any, from the amounts appropriated under subsection (a) for the previous year but not allocated for such previous year; and “(2) if the Administrator determines that any funds were not so allocated for such previous year, allocate such remaining funds, in accordance with the allocation methodology specified pursuant to subsection (b)(2)(B)— “(A) to States that have submitted an application approved under section 2203(a) for such previous year for any purpose for which such an application was approved; and “(B) for States for which allocations were made pursuant to section 2203(b) for such previous year, to be used by the Administrator for such States, to carry out the Federal Invisible Risk Sharing Program in such States under section 2205; with, respect to a year before 2034, any remaining funds being made available for allocations to States for the subsequent year. “(d) Availability.—Amounts appropriated under subsection (a) for a year and allocated to States in accordance with this section shall remain available for expenditure through December 31, 2034. “(e) Conditions for and limitations on receipt of funds.—The Secretary may not make an allocation under this title for a State, with respect to a purpose described in section 2202— “(1) in the case of an allocation that would be made to a State pursuant to section 2203(a), if the State does not agree that the State will make available non-Federal contributions towards such purpose in an amount equal to— “(A) for 2028, 7 percent of the amount allocated under this subsection to such State for such year and purpose; “(B) for 2029, 14 percent of the amount allocated under this subsection to such State for such year and purpose; “(C) for 2030, 21 percent of the amount allocated under this subsection to such State for such year and purpose; “(D) for 2031, 28 percent of the amount allocated under this subsection to such State for such year and purpose; “(E) for 2032, 35 percent of the amount allocated under this subsection to such State for such year and purpose; “(F) for 2033, 42 percent of the amount allocated under this subsection to such State for such year and purpose; and “(G) for 2034, 50 percent of the amount allocated under this subsection to such State for such year and purpose; “(2) in the case of an allocation that would be made for a State pursuant to section 2203(b), if the State does not agree that the State will make available non-Federal contributions towards such purpose in an amount equal to— “(A) for 2028, 10 percent of the amount allocated under this subsection to such State for such year and purpose; “(B) for 2029, 20 percent of the amount allocated under this subsection to such State for such year and purpose; and “(C) for 2030, 30 percent of the amount allocated under this subsection to such State for such year and purpose; “(D) for 2031, 40 percent of the amount allocated under this subsection to such State for such year and purpose; “(E) for 2032, 50 percent of the amount allocated under this subsection to such State for such year and purpose; “(F) for 2033, 50 percent of the amount allocated under this subsection to such State for such year and purpose; and “(G) for 2034, 50 percent of the amount allocated under this subsection to such State for such year and purpose; or “(3) if such an allocation for such purpose would not be permitted under subsection (c)(7) of section 2105 if such allocation were payment made under such section. “Sec. 2205. Federal Invisible Risk Sharing Program. “(a) In general.—There is established within the Patient and State Stability Fund a Federal Invisible Risk Sharing Program (in this section referred to as the ‘Program’), to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the ‘Administrator’), to provide payments to health insurance issuers with respect to claims for eligible individuals for the purpose of lowering premiums for health insurance coverage offered in the individual market. “(b) Funding.— “(1) APPROPRIATION.—For the purpose of providing funding for the Program there is appropriated, out of any money in the Treasury not otherwise appropriated, $15,000,000,000 for the period beginning on January 1, 2028, and ending on December 31, 2034. “(2) USE OF UNALLOCATED FUNDS.—Funds provided under section 2204(c)(2)(B) to carry out this section are in addition to the amount appropriated under paragraph (1). “(c) Operation of program.— “(1) IN GENERAL.—The Administrator shall establish, after consultation with health care consumers, health insurance issuers, State insurance commissioners, and other stakeholders and after taking into consideration high cost health conditions and other health trends that generate high cost, parameters for the operation of the Program consistent with this section and consistent with the same limitation on payment with respect to health insurance coverage that applies to payment with respect health benefits coverage under section 2105(c)(7). “(2) DEADLINE FOR INITIAL OPERATION.—Not later than 60 days after the date of the enactment of this title, the Administrator shall establish sufficient parameters to specify how the Program will operate for plan year 2028. “(3) STATE OPERATION OF PROGRAM.—The Administrator shall establish a process for a State to operate the Program in such State beginning with plan year 2028. “(d) Details of program.—The parameters for the Program shall include the following: “(1) ELIGIBLE INDIVIDUALS.—A definition for eligible individuals. “(2) HEALTH STATUS STATEMENTS.—The development and use of health status statements with respect to such individuals. “(3) STANDARDS FOR QUALIFICATION.— “(A) AUTOMATIC QUALIFICATION.—The identification of health conditions that automatically qualify individuals as eligible individuals at the time of application for health insurance coverage. “(B) VOLUNTARY QUALIFICATION.—A process under which health insurance issuers may voluntarily qualify individuals, who do not automatically qualify under subparagraph (A), as eligible individuals at the time of application for such coverage. “(4) PERCENTAGE OF INSURANCE PREMIUMS TO BE APPLIED.—The percentage of the premiums paid, to health insurance issuers for health insurance coverage by eligible individuals, that shall be collected and deposited to the credit (and available for the use) of the Program. “(5) ATTACHMENT DOLLAR AMOUNT AND PAYMENT PROPORTION.—The dollar amount of claims for eligible individuals after which the Program will provide payments to health insurance issuers and the proportion of such claims above such dollar amount that the Program will pay. “Sec. 2206. Territorial Risk Fund. “(a) There is hereby established the ‘Territorial Risk Fund’ to be administered by the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the ‘Administrator’), to provide funding, in accordance with this title, to the territories named in subsection (b) during the period, subject to section 2204(c), beginning on January 1, 2028, and ending on December 31, 2035, for the purposes described in sections 2202 and 2205. “(b) The Territories funded by this Fund shall include— “(1) the District of Columbia, “(2) Puerto Rico, “(3) American Samoa, “(4) the United States Virgin Islands, “(5) Guam, and “(6) the Northern Mariana Islands. “(c) For the purpose of providing funding for the Fund there is appropriated, out of any money in the Treasury not otherwise appropriated, $500,000,000 for the period beginning January 1, 2028 and ending December 31, 2034. “Sec. 2207. Transitional High-Risk Patient Program. “(a) For the purposes of providing the services which will eventually be provided under sections 2202 and 2205, the Secretary of Health and Human Services (acting through the Administrator of the Centers for Medicare & Medicaid Services, in this section referred to as the ‘Administrator’) shall provide funding, in accordance with this title, to any person to whom necessary funds should be paid for the fulfillment of such purposes in the short term. “(b) For the purpose of providing funding to the Transitional High-Risk Patient Program there is appropriated, out of any money in the Treasury not otherwise appropriated, $500,000,000 to be expended during fiscal years 2027 and 2028. “(c) Nothing in this section shall be interpreted as requiring implementation of other sections in a similar manner as this section shall be implemented by the Secretary.”. Subtitle E—Implementation Funding Sec. 141. American Health Care Implementation Fund. (a) In general.—There is hereby established an American Health Care Implementation Fund (referred to in this section as the “Fund”) within the Department of Health and Human Services to carry out this Act. (b) Funding.—There is appropriated to the Fund, out of any funds in the Treasury not otherwise appropriated, $10,500,000,000 for Federal administrative expenses to carry out the sections described in subsection (a) (including the amendments made by such sections). (c) Transitional use.—The Secretary may use the Fund to provide for transitional use of monies to prevent increases in healthcare costs caused by changes to the healthcare system. (d) Reallocation.—The President shall, in order to supplement funds appropriated under subsection (a), reallocate any funds provided by an Act other than the Social Security Act or Internal Revenue Code: Provided, that such funds shall only be reallocated by an executive order published in the Federal Register by January 20, 2031. Furthermore, the President may reallocate any monies in the American Health Care Implementation Fund to any other Fund or Program established by this Act: Provided, that no such reallocations from the American Health Care Implementation Fund shall occur prior to the beginning of fiscal year 2028. Sec. 142. Repeal of Patient Identification Program. 42 U.S.C. 1320d–2(b) (Section 1173(b) of the Social Security Act) is repealed. Sec. 143. Parental Rights in Mental Health. (a) Universal Or Mandatory Mental Health Screening Program.—No Federal funds may be used to establish or implement any universal or mandatory mental health, psychiatric, or socioemotional screening program. (b) Refusal To Consent As Basis Of A Charge Of Child Abuse Or Education Neglect.—No Federal education funds may be paid to any local educational agency or other instrument of government that uses the refusal of a parent or legal guardian to provide express, written, voluntary, informed consent to mental health screening for his or her child as the basis of a charge of child abuse, child neglect, medical neglect, or education neglect until the agency or instrument demonstrates that it is no longer using such refusal as a basis of such a charge. (c) Definition.—For purposes of this Act, the term “universal or mandatory mental health, psychiatric, or socioemotional screening program”— (1) means any mental health screening program in which a set of individuals (other than members of the Armed Forces or individuals serving a sentence resulting from conviction for a criminal offense) is automatically screened without regard to whether there was a prior indication of a need for mental health treatment; and (2) includes— (A) any program of State incentive grants for transformation to implement recommendations in the July 2003 report of the New Freedom Commission on Mental Health, the State Early Childhood Comprehensive System, grants for TeenScreen, and the Foundations for Learning Grants; and (B) any student mental health screening program that allows mental health screening of individuals under 18 years of age without the express, written, voluntary, informed consent of the parent or legal guardian of the individual involved. Sec. 144. Quotas in Federal Policing. (a) Quotas suspended.—Requirements for the Department of Justice to meet quotas, including by means of enticing persons to commit crimes, are indefinitely suspended. (b) Activity prohibited.—The Department of Justice shall not be permitted to make any expenditure on the establishment or meeting of any quota for law enforcement, except to such an extent that such quotas may be established by the Attorney General for raising Federal revenue to fund the Department. The Department of Justice shall not be permitted to entice persons to commit crimes or otherwise fabricate crimes or falsify crimes. (c) Publishing mandated.—The Department of Justice shall make and publish detailed statistics regarding acts of enticements and fabrications of crimes. Failure to admit to the Department's use of such tactics shall be regarded as grounds for immediate rescission of all Department funding, and notwithstanding any other Act neither the Department nor any of its agencies shall receive any funding in any fiscal year after the fiscal year of the enactment of this Act where statistics have not been made available. The Attorney-General would also be ineligible for any Federal salary for the remainder of such term where no publication of statistics admitting to Department enticement and fabrication activities has occurred and would be obligated to repay the taxpayers for any and all prior wages and benefits. Sec. 145. Defunding sexually suggestive education. (a) Federal Funds Limitation.—No Federal funds may be made available to develop, implement, facilitate, or fund any sexually oriented program, event, or literature for children under the age of 10, including hosting or promoting any program, event, or literature involving sexually oriented material, or any program, event, or literature that exposes children under the age of 10 to nude adults, individuals who are stripping, or lewd or lascivious dancing. (b) Prohibition At Federal Facilities.—A federally owned facility or property may not be used to host or promote any sexually oriented program, event, or literature for children under the age of 10, including any program, event, or literature listed in subsection (a). (c) Civil Action.— (1) PRIVATE RIGHT OF ACTION.—A parent or legal guardian of a child may bring a civil action for injunctive relief in any Federal district court of appropriate jurisdiction against a government official, government agency, or private entity for a violation of subsection (a) or subsection (b) by such an official, agency, or entity if the child was— (A) exposed to sexually oriented material funded in part or in whole by Federal funds; and (B) under the age of 10 at the time that such exposure occurred. (2) STATUTE OF LIMITATIONS.—An action under this subsection may commence not later than 1 year after a violation occurs under subsection (a) or (b). (3) ATTORNEY’S FEES AND OTHER COSTS.—In any action brought under this subsection, the court, in its discretion, may award a prevailing plaintiff reasonable attorney’s fees, expert witness fees, and other costs of litigation. (d) Prohibition On Federal Funds.— (1) ADMINISTRATIVE ENFORCEMENT.—The head of a Federal agency may not disburse Federal funds to any Federal program, State or local government agency, or private entity for 3 fiscal years if that entity receives 2 or more injunctions for violations of subsection (a) or (b) in a 5-year period. (2) NOTIFICATION.—The appropriate head of a Federal agency shall submit to a government agency or private entity written notice of the prohibition on the disbursement of Federal funds under paragraph (1). (3) APPEAL.—Not later than 30 days after receiving a notice pursuant to paragraph (2), a government agency or private entity may appeal a prohibition on the disbursement of Federal funds under paragraph (1) in an administrative hearing of the appropriate agency. (e) Definitions.—In this section: (1) SEXUALLY ORIENTED MATERIAL.—The term “sexually oriented material” means any depiction, description, or simulation of sexual activity, any lewd or lascivious depiction or description of human genitals, or any topic involving gender identity, gender dysphoria, transgenderism, sexual orientation, or related subjects. (2) STRIPPING.—The term “stripping” means any act which involves the removal or simulated removal of clothing in a sexual manner for the entertainment of one or more individuals. Sec. 146. Ban on funding for racist programs. (a) Prohibition On Award Of Funds To Certain Elementary And Secondary Schools.—No Federal funds received by a State or local educational agency may be allocated to an elementary or secondary school that promotes the race-based theories described in subsection (c) or compels teachers or students to affirm, adhere to, adopt, or process beliefs in a manner that violates title VI of the Civil Rights Act of 1964. (b) Prohibition On Award Of Funds To Certain Institutions Of Higher Education.—No Federal funds may be awarded to an institution of higher education if such institution promotes the race-based theories described in subsection (c) or compels teachers or students to affirm, adhere to, adopt, or process beliefs in a manner that violates title VI of the Civil Rights Act of 1964. (c) Race-Based Theories Described.—The race-based theories described in this subsection are the following: (1) Any race is inherently superior or inferior to any other race, color, or national origin, or possesses another trait which may be described as "inherently superior or inferior" including "racist". (2) The United States is a fundamentally racist country. (3) The Declaration of Independence or Constitution of the United States are fundamentally racist documents. (4) An individual’s moral character or worth is determined by the individual’s race, color, or national origin. (5) An individual, by virtue of the individual’s race, is inherently racist or oppressive, whether consciously or unconsciously, including via being born as part of a "racist race" as defined by such theory and otherwise. (6) An individual, because of the individual’s race, bears responsibility for the actions committed by other members of the individual’s race, color, or national origin. (8) That individuals of a certain race, ethnicity, color, or national origin are inherently superior or inferior to individuals of a different race, ethnicity, color, or national origin. (9) That an individual should be treated adversely or advantageously based on the race, ethnicity, color, or national origin of such individual. (10) That individuals, based on race, ethnicity, color, or national origin, bear collective guilt and are inherently responsible for actions committed in the past by individuals of the same race, ethnicity, color, or national origin. (d) Protections for staff.—A covered school may not— (1) compel any employee (including any unpaid volunteer or any other person who is not a full-time employee) or student to adopt, affirm, adhere to, or profess the race-based theories described in subsection (c). (2) compel a student to observe or espouse obscene or sexual materials without the consent of a parent of such student; (3) instruct or require an employee of such school to refer to a student using a pronoun not associated with the biological sex of such student, without obtaining consent to do so from a parent of such student; (4) act as the agent of a parent of a student enrolled in such school, for purposes of— (A) providing verifiable parental consent; or (B) receiving a notice or other information required to be provided to a parent of such student; or (5) neglect to report sexual assault or sexual harassment on school property to the appropriate law enforcement authorities. (e) Rules Of Construction.— (1) PROTECTED SPEECH NOT RESTRICTED.—Nothing in this section shall be construed to restrict speech which is protected under the First Amendment to the United States Constitution or the Religious Freedom Restoration Act. (2) ACCESS TO MATERIALS FOR THE PURPOSE OF RESEARCH OR INDEPENDENT STUDY.—Nothing in this section shall be construed to prevent an individual from accessing materials that advocate theories described in subsection (c) for the purpose of research or independent study. (3) CONTEXTUAL EDUCATION.—Nothing in this section shall be construed to prevent a covered school from stating theories described in subsection (c) or assigning materials that advocate such theories for educational purposes in contexts that make it clear the school does not sponsor, approve, or endorse such theories or materials. (f) Definitions.—In this section: (1) COVERED SCHOOL.—The term “covered school” means an elementary school, a secondary school, or an institution of higher education. (2) ESEA TERMS.—The terms “elementary school”, “local educational agency”, “secondary school”, and “State” have the meanings given those terms in section 8101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801). (3) INSTITUTION OF HIGHER EDUCATION.—The term “institution of higher education” has the meaning given that term in section 102 of the Higher Education Act of 1965 (20 U.S.C. 1002). (4) PROMOTE.—The term “promote”, when used with respect to a race-based theory described in subsection (c), means— (A) to include such theories or materials that advocate such theories in curricula, reading lists, seminars, workshops, trainings, or other educational or professional settings in a manner that could reasonably give rise to the appearance of official sponsorship, approval, or endorsement; (B) to contract with, hire, or otherwise engage speakers, consultants, diversity trainers, and other persons for the purpose of advocating such theories; (C) to compel students to profess a belief in such theories; or (D) to segregate students or other individuals by race in any setting, including in educational or training sessions. (5) BIOLOGICAL MAN.—The term “biological man” means an individual who is recognized as a male on the date of the birth of such individual, based on the genetic and reproductive biological characteristics of such individual. (6) BIOLOGICAL SEX.—The term “biological sex” means the sex recognized on the date of birth of the individual based on the genetic and reproductive biological characteristics of such individual. (7) BIOLOGICAL WOMAN.—The term “biological woman” means an individual who is recognized as a female on the date of the birth of such individual, based on the genetic and reproductive biological characteristics of such individual. (8) OBSCENE MATERIAL.—The term “obscene material” means material that, considered as a whole— (A) appeals to— (i) the prurient interest; or (ii) a shameful or morbid interest in nudity, sexual conduct, sexual excitement, excretory functions or products thereof, or sadomasochistic abuse; (B) goes substantially beyond customary limits of candor in description or representation of the matters described in clause (A)(ii); and (C) does not have serious literary, artistic, political, or scientific value. (8) PARENT.—The term “parent” has the meaning given such term in section 8101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801). (g) Private right of action.—A parent or student aggrieved by a violation of this section may commence a civil action against the covered school responsible for the violation, and in any action under this subsection, the court may award appropriate relief, including— (1) temporary, preliminary, or permanent injunctive relief; (2) compensatory damages; (3) punitive or exemplary damages; and (4) reasonable fees for attorneys. (h) Attorney General.—In a case in which a parent commences a civil action under subsection (a), the Attorney General shall have the exclusive authority to oversee, as appropriate, any investigation conducted by the Federal Government in connection with such action. Sec. 147. Deregulation of school lunch. Section 9(a)(2) of the Richard B. Russell National School Lunch Act (42 U.S.C. 1758(a)(2)) is amended— (1) by amending subparagraph (A) to read as follows: “(A) IN GENERAL.—Lunches served by schools participating in the school lunch program under this Act— “(i) shall offer students a variety of fluid milk; “(ii) may offer students flavored and unflavored organic or non-organic whole, reduced-fat, low-fat and fat-free fluid milk and lactose-free fluid milk; and “(iii) shall provide a substitute for fluid milk for students whose disability restricts their diet, on receipt of a written statement from a licensed physician that identifies the disability that restricts the student’s diet and that specifies the substitute for fluid milk.”; and (2) by adding at the end the following: “(D) SATURATED FAT.—Milk fat included in any fluid milk provided under subparagraph (A) shall not be considered saturated fat for purposes of measuring compliance with the allowable average saturated fat content of a meal under section 210.10 of title 7, Code of Federal Regulations (or successor regulations). “(E) PROHIBITION ON CERTAIN PURCHASES.—The Secretary shall prohibit schools participating in the school lunch program under this Act from purchasing or offering milk produced by China state-owned enterprises or by any non-market economy. “(F) LIMITATION ON AUTHORITY.—The Secretary may not prohibit any school participating in the school lunch program under this Act from offering students the milk described in subparagraph (A)(ii).”. Subtitle F—Research Sec. 151. Restriction on research related to abortion. (a) In general.—Section 498A of the Public Health Service Act is amended as follows: “SEC. 498A. NO RESEARCH INVOLVING HUMAN FETAL CELLS OBTAINED PURSUANT TO AN INDUCED ABORTION. “The Secretary may not conduct or support any research involving human fetal cells that are obtained pursuant to an induced abortion.”. (b) Definition of human fetal tissue.—Section 498B(e)(1) of the Public Health Service Act is amended by striking “has the meaning given such term in section 289g–1(g) of this title.” and inserting “means tissue or cells obtained from a dead human embryo, zygote, or fetus after a spontaneous or induced abortion, or after a stillbirth.”. (c) Effective date.—This section shall go into effect on January 1, 2028. Sec. 152. Cosmetic surgery and treatment research. (a) In general.—Section 498C of the Public Health Service Act is amended as follows— “Cosmetic surgery and treatment research.—The Director of NIH may conduct or support research to examine the short-term and long-term health implications of cosmetic surgeries and treatments (including such surgeries and treatments when administered for reconstructive purposes), including— “(a) developing and examining techniques to measure concentrations of substances which may be implanted or injected into a patient during any cosmetic surgery or treatment in body fluids and tissues, “(b) conducting surveillance of patients and their long-term outcomes and local complications, as well as psychological and social effects of such surgeries and treatments.”. (b) Effective date.—This section shall go into effect on January 1, 2028. Sec. 153. Inclusivity in research. Section 492B of the Public Health Service Act is amended— (1) in paragraph (a)(1) by striking “ensure” and all that follows and inserting “ensure that such research shall obtain relevant information to understand biological and genetic similarities and differences between people of different ages, biological sexes, races, and ethnic groups, as well as people with medical conditions (including mental health conditions found in Diagnostic and Statistical Manual of Mental Disorders, Third Edition or Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) as the Director of the NIH may deem appropriate.”. (2) in paragraph (a)(2) by— (A) striking “and” and inserting “, the Administrator of the Centers for Medicare and Medicaid Services (in addition to any other person designated by the Secretary of Health and Human Services for representation of the elderly, disabled, or other people who the Director of NIH or Secretary of Health and Human Services may deem necessary), and”, and (B) striking “women and members of minority groups” and inserting “people based on traits described in paragraph (1)”. (3) in paragraph (a)(3)(A) by— (A) striking the second instance of the word “and” and inserting “, the Administrator of the Centers for Medicare and Medicaid Services (in addition to any other person designated by the Secretary of Health and Human Services for representation of the elderly, disabled, or other people who the Director of NIH or Secretary of Health and Human Services may deem necessary), and”, and (B) striking “women and members of minority groups” and inserting “traits described in paragraph (1)”. (4) in every subsection of section 492B other than (a) by— (A) striking the only instance of the word “and” in any instance of “Director of the Office of Research on Women's Health and the Director of the Office of Research on Minority Health” and inserting “, the Administrator of the Centers for Medicare and Medicaid Services (in addition to any other person designated by the Secretary of Health and Human Services for representation of the elderly, disabled, or other people who the Director of NIH or Secretary of Health and Human Services may deem necessary), and”, and (B) striking “women and members of minority groups” and inserting “people with traits described in paragraph (1)”. (5) in subsection (e) by— (A) inserting “through 2027” after “fiscal years” and (B) inserting a new paragraph (3) as follows: “(3) 2027 Amendment.—The amendment made to this section by the Health Care Act of 2027 shall apply for all fiscal years starting 2028, and the Director of NIH shall be required to enforce guidelines to ensure that this section is enforced with regard to all new clinical research, while ensuring that previous regulations remain constant for all preexisting studies to avoid spoilage of data. Notwithstanding the rest of this section, methodologies must remain constant to ensure the accuracy of scientific data.” Sec. 154. Stillbirth research. Title III of the Public Health Service Act is amended by inserting after section 317L–1 of such Act (42 U.S.C. 247b–13a) the following: “SEC. 317L–2. STILLBIRTH RESEARCH AND DATA COLLECTION IMPROVEMENTS. “(a) Stillbirth Surveillance And Risk Factor Studies.— “(1) IN GENERAL.—The Secretary may award grants to States for purposes of— “(A) conducting surveillance and collecting data, including from existing datasets like State or sub-State maternal mortality data and Fetal and Infant Mortality Review data, with respect to stillbirths for public health and research purposes; “(B) building State and local public health capacity to assess stillbirth data; and “(C) collecting and reporting data on stillbirth risk factors, including any quantifiable outcomes with respect to such risk factors. “(2) CONDITION.—As a condition of receipt of funds under this section, all data collected shall be in a manner that protects personal privacy and in a manner that is consistent with applicable Federal and State privacy law, at a minimum. “(3) AUTHORIZATION OF APPROPRIATIONS.—To carry out this subsection, there is authorized to be appropriated $5,000,000 for each of fiscal years 2028 through 2032. “(b) Guidelines And Educational Awareness Materials.— “(1) IN GENERAL.—The Secretary shall— “(A) issue guidelines to State departments of health and State and local vital statistics units on— “(i) collecting data on stillbirth from health care providers, and with the consent of the woman who experienced the stillbirth, including any such data with respect to the clinical history, postmortem examination, and placental pathology; and “(ii) improving processes and training related to stillbirth data collection and reporting to ensure standardization and completeness of data; and “(B) develop, and make publicly available, educational awareness materials on stillbirths. “(2) CONSULTATION.—In carrying out paragraph (1), the Secretary may consult with— “(A) national health care professional associations; “(B) national associations representing State and local public health officials; “(C) organizations that assist families with burial support and bereavement services; “(D) nurses and nurse practitioners; “(E) obstetricians and gynecologists; “(F) pediatricians; “(G) maternal-fetal medicine specialists; “(H) nurse midwives and midwives; “(I) mental health professionals; “(J) statisticians; “(K) individuals who have experienced a stillbirth; and “(L) advocacy organizations representing such individuals. “(3) AUTHORIZATION OF APPROPRIATIONS.—To carry out this subsection, there is authorized to be appropriated $1,000,000 for each of fiscal years 2028 through 2032. “(c) Vital Statistics Unit Defined.—In this section, the term ‘vital statistics unit’ means the entity that is responsible for maintaining vital records for a State, or a political subdivision of such State, including official records of live births, deaths, fetal deaths, marriages, divorces, and annulments.”. Sec. 155. Perinatal Pathology Fellowships. The Public Health Service Act is amended by inserting after section 1122 of such Act (42 U.S.C. 300c–12) the following: “SEC. 1123. IMPROVING PERINATAL PATHOLOGY. “(a) In General.—The Secretary shall incorporate into an existing training program a Perinatal Pathology Fellowship Program, a Postdoctoral Research Fellowship on Factors Associated with Stillbirth Program, or both. “(b) Activities.—Each program incorporated under subsection (a) shall— “(1) provide training in perinatal autopsy pathology; “(2) provide practice-based learning opportunities to foster exchange and connection with State efforts concerning fetal death review that are supported under title V of the Social Security Act; “(3) conduct research on, and improve data collection with respect to, stillbirths, including through fetal autopsies; and “(4) address challenges in stillbirth education, research, and data collection. “(c) Authorization Of Appropriations.—There is authorized to be appropriated to carry out this section $3,000,000 for each of fiscal years 2026 through 2032.”. Sec. 156. Ectopic Pregnancy Research. The Public Health Service Act is amended by inserting after section 1123 of such Act (as established by section 155 of this Act) the following: “SEC. 1124. Ectopic Pregnancy Research. “(a) In General.—The Secretary shall establish program intended to prevent and treat ectopic pregnancy. “(b) Activities.—The program established under subsection (a) shall— “(1) provide training and information for ectopic pregnancy mitigation; “(2) provide recommendations to the Secretary to reduce ectopic pregnancy; “(3) conduct research on, and improve data collection with respect to, ectopic pregnancies, including through investigations of remains, with the goal of ensuring that ectopic pregnancy can be treated for both mother and child safely, reducing in particular the child mortality rate of ectopic pregnancy and its treatments; and “(4) develop cures, mitigations, preventatives, and treatments for ectopic pregnancy which shall reduce child mortality and allow safe delivery of children conceived in ectopic pregnancies. “(c) Authorization Of Appropriations.—There is authorized to be appropriated to carry out this section $4,000,000 for each of fiscal years 2026 through 2032, provided that no such monies shall go to researching new means of ectopic pregnancy treatment which imperil the life of the unborn child in an ectopic pregnancy.”. Sec. 157. New generic medications research. The Public Health Service Act is amended by inserting after section 937 of such Act (as established by section 155 of this Act) the following: “SEC. 938. New generic medications research. “(a) In General.—The Secretary shall establish program intended to examine the usefulness of public domain medications which are not approved by FDA. “(b) Activities.—The program established under subsection (a) shall— “(1) investigate medications from countries which historically or presently do not export drugs to the United States; “(2) investigate non-patented alternatives to American medications available abroad; “(3) investigate new uses for medications with expired patents; and “(4) otherwise seek out potential opportunities for generic medications to be released to the market. “(c) Authorization Of Appropriations.—There is authorized to be appropriated to carry out this section $6,000,000 for each of fiscal years 2026 through 2032, provided that no such monies shall go to researching new means of ectopic pregnancy treatment which imperil the life of the unborn child in an ectopic pregnancy.”. Subtitle G—Adoption Sec. 161. Religious adoption services. Section 408 of the Social Security Act (42 U.S.C. 608) is amended by inserting at the end a new subsection (h) as follows— “(h) Religious non-discrimination” “Each State to which a grant is made under section 603 of this title (or under any other Federal law authorizing funds for adoption) shall not discriminate against any person, including any adoption agency, on the basis of religious belief or practice. Refusal to provide adoption services, including via prioritization, shall be considered an example of religious practice as defined under this section if such practice is partially or wholly motivated by sincere religious belief.” Subtitle H—Medicare Expansion Sec. 171. Freestanding Emergency Centers. (a) Coverage Under Medicare Part B.—42 U.S.C. 1395k(a) (Section 1832(a)(2) of the Social Security Act ) is amended— (1) in subparagraph (I), by striking “and” at the end; (2) in subparagraph (J), by striking the period at the end and inserting “; and”; and (3) by adding at the end the following new subparagraph: “(K) emergency services (as defined in section 2799A–1(a)(3)(C) of the Public Health Service Act) provided by a freestanding emergency center (as defined in section 1861(lll)).”. (b) Freestanding Emergency Center Defined.—42 U.S.C. 1395x (Section 1861 of the Social Security Act) is amended by adding at the end the following new subsection: “(lll) Freestanding Emergency Center.—The term ‘freestanding emergency center’ means a health care facility that— “(1) is an independent freestanding emergency department (as defined in section 2799A–1(a)(3)(D) of the Public Health Service Act); “(2) is operational 24 hours a day, 7 days a week, and 365 days a year with a physician (as defined in subsection (r)) onsite at all times; “(3) has in place mechanisms to allow for appropriate transfers and referrals; “(4) develops, implements, and maintains an ongoing, data-driven quality assessment and performance improvement (QAPI) program; “(5) is located— “(A) in a metropolitan statistical area; or “(B) (i) in the case of a facility established prior to 2020, in a rural county; or “(ii) in the case of a facility established on or after January 1, 2020, in a rural county that does not have a Medicare-certified hospital or a rural emergency hospital (as defined in subsection (kkk)(2)); “(6) has established a governing body to determine, implement, and monitor policies governing the total operation of the facility, and has oversight and accountability for the QAPI program, ensuring that facility policies and such QAPI program are administered so as to provide quality health care in a safe environment; and “(7) meets all State requirements applicable to facilities which furnish emergency medical services to individuals but do not typically provide for stays in excess of 24 hours, and meets such other requirements as the Secretary may prescribe not in excess of the conditions of participation under this title that are specifically applicable to off campus dedicated emergency departments of hospitals (as described in section 482.55 of title 42, Code of Federal Regulations (or any successor regulation)), and not the conditions of participation under this title that are applicable to hospitals (as defined in subsection (e)), including rural emergency hospitals (as defined in subsection (kkk)(2)), other than with respect to compliance with the requirements described in section 1867;”. (c) Payment Under Medicare.—42 U.S.C. 1395l(t)(21) (Section 1833(t)(21) of the Social Security Act) is amended by adding at the end the following new subparagraph: “(F) TREATMENT OF FREESTANDING EMERGENCY CENTERS.—The facility payment rate for services of a freestanding emergency center (as defined in section 1861(lll)) for higher acuity evaluation or management level services (as represented by HCPCS codes 99283–99285, or any successor codes) shall be in an amount equal to the payment that would otherwise apply to a hospital outpatient department under this subsection, including the application of the geographic adjustment under paragraph (2)(D) and the OPD fee schedule increase factor under paragraph (3)(C)(iv).”. (d) Coverage Under Medicaid.—42 U.S.C. 1396d(a)(2)(A) (Section 1905(a)(2)(A) of the Social Security Act) is amended by inserting “, which shall include the services of freestanding emergency centers, as defined in section 1861(lll)” after “outpatient hospital services”. (e) Effective Date.—The amendments made by this Act shall apply to items and services furnished on or after January 1, 2027, or the first day following the termination of the emergency period (as defined in 42 U.S.C. 1320b–5(g)(1)(B)) (section 1135(g)(1)(B) of the Social Security Act), whichever comes first. Sec. 172. Sole community hospitals. Section 1886(d)(5)(D)(iii) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(D)(iii)) is amended— (1) in subclause (II), by striking at the end “or”; (2) in subclause (III), by striking the period at the end and inserting “, or”; and (3) by adding at the end the following new subclause: “(IV) for the 10-year period beginning on the date of the enactment of this subclause, that met either of the requirements specified in subclauses (I) through (III) (as in effect on the date of the enactment of this subclause) on or before March 13, 2020.”. Sec. 173. Chiropractor coverage. (a) In General.—Section 1861(r)(5) of the Social Security Act (42 U.S.C. 1395x(r)(5)) is amended— (1) by striking “for the purpose of sections 1861(s)(1) and 1861(s)(2)(A) and only”; (2) by inserting “, evaluation and management services (including examination and imaging services), and such other functions (not including the prescribing of drugs)” after “(to correct a subluxation)”; and (3) by inserting “, service, or function (as applicable)” after “such treatment”. (b) Allowing Chiropractors To Provide Items And Services Through Private Contracts With Medicare Beneficiaries.—Section 1802(b)(6)(B) of the Social Security Act (42 U.S.C. 1395a(b)(6)(B)) is amended by striking “paragraphs (1), (2), (3), and (4) of”. (c) Effective Date.—The amendments made by this section shall apply with respect to items and services furnished on or after the date that is 30 days after the date of the enactment of this Act. Sec. 174. Legalizing discounts for Medicare Part D purchases. (a) Exclusion Of Discounts.—Section 1128B(b)(3) of the Social Security Act (42 U.S.C. 1320a–7b(b)(3)) is amended— (1) in subparagraph (J)— (A) by moving such subparagraph 2 ems to the left; and (B) by striking “and” at the end; (2) in subparagraph (K)— (A) by moving such subparagraph 2 ems to the left; and (B) by striking the period at the end and inserting “; and”; and (3) by adding at the end the following new subparagraph: “(L) a discount, including through a rebate, discount card, or coupon, with respect to a covered part D drug (as defined in section 1860D–2(e)) under part D of title XVIII if— “(i) the full value of such discount is provided initially to a part D eligible individual (as defined in section 1860D–1(a)(3)(A)) enrolled in a part D plan (as defined in section 1860D–23(a)(5)), and the discount is not structured for the specific purpose of providing a price concession, other than a bona fide service fee, to another individual or entity; and “(ii) in the case where such discount includes a reduction in price applicable to individuals enrolled in a health plan but not to individuals enrolled in a prescription drug plan under such part D or a MA–PD plan under part C of such title XVIII, such discount is not structured for the specific purpose of increasing utilization of such covered part D drug under such a prescription drug plan or MA–PD plan.”. (b) Application Of The Protection Against Out-Of-Pocket Expenditures.—Section 1860D–2(b)(4)(C)(iii) of the Social Security Act (42 U.S.C. 1395w–102(b)(4)(C)(iii)) is amended— (1) in subclause (III), by striking “or” at the end; (2) in subclause (IV), by striking the period at the end and inserting “; or”; and (3) by adding at the end the following: “(V) under an arrangement described in section 1128B(b)(3)(L).”. (c) Effective Date.—The amendments made by this section shall take effect on January 1, 2026. Sec. 175. Coverage for obesity medication. (a) In General.—Section 1860D–2(e)(2)(A) of the Social Security Act (42 U.S.C. 1395w–102(e)(2)(A)) is amended, in the first sentence— (1) by striking “and other than” and inserting “other than”; and (2) by inserting after “benzodiazepines),” the following: “and other than subparagraph (A) of such section if the drug is used for the treatment of obesity (as defined in section 1861(yy)(2)(C)) or for weight loss management for an individual who is overweight (as defined in section 1861(yy)(2)(F)(i)) and has one or more related comorbidities (provided that such cost is not raised for weight loss or weight management),”. (b) Effective Date.—The amendments made by subsection (a) shall apply to plan years beginning on or after January 1, 2026. Sec. 176. Clinical laboratory tests. (a) Use Of Statistical Sampling For Widely Available Clinical Diagnostic Laboratory Tests.— (1) IN GENERAL.—Section 1834A(a)(1) of the Social Security Act (42 U.S.C. 1395m–1(a)(1)) is amended— (A) in subparagraph (A), by striking “Subject to subparagraph (B)” and inserting “Subject to subparagraphs (B) and (C)”; and (B) by adding at the end the following new subparagraph: “(C) USE OF STATISTICAL SAMPLING FOR WIDELY AVAILABLE CLINICAL DIAGNOSTIC LABORATORY TESTS.— “(i) IN GENERAL.—Subject to clause (ii), with respect to data collection periods for reporting periods beginning on or after January 1, 2030, in the case of a widely available clinical diagnostic laboratory test (as defined in clause (iii)), in lieu of requiring the reporting of applicable information from each applicable laboratory, the Secretary shall require the collection and reporting of applicable information from a statistically valid sample of applicable laboratories for each such widely available clinical diagnostic laboratory test. “(ii) REQUIREMENTS FOR STATISTICAL SAMPLING.— “(I) IN GENERAL.—The Secretary, in consultation with stakeholders, shall develop a methodology for a statistically valid sample under clause (i), using the maximal brewer selection method, to establish the payment amount for a widely available clinical diagnostic laboratory test under paragraph (2) of subsection (b) for each applicable HCPCS code for a widely available clinical diagnostic laboratory test. “(II) REPRESENTATIVE SAMPLING.—The methodology under subclause (I) for a statistically valid sample under clause (i) shall, for each applicable HCPCS code for a widely available clinical diagnostic laboratory test— “(aa) provide for a sample that allows for the payment amounts established under paragraph (2) of subsection (b) for such a test to be representative of rates paid by private payors to applicable laboratories receiving payment under this section, including independent laboratories, hospital laboratories, hospital outreach laboratories, and physician office laboratories that furnish the widely available clinical diagnostic laboratory test; “(bb) include applicable information (as defined in paragraph (3)) with respect to such widely available clinical diagnostic laboratory test from such different types of applicable laboratories; and “(cc) be of sufficient size to accurately and proportionally represent the range of private payor payment rates received by each such type of applicable laboratory weighted according to the utilization rates of each type of applicable laboratory for the widely available clinical diagnostic laboratory test during the first 6 months of the calendar year immediately preceding the data collection period applicable to the sample to be collected. “(III) LEAST BURDENSOME DATA COLLECTION AND REPORTING PROCESSES.—The methodology developed by the Secretary shall be designed to reduce administrative burdens of data collection and reporting on applicable laboratories and the Centers for Medicare & Medicaid Services to the greatest extent practicable. “(IV) PUBLICATION OF LIST OF WIDELY AVAILABLE CLINICAL DIAGNOSTIC LABORATORY TESTS AND NOTIFICATION TO APPLICABLE LABORATORIES REQUIRED TO REPORT APPLICABLE INFORMATION.—Not later than September 30 of the year immediately preceding each data collection period (as defined in paragraph (4)), the Secretary shall publish in the Federal Register a list of widely available clinical diagnostic laboratory tests and shall directly notify applicable laboratories required to report applicable information under this subsection. “(iii) DEFINITION OF WIDELY AVAILABLE CLINICAL DIAGNOSTIC LABORATORY TEST.—In this subparagraph, the term ‘widely available clinical diagnostic laboratory test’ means a clinical diagnostic laboratory test that meets both of the following criteria during the first 6 months of the calendar year immediately preceding the data collection period applicable to the sample to be collected: “(I) PAYMENT RATE.—The payment amount determined for the clinical diagnostic laboratory test under this section is less than $1,000 per test. “(II) NUMBER OF LABORATORIES PERFORMING THE TEST.—The number of applicable laboratories receiving payments under this section for the clinical diagnostic laboratory test (as determined by the Secretary using the national provider identifier of the provider of services or supplier on the claim submitted for payment under this part for such test) exceeds 100.”. (2) DELAYS TO REVISED REPORTING PERIODS AND REPORTING PERIOD FREQUENCY.— (A) IN GENERAL.—Section 1834A(a)(1)(B) of the Social Security Act (42 U.S.C. 1395m–1(a)(1)(B)) is amended— (i) in clause (i), by striking “December 31, 2027” and inserting “December 31, 2030”; (ii) in clause (ii), by striking “beginning January 1, 2028, and ending March 31, 2028” and inserting “beginning January 1, 2031, and ending March 31, 2031”; and (iii) in clause (iii) by striking “every three years” and inserting “every four years”. (B) CONFORMING CHANGE TO DEFINITION OF DATA COLLECTION PERIOD.—Section 1834A(a)(4)(B) of the Social Security Act (42 U.S.C. 1395m–1(a)(4)(B)) is amended by striking “January 1, 2019, and ending June 30, 2019” and inserting “January 1, 2030, and ending June 30, 2030”. (b) Elimination Of Majority Of Medicare Revenues Test.—The first sentence of section 1834A(a)(2) of the Social Security Act (42 U.S.C. 1395m–1(a)(2)) is amended by striking “In this section” and all that follows through the period and inserting the following: “Notwithstanding determinations of applicable laboratories made prior to January 1, 2029, the term ‘applicable laboratory’ means a laboratory that receives at least $12,500 in payments under this section during the first 6 months of the calendar year immediately preceding the applicable data collection period.”. (c) Modifications To Applicable Information Reported.— (1) MEDICAID MANAGED CARE RATES.—Section 1834A(a)(8)(C) of the Social Security Act (42 U.S.C. 1395m–1(a)(8)(C)) is amended by striking “A medicaid managed care organization” and inserting “With respect to data collection periods for reporting periods beginning before January 1, 2031, a medicaid managed care organization (as defined in section 1903(m))”. (2) AUTHORITY TO EXCLUDE MANUAL REMITTANCES.—Section 1834A(a)(3) of the Social Security Act (42 U.S.C. 1395m–1(a)(3)) is amended— (A) in subparagraph (A), by striking “subject to subparagraph (B),” and inserting “subject to subparagraphs (B) and (C)”; and (B) by adding at the end the following new subparagraph: “(C) EXCLUSION OF MANUAL REMITTANCES.—An applicable laboratory for which less than 10 percent of its total paid claims during a data collection period are paid by private payors by means other than an electronic standard transaction (as defined in section 162.103 of title 45, Code of Federal Regulations (or any successor regulation)) may exclude from the definition of applicable information under this paragraph payments made by private payors that are not made through an electronic standard transaction.”. (d) Modification To Limits On Payment Reductions; Imposition Of Annual Cap On Payment Increases.— (1) PAYMENT REDUCTION LIMITS.—Section 1834A(b)(3) of the Social Security Act (42 U.S.C. 1395m–1(b)(3)) is amended— (A) in subparagraph (A), by striking “for each of 2017 through 2030” and inserting “for 2017 and each succeeding year”; and (B) in subparagraph (B)— (i) in clause (ii), by striking “and” at the end; and (ii) by striking clause (iii) and inserting the following: “(iii) for 2028, 0 percent; “(iv) for 2029, 2.5 percent; and “(v) for 2030 and each subsequent year, 5 percent.”. (2) ANNUAL CAP ON PAYMENT RATE INCREASES.—Section 1834A(b)(3) of the Social Security Act (42 U.S.C. 1395m–1(b)(3)), as amended by paragraph (1), is amended— (A) in subparagraph (A)— (i) by striking “test for 2017 and each succeeding year—” and inserting “test— “(i) for 2017 and each succeeding year”; (ii) in clause (i), as added by clause (i) of this subparagraph, by striking the period and inserting “; and”; and (iii) by adding at the end the following new clause: “(ii) for 2028 and each succeeding year, shall not result in an increase in payments for a clinical diagnostic laboratory test for the year of greater than the applicable percent (as defined in subparagraph (D)) of the amount of payment for the test for the preceding year.”; (B) in subparagraph (B), in the matter preceding clause (i), by striking “In this paragraph” and inserting “In clause (i) of subparagraph (A)”; and (C) by adding at the end the following new subparagraph: “(D) DEFINITION OF APPLICABLE PERCENT FOR PURPOSES OF ANNUAL CAP ON PAYMENT INCREASES.—In clause (ii) of subparagraph (A), the term ‘applicable percent’ means the following: “(i) WIDELY AVAILABLE CLINICAL DIAGNOSTIC LABORATORY TESTS.—With respect to a widely available clinical diagnostic laboratory test— “(I) for 2028, 2.5 percent; “(II) for 2029, 2.5 percent; “(III) for 2030, 3.75 percent, “(IV) for 2031, 3.75 percent; and “(V) for 2032 and each subsequent year, 5 percent. “(ii) OTHER CLINICAL DIAGNOSTIC LABORATORY TESTS.—With respect to a clinical diagnostic laboratory test not described in clause (i), 5 percent.”. (3) CONFORMING AMENDMENT.—Section 1834A(b)(3) of the Social Security Act (42 U.S.C. 1395m–1(b)(3)) is amended in the heading by striking “REDUCTIONS” and inserting “MEDICARE PAYMENT CHANGES”. (e) Regulations.— (1) Not later than December 31, 2026, the Secretary of Health and Human Services shall implement the amendments made by this section (other than subsection (d)) through notice and comment rulemaking. (2) The Secretary of Health and Human Services may implement the amendments made by subsection (d) through interim final rulemaking, program instruction, or otherwise. Sec. 177. Pharmacist services under Medicare Part B. (a) Coverage.—Section 1861(s) of the Social Security Act (42 U.S.C. 1395x(s)) is amended— (1) in paragraph (2)— (A) in subparagraph (II), by striking “and” at the end; (B) in subparagraph (JJ), by striking the period at the end and inserting “; and”; and (C) by adding at the end the following new subparagraph: “(KK) pharmacist services and such services and supplies furnished as an incident to the pharmacist’s service as would otherwise be covered under part B if furnished by a physician or as an incident to a physician’s service that— “(i) are furnished by a pharmacist— “(I) as licensed under State law; or “(II) pursuant to a Federal emergency authority described under section 319F–3 or section 361 of the Public Health Service Act, or other similar Federal law; “(ii) would otherwise be covered under part B if furnished by a physician; and “(iii) are services— “(I) for encounters for the evaluation and management of patients for testing or treatment for COVID–19, influenza, respiratory syncytial virus, or streptococcal pharyngitis; or “(II) that address a public health need related to a public health emergency under section 319F–3 or section 361 of the Public Health Service Act, or other similar Federal law.”; and (2) in paragraph (10), in each of subparagraphs (A) and (B), by inserting “, including when furnished by a pharmacist” before the semicolon in each such subparagraph. (b) Payment.—Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended— (1) by striking “and (HH)” and inserting “(HH)”; and (2) by inserting before the semicolon at the end the following: “and (II) with respect to pharmacist services described in section 1861(s)(2)(KK), the amounts paid shall be equal to 80 percent of the lesser of (i) the actual charge for the services or (ii) 85 percent (or 100 percent, in the case of such services furnished pursuant to a Federal emergency authority described in clause (i)(II) of such section) of the amount determined under the payment basis under section 1848 for such services.”. (c) Prohibition On Balance Billing For Pharmacist Services.—Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following: “(ix) A pharmacist.”. (d) Rule Of Construction.—Nothing in this section shall be construed to restrict the ability of pharmacies and pharmacists to enroll and obtain reimbursement under existing pathways under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) as of the date of the enactment of this Act, including payment as mass immunizers. (e) Implementation Authority.—Notwithstanding any other provision of law, the Secretary of Health and Human Services shall implement the provisions of, and the amendments made by, this section by interim final rule, program instruction, or otherwise not later than the date that is 60 days after the date of the enactment of this Act. Sec. 178. Long-term care for Seniors. Section 1886(m)(6)(A) of the Social Security Act (42 U.S.C. 1395ww(m)(6)(A)) is amended— (1) by striking “or the ventilator criterion under clause (iv)” and inserting “, the ventilator criterion under clause (iv), or the high acuity criterion described in clause (v)”; and (2) by adding at the end the following new clause: “(v) HIGH ACUITY CRITERION.— “(I) IN GENERAL.—The criterion specified in this clause (in this paragraph referred to as the ‘high acuity criterion’) for a discharge from a long-term care hospital in a fiscal year is that— “(aa) the individual discharged had a primary diagnosis assigned to a Medicare-Severity-Long-Term-Care-Diagnosis-Related-Group (MS–LTC–DRG) with a relative weight for such fiscal year that was equal to or greater than the specified amount for such fiscal year; and “(bb) the discharge occurred on or after October 1, 2029. “(II) SPECIFIED AMOUNT DEFINED.—For purposes of subclause (I), the term ‘specified amount’ means, with respect to a fiscal year, an amount equal to the 80th percentile of the relative weights for Medicare-Severity-Long-Term-Care-Diagnosis-Related-Groups that were assigned to primary diagnoses for all discharges occurring in the preceding fiscal year.”. TITLE II—Revenues Sec. 201. Taxes on certain insurance plans offering luxury coverage. (a) A new subchapter C is created under Chapter 34 of the Internal Revenue Code of 1986 which shall be titled “Taxes on certain insurance plans offering luxury coverage.” (b) Within subchapter C of Chapter 34 of the Internal Revenue Code of 1986, a new section 4378 shall be inserted as follows— “(a) Imposition of tax. In the case of any applicable luxury health plan for each plan year ending after September 30, 2027, there is hereby imposed a tax equal to 15% of that plan's premium levied as an additional fee on top of it, which shall be paid either by the purchaser or by the insurer on behalf of the purchaser. “(b) “Applicable luxury health plan” means any plans that provide coverage for— “(1) abortion, “(2) contraceptives and sterilizations, “(3) cosmetic surgery or other cosmetic treatments (including circumcision), “(4) treatments or tests for sexually transmitted diseases (including any medication or vaccine used to prevent sexually transmitted diseases), “(5) abortifacients, “(6) hormonal replacement therapy (when not used for treatment of a physical medical condition), “(7) medicines or treatments which are not scientifically proven to be effective, “(8) sex change surgery (including any child sexual mutilation as defined by section 2260B(d) of title 18, United States Code), “(9) marijuana or tobacco, “(10) anything that intentionally ends the life of a patient, “(11) assisted reproduction technology products and services including ovulation inductions and in vitro fertilizations, “(12) preparation and planning for any other item described here or in section 5892, “(13) hymen reconstruction or any other procedure intended to falsify or restore biological virginity, “(14) any drug or treatment which is unlawful, or “(15) preparation and planning for any other item described under this subsection, including any employment contract which includes any coverage for travel or other expenditure intended to avoid any law prohibiting any item described under this subsection. “(c) No person shall be interpreted as being under any legal obligation to purchase any applicable luxury health plan. “(d) Persons with applicable luxury health plans have the right to change their health plans in order to avoid paying the tax on applicable luxury health plans. “(e) This section shall not be interpreted as legalizing or decriminalizing anything prohibited by any Federal law or as preempting any State law, except as such State law may restrict out-of-State health insurance coverage. “(f) For the purposes of subsection (b), words and phrases shall have similar meanings to those assigned to such words and phrases by section 5892, and exceptions shall apply as treated by such section. “(g) There is hereby imposed, on each applicable luxury health plan issued by a foreign insurer or reinsurer who is a nonresident alien individual, foreign partnership, or foreign corporation, including all nonresident alien individuals, foreign partnerships, and foreign corporations which may be bound to fulfill the obligations related to such insurance, an additional tax of 20% of the cost of such applicable luxury health plan, as well as an additional $1000 per year. “(h) General rule. Every person engaged in business issuing or reissuing applicable luxury health plans or bound to fulfill obligations related to such plans shall pay a tax of $1,000 per year. Any corporation or other person may be charged any tax established by any provision of this section retroactively, provided that retroactive taxation is possible against such person. “(i) Penalty. Any person engaged in a business referred to in subsection (h) who willfully fails to pay a tax imposed by this section shall be fined not more than $10,000, or imprisoned not more than 4 years, or both, for each such offense, as well as either all due but unpaid taxes owed under this section if such violation was done either with knowledge of the tax avoided or subsequent to July 4, 2028 or ten percent of such unpaid taxes if such taxes are evaded without prior knowledge that they are owed.”. (c) Subsections (c), (d), and (e) of the section created by subsection (b) of this section shall go into effect immediately upon the enactment of this Act with retroactive effect. (d) Section 275(a) of such Code is amended by adding “Taxes imposed by sections by sections 4378 and 5892.”. Sec. 202. Corrective excise tax. (a) A new Chapter 56 is created under Subtitle E of the Internal Revenue Code of 1986 which is titled “Certain healthcare associated excise taxes”. (b) A new section 5892 is inserted as follows in such chapter of such subtitle of such Code: “(a) Imposition of tax. Applicable healthcare associated products are to be subject to a 15% sales tax, effective January 1, 2028. “(b) The following products and services shall be defined as “applicable healthcare associated products”— “(1) abortion, “(2) contraception (including sterilization) which do not involve either the complete removal of the testes or the removal of the uterus (or one or both ovaries) to treat or cure a medical condition, “(3) cosmetic surgery or other cosmetic treatments (including circumcision), “(4) treatments or tests for sexually transmitted diseases (including any medication or vaccine used to prevent sexually transmitted diseases), “(5) abortifacient substances and products designated or approved as "vaccines" as of January 2026 or any later date, “(6) hormonal replacement therapy (when not used for treatment of a physical medical condition), “(7) medicines or treatments which are unlawful, “(8) anything which intentionally ends the life of a patient, “(9) assisted reproductive technology products and services including ovulation inductions and in vitro fertilizations, “(10) sex change surgery (including any hormone-blocking substance or procedure not used to treat a physical medical condition, as well as all child sexual mutilation as defined by section 2260B(d) of title 18, United States Code), “(11) hymen reconstruction or any other procedure intended to falsify or restore biological virginity, and “(12) preparation and planning for any other item described under this subsection, including any employment contract which includes any coverage for travel or other expenditure intended to avoid any law prohibiting any item described under this subsection. “(c) For the purposes of subsection (b): “(1) The word “contraceptives” and phrase “assisted reproductive technology products and services” shall not include neither any application, calendar, or other means which assists one in using any method based on timing, especially in cases in which such means shall be useful for the beneficiary to conceive via sexual intercourse nor any removal of a contraceptive; “(2) The words “abortion” and “abortifacient substances” shall not include such cases where it shall be necessary to preserve the beneficiary's life; “(3) The phrase “cosmetic surgery or other cosmetic treatments (including circumcision)” shall not include any surgery or treatment that is defined as “aesthetic treatment” by subsection (h), but shall otherwise include the use for cosmetic purposes of one or more prostheses, surgery, injection of a toxin or chemical (as defined by the Secretary of the Treasury), lasers, chemical peels, drugs, or any other procedure defined by the Secretary for the purpose of improving or altering a person's appearance or attractiveness; “(4) The phrase “treatments or tests for sexually transmitted diseases” shall not include such cases where a disease was one not generally transmitted by a sexual act or when it may treat a woman at risk of ectopic pregnancy; and “(5) Any bundle including any applicable healthcare associated product or advertisement for an applicable healthcare associated product shall be considered an applicable healthcare associated product. “(d) In any case in which any applicable healthcare associated products are imported into the United States or performed or provided by a foreign person (including any non-United States business entity or non-United States citizen), the occupational and sales tax rates imposed by this section are doubled. “(e) Occupational tax. Every person engaged in business as a manufacturer, warehouse proprietor, importer, service provider, retailer, or other person who gains revenue from the business of applicable healthcare associated products shall pay a tax of $1,000 per year in respect of each premises at which such business is carried on. Any corporation or other person may be charged any tax established by any provision of this section retroactively, provided that retroactive taxation is possible against such person. “(f) Penalty. Any person engaged in a business referred to in subsection (e) who willfully fails to pay a tax imposed by subsection (a) or (e) shall be fined not more than $10,000, or imprisoned not more than 4 years, or both, for each such offense, as well as either all due but unpaid taxes owed under this section if such violation was done with knowledge of the tax avoided or ten percent of such unpaid taxes if such taxes are evaded without prior knowledge that they are owed. “(g) No force, legal or otherwise, may compel a person to purchase anything defined as an applicable healthcare associated product by this section. “(h) The phrase “aesthetic treatment” shall refer to a cosmetic surgery or treatment for— “(1) dental or orthodontal purposes, “(2) restoring or improving appearance after injury, disease, medical treatment, childbirth, or medically recognized condition which results in damage to appearance, “(3) reducing excess fat, managing weight, or relocating fat to healthier areas of the body to promote physical health.”. (c) Subsection (g) of the section created by subsection (b) of this section shall be interpreted as having immediate and retroactive effect. (d) Part IX of Subchapter B of Chapter 1 of the Internal Revenue Code of 1986 is amended by inserting a new section 270 after section 269B as follows: “Applicable healthcare associated products. No deduction shall be allowed for applicable luxury health plans or applicable healthcare associated products.”. Sec. 203. Small business tax credit. (a) In general.—Section 45R of the Internal Revenue Code of 1986 is amended as follows— “Sec. 45R. Small business health insurance credit. “(a) GENERAL CREDIT.—For purposes of section 38, in the case of an eligible small business under section (d), the small business health insurance credit determined under this section for any taxable year is the amount determined under subsection (b). “(b) CREDIT AMOUNT.—The amount determined with respect to any eligible small business shall be the aggregate amount of contributions the business made on behalf of its employees during the taxable year for qualified health plans offered by the employer to its employees, multiplied by— “(1) 50 percent in the case of a business with 25 or less employees, “(2) 35 percent in the case of a business with 26 to 50 employees, “(3) 20 percent in the case of a business with 51 to 75 employees, or “(4) 5 percent in the case of a business with 76 or more employees. “(c) DEFINITIONS.— “(1) ELIGIBLE SMALL BUSINESS.—The term ‘eligible small business’ means, with respect to any taxable year, an employer (including one which is exempt from taxation under section 501(a)) which offers fringe benefits including health insurance and which has 100 or less full-time equivalent employees. “(2) FULL-TIME EQUIVALENT EMPLOYEES.—The term ‘full-time equivalent employees’ means the total number of work-hours contributed by employees (excluding overtime hours) divided by 2080. “(3) QUALIFIED HEALTH PLAN.—The term ‘qualified health plan’ means a health insurance plan offered through a federally-authorized health insurance exchange which is not an applicable luxury health plan as defined by section 4378. “(d) EXPIRATION.—This section shall not apply with respect to amounts paid or incurred in taxable years beginning after December 31, 2035. “(e) REGULATIONS.—The Secretary shall, in consultation with any appropriate officials, prescribe such regulations as may be necessary to carry out the provisions of this section. “(e) ADULT CHILDREN.—Provided that a qualified health plan also provides coverage for dental and vision expenses for employees' family dependents who are between the ages of 19 and 26, any percent specified in subsection (b) shall be treated as five percent higher.”. (b) Conforming amendment.—Section 38(b)(31) of such Code is amended by striking “employer” and inserting “business”. (c) Effective date.—The amendments made by this section shall apply to taxable years beginning after December 31, 2027. Sec. 204. Miscellaneous tax repeals. (a) Section 5000A of the Internal Revenue Code of 1986 is repealed effective upon the entry of this Act into force, except insofar as it may be necessary to use its provisions to provide definitions utilized by other provisions of law. (b) Chapters 48 and 49 of such Code are struck. (c) Section 9815 of such Code is repealed. (d) Section 4980H(c) of the Internal Revenue Code of 1986 is repealed. (e) Effective date.—The amendments made by this section shall apply to months beginning after December 31, 2015. (f) Refunds.—No refund or credit shall be issued based on this section. Sec. 205. Reduction tax. (a) Section 5893 is inserted as follows in Chapter 56 of Subtitle E of the Internal Revenue Code of 1986 as follows: “Sec. 5893. Reduction tax. “(a) Imposition of tax. Effective January 1, 2027, a 45% sales tax is imposed on any procedure or service that reduces body size or mass for cosmetic, contraceptive, or gender-altering purposes. This includes, but is not limited to, reductions or removals of the following: “(1) Breast tissue or buttock tissue. “(2) Internal body structures, such as muscles, organs, or bone tissue. “(3) Other body parts (excluding fat tissues not located in the breasts or buttocks), when the primary purpose is a reduction in body size or mass. “(b) Removal or replacement of breast implants shall not be considered a reduction under this section. No removal or reduction which is not considered an applicable healthcare associated product shall be subject to any tax imposed by this section. “(c) Payment of tax on applicable healthcare associated products shall not exempt any person from payment of any tax established under this section. “(d) In any case in which any such reductions are provided using products imported into the United States or performed or provided by a foreign person (including any non-United States business entity or non-United States citizen), the occupational and sales tax rates imposed by this section are doubled. “(e) Occupational tax. Every person engaged in business as a service provider of such reductions shall pay a tax of $6,000 per year in respect of each premises at which such business is carried on. Any corporation or other person may be charged any tax established by any provision of this section retroactively, provided that retroactive taxation is possible against such person. “(f) Penalty. Any person engaged in a business referred to in subsection (e) who willfully fails to pay a tax imposed by subsection (a) or (e) shall be fined not more than $50,000, or imprisoned not more than 6 years, or both, for each such offense, as well as either all due but unpaid taxes owed under this section if such violation was done with knowledge of the tax avoided or ten percent of such unpaid taxes if such taxes are evaded without prior knowledge that they are owed. “(g) No force, legal or otherwise, may compel a person to purchase anything defined as a reduction by this section. “(h) Any bundle including such reductions shall be considered a reduction, except insofar as negligible numbers of fat cells may be transferred from one area of the body to another to prevent surgical complications when a sex change related procedure is not part of the bundle or package.”. (b) Subsection (g) of the section created by subsection (a) of this section shall be interpreted as having immediate and retroactive effect. Sec. 206. Reform of nonprofit CO-OP insurance. (a) In general.—Section 501(c)(29)(B) of the Internal Revenue Code of 1986 is amended— (1) In clause (iii), by striking “and,” (2) In clause (iv), by striking “.” and inserting “, and”, and (3) By inserting a new clause (v) as follows— “(v) the organization does not provide any applicable healthcare associated products as defined by section 5892 or issue any applicable luxury health plan as defined by section 4378.”. (b) Effective date.—The amendments made by subsection (a) of this section shall apply to taxable years beginning after December 31, 2027. Sec. 207. Reform of health savings accounts. (a) Increase in deductible HSA contribution limitations.—Section 223(b)(1) of such Code is amended as follows— “(1) The amount allowable as a deduction under subsection (a) to an individual for the taxable year shall not exceed $10,000, or $20,000 in the case of a joint return.”. (b) Medicare eligible individuals eligible to contribute to HSA.—Section 223(b) of such Code is amended by striking paragraph (7). (c) Purchase of health insurance.—Section 223(d)(2) of such Code is amended— (1) by striking subparagraphs (B) and (C), (2) by redesignating (D) as (B), and (3) by inserting “(C) Applicable healthcare associated products.—Subparagraph (A) shall not apply to an amount paid by an account holder for any applicable healthcare associated products as defined by section 5892.” after (B). (d) Cost-of-Living adjustment for catchup contributions.—Section 223(f)(1) of such Code (as redesignated by subsection (g)(3)) is amended by striking “Each dollar amount in subsections (b)(2) and (c)(2)(A)” and inserting “In the case of a taxable year beginning after December 31, 2027, each dollar amount in paragraphs (1) and (2) of subsection (b)”. (e) Cost-of-Living adjustment indexed to CPI medical care component.—Section 223(f) (as so redesignated) is amended by adding at the end the following new paragraph: “(3) CPI MEDICAL CARE COMPONENT.— “(A) IN GENERAL.—For purposes of paragraph (1), the cost-of-living adjustment determined under section 1(f)(3) for the calendar year shall be determined by substituting ‘CPI medical care component’ for ‘CPI’. “(B) CPI MEDICAL CARE COMPONENT.—For purposes of subparagraph (A), the term ‘CPI medical care component’ means the medical care component for the Consumer Price Index for All Urban Consumers published by the Department of Labor.”. (f) HSA penalty reduction.—Section 223(e)(4)(A) (as redesignated by subsection (g)(3)) of the Internal Revenue Code of 1986 is amended by striking “20 percent” and inserting “10 percent”. (g) Conforming amendments.— (1) Section 223(b) of such Code is amended by striking paragraphs (2), (5), and (8) and by redesignating paragraphs (3), (4), and (6) as paragraphs (2), (3), and (4), respectively. (2) Section 223(b)(3) of such Code (as redesignated by paragraph (1)) is amended by striking the last sentence. (3) Section 223 of such Code is amended by striking subsection (c) and redesignating subsections (d) through (h) as subsections (c) through (g), respectively. (4) Section 223(c)(1)(A) of such Code (as redesignated by paragraph (3)) is amended— (A) by striking “subsection (f)(5)” and inserting “subsection (e)(5)”; and (B) in clause (ii) by striking “the sum of—” and all that follows and inserting “the dollar amount in effect under subsection (b)(1).”. (5) Section 223(f)(1) (as redesignated by paragraph (3)) is amended by striking “calendar year 2003” and inserting “calendar year 2014”. (6) Section 26(b)(2)(U) of such Code is amended by striking “section 223(f)(4)” and inserting “section 223(e)(4)”. (7) Sections 35(g)(3), 220(f)(5)(A), 848(e)(1)(v), 4973(a)(5), and 6051(a)(12) of such Code are each amended by striking “section 223(d)” each place it appears and inserting “section 223(c)”. (8) Section 106(d)(1) of such Code is amended— (A) by striking “who is an eligible individual (as defined in section 223(c)(1))”; and (B) by striking “section 223(d)” and inserting “section 223(c)”. (9) Section 408(d)(9) of such Code is amended— (A) in subparagraph (A) by striking “who is an eligible individual (as defined in section 223(c)) and”; and (B) in subparagraph (C) by striking “computed on the basis of the type of coverage under the high deductible health plan covering the individual at the time of the qualified HSA funding distribution”. (10) Section 877A(g)(6) of such Code is amended by striking “223(f)(4)” and inserting “223(e)(4)”. (11) Section 4973(g) of such Code is amended— (A) by striking “section 223(d)” and inserting “section 223(c)”; (B) in paragraph (2), by striking “section 223(f)(2)” and inserting “section 223(e)(2)”; and (C) by striking “section 223(f)(3)” and inserting “section 223(e)(3)”. (12) Section 4975 of such Code is amended— (A) in subsection (c)(6)— (i) by striking “section 223(d)” and inserting “section 223(c)”; and (ii) by striking “section 223(e)(2)” and inserting “section 223(d)(2)”; and (B) in subsection (e)(1)(E), by striking “section 223(d)” and inserting “section 223(c)”. (13) Section 6693(a)(2)(C) of such Code is amended by striking “section 223(h)” and inserting “section 223(g)”. (14) Section 223(e)(5)(A) of such Code, as amended by section 2, is amended by inserting “or Medicare Advantage MSA” after “into a health savings account”. (h) Effective date.—The amendments made by this section shall apply to taxable years beginning after December 31, 2027. (i) Archer MSAs.—Subparagraph (D) of section 220(d)(2) of the Internal Revenue Code of 1986 is created as follows— “(D) Applicable healthcare associated products.—Subparagraph (A) shall not apply to an amount paid by an account holder for any applicable healthcare associated products as defined by section 5892.”. (j) Health flexible spending arrangements and health reimbursement arrangements.—Section 106(f) of the Internal Revenue Code of 1986 is amended by inserting “, and all applicable healthcare associated products as defined by section 5892 shall not be treated as expenses incurred for medical care” after “medical care”. (k) Menstrual care products.—Subparagraph (D) of section 223(d)(2) is amended by inserting “, provided that such products do not damage the hymen and are not applicable healthcare associated products as defined by section 5892” after “secretions”. (l) Treatment of HSA after death of account beneficiary.—Section 223(f)(8) of the Internal Revenue Code of 1986 is amended to read as follows: “(8) Treatment of HSA after death of account beneficiary.—If an individual acquires an account beneficiary’s interest in a health savings account by reason of the death of the account beneficiary, such health savings account shall be treated as if the individual were the account beneficiary.”. (m) Abolition of monthly contribution limit.—Section 223(b)(2) of such Code is repealed. (n) Subsection 223(f) of such Code, as amended, is further amended by adding at the end the following new paragraph: “(9) Contributions to child account.—A contribution to the health savings account of a child of a taxpayer shall be treated as a qualified medical expense, provided that such child has not attained the age of 27 at the beginning of such taxable year and no contribution made to such account shall exceed any limitations established by subsection (b) of this section.”. (o) Bankruptcy Protections.—Section 522 of title 11, United States Code, is amended by adding at the end the following new subsection: “(r) For purposes of this section, any health savings account (as described in section 223 of the Internal Revenue Code of 1986) shall be treated in the same manner as an individual retirement account described in section 408 of such Code.”. (q) Restriction on benefit use.—Section 223(d)(2)(A) of such Code is amended by inserting “No amounts paid for applicable healthcare associated products as defined by section 5892 shall be treated as medical care.” at the end. Sec. 208. Reform of Archer MSAs and flexible spending accounts. (a) Archer MSAs.—Section 220(f)(4)(A) of such Code is amended by striking “20 percent” and inserting “15 percent”. (b) Flexible spending accounts.—Section 125(i) of the Internal Revenue Code of 1986 is amended as follows— “(i) Limitation on health flexible spending arrangements.—Applicable healthcare associated products as defined by section 5892 and applicable luxury health plans as defined by section 4378 shall not be treated as qualified benefits. Flexible spending arrangements may be used as the basis for a credit card, provided that such credit card is used only for expenditures allowable in the case of a direct debit expenditure, and any interest expense is paid via non-contribution funds.”. (c) Repeal of PPACA.—Section 125(f)(3) is repealed. (d) Effective date.—The amendments made by this section shall apply to distributions made after December 31, 2027. (e) Luxury expenditure.—Section 106(f) is amended as follows: “(f) Restriction on luxury expenditure. Expenses incurred for applicable healthcare associated products (as defined by section 5892) or applicable luxury health plans (as defined by section 4378) shall not be treated as medical expenses.” (f) Contributions Permitted If Spouse Has A Health Flexible Spending Account.—Section 223(c)(1)(B) of the Internal Revenue Code of 1986 is amended by striking “and” at the end of clause (ii), by striking the period at the end of clause (iii) and inserting “, and”, and by inserting after clause (iii) the following new clause: “(iv) coverage under a health flexible spending arrangement of the spouse of the individual for any plan year of such arrangement if the aggregate reimbursements under such arrangement for such year do not exceed the aggregate expenses which would be eligible for reimbursement under such arrangement if such expenses were determined without regard to any expenses paid or incurred with respect to such individual.”. Sec. 209. Deduction for qualified charity care. (a) In general.—Part VI of subchapter B of chapter 1 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section: “SEC. 199B. Qualified charity care. “(a) In general.—There shall be allowed as a deduction for the taxable year an amount equal to— “(1) in the case of a direct primary care physician, an amount equal to the sum of— “(A) the fee (as published on a publicly available website of such physician) for physicians’ services that are qualified charity care furnished by such taxpayer during such year, and “(B) for each visit by a patient to such physician during which qualified charity care is furnished, half of so much of the lowest subscription fee of such physician that is attributable to a month, and “(2) in the case of any other individual, the unreimbursed Medicare-based value of qualified charity care furnished by such taxpayer during such year. “(b) Definitions.—For purposes of this section: “(1) UNREIMBURSED MEDICARE-BASED VALUE.—The term ‘unreimbursed Medicare-based value’ means, with respect to physicians’ services, the amount payable for such services under the physician fee schedule established under section 1848 of the Social Security Act. “(2) QUALIFIED CHARITY CARE.—The term ‘qualified charity care’ means physicians’ services that are not applicable healthcare associated products (as defined by section 5892) that are furnished— “(A) without expectation of reimbursement, and “(B) to an individual enrolled— “(i) under a State plan under title XIX of the Social Security Act (or a waiver of such plan), or “(ii) under a State child health plan under title XXI of the Social Security Act (or a waiver of such plan). “(3) DIRECT PRIMARY CARE PHYSICIAN.—The term ‘direct primary care physician’ means a physician (as defined in section 1861(r) of the Social Security Act) who provides primary care— “(A) to individuals who have paid a periodic subscription fee, and “(B) in exchange for a fee that is published on a publicly available website of such physician. “(4) PHYSICIANS’ SERVICES.—The term ‘physicians’ services’ has the meaning given such term by section 1861(q) of the Social Security Act. “(c) Limitation.—The amount allowed as a deduction under subsection (a) for a taxable year shall not exceed the gross receipts attributable to physicians’ services furnished by the taxpayer during the taxable year.”. (b) Clerical amendment.—The table of sections for part VI of subchapter B of chapter 1 of the Internal Revenue Code of 1986 is amended by adding at the end the following new item: “Sec. 199B. Qualified charity care.”. Sec. 210. Establishment of a tax credit for medical infrastructure investment. (a) In general.—A new section 48D of the Internal Revenue Code of 1986 is created by inserting after section 38C of such Code the following— “Sec. 48D. Qualifying medical infrastructure investment “(a) For purposes of section 46, the qualifying medical infrastructure investment credit is an amount equal to 100 percent of the qualified investment for such taxable year. “(b) For purposes of subsection (a), the qualified investment for any taxable year is the basis of eligible property acquired, manufactured, constructed, reconstructed, erected, or maintained and declared as intended for medical purposes (including to serve as reserve infrastructure for mitigating surges in demand for healthcare services) excluding anything for which tax is owed pursuant to sections 5892 and 4378 of the Internal Revenue Code of 1976 or for the purpose of providing or issuing applicable healthcare associated products or applicable luxury health plans as provided by sections 5892 and 4378. “(c) Rules similar to section 48(a)(4) (without regard to subparagraph (D) thereof) and shall apply for purposes of this section. “(d) Beginning fiscal year 2035, the word “maintained” as used in this section does not include maintenance for items in active use during such taxable year qualified investments have been declared. “(e) For purposes of subsections (a) and (b), a qualified investment shall be treated as only including the expenses related to the acquisition, manufacturing, construction, reconstruction, erection, or maintenance of medical infrastructure. “(f) The word “acquired” does not include importation for purposes of this section, and the use of foreign labor or imported items for construction, manufacturing, acquisition, reconstruction, erection, or maintenance under this section shall not be considered qualifying under this section. “(g) Beginning fiscal year 2035, the amount defined by subsection (a) shall be treated as 20 percent of up to $20,000,000 worth of qualified investment for such taxable year. “(h) A “fitness facility” as defined by section 213 may be considered medical infrastructure for purposes of this section.”. (b) Secondary amendment.—Section 46 of the Internal Revenue Code of 1986 is amended by striking subsection (6) and inserting follows “(6) the qualifying medical infrastructure investment credit.”. (c) Effective date.—This section shall take effect for the first taxable year after its enactment into law. Sec. 211. Restoration of deduction for expenses allocable to Medicare part D subsidy. (a) In general.—Section 139A of the Internal Revenue Code of 1986 is amended by adding at the end the following new sentence: “This section shall not be taken into account for purposes of determining whether any deduction is allowable with respect to any cost taken into account in determining such payment.”. (b) Effective date.—The amendment made by this section shall apply to taxable years beginning after December 31, 2027. Sec. 212. Reduction of income threshold for determining medical care deduction. (a) In general.—Subsection (a) of section 213 of the Internal Revenue Code of 1986 is amended by striking “10 percent” and inserting “5.8 percent”. (b) Restriction of use.—Section 213 of the Internal Revenue Code of 1986 is amended by striking paragraph (d)(9) and inserting the following— “(9) Amounts paid for luxury services not taken into account.—The term “medical care” does not include applicable healthcare associated products and applicable luxury health plans as defined by sections 5892 and 4378 of the Internal Revenue Code.”. (c) Extension of temporary special rule.—Section 213 of the Internal Revenue Code of 1986 is amended by striking the number “2027” in subsection (f) and inserting “2028”. (d) Dependents included.—Section 213 of the Internal Revenue Code of 1986 is amended by inserting “except as not allowable under a credit under section 21” after “medical care”. (e) Effective date.—The amendment made by this section shall apply to taxable years beginning after December 31, 2027. Sec. 213. Repeal of Medicare tax increase. (a) In general.—Subsection (b) of section 3101 of the Internal Revenue Code of 1986 is amended to read as follows— “(b) Hospital insurance.—In addition to the tax imposed by the preceding subsection, there is hereby imposed on the income of every individual a tax equal to 1.45 percent of the wages (as defined in section 3121(a)) received by such individual with respect to employment (as defined in section 3121(b)).”. (b) SECA.—Subsection (b) of section 1401 of the Internal Revenue Code of 1986 is amended to read as follows— “(b) Hospital insurance.—In addition to the tax imposed by the preceding subsection, there shall be imposed for each taxable year, on the self-employment income of every individual, a tax equal to 2.9 percent of the amount of the self-employment income for such taxable year.”. (c) Effective date.—The amendments made by this section shall apply with respect to remuneration received after, and taxable years beginning after, December 31, 2028. Sec. 214. Refundable tax credit for health insurance coverage. (a) In general.—Section 36B of the Internal Revenue Code of 1986 is amended to read as follows— “Sec. 36B. Refundable credit for coverage under a qualified health plan. “(a) Allowance of premium tax credit.—In the case of an individual, there shall be allowed as a credit against the tax imposed by this Subtitle for the taxable year the sum of the monthly credit amounts with respect to such taxpayer for calendar months during such taxable year which are eligible coverage months appropriately taken into account under subsection (b)(2) with respect to the taxpayer or any qualifying family member of the taxpayer. “(b) Monthly credit amounts.— “(1) IN GENERAL.—The monthly credit amount with respect to any taxpayer for any calendar month is the lesser of— “(A) the sum of the monthly limitation amounts determined under subsection (c) with respect to the taxpayer and the taxpayer’s qualifying family members for such month, or “(B) the amount paid for a qualified health plan for the taxpayer and the taxpayer’s qualifying family members for such month. “(2) ELIGIBLE COVERAGE MONTH REQUIREMENT.—No amount shall be taken into account under subparagraph (A) or (B) of paragraph (1) with respect to any individual for any month unless such month is an eligible coverage month with respect to such individual. “(c) Monthly limitation amounts.— “(1) IN GENERAL.—The monthly limitation amount with respect to any individual for any eligible coverage month during any taxable year is 1⁄12 of— “(A) $2,000 in the case of an individual who has not attained age 30 as of the beginning of such taxable year, “(B) $2,500 in the case of an individual who has attained age 30 but who has not attained age 40 as of such time, “(C) $3,000 in the case of an individual who has attained age 40 but who has not attained age 50 as of such time, “(D) $3,500 in the case of an individual who has attained age 50 but who has not attained age 60 as of such time, and “(E) $4,000 in the case of an individual who has attained age 60 as of such time. “(2) LIMITATION BASED ON MODIFIED ADJUSTED GROSS INCOME.—The credit allowed under subsection (a) with respect to any taxpayer for any taxable year shall be reduced (but not below zero) by 10 percent of the excess (if any) of— “(A) the taxpayer’s modified adjusted gross income for such taxable year, over “(B) $75,000 (twice such amount in the case of a joint return). “(3) AGGREGATE DOLLAR LIMITATION.—The sum of the monthly limitation amounts taken into account under this section with respect to any taxpayer for any taxable year shall not exceed $20,000. “(d) Eligible coverage month.—For purposes of this section, the term ‘eligible coverage month’ means, with respect to any individual, any month if, as of the first day of such month, the individual meets the following requirements: “(1) The individual is covered by a qualified health plan, including by being a qualifying family member. “(2) The individual is not eligible for coverage under a group health plan (within the meaning of section 5000(b)(1)) other than coverage under a plan substantially all of the coverage of which is of excepted benefits described in section 9832(c). “(3) The individual is either a citizen or national of the United States. “(4) The individual is not incarcerated, other than incarceration pending the disposition of charges. “(e) Qualifying family member.—For purposes of this section, the term ‘qualifying family member’ means— “(1) the taxpayer’s spouse, “(2) any dependent of the taxpayer, and “(3) with respect to any eligible coverage month, any child (as defined in section 152(f)(1)) of the taxpayer who as of the end of the taxable year has not attained age 27 if such child is covered for such month under a qualified health plan which also covers the taxpayer (in the case of a joint return, either spouse). “(f) Qualified health plan.—For purposes of this section, the term ‘qualified health plan’ means any health insurance coverage (as defined in section 9832(b)) if— “(1) such coverage is offered via a federally-authorized health insurance exchange, was offered prior to the establishment of the first federally-authorized health insurance exchange; “(2) substantially all of such coverage is not of excepted benefits described in section 9832(c); and “(3) such health plan is not an applicable luxury health plan as defined by section 4378 and such coverage does not include applicable healthcare associated products as defined by section 5892. “(g) Special rules.— “(1) MARRIED COUPLES MUST FILE JOINT RETURN.—If the taxpayer is married (within the meaning of section 7703) at the close of the taxable year, no credit shall be allowed under this section to such taxpayer unless such taxpayer and the taxpayer’s spouse file a joint return for such taxable year. “(2) COORDINATION WITH MEDICAL EXPENSE DEDUCTION.—Amounts described in subsection (b)(1)(B) with respect to any month shall not be taken into account in determining the deduction allowed under section 213 except to the extent that such amounts exceed the amount described in subsection (b)(1)(A) with respect to such month. “(3) COORDINATION WITH ADVANCE PAYMENTS OF CREDIT.—With respect to any taxable year— “(A) the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a) shall be reduced (but not below zero) by the aggregate amount paid on behalf of such taxpayer for months beginning in such taxable year, and “(B) the tax imposed by section 1 for such taxable year shall be increased by the excess (if any) of— “(i) the aggregate amount paid on behalf of such taxpayer under such section 1412 for months beginning in such taxable year, over “(ii) the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a). “(4) SPECIAL RULES FOR QUALIFIED SMALL EMPLOYER HEALTH REIMBURSEMENT ARRANGEMENTS.— “(A) IN GENERAL.—If the taxpayer or any qualifying family member of the taxpayer is provided a qualified small employer health reimbursement arrangement for an eligible coverage month, the sum determined under subsection (b)(1)(A) with respect to the taxpayer shall be reduced (but not below zero) by 1⁄12 of the permitted benefit (as defined in section 9831(d)(3)(C)) under such arrangement for each such month such arrangement is provided to such taxpayer. “(B) QUALIFIED SMALL EMPLOYER HEALTH REIMBURSEMENT ARRANGEMENT.—For purposes of this paragraph, the term ‘qualified small employer health reimbursement arrangement’ has the meaning given such term by section 9831(d)(2). “(C) COVERAGE FOR LESS THAN ENTIRE YEAR.—In the case of an employee who is provided a qualified small employer health reimbursement arrangement for less than an entire year, subparagraph (A) shall be applied by substituting ‘the number of months during the year for which such arrangement was provided’ for ‘12’. “(5) INFLATION ADJUSTMENT.— “(A) IN GENERAL.—In the case of any taxable year beginning in a calendar year after 2020, each dollar amount in subsection (c)(1), the $75,000 amount in subsection (c)(2)(B), and the dollar amount in subsection (c)(3)(A), shall be increased by an amount equal to— “(i) such dollar amount, multiplied by “(ii) the cost-of-living adjustment determined under section 1(f)(3) for the calendar year in which the taxable year begins, determined— “(I) by substituting ‘calendar year 2027’ for ‘calendar year 1992’ in subparagraph (B) thereof, and “(II) by substituting for the CPI referred to section 1(f)(3)(A) the amount that such CPI would have been if the annual percentage increase in CPI with respect to each year after 2019 had been one percentage point greater. “(B) TERMS RELATED TO CPI.— “(i) ANNUAL PERCENTAGE INCREASE.—For purposes of subparagraph (A)(ii)(II), the term ‘annual percentage increase’ means the percentage (if any) by which CPI for any year exceeds CPI for the prior year. “(ii) OTHER TERMS.—Terms used in this paragraph which are also used in section 1(f)(3) shall have the same meanings as when used in such section. “(C) ROUNDING.—Any increase determined under subparagraph (A) shall be rounded to the nearest multiple of $50. “(6) RULES RELATED TO STATE CERTIFICATION OF QUALIFIED HEALTH PLANS.—A certification shall not be taken into account under subsection (d)(1) unless such certification is made available to the public and meets such other requirements as the Secretary may provide. “(7) REGULATIONS.—The Secretary may prescribe such regulations and other guidance as may be necessary or appropriate to carry out this section and ensure that monthly advance payments of this credit may be issued and excess payments of this credit may be recaptured.” “(h) Excess Credit May Be Deposited Into A Health Savings Account.— “(1) IN GENERAL.—If the amount described in subparagraph (B) of subsection (b)(2) exceeds the amount described in subparagraph (A) of such subsection with respect to any coverage month and an election under paragraph (2) is in effect with respect to the applicable taxpayer, the Secretary shall deposit such excess into a health savings account of such taxpayer. “(2) ELECTION TO DEPOSIT EXCESS CREDIT INTO A HEALTH SAVINGS ACCOUNT.—A taxpayer may elect (at such time and in such manner as the Secretary may provide) to have the Secretary deposit the excess described in paragraph (1) into a health savings account of the taxpayer. Any such election shall only be treated as being in effect if the taxpayer provides the Secretary with such information as the Secretary may require to allow the Secretary to make such deposit. “(3) COORDINATION WITH HEALTH SAVINGS ACCOUNT RULES.—Any amount deposited in a health savings account by the Secretary under this subsection shall— “(A) be includible in the gross income of the applicable taxpayer, and “(B) be taken into account as an amount paid to such account for purposes of this section. “(4) TREATMENT OF DEPOSITS.—For purposes of section 1324 of title 31, United States Code, any deposit made under this subsection shall be treated as a credit allowed under this section.”. (b) Increased penalty on erroneous claims of credit.—Section 6676(a) of the Internal Revenue Code of 1986 is amended by inserting “(25 percent in the case of a claim for refund or credit relating to the health insurance coverage credit under section 36B)”. (c) Reporting by employers.—Section 6051(a) of such Code is amended by striking “and” at the end of paragraph (14), by striking the period at the end of paragraph (15) and inserting “, and”, and by inserting after paragraph (15) the following new paragraph: “(16) each month with respect to which the employee is eligible for coverage described in section 36B(d)(2) in connection with employment with the employer.”. (d) Coordination with other tax benefits.— (1) CREDIT FOR HEALTH INSURANCE COSTS OF ELIGIBLE INDIVIDUALS.—Section 35(g) of such Code is amended by— (i) adding at the end the following new paragraph: “(14) COORDINATION WITH HEALTH INSURANCE COVERAGE CREDIT.— “(A) IN GENERAL.—An eligible coverage month to which the election under paragraph (11) applies shall not be treated as an eligible coverage month (as defined in section 36B(d)) for purposes of section 36B with respect to the taxpayer or any of the taxpayer’s qualifying family members (as defined in section 36B(e)). “(B) COORDINATION WITH ADVANCE PAYMENTS OF HEALTH INSURANCE COVERAGE CREDIT.—In the case of a taxpayer who makes the election under paragraph (11) with respect to any eligible coverage month in a taxable year or on behalf of whom any advance payment is made under section 7527 with respect to any month in such taxable year— “(i) the tax imposed by this chapter for the taxable year shall be increased by the excess, if any, of— “(I) the sum of any advance payments made on behalf of the taxpayer to pay for a qualified health plan, over “(II) the sum of the credits allowed under this section (determined without regard to paragraph (1)) and section 36B (determined without regard to subsection (g)(4)(A) thereof) for such taxable year, and “(ii) section 36B(g)(4)(B) shall not apply with respect to such taxpayer for such taxable year.”, and (ii) by striking “under section 1412 of the Patient Protection and Affordable Care Act and section 7527 for months during such taxable year” and inserting “under section 36B”. (2) TRADE OR BUSINESS DEDUCTION.—Section 162(l) of such Code is amended by adding at the end the following new paragraph: “(6) COORDINATION WITH HEALTH INSURANCE COVERAGE CREDIT.—The deduction otherwise allowable to a taxpayer under paragraph (1) for any taxable year shall be reduced (but not below zero) by the amount of the credit allowable to such taxpayer under section 36B (determined without regard to subsection (g)(4)(A) thereof) for such taxable year.”. (3) QUALIFIED HEALTH INSURANCE DEFINITION.—Section 35(e)(1)(J) of such Code is amended by striking “(other than coverage enrolled in through an Exchange established under the Patient Protection and Affordable Care Act)”. (4) COVERED HEALTH INSURANCE PROVIDER DEFINITION.—Section 162(m)(6)(C)(i) is amended as follows— “(i) The term “covered health insurance provider” means any employer which is a health insurance issuer (as defined in section 9832(b)(2)) and which receives premiums from providing health insurance coverage (as defined in section 9832(b)(1)).” (e) Effective date.—The amendments made by this section shall apply to months beginning after December 31, 2027, in taxable years ending after such date. The Internal Revenue Service may, during the first subsequent fiscal year, make transitional exceptions to permit continued use of the credit by currently-eligible taxpayers. Sec. 215. Maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation. (a) Self-Only coverage.—Section 223(b)(2)(A) of the Internal Revenue Code of 1986 is amended by striking “$2,250” and inserting “the amount in effect under subsection (c)(2)(A)(ii)(I)”. (b) Family coverage.—Section 223(b)(2)(B) of such Code is amended by striking “$4,500” and inserting “the amount in effect under subsection (c)(2)(A)(ii)(II)”. (c) Conforming amendments.—Section 223(g)(1) of such Code is amended— (1) by striking “subsections (b)(2) and” both places it appears and inserting “subsection”, and (2) in subparagraph (B), by striking “determined by” and all that follows through “ ‘calendar year 2003’.” and inserting “determined by substituting ‘calendar year 2003’ for ‘calendar year 1992’ in subparagraph (B) thereof.”. (d) Child coverage.—Section 223(c)(2)(A)(ii)(II) is amended by inserting “with $500 added for each child covered” after “subclause (I)”. (e) Effective date.—The amendments made by this section shall apply to taxable years beginning after December 31, 2027. Sec. 216. Allow both spouses to make catch-up contributions to the same health savings account. (a) In general.—Section 223(b)(5) of the Internal Revenue Code of 1986 is amended to read as follows— “(5) SPECIAL RULE FOR MARRIED INDIVIDUALS WITH FAMILY COVERAGE.— “(A) IN GENERAL.—In the case of individuals who are married to each other, if both spouses are eligible individuals and either spouse has family coverage under a high deductible health plan as of the first day of any month— “(i) the limitation under paragraph (1) shall be applied by not taking into account any other high deductible health plan coverage of either spouse (and if such spouses both have family coverage under separate high deductible health plans, only one such coverage shall be taken into account), “(ii) such limitation (after application of clause (i)) shall be reduced by the aggregate amount paid to Archer MSAs of such spouses for the taxable year, and “(iii) such limitation (after application of clauses (i) and (ii)) shall be divided equally between such spouses unless they agree on a different division. “(B) TREATMENT OF ADDITIONAL CONTRIBUTION AMOUNTS.—If both spouses referred to in subparagraph (A) have attained age 55 before the close of the taxable year, the limitation referred to in subparagraph (A)(iii) which is subject to division between the spouses shall include the additional contribution amounts determined under paragraph (3) for both spouses. In any other case, any additional contribution amount determined under paragraph (3) shall not be taken into account under subparagraph (A)(iii) and shall not be subject to division between the spouses.”. (b) Effective date.—The amendment made by this section shall apply to taxable years beginning after December 31, 2027. Sec. 217. Special rule for certain medical expenses incurred before establishment of health savings account. (a) In general.—Section 223(d)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph: “(D) TREATMENT OF CERTAIN MEDICAL EXPENSES INCURRED BEFORE ESTABLISHMENT OF ACCOUNT.—If a health savings account is established during the 60-day period beginning on the date that coverage of the account beneficiary under a high deductible health plan begins, then, solely for purposes of determining whether an amount paid is used for a qualified medical expense, such account shall be treated as having been established on the date that such coverage begins.”. (b) Effective date.—The amendment made by this section shall apply with respect to coverage beginning after December 31, 2027. Sec. 218. Expansion of medical expense deduction. (a) Exercise expenses.—Subsection (d) of section 213 of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraphs: “(12) EXERCISE EQUIPMENT AND PHYSICAL FITNESS ACTIVITY.— “(A) IN GENERAL.—The term ‘medical care’ shall include amounts paid— “(i) for equipment for use in a program (including a self-directed program) of physical exercise or physical activity, “(ii) to participate, or receive instruction (including videos, books, and similar materials), in a program of physical exercise, nutrition, or health coaching (including a self-directed program), and “(iii) for membership at a fitness facility. “(B) OVERALL DOLLAR LIMITATION.— “(i) IN GENERAL.—Amounts treated as medical care under subparagraph (A) shall not exceed $1,200 with respect to any individual for any taxable year. “(ii) EXCEPTION.—Clause (i) shall not apply for purposes of determining whether expenses reimbursed through a health flexible spending arrangement subject to section 125(i)(1) are incurred for medical care. “(C) LIMITATIONS RELATED TO SPORTS AND FITNESS EQUIPMENT.—Amounts paid for equipment described in subparagraph (A)(i) shall be treated as medical care only— “(i) if such equipment is utilized exclusively for participation in fitness, exercise, sport, or other physical activity programs, “(ii) if such equipment is not apparel or footwear, and “(iii) in the case of any item of sports equipment (other than exercise equipment), to the extent the amount paid for such item does not exceed $400. “(D) FITNESS FACILITY.—For purposes of subparagraph (A)(iii), the term ‘fitness facility’ means a facility— “(i) which provides instruction in a program of physical exercise, offers facilities for the preservation, maintenance, or development of physical fitness, or serves as the site of such a program of a State or local government, “(ii) which is not a private club owned and operated by its members, “(iii) which does not offer golf, hunting, sailing, or riding facilities, “(iv) whose health or fitness facility is not incidental to its overall function and purpose, and “(v) which provides exercise equipment for use by members. “(13) NUTRITIONAL AND DIETARY SUPPLEMENTS.— “(A) IN GENERAL.—The term ‘medical care’ shall include amounts paid to purchase herbs, vitamins, minerals, ketogenic foods and products, meal replacement products, and other dietary and nutritional supplements. “(B) LIMITATION.—Amounts treated as medical care under subparagraph (A) shall not exceed $2,000 with respect to any individual for any taxable year. “(C) MEAL REPLACEMENT PRODUCT.—For purposes of this paragraph, the term ‘meal replacement product’ means any product that— “(i) is permitted to bear labeling making a claim described in section 403(r)(3) of the Federal Food, Drug, and Cosmetic Act, and “(ii) is permitted to claim under such section that such product is low in fat and is a good source of protein, fiber, and multiple essential vitamins and minerals. “(14) PERIODIC PROVIDER FEES.—The term ‘medical care’ shall include— “(A) periodic fees paid to a primary care physician for a defined set of medical services or the right to receive medical services on an as-needed basis, and “(B) pre-paid primary care services designed to screen for, diagnose, cure, mitigate, treat, or prevent disease and promote wellness. “(15) TREATMENT OF CAPITATED PRIMARY CARE PAYMENTS.—Capitated primary care payments shall be treated as amounts paid for medical care. “(16) MENSTRUAL CARE PRODUCTS.—The term ‘medical care’ shall include products as defined by section 223(d)(2)(D).”. (e) Effective Date.—The amendment made by this section shall apply to taxable years beginning after the date of the enactment of this Act. Subtitle B—Repeal of Certain Consumer Taxes Sec. 221. Repeal of tax on prescription medications. Section 9008 of the Patient Protection and Affordable Care Act is repealed effective for the first fiscal year beginning after this Act enters into force. Subtitle C—Childcare-related provisions. Sec. 231. Encouragement of adoption of domestic orphans. (a) Special rules for foreign adoptions.—Section 23(e) of the Internal Revenue Code of 1986 is amended to read as follows— “(e) Special rules for foreign adoptions In the case of an adoption of a child who is not a citizen of the United States, subsection (a) shall not apply to any qualified adoption expense with respect to such adoption.” (b) Income limitation.—Section 23(b)(2) of such Code is amended by inserting the following subparagraph at the end— “(C) Suspension of income limitation For each taxable year from 2028 to 2033, the limitations established by this paragraph shall not apply.” (c) Special needs.—Section 23(d)(3) of such Code is amended to read as follows— “(3) Child with special needs The term “child with special needs” means any child if such child is a natural-born United States citizen and has a non-treatable disability which will hinder gainful employment for such child.” (d) Effective date.—The amendment made by this section shall apply to taxable years beginning after December 31, 2027. Sec. 232. Child tax deduction. (a) Definition of qualifying child.—Section 24(c)(1) of the Internal Revenue Code of 1986 is amended to strike “17” and insert “18”. (b) Special needs children.—Section 24(i) of the Internal Revenue Code of 1986 is amended to read as follows— “(i) Special increase for special-needs children In the case that a qualifying child is also a child with special needs as defined by section 23, any relevant amounts defined under this section should be treated as doubled.” (c) Special credit.—Section 24(k) of the Internal Revenue Code of 1986 is amended to read as follows— “(k) Special credit for treatment of developmental disability In the case that a qualifying child has autism or any other developmental disability or disorder, there shall be allowed an additional credit against the tax imposed by this chapter for the taxable year with respect to each qualifying child of the taxpayer for which the taxpayer is allowed a deduction under section 151 an amount up to or equal to $1,000 for the treatment of such developmental disability or disorder.” Subtitle D—Remuneration From Certain Insurers Sec. 241. Remuneration from certain insurers. Paragraph (6) of section 162(m) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph: “(I) TERMINATION.—This paragraph shall not apply to taxable years beginning after December 31, 2027.”. Subtitle E—Repeal of Net Investment Income Tax Sec. 251. Repeal of net investment income tax. (a) In general.—Subtitle A of the Internal Revenue Code of 1986 is amended by striking chapter 2A. (b) Effective date.—The amendment made by this section shall apply to taxable years beginning after December 31, 2027. TITLE III—Abortion and Contraception Subtitle A—Regulation of abortion. Sec. 301. All humans considered human. Section 8 of Chapter 1 of Title 1, United States Code is amended by inserting “or unborn (including any child in utero)” after “born alive”. Sec. 302. No Federal funds may be used for— (1) the HHS Reproductive Healthcare Access Task Force, which is hereby forever abolished and prohibited; or (2) any successor or substantially similar task force. Sec. 303. Diplomatic provisions. Chapter 117 of title 18, United States Code, is amended by inserting after section 2428 the following: “§2429. Department of State mandated to take action “(a) Recognition of foreign actions.—Any foreign government performing abortions or allowing abortions to be performed that would otherwise be illegal if performed in the United States shall be regarded as engaging in the unlawful execution of American citizens without due process. “(b) Department of State action.—The United States Department of State is authorized to prepare sanctions and other diplomatic consequences for such actions against American unborn children. “(c) Delegated authority.—The President of the United States and the Department of State are mandated to take necessary measures to ensure that the United States has sufficient capability to take action under this section, including to reallocate funds within the Department of State and if necessary authorize action by other Federal agencies when an activity is not best suited for the Department of State and collaborate with State, tribal, and local governments to enforce this section. “(d) Communications with foreign governments.—The President of the United States and the Department of State are mandated to communicate to foreign governments with information regarding when they should not allow American citizens to procure abortions. Sec. 304. Import and export regulation to prevent ectopic pregnancies. Section 801 of the Federal Food, Drug, and Cosmetic Act is amended by inserting after subsection (u) the following: “(v) Prohibition of imports and exports of drugs, substances, and devices causing ectopic pregnancies.—The Secretary shall prohibit the import and export of any drug, substance, or device that is found to be correlated to an increased risk in ectopic pregnancy. Exceptions may be made for lifesaving medical treatments and alcohol and tobacco products, provided appropriate regulation for risk-mitigation and labeling is enforced. Sec. 305. Abortifacient contraceptive regulation. (a) Section 505(v) of the Federal Food, Drug, and Cosmetic Act is amended as follows: “(v) Special standards for contraceptives.—No contraceptive shall be approved under this section, and any approval for such a contraceptive shall be withdrawn, if such contraceptive— “(1) increases the risk of ectopic pregnancy, complication of pregnancy, miscarriage, any condition that would result in damage to the reproductive system, or any condition which would in a reasonable medical judgment require treatment by salpingectomy or any other procedure which damages the reproductive system; “(2) causes depression, weight gain, or any other serious long-term mental or physical health problem; “(3) can be utilized as an abortifacient drug in proper dosage or increased dosage; or “(4) increases the risk of breast cancer or any other potentially fatal physical condition.”. (b) Section 201 of the Federal Food, Drug, and Cosmetic Act is amended by adding at the end the following new subsection (ss) as follows: “(ss) The term “contraceptive” refers to anything which is intended to prevent the conception of human children.”. (c) Section 516 of the Federal Food, Drug, and Cosmetic Act is amended by adding at the end the following new subsection (c) as follows: “(c) Special rule.—Whenever the Secretary finds, on the basis of all available data and information, that a contraceptive device— “(1) increases the risk of ectopic pregnancy, complication of pregnancy, miscarriage, any condition that would result in damage to the reproductive system, or any condition which would in a reasonable medical judgment require treatment by salpingectomy or any other procedure which damages the reproductive system; “(2) causes depression, weight gain, or any other serious long-term mental or physical health problem; or “(3) increases the risk of breast cancer or any other potentially fatal physical condition; “the Secretary may initiate a proceeding to promulgate a regulation to make such device a banned device.”. (d) Chapter VII of the Federal Food, Drug, and Cosmetic Act is amended by adding at the end of subchapter C the following: “Part 11—Fees relating to contraceptives. “Sec. 744O. Beginning in fiscal year 2028, the Secretary shall assess and collect fees from each person who submits an application to the Secretary for a contraceptive as needed to reflect the workload for the process for the review of contraceptives.”. (e) Neither this section nor any amendment made by it shall be interpreted as— (1) providing any immunity to any person in any civil or criminal action; (2) providing that, absent a regulation, rejection, or withdrawal issued by the Secretary, any contraceptive does not fulfill the conditions necessary for the rejection, withdrawal of approval, or issuance of a regulation to make a contraceptive a banned device; (3) providing that any contraceptive is safe to use or exempt from labeling requirements; (4) prohibiting the Secretary from rejecting any application for approval, withdrawing any approval, or issuing a regulation to make a contraceptive a banned device under general rules; or (5) permitting any ordinance or regulation which would reduce the need for transparency of the drawbacks of contraceptives. Sec. 306. Control of abortifacient drugs. Section 802 of Chapter 13 of title 21, United States Code is amended by adding at the end the following: “(59) The term “abuse” means— “any use of which could be addictive, abortifacient (to the child of a patient), or otherwise harmful to a patient.” Sec. 307. Enhancement of Criminal Penalties. (a) Civilian justice system.—Section 1841 of Title 18 of the United States Code is amended by— (1) striking subparagraph (a)(2)(D), (2) inserting “any Federal law, including” after “violates”, and (3) striking paragraphs (c)(1), (c)(2), and (c)(3) and inserting “of any act which is a constitutionally protected right.” (b) Military justice system.—Section 919a of Title 10 of the United States Code is amended by— (1) striking paragraph (a)(4), (2) striking “other than” and inserting “including”, and (3) striking paragraphs (c)(1), (c)(2), and (c)(3) and inserting “of any act which is a constitutionally protected right.” Sec. 308. Prohibition of anti-fetal hate crimes. (a) Discrimination by abortion against an unborn child on the basis of Down syndrome or other conditions prohibited.—Chapter 13 of title 18, United States Code, is amended by adding at the end the following: “§ 250. Discrimination by abortion against an unborn child on the basis of Down syndrome or other conditions prohibited “(a) Definitions.—In this section: “(1) DOWN SYNDROME.—The term ‘Down syndrome’ means a chromosomal disorder associated with— “(A) an extra copy of the chromosome 21, in whole or in part; or “(B) an effective trisomy for chromosome 21. “(b) Offense.—It shall be unlawful to— “(1) perform an abortion— “(A) with the knowledge that a pregnant woman is seeking an abortion, in whole or in part, on the basis of— “(i) a test result indicating that the unborn child has Down syndrome or another medical condition; “(ii) a prenatal diagnosis that the unborn child has Down syndrome or another medical condition; or “(iii) any other reason to believe that the unborn child has or may have Down syndrome or another medical condition; or “(B) without first— “(i) asking the pregnant woman if she is aware of any test results, prenatal diagnosis, or any other evidence that the unborn child has or may have Down syndrome or any other specific medical condition indicated, diagnosed, or otherwise reasoned to be associated to the unborn child; and “(ii) if the woman is aware that the unborn child has or may have Down syndrome or another medical condition, informing the pregnant woman of the prohibitions on abortion under this section; “(2) use force or the threat of force to intentionally injure or intimidate any person for the purpose of coercing an abortion described in paragraph (1)(A); “(3) solicit or accept funds for the performance of an abortion described in paragraph (1)(A); or “(4) knowingly transport a woman into the United States or across a State line for the purpose of obtaining an abortion described in paragraph (1)(A). “(c) Criminal penalty.—Any person that violates, or attempts to violate, subsection (b) shall be fined under this title, imprisoned not more than 5 years, or both. “(d) Civil remedies.— “(1) CIVIL ACTION BY WOMAN ON WHOM ABORTION IS PERFORMED.—A woman upon whom an abortion has been performed or attempted in violation of subsection (b)(2) may bring a civil action in an appropriate court against any person who engaged in a violation of subsection (b)(2) to obtain appropriate relief. “(2) CIVIL ACTION BY RELATIVES.— “(A) IN GENERAL.—Except as provided in subparagraph (B), the father of an unborn child who is the subject of an abortion performed or attempted in violation of subsection (b), or a maternal grandparent of the unborn child if the pregnant woman is an unemancipated minor, may bring a civil action in an appropriate court against any person who engaged in the violation to obtain appropriate relief. “(B) EXCEPTIONS.—Subparagraph (A) shall not apply if— “(i) the pregnancy or abortion resulted from the criminal conduct of the plaintiff described in subparagraph (A); or “(ii) the plaintiff described in subparagraph (A) consented to the abortion. “(3) APPROPRIATE RELIEF.—Appropriate relief in a civil action under this subsection includes— “(A) objectively verifiable money damages for all injuries, psychological and physical, including loss of companionship and support, occasioned by the violation of this section; and “(B) punitive damages. “(4) INJUNCTIVE RELIEF.—A qualified plaintiff may bring a civil action in an appropriate court to obtain injunctive relief to prevent an abortion provider from performing or attempting further abortions in violation of this section. “(5) ATTORNEY’S FEES FOR PLAINTIFF.—The court shall award a reasonable attorney’s fee as part of the costs to a prevailing plaintiff in a civil action under this subsection. “(e) Bar to prosecution.—A woman upon whom an abortion is performed may not be prosecuted or held civilly liable for any violation of this section or for a conspiracy to violate this section. “(f) Loss of Federal funding.—A violation of subsection (b) shall be deemed discrimination for the purposes of section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794). “(g) Reporting requirement.— “(1) IN GENERAL.—A physician, physician’s assistant, nurse, counselor, or other medical or mental health professional shall report known or suspected violations of any of this section to appropriate law enforcement authorities. “(2) CRIMINAL PENALTY.—Any person who violates paragraph (1) shall be fined under this title, imprisoned not more than 1 year, or both. “(h) Expedited consideration.—It shall be the duty of the district courts of the United States, the courts of appeals of the United States, and the Supreme Court of the United States to advance on the docket and to expedite to the greatest possible extent the disposition of any matter brought under this section. “(i) Protection of privacy in court proceedings.— “(1) IN GENERAL.—Except to the extent the Constitution of the United States or other similarly compelling reason requires, in every civil or criminal action under this section, the court shall make such orders as are necessary to protect the anonymity of any woman upon whom an abortion has been performed or attempted if she does not give her written consent to such disclosure. Such orders may be made upon motion, but shall be made sua sponte if not otherwise sought by a party. “(2) ORDERS TO PARTIES, WITNESSES, AND COUNSEL.—The court shall issue appropriate orders to the parties, witnesses, and counsel and shall direct the sealing of the record and exclusion of individuals from courtrooms or hearing rooms to the extent necessary to safeguard the identity of a woman described in paragraph (1) from public disclosure. “(3) PSEUDONYM REQUIRED.—In the absence of written consent of the woman upon whom an abortion has been performed or attempted, any party, other than a public official, who brings an action under this section shall do so under a pseudonym. “(4) LIMITATION.—This subsection may not be construed to conceal the identity of the plaintiff or of witnesses from the defendant or from attorneys for the defendant.”. (b) Clerical amendment.—The table of sections of chapter 13 of title 18, United States Code, is amended by adding at the end the following: “250. Discrimination by abortion against an unborn child on the basis of Down syndrome prohibited.”. (c) Age as reason.—Section 249 of Title 18 of the United States Code is amended by adding “ age,” after each reference to “religion” and by amending paragraph (c)(4) as “the term “age” includes any crime committed against a human who is deemed permissible to harm or kill on the basis of age or any crime intended to kill an unborn person in a woman who is pregnant or perceived to be pregnant; and” Subtitle B—Technical provisions. Sec. 311. HHS authority. The Secretary of Health and Human Services is authorized to administer chapters 74 and 117 of the United States Code pending the transfer of authority to a new or different agency or agencies by the President of the United States. No territory or district of the United States, notwithstanding any other law, may refuse to take action to enforce this Act or any provision created or amended by it. Sec. 312. Role of State, tribal, and local law. Neither this Act nor any section amended or created by it shall be regarded as preempting any State, tribal, or local law restricting abortion, contraception, or anything that causes ectopic pregnancy; states are authorized to take action to create laws for the purpose of concurrent enforcement of this Act within their borders. This Act and all provisions of law amended or created by it are effective as of their proper effective dates notwithstanding any State law which may claim to mandate noncompliance. State, tribal, and local governments are fully enabled to engage in concurrent enforcement and no law restricting abortion or contraception shall be interpreted as having been pre-empted by this Title. Sec. 313. Effective date. Except as otherwise specified, this Title and all provisions created or amended by it shall enter into force on January 1, 2028. Sec. 314. Authorization of appropriations. There is authorized to be appropriated to carry out this Title, $10,000,000 per fiscal year for the first three fiscal years it remains in effect, in addition to any funds otherwise appropriated. Subtitle C—Other regulations relating to remains and contraception. Sec. 321. Closing "valuable consideration" loopholes. Section 498B(e) of the Public Health Service Act (42 U.S.C. 289–2(e)) is amended by striking paragraph (3) and inserting the following new paragraph: “(3) The term ‘valuable consideration’ includes— “(A) any payment made or debt incurred; “(B) any gift, honorarium, or recognition of value bestowed; “(C) any price, charge, or fee which is waived, forgiven, reduced, or indefinitely delayed; “(D) any loan or debt which is canceled or otherwise forgiven; “(E) the transfer of any item from one person to another or provision of any service or granting of any opportunity for which a charge is customarily made, without charge or for a reduced charge; and “(F) any payments associated with the transportation, implantation, processing, preservation, quality control, or storage of human fetal tissue.”. Sec. 322. Cleaning American water supplies. Part H of title IV of the Public Health Service Act (42 U.S.C. 289 et seq.) is amended by adding at the end the following: “SEC. 498F. PROHIBITION OF HUMAN REMAINS IN PUBLICLY OWNED WATER SYSTEMS. “(a) In General.—The intentional disposal of human remains in publicly-owned water systems is prohibited. “(b) Penalties For Violation.—Any person who violates subsection (a) shall be fined in accordance with title 18, United States Code, imprisoned not more than 7 years, or both. “(c) Definitions.—In this section: “(1) HUMAN REMAINS.—The term ‘human remains’ means— “(A) the remains of any deceased human (or a portion thereof); “(B) the detached body parts of living humans; and “(B) any other medical waste associated with an abortion. “(2) PUBLICLY OWNED WATER SYSTEM.—The term ‘publicly owned water system’ means a system of facilities owned or controlled by a Federal, State, or local government entity, the purpose of which is to provide, transport, or treat water, including the drains, pipes, and other devices that connect to such system.”. Sec. 323. Conservatorships prohibited from excessive control over reproduction. Section 1128(a) of the Social Security Act (42 U.S.C. 1320a–7(a)) is amended by adding at the end the following new paragraph: “(5) CERTAIN ACTS FORCING CONTRACEPTION WITH RESPECT TO INDIVIDUALS SUBJECT TO CONSERVATORSHIP.—Any health care provider that on or after the date of the enactment of this paragraph— “(A) denies the removal of an intrauterine device or other contraceptive device from an individual who is subject to a conservatorship by reason of the conservator not approving of such removal; “(B) knowingly sterilizes (including by means of castration or hysterectomy) an individual who is subject to a conservatorship by reason of the conservator approving such sterilization; or “(B) knowingly prescribes birth control medication (including any method of contraception approved or otherwise authorized by the Food and Drug Administration) to an individual subject to a conservatorship without the written consent of such individual.”. Subtitle D—Backup regulations. Sec. 331. Definitions. Chapter 74 of title 18, United States Code, is amended by inserting after section 1531 the following: “§1532. Definitions.—In this chapter the following definitions apply: “(a) ABORTION.—The term ‘abortion’ means the use or prescription of any instrument, medicine, drug, or any other substance, device, procedure, or other means— “(1) to intentionally kill the unborn child of a woman known to be pregnant; or “(2) to intentionally terminate the pregnancy of a woman known to be pregnant, with an intention other than— “(A) after viability to produce a live birth and preserve the life and health of the child born alive; or “(B) to remove a dead unborn child. “(b) ATTEMPT.—The term ‘attempt’, with respect to an abortion, means conduct that, under the circumstances as the actor believes them to be, constitutes a substantial step in a course of conduct planned to culminate in performing an abortion. “(c) COUNSELING.—The term ‘counseling’ means counseling provided by a counselor licensed by the State, or a victims rights advocate provided by a law enforcement agency. “(d) FACILITY.—The term ‘facility’ means any medical or counseling group, center or clinic and includes the entire legal entity, including any entity that controls, is controlled by, or is under common control with such facility. “(e) FERTILIZATION.—The term ‘fertilization’ means the fusion of human spermatozoon with a human ovum. “(f) MEDICAL TREATMENT.—The term ‘medical treatment’ means treatment provided at a hospital licensed by the State or operated under authority of a Federal agency, at a medical clinic licensed by the State or operated under authority of a Federal agency, or from a personal physician licensed by the State. “(g) MINOR.—The term ‘minor’ means an individual who has not attained the age of 21 years. “(h) PERFORM.—The term ‘perform’, with respect to an abortion, includes inducing an abortion through a medical or chemical intervention including writing a prescription for a drug or device intended to result in an abortion. “(i) PHYSICIAN.—The term ‘physician’ means— “(1) a person licensed to practice medicine and surgery or osteopathic medicine and surgery, or otherwise legally authorized to perform an abortion, “(2) a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which the doctor performs such activity, “(3) any other individual legally authorized by the State to perform abortions, or “(4) any individual who is not a physician or not otherwise legally authorized by the State to perform abortions, but who nevertheless directly performs an abortion prohibited in this chapter. “(j) POST-FERTILIZATION AGE.—The term ‘post-fertilization age’ means the age of the unborn child as calculated from the fusion of a human spermatozoon with a human ovum. “(k) PROBABLE POST-FERTILIZATION AGE OF THE UNBORN CHILD.—The term ‘probable post-fertilization age of the unborn child’ means what, in reasonable medical judgment, will with reasonable probability be the post-fertilization age of the unborn child at the time the abortion is planned to be performed or induced. “(l) REASONABLE MEDICAL JUDGMENT.—The term ‘reasonable medical judgment’ means a medical judgment that would be made by a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved. “(m) UNBORN CHILD.—The term ‘unborn child’ means an individual organism of the species homo sapiens, beginning at fertilization, until the point of being born alive as defined in section 8(b) of title 1. “(n) WOMAN.—The term ‘woman’ means a female human being whether or not she has reached the age of majority. For the purposes of this chapter, women who have had legal sex changes shall also be classified as women. “(o) MEDICAL CONDITION.—The term ‘medical condition’ means any illness, syndrome, disease, infection, disorder, addiction, element of a medical history, or other health issue. “(p) DELIVERY.—The term ‘delivery’ means the use or prescription of any instrument, medicine, drug, or any other substance or device to intentionally terminate the pregnancy of a woman known to be pregnant after viability to produce a live birth and preserve the life and health of the child born alive. “(q) DISMEMBERMENT ABORTION.—The term ‘dismemberment abortion’— “(1) means, with the purpose of causing the death of an unborn child, knowingly dismembering a living unborn child and extracting such unborn child one piece at a time or intact but crushed from the uterus through the use of clamps, grasping forceps, tongs, scissors, or similar instruments that, through the convergence of two rigid levers, slice, crush, or grasp a portion of the unborn child’s body in order to cut or rip it off or crush it; and “(2) does not include an abortion that uses suction to dismember the body of the unborn child by sucking fetal parts into a collection container unless the actions described in subparagraph (A) are used to cause the death of an unborn child but suction is subsequently used to extract fetal parts after the death of the unborn child. “(r) ABORTION PROVIDER.—The term ‘abortion provider’ means any individual, site, facility, or entity that either performs abortions or is used to perform abortions or is a physician as defined by subsection (i); and “(s) HUMAN FETAL TISSUE.—The term ‘human fetal tissue’ means any organ, tissue, cells, or other material obtained from a dead unborn child, including a zygote, embryo, or fetus which are obtained via spontaneous, induced, or forced abortion, miscarriage, or stillbirth. “(t) QUALIFIED PLAINTIFF.—The term ‘qualified plaintiff’ means— “(1) a woman upon whom an abortion is performed or attempted in violation of this section; “(2) a maternal grandparent of the unborn child if the woman upon whom an abortion is performed or attempted in violation of this section is an unemancipated minor; “(3) the father of an unborn child who is the subject of an abortion performed or attempted in violation of this section unless the pregnancy or abortion resulted from the criminal conduct of the father; or “(4) the Attorney General. “(u) The term “abortion drug” means any medicine, drug, or any other substance or combination of drugs, medicine or substances used for an abortion. “(v) The term “certified health care provider” means an abortion provider that has completed a Prescriber Agreement Form pursuant to the elements for safe use under the applicable risk evaluation and mitigation strategy under section 505–1 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355–1) relating to abortion drugs, under which the provider agrees to the following: “(A) The provider has the following qualifications: “(i) Ability to assess the duration of pregnancy accurately. “(ii) Ability to diagnose ectopic pregnancies. “(iii) Ability to provide surgical intervention in cases of incomplete abortion or severe bleeding, or to have made plans to provide such care through others, and ability to assure patient access to medical facilities equipped to provide blood transfusions and resuscitation, if necessary. “(B) The provider will follow the guidelines for use of mifepristone under the applicable risk evaluation and mitigation strategy under section 505–1 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355–1) relating to abortion drugs.”. Sec. 332. Pain-capable unborn child protection. (a) In general.—Chapter 74 of title 18, United States Code, is amended by inserting after section 1532 the following: “§1533. Pain-capable unborn child protection “(a) Unlawful conduct.—Notwithstanding any other provision of law, it shall be unlawful for any person to perform an abortion or attempt to do so, unless in conformity with the requirements set forth in subsection (b). “(b) Requirements for Abortions.— “(1) ASSESSMENT OF THE AGE OF THE UNBORN CHILD.—The physician performing or attempting the abortion shall first make a determination of the probable post-fertilization age of the unborn child or reasonably rely upon such a determination made by another physician. In making such a determination, the physician shall make such inquiries of the pregnant woman and perform or cause to be performed such medical examinations and tests as a reasonably prudent physician, knowledgeable about the case and the medical conditions involved, would consider necessary to make an accurate determination of post-fertilization age. “(2) PROHIBITION ON PERFORMANCE OF CERTAIN ABORTIONS.— “(A) GENERALLY FOR UNBORN CHILDREN 10 WEEKS OR OLDER.—Except as provided in subparagraph (B), the abortion shall not be performed or attempted, if the probable post-fertilization age, as determined under paragraph (1), of the unborn child is 10 weeks or greater. “(B) EXCEPTIONS.—Subparagraph (A) does not apply if in reasonable medical judgment, the abortion is necessary to save the life of a pregnant woman whose life is endangered by a physical medical condition caused by or arising from the pregnancy itself, but not including psychological or emotional conditions. “(C) REQUIREMENT AS TO MANNER OF PROCEDURE PERFORMED.—Notwithstanding the definitions of ‘abortion’ and ‘attempt an abortion’ in this chapter, a physician terminating or attempting to terminate a pregnancy under an exception provided by subparagraph (B) may do so only in the manner which, in reasonable medical judgment, provides the best opportunity for the unborn child to survive. “(D) REQUIREMENT THAT A PHYSICIAN TRAINED IN NEONATAL RESUSCITATION BE PRESENT.—If, in reasonable medical judgment, the pain-capable unborn child has the potential to survive outside the womb, the physician who performs or attempts an abortion under an exception provided by subparagraph (B) shall ensure a second physician trained in neonatal resuscitation is present and prepared to provide care to the child consistent with the requirements of subparagraph (E). “(E) CHILDREN BORN ALIVE AFTER ATTEMPTED ABORTIONS.—When a physician performs or attempts an abortion in accordance with this section, and the child is born alive, as defined in section 8 of title 1 (commonly known as the Born-Alive Infants Protection Act of 2002), the following shall apply: “(i) DEGREE OF CARE REQUIRED.—Any health care practitioner present at the time shall humanely exercise the same degree of professional skill, care, and diligence to preserve the life and health of the child as a reasonably diligent and conscientious health care practitioner would render to a child born alive at the same gestational age in the course of a natural birth. “(ii) IMMEDIATE ADMISSION TO A HOSPITAL.—Following the care required to be rendered under clause (i), the child born alive shall be immediately transported and admitted to a hospital. “(iii) MANDATORY REPORTING OF VIOLATIONS.—A health care practitioner or any employee of a hospital, a physician’s office, or an abortion clinic who has knowledge of a failure to comply with the requirements of this subparagraph must immediately report the failure to an appropriate State or Federal law enforcement agency or both. “(F) DOCUMENTATION REQUIREMENTS.— “(i) DOCUMENTATION PERTAINING TO ADULTS.—A physician who performs or attempts to perform an abortion under an exception provided by subparagraph (B)(ii) shall, prior to the abortion, place in the patient medical file documentation from a hospital licensed by the State or operated under authority of a Federal agency, a medical clinic licensed by the State or operated under authority of a Federal agency, from a personal physician licensed by the State, a counselor licensed by the State, or a victim’s rights advocate provided by a law enforcement agency that the adult woman seeking the abortion obtained medical treatment or counseling for the rape or an injury related to the rape. “(ii) DOCUMENTATION PERTAINING TO MINORS.—A physician who performs or attempts to perform an abortion under an exception provided by subparagraph (B)(iii) shall, prior to the abortion, place in the patient medical file documentation from a government agency legally authorized to act on reports of child abuse that the rape or incest was reported prior to the abortion; or, as an alternative, documentation from a law enforcement agency that the rape or incest was reported prior to the abortion. “(G) INFORMED CONSENT.— “(i) CONSENT FORM REQUIRED.—The physician who intends to perform or attempt to perform an abortion under the provisions of subparagraph (B) may not perform any part of the abortion procedure without first obtaining a signed Informed Consent Authorization form in accordance with this subparagraph. “(ii) CONTENT OF CONSENT FORM.—The Informed Consent Authorization form shall be presented in person by the physician and shall consist of— “(I) a statement by the physician indicating the probable post-fertilization age of the pain-capable unborn child; “(II) a statement that Federal law allows abortion after 20 weeks fetal age only if the mother’s life is endangered by a physical disorder, physical illness, or physical injury, when the pregnancy was the result of rape, or an act of incest against a minor; “(III) a statement that the abortion must be performed by the method most likely to allow the child to be born alive unless this would cause significant risk to the mother; “(IV) a statement that in any case in which an abortion procedure results in a child born alive, Federal law requires that child to be given every form of medical assistance that is provided to children spontaneously born prematurely, including transportation and admittance to a hospital; “(V) a statement that these requirements are binding upon the physician and all other medical personnel who are subject to criminal and civil penalties and that a woman on whom an abortion has been performed may take civil action if these requirements are not followed; and “(VI) affirmation that each signer has filled out the informed consent form to the best of their knowledge and understands the information contained in the form. “(iii) SIGNATORIES REQUIRED.—The Informed Consent Authorization form shall be signed in person by the woman seeking the abortion, the physician performing or attempting to perform the abortion, and a witness. “(iv) RETENTION OF CONSENT FORM.—The physician performing or attempting to perform an abortion must retain the signed informed consent form in the patient’s medical file. “(H) REQUIREMENT FOR DATA RETENTION.—Paragraph (j)(2) of section 164.530 of title 45, Code of Federal Regulations, shall apply to documentation required to be placed in a patient’s medical file pursuant to subparagraph (F) of subsection (b)(2) and a consent form required to be retained in a patient’s medical file pursuant to subparagraph (G) of such subsection in the same manner and to the same extent as such paragraph applies to documentation required by paragraph (j)(1) of such section. “(I) ADDITIONAL EXCEPTIONS AND REQUIREMENTS.— “(i) IN CASES OF RISK OF DEATH OR MAJOR INJURY TO THE MOTHER.—Subparagraphs (c), (D), and (G) shall not apply if, in reasonable medical judgment, compliance with such paragraphs would pose a greater risk of— “(I) the death of the pregnant woman; or “(II) the substantial and irreversible physical impairment of a major bodily function, not including psychological or emotional conditions, of the pregnant woman. “(ii) EXCLUSION OF CERTAIN FACILITIES.—Notwithstanding the definitions of the terms ‘medical treatment’ and ‘counseling’ in this chapter, the counseling or medical treatment described in subparagraph (B)(ii) may not be provided by a facility that performs abortions (unless that facility is a hospital). “(iii) RULE OF CONSTRUCTION IN CASES OF REPORTS TO LAW ENFORCEMENT.—The requirements of subparagraph (B)(ii) do not apply if the rape has been reported at any time prior to the abortion to a law enforcement agency or Department of Defense victim assistance personnel. “(iv) COMPLIANCE WITH CERTAIN STATE LAWS.— “(I) STATE LAWS REGARDING REPORTING OF RAPE AND INCEST.—The physician who performs or attempts to perform an abortion under an exception provided by subparagraph (B) shall comply with such applicable State laws that are in effect as the State’s Attorney General may designate, regarding reporting requirements in cases of rape or incest. “(II) STATE LAWS REGARDING PARENTAL INVOLVEMENT.—The physician who intends to perform an abortion on a minor under an exception provided by subparagraph (B) shall comply with any applicable State laws requiring parental involvement in a minor’s decision to have an abortion. “(c) Criminal penalty.—Whoever violates subsection (a) or serves as an accomplice to such violation shall be punished by both confiscation of all property and by either death or imprisonment for life. “(d) Bar to prosecution.—A woman upon whom an abortion in violation of subsection (a) is performed or attempted may not be prosecuted under, or for a conspiracy to violate, subsection (a), or for an offense under section 2, 3, or 4 of this title based on such a violation. “(e) Civil remedies.— “(1) CIVIL ACTION BY A WOMAN ON WHOM AN ABORTION IS PERFORMED.—A woman upon whom an abortion has been performed or attempted in violation of any provision of this section may, in a civil action against any person who committed the violation, obtain appropriate relief. “(2) CIVIL ACTION BY A PARENT OF A MINOR ON WHOM AN ABORTION IS PERFORMED.—A parent of a minor upon whom an abortion has been performed or attempted under an exception provided for in subsection (b)(2)(B), and that was performed in violation of any provision of this section may, in a civil action against any person who committed the violation obtain appropriate relief, unless the pregnancy resulted from the plaintiff’s criminal conduct. “(3) APPROPRIATE RELIEF.—Appropriate relief in a civil action under this subsection includes— “(A) objectively verifiable money damages for all injuries, psychological and physical, occasioned by the violation; “(B) statutory damages equal to three times the cost of the abortion; and “(C) punitive damages. “(4) ATTORNEYS FEES FOR PLAINTIFF.—The court shall award a reasonable attorney’s fee as part of the costs to a prevailing plaintiff in a civil action under this subsection. “(5) ATTORNEYS FEES FOR DEFENDANT.—If a defendant in a civil action under this subsection prevails and the court finds that the plaintiff’s suit was frivolous, the court shall award a reasonable attorney’s fee in favor of the defendant against the plaintiff. “(6) AWARDS AGAINST WOMAN.—Except under paragraph (5), in a civil action under this subsection, no damages, attorney’s fee or other monetary relief may be assessed against a woman upon whom an abortion was performed or attempted without consent. “(f) Data collection.— “(1) DATA SUBMISSIONS.—Any physician who performs or attempts an abortion described in subsection (b)(2)(B) shall annually submit a summary of all such abortions to the National Center for Health Statistics (hereinafter referred to as the ‘Center’) not later than 60 days after the end of the calendar year in which the abortion was performed or attempted. “(2) CONTENTS OF SUMMARY.—The summary shall include the number of abortions performed or attempted on an unborn child who had a post-fertilization age of 20 weeks or more and specify the following for each abortion under subsection (b)(2)(B): “(A) the probable post-fertilization age of the unborn child; “(B) the method used to carry out the abortion; “(C) the location where the abortion was conducted; “(D) the exception under subsection (b)(2)(B) under which the abortion was conducted; and “(E) any incident of live birth resulting from the abortion. “(3) EXCLUSIONS FROM DATA SUBMISSIONS.—A summary required under this subsection shall not contain any information identifying the woman whose pregnancy was terminated and shall be submitted consistent with the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note). “(4) PUBLIC REPORT.—The Center shall annually issue a public report providing statistics by State for the previous year compiled from all of the summaries made to the Center under this subsection. The Center shall take care to ensure that none of the information included in the public reports could reasonably lead to the identification of any pregnant woman upon whom an abortion was performed or attempted. The annual report shall be issued by July 1 of the calendar year following the year in which the abortions were performed or attempted.”. (b) Clerical amendment.—The table of sections at the beginning of chapter 74 of title 18, United States Code, is amended by adding at the end the following new items: “1532. Definitions.”. “1533. Pain-capable unborn child protection.”. “1534. Abortion statistics and accountability.”. “1534A. Abortion recipient identification.”. “1534B. Abortion provider licensing.”. “1535. Forced abortion.”. “1536. Abortions prohibited without a healthcare provider physically present.”. “1537. Requirements pertaining to born-alive abortion survivors.”. “1538. Dismemberment abortion ban.”. “1539. Dismemberment abortion ban.”. (c) Chapter heading amendments.— (1) CHAPTER HEADING IN CHAPTER.—The chapter heading for chapter 74 of title 18, United States Code, is amended by striking “Partial-Birth Abortions” and inserting “Abortions”. (2) TABLE OF CHAPTERS FOR PART I.—The item relating to chapter 74 in the table of chapters at the beginning of part I of title 18, United States Code, is amended to read as follows— “74. Abortions ................................................................................​........ 1531”. Sec. 333. Abortion statistics and accountability. Chapter 74 of title 18, United States Code, is amended by inserting after section 1533 the following: “§1534. Abortion statistics and accountability “(a) Unlawful conduct.—Notwithstanding any other provision of law, it shall be unlawful for any person to perform an abortion or attempt to do so, unless in conformity with the requirements set forth in subsection (b). “(b) It shall be lawful for a federally-licensed abortion provider to perform an abortion or attempt to do so provided the following requirements are fulfilled.— “(1) Post-abortion reporting.—After any otherwise lawful abortion, reports must be submitted to Federal, State, tribal, and local governments on a quarterly basis, containing information on the financial revenues and expenditures related to any post-abortion activities, including but not limited to disposal, transfer of ownership or custody, donation, or burial, as well as how many aborted unborn children were involved by the person providing abortion services in each of these. Expenditures must be comprehensively broken down in order to reveal how much of them went to salaries, savings, marketing/sales, management purposes, and other categories which shall be established by the National Center for Health Statistics. “(2) Medical reporting.—Before any otherwise lawful abortion, abortion providers are mandated to survey any FDA-approved drugs, controlled substances, alcohol or tobacco products, or other medical devices or treatments a woman was taking or using, as well as any illnesses from which the woman suffered, and any medical conditions afflicting the woman, as well as any complications relating to her pregnancy or abortion, and then report statistics derived from said surveys to Federal, State, tribal, and local governments on a quarterly basis. In cases of emergency or otherwise dire need, the survey may be postponed for health purposes, but the amount of postponements for such purposes must be reported as well. “(3) Rationale reporting.—Before any otherwise lawful abortion, abortion providers are mandated to survey the reasons for which a woman has decided to obtain an abortion and then report statistics derived from said surveys to Federal, State, tribal, and local governments on a quarterly basis. In cases of emergency or otherwise dire need, the survey may be cancelled or postponed for health purposes, but the amount of cancellations or postponements for such purposes must be reported as well, and in the case of a cancellation, abortion providers shall be required to honestly submit approximate guesses, under penalty of perjury. “(4) Demographic reporting.—Before any otherwise lawful abortion, abortion providers are mandated to survey the demographics—including race, religion, ethnicity, ancestry, sexual orientation, gender identity, marital status, age, tribe, location of residence (such as Census-Designated Place, county or county-equivalent, or city or county, etc.), and nationality/citizenship, as well as the potential father or fathers of the child including the same information—of a woman who has decided to obtain an abortion and then report statistics derived from said surveys to Federal, State, tribal, and local governments on a quarterly basis. In cases of emergency or otherwise dire need, the survey may be cancelled or postponed for health purposes, but the amount of cancellations or postponements for such purposes must be reported as well. “(5) Gestational reporting.—Before any otherwise lawful abortion, abortion providers are mandated to acquire information regarding the development of the unborn child—including its age, vital signs, and capabilities—and then report statistics derived from said surveys to Federal, State, tribal, and local governments on a quarterly basis. In cases of emergency or otherwise dire need, this mandate may be alternatively fulfilled by providing the a reasonable medical judgment of the gestational period. “(6) Comprehensiveness of reporting.—All reports are required to be comprehensive and inter-sectional and display the maximum level of detail, allowing maximum flexibility when these statistics are ultimately compiled and published to the website of the Center—each case sharing 100% the same characteristics for reporting purposes shall be displayed together in an anonymous fashion. “(7) Privacy.—In extreme cases of lack of low sample sizes relating to the location of residence or tribe which seriously threaten the anonymity of a woman, there shall be no publishing of such statistics. A woman seeking an abortion has the right to refuse to disclose information for survey purposes, and such refusals must be disclosed in reported statistics. Abortion providers shall be required to ensure that women shall feel comfortable disclosing such information (including informing them of their privacy rights related to said surveys) and shall be prohibited from intentionally taking action to make them uncomfortable in doing so. “(c) States permitted to refuse to participate.—It shall be lawful for a federally-licensed abortion provider to fail to perform reporting to a State or local government under subsection (b) if said State or local government refuses to accept reports from abortion providers or does not provide a means to submit such reports. “(d) Medical reporting for non-abortive purposes.—After any medical treatment to remove a dead unborn child or to produce a live birth and preserve the life and health of the child born alive, a person who performed such a medical treatment is mandated to perform similar surveys and submit similar reports as required by subsection (b) except for subsection (b)(3); likewise, the protection granted by subsection (c) applies to such persons. “(e) Agency responsible.—Reports submitted to comply with this section shall be submitted to the National Center for Health Statistics, which shall issue at least one annual report providing detailed statistics regarding abortion to the public, and such reports shall be issued no later than July 1 of the calendar year following the year in which the abortions were performed or attempted. The National Center for Health Statistics shall be permitted to cooperate with other agencies and launch independent investigations as may be necessary to ensure the honesty of physicians. “(f) Emergency situations.—An emergency room or hospital containing an emergency room is required to provide similar statistics when an abortion is performed; however, the National Center for Health Statistics shall be permitted to waive restrictions as may be necessary for realistic purposes. “(g) Comprehensive data.—In collecting and making available information on death and injury numbers and rates in the United States, the National Center for Health Statistics shall, to the extent possible, include in such numbers and rates any abortion or other prenatal death of an unborn child, including any human zygote, embryo, or fetus. Furthermore, other agencies including the Centers for Disease Control and Prevention shall utilize such data as shall be shared by the National Center for Health Statistics in their own publications as appropriate, including in all publications of death statistics, except that age-restricted statistics may be published provided such statistics shall not generally include only postnatal persons or otherwise discriminate against the unborn. A private right of action, to be utilized by citizens of the United States in general, is established to enforce this requirement for data publication and protect the public right to information.”. Sec. 334. Abortion recipient identification. Chapter 74 of title 18, United States Code, is amended by inserting after section 1534 the following: “1534A. Abortion recipient identification. “(a) Unlawful conduct.—Notwithstanding any other provision of law, it shall be unlawful for any person to perform an abortion or attempt to do so, unless in conformity with the requirements set forth in subsection (b), unless an abortion is performed as an emergency treatment for a medical condition that threatens the life of a woman. “(b) It shall be lawful for a federally-licensed abortion provider to perform an abortion or attempt to do so provided the following requirements are fulfilled.— “(1) Abortion recipient identification.—Before any otherwise lawful abortion, abortion providers are mandated to request the passport, visa, proof of citizenship, or other foreign, Federal, State, tribal, or local identification, in order to ascertain the residency of a woman seeking an abortion. “(2) Foreign, State, and tribal law knowledge.—Before any otherwise lawful abortion, abortion providers are mandated to maintain knowledge of whether or not an abortion would be lawful in the State, tribe, or foreign nation of which the woman seeking an abortion is a resident, member, or national. “(3) Denial of service.—Unless there is an emergency or otherwise dire need to perform an abortion, an abortion provider must refuse to perform any abortion that would be illegal to perform in a State, tribe, or foreign nation based on knowledge acquired via this statute. “(c) Criminal penalty.—Whoever violates subsection (a) shall be fined under this title or imprisoned for not more than 5 years, or both.”. Sec. 335. Abortion provider licensing. Chapter 74 of title 18, United States Code, is amended by inserting after section 1535 the following: “1534B. Abortion provider licensing. “(a) Unlawful conduct.—Notwithstanding any other provision of law, it shall be unlawful for any person other than an emergency room or hospital containing one which performs abortions solely for emergency purposes to perform an abortion or attempt to do so, unless said person is a federally-licensed abortion provider. “(b) Requirements for Federal licensing.—Any abortion provider shall be required to ensure the safety (including emergency-preparedness), lawfulness, and accountability of its activities, including its compliance with non-abortion-related laws, and its maintenance of State, tribal, and local authorization to perform abortions, and if applicable its compliance with State, tribal, and local laws and regulations, including those not related to abortion. Approval by the United States Food and Drug Administration shall also be required to obtain a license. “(c) Periods and costs for Federal licensing.—Status as a federally-licensed abortion provider shall be granted for periods of five years per renewal; each renewal shall cost $2500 per quarter paid quarterly until such a time that an abortion provider decides to allow said authorization to lapse, and each new license to conduct abortions shall cost double for the first year; physicians working as abortion providers shall be allowed a reduced rate of $500 per quarter but shall still be subject to a $1000 per quarter fee for the first year. In addition, a minimum of fifty dollars shall be collected for each abortion performed by each federally-licensed abortion provider. These costs may be raised, to a level exceeding that which would be ordinarily prescribed based on inflation, by the President. “(d) Revocation of Federal licensing.—Any intentional violation of any Federal, State, tribal, or local law (including failure to comply with tax laws or other non-abortion-related laws) or failure to maintain a State, tribal, or local status as a legal abortion provider except as a result of relocation by a federally-licensed abortion provider may be punished by revocation of Federal licensing, in addition to a fine of $5000 plus $20 for each abortion procedure performed prior to formal revocation and two years in prison. “(e) Occupational taxation status.—Federally-licensed abortion providers shall not be required to pay the tax established by section 5892(e) of the Internal Revenue Code of 1986 if they provide only one of the applicable healthcare associate products defined in subsection (b) of such section of such Code. “(f) Enforcement.—Requirements for the capability of persons employed, including tests, inspections, educational requirements, and other requirements necessary to ensure that abortion facilities, abortion practicioners, and all staff involved are capable of complying with Federal, State, tribal, and local law by the United States Food and Drug Administration; such Administration may also take into account any other factor, including criminal records and civil lawsuit records, when deciding whether or not to approve or renew Federal licensing under this section. “(g) Criminal penalty.—Whoever violates subsection (a) shall be fined under this title or imprisoned for not more than 50 years, or both. “(h) Constitutional flexibility.—The regulations applied pursuant to this section may be relaxed in accordance with final decisions of the United States Supreme Court. “(i) Effect on other law.—This section shall not be construed as legalizing, permitting, or enabling any activity prohibited under any federal or state law. “(j) Revenue restriction.—The act of performing an abortion in exchange for funds shall be treated as a form of murder in or affecting commerce. No federally-licensed abortion provider shall be permitted to accept any compensation for performing any abortion, and "compensation" shall include all "valuable consideration" as defined by the Public Health Service Act but shall not be limited to such. This law shall not prevent any prosecution under 18 U.S. Code § 1111.”. Sec. 336. Forced abortion. Chapter 74 of title 18, United States Code, is amended by inserting after section 1536 the following: “1535. Forced abortion. “(a) Unlawful conduct.—It is illegal to perform an abortion without the consent of the woman who is pregnant. “(b) Obligation to report crimes.—Any crime reported to an abortion clinic, by a patient or otherwise, must be reported to the proper authorities and to the National Center for Health Statistics. “(c) No consent produced by coercion, threat, extortion, or any means otherwise prohibited by law shall be regarded as valid under this section or section 1841 of this Title, and any abortion illegally performed under this title shall be treated as a ransom or reward under this title. “(d) Criminal penalty.— “(1) Forced abortion.—Whoever violates subsection (a) shall be fined under this title or imprisoned for not more than 12 years, or both. “(2) Reporting.—Whoever violates subsection (a) shall be fined under this title not more than $50,000 or imprisoned for not more than 3 years, or both.”. Sec. 337. Teleabortion prevention. Chapter 74 of title 18, United States Code, is amended by inserting after section 1535 the following: “§1536. Abortions prohibited without a healthcare provider physically present “(a) Offense.—Any person, in or affecting interstate or foreign commerce, knowingly provides or attempts to provide an abortion— “(1) without physically examining the patient; “(2) without being physically present at the location of the abortion; “(3) without utilizing a licensed abortion facility which is or “(3) without scheduling a follow-up visit for the patient to occur not more than 14 days after the administration or use of the drug to assess the patient’s physical condition, shall be fined not more than $5,000 or imprisoned not more than 3 years, or both. “(b) Patient rights.—A patient upon whom an abortion is performed may not be prosecuted under this section or for a conspiracy to violate this section, and may file suit for up to $100,000 in damages if any person who prescribes or provides an abortion. “(c) Effects on registration.—Any person convicted of an offense under subsection (a) of this Section who is a federally-licensed abortion provider shall not be permitted to maintain such status. “(d) Criminal penalty.—Whoever violates subsection (a) shall be fined under this title or imprisoned for not more than 5 years, or both.”. Sec. 338. Born-alive infants protection. Chapter 74 of title 18, United States Code, is amended by inserting after section 1531 the following: “§1537. Requirements pertaining to born-alive abortion survivors “(a) Requirements for health care practitioners.—In the case of an abortion or attempted abortion that results in a child born alive (as defined in section 8 of title 1, United States Code (commonly known as the ‘Born-Alive Infants Protection Act’)): “(1) Degree of care required; immediate admission to a hospital.—Any health care practitioner present at the time the child is born alive shall— “(A) exercise the same degree of professional skill, care, and diligence to preserve the life and health of the child as a reasonably diligent and conscientious health care practitioner would render to any other child born alive at the same gestational age; and “(B) following the exercise of skill, care, and diligence required under subparagraph (A), ensure that the child born alive is immediately transported and admitted to a hospital. “(2) Mandatory reporting of violations.—A health care practitioner or any employee of a hospital, a physician’s office, or an abortion clinic who has knowledge of a failure to comply with the requirements of paragraph (1) shall immediately report the failure to all appropriate law enforcement agencies. “(3) Regulation to ensure compliance ability.—The United States Food and Drug Administration shall issue such regulations as may be necessary to ensure that federally-licensed abortion providers will be able to ensure the health of children, including by means of requiring regular inspection. “(b) Penalties.— “(1) In general.—Whoever violates subsection (a) by failure to report or by willfully failing to comply with paragraph (1) shall be fined under this title or imprisoned for not more than 5 years, or both. “(2) Intentional crimes against child born alive.—Whoever intentionally performs or attempts to perform any Federal, State, tribal, or local crime against a child born alive described under subsection (a) shall be punished to the maximum extent of the law. This paragraph shall not be interpreted as exempting any person from prosecution for any crime. “(3) Revocation of Federal licensing.—Any federally-licensed abortion provider who violates the reporting requirement of subsection (a), deliberately fails to provide care for a child born alive as mandated by law, or fails to abide by any regulation issued under it shall be “(c) Bar to prosecution.—The mother of a child born alive described under subsection (a) may not be prosecuted under such subsection. “(d) Civil remedies.— “(1) CIVIL ACTION BY A WOMAN ON WHOM AN ABORTION IS PERFORMED.—If a child is born alive and there is a violation of subsection (a), the woman upon whom the abortion was performed or attempted may, in a civil action against any person who committed the violation, obtain appropriate relief. “(2) APPROPRIATE RELIEF.—Appropriate relief in a civil action under this subsection includes— “(A) objectively verifiable money damage for all injuries, psychological and physical, occasioned by the violation of subsection (a); “(B) statutory damages equal to 3 times the cost of the abortion or attempted abortion; and “(C) punitive damages. “(3) ATTORNEY’S FEE FOR PLAINTIFF.—The court shall award a reasonable attorney’s fee to a prevailing plaintiff in a civil action under this subsection. “(4) ATTORNEY’S FEE FOR DEFENDANT.—If a defendant in a civil action under this subsection prevails and the court finds that the plaintiff’s suit was frivolous, the court shall award a reasonable attorney’s fee in favor of the defendant against the plaintiff.”. Sec. 339. Dismemberment abortion ban. Chapter 74 of title 18, United States Code, is amended by inserting after section 1531 the following: “§ 1538. Dismemberment abortion ban “(a) Dismemberment abortion prohibited.— “(1) OFFENSE.—Any physician who, in or affecting interstate or foreign commerce, knowingly performs a dismemberment abortion and thereby kills an unborn child shall be fined under this title, imprisoned not more than 2 years, or both. “(2) LIMITATION.—Paragraph (1) shall not apply to a dismemberment abortion that is necessary to save the life of a mother whose life is endangered by a physical disorder, physical illness, or physical injury, including a life-endangering physical condition caused by or arising from the pregnancy itself. “(b) Rule of construction.—Nothing in this section shall be construed to limit abortions performed for any reason, including when the pregnancy is a result of rape or incest, if performed by a method other than dismemberment abortion. “(c) Civil remedies.— “(1) CIVIL ACTION BY A WOMAN ON WHOM AN ABORTION IS PERFORMED.—A woman upon whom an abortion has been performed in violation of any provision of this section may, in a civil action against any person who committed the violation, obtain appropriate relief. “(2) CIVIL ACTION BY A PARENT OF A MINOR ON WHOM AN ABORTION IS PERFORMED.—A parent of a minor upon whom an abortion has been performed in violation of any provision of this section may, in a civil action against any person who committed the violation, obtain appropriate relief, unless the pregnancy resulted from the plaintiff’s criminal conduct. “(3) APPROPRIATE RELIEF.—Appropriate relief in a civil action under this subsection includes— “(A) objectively verifiable money damages for all injuries, psychological and physical, occasioned by the violation; “(B) statutory damages equal to 3 times the cost of the abortion; and “(C) punitive damages. “(4) ATTORNEY'S FEES FOR PLAINTIFF.—The court shall award a reasonable attorney’s fee as part of the costs to a prevailing plaintiff in a civil action under this subsection. “(5) ATTORNEY'S FEES FOR DEFENDANT.—If a defendant in a civil action under this subsection prevails and the court finds that the plaintiff’s suit was frivolous, the court shall award a reasonable attorney’s fee in favor of the defendant against the plaintiff. “(6) AWARDS AGAINST WOMAN.—Except as provided in paragraph (5), in a civil action under this subsection, no damages, attorney’s fee, or other monetary relief may be assessed against the woman upon whom the abortion was performed or attempted. “(d) Immunity from prosecution for woman upon whom a dismemberment abortion is performed.—A woman upon whom a dismemberment abortion is performed may not be prosecuted under this section, for a conspiracy to violate this section, or for an offense under section 2, 3, or 4 of this title based on a violation of this section.”. Subtitle E—Further provisions. Sec. 341. Foreign abortion and sex-related tourism. (a) The title of Section 2427 of Chapter 117 of title 18, United States Code, is amended as follows— “Inclusion of offenses relating to child pornography and other sex-related crimes in definition of sexual activity for which any person can be charged with a criminal offense.” (b) Section 2427 of Chapter 117 of title 18, United States Code, is amended as follows— “In this chapter, the term “sexual activity for which any person can be charged with a criminal offense” includes— “(a) the production or possession of child pornography, as defined in section 2256(8) or any State law prohibiting any action or status associated to child pornography; “(b) any activity declared unlawful under Chapter 74 of title 18 of the United States Code; “(c) any State, tribal, or local law restricting abortion or protecting an unborn child; “(d) any activity involving a minor which is prohibited by Federal, State, tribal, or local law; and “(e) obtaining any sex-related drug which is restricted by Federal, State, tribal, or local law. (c) Clerical amendment.—The table of sections at the beginning of chapter 74 of title 18, United States Code, is editing the entry preceding “§2428 - Forfeitures.” as follows— “2427. Inclusion of offenses relating to child pornography and other sex-related crimes in definition of sexual activity for which any person can be charged with a criminal offense.”. Sec. 342. Safe Crisis Pregnancy Centers. Section 248(e)(5) of Chapter 117 of title 18, United States Code, is amended as follows— “The term “reproductive health services” means services provided in a hospital, clinic, physician’s office, or other facility (including any Title X Service Site or family planning project as defined by the Public Health Service Act and Secretary of Health and Human Services), and includes medical, surgical, counselling or referral services relating to the human reproductive system, including services relating to pregnancy but never to any act (regardless of any pretense to offer a "service") which involves the intentional ending of the life of a human being.”. Sec. 343. No charge for failed delivery. Section 1395dd of Chapter 7 of title 42, United States Code, is amended by— (a) inserting a new subsection (j) after subsection (i) as follows— “(j) Special treatment for unborn children and expectant mothers.—” “In the case of any pregnant woman with an emergency medical condition, no participating hospital may request compensation for any treatment which results in the death of either the pregnant woman or sny unborn child of such pregnant woman.”, (b) inserting “This section does not preempt any state law restricting the intentional termination of patient lives.” at the end of subsection (f), and (b) inserting a new paragraph (e)(6) at the end of subsection (e) as follows: “(6) Any person with an emergency medical condition as defined by this subsection, including any unborn child of any woman who has an emergency medical condition or any unborn child who has an emergency medical condition.” Sec. 344. Restriction on HHS. (a) Prohibition.—The Secretary of Health and Human Services shall not use or declare any public health emergency under section 319 or 319F–3 of the Public Health Service Act (42 U.S.C. 247d, 247d–6b) with respect to abortion, except to take measures to prevent abortion by increasing restrictions on such activity. (b) Termination Of Any Declaration In Effect.—Any declaration described in subsection (a) that is in effect as of the date of enactment of this Act is hereby terminated. Sec. 345. Release of political prisoners. All persons incarcerated for actions intended to support the President of the United States Donald Trump or actions which allegedly violated section 248 but do not violate the section as amended by this Act are ordered to be immediately released from prison. Funds from the American Health Care Implementation Fund shall be used to provide restitution and temporary assistance to these persons. The President shall have the authority to establish a program to ensure these people are able to support themselves on release from federal prison. TITLE IV—Regulations Subtitle A—General Regulation Reduction and Reform Sec. 401. Codification of minimum ages. (a) A new Chapter 112 is created under Title 12, U.S.C., titled “Age limitations on products.” (b) A new section 8550 is created under Chapter 112, Title 12, U.S.C. as follows— “(a) The minimum age to purchase, receive, possess, use, or sell contraception is twenty-two years. “(b) The minimum age to purchase, receive, possess, use, administer, perform, or sell an abortion or abortifacient for a purpose other than the preservation of the pregnant woman's life is twenty-two years. “(c) The minimum age to undergo a breast or buttock augmentation, or any other cosmetic surgery excluding circumcision, is eighteen years, unless for the purpose of repairing damage done to the body of a person under eighteen years, or to repair a birth defect, except that with parental consent the minimum age may be treated as fifteen. “(d) The minimum age to undergo hormone replacement therapy or a sex change surgery (or any child sexual mutilation as defined by section 2260B of title 18, United States Code) is twenty-seven years. “(e) The minimum age to purchase, receive, possess, or sell alcoholic beverages and tobacco is twenty-one years. “(f) The minimum age to participate or work in the pornography industry or consume pornography, to visit or work at any strip club, to visit or work as a prostitute, or other salacious establishment, is twenty-one years. “(g) The minimum age to undergo any cosmetic surgery which involves any modification to the skeleton is twenty-four years. “(h) State governments are permitted to concurrently enforce this section and no State law raising any minimum age above that which is defined by this section shall be preempted by this section. “(i) Persons violating or encouraging or facilitating violation of the age limits set by this section shall be punished by a fine, a prison sentence not exceeding twenty years, or both. “(j) State and local laws mandating or encouraging the violation of this section are hereby preempted, and any State or locality which violates this section shall be punished by a fine not exceeding ten million dollars. “(k) In this section, the word “encouraging” does not include speech protected by the First Amendment to the Constitution; however, it does include any activity which allows or incites violation of this Section. “(l) In this section, the word “sell” includes any transfer to or from the possession of a person below a minimum age defined by this section of any thing for which a minimum age is established by this section. “(m) Nothing in this secton may be interpreted as restricting the authority of executive agencies to establish higher standards as prescribed by law.”. (c) This section shall be effective beginning the sooner of either the following fourth of July or the following first of January after its passage into law, not counting the first thirty days of this Act's passage into law. (d) Child sexual mutilation on youth prohibited.—Chapter 110 of title 18, United States Code, is amended— (1) by adding at the end the following: “§ 2260B. Child sexual mutilation on minors “(a) In General.—Whoever, in any circumstance described in subsection (e), knowingly performs any child sexual mutilation on a person below 22 years of age is guilty of a class C felony. “(b) Prohibition On Prosecution Of Person On Whom Intervention Is Performed.—No person on whom the child sexual mutilation under subsection (a) is performed may be arrested or prosecuted for an offense under this section. “(c) Civil Action.—A person on whom child sexual mutilation is performed under this section may bring a civil action for appropriate relief, including compensatory and punitive damages, against each person who performed the child sexual mutilation. “(d) Definitions.—In this section: “(1) CHILD SEXUAL MUTILATION DEFINED.— “(A) IN GENERAL.—For purposes of this chapter, except as provided in subparagraph (B), the term ‘Child sexual mutilation’ means, with respect to an individual, any of the following: “(i) Performing any surgery for the purpose of changing the body of such individual to correspond to a sex that differs from their biological sex, including— “(I) castration; “(II) orchiectomy; “(III) scrotoplasty; “(IV) vasectomy; “(V) hysterectomy; “(VI) oophorectomy; “(VII) ovariectomy; “(VIII) metoidioplasty; “(IX) penectomy; “(X) phalloplasty; “(XI) vaginoplasty; “(XII) vaginectomy; “(XIII) vulvoplasty; “(XIV) reduction thyrochondroplasty; “(XV) chondrolaryngoplasty; and “(XVI) mastectomy. “(ii) Any plastic surgery that feminizes or masculinizes the facial features for the purposes described in clause (i). “(iii) Any placement of chest implants to create feminine breasts for the purposes described in clause (i). “(iv) Any placement of fat or artificial implants in the gluteal region for the purposes described in clause (i). “(v) Administering, supplying, prescribing, dispensing, distributing, or otherwise conveying to an individual medications for the purposes described in clause (i), including— “(I) gonadotropin-releasing hormone (GnRH) analogues or other puberty-blocking drugs to stop or delay normal puberty; “(II) testosterone or other androgens to biological females at doses that are supraphysiologic to the female sex; and “(III) estrogen to biological males at doses that are supraphysiologic to the male sex. “(B) EXCEPTION.—Subparagraph (A) shall not apply to the following individuals: “(i) An individual with both ovarian and testicular tissue. “(ii) An individual with respect to whom a physician has determined through genetic or biochemical testing that the individual does not have normal sex chromosome structure, sex steroid hormone production, or sex steroid hormone action. “(iii) An individual experiencing infection, disease, injury, or disorder caused or exacerbated by previous legal child sexual mutilation. “(iv) An individual suffering from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in imminent danger of death or impairment of a major bodily function unless the procedure is performed. “(2) BIOLOGICAL SEX.—The term ‘biological sex’ means the indication of male or female sex by reproductive potential or capacity, sex chromosomes, naturally occurring sex hormones, gonads, or internal or external genitalia present at birth. “(e) Circumstances Described.—For purposes of subsection (a), the circumstances described in this subsection are that— “(1) the defendant or victim traveled in interstate or foreign commerce, or traveled using a means, channel, facility, or instrumentality of interstate or foreign commerce, in furtherance of or in connection with the conduct described in subsection (a); “(2) the defendant used a means, channel, facility, or instrumentality of interstate or foreign commerce in furtherance of or in connection with the conduct described in subsection (a); “(3) any payment of any kind was made, directly or indirectly, in furtherance of or in connection with the conduct described in subsection (a) using any means, channel, facility, or instrumentality of interstate or foreign commerce or in or affecting interstate or foreign commerce; “(4) the defendant transmitted in interstate or foreign commerce any communication relating to or in furtherance of the conduct described in subsection (a) using any means, channel, facility, or instrumentality of interstate or foreign commerce or in or affecting interstate or foreign commerce by any means or in manner, including by computer, mail, wire, or electromagnetic transmission; “(5) any instrument, item, substance, or other object that has traveled in interstate or foreign commerce was used to perform the conduct described in subsection (a); “(6) the conduct described in subsection (a) occurred within the special maritime and territorial jurisdiction of the United States, or any territory or possession of the United States; or “(7) the conduct described in subsection (a) otherwise occurred in or affected interstate or foreign commerce. “(f) Rule Of Construction.—Nothing in this section shall be construed as prohibiting provision of the medical services described in subsection (d)(1)(A) to address legitimate health issues, such as any male or female reproductive cancers, apart from changing the body to correspond to a sex that differs from one’s biological sex.”; and (2) by amending the table of sections for such chapter by adding at the end the following: “2260B. Child sexual mutilation on minors.”. (e) Immigration consequences of foreign child sexual mutilation.— (1) Definitions.—Section 101(a) of the Immigration and Nationality Act (8 U.S.C. 1101(a)) is amended by adding at the end the following: “(53) The term ‘child sexual mutilation’ shall have the meaning given such term in section 2260B(d) of title 18, United States Code.”. (2) Classes Of Aliens Ineligible For Visas Or Admission.—Section 212(a)(1)(A) of the Immigration and Nationality Act (8 U.S.C. 1182(a)(1)(A)) is amended— (A) in clause (iii)(II), strike “or” at the end; (B) in clause (iv), strike the comma at the end and insert “, or”; and (C) by adding at the end the following: “(v) who is determined to have performed child sexual mutilation on a person that has not attained the age of 22 years old,”. (3) Classes Of Deportable Aliens.—Section 237(a) of the Immigration and Nationality Act (8 U.S.C. 1227(a)) is amended by adding at the end the following: “(8) CHILD SEXUAL MUTILATION.—Any alien who has performed child sexual mutilation on a person that has not attained the age of 22 years old is deportable.”. (f) RICO enforcement.—18 U.S. Code § 1961 is amended by inserting “chapter 74 (relating to abortion), section 2260B (relating to child sexual mutilation), section 250 (relating to hate crimes against persons with certain conditions), ” after “(relating to sexual exploitation of children), ”. Sec. 402. Capping out-of-pocket costs of insulin. (a) Individuals Enrolled In Certain Health Plans.—Title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended by inserting after section 2729 the following: “SEC. 2729A. COVERAGE OF INSULIN DRUGS. “Beginning with plan year 2026, a group health plan or health insurance issuer offering group or individual health insurance coverage that provides coverage for prescription insulin drugs may not impose any deductible, copayment, coinsurance, or other cost-sharing requirement with respect to such drugs that results in out-of-pocket costs to the enrollee that exceed $50 per prescription for a 30-day supply of covered prescription insulin drugs, regardless of the amount of insulin drugs needed to fill the enrollee's insulin prescriptions.”. (b) Individuals Enrolled In Other Coverage.— (1) MEDICARE, MEDICAID, AND CHIP.—The Secretary of Health and Human Services shall take such administrative action as is necessary to ensure that in no event shall any State plan or waiver under title XIX or XXI of the Social Security Act or prescription drug plan under part D of title XVIII of such Act or MA–PD plan under part C of such title of such Act that provides coverage for prescription insulin drugs impose any deductible, copayment, coinsurance, or other cost-sharing requirement with respect to such drugs that results in out-of-pocket costs to an individual enrolled in such coverage that exceeds $50 per prescription for a 30-day supply of covered prescription insulin drugs, regardless of the amount of insulin drugs needed to fill the enrollee's insulin prescriptions. (2) VETERANS.—The Secretary of Veterans Affairs shall take such administrative action as is necessary to ensure that prescription insulin drugs written by eligible health care providers for veterans do not impose any deductible, copayment, coinsurance, or other cost-sharing requirement with respect to such drugs that results in out-of-pocket costs to the veteran that exceeds $50 per prescription for a 30-day supply of covered prescription insulin drugs, regardless of the amount of insulin drugs needed to fill the veteran's insulin prescriptions. For purposes of the preceding sentence, the term “eligible health care provider” means a health care provider under section 1703(c) of title 38, United States Code, or an eligible entity or provider under section 1703A(b) of such title. (3) TRICARE.—The Secretary of Defense shall take such administrative action as is necessary to ensure that prescription insulin drugs written by health care providers for enrollees in the TRICARE program under chapter 55 of title 10, United States Code, do not impose any deductible, copayment, coinsurance, or other cost-sharing requirement with respect to such drugs that results in out-of-pocket costs to enrollees that exceeds $50 per prescription for a 30-day supply of covered prescription insulin drugs, regardless of the amount of insulin drugs needed to fill the enrollee's insulin prescriptions. (c) Price cap for uninsured persons.—Beginning on January 1, 2026, in the case of an individual who is not enrolled in any public or private health plan, the cash price for a 30-day supply of such individual's prescription insulin drugs, regardless of the amount of insulin drugs needed to fill the individual's insulin prescriptions, shall be not more than $100. Sec. 403. Intellectual property of unavailable products. (a) A new section 123 is inserted at the end of chapter 1 of the Copyright Act of 1976 as follows— “123. Limitations on exclusive rights: Unavailable medical products “In case of any medical copyright owned by a non-US entity, including copyrighted code for medical equipment, medical literature, etc. which has been barred from publication or utilization in the United States, such copyright is regarded as void. For the purposes of this section, the word “medical” does not describe any equipment, literature, or other copyrighted word used or published to intentionally end the life of a patient.”. (b) 35 U.S.C. 271(c) is amended as follows— “(c) Whoever offers to sell or sells within the United States or imports into the United States a component of a patented machine, manufacture, combination or composition, or a material or apparatus for use in practicing a patented process, constituting a material part of the invention, knowing the same to be especially made or especially adapted for use in an infringement of such patent, and not a staple article or commodity of commerce suitable for substantial noninfringing use, shall be liable as a contributory infringer except in cases wherein a medical device or medicine is sold within the United States or imported into the United States when a non-US entity has prohibited the sale within and imported into the United States of such medical device or medicine, except in such a case where such a medical device or medicine is intended to be used to intentionally end the life of a patient.”. Sec. 404. Act not found. (a) In general.—Excluding those sections otherwise repealed or amended by this Act, all sections of the Patient Protection and Affordable Care Act and Healthcare and Education Reconciliation Act found in Chapters 157 and 158 of Title 42 of the United States Code are repealed. (b) Repeal of PHSA amendments.—The following provisions of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) are repealed: (1) Section 2701 (42 U.S.C. 300gg). (2) Section 2702 (42 U.S.C. 300gg–1). (3) Section 2703 (42 U.S.C. 300gg–2). (4) Section 2704 (42 U.S.C. 300gg–3). (5) Section 2705 (42 U.S.C. 300gg–4). (6) Section 2707 (42 U.S.C. 300gg–6). (7) Section 2708 (42 U.S.C. 300gg–7). (8) Section 2711 (42 U.S.C. 300gg–11). (9) Section 2712 (42 U.S.C. 300gg–12). (10) Section 2713 (42 U.S.C. 300gg–13). (11) Section 2715 (42 U.S.C. 300gg–15). (12) Section 2715A (42 U.S.C. 300gg–15a). (13) Section 2716 (42 U.S.C. 300gg–16). (14) Section 2718 (42 U.S.C. 300gg–18). (15) Section 2719 (42 U.S.C. 300gg–19). (16) Section 2719A (42 U.S.C. 300gg–19a). (17) Section 2794 (42 U.S.C. 300gg–94). (c) Reinstating pre-PPACA law.—Sections 2701, 2702, 2711, and 2712 of the Public Health Service Act as in effect on the day before the date of enactment of the Patient Protection and Affordable Care Act (Public Law 111–148) shall be restored or revived as if such Act had not been enacted (subject to paragraphs (1), (2), (6), and (7) of subsection (d) and other amendments created by this Act). (d) Redesignations and transfers.—The following provisions of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) shall be redesignated and transferred as follows: (1) Section 2701, as restored or revived under subsection (c), shall be transferred so as to appear as the first section in subpart I of part A. (2) Section 2702, as restored or revived under subsection (c), shall be transferred so as to appear after such section 2701. (3) Section 2706 (42 U.S.C. 300gg–5) shall be redesignated as section 2703 and transferred so as to appear after such section 2702. (4) Section 2709 (42 U.S.C. 300gg–8), relating to coverage for individuals participating in approved clinical trials, shall be redesignated as section 2704 and transferred so as to appear after section 2703 (as so redesignated). (5) Section 2709 (42 U.S.C. 300gg–9), relating to disclosure of information, shall be redesignated as section 2705 and transferred so as to appear after section 2704 (as so redesignated). (6) Section 2711, as restored or revived under subsection (c), shall be redesignated as section 2706 and transferred so as to appear after section 2705 (as so redesignated). (7) Section 2712, as restored or revived under subsection (c), shall be redesignated as section 2707 and transferred so as to appear after section 2706 (as so redesignated). (8) Section 2714 (42 U.S.C. 300gg–14) shall be redesignated as section 2711 and transferred so as to appear as the first section under subpart II of part A. (9) Section 2717 (42 U.S.C. 300gg–17) shall be redesignated as section 2712 and transferred so as to appear after section 2711 (as so redesignated). (e) Effective dates.— (1) IN GENERAL.—Except as otherwise provided, the repeals under this section shall take effect on the date of enactment of this Act and shall apply to plan years beginning after such date of enactment. (2) DELAYED EFFECTIVE DATES.—The repeals under paragraphs (2), (3), (4), and (5) of subsection (b), the provisions restored or revived under subsection (b), and the conforming amendment in section 104(a)(2) shall be effective for plan years beginning on January 1, 2019, and (notwithstanding subsection (c)) the provisions of law repealed by such paragraphs of subsection (b) or amended by such conforming amendment shall continue to remain in effect until such date. (f) Technical amendments.— (1) ERISA.—Section 715 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185d) is amended— (A) in subsection (a)(1), by striking “(as amended by the Patient Protection and Affordable Care Act)” and inserting “(including any subsequent amendments to such part)”; and (B) in subsection (b)— (i) by striking “(as amended by the Patient Protection and Affordable Care Act)” and inserting “(including any subsequent amendments to such part)”; and (ii) by striking “(as so amended)”. (2) IRC.—Section 9815 of the Internal Revenue Code of 1986 is amended— (A) in subsection (a)(1), by striking “(as amended by the Patient Protection and Affordable Care Act)” and inserting “(including any subsequent amendments to such part)”; and (B) in subsection (b)— (i) by striking “(as amended by the Patient Protection and Affordable Care Act)” and inserting “(including any subsequent amendments to such part)”; and (ii) by striking “(as so amended)”. (3) Applicability.—The amendments made by this subsection shall take effect as though included in the enactment of the Patient Protection and Affordable Care Act (Public Law 111–148). (g) Repeal of remaining provisions.—All provisions of the Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act of 2010 (including amendments made to other laws by the two Acts) not otherwise repealed or amended by this Act are immediately repealed. (h) Repeal of IRA.—The Inflation Reduction Act and all amendments made by it are immediately repealed, and all amendments to the Internal Revenue Code made by it are repealed for fiscal years beginning 2026. Neither the Federal Government nor any State or Territory shall be obligated to pay any cancellation fee to any contract made under such Act. Monies may be appropriated from the American Health Care Implementation Fund for the purpose of ensuring that the public health shall not be impaired by the cancellation of such projects. (i) Repeal of ARPA.—The American Rescue Plan Act and all amendments made by it are immediately repealed, and all amendments to the Internal Revenue Code made by it are repealed for fiscal years beginning 2026. Neither the Federal Government nor any State or Territory shall be obligated to pay any cancellation fee to any contract made under such Act. Monies may be appropriated from the American Health Care Implementation Fund for the purpose of ensuring that the public health shall not be impaired by the cancellation of such projects. Sec. 405. Constructions. (a) No ratings based on sex.—Nothing in this Act shall be construed as permitting health insurance issuers to discriminate in rates for health insurance coverage on the basis of sex. (b) No limiting access to coverage for individuals with preexisting conditions.—Nothing in this Act shall be construed as permitting health insurance issuers to limit access to health coverage for individuals with preexisting conditions. Sec. 406. Right to try reform. (a) Section 561B (21 U.S.C. 360bbb-0a) of Chapter V of the Federal Food, Drug, and Cosmetic Act is amended by inserting “any known benefits which could result in approval,” after “the uses for which the drug was made available,”. (b) A new subsection (e) is added at the end of Section 561B (21 U.S.C. 360bbb-0a) of Chapter V of the Federal Food, Drug, and Cosmetic Act as follows— “(e) New disease rapid response testing.— “Pursuant to a discovery of a new disease or an epidemic of a disease for which insufficient treatment information is available, the Secretary of Health and Human Services may declare that all patients undergoing treatment for such a disease are part of one unified national trial, and collect data relevant to experimental treatments as necessary for the treatment of such diseases through the National Center for Health Statistics, which shall direct the unified national trial under the guidance of the Secretary and the President and with the cooperation of other agencies as may be necessary to preserve the public health. Neither the President of the United States nor any agency of the Executive may restrict or hinder, in any way, the collection of data for such a trial, or delete such data.”. Sec. 407. Reducing administrative costs and burdens in health care. Title II of the Public Health Service Act (42 U.S.C. 202 et seq.) is amended by adding at the end the following: “PART E—Reducing administrative costs and burdens in health care “SEC. 281. Eliminating unnecessary administrative burdens and costs. “(a) Reducing administrative burdens and costs.—The Secretary, in consultation with providers of health services, health care suppliers of services, health care payers, health professional societies, health vendors and developers, health care standard development organizations and operating rule entities, health care quality organizations, health care accreditation organizations, public health entities, States, patients, and other appropriate entities, shall, in accordance with subsection (b)— “(1) establish a goal of reducing unnecessary costs and administrative burdens across the health care system, including the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the private health insurance market, by at least half over a period of 10 years from the date of enactment of this section; “(2) develop strategies and benchmarks for meeting the goal established under paragraph (1); “(3) develop recommendations for meeting the goal established under paragraph (1); and “(4) take action to reduce unnecessary costs and administrative burdens based on recommendations identified in this subsection. “(b) Strategies, recommendations, and actions.— “(1) IN GENERAL.—To achieve the goal established under subsection (a)(1), the Secretary, in consultation with the entities described in such subsection, shall not later than 1 year after the date of enactment of this section, develop strategies and recommendations and take actions to meet such goal in accordance with this subsection. No strategies, recommendation, or action shall undermine the quality of patient care or patient health outcomes. “(2) STRATEGIES.—The strategies developed under paragraph (1) shall address unnecessary costs and administrative burdens. Such strategies shall include broad public comment and shall prioritize— “(A) recommendations identified as a result of efforts undertaken to implement section 3001; “(B) recommendations and best practices identified as a result of efforts undertaken under this part; “(C) a review of regulations, rules, and requirements of the Department of Health and Human Services that could be modified or eliminated to reduce unnecessary costs and administrative burden imposed on patients, providers, payers, and other stakeholders across the health care system; and “(D) feedback from stakeholders in rural or frontier areas on how to reduce unnecessary costs and administrative burdens on the health care system in those areas. “(3) RECOMMENDATIONS.—The recommendations developed under paragraph (1) shall include— “(A) actions that improve the standardization and automation of administrative transactions; “(B) actions that integrate clinical and administrative functions; “(C) actions that improve patient care and reduce unnecessary costs and administrative burdens borne by patients, their families, and other caretakers; “(D) actions that advance the development and adoption of open application programming interfaces and other emerging technologies to increase transparency and interoperability, empower patients, and facilitate better integration of clinical and administrative functions; “(E) actions to be taken by the Secretary and actions that need to be taken by other entities; and “(F) other areas, as the Secretary determines appropriate, to reduce unnecessary costs and administrative burdens required of health care providers. “(4) CONSISTENCY.—Any improvements in electronic processes proposed by the Secretary under this section should leverage existing information technology definitions under Federal Law. Specifically, any electronic processes should not be construed to include a facsimile, a proprietary payer portal that does not meet standards specified by the Secretary, or an electronic form image. “(5) ACTIONS.—The Secretary shall take action to achieve the goal established under subsection (a)(1), and, not later than 1 year after the date of enactment of this section, and biennially thereafter, submit to Congress and make publically available, a report describing the actions taken by the Secretary pursuant to goals, strategies, and recommendations described in this subsection. “(6) FACA.—The Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the development of the goal, strategies, recommendations, or actions described in this section. “(7) RULE OF CONSTRUCTION.—Nothing in this subsection shall be construed to authorize, or be used by, the Federal Government to inhibit or otherwise restrain efforts made to reduce waste, fraud, and abuse across the health care system. “SEC. 282. Grants to States to develop and implement recommendations to accelerate State innovation to reduce health care administrative costs. “(a) Grants.— “(1) IN GENERAL.—Not later than 6 months after the date of enactment of this section, the Secretary shall award grants to at least 15 States, and one coordinating entity designated as provided for under subsection (e), to enable such States to establish and administer private-public multi-stakeholder commissions for the purpose of reducing health care administrative costs and burden within and across States. Not less than 3 of such grants shall be awarded to States that are primarily rural, frontier, or a combination thereof, in nature. “(2) ENTITIES.—For purposes of this section, the term ‘State’ means a State, a State designated entity, or a multi-State collaborative (as defined by the Secretary). “(3) PRIORITY.—In awarding grants under this section, the Secretary shall give priority to applications submitted by States that propose to carry out a pilot program or support the adoption of electronic health care transactions and operating rules. “(b) Application.— “(1) IN GENERAL.—To be eligible to receive a grant under subsection (a) a State shall submit to the Secretary an application in such a manner and containing such information as the Secretary may reasonably require, including the information described in paragraph (2). “(2) REQUIRED INFORMATION.—In addition to any additional information required by the Secretary under this subsection, an application shall include a description of— “(A) the size and composition of the commission to be established under the grant, including the stakeholders represented and the degree to which the commission reflects important geographic and population characteristics of the State; “(B) the relationship of the commission to the State official responsible for coordinating and implementing the recommendations resulting from the commission, and the role and responsibilities of the State with respect to the commission, including any participation, review, oversight, implementation or other related functions; “(C) the history and experience of the State in addressing health care administrative costs, and any experience similar to the purpose of the commission to improve health care administrative processes and the exchange of health care administrative data; “(D) the resources and expertise that will be made available to the commission by commission members or other possible sources, and how Federal funds will be used to leverage and complement these resources; “(E) the governance structure and procedures that the commission will follow to make, implement, and pilot recommendations; “(F) the proposed objectives relating to the simplification of administrative transactions and operating rules, increased standardization, and the efficiency and effectiveness of the transmission of health information; “(G) potential cost savings and other improvements in meeting the objectives described in subparagraph (F); and “(H) the method or methods by which the recommendations described in subsection (c) will be reviewed, tested, adopted, implemented, and updated as needed. “(c) Multi-Stakeholder commission.— “(1) IN GENERAL.—Not later than 90 days after the date on which a grant is awarded to a State under this section, the State official described in subsection (b)(2)(B), the State insurance commissioner, or other appropriate State official shall convene a multi-stakeholder commission, in accordance with this subsection. “(2) MEMBERSHIP.—The commission convened under paragraph (1) shall include representatives from health plans, health care providers, health vendors, relevant State agencies, health care standard development organizations, and operating rule entities, relevant professional and trade associations, patients, and other entities determined appropriate by the State. “(3) RECOMMENDATIONS.—Not later than one year after the date on which a grant is awarded to a State under this section, the commission shall make recommendations and plans, consistent with the application submitted by the State under subsection (b), and intended to meet the objectives defined in the application. Such recommendations shall comply with, and build upon, all relevant Federal requirements and regulations, and may include— “(A) common, uniform specifications, best practices, and conventions, for the efficient, effective exchange of administrative transactions adopted pursuant to the Health Insurance Portability and Accountability Act of 1996 (Public Law 104–191); “(B) the development of streamlined business processes for the exchange and use of health care administrative data; and “(C) specifications, incentives, requirements, tools, mechanisms, and resources to improve— “(i) the access, exchange, and use of health care administrative information through electronic means; “(ii) the implementation of utilization management protocols; and “(iii) compliance with Federal and State laws. “(d) Use of funds for implementation.—A State may use amounts received under a grant under this section for one or more of the following: “(1) The development, implementation, and best use of shared data infrastructure that supports the electronic transmission of administrative data. “(2) The development and provision of training and educational materials, forums, and activities as well as technical assistance to effectively implement, use, and benefit from electronic health care transactions and operating rules. “(3) To accelerate the early adoption and implementation of administrative transactions and operating rules designated by the Secretary and that have been adopted pursuant to the Health Insurance Portability and Accountability Act of 1996 (Public Law 104–191), including transactions and operating rules described in section 1173(a)(2) of the Social Security Act. “(4) To accelerate the early adoption and implementation of additional or updated administrative transactions, operating rules, and related data exchange standards that are being considered for adoption under the Health Insurance Portability and Accountability Act of 1996 or are adopted pursuant to such Act, or as designated by the Secretary, including the electronic claim attachment. “(5) To conduct pilot projects to test approaches to implement and use the electronic health care transactions and operating rules in practice under a variety of different settings. With respect to the electronic attachment transaction, priority shall be given to pilot projects that test and evaluate methods and mechanisms to most effectively incorporate patient health data from electronic health records and other electronic sources with the electronic attachment transaction. “(6) To assess barriers to the adoption, implementation, and effective use of electronic health care transactions and operating rules, as well as to explore, identify, and plan options, approaches, and resources to address barriers and make improvements. “(7) The facilitation of public and private initiatives to reduce administrative costs and accelerate the adoption, implementation, and effective use of electronic health care transactions and operating rules for State programs. “(8) Developing, testing, implementing, and assessing additional data exchange specifications, operating rules, incentives, requirements, tools, mechanisms, and resources to accelerate the adoption and effective use of the transactions and operating rules. “(9) Ongoing needs assessments and planning related to the development and implementation of administrative simplification initiatives. “(e) Coordinating entity.— “(1) FUNCTIONS.—Not later than 6 months after the date of enactment of this section, the Secretary shall designate a coordinating entity under this subsection for the purpose of— “(A) providing technical assistance to States relating to the simplification of administrative transactions and operating rules, increased standardization, and the efficiency and effectiveness of the transmission of health care information; “(B) evaluating pilot projects and other efforts conducted under this section for impact and best practices to inform broader national use; “(C) using consistent evaluation methodologies to compare return on investment across efforts conducted under this section; “(D) compiling, synthesizing, disseminating, and adopting lessons learned to promote the adoption of electronic health care transactions and operating rules across the health care system; and “(E) making recommendations to the Secretary and the National Committee on Vital and Health Statistics regarding the national adoption of efforts conducted under this section. “(2) ELIGIBILITY.—The entity designated under paragraph (1) shall be a qualified nonprofit entity that— “(A) focuses its mission on administrative simplification; “(B) has demonstrated experience using a multi-stakeholder and consensus-based process for the development of common, uniform specifications, operating rules, best practices, and conventions, for the efficient, effective exchange of administrative transactions that includes representation by or participation from health plans, health care providers, vendors, States, relevant Federal agencies, and other health care standard development organizations; “(C) has demonstrated experience providing technical assistance to health plans, health care providers, vendors, and States relating to the simplification of administrative transactions and operating rules, increased standardization, and the efficiency and effectiveness of the transmission of health care information; “(D) has demonstrated experience evaluating and measuring the adoption and return on investment of administrative transactions and operating rules; “(E) has demonstrated experience gathering, synthesizing, and adopting common, uniform specifications, operating rules, best practices, and conventions for national use based on lessons learned to promote the adoption of electronic health care transactions and operating rules across the health care system; “(F) has a public set of guiding principles that ensure processes are open and transparent, and supports nondiscrimination and conflict of interest policies that demonstrate a commitment to open, fair, and nondiscriminatory practices; “(G) builds on the transaction standards issued under Health Insurance Portability and Accountability Act of 1996; and “(H) allows for public review and updates of common, uniform specifications, operating rules, best practices, and conventions to support administrative simplification. “(f) Period and amount.—A grant awarded to a State under this section shall be for a period of 5 years and shall not exceed $50,000,000 for such 5-year period. A grant awarded to the coordinating entity designated by the Secretary under subsection (e) shall be for a period of 5 years and shall not exceed $15,000,000 for such 5-year period. “(g) Reports.— “(1) STATES.—Not later than 1 year after receiving a grant under this section, and biennially thereafter, a State shall submit to the Secretary a report on the outcomes experienced by the State under the grant. “(2) COORDINATING ENTITY.—Not later than 1 year after receiving a grant under this section, and at least biennially thereafter, the coordinating entity shall submit to the Secretary and the National Committee on Vital and Health Statistics a report of evaluations conducted under the grant under this section and recommendations regarding the national adoption of efforts conducted under this section. “(3) SECRETARY.—Not later than 6 months after the date on which the States and coordinating entity submit the report required under paragraphs (1) and (2), the Secretary, in consultation with National Committee on Vital and Health Statistics, shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives, a report on the outcomes achieved under the grants under this section. “(4) GAO.—Not later than 6 months after the date on which the Secretary submits the final report under paragraph (3), the Comptroller General of the United States shall conduct a study, and submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives, a report on the outcomes of the activities carried out under this section which shall contain a list of best practices and recommendations to States concerning administrative simplification. “(h) Authorization of appropriations.—There is authorized to be appropriated to carry out this section, $250,000,000 for the 5-fiscal-year period beginning with fiscal year 2028.”. Sec. 408. Requirements for cosmetic medical procedures. Section 311 of the Federal Food, Drug, and Cosmetic Act is amended by adding the following new subsection after subsection (eee): “(fff) Performing any procedure including a plastic surgery, injection of toxin, or abortion which is not intended to resolve a medical condition while outside of a licensed medical facility or while a patient is under the influence of alcohol. Use of medical alcohol may be approved notwithstanding this subsection.” Sec. 409. Local-level deregulation. (a) Waiving national restrictions on physician-owned facilities.—Section 1877 of the Social Security Act (42 U.S.C. 1395nn) is amended by adding at the end the following new subsection: “(j) Waiver authority.—A physician or other entity may apply to the Secretary to waive any provision of this section and the Secretary may waive such provision with respect to such physician or entity if the Secretary determines that such waiver would— “(1) increase competition within the health care market; “(2) reduce the costs of health care; and “(3) increase the quality of health care.”. (b) Removing certain State and local licensure or certification restrictions.— (1) APPLICATION FOR WAIVER OF RESTRICTIONS.—An individual who is required to be licensed or certified by a State as a condition of furnishing items or services as a health care professional (as defined by the Secretary of Health and Human Services) may submit to the Secretary an application to waive any condition of such licensure or certification. (2) STANDARD.—The Secretary may grant a waiver submitted under paragraph (1) if the Secretary determines such waiver would— (A) increase competition within the health care market; (B) reduce the costs of health care; and (C) increase the quality of health care. (3) PREEMPTION.—In the case of a health care professional granted a waiver under paragraph (2), any requirement with respect to which such waiver is granted is preempted to the extent specified in such waiver. (c) Effect on certain laws.—No applicable healthcare-associated service taxed by section 5892 of the Internal Revenue Code or any insurance policy shall be regarded as “health care” under this section. Sec. 410. Termination of patient lives. The following is added to the United States Code after the section established by section 507(b) of this Act— “1124. Involuntary Do-Not-Resusitate Prohibited. “(a) In general.—Paramedics will, in any circumstance in which a patient requests help or has not explicitly requested for it to be withheld, provide any treatment necessary, including resuscitation, except in such a case where it is outside of a reasonable medical judgment that such a patient would require such treatment. “(b) Preemption.—Any law which claims to mandate the violation of subsection (a) is hereby preempted. “(c) Penalty.—Any person convicted of violating the provisions of subsection (a) shall be subject to a fine under this title of not less than $10,000, imprisoned for not less than 1 year, or both.”. Sec. 411. Indian Healthcare. (a) The Indian Health Care Improvement Act of 1976 is amended by inserting a new section 809 after section 808 of such Act as follows— “809. Indian Healthcare Deregulation. “(a) Tribal deregulation authority.—Subsequent to any application compliant with subsection (b) of this section, an Indian tribe may obtain an exemption from the Secretary of Health and Human Services waiving any regulation established under the Federal Food, Drug, and Cosmetic Act, provided that such Indian tribe continuously complies with subsection (c) of this section. “(b) Restrictions on applications.—No application which contains a request to deregulate food, water, sanitation, abortion, contraception, controlled substances (as defined by the Controlled Substances Act and regulated by the Drug Enforcement Agency), tobacco, or anything not regulated by the Federal Food, Drug, and Cosmetic Act shall be accepted under subsection (a). Furthermore, the territorial extent of such an application must be declared in such an application and may not exceed the extent to which exemptions and preemptions are permitted to take effect under subsection (e). Furthermore, no exemption for any provision of the Federal Food, Drug, and Cosmetic Act intended to protect intellectual property rights may be approved. “(c) Transparency.—Indian tribes which have obtained any exemption under subsection (a) shall disclose all regulations not in force when providing healthcare services to persons who are citizens or nationals of the United States. “(d) State, territorial, and local regulations.—Subsequent to the acceptance of any exemption under subsection (a), any State, territorial, or local ordinance or regulation which may prohibit anything for which a waiver has been granted under subsection (a) shall be preempted insofar as a waiver has been granted under subsection (a). “(e) Territorial extent.—No exemption or preemption under this Act shall take effect except on the Indian lands as defined by section 4 of the Indian Gaming Regulatory Act which are not subject to the prohibition established by section 20 of such Act. “(f) Revenue treatment.—The Secretary of the Treasury, in consultation with the Secretaries of the Interior and of Health and Human Services, shall create such regulations as may be necessary to determine the treatment of revenues under this section for purposes of the Internal Revenue Code of 1986 and other Federal laws, including by means of adjusting Federal spending levels. “(g) Criminal investigations.—The Attorney General, and any persons authorized by the Attorney General, shall investigate activities associated with exemptions authorized by this section which may be a violation of Federal law.”. (a) Abrogation of sovereign immunity.—Title 35, United States Code, is amended— (1) in section 135, by adding at the end the following: “(g) Sovereign immunity.— “(1) DEFINITIONS.—In this subsection— “(A) the term ‘foreign State’ has the meaning given the term in section 1603(a) of title 28; and “(B) the term ‘Indian tribe’ has the meaning given the term in section 4(e) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(e)). “(2) ABROGATION OF SOVEREIGN IMMUNITY.—Except as provided in paragraph (3), and subject to paragraph (4), a patent owner may not assert sovereign immunity, including the sovereign immunity accorded to an Indian tribe, as a defense in— “(A) a derivation proceeding instituted under subsection (a); or “(B) a review by a court of the United States with respect to a decision reached in a proceeding described in subparagraph (A). “(3) IMMUNITY OF FOREIGN STATES.—If a patent owner is a foreign State, for the purposes of any proceeding described in paragraph (2)(A), the Patent Trial and Appeal Board shall determine whether the patent owner is immune from the jurisdiction of the Patent Trial and Appeal Board, in accordance with chapter 97 of title 28 as if the Patent Trial and Appeal Board were a court of the United States. “(4) LIMITATION.—This subsection shall apply only to the extent permitted under the 11th amendment to the Constitution of the United States.”; (2) in section 296— (A) in the section heading, by striking “and State officials” and inserting “, State officials, and Indian tribes”; and (B) by adding at the end the following: “(c) Abrogation of tribal sovereign immunity.— “(1) DEFINITIONS.—In this subsection— “(A) the term ‘covered claim’ means any claim, counterclaim, or third-party claim that arises under— “(i) this title relating to infringement of a patent; or “(ii) section 351 of the Public Health Service Act (42 U.S.C. 262); and “(B) the term ‘Indian tribe’ has the meaning given the term in section 4(e) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(e)). “(2) ABROGATION.—In any action that involves a covered claim that is otherwise within the jurisdiction of a court of the United States, an Indian tribe may not assert sovereign immunity as a defense.”; (3) in section 305— (A) in the first sentence, by striking “After the” and inserting the following: “(a) In general.—After the”; and (B) by adding at the end the following: “(b) Sovereign immunity.— “(1) DEFINITIONS.—In this subsection— “(A) the term ‘foreign State’ has the meaning given the term in section 1603(a) of title 28; and “(B) the term ‘Indian tribe’ has the meaning given the term in section 4(e) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(e)). “(2) ABROGATION OF SOVEREIGN IMMUNITY.—Except as provided in paragraph (3), and subject to paragraph (4), a patent owner may not assert sovereign immunity, including the sovereign immunity accorded to an Indian tribe, as a defense in— “(A) any reexamination proceeding under this section, including any appeal to the Patent Trial and Appeal Board; or “(B) a review by a court of the United States with respect to a decision reached in a proceeding described in subparagraph (A). “(3) IMMUNITY OF FOREIGN STATES.—If a patent owner is a foreign State, for the purposes of any proceeding described in paragraph (2)(A), the Office or the Patent Trial and Appeal Board, as applicable, shall determine whether the patent owner is immune from the jurisdiction of the Office or the Patent Trial and Appeal Board, as applicable, in accordance with chapter 97 of title 28 as if the Office or the Patent Trial and Appeal Board, as applicable, were a court of the United States. “(4) LIMITATION.—This subsection shall apply only to the extent permitted under the 11th amendment to the Constitution of the United States.”; (4) in section 316, by adding at the end the following: “(f) Sovereign immunity.— “(1) DEFINITIONS.—In this subsection— “(A) the term ‘foreign State’ has the meaning given the term in section 1603(a) of title 28; and “(B) the term ‘Indian tribe’ has the meaning given the term in section 4(e) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(e)). “(2) ABROGATION OF SOVEREIGN IMMUNITY.—Except as provided in paragraph (3), and subject to paragraph (4), a patent owner may not assert sovereign immunity, including the sovereign immunity accorded to an Indian tribe, as a defense in— “(A) an inter partes review instituted under this chapter; or “(B) a review by a court of the United States with respect to a decision reached in a proceeding described in subparagraph (A). “(3) IMMUNITY OF FOREIGN STATES.—If a patent owner is a foreign State, for the purposes of any review described in paragraph (2)(A), the Patent Trial and Appeal Board shall determine whether the patent owner is immune from the jurisdiction of the Patent Trial and Appeal Board, in accordance with chapter 97 of title 28 as if the Patent Trial and Appeal Board were a court of the United States. “(4) LIMITATION.—This subsection shall apply only to the extent permitted under the 11th amendment to the Constitution of the United States.”; and (5) in section 326, by adding at the end the following: “(f) Sovereign immunity.— “(1) DEFINITIONS.—In this subsection— “(A) the term ‘foreign State’ has the meaning given the term in section 1603(a) of title 28; and “(B) the term ‘Indian tribe’ has the meaning given the term in section 4(e) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(e)). “(2) ABROGATION OF SOVEREIGN IMMUNITY.—Except as provided in paragraph (3), and subject to paragraph (4), a patent owner may not assert sovereign immunity, including the sovereign immunity accorded to an Indian tribe, as a defense in— “(A) a post-grant review instituted under this chapter; or “(B) a review by a court of the United States with respect to a decision reached in a proceeding described in subparagraph (A). “(3) IMMUNITY OF FOREIGN STATES.—If a patent owner is a foreign State, for the purposes of any review described in paragraph (2)(A), the Patent Trial and Appeal Board shall determine whether the patent owner is immune from the jurisdiction of the Patent Trial and Appeal Board, in accordance with chapter 97 of title 28 as if the Patent Trial and Appeal Board were a court of the United States. “(4) LIMITATION.—This subsection shall apply only to the extent permitted under the 11th amendment to the Constitution of the United States.”. (c) Amendments to the Tariff Act of 1930.—Section 337 of the Tariff Act of 1930 (19 U.S.C. 1337) is amended by adding at the end the following: “(o) Abrogation of tribal sovereign immunity.— “(1) DEFINITIONS.—In this subsection— “(A) the term ‘covered person’— “(i) means a person; and “(ii) includes— “(I) an Indian tribe; and “(II) any other person that claims immunity on account of the sovereign status of an Indian tribe; and “(B) the term ‘Indian tribe’ has the meaning given the term in section 4(e) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(e)). “(2) ABROGATION.—In any proceeding under this section, no covered person may assert as a defense the sovereign immunity that is accorded to an Indian tribe.”. (d) Technical and conforming amendment.—The table of sections for chapter 29 of title 35, United States Code, is amended by striking the item relating to section 296 and inserting the following: “296. Liability of States, instrumentalities of States, State officials, and Indian tribes for infringement of patents.”. Sec. 412. Guidelines for medical practice. (a) Selection.—Not later than 6 months after the date of enactment of this Act, eligible professional organizations that have established, published, maintained, and updated on a regular basis, clinical practice guidelines, including when applicable, appropriate use criteria, that incorporate best practices, may submit such guidelines to the Secretary. Not later than 6 months after the last day for submitting such guidelines, the Secretary shall select and designate one or more eligible professional organizations to provide and maintain such clinical practice guidelines on behalf of the Secretary. Not later than 6 months after designating each such eligible professional organization, the Secretary shall enter into an agreement with each such eligible professional organization for maintenance, publication, and updating of such clinical practice guidelines. (b) Maintenance.— (1) PERIODIC REVIEW.—Not later than 5 years after the Secretary enters into an agreement with each eligible professional organization under subsection (a), and every 5 years thereafter, the Secretary shall review the clinical practice guidelines of such organization and shall, as necessary, enter into agreements with additional eligible professional organizations, as appropriate, in accordance with subsection (a). (2) UPDATE BY ELIGIBLE PROFESSIONAL ORGANIZATION.—An eligible professional organization that collaborated in the establishment of a clinical practice guideline may submit amendments to that clinical practice guideline at any time to the Secretary for review by the Secretary. (3) NOTIFICATION REQUIRED FOR CERTAIN UPDATES.—An amendment under paragraph (2) may not add, materially change, or remove a guideline from a set of guidelines, unless notification of such update is made available to applicable eligible professionals. (4) COMPETITION AMONG PROFESSIONAL ORGANIZATIONS.—The Secretary shall be requird to take into consideration the Sherman Anti-Trust Act and other Federal laws to ensure that no monopoly may exist among eligible professional organizations under this section. (5) OLD VERSION OPTION.—The Secretary shall maintain the option to continue to allow use of non-updated clinical practice guidelines. (6) ATTORNEY GENERAL CONSULTATION.—The Attorney General of the United States shall be consulted prior to the designation of all eligible clinical practice guidelines and as part of the review of such guidelines. (7) HOMELAND SECURITY CONSULTATION.—The Secretary of Homeland Security shall be consulted prior to the designation of all eligible clinical practice guidelines and as part of the review of such guidelines. (c) Guideline standards.—The Secretary shall ensure that, to the extent practicable, the development of clinical practice guidelines are guided by the Standards for Developing Trustworthy Clinical Practice Guidelines of the Institute of Medicine and— (1) are developed through a transparent process that minimizes conflicts of interest; (2) are developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups; (3) take into consideration important patient subgroups and patient preferences, as appropriate; (4) are based on a systematic review of the existing evidence; (5) except in the case of diagnostic guidelines, provide a clear explanation of the relationship between care options and health outcomes; (6) except in the case of diagnostic guidelines, provide ratings of both the quality of evidence and strength of recommendation; (7) are reconsidered and revised when new evidence emerges; (8) do not protect or mandate violation of or complicity in violation of Federal law; (9) do not protect or mandate violation of or complicity in sexual exploitation of persons under the age of eighteen (except that cosmetic surgeries explicitly allowed under 12 U.S.C. 8550 shall not be considered sexual exploitation) or discouragement of firearm ownership (except when this may be suitable for a mental health professional); (10) take into consideration preparedness for emergency situations, not limited to public health emergencies; and (11) clearly identify any exceptions to the application of the clinical practice guideline. (d) Required disclosures from eligible professional organizations.—Any person who is affiliated with an eligible professional organization and who directly participated in the creation of a clinical practice guideline shall follow that particular eligible professional organization’s conflict of interest protocol. (e) Neither an eligible professional organization nor the participants in its guideline development and approval process, may be held liable for any injury alleged to be caused by adhering to a clinical practice guideline to which they contributed. (f) The Secretary shall publish on the Internet through the National Guideline Clearinghouse or other appropriate sites or sources, all clinical practice guidelines, including all data and methodology used in the development and selection of the guidelines in compliance with data disclosure standards in the Health Insurance Portability and Accountability Act of 1996 (Public Law 104–191). (g) Limitation.—This section shall not preempt or supersede any State or Federal law that— (1) imposes procedural or substantive protections for health care providers and health care organizations from liability, loss, or damages greater than such protections provided by this title; or (2) creates a cause of action related to the provision of health care goods or services. (h) State Flexibility.—No provision of this Act shall be construed to preempt any defense available to a party in a health care liability action under any other provision of State or Federal law. (i) Health care liability claims.—Chapter 85 of title 28, United States Code, is amended by adding at the end the following: “§ 1370. Health care liability claims “(a) Definitions.—In this section, the terms ‘applicable eligible professional’, ‘health care goods or services’, ‘health care liability action’, ‘health care liability claim’, ‘health care organization’, and ‘health care provider’ have the meaning given such terms in section 10 of the Saving Lives, Saving Costs Act. “(b) Jurisdiction of claims.—The district courts shall have original jurisdiction of a health care liability action against an applicable eligible professional, health care provider, or health care organization. “(c) Substantive law.—The substantive law for decision in a health care liability action brought under subsection (b) shall be derived from the law, including choice of law principles, of the State in which the provision of, use of, or payment for (or the failure to provide, use, or pay for) health care goods or services giving rise to the health care liability claim occurred unless such law is inconsistent with or preempted by Federal law.”. (j) Technical and conforming amendment.—The table of sections for chapter 85 of title 28, United States Code, is amended by adding at the end the following: “1370. Health care liability claims.”. (k) Right of removal.—Section 1441 of title 28, United States Code, is amended by adding at the end the following: “(g) Certain actions against medical professionals.—A health care liability action brought in a State court against an applicable eligible professional, health care provider, or health care organization may be removed by any defendant or the defendants to the district court of the United States for the district and division embracing the place where such action is pending. (l) Mandatory review by independent medical panel.—If, in any health care liability action removed to Federal court pursuant to section 1441(g) of title 28, United States Code, against an applicable eligible professional, health care provider, or health care organization, the applicable eligible professional, health care provider, or health care organization alleges, in response to a filing of the claimant, that the applicable eligible professional, health care provider, or health care organization adhered to an applicable clinical practice guideline in the provision of health care goods or services to the claimant, then the court shall suspend further proceedings on the health care liability action prior to discovery proceedings, until the completion of a review of the action by an independent medical review panel. (m) Independent medical review panel.— (1) COMPOSITION.—An independent medical review panel under this section shall be composed of 3 members who are experts in the relevant field of clinical practice, appointed in accordance with paragraph (5). (2) REQUIREMENTS FOR MEMBER ELIGIBILITY.— (A) IN GENERAL.—To be eligible to serve on an independent medical review panel, a member shall— (i) be an experienced physician certified by a board recognized by the American Board of Medical Specialties or the American Osteopathic Association Bureau of Osteopathic Specialists; (ii) not earlier than 2 years prior to the date of selection to the board, have been in active medical practice or devoted a substantial portion of his or her time to teaching at an accredited medical school, or have been engaged in university-based research in relation to the medical care and type of treatment at issue; and (iii) be approved by his or her specialty society. (B) REGIONAL PREFERENCE.—When possible, members should be from the region where the case in question originates to account for geographical practice variation. (3) NO CIVIL LIABILITY FOR MEMBERS.—No civil action shall be brought in any court against any member for any act, failure to act, or statement or opinion made, within the scope of his or her duties as a member of the independent medical review panel. (4) CONSIDERATIONS IN MAKING DETERMINATIONS.—The members of the independent medical review panel shall acknowledge that, under certain circumstances, it may be appropriate for a physician to depart from the recommendations in clinical practice guidelines in the care of individual patients. (5) SELECTION OF MEMBERS.—Each member of the independent medical review panel shall be jointly selected by the parties. A member whose selection one party does not concur in may not serve on the panel, except that, if, not later than 30 days after a response to the health care liability action is filed, 3 members have not been selected by the parties, the court shall appoint any remaining members. (6) COMPENSATION OF MEMBERS.—The costs of compensation to the members of the independent medical review panel shall be shared between the parties equally, unless otherwise agreed to by the parties. (n) Terms of review.—A review by an independent medical review panel under this section shall comply with the following: (1) STANDARD OF CONDUCT.—The mandatory independent medical review panel that is charged with the responsibility of making a preliminary finding as to liability of the defendant applicable eligible professional shall deem the prescribed clinical practice guidelines as the standard of conduct, care, and skill expected of members of the medical profession engaged in the defendant’s field of practice under the same or similar circumstances, subject to the provisions of subsection (m)(4). (2) RECORD FOR REVIEW.—The independent medical review panel shall make a preliminary finding based solely upon the pre-discovery evidence submitted to it pursuant to Rule 26 of the Federal Rules of Civil Procedure, any medical records that would be discoverable if the lawsuit advances to trial, and the applicable prescribed clinical practice guidelines. (3) LIMITATION.—The independent medical review panel shall not make a finding of negligence from the mere fact that a treatment or procedure was unsuccessful or failed to bring the best result, or that the patient died. (4) USE AT TRIAL OF WORK PRODUCT OF REVIEW PANEL.—No preliminary finding by the independent medical review panel that the defendant applicable eligible professional breached the standard of care as set forth under the prescribed clinical practice guidelines shall constitute negligence per se or conclusive evidence of liability, but findings, opinions, and conclusions of the review panel shall be admissible as evidence in any and all subsequent proceedings before the court, including for purposes of motions for summary judgment and at trial. (o) Results of review.— (1) IN GENERAL.—Not later than 60 days after all members of the independent medical review panel have been selected, the panel shall complete a review of the record of the liability action and shall make a finding under this subsection. (2) FINDING DESCRIBED.—A finding under this subsection shall include the following: (A) A determination of whether there are any applicable clinical practice guidelines to the health care liability action that substantively pertains to the injury suffered by the claimant. (B) Whether the applicable eligible professional has alleged adherence to any such guideline. (C) Whether the applicable eligible professional adhered to any such guideline. (D) Whether there is a reasonable probability that— (i) the applicable eligible professional violated the applicable clinical practice guideline; (ii) that violation proximately caused the claimant’s alleged injury; and (iii) the claimant suffered damages as a result of the injury. (3) USE AT TRIAL.—The finding under this subsection may be received into evidence by the court. If the independent medical review panel made any finding under paragraph (2)(D) that there was no reasonable probability of the matters described in clauses (i) through (iii), the court may issue a summary judgment in favor of the applicable eligible professional unless the claimant is able to show otherwise by clear and convincing evidence. If the panel made a finding under subparagraphs (A) through (C) of paragraph (2) that there was an applicable clinical practice guideline that the defendant adhered to, the court shall issue summary judgment in favor of the applicable eligible professional unless the claimant is able to show otherwise by clear and convincing evidence. Any preliminary finding that the defendant applicable eligible professional did not breach the standard of care as set forth under the prescribed medical practice guidelines or that the defendant applicable eligible professional's nonadherence to the applicable standard was neither the cause in fact nor the proximate cause of the plaintiff's injury or that the plaintiff did not incur any damages as a result shall be given deference by the court and shall entitle the defendant applicable eligible professional to summary judgment unless the plaintiff is able to show by clear and convincing evidence that the independent medical review panel was in error and that there is a genuine issue as to a material fact in the case. (p) Definitions.— (1) APPLICABLE ELIGIBLE PROFESSIONAL.—The term “applicable eligible professional” means a physician practicing within clinical practice guidelines submitted by an eligible professional organization and includes employees and agents of a physician. (2) APPROPRIATE USE CRITERIA.—The term “appropriate use criteria” means established evidence-based guidelines developed or endorsed by an eligible professional organization that specify when the health benefits of a procedure or service exceed the expected health risks by a significantly wide margin. (3) CLINICAL PRACTICE GUIDELINE.—The term “clinical practice guideline” means systematically developed statements based on the review of clinical evidence for assisting a health care provider to determine the appropriate health care in specific clinical circumstances. (4) DIAGNOSTIC GUIDELINE.—The term “diagnostic guideline” means a clinical practice guideline that provides recommendation regarding the utility of diagnosis procedures for a specific clinical scenario. (5) ELIGIBLE PROFESSIONAL ORGANIZATION.—The term “eligible professional organization” means a national, State, or Territorial medical society or medical specialty society, including such societies which may be based on particular philosophies of medicine or based on religious principles. (6) FEDERAL PAYOR.—The term “Federal payor” includes reimbursements made under the Medicare program under title XVIII of the Social Security Act or the Medicaid program under title XIX of the Social Security Act, premium tax credits under section 36B of the Internal Revenue Code of 1986 or cost-sharing reductions under section 1402 of the Patient Protection and Affordable Care Act, or medical screenings, treatments, or transfer services provided pursuant to section 1867 of the Social Security Act. (7) HEALTH CARE GOODS OR SERVICES.—The term “health care goods or services” means any goods or services provided by a health care organization, provider, or by any individual working under the supervision of a health care provider, that relates to the diagnosis, prevention, or treatment of any human disease or impairment, or the assessment or care of the health of human beings. (8) HEALTH CARE LIABILITY ACTION.—The term “health care liability action” means a civil action against an applicable eligible professional, a health care provider, or a health care organization, regardless of the theory of liability on which the claim is based, or the number of plaintiffs, defendants, or other parties, or the number of causes of action, in which the claimant alleges a health care liability claim. (9) HEALTH CARE LIABILITY CLAIM.—The term “health care liability claim” means a claim by any person against an applicable eligible professional, a health care provider, or a health care organization which is based upon the provision of, use of, or payment for (or the failure to provide, use, or pay for) health care goods or services for which at least partial payment was made by a Federal payor or which was mandated by Federal law, regardless of the theory of liability on which the claim is based. (10) HEALTH CARE ORGANIZATION.—The term “health care organization” means any person or entity which is obligated to provide or pay for health benefits under any health plan, including any person or entity acting under a contract or arrangement with a health care organization to provide or administer any health benefit. (11) HEALTH CARE PROVIDER.—The term “health care provider” means any person or entity required by State or Federal laws or regulations to be licensed, registered, or certified to provide health care services, and being either so licensed, registered, or certified, or exempted from such requirement by other statute or regulation. (12) SECRETARY.—The term “Secretary” means the Secretary of Health and Human Services. (q) Effect on copyright law.—No clinical practice guideline, or previous version of such guideline, shall be regarded as a copyrightable work under the Copyright Act of 1976. (s) Lenience regarding modular or limited-scope guidelines.—If a guideline is extremely limited in scope, then it may be exempted from certain requirements under this section on account of brevity, provided that such a guideline is intended for use accompanied by at least one other guideline and the scope of such a guideline is too limited to allow the consideration of a requirement. No person shall enjoy protections as an applicable eligible professional under this section if such a professional does not practice either one clinical practice guideline which conforms to all requirements of such guidelines or multiple guidelines which comply with all requirements. Sec. 413. Medical supply chain security. (a) Additional manufacturer reporting for essential medical devices.—Section 506C of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 356c) is amended— (1) in subsection (a)— (A) in the matter preceding paragraph (1), by inserting “or device” after “a drug”; and (B) in the flush matter by inserting “or device” after “drug” each place such term appears; (2) in subsection (c), by inserting “and devices” after “drugs”; (3) in subsection (g)— (A) in the matter preceding paragraph (1), by striking “drug shortage of a drug” and inserting “shortage of a drug or device”; (B) in paragraph (1), by striking “; or” and inserting a semicolon; (C) by redesignating paragraph (2) as paragraph (3); (D) by inserting after paragraph (1) the following: “(2) expedite the review of a device subject to premarket approval under section 515 that could help mitigate or prevent such shortage; or”; and (E) in paragraph (3), as so redesignated, by striking “drug shortage” and inserting “shortage”; (4) in subsection (h)— (A) by amending paragraph (2) to read as follows: “(2) the term ‘shortage’, with respect to a drug or device, means a period of time when the demand or projected demand for the drug or device within the United States exceeds the supply of the drug or device; and”; and (B) in paragraph (3)(A), by inserting “or device” after “drug”; and (5) by adding at the end the following: “(j) Additional manufacturer reporting for essential drugs and devices.—Each manufacturer of a drug or device described in subsection (a) shall provide to the Food and Drug Administration, on an annual basis, or more frequently at the request of the Secretary, information related to the manufacturing capacity of such drug or device. Such information shall include— “(1) details about— “(A) all locations of production; “(B) the sourcing of all component parts; “(C) the sourcing of any active pharmaceutical ingredients; and “(D) the use of any scarce raw materials; and “(2) any other information determined by the Secretary to be relevant to the security of the supply chain of the drug or device.”. (b) Provision of additional information.—Section 506C–1 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 356c–1) is amended— (1) in the heading, by striking “drug shortages” and inserting “drug or device shortages”; (2) by striking “drug shortages” each place it appears and inserting “drug or device shortages”; (3) in subsection (a)— (A) in paragraph (3)(B)— (i) in clause (i), by striking “section 506C(g)(1)” and inserting “paragraph (1) or (2) of section 506C(g)”; and (ii) in clause (ii), by striking “section 506C(g)(2)” and inserting “section 506C(g)(3)”; and (B) in paragraph (5), by striking “drug shortage” and inserting “drug or device shortage”; and (4) in subsection (c), by striking “‘drug shortage’ or”. Sec. 414. Healthcare lawsuits. (a) Statute of limitations.— (1) IN GENERAL.—Except as provided in paragraph (2), the time for the commencement of a health care lawsuit shall be, whichever occurs first of the following: (A) 3 years after the date of the occurrence of the breach or tort; (B) 3 years after the date the medical or health care treatment that is the subject of the claim is completed; (C) 1 year after the claimant discovers, or through the use of reasonable diligence should have discovered, the injury; (D) 2 years after a lawsuit becomes a legally available remedy for such an action, regardless of whether a prior limitation would restrict standing. (2) TOLLING.—In no event shall the time for commencement of a health care lawsuit exceed 3 years after the date of the occurrence of the breach or tort or 3 years after the date the medical or health care treatment that is the subject of the claim is completed (whichever occurs first) unless tolled for any of the following— (A) upon proof of fraud; (B) intentional concealment; or (C) the presence of a foreign body, which has no therapeutic or diagnostic purpose or effect, in the person of the injured person. (3) ACTIONS BY A MINOR.—Actions by a minor shall be commenced within 3 years after the date of the occurrence of the breach or tort or 3 years after the date of the medical or health care treatment that is the subject of the claim is completed (whichever occurs first) except that actions by a minor under the full age of 6 years shall be commenced within 3 years after the date of the occurrence of the breach or tort, 3 years after the date of the medical or health care treatment that is the subject of the claim is completed, or 1 year after the injury is discovered, or through the use of reasonable diligence should have been discovered, or prior to the minor’s 8th birthday, whichever provides a longer period. Such time limitation shall be tolled for minors for any period during which a parent or guardian and a health care provider have committed fraud or collusion in the failure to bring an action on behalf of the injured minor. (4) State flexibility.—No provision of this subsection shall be construed to preempt any State law (whether effective before, on, or after the date of the enactment of this Act) that— (A) specifies a time period of less than 3 years after the date of injury or less than 1 year after the claimant discovers, or through the use of reasonable diligence should have discovered, the injury, for the filing of a health care lawsuit; (B) that specifies a different time period for the filing of lawsuits by a minor; (C) that triggers the time period based on the date of the alleged negligence; or (D) establishes a statute of repose for the filing of health care lawsuit. (b) Compensating patient injury.— (1) Unlimited amount of damages for actual economic losses in health care lawsuits.—In any health care lawsuit, nothing in this section shall limit a claimant’s recovery of the full amount of the available economic damages, notwithstanding the limitation in paragraph (2). (2) Additional noneconomic damages.—In any health care lawsuit, the amount of noneconomic damages, if available, shall not exceed $250,000, regardless of the number of parties against whom the action is brought or the number of separate claims or actions brought with respect to the same injury. (3) No discount of award for noneconomic damages.—For purposes of applying the limitation in paragraph (2), future noneconomic damages shall not be discounted to present value. The jury shall not be informed about the maximum award for noneconomic damages. An award for noneconomic damages in excess of $250,000 shall be reduced either before the entry of judgment, or by amendment of the judgment after entry of judgment, and such reduction shall be made before accounting for any other reduction in damages required by law. If separate awards are rendered for past and future noneconomic damages and the combined awards exceed $250,000, the future noneconomic damages shall be reduced first. (4) Fair share rule.—In any health care lawsuit, each party shall be liable for that party’s several share of any damages only and not for the share of any other person. Each party shall be liable only for the amount of damages allocated to such party in direct proportion to such party’s percentage of responsibility. Whenever a judgment of liability is rendered as to any party, a separate judgment shall be rendered against each such party for the amount allocated to such party. For purposes of this subsection, the trier of fact shall determine the proportion of responsibility of each party for the claimant’s harm. (5) State flexibility.—No provision of this subsection shall be construed to preempt any State law (whether effective before, on, or after the date of the enactment of this Act) that specifies a particular monetary amount of economic or noneconomic damages (or the total amount of damages) that may be awarded in a health care lawsuit, regardless of whether such monetary amount is greater or lesser than is provided for under this subsection. (c) Court supervision of share of damages actually paid to claimants.—In any health care lawsuit, the court shall supervise the arrangements for payment of damages to protect against conflicts of interest that may have the effect of reducing the amount of damages awarded that are actually paid to claimants. In particular, in any health care lawsuit in which the attorney for a party claims a financial stake in the outcome by virtue of a contingent fee, the court shall have the power to restrict the payment of a claimant’s damage recovery to such attorney, and to redirect such damages to the claimant based upon the interests of justice and principles of equity. In no event shall the total of all contingent fees for representing all claimants in a health care lawsuit exceed the following limits: (1) Forty percent of the first $50,000 recovered by the claimant(s). (2) Thirty-three and one-third percent of the next $50,000 recovered by the claimant(s). (3) Twenty-five percent of the next $500,000 recovered by the claimant(s). (4) Fifteen percent of any amount by which the recovery by the claimant(s) is in excess of $600,000. (d) Applicability.—The limitations in subsection (c) shall apply whether the recovery is by judgment, settlement, mediation, arbitration, or any other form of alternative dispute resolution. In a health care lawsuit involving a minor or incompetent person, a court retains the authority to authorize or approve a fee that is less than the maximum permitted under this subsection. The requirement for court supervision in the first two sentences of subsection (a) applies only in civil actions. (e) State flexibility.—No provision of subsection (c) shall be construed to preempt any State law (whether effective before, on, or after the date of the enactment of this Act) that specifies a lesser percentage or lesser total value of damages which may be claimed by an attorney representing a claimant in a health care lawsuit. (f) Authorization of payment of future damages to claimants in health care lawsuits.—In any health care lawsuit, if an award of future damages, without reduction to present value, equaling or exceeding $50,000 is made against a party with sufficient insurance or other assets to fund a periodic payment of such a judgment, the court shall, at the request of any party, enter a judgment ordering that the future damages be paid by periodic payments, in accordance with the Uniform Periodic Payment of Judgments Act promulgated by the National Conference of Commissioners on Uniform State Laws. This subsection applies to all actions which have not been first set for trial or retrial before the effective date of this Act. No provision of this subsection shall be construed to preempt any State law (whether effective before, on, or after the date of the enactment of this Act) that specifies periodic payments for future damages at any amount other than $50,000 or that mandates such payments absent the request of either party. (g) Product liability for health care providers.—A health care provider who prescribes, or who dispenses pursuant to a prescription, a medical product approved, licensed, or cleared by the Food and Drug Administration shall not be named as a party to a product liability lawsuit involving such product and shall not be liable to a claimant in a class action lawsuit against the manufacturer, distributor, or seller of such product. (h) Definitions.—In this Act: (1) ALTERNATIVE DISPUTE RESOLUTION SYSTEM; ADR.—The term “alternative dispute resolution system” or “ADR” means a system that provides for the resolution of health care lawsuits in a manner other than through a civil action brought in a State or Federal court. (2) CLAIMANT.—The term “claimant” means any person who brings a health care lawsuit, including a person who asserts or claims a right to legal or equitable contribution, indemnity, or subrogation, arising out of a health care liability claim or action, and any person on whose behalf such a claim is asserted or such an action is brought, whether deceased, incompetent, or a minor. (3) COLLATERAL SOURCE BENEFITS.—The term “collateral source benefits” means any amount paid or reasonably likely to be paid in the future to or on behalf of the claimant, or any service, product, or other benefit provided or reasonably likely to be provided in the future to or on behalf of the claimant, as a result of the injury or wrongful death, pursuant to— (A) any State or Federal health, sickness, income-disability, accident, or workers’ compensation law; (B) any health, sickness, income-disability, or accident insurance that provides health benefits or income-disability coverage; (C) any contract or agreement of any group, organization, partnership, or corporation to provide, pay for, or reimburse the cost of medical, hospital, dental, or income-disability benefits; and (D) any other publicly or privately funded program. (4) CONTINGENT FEE.—The term “contingent fee” includes all compensation to any person or persons which is payable only if a recovery is effected on behalf of one or more claimants. (5) ECONOMIC DAMAGES.—The term “economic damages” means objectively verifiable monetary losses incurred as a result of the provision or use of (or failure to provide or use) health care services or medical products, such as past and future medical expenses, loss of past and future earnings, cost of obtaining domestic services, loss of employment, and loss of business or employment opportunities, unless otherwise defined under applicable State law. In no circumstances shall damages for health care services or medical products exceed the amount actually paid or incurred by or on behalf of the claimant. (6) FUTURE DAMAGES.—The term “future damages” means any damages that are incurred after the date of judgment, settlement, or other resolution (including mediation, or any other form of alternative dispute resolution). (7) HEALTH CARE LAWSUIT.—The term “health care lawsuit” means any health care liability claim concerning the provision of goods or services for which coverage was provided in whole or in part via a Federal program, subsidy or tax benefit, or any health care liability action concerning the provision of goods or services for which coverage was provided in whole or in part via a Federal program, subsidy or tax benefit, brought in a State or Federal court or pursuant to an alternative dispute resolution system, against a health care provider regardless of the theory of liability on which the claim is based, or the number of claimants, plaintiffs, defendants, or other parties, or the number of claims or causes of action, in which the claimant alleges a health care liability claim. Such term does not include a claim or action which is based on criminal liability; which seeks civil fines or penalties paid to Federal, State, or local government; or which is grounded in antitrust. (8) HEALTH CARE LIABILITY ACTION.—The term “health care liability action” means a civil action brought in a State or Federal court or pursuant to an alternative dispute resolution system, against a health care provider regardless of the theory of liability on which the claim is based, or the number of plaintiffs, defendants, or other parties, or the number of causes of action, in which the claimant alleges a health care liability claim. (9) HEALTH CARE LIABILITY CLAIM.—The term “health care liability claim” means a demand by any person, whether or not pursuant to ADR, against a health care provider, including, but not limited to, third-party claims, cross-claims, counter-claims, or contribution claims, which are based upon the provision or use of (or the failure to provide or use) health care services or medical products, regardless of the theory of liability on which the claim is based, or the number of plaintiffs, defendants, or other parties, or the number of causes of action. (10) HEALTH CARE PROVIDER.—The term “health care provider” means any person or entity required by State or Federal laws or regulations to be licensed, registered, or certified to provide health care services, and being either so licensed, registered, or certified, or exempted from such requirement by other statute or regulation, as well as any other individual or entity defined as a health care provider, health care professional, or health care institution under State law. (11) HEALTH CARE SERVICES.—The term “health care services” means the provision of any goods or services (including safety, professional, or administrative services directly related to health care) by a health care provider, or by any individual working under the supervision of a health care provider, that relates to the diagnosis, prevention, or treatment of any human disease or impairment, or the assessment or care of the health of human beings. (12) MEDICAL PRODUCT.—The term “medical product” means a drug, device, or biological product intended for humans, and the terms “drug”, “device”, and “biological product” have the meanings given such terms in sections 201(g)(1) and 201(h) of the Federal Food, Drug and Cosmetic Act (21 U.S.C. 321(g)(1) and (h)) and section 351(a) of the Public Health Service Act (42 U.S.C. 262(a)), respectively, including any component or raw material used therein, but excluding health care services. (13) NONECONOMIC DAMAGES.—The term “noneconomic damages” means damages for physical and emotional pain, suffering, inconvenience, physical impairment, mental anguish, disfigurement, loss of enjoyment of life, loss of society and companionship, loss of consortium (other than loss of domestic service), hedonic damages, injury to reputation, and all other nonpecuniary losses of any kind or nature incurred as a result of the provision or use of (or failure to provide or use) health care services or medical products, unless otherwise defined under applicable State law. (14) RECOVERY.—The term “recovery” means the net sum recovered after deducting any disbursements or costs incurred in connection with prosecution or settlement of the claim, including all costs paid or advanced by any person. Costs of health care incurred by the plaintiff and the attorneys’ office overhead costs or charges for legal services are not deductible disbursements or costs for such purpose. (15) REPRESENTATIVE.—The term “representative” means a legal guardian, attorney, person designated to make decisions on behalf of a patient under a medical power of attorney, or any person recognized in law or custom as a patient’s agent. (16) STATE.—The term “State” means each of the several States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, the Trust Territory of the Pacific Islands, and any other territory or possession of the United States, or any political subdivision thereof. (i) Effect on other laws.— (1) Vaccine injury.— (A) To the extent that title XXI of the Public Health Service Act establishes a Federal rule of law applicable to a civil action brought for a vaccine-related injury or death— (i) this section does affect the application of the rule of law to such an action, except that no defendant in a vaccine injury case may take advantage of this section until after 2034; and (ii) any rule of law prescribed by this section in conflict with a rule of law of such title XXI shall apply to such action. (2) If there is an aspect of a civil action brought for a vaccine-related injury or death to which a Federal rule of law under title XXI of the Public Health Service Act does not apply, then this Act or otherwise applicable law (as determined under this section) will apply to such aspect of such action. (2) Other Federal law.—Except as provided in this subsection, nothing in this Act shall be deemed to prohibit any defense available to a defendant in a health care lawsuit or action under any other provision of Federal law. (j) Rules of construction.— (1) Health care lawsuits.—Unless otherwise specified in this section, the provisions governing health care lawsuits set forth in this section preempt, subject to paragraphs (2) and (3), State law to the extent that State law prevents the application of any provisions of law established by or under this Act. The provisions governing health care lawsuits set forth in this Act supersede chapter 171 of title 28, United States Code, to the extent that such chapter— (A) provides for a greater amount of damages or contingent fees, a longer period in which a health care lawsuit may be commenced, or a reduced applicability or scope of periodic payment of future damages, than provided in this Act; or (B) prohibits the introduction of evidence regarding collateral source benefits, or mandates or permits subrogation or a lien on collateral source benefits. (2) Protection of States’ rights and other laws.—Any issue that is not governed by any provision of law established by or under this Act (including State standards of negligence) shall be governed by otherwise applicable State or Federal law. (3) State Flexibility.—No provision of this section shall be construed to preempt any defense available to a party in a health care lawsuit under any other provision of State or Federal law. (k) Effective date.—This ssection shall apply to any health care lawsuit brought in a Federal or State court, or subject to an alternative dispute resolution system, that is initiated on or after the date of the enactment of this Act, except that any health care lawsuit arising from an injury occurring prior to the date of the enactment of this Act shall be governed by the applicable statute of limitations provisions in effect at the time the cause of action accrued. (l) Limitation on expert witness testimony.— (1) In general.—Unless such person is an eligible professional organization or an authorized representative of one describing clinical practice guidelines, diagnostic guidelines, or other guidelines currently established through an agreement with the Secretary of Health and Human Services under section 415 of this Act, no person in a health care profession requiring licensure under the laws of a State or under the laws of any Territory of the United States shall be competent to testify in any court of law to establish the following facts— (A) the recognized standard of acceptable professional practice and the specialty thereof, if any, that the defendant practices, which shall be the type of acceptable professional practice recognized in the defendant’s community or in a community similar to the defendant’s community that was in place at the time the alleged injury or wrongful action occurred; (B) that the defendant acted with less than or failed to act with ordinary and reasonable care in accordance with the recognized standard; and (C) that as a proximate result of the defendant’s negligent act or omission, the claimant suffered injuries which would not otherwise have occurred, unless the person was licensed to practice, in the State or a contiguous bordering State, a profession or specialty which would make the person’s expert testimony relevant to the issues in the case and had practiced this profession or specialty in one of these States during the year preceding the date that the alleged injury or wrongful act occurred. (2) Applicability.—The requirements set forth in this subsection shall also apply to expert witnesses testifying for the defendant as rebuttal witnesses. (3) Waiver authority.—The court may waive the requirements in this subsection if it determines that the appropriate witnesses otherwise would not be available. (m) Provider communications.—In any health care liability action, any and all statements, affirmations, gestures, or conduct expressing apology, fault, sympathy, commiseration, condolence, compassion, or a general sense of benevolence which are made by a health care provider or an employee of a health care provider to the patient, a relative of the patient, or a representative of the patient and which relate to the discomfort, pain, suffering, injury, or death of the patient as the result of the unanticipated outcome of medical care shall be inadmissible for any purpose as evidence of an admission of liability or as evidence of an admission against interest. No provision of this subsection shall be construed to preempt any State law (whether effective before, on, or after the date of the enactment of this Act) that makes additional communications inadmissible as evidence of an admission of liability or as evidence of an admission against interest. (n) Expert witness qualifications.—In any health care lawsuit, an individual shall not give expert testimony on the appropriate standard of practice or care involved unless the individual is licensed as a health professional in one or more States and the individual meets the following criteria: (1) If the party against whom or on whose behalf the testimony is to be offered is or claims to be a specialist, the expert witness shall specialize at the time of the occurrence that is the basis for the lawsuit in the same specialty or claimed specialty as the party against whom or on whose behalf the testimony is to be offered. If the party against whom or on whose behalf the testimony is to be offered is or claims to be a specialist who is board certified, the expert witness shall be a specialist who is board certified in that specialty or claimed specialty. (2) During the 1-year period immediately preceding the occurrence of the action that gave rise to the lawsuit, the expert witness shall have devoted a majority of the individual’s professional time to one or more of the following: (A) The active clinical practice of the same health profession as the defendant and, if the defendant is or claims to be a specialist, in the same specialty or claimed specialty. (B) The instruction of students in an accredited health professional school or accredited residency or clinical research program in the same health profession as the defendant and, if the defendant is or claims to be a specialist, in an accredited health professional school or accredited residency or clinical research program in the same specialty or claimed specialty. (3) If the defendant is a general practitioner, the expert witness shall have devoted a majority of the witness’s professional time in the 1-year period preceding the occurrence of the action giving rise to the lawsuit to one or more of the following: (A) Active clinical practice as a general practitioner. (B) Instruction of students in an accredited health professional school or accredited residency or clinical research program in the same health profession as the defendant. (o) Lawsuits against entities.—If the defendant in a health care lawsuit is an entity that employs a person against whom or on whose behalf the testimony is offered, the provisions of subsection (n) apply as if the person were the party or defendant against whom or on whose behalf the testimony is offered. Nothing in this subsection or in subsection (n) shall limit the power of the trial court in a health care lawsuit to disqualify an expert witness on grounds other than the qualifications set forth under this subsection. (p) Limitation.—An expert witness in a health care lawsuit shall not be permitted to testify if the fee of the witness is in any way contingent on the outcome of the lawsuit. No provision of this subsection or in subsections (l), (n), or (o) shall be construed to preempt any State law (whether effective before, on, or after the date of the enactment of this Act) that places additional qualification requirements upon any individual testifying as an expert witness. (q) Affidavit of merit.— (1) Required filing.—Subject to paragraph (2), the plaintiff in a health care lawsuit alleging negligence or, if the plaintiff is represented by an attorney, the plaintiff’s attorney shall file simultaneously with the health care lawsuit an affidavit of merit signed by a health professional who meets the requirements for an expert witness under this subsection. The affidavit of merit shall certify that the health professional has reviewed the notice and all medical records supplied to him or her by the plaintiff’s attorney concerning the allegations contained in the notice and shall contain a statement of each of the following: (A) The applicable standard of practice or care. (B) The health professional’s opinion that the applicable standard of practice or care was breached by the health professional or health facility receiving the notice. (C) The actions that should have been taken or omitted by the health professional or health facility in order to have complied with the applicable standard of practice or care. (D) The manner in which the breach of the standard of practice or care was the proximate cause of the injury alleged in the notice. (E) A listing of the medical records reviewed. (2) Filing extension.—Upon motion of a party for good cause shown, the court in which the complaint is filed may grant the plaintiff or, if the plaintiff is represented by an attorney, the plaintiff’s attorney an additional 28 days in which to file the affidavit required under subsection (a). (3) State flexibility.—No provision of this subsection shall be construed to preempt any State law (whether effective before, on, or after the date of the enactment of this Act) that establishes additional requirements for the filing of an affidavit of merit or similar pre-litigation documentation. (s) Notice of intent to commence lawsuit.— (1) Advance notice.—A person shall not commence a health care lawsuit against a health care provider unless the person has given the health care provider 90 days written notice before the action is commenced. (2) Exceptions.—A health care lawsuit against a health care provider filed within 6 months of the statute of limitations expiring as to any claimant, or within 1 year of the statute of repose expiring as to any claimant, shall be exempt from compliance with this subsection. (3) State flexibility.—No provision of this subsection shall be construed to preempt any State law (whether effective before, on, or after the date of the enactment of this Act) that establishes a different time period for the filing of written notice. Sec. 415. Protection against political discrimination. (a) In General.—Section 1128 of the Social Security Act (42 U.S.C. 1320a–7) is amended— (1) in subsection (a), by adding at the end the following new paragraph: “(5) FAILURE TO PROVIDE CARE BASED ON COVERED STATEMENT.— “(A) IN GENERAL.—Any individual or entity that the Secretary determines has failed to furnish items or services to a patient based on a covered statement (as defined in subsection (k)) made by such patient. “(B) ENFORCEMENT.—Not later than 6 months after the date of enactment of this paragraph, the Secretary shall establish a process under which the Office of Civil Rights of the Department of Health and Human Services shall investigate a claim of failure to provide care based on a covered statement (as described in subparagraph (A)).”; (2) in subsection (c)(3)— (A) in subparagraph (B), by striking “subparagraph (G)” and inserting “subparagraphs (G) and (H)”; and (B) by adding at the end the following new subparagraph: “(H) (i) Subject to clause (ii), in the case of an exclusion of an individual or entity under subsection (a)(5), the period of such exclusion from a Federal health program and a State health program shall be not less than 1 year. “(ii) In the case of an exclusion of an individual or entity under subsection (a)(5), if such failure to furnish items or services causes a patient to be in violation of a public health emergency declared under section 319 of the Public Health Service Act, the period of the exclusion from a Federal health program and a State health program shall be not less than 2 years.”; and (3) by adding at the end the following new subsection: “(k) Definitions.—For purposes of subsection (a)(5): “(1) AFFILIATED ORGANIZATION.—The term ‘affiliated organization’ means an organization that is operated, supervised, or controlled by or in connection with a political party. “(2) COVERED STATEMENT.— “(A) IN GENERAL.—Subject to subparagraph (B), the term ‘covered statement’ means a written or oral statement that— “(i) expresses support of, or endorses, a national political party, State political party, or an affiliated organization; “(ii) expresses support of, or affiliation with, a special interest group that may have a political message, including related to the medical profession in any way; or “(iii) denigrates, disagrees with, or disparages the political views of a national political party, a State political party, an affiliated organization, or a special interest group that may have a political message, including related to the medical profession in any way. “(B) EXCEPTION.—A ‘covered statement’ does not include the following: “(i) A crime of violence (as such term is defined in section 16 of title 18, United States Code). “(ii) Harassment. “(iii) Incitement of violence or harassment. “(3) HARASSMENT.—The term ‘harassment’ means the targeting of an individual or entity with behavior meant to alarm, annoy, torment, or terrorize such individual or entity, including by directing abuse towards groups protected under title VII of the Civil Rights Act of 1964, in a manner that causes such individual or entity to feel reasonable fear for the safety of such individual or entity, or the family or property of such individual or entity. “(4) INCITEMENT.—The term ‘incitement’ means the urging of an individual to commit a criminal offense under Federal or State law. “(5) SPECIAL INTEREST GROUP.—The term ‘special interest group’ means an organization with a political, cultural, or religious message that is not operated, supervised, or controlled by a political party.”. (b) Effective Date.—The amendments made by subsection (a) shall apply with respect to items or services furnished seven months after the date of enactment of this Act, except that for corporations all amendments made by this section shall be retroactively enforced. Sec. 416. Non-invasive diagnostics. Section 201(h) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321(h)) is amended— (1) in the second sentence by inserting before the period at the end the following: “or any non-invasive diagnostic device”; and (2) by adding at the end the following: “For purposes of the preceding sentence, the term ‘non-invasive’ means, with respect to a diagnostic device, that the device does not penetrate the skin or any other membrane of the body, is not inserted or implanted into the body, causes no more than ephemeral compression or temperature changes to in situ bodily tissues, and does not subject bodily tissues to ionizing radiation.”. Sec. 417. Patient visitation rights. Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended— (1) in subsection (e)— (A) in paragraph (8), by striking “and” at the end; (B) by redesignating paragraph (9) as paragraph (10); (C) by inserting after paragraph (8) the following new paragraph: “(9) has written policies and procedures regarding the visitation rights of individuals receiving items and services at the institution, which shall include a description of any clinically necessary or reasonable restriction or limitation that such institution may need to place on such rights and the reasons for the clinical restriction or limitation, and a requirement that such institution— “(A) inform each such individual of his or her visitation rights, including any clinical restriction or limitation on such rights; “(B) inform each such individual of the right, subject to the individual’s consent, to receive the visitors whom the individual designates, including a spouse, another family member, or a friend, and the individual’s right to withdraw or deny such consent at any time; “(C) may not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, or disability; and “(D) ensure that all visitors enjoy full and equal visitation privileges consistent with this paragraph; and”; and (D) in the matter following paragraph (10), as redesignated, by striking “paragraph (9)” each place it appears and inserting “paragraph (10)” in each such place; and (2) in subsection (f), by striking “(9)” and inserting “(10)”. Sec. 418. Abolition of certificates of need. Notwithstanding any other provision of law (including any contradictory law of any State, Territory, or District) there shall be no need for any new medical establishment or business to prove any need for its services in any area. Subtitle B—Regulatory Reform for Health Insurance and Exchanges Sec. 421. Increasing competition in insurance exchange. (a) A new subchapter IV is created at the end of Chapter 156 of Title 42 of the United States Code which is titled “Health insurance exchanges”. (b) Within subchapter IV of Chapter 156 of Title 42, a new section 17961 shall be inserted as follows— “17961. Federally-authorized health insurance exchanges” “(a) The following shall be defined as federally-authorized health insurance exchanges— “(1) State-operated exchanges which are compliant with Federal law. “(2) Privately-operated exchanges registered with the Department of Health and Human Services. “(3) Any exchanges operated by the Federal government. “(b) Federally-authorized health insurance exchanges must provide any and all information relevant to Federal tax law, including such information that may be relevant for tax purposes, and shall pay an occupational tax established by the Secretary of Health and Human Services. “(c) The Department of Health and Human Services will commence operation of a directory of federally-authorized health insurance exchanges, which may be funded by use of any acceptable business practices permitted by Federal law, prior to July 4, 2028. “(d) Subsection (c) does not preclude the operation of directories or other means of helping to expand awareness of exchanges by other organizations. “(e) The Secretary of Health and Human Services, with the input of the Secretary of Commerce, shall establish necessary security standards and regulations for federally-authorized health insurance exchanges. These regulations shall protect private information from persons based on criminal and civil records. Notwithstanding any requirements to the contrary, no person ever convicted of a felony which involving the theft of personal information may be employed in a capacity where any consumer's personal information shall be accessible at a federally-authorized insurance exchange or at any related Federal agency. “(f) The Secretary of Health and Human Services shall provide regulations intended to ensure transparency on federally-authorized health insurance exchanges. “(g) No law shall restrict the ability of federally-authorized health insurance exchanges to specify any enrollment period, including to allow enrollment at any time. “(h) Nothing in this subchapter shall be construed as preventing appropriate regulation of federally-authorized health insurance exchanges for compliance with any law. “(i) Federally-authorized health insurance exchanges shall be treated as individual markets, group markets, or otherwise subjected to similar regulations or regulations applied to both by the Secretary. “(j) The Secretary may issue special regulations, including regulatory exemptions, to enable the operation of startups with innovative interests in such regulations, provided that such regulations do not harm consumers. “(k) Any State or Territorial law which prohibits privately-operated exchanges is pereempted.” Sec. 422. Interstate purchasing of health insurance. (a) In General.—Title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended by adding at the end the following new part: “PART D—Cooperative Governing of Individual Health Insurance Coverage “Sec. 2795. Definitions. “In this part: “(1) PRIMARY STATE.—The term ‘primary State’ means, with respect to individual health insurance coverage offered by a health insurance issuer, the State designated by the issuer as the State whose covered laws shall govern the health insurance issuer in the sale of such coverage under this part. An issuer, with respect to a particular policy, may only designate one such State as its primary State with respect to all such coverage it offers. Such an issuer may not change the designated primary State with respect to individual health insurance coverage once the policy is issued, except that such a change may be made upon renewal of the policy. With respect to such designated State, the issuer is deemed to be doing business in that State. “(2) SECONDARY STATE.—The term ‘secondary State’ means, with respect to individual health insurance coverage offered by a health insurance issuer, any State that is not the primary State. In the case of a health insurance issuer that is selling a policy in, or to a resident of, a secondary State, the issuer is deemed to be doing business in that secondary State. “(3) HEALTH INSURANCE ISSUER.—The term ‘health insurance issuer’ has the meaning given such term in section 2791(b)(2), except that such an issuer must be licensed in the primary State and be qualified to sell individual health insurance coverage in that State. “(4) INDIVIDUAL HEALTH INSURANCE COVERAGE.—The term ‘individual health insurance coverage’ means health insurance coverage offered in the individual market, as defined in section 2791(e)(1). “(5) APPLICABLE STATE AUTHORITY.—The term ‘applicable State authority’ means, with respect to a health insurance issuer in a State, the State insurance commissioner or official or officials designated by the State to enforce the requirements of this title for the State with respect to the issuer. “(6) HAZARDOUS FINANCIAL CONDITION.—The term ‘hazardous financial condition’ means that, based on its present or reasonably anticipated financial condition, a health insurance issuer is unlikely to be able— “(A) to meet obligations to policyholders with respect to known claims and reasonably anticipated claims; or “(B) to pay other obligations in the normal course of business. “(7) COVERED LAWS.— “(A) IN GENERAL.—The term ‘covered laws’ means the laws, rules, regulations, agreements, and orders governing the insurance business pertaining to— “(i) individual health insurance coverage issued by a health insurance issuer; “(ii) the offer, sale, rating (including medical underwriting), renewal, and issuance of individual health insurance coverage to an individual; “(iii) the provision to an individual in relation to individual health insurance coverage of health care and insurance related services; “(iv) the provision to an individual in relation to individual health insurance coverage of management, operations, and investment activities of a health insurance issuer; and “(v) the provision to an individual in relation to individual health insurance coverage of loss control and claims administration for a health insurance issuer with respect to liability for which the issuer provides insurance. “(B) EXCEPTION.—Such term does not include any law, rule, regulation, agreement, or order governing the use of care or cost management techniques, including any requirement related to provider contracting, network access or adequacy, health care data collection, or quality assurance. “(8) STATE.—The term ‘State’ means the 50 States and includes the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. “(9) UNFAIR CLAIMS SETTLEMENT PRACTICES.—The term ‘unfair claims settlement practices’ means only the following practices: “(A) Knowingly misrepresenting to claimants and insured individuals relevant facts or policy provisions relating to coverage at issue. “(B) Failing to acknowledge with reasonable promptness pertinent communications with respect to claims arising under policies. “(C) Failing to adopt and implement reasonable standards for the prompt investigation and settlement of claims arising under policies. “(D) Failing to effectuate prompt, fair, and equitable settlement of claims submitted in which liability has become reasonably clear. “(E) Refusing to pay claims without conducting a reasonable investigation. “(F) Failing to affirm or deny coverage of claims within a reasonable period of time after having completed an investigation related to those claims. “(G) A pattern or practice of compelling insured individuals or their beneficiaries to institute suits to recover amounts due under its policies by offering substantially less than the amounts ultimately recovered in suits brought by them. “(H) A pattern or practice of attempting to settle or settling claims for less than the amount that a reasonable person would believe the insured individual or his or her beneficiary was entitled by reference to written or printed advertising material accompanying or made part of an application. “(I) Attempting to settle or settling claims on the basis of an application that was materially altered without notice to, or knowledge or consent of, the insured. “(J) Failing to provide forms necessary to present claims within 15 calendar days of a requests with reasonable explanations regarding their use. “(K) Attempting to cancel a policy in less time than that prescribed in the policy or by the law of the primary State. “(10) FRAUD AND ABUSE.—The term ‘fraud and abuse’ means an act or omission committed by a person who, knowingly and with intent to defraud, commits, or conceals any material information concerning, one or more of the following: “(A) Presenting, causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer, a reinsurer, broker or its agent, false information as part of, in support of or concerning a fact material to one or more of the following: “(i) An application for the issuance or renewal of an insurance policy or reinsurance contract. “(ii) The rating of an insurance policy or reinsurance contract. “(iii) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract. “(iv) Premiums paid on an insurance policy or reinsurance contract. “(v) Payments made in accordance with the terms of an insurance policy or reinsurance contract. “(vi) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction. “(vii) The financial condition of an insurer or reinsurer. “(viii) The formation, acquisition, merger, reconsolidation, dissolution or withdrawal from one or more lines of insurance or reinsurance in all or part of a State by an insurer or reinsurer. “(ix) The issuance of written evidence of insurance. “(x) The reinstatement of an insurance policy. “(B) Solicitation or acceptance of new or renewal insurance risks on behalf of an insurer reinsurer or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction. “(C) Transaction of the business of insurance in violation of laws requiring a license, certificate of authority or other legal authority for the transaction of the business of insurance. “(D) Attempt to commit, aiding or abetting in the commission of, or conspiracy to commit the acts or omissions specified in this paragraph. “Sec. 2796. Application of law. “(a) In General.—The covered laws of the primary State shall apply to individual health insurance coverage offered by a health insurance issuer in the primary State and in any secondary State, but only if the coverage and issuer comply with the conditions of this section with respect to the offering of coverage in any secondary State. “(b) Exemptions From Covered Laws in a Secondary State.—Except as provided in this section, a health insurance issuer with respect to its offer, sale, rating (including medical underwriting), renewal, and issuance of individual health insurance coverage in any secondary State is exempt from any covered laws of the secondary State (and any rules, regulations, agreements, or orders sought or issued by such State under or related to such covered laws) to the extent that such laws would— “(1) make unlawful, or regulate, directly or indirectly, the operation of the health insurance issuer operating in the secondary State, except that any secondary State may require such an issuer— “(A) to pay, on a nondiscriminatory basis, applicable premium and other taxes (including high risk pool assessments) which are levied on insurers and surplus lines insurers, brokers, or policyholders under the laws of the State; “(B) to register with and designate the State insurance commissioner as its agent solely for the purpose of receiving service of legal documents or process; “(C) to submit to an examination of its financial condition by the State insurance commissioner in any State in which the issuer is doing business to determine the issuer’s financial condition, if— “(i) the State insurance commissioner of the primary State has not done an examination within the period recommended by the National Association of Insurance Commissioners; and “(ii) any such examination is conducted in accordance with the examiners’ handbook of the National Association of Insurance Commissioners and is coordinated to avoid unjustified duplication and unjustified repetition; “(D) to comply with a lawful order issued— “(i) in a delinquency proceeding commenced by the State insurance commissioner if there has been a finding of financial impairment under subparagraph (C); or “(ii) in a voluntary dissolution proceeding; “(E) to comply with an injunction issued by a court of competent jurisdiction, upon a petition by the State insurance commissioner alleging that the issuer is in hazardous financial condition; “(F) to participate, on a nondiscriminatory basis, in any insurance insolvency guaranty association or similar association to which a health insurance issuer in the State is required to belong; “(G) to comply with any State law regarding fraud and abuse (as defined in section 2795(10)), except that if the State seeks an injunction regarding the conduct described in this subparagraph, such injunction must be obtained from a court of competent jurisdiction; “(H) to comply with any State law regarding unfair claims settlement practices (as defined in section 2795(9)); or “(I) to comply with the applicable requirements for independent review under section 2798 with respect to coverage offered in the State; “(2) require any individual health insurance coverage issued by the issuer to be countersigned by an insurance agent or broker residing in that Secondary State; “(2) regulate or prohibit applicable luxury health plans as defined by 26 U.S.C. 4378; or “(4) otherwise discriminate against the issuer issuing insurance in both the primary State and in any secondary State. “(c) Clear and Conspicuous Disclosure.—A health insurance issuer shall provide the following notice, via mail or online notification, in any insurance coverage offered in a secondary State under this part by such a health insurance issuer and at renewal of the policy, with the 5 blank spaces therein being appropriately filled with the name of the health insurance issuer, the name of primary State, the name of the secondary State, the name of the secondary State, and the name of the secondary State, respectively, for the coverage concerned: This policy is issued by _____ and is governed by the laws and regulations of the State of _____, and it has met all the laws of that State as determined by that State’s Department of Insurance. This policy may be less expensive than others because it is not subject to all of the insurance laws and regulations of the State of _____, including coverage of some services or benefits mandated by the law of the State of _____. Additionally, this policy is not subject to all of the consumer protection laws or restrictions on rate changes of the State of _____. As with all insurance products, before purchasing this policy, you should carefully review the policy and determine what health care services the policy covers and what benefits it provides, including any exclusions, limitations, or conditions for such services or benefits. “(d) Prohibition on Certain Reclassifications and Premium Increases.— “(1) IN GENERAL.—For purposes of this section, a health insurance issuer that provides individual health insurance coverage to an individual under this part in a primary or secondary State may not upon renewal— “(A) move or reclassify the individual insured under the health insurance coverage from the class such individual is in at the time of issue of the contract based on the health-status related factors of the individual; or “(B) increase the premiums assessed the individual for such coverage based on a health status-related factor or change of a health status-related factor or the past or prospective claim experience of the insured individual. “(2) CONSTRUCTION.—Nothing in paragraph (1) shall be construed to prohibit a health insurance issuer— “(A) from terminating or discontinuing coverage or a class of coverage in accordance with subsections (b) and (c) of section 2742; “(B) from raising premium rates for all policy holders within a class based on claims experience; “(C) from changing premiums or offering discounted premiums to individuals who engage in wellness activities at intervals prescribed by the issuer, if such premium changes or incentives— “(i) are disclosed to the consumer in the insurance contract; “(ii) are based on specific wellness activities that are not applicable to all individuals; and “(iii) are not obtainable by all individuals to whom coverage is offered; “(D) from reinstating lapsed coverage; or “(E) from retroactively adjusting the rates charged an insured individual if the initial rates were set based on material misrepresentation by the individual at the time of issue. “(e) Prior Offering of Policy in Primary State.—A health insurance issuer may not offer for sale individual health insurance coverage in a secondary State unless that coverage is currently offered for sale in the primary State. “(f) Licensing of Agents or Brokers for Health Insurance Issuers.—Any State may require that a person acting, or offering to act, as an agent or broker for a health insurance issuer with respect to the offering of individual health insurance coverage obtain a license from that State, with commissions or other compensation subject to the provisions of the laws of that State, except that a State may not impose any qualification or requirement which discriminates against a nonresident agent or broker. “(g) Documents for Submission to State Insurance Commissioner.—Each health insurance issuer issuing individual health insurance coverage in both primary and secondary States shall submit— “(1) to the insurance commissioner of each State in which it intends to offer such coverage, before it may offer individual health insurance coverage in such State— “(A) a copy of the plan of operation or feasibility study or any similar statement of the policy being offered and its coverage (which shall include the name of its primary State and its principal place of business); “(B) written notice of any change in its designation of its primary State; and “(C) written notice from the issuer of the issuer’s compliance with all the laws of the primary State; and “(2) to the insurance commissioner of each secondary State in which it offers individual health insurance coverage, a copy of the issuer’s quarterly financial statement submitted to the primary State, which statement shall be certified by an independent public accountant and contain a statement of opinion on loss and loss adjustment expense reserves made by— “(A) a member of the American Academy of Actuaries; or “(B) a qualified loss reserve specialist. “(h) Power of Courts To Enjoin Conduct.—Nothing in this section shall be construed to affect the authority of any Federal or State court to enjoin— “(1) the solicitation or sale of individual health insurance coverage by a health insurance issuer to any person or group who is not eligible for such insurance; or “(2) the solicitation or sale of individual health insurance coverage that violates the requirements of the law of a secondary State which are described in subparagraphs (A) through (H) of section 2796(b)(1). “(i) Power of Secondary States To Take Administrative Action.—Nothing in this section shall be construed to affect the authority of any State to enjoin conduct in violation of that State’s laws described in section 2796(b)(1). “(j) State Powers To Enforce State Laws.— “(1) IN GENERAL.—Subject to the provisions of subsection (b)(1)(G) (relating to injunctions) and paragraph (2), nothing in this section shall be construed to affect the authority of any State to make use of any of its powers to enforce the laws of such State with respect to which a health insurance issuer is not exempt under subsection (b). “(2) COURTS OF COMPETENT JURISDICTION.—If a State seeks an injunction regarding the conduct described in paragraphs (1) and (2) of subsection (h), such injunction must be obtained from a Federal or State court of competent jurisdiction. “(3) STATE EXCHANGE MANAGEMENT.—States may choose to refrain from advertising policies for which they are not the primary State in their own State health insurance exchanges. “(k) States’ Authority To Sue.—Nothing in this section shall affect the authority of any State to bring action in any Federal or State court. “(l) Generally Applicable Laws.—Nothing in this section shall be construed to affect the applicability of State laws generally applicable to persons or corporations. “(m) Guaranteed Availability of Coverage to HIPAA Eligible Individuals.—To the extent that a health insurance issuer is offering coverage in a primary State that does not accommodate residents of secondary States or does not provide a working mechanism for residents of a secondary State, and the issuer is offering coverage under this part in such secondary State which has not adopted a qualified high risk pool as its acceptable alternative mechanism (as defined in section 2744(c)(2)), the issuer shall, with respect to any individual health insurance coverage offered in a secondary State under this part, comply with the guaranteed availability requirements for eligible individuals in section 2741. “Sec. 2797. Primary State must meet Federal floor before issuer may sell into secondary States. “A health insurance issuer may not offer, sell, or issue individual health insurance coverage in a secondary State if the State insurance commissioner does not use a risk-based capital formula for the determination of capital and surplus requirements for all health insurance issuers. “Sec. 2798. Independent external appeals procedures. “(a) Right to External Appeal.—A health insurance issuer may not offer, sell, or issue individual health insurance coverage in a secondary State under the provisions of this title unless— “(1) both the secondary State and the primary State have legislation or regulations in place establishing an independent review process for individuals who are covered by individual health insurance coverage, or “(2) in any case in which the requirements of subparagraph (A) are not met with respect to the either of such States, the issuer provides an independent review mechanism substantially identical (as determined by the applicable State authority of such State) to that prescribed in the ‘Health Carrier External Review Model Act’ of the National Association of Insurance Commissioners for all individuals who purchase insurance coverage under the terms of this part, except that, under such mechanism, the review is conducted by an independent medical reviewer, or a panel of such reviewers, with respect to whom the requirements of subsection (b) are met. “(b) Qualifications of Independent Medical Reviewers.—In the case of any independent review mechanism referred to in subsection (a)(2)— “(1) IN GENERAL.—In referring a denial of a claim to an independent medical reviewer, or to any panel of such reviewers, to conduct independent medical review, the issuer shall ensure that— “(A) each independent medical reviewer meets the qualifications described in paragraphs (2) and (3); “(B) with respect to each review, each reviewer meets the requirements of paragraph (4) and the reviewer, or at least 1 reviewer on the panel, meets the requirements described in paragraph (5); and “(C) compensation provided by the issuer to each reviewer is consistent with paragraph (6). “(2) LICENSURE AND EXPERTISE.—Each independent medical reviewer shall be a physician (allopathic or osteopathic) or health care professional who— “(A) is appropriately credentialed or licensed in 1 or more States to deliver health care services; and “(B) typically treats the condition, makes the diagnosis, or provides the type of treatment under review. “(3) INDEPENDENCE.— “(A) IN GENERAL.—Subject to subparagraph (B), each independent medical reviewer in a case shall— “(i) not be a related party (as defined in paragraph (7)); “(ii) not have a material familial, financial, or professional relationship with such a party; and “(iii) not otherwise have a conflict of interest with such a party (as determined under regulations). “(B) EXCEPTION.—Nothing in subparagraph (A) shall be construed to— “(i) prohibit an individual, solely on the basis of affiliation with the issuer, from serving as an independent medical reviewer if— “(I) a non-affiliated individual is not reasonably available; “(II) the affiliated individual is not involved in the provision of items or services in the case under review; “(III) the fact of such an affiliation is disclosed to the issuer and the enrollee (or authorized representative) and neither party objects; and “(IV) the affiliated individual is not an employee of the issuer and does not provide services exclusively or primarily to or on behalf of the issuer; “(ii) prohibit an individual who has staff privileges at the institution where the treatment involved takes place from serving as an independent medical reviewer merely on the basis of such affiliation if the affiliation is disclosed to the issuer and the enrollee (or authorized representative), and neither party objects; or “(iii) prohibit receipt of compensation by an independent medical reviewer from an entity if the compensation is provided consistent with paragraph (6). “(4) PRACTICING HEALTH CARE PROFESSIONAL IN SAME FIELD.— “(A) IN GENERAL.—In a case involving treatment, or the provision of items or services— “(i) by a physician, a reviewer shall be a practicing physician (allopathic or osteopathic) of the same or similar specialty, as a physician who, acting within the appropriate scope of practice within the State in which the service is provided or rendered, typically treats the condition, makes the diagnosis, or provides the type of treatment under review; or “(ii) by a non-physician health care professional, the reviewer, or at least 1 member of the review panel, shall be a practicing non-physician health care professional of the same or similar specialty as the non-physician health care professional who, acting within the appropriate scope of practice within the State in which the service is provided or rendered, typically treats the condition, makes the diagnosis, or provides the type of treatment under review. “(B) PRACTICING DEFINED.—For purposes of this paragraph, the term ‘practicing’ means, with respect to an individual who is a physician or other health care professional, that the individual provides health care services to individual patients on average at least 2 days per week. “(5) PEDIATRIC EXPERTISE.—In the case of an external review relating to a child, a reviewer shall have expertise under paragraph (2) in pediatrics. “(6) LIMITATIONS ON REVIEWER COMPENSATION.—Compensation provided by the issuer to an independent medical reviewer in connection with a review under this section shall— “(A) not exceed a reasonable level; and “(B) not be contingent on the decision rendered by the reviewer. “(7) RELATED PARTY DEFINED.—For purposes of this section, the term ‘related party’ means, with respect to a denial of a claim under a coverage relating to an enrollee, any of the following: “(A) The issuer involved, or any fiduciary, officer, director, or employee of the issuer. “(B) The enrollee (or authorized representative). “(C) The health care professional that provides the items or services involved in the denial. “(D) The institution at which the items or services (or treatment) involved in the denial are provided. “(E) The manufacturer of any drug or other item that is included in the items or services involved in the denial. “(F) Any other party determined under any regulations to have a substantial interest in the denial involved. “(8) DEFINITIONS.—For purposes of this subsection: “(A) ENROLLEE.—The term ‘enrollee’ means, with respect to health insurance coverage offered by a health insurance issuer, an individual enrolled with the issuer to receive such coverage. “(B) HEALTH CARE PROFESSIONAL.—The term ‘health care professional’ means an individual who is licensed, accredited, or certified under State law to provide specified health care services and who is operating within the scope of such licensure, accreditation, or certification. “Sec. 2799. Enforcement. “(a) In General.—Subject to subsection (b), with respect to specific individual health insurance coverage the primary State for such coverage has sole jurisdiction to enforce the primary State’s covered laws in the primary State and any secondary State. “(b) Secondary State’s Authority.—Nothing in subsection (a) shall be construed to affect the authority of a secondary State to enforce its laws as set forth in the exception specified in section 2796(b)(1). “(c) Court Interpretation.—In reviewing action initiated by the applicable secondary State authority, the court of competent jurisdiction shall apply the covered laws of the primary State. “(d) Notice of Compliance Failure.—In the case of individual health insurance coverage offered in a secondary State that fails to comply with the covered laws of the primary State, the applicable State authority of the secondary State may notify the applicable State authority of the primary State.”. (b) Effective Date.—The amendment made by subsection (a) shall apply to individual health insurance coverage offered, issued, or sold after the date that is one year after the date of the enactment of this Act. (c) GAO Ongoing Study and Reports.— (1) STUDY.—The Comptroller General of the United States shall conduct an ongoing study concerning the effect of the amendment made by subsection (a) on— (A) the number of uninsured and under-insured; (B) the availability and cost of health insurance policies for individuals with preexisting medical conditions; (C) the availability and cost of health insurance policies generally; (D) the elimination or reduction of different types of benefits under health insurance policies offered in different States; and (E) cases of fraud or abuse relating to health insurance coverage offered under such amendment and the resolution of such cases. (2) ANNUAL REPORTS.—The Comptroller General shall submit to Congress an annual report, after the end of each of the 5 years following the effective date of the amendment made by subsection (a), on the ongoing study conducted under paragraph (1). Sec. 423. Limits on coverage. The Public Health Service Act, as amended by this Act, is further amended by inserting a new section 2755 (42 U.S.C. 300gg-56) after section 2754 (42 U.S.C. 300gg-55) of such Act as follows— “2755. Limits on coverage. “(a) In general.—Unless otherwise permitted by this section, a health insurance issuer may not impose any annual or lifetime limits on health insurance coverage. “(b) State waivers.—A State may, through use of the Patient and State Stability Fund established by section 2202 of the Social Security Act, permit annual or lifetime limits on health insurance coverage. “(c) Territorial exception.—A Territory may, under the guidance of the Secretary of Health and Human Services, permit annual or lifetime limits, by use of the Territorial Risk Fund established by section 2206 of the Social Security Act. “(d) Transitional exception.—A health insurance issuer may, by participation in the Transitional High-Risk Patient Program established by section 2207 of the Social Security Act, allow such program to assume costs beyond an annual or lifetime limit which may be permitted by the Secretary of Health and Human Services acting through the Administrator of the Centers for Medicare & Medicaid Services. “(e) Additional requirements.—The Secretary may, as appropriate, establish restrictions on limits on health insurance coverage as may be necessary to— “(1) prevent overuse of the relevant funds and programs established by the Social Security Act, “(2) prevent health insurance issuers from committing fraudulent denial of coverage, and “(3) prohibit the continued use of limits based on potential exceptions which are no longer available. “(f) Over-Limit Requirement.—If no funds are provided through any Fund or Program referenced in this section on par with those funds which would otherwise be provided by a health insurance issuer, then no annual or lifetime limit may be permitted by this section.”. Sec. 424. Surprise billing prevention. (a) Insurance cost transparency.—The Public Health Service Act, as amended, is further amended by inserting a new section 2707 after section 2706 (as restored by this Act) as follows: “2707. Insurance cost transparency. “(a) Deductibles.—Any group health plan or health insurance coverage (henceforth called "insurance" in this section) must maintain a single standard deductible and must make such deductible available to all potential enrollees in advance. “(b) Premiums.—Any insurance must inform any potential or current enrollee of any premium (or change in premium) charged for health insurance. “(c) Copays.—Any insurance must inform any potential or current enrollee of any copays which may be charged. “(d) Ambulances.—Any insurance must inform any potential or current enrollee or any ambulance fees which may be charged. “(e) Enforcement.—The Secretary of Health and Human Services may establish regulations to enforce this section and to require additional transparency for insurance costs.”. (b) Equal coverage for emergency bills.—The Public Health Service Act, as amended, is further amended by inserting a new section 2708 after section 2707 (as created by this Act) as follows: “2708. Treatment of emergency rooms and other emergency bills. “(a) Emergency billing.—The Secretary of Health and Human Services may, including via any designated person or agency, issue regulations to ensure equal treatment of emergency healthcare for billing purposes. “(b) Ambulance billing.—The Secretary may, including via any designated person, issue regulations to ensure equal treatments of different types of ambulances for billing purposes. “(c) Limitation.—The Secretary may not use this section to regulate emergency healthcare or ambulances in such a way that would deprive patients of healthcare access.”. Sec. 425. Health Insurance Anti-Trust. (a) Amendment to McCarran-Ferguson Act.—Section 3 of the Act of March 9, 1945 (15 U.S.C. 1013), commonly known as the McCarran-Ferguson Act, is amended by adding at the end the following: “(c) (1) Nothing contained in this Act shall modify, impair, or supersede the operation of any of the antitrust laws with respect to the business of health insurance (including the business of dental insurance and limited-scope dental benefits). “(2) Paragraph (1) shall not apply with respect to making a contract, or engaging in a combination or conspiracy— “(A) to collect, compile, or disseminate historical loss data; “(B) to determine a loss development factor applicable to historical loss data; “(C) to perform actuarial services if such contract, combination, or conspiracy does not involve a restraint of trade; or “(D) to develop or disseminate a standard insurance policy form (including a standard addendum to an insurance policy form and standard terminology in an insurance policy form) if such contract, combination, or conspiracy is not to adhere to such standard form or require adherence to such standard form. “(3) For purposes of this subsection— “(A) the term ‘antitrust laws’ has the meaning given it in subsection (a) of the first section of the Clayton Act (15 U.S.C. 12), except that such term includes section 5 of the Federal Trade Commission Act (15 U.S.C. 45) to the extent that such section 5 applies to unfair methods of competition; “(B) the term ‘business of health insurance (including the business of dental insurance and limited-scope dental benefits)’ does not include— “(i) the business of life insurance (including annuities); or “(ii) the business of property or casualty insurance, including but not limited to— “(I) any insurance or benefits defined as ‘excepted benefits’ under paragraph (1), subparagraph (B) or (C) of paragraph (2), or paragraph (3) of section 9832(c) of the Internal Revenue Code of 1986 (26 U.S.C. 9832(c)) whether offered separately or in combination with insurance or benefits described in paragraph (2)(A) of such section; and “(II) any other line of insurance that is classified as property or casualty insurance under State law; “(C) the term ‘historical loss data’ means information respecting claims paid, or reserves held for claims reported, by any person engaged in the business of insurance; and “(D) the term ‘loss development factor’ means an adjustment to be made to reserves held for losses incurred for claims reported by any person engaged in the business of insurance, for the purpose of bringing such reserves to an ultimate paid basis.”. (b) Related provision.—For purposes of section 5 of the Federal Trade Commission Act (15 U.S.C. 45) to the extent such section applies to unfair methods of competition, section 3(c) of the McCarran-Ferguson Act shall apply with respect to the business of health insurance without regard to whether such business is carried on for profit, notwithstanding the definition of “Corporation” contained in section 4 of the Federal Trade Commission Act. (c) Empowering small insurers.— (1) Exemption.—It shall not be a violation of the antitrust laws for one or more private health insurer issuers or their designated agents to jointly negotiate prices of particular hospital services with a hospital provider with regards to the reimbursement policies of the insurers for those services. (2) Definitions.—For purposes of this section: (A) ANTITRUST LAWS.—The term “antitrust laws” has the meaning given it in subsection (a) of the 1st section of the Clayton Act (15 U.S.C. 12(a)), except that such term includes section 5 of the Federal Trade Commission Act (15 U.S.C. 45) to the extent such section 5 applies to unfair methods of competition. (B) HEALTH INSURANCE ISSUER.—The term “health insurance issuer” means an insurance company, insurance service, or insurance organization (including a health maintenance organization, as defined in subparagraph (C)) which is licensed to engage in the business of insurance in a State and which is subject to State law which regulates insurance (within the meaning of section 514(b)(2) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)(2))). Such term does not include a group health plan. (C) HEALTH MAINTENANCE ORGANIZATION.—The term “health maintenance organization” means— (i) a Federally qualified health maintenance organization (as defined in section 300e(a) of title 42 of the United States Code), (ii) an organization recognized under State law as a health maintenance organization, or (iii) a similar organization regulated under State law for solvency in the same manner and to the same extent as such a health maintenance organization. (3) Effective Date.—This subsection shall take effect on the date of the enactment of this Act but shall not apply with respect to conduct that occurs before such date. Sec. 426. Limited-duration insurance. Section 2791(b) of the Public Health Service Act (42 U.S.C. 300gg–91(b)) is amended by adding at the end the following new paragraph: “(6) SHORT-TERM LIMITED DURATION INSURANCE.—The term ‘short-term limited duration insurance’ means health insurance coverage provided under a contract with a health insurance issuer that— “(A) has an expiration date specified in the contract that is less than 12 months after the original effective date of the contract; and “(B) has a duration of not more than 3 years (taking into account renewals or extensions) after the original effective date of the contract.”. Sec. 427. Coverage for preexisting conditions. (a) Section 2753 of the Public Health Service Act (42 U.S.C. 300gg-53) is amended by— (1) inserting a new subsection (g) at the end as follows: “(g) Genetic conditions treated as genetic information.—For purposes of this section, any potentially genetic or hereditary condition, family history of any medical condition, or other genetics-related condition shall be treated as genetic information.”, and (2) amending subsection (c) as follows: “(c) Prohibition on genetic information as preexisting condition.—A health insurance issuer offering health insurance coverage in the individual market may not, on the basis of genetic information, impose any preexisting condition exclusion (as defined by section 2701 of this Act) with respect to such coverage.”. (b) The Public Health Service Act is amended by inserting a new section 2754 (42 U.S.C. 300gg-55) after section 2753 (42 U.S.C. 300gg-54) of such Act as follows— “2754. Coverage of All Preexisting Conditions. “A health insurance issuer offering health insurance coverage in the individual market may not impose any preexisting condition exclusion (as defined by section 2701 of this Act) with respect to such coverage. The Attorney General, in consultation with the Secretary of Health and Human Services, shall investigate insurance fraud based on preexisting conditions.”. (c) Section 2701 of the Public Health Service Act (as amended, restored, or redesignated by this Act) is further amended by striking subparagraph (b)(1)(B). Subtitle C—Prescription Drugs and Related Provisions Sec. 431. Vaccine injury or death. Notwithstanding any other provision of law, including the National Childhood Vaccine Injury Act and Public Health Service Act, petitioners may bring suit to both the Special Masters established by law to handle vaccine injury and to any appropriate jurisdictional court where a vaccine was administered to file suit based on potential damages or death caused by any vaccination, including against persons responsible for administering vaccines as well as manufacturers and any persons who may have attempted to coerce vaccination, including a Federal, Territorial, District, or State government or any educational institution or employer of the United States. Notwithstanding any other provision of law, no persons (including but not limited to all aforementoined persons including vaccine manufacturers) may claim immunity from criminal or civil charges related to vaccine injury or death. Privileged immunity is hereby revoked for all persons involved in the approval of vaccines which have caused vaccine injury or death and all such persons who have been involved may be held criminally as well as civilly responsible. Judges and justices who demonstrate bias against petitioners likewise may be held criminally and civilly responsible for vaccine injury and death. The administration of any vaccine on a nonconsenting minor (including any person under 21 whose parent or guardian did not consent to such administration) or any nonconsenting person shall be considered an injury under this section, and any other injury (including death) caused or possibly caused by such an administration shall be subject to ten times the regular penalty that would normally be applied for such injury or death. All cases in which an administration was mishandled by overdose or otherwise, which denies to the patient the ability to know that such administration was improperly conducted, shall be treated as cases of administration of a vaccine on a nonconsenting person. Consent for vaccination must include any and all relevant information for the patient, including risks, historical immunity from prosecution, potential religious objections including the use of human cells and genetic alteration abilities, and reasons that benefits may be fringe or nonexistent. Sec. 432. Chief Pharmaceutical Trade Negotiator. (a) Establishment.—Section 141(b) of the Trade Act of 1974 (19 U.S.C. 2171(b)), is amended as follows: (1) In paragraph (2)— (A) in the first sentence, by inserting “one Chief Pharmaceutical Trade Negotiator,” after “one Chief Agricultural Negotiator,”; and (B) by inserting “the Chief Pharmaceutical Trade Negotiator,” after “the Chief Agricultural Negotiator,” each place it appears. (2) By adding at the end the following new paragraph: “(7) The principal functions of the Chief Pharmaceutical Trade Negotiator shall be to conduct trade negotiations, enforce trade agreements relating to United States pharmaceutical products, and take appropriate action (including such actions as may be established by Federal law, including the Health Care Act of 2027) to address acts, policies, or practices of high-income countries that have a significant adverse impact on the ability of United States pharmaceutical manufacturers to enjoy full market access. The Chief Pharmaceutical Trade Negotiator shall be a vigorous advocate on behalf of United States manufacturers and consumers of pharmaceutical products and shall perform such other functions as the United States Trade Representative may direct.”. (b) Annual Report.— (1) LIST OF HIGH-INCOME COUNTRIES.—The United States Trade Representative shall compile and annually update a list of each foreign country that is defined as “high-income” by the official statistics of the International Bank for Reconstruction and Development of the World Bank. (2) REPORT REQUIRED.—With respect to each country included on the most recent list required under paragraph (1), the United States Trade Representative, acting through the Chief Pharmaceutical Trade Negotiator, (as established pursuant to the amendments made by subsection (a)) shall annually submit to the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate a report that— (A) describes in detail the results of a review of the acts, policies, and practices of such country relating to the trade in pharmaceutical products in the previous fiscal year; (B) determines whether such acts, policies, or practices— (i) are not developed and implemented in a fair, nondiscriminatory, and transparent manner; (ii) are not market-based or do not appropriately recognize the value of innovative medicines; (iii) deny reciprocal market access for United States products; (iv) diminish incentives for innovation in a manner that delays, prevents, or otherwise adversely impacts the introduction of new medicines in the United States; (v) violate or are inconsistent with the provisions of, or otherwise deny benefits to the United States under, any bilateral or multilateral trade agreement with such country; (vi) are unjustifiable or impose a significant burden or unreasonable or discriminatory restriction on United States commerce with such country; and (C) describes the current status of any responsive actions taken by the United States with respect to acts, policies, or practices for which the United States Trade Representative has determined and included in any prior report, pursuant to subparagraph (B), that the interests of the United States are harmed, including responsive actions pursuant to title III of the Trade Act of 1974 (19 U.S.C. 2411 et seq.). (c) Response To Adverse Actions.—Not later than 30 days after the United States Trade Representative determines that an act, policy, or practice of a country included in the applicable list required under subsection (b)(1) meets any of the criteria described in subsection (b)(2)(B), the United States Trade Representative shall submit to Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate a plan to respond to such adverse action, which may include initiating an investigation under chapter 1 title III of the Trade Act of 1974 (19 U.S.C. 2411 et seq.), in accordance with section 302(b)(1) of such chapter. Sec. 433. Orange Book modernization. (a) Submission of patent information for brand name drugs.— (1) IN GENERAL.—Paragraph (1) of section 505(b) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(b)(1)) is amended to read as follows: “(1) (A) Any person may file with the Secretary an application with respect to any drug subject to the provisions of subsection (a). Such persons shall submit to the Secretary as part of the application— “(i) full reports of investigations which have been made to show whether or not such drug is safe for use and whether such drug is effective in use; “(ii) a full list of the articles used as components of such drug; “(iii) a full statement of the composition of such drug; “(iv) a full description of the methods used in, and the facilities and controls used for, the manufacture, processing, and packing of such drug; “(v) such samples of such drug and of the articles used as components thereof as the Secretary may require; “(vi) specimens of the labeling proposed to be used for such drug; “(vii) any assessments required under section 505B; “(viii) the patent number and expiration date, of each patent for which a claim of patent infringement could reasonably be asserted if a person not licensed by the owner engaged in the manufacture, use, or sale of the drug, and that— “(I) claims the drug for which the applicant submitted the application and is a drug substance patent or a drug product patent; or “(II) claims the method of using the drug for which approval is sought or has been granted in the application; “(ix) a full description of any software or hardware used in any computer used as a component, including related intellectual property information; and “(x) a full description on the intended uses of such drug. “(B) If an application is filed under this subsection for a drug, and a patent of the type described in subparagraph (A)(viii) that claims such drug or a method of using such drug is issued after the filing date, the applicant shall amend the application to include such patent information. “(C) The Secretary shall define the term “full description” as used in subparagraph (A)(ix).”. (2) GUIDANCE.—The Secretary of Health and Human Services shall, in consultation with the Director of the National Institutes of Health and with representatives of the drug manufacturing industry, review and develop guidance, as appropriate, on the inclusion of women and minorities in clinical trials required under subsection (b)(1)(A)(i) of section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355), as amended by paragraph (1). (b) Conforming changes to requirements for subsequent submission of patent information.—Section 505(c)(2) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(c)(2)) is amended— (1) by inserting before the first sentence the following: “Not later than 30 days after the date of approval of an application under subsection (b), the holder of the approved application shall file with the Secretary the patent number and the expiration date of any patent described in subclause (I) or (II) of subsection (b)(1)(A)(viii), except that a patent that is identified as claiming a method of using such drug shall be filed only if the patent claims a method of use approved in the application. The holder of the approved application shall file with the Secretary the patent number and the expiration date of any patent described in subclause (I) or (II) of subsection (b)(1)(A)(viii) that is issued after the date of approval of the application, not later than 30 days after the date of issuance of the patent, except that a patent that claims a method of using such drug shall be filed only if approval for such use has been granted in the application.”; (2) by inserting after “the patent number and the expiration date of any patent which” the following: “fulfills the criteria in subsection (b) and”; (3) by inserting after the third sentence (as amended by paragraph (1)) the following: “Patent information that is not the type of patent information required by subsection (b)(1)(A)(viii) shall not be submitted under this paragraph.”; and (4) by inserting after “could not file patent information under subsection (b) because no patent” the following: “of the type required to be submitted in subsection (b)(1)(A)(viii)”. (c) Listing of exclusivities.—Subparagraph (A) of section 505(j)(7) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(j)(7)) is amended by adding at the end the following: “(iv) For each drug included on the list, the Secretary shall specify any exclusivity period that is applicable, for which the Secretary has determined the expiration date, and for which such period has not yet expired under— “(I) clause (ii), (iii), or (iv) of subsection (c)(3)(E) of this section; “(II) clause (iv) or (v) of paragraph (5)(B) of this subsection; “(III) clause (ii), (iii), or (iv) of paragraph (5)(F) of this subsection; “(IV) section 505A; “(V) section 505E; “(VI) section 527(a); or “(VII) subsection (u)”. (d) Orange book updates with respect to invalidated patents.— (1) IN GENERAL.— (A) AMENDMENTS.—Section 505(j)(7)(A) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(j)(7)(A)), as amended by subsection (c), is further amended by adding at the end the following: “(v) In the case of a listed drug for which the list under clause (i) includes a patent for such drug, and where the Under Secretary of Commerce for Intellectual Property and Director of the United States Patent and Trademark Office have cancelled any claim of the patent pursuant to a decision by the Patent Trial and Appeal Board in an inter partes review conducted under chapter 31 of title 35, United States Code, or a post-grant review conducted under chapter 32 of that title, and from which no appeal has been taken, or can be taken, the holder of the applicable approved application shall notify the Secretary, in writing, within 14 days of such cancellation, and, if the patent has been deemed wholly inoperative or invalid, or if a patent claim has been cancelled, the revisions required under clause (iii) shall include striking the patent or information regarding such patent claim from the list with respect to such drug, as applicable, except that the Secretary shall not remove a patent from the list before the expiration of any 180-day exclusivity period under paragraph (5)(B)(iv) that relies on a certification described in paragraph (2)(A)(vii)(IV) with respect to such patent.”. (B) APPLICATION.—The amendment made by subparagraph (A) shall not apply with respect to any determination with respect to a patent or patent claim that is made prior to the date of enactment of this Act. (2) NO EFFECT ON FIRST APPLICANT EXCLUSIVITY PERIOD.—Section 505(j)(5)(B)(iv)(I), as amended by section 205, is amended by adding at the end the following: “This subclause shall apply even if a patent is stricken from the list under paragraph (7)(A), pursuant to paragraph (7)(A)(v), provided that, at the time that the first applicant submitted an application under this subsection containing a certification described in paragraph (2)(A)(vii)(IV), the patent that was the subject of such certification was included in such list with respect to the listed drug.”. Sec. 434. Clarification of Controlled Substances Act. Section 823 of Title 21 of the United States Code is amended— (a) by striking “and” from paragraph (a)(5), (b) by striking “.” from paragraph (a)(6) and inserting “; and”, (c) by inserting a new paragraph (a)(7) as follows: “(7) that no medication may be utilized to intentionally end the life of any patient.”, (d) by striking “and” from paragraph (d)(5), (e) by striking “.” from paragraph (d)(6) and inserting “; and”, (f) by inserting a new paragraph (d)(7) as follows: “(7) that no medication may be utilized to intentionally end the life of any patient.”, (g) by striking “and” from paragraph (e)(4), (h) by striking “.” from paragraph (e)(5) and inserting “; and”, (i) by inserting a new paragraph (e)(6) as follows: “(6) that no medication may be utilized to intentionally end the life of any patient.”, (j) by striking “and” from paragraph (b)(4), (k) by striking “.” from paragraph (b)(5) and inserting “; and”, (l) by inserting a new paragraph (b)(6) as follows: “(6) that no medication may be utilized to intentionally end the life of any patient.”, Sec. 435. Biological product patent transparency. (a) Additional requirements.—Section 351 of the Public Health Service Act (42 U.S.C. 262) is amended by adding at the end the following: “(o) Additional requirements with respect to patents.— “(1) APPROVED APPLICATION HOLDER LISTING REQUIREMENTS.— “(A) IN GENERAL.—Within 60 days of approval of an application under subsection (a) or (k), the holder of such approved application shall submit to the Secretary a list of each patent required to be disclosed (as described in paragraph (3)). “(B) PREVIOUSLY APPROVED OR LICENSED BIOLOGICAL PRODUCTS.— “(i) PRODUCTS LICENSED UNDER SECTION 351 OF THE PHSA.—The holder of a biological product license that was approved under subsection (a) or (k) shall submit to the Secretary a list of each patent required to be disclosed (as described in paragraph (3)). “(ii) PRODUCTS APPROVED UNDER SECTION 505 OF THE FFDCA.—The holder of an approved application for a biological product under section 505 of the Federal Food, Drug, and Cosmetic Act that is deemed to be a license for the biological product shall submit to the Secretary a list of each patent required to be disclosed (as described in paragraph (3)). “(C) UPDATES.—The holder of a biological product license that is the subject of an application under subsection (a) or (k) shall submit to the Secretary a list that includes— “(i) any patent not previously required to be disclosed (as described in paragraph (3)) under subparagraph (A) or (B), as applicable, within 30 days of the earlier of— “(I) the date of issuance of such patent by the United States Patent and Trademark Office; or “(II) the date of approval of a supplemental application for the biological product; and “(ii) any patent, or any claim with respect to a patent, included on the list pursuant to this paragraph, that the Patent Trial and Appeal Board of the United States Patent and Trademark Office determines in a written decision to cancel as unpatentable, within 30 days of such decision. “(2) PUBLICATION OF INFORMATION.— “(A) IN GENERAL.—The Secretary shall publish and make available to the public a single, easily searchable list that includes— “(i) the official and proprietary name of each biological product licensed, or deemed to be licensed, under subsection (a) or (k); “(ii) with respect to each biological product described in clause (i), each patent submitted in accordance with paragraph (1); “(iii) the date of licensure and application number for each such biological product; “(iv) the marketing status, dosage form, route of administration, strength, and, if applicable, reference product, for each such biological product; “(v) the licensure status for each such biological product, including whether the license at the time of listing is approved, withdrawn, or revoked; “(vi) with respect to each such biological product, any period of exclusivity under paragraph (6), (7)(A), or (7)(B) of subsection (k) of this section or section 527 of the Federal Food, Drug, and Cosmetic Act, and any extension of such period in accordance with subsection (m) of this section, for which the Secretary has determined such biological product to be eligible, and the date on which such exclusivity expires; “(vii) any determination of biosimilarity or interchangeability for each such biological product; and “(viii) information regarding approved indications for each such biological product, in such manner as the Secretary determines appropriate. “(B) UPDATES.—Every 30 days after the publication of the first list under subparagraph (A), the Secretary shall revise the list to include— “(i) (I) each biological product licensed under subsection (a) or (k) during the 30-day period; and “(II) with respect to each biological product described in subclause (I), the information described in clauses (i) through (viii) of subparagraph (A); and “(ii) any updates to information previously published in accordance with subparagraph (A). “(C) NONCOMPLIANCE.—Beginning 18 months after the date of enactment of the Lower Health Care Costs Act, the Secretary, in consultation with the Director of the United States Patent and Trademark Office, shall publish and make available to the public a list of any holders of biological product licenses, and the corresponding biological product or products, that failed to submit information as required under paragraph (1), including any updates required under paragraph (1)(C), in such manner and format as the Secretary determines appropriate. If information required under paragraph (1) is submitted following publication of such list, the Secretary shall remove such holders of such biological product licenses from the public list in a reasonable period of time. “(3) PATENTS REQUIRED TO BE DISCLOSED.—In this section, a ‘patent required to be disclosed’ is any patent for which the holder of a biological product license approved under subsection (a) or (k), or a biological product application approved under section 505 of the Federal Food, Drug, and Cosmetic Act and deemed to be a license for a biological product under this section believes a claim of patent infringement could reasonably be asserted by the holder, or by a patent owner that has granted an exclusive license to the holder with respect to the biological product that is the subject of such license, if a person not licensed by the owner engaged in the making, using, offering to sell, selling, or importing into the United States of the biological product that is the subject of such license. “(4) IMMUNITY FROM CIVIL ACTION.—Effective January 1, 2029, immunity from civil action shall be granted to protect persons required to submit a list under paragraph (1) for relevant biological products, provided that— “(A) the Secretary, in consultation with the Director of the United States Patent and Trademark Office, has performed all relevant duties under subparagraph (2)(C); “(B) the alleged patent infringement was not an act of infringement against a preexisting and public patent or pending patent and was not committed after the date of publication; “(C) the civil action was not initiated within two years of the publication under paragraph (2); and “(D) the civil action is based on alleged patent infringement.”. (b) Disclosure of patents.—Section 351(l)(3)(A)(i) of the Public Health Service Act (42 U.S.C. 262(l)(3)(A)(i)) is amended by inserting “included in the list provided by the reference product sponsor under subsection (o)(1)” after “a list of patents”. (c) Regulations.—The Secretary of Health and Human Services may promulgate regulations to carry out subsection (o) of section 351 of the Public Health Service Act (42 U.S.C. 262), as added by subsection (a). (d) Rule of construction.—Nothing in this Act, including an amendment made by this Act, shall be construed to require or allow the Secretary of Health and Human Services to delay the licensing of a biological product under section 351 of the Public Health Service Act (42 U.S.C. 262). (e) Effective date.—Except as otherwise specified, this section shall go into effect immediately upon the enactment of this Act, and such actions required under it shall be required within twelve months, with six months of further delays permissible at the discreation of the Secretary of Health and Human Services. Sec. 436. Fast track review for certain generic drugs. (a) Section 505(j) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(j)) is amended by adding at the end the following: “(14) (A) Notwithstanding any other provision of law, the Secretary shall prioritize the review of a qualifying application under this subsection and shall, within 150 days of the initial receipt of such qualifying application, take final agency action on the application. “(B) For purposes of this paragraph, the term ‘qualifying application’ means an application— “(i) that does not contain a certification under subclause (IV) of paragraph (2)(A)(vii); “(ii) that may contain a certification under subclause (III) of paragraph (2)(A)(vii) only if such certification asserts that an existing patent will expire not more than 15 months after the date of such certification; “(iii) for a drug where the reference drug is a drug for which there is no exclusivity period in effect, including an exclusivity period under paragraph (5)(F), or under section 505A, section 527, or section 505E; and “(iv) for a drug where the reference drug has not been the reference drug for more than one other drug that— “(I) is approved under this subsection; and “(II) has been introduced into interstate commerce in the 3-month period preceding the date of the qualifying application. “(C) Notwithstanding any other provision of this paragraph and regardless of the date of submission, a qualifying application shall lose status as an application for priority review, and the Secretary’s timeline for taking action on such an application described in subparagraph (A) shall no longer apply, if the application no longer meets the definition of a qualifying application.”. “(D) For purposes of this paragraph, the term ‘qualifying application’ also means an application for a drug which is subject to only patents which, pursuant to a special agreement with the Secretary, shall be licensed under fair, reasonable, and non-discriminatory terms to any United States person. Patents which are expired or scheduled to expire within 12 months of an application's submission shall not be considered patents for purposes of this subparagraph. (b) Report.—Not later than 6 months after enactment and every 6 months thereafter, the Secretary of Health and Human Services, acting through the Commissioner of Food and Drugs, shall submit a report to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives containing the information described in subsection (c). (c) Definition.—In this section the term “generic fast track review” means review under paragraph (11) of section 505(j) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(j)), as added by this section of this Act. (d) Contents of report.—The report described in subsection (a) shall include the following information: (1) The number of applications in the most recent 6-month period that are subject to generic fast track review, and which of those applications— (A) are for a drug where the reference drug has not been the reference drug for any other application that is approved under subsection (j) of section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355); (B) are for a drug where the reference drug has been the reference drug for not more than one other application that is approved under subsection (j) of such section; and (C) are for a drug that is on the drug shortage list established under section 506E of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 356e). (2) The average and median time before an applicant receives an approval decision for an application subject to generic fast track review. (3) The number of applications subject to generic fast track review that were approved. (4) At the time such report is submitted, the number of applications subject to fast track review— (A) that have been withdrawn by the applicant; (B) that have been granted tentative approval; (C) with respect to which the Food and Drug Administration has requested additional information from the sponsor of the application; (D) that are awaiting review by the Food and Drug Administration after additional information has been supplied, as described in subparagraph (C); and (E) with respect to which the Food and Drug Administration has recorded reception of the application but has yet to contact the sponsor regarding the status of the application. (5) A prediction of how long the Food and Drug Administration will take to respond to such applications that are awaiting review with either an approval or a rejection, and how many of such applications are expected to be withdrawn by the applicant. (6) The average review time for such applications that are receiving generic fast track review versus the standard review period. (7) The information described in paragraphs (1) through (6) with respect to applications for drugs under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) that are subject to another form of priority review or fast-track review. (8) An annual accounting of how the Food and Drug Administration has spent the fees it has received under part 7 of subchapter C of chapter VII of such Act (21 U.S.C. 379f et seq.) to include the proportion of such fees that such Administration has spent on personnel costs. (e) Expedited production.—21 U.S.C. 355(j)(10)(A) (Section 505(j)(10)(A) of the Federal Food, Drug, and Cosmetic Act) is amended by striking clauses (i) through (iv) and inserting the following: “(i) the application is otherwise eligible for approval under this subsection except that— “(I) (aa) the listed drug has an active patent, the listed drug has an active exclusivity period, or there is a delay in approval as described in paragraph (5)(B)(iii); and “(bb) a revision to the labeling of the listed drug has been approved by the Secretary within 90 days of expiration of a patent, exclusivity period, or delay in approval referenced in item (aa); or “(II) a revision to the labeling of the listed drug has been approved by the Secretary, within 90 days of when the application is otherwise eligible for approval under this subsection; “(ii) the sponsor of the application agrees to submit revised labeling for the drug that is the subject of the application not later than 90 days after approval under this subsection of the application; and “(iii) the labeling revision described under clause (i) does not include a change to the ‘Warnings’ section of the labeling.”. (f) Small business fees.—21 U.S.C. 379j–72 (Section 744M of the Federal Food, Drug, and Cosmetic Act) is amended by inserting after subsection (c) the following: “(d) Fee Waiver And Reduction For Small Businesses.— “(1) IN GENERAL.—Beginning with respect to fiscal year 2026: “(A) The Secretary shall waive the fee under subsection (a)(2) with respect to the first OTC monograph order request that a small business submits to the Secretary for review. “(B) The Secretary shall reduce the fees that are applicable to a small business under subsections (a)(1) (facility fees) and (a)(2) (OTC monograph order request fees), and not waived under subparagraph (A), to 25 percent of the amount otherwise owed. “(2) CERTIFICATION.—The Secretary shall require any person who applies for a waiver or reduction of fees under paragraph (1) to certify their qualification for the waiver or reduction. The Secretary shall periodically publish in the Federal Register a list of persons making such certifications. No drug produced outside of the United States shall be eligible for any waiver or reduction under this subsection. “(3) SMALL BUSINESS DEFINED.—In this subsection, the term ‘small business’ means a United States entity that has fewer than 500 employees, including employees of affiliates, over 50% of whom are United States citizens.”. Sec. 437. Country of origin of drugs. (a) In general.—Subchapter A of chapter V of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 351 et seq.) is amended by adding at the end the following: “SEC. 524B. Registry of drugs produced outside the United States. “(a) In general.—The Secretary shall compile and maintain a list of all drugs approved under subsection (c) or (j) of section 505 of this Act or licensed under subsection (a) or (k) of section 351 of the Public Health Service Act, and any active ingredients in such drugs, that— “(1) are manufactured outside of the United States; and “(2) are determined by the Secretary to be critical to the health and safety of consumers in the United States. “(b) Additional list.—In conjunction with the list described in subsection (a), the Secretary shall compile and maintain a list of drugs included on such list that are exclusively produced in, or use active or inactive ingredients produced in, the People's Republic of China. “(c) Requirement.—The list described in subsection (a) shall, with respect to each drug included on the list, provide information about the drug’s supply chain, including each step in the supply chain that occurs prior to the drug’s importation into the United States.”. (b) Federal health program purchase of, or reimbursement for, drugs.— (1) IN GENERAL.—Notwithstanding any other provision of law, the Department of Health and Human Services, the Department of Veterans Affairs, the Department of Defense, and any other Federal health care program (as defined in 42 U.S.C. 1320a–7b(b) (section 1128B(f) of the Social Security Act), with respect to the purchase of, or reimbursement for, a drug by such agency or program, the following shall apply: (A) By 2028, a purchaser of, or reimbursor for, drugs described in this subsection shall purchase drugs or reimburse for drugs only if such drugs contain 60 percent or more of their active pharmaceutical ingredients manufactured in countries— (i) other than the People’s Republic of China; and (ii) that meet the Food and Drug Administration’s health and safety standards. (B) By 2029, a purchaser of, or reimbursor for, drugs described in this subsection shall purchase drugs or reimburse for drugs only if such drugs contain 100 percent of their active pharmaceutical ingredients manufactured in countries— (i) other than the People’s Republic of China; and (ii) that meet the Food and Drug Administration’s health and safety standards. (2) WAIVERS.—The Secretary of Health and Human Services may issue waivers of the requirements under paragraph (1) for any agency or program that is unable to meet such requirements and demonstrates a need for the waiver. No waiver may be issued under this paragraph for drugs that are purchased on or after January 1, 2031. (c) Labeling requirement.—Section 502 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 352) is amended by adding at the end the following: “(ee) If it is a drug and its labeling does not specify the country of origin of each active ingredient contained in the drug.”. (d) Temporary 100 percent expensing for pharmaceutical and medical device manufacturing property.—For purposes of section 168(k) of the Internal Revenue Code of 1986, in the case of any qualified pharmaceutical and medical device manufacturing property which is placed in service after December 31, 2019, and before January 1, 2032— (1) such property shall be treated as qualified property (within the meaning of such section), (2) the applicable percentage otherwise determined under section 168(k)(6) of such Code with respect to such property shall be 100 percent, and (3) paragraph (8) of such section shall not apply. (e) Qualified pharmaceutical and medical device manufacturing property.—For purposes of this section, the term “qualified pharmaceutical and medical device manufacturing property” means any tangible property placed in service in the United States as part of the construction or expansion of property for the manufacture of drugs (as defined in section 201(g) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321(g))) or medical devices (as defined in section 201(h) of such Act (21 U.S.C. 321(h))). Sec. 438. FDA Modernization. (a) Testing standards.—Section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) is amended— (1) in subsection (b)(5)(B)(i)(II), by striking “animal” and inserting “nonclinical tests or studies”; (2) in subsection (i)— (A) in paragraph (1)(A), by striking “preclinical tests (including tests on animals)” and inserting “nonclinical tests”; and (B) in paragraph (2)(B), by striking “animal” and inserting “nonclinical tests or studies”; and (3) after subsection (y), by inserting the following: “(z) Nonclinical Test Or Study Defined.—For purposes of this section, the term ‘nonclinical test or study’ means a test or study conducted in vitro, in silico, in chemico, or in vivo that occurs before or during the clinical trial phase of the investigation of the safety and effectiveness of a drug, and may include the following: “(1) Cell-based assays. “(2) Organ chips and microphysiological systems. “(3) Computer models. “(4) Other non-animal or human biology-based test methods. “(5) Animal tests.”. (b) Foreign medication.—Section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) is further amended— (1) in subsection (b), by adding at the end the following: “(7) An application described in paragraph (2) may rely upon investigations conducted in a country listed under subparagraph (A) or designated under subparagraph (B) of section 802(b)(1), including premarket clinical and nonclinical investigations and postmarket surveillance studies, if the drug that is the subject of such application has been approved in such country, provided that such investigations occurred prior to the year 2000.”; and (2) in subsection (c)— (A) in paragraph (1), by striking “Within” and inserting “Except as provided in paragraph (5), within”; and (B) by adding at the end the following: “(5) In the case of an application that relies on investigations conducted in a foreign country, as described in subsection (b)(7), within 90 days after the filing of such application under subsection (b), the Secretary shall approve the application if the Secretary finds that none of the grounds for denying approval specified in subsection (d) applies or take action described in paragraph (1)(B). If the Secretary does not approve the application or take such other action within such 90-day period, the application shall be considered approved under this subsection.”. (c) Authority Over Laboratory-Developed Testing Procedures.—All aspects of a laboratory-developed testing procedures shall be regulated by the Secretary of Health and Human Services under section 353 of the Public Health Service Act (42 U.S.C. 263a), and no aspects of laboratory-developed testing procedures shall be regulated under the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.), including during a public health emergency declared under section 319 of the Public Health Service Act (42 U.S.C. 247d). (d) Definition.—In this section, the term “laboratory-developed testing procedure” means a professional medical service that utilizes a laboratory examination in the context of clinical care or public health services and that has proper scientific control and sample size and meets the standards for establishment of performance specifications established by regulation under section 353(f) of the Public Health Service Act (42 U.S.C. 263a(f)) applicable to— (1) laboratory modifications of test systems approved, cleared, or authorized by the Food and Drug Administration under section 510(k), 513, 515, or 564 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360(k), 360c, 360e, 360bbb–3); (2) methods developed or performed, and results produced and interpreted, within a laboratory or laboratories under common ownership or within the same organization, certified as required under section 353(c) of the Public Health Service Act (42 U.S.C. 263a(c)); (3) standardized methods such as those that are available in textbooks and peer-reviewed publications; or (4) methods in which performance specifications are not provided by the manufacturer of test systems or components. (e) Requirements.—No sooner than January 1, 2028, the Commissioner of Food and Drugs shall make publicly available all statistical outcome requirements necessary for all approvals and authorizations and publish all relevant statistics related to approved and authorized products. TITLE V—Pandemics and Epidemics Subtitle A—Pandemic preparedness Sec. 501. Emergency public health emergency construction. (a) In general.—During a State of public health emergency declared under 42 U.S.C. §247d, the Secretary of Health and Human Services, Centers for Disease Control, Public Health Service, and related institutions shall take all actions the Secretary determines necessary and appropriate to achieve and maintain operational health over the entire land and maritime territory of the United States and its protectorates, including the following— (1) systematic surveillance to prevent the spread of disease, as well as to prevent its spread into the United States from abroad; (2) physical infrastructure enhancements to prevent entry of a disease from abroad, including via humans, trade, non-human organisms, and any other means of transmission; (3) hospitals and other health facilities to quarantine, treat, and cure patients, including potential future patients; and (4) facilities to produce anything necessary to fulfill the requirements of a public health emergency, including personal protective equipment and sanitary products. (b) Operational Health Defined.—In this section, the term ''operational health'' means the prevention of all transmissions of disease from abroad, as well as the production of all things necessary to mitigate and eliminate a pandemic or epidemic, as well as complete knowledge over where affected persons and carriers may be located. (c) Economy.—Emergency measures including the hiring of potentially non-qualified personnel may be taken to ensure that the economy is stable during such a crisis. (d) Research.—In order to determine all possible means of transmission of any disease and determine necessities in the course of combating such emergencies, up to $1,000,000,000 are allocated until January 1, 2035. Furthermore, in cases in which research is insufficient during any public health emergency, the Government of the United States must ensure that thorough research is conducted to ensure that specific vectors of transmission including humans, pets including dogs and cats, mosquitoes, and object-based transmissions Sec. 502. Transportation safety during pandemics. (a) In general.—The Secretary of Transportation shall establish regulations to prevent the spread of epidemics on airplanes and sailing vessels with capacities exceeding five persons and to ensure that vehicles are available to repatriate United States citizens who are abroad in epidemic-striken areas abroad. Any regulations which further the spread of epidemics on such airplanes and sailing vessels are to be revoked. No such measure shall include any mandatory vaccination. (b) Funding.—The Secretary of Transportation shall be authorized to issue up to $200,000,000 in funds to assist businesses in complying with any new regulations issued under this section, provided that the Secretary prioritizes small businesses when distributing funds. (c) Report.—The Secretary of Transportation shall submit to the Committee on Homeland Security of the House of Representatives and the Committee on Health, Education, Labor, and Pensions of the Senate a report regarding the safety of airplanes and sailing vessels not later than 90 days after the end of fiscal year 2027, and shall issue subsequent reports regarding the implementation of such regulations, the impediments to commerce caused by such regulations, and the impact of such regulations on jobs and small businesses; such reports shall include any regulations established or revoked under this section. Sec. 503. Public health emergency employment stability. (a) In general.—The Secretary of Commerce shall, preceding and during a State of public health emergency, make every effort to ensure continuing employment for U.S. citizens, and prepare plans in advance to mitigate economic damage that may be caused by such emergencies. (b) Regulatory authority.—The Secretary of Commerce shall be permitted, for up to 90 days after the enactment of this Act and subsequently for up to 90 days after the submission of the report described under section (c), to establish regulations (and disestablish existing regulations) in order to ensure that the United States is ready for a public health emergency, especially taking into account what has occurred in historic public health emergencies. (c) Funding.—The Secretary of Commerce shall be authorized to issue up to $200,000,000 in funds to assist businesses in complying with any new regulations issued under this section, provided that the Secretary prioritizes small businesses when distributing funds. (d) Report.—Not later than one year after the date of the enactment of this Act, the Secretary of Commerce shall submit to the Committee on Energy and Commerce of the House of Representatives and the Committee on Commerce, Science, and Transportation of the Senate a report that contains the results of the study conducted under subsection (a); furthermore, the Secretary shall report all regulations established or disestablished in order to enable greater public health emergency readiness to the same committees. (e) HHS cooperation.—To fulfill the requirements of this section, the Secretary of Commerce shall consult with the Secretary of Health and Human Services and the Secretary of Veterans Affairs. Sec. 504. Evaluation and reported related to ability to seal borders in times of emergency. (a) Evaluation.—Not later than 30 days after the date of the enactment of this Act, the Secretary of Homeland Security shall— (1) evaluate the authority of personnel of United States Customs and Border Protection to stop vehicles that enter the United States illegally and refuse to stop when ordered to do so by such personnel, compare such Customs authority with the authority of the Coast Guard to stop vessels under section 637 of title 14, United States Code, and make an assessment as to whether such Customs authority should be expanded; (2) review the equipment and technology available to United States Customs and Border Protection personnel to stop vehicles described in paragraph (1) and make an assessment as to whether or not better equipment or technology is available or should be developed; and (3) evaluate the training provided to United States Customs and Border Protection personnel to stop vehicles described in paragraph (1). (b) Report.—Not later than 60 days after the date of the enactment of this Act, the Secretary of Homeland Security shall submit to the Committee on Homeland Security of the House of Representatives and the Committee on Homeland Security and Governmental Affairs of the Senate a report that contains the results of the evaluation conducted under subsection (a); the Secretary shall submit further reports not later than 90 days after the conclusions of fiscal years 2027, 2028, 2029, 2030, and 2031. Sec. 505. International travel during public health crises. Section 319 of the Public Health Service Act (42 U.S.C. §247d) is amended by adding at the end the following subsection: “(f) International travel. “(1) During a State of public health emergency declared under this Section, the Secretary of Homeland Security and Department of State shall not be authorized to issue any B1, B2, F-1, H-1B, H-2B, J-1, K-1, or TN-NAFTA visas, and all previously issued visas for persons currently not within the borders of the United States revoked, unless such issuance is approved by the Secretary of Health and Human Services as a person necessary to achieve and maintain operational health, unless it has been determined that unemployment rates are decreasing notwithstanding the emergency. “(2) The application of paragraph (1) may be limited if an epidemic is localized to a single area of the United States or limited to countries which have been affected by a global health emergency. “(3) In order to provide training for work-from-home and essential employment during a State of public health emergency, up to $200,000,000 are allocated until January 1, 2035. “(4) Any immigrant who is permitted to enter the United States pursuant to paragraph (2) must be required to undergo a quarantine of not less than the greater of 40 days or the maximum time necessary to prevent disease spread according to scientific research, and must pay any fees necessary to receive tests for all diseases related to an ongoing public health emergency. “(5) The United States Government may require medical testing and quarantine for any United States citizen who returns to the territory of the United States during a public health emergency, and when administering such testing, necessary precautions must be taken to ensure that no disease spreads from a potentially infected citizen. “(6) Intentional failure by employees or elected officials of the United States Government to meet requirements to control diseases may result in prosecution under Federal law. “(7) The application of paragraph (1) shall include any month for which the unemployment rate exceeds one percent following a public health emergency, provided that at least one month subsequent to such a declaration included an increase in unemployment rate, including after the end of a public health emergency.”. Sec. 506. Definition of public health emergency expanded. Section 319 of the Public Health Service Act (42 U.S.C. §247d) is amended as follows— (a) In paragraph (a)(1) by striking the word “or”, (b) In paragraph (a)(2) by striking the final comma and inserting at the end a semicolon, (c) By inserting paragraphs after (a)(2) as follows— “(3) a global health emergency or pandemic has been identified by the Secretary of Health and Human Services or when it is otherwise necessary to prevent any foreign disease or epidemic from traveling to the United States, including when any foreign epidemic or health emergency may be kept secret by any foreign government, international body, or other organization; “(4) a public health emergency caused by actions of any State or Territorial government; or “(5) a disease, disorder, or reasonable concern of a nuclear, biological, or chemical attack which could cause a public health emergency among United States citizens, their pets, or their food supply exists; then”. Sec. 507. Intentional spread of disease. (a) Subsection (c) of 18 U.S. Code §1122 is amended as follows— “(c) Penalty.— “(1) Any person convicted of violating the provisions of subsection (a) shall be subject to a fine under this title of not less than $20,000, imprisoned for not less than 1 year nor more than 10 years, or both. “(2) Penalties are doubled under paragraph (1) are doubled during states of public health emergency declared under 42 U.S.C. §247d.”. (b) After 18 U.S. Code §1122, a new section §1123 is added as follows— “1123. Prevention of disease spread “(a) In general.— “Any person who knowingly attempts to become a carrier for an infectious disease, or after testing positive for a disease knowingly attempts to infect another person, shall be punished in accordance with subsection (c). “(b) Transmission Not Required.— “Transmission of the disease involved does not have to occur for a person to be convicted of a violation of this section. “(c) Mask Not Required.— “Failure to wear a mask to prevent transmission of disease does not constitute a violation of this section. “(d) Special measures relating to the issuance of false information during a public health emergency.— “Intentional censorship of correct information on the basis of supposed inaccuracy, promotion of incorrect information, and attempts to debunk accurate information conducted by publicly-traded corporations or interactive computer services shall constitute intentional spread of disease when such actions occur during a public health emergency. Attempts to justify such censorship by claiming that medicines approved for humans are approved for non-human animals shall incur tripled fines and imprisonment of a minimum of seven years for all persons involved in such claims. Penalties shall be counted based on the number of such individual occurrences on the websites, applications, videos, or other documentation provided by such corporations or services, including for each post censored. For each person prohibited from use of an interactive computer service for sharing correct information about diseases, disease prevention, and disease treatment each such individual shall be paid compensation of a minimum of thitrty thousand dollars and fines shall be further doubled. “(e) Penalty.— “(1) Any person convicted of violating the provisions of subsection (a) shall be subject to a fine under this title of not less than $20,000, imprisoned for not less than 1 year nor more than 10 years, or both. “(2) Penalties described under paragraph (1) are doubled during states of public health emergency declared under 42 U.S.C. §247d.”. Sec. 508. Defense Production Act amendments. (a) Section 103 of the Defense Production Act (50 U.S.C. §4513) is amended by striking “$10,000” and inserting “$50,000” in its place. (b) Section 303 of the Defense Production Act (50 U.S.C. §4533) is amended by adding a new subsection (h) as follows— “(h) Civilian manufacturing and distribution “When, in a public health emergency or other emergency, the President has deemed it necessary to distribute certain items to civilians for defense purposes, the President shall have the authority to compel retailers to distribute such items and ensure that such items are made available for United States citizens, including by means of lessening conditions imposed by retailers on businesses (particularly businesses which are small, American, or both) which attempt to sell through them: Provided, That no provision of this chapter shall mandate the production or distribution of any applicable healthcare associated product or applicable luxury health plan defined in the Internal Revenue Code.”. (c) Section 713 of the Defense Production Act (50 U.S.C. §4562) is amended by striking the phrase “Territories and possessions” and inserting “insular areas” in its place. (d) The Defense Production Act is amended by adding a new section 724 (50 U.S.C. §4569) as follows— “724. Effect on other laws. “(a) In any case in which any law, Federal or otherwise, may hinder the implementation of this Act, such law may be waived or preempted. “(b) This section may not be used against any Associated State of the United States without the explicit and continuous consent of such Associated State.”. Sec. 509. Waivers for pandemic readiness. The requirements of any regulation or Act (other than the Internal Revenue Act of 1986 or any other Act which may be intended to raise revenue, to restrict outsourcing to foreign persons, to restrict international transportation of persons, or to restrict or tax international commerce) may be waived in order to improve the readiness of the United States against a public health emergency or to comply with any regulation established under this Act. Subtitle B—Public Health Service Sec. 511. Conscription into the Public Health Service. (a) In general.—A new subsection (l) is added to section 4 of the Military Selective Service Act (50 U.S. Code §3803) as follows— “(l) Conscription into the Public Health Service “(1) Notwithstanding provisions otherwise provided by this chapter, every person required to register pursuant to section 3802 of this chapter who is found to be capable of serving or has an intelligence quotient of at least 115, including persons between the ages of 18 and 26, shall be liable for training and service in the United States Public Health Service. “(2) Any person who is a licensed medical professional, including persons above the age of 26, may be conscripted into the Public Health Service or compelled to provide medical services except when such a professional is— “(A) Unable to perform medical work whatsoever including the training and/or supervision of persons liable for training and service in the United States Public Health Service, “(B) Below the age of 18, “(C) Obeying directions issued by the Public Health Service under 42 U.S.C. 300hh-18 or otherwise assisting in a public health emergency, or “(D) Exempt for reason of illness, preexisting employment in the national interest or service in the military, or another reason deemed reasonable for exemption by the Under-Secretary of Health. “(3) Subsequent to any required service under this subsection, any person who participates in such a capacity shall be considered for expedited licensing as a medical professional unless such a person did not serve in a medical capacity. “(4) Any person who is eligible to be conscripted under this subsection may enlist in the PHS during a State of public health emergency. “(5) The Public Health Service shall maintain tests, including for intelligence quotient, to gauge the suitability of potential conscripts.”. (b) Medical services open.—Part B, Subchapter XXVI, Chapter 6A of Title 42 of the United States Code is amended by adding at the end the following new section, which shall be numbered 2816 in the Public Health Service Act: “42 U.S.C. 300hh-18. Emergency Opening of Primary Care Providers “(a) During any public health emergency, the Public Health Service may direct the opening, reopening, or continued operation of any medical firm, subject to compliance with safety standards established by the Centers for Disease Control, as well as the refocusing of such services as necessary to ensure public health and safety. “(b) Failure to comply with directions of the United States Public Health Service under this section may incur fines of up to two million dollars, imprisonment or mandatory public health service of up to five years, or both. “(c) In cases in which diseases may spread between humans and domestic animals, veterinarians and other professionals involved in animal healthcare may be subject to this section. “(d) The Public Health Service may issue temporary price controls, which shall not last longer than three months without Congressional reauthorization, to enforce this section.”. (c) Creation of enlisted ranks within the Public Health Service.—After section 216 of the Public Health Service Act (42 U.S.C. §217), a new section 216a (42 U.S.C. §217a) is inserted as follows— “217a. Enlisted ranks “During a war or public health emergency, the President may permit the utilization of enlisted ranks within the Public Health Service, which shall be known as follows— “(a) Medic recruit, E-1 “(b) Medic apprentice, E-2 “(c) Medic, E-3 “(d) Senior medic, E-4 “(e) Petty medical officer second class, E-5 “(f) Petty medical officer first class, E-6 “(g) Chief petty medical officer, E-7”. Sec. 512. Veterinary care during public health emergencies. (a) The word “medical,” within the context of section 2816 of the Public Health Service Act, includes veterinary care. (b) As may be necessary, a State of public health emergency may include aid for veterinary care as well as directives intended to advance such care. Sec. 513. Public access to information regarding epidemics and potential epidemics. Section 230 of the Communications Act of 1934 (47 U.S.C. 230) is amended by inserting a new subsection (g) as follows “(g) No interactive computer service may— “(1) censor (by means of content removal or by adding, appending, prefixing, or otherwise sharing additional information which may contradict the views expressed by persons censored) any information which is necessary for public safety in any environment where such information could otherwise be tolerable, regardless of whether such information is verified by the United States Government or by any State or Territory of the United States; “(2) censor (by means of content removal or by adding, appending, prefixing, or otherwise sharing additional information which may contradict the views expressed by persons censored) against agencies or officials of the United States Government regarding public health emergencies; or “(3) impose or maintain any ban, suspension, or other censorship or revocation of service for sharing any information which may be necessary during a public health emergency; “and simultaneously enjoy the protections provided by this section for a period of two years thereafter.”. Sec. 514. Relationship with State law. (a) Notwithstanding subsection (b), State law are preempted by this Act and the amendments by it insofar as State law may impair the ability of the United States, including any United States person or State thereof, to mitigate and control outbreaks of disease or to organize subsequent economic recovery. (b) No law enabling concurrent enforcement of any law enabling greater control over the borders of the United States, including its ability to control illegal immigration, is preempted by Federal law. (c) The word "State" as used in this subsection includes all United States territories and all subdivisions within States. (d) State law concerning the authority of subdivisions of states shall be considered State law for purposes of subsection (a) except insofar as such State law may be permissible to establish statewide uniform concurrent enforcement legislation pursuant to subsection (b). (e) Any State law facilitating concurrent enforcement of any provision of this Act or any amendment made by this Act is not preempted by Federal law. Sec. 515. Territorial enforcement. No United States territory, including the District of Columbia, may refuse to enforce any provision of this Act. Sec. 516. Eradication of Yersinia pestis. (a) The Department of Health and Human Services is authorized to eradicate the bacteria Yersinia pestis and the animal Xenopsylla cheopis, as well as carriers of the plague. (b) The Department of Health and Human Services is mandated to submit a report on the status of eradicating the two species specified by subsection (a) by 2029, and must submit further reports every year until the confirmed eradication of Yersinia pestis. (c) In order to eradicate the bacteria Yersinia pestis, up to $2,000,000,000 are allocated each fiscal year until January 1, 2035. Sec. 517. Limitation on liability for volunteer health care professionals. (a) In general.—Title II of the Public Health Service Act (42 U.S.C. 202 et seq.) is amended by inserting after section 224 the following: “SEC. 224A. Limitation on liability for volunteer health care professionals. “(a) Limitation on liability.—Except as provided in subsection (b), a health care professional shall not be liable under Federal or State law for any harm caused by an act or omission of the professional if— “(1) the professional is serving as a volunteer for purposes of responding to a disaster; and “(2) the act or omission occurs— “(A) during the period of the disaster, as determined under the laws listed in subsection (e)(1); “(B) in the health care professional’s capacity as such a volunteer; and “(C) in a good faith belief that the individual being treated is in need of health care services. “(b) Exceptions.—Subsection (a) does not apply if— “(1) the harm was caused by an act or omission constituting willful or criminal misconduct, gross negligence, reckless misconduct, or a conscious flagrant indifference to the rights or safety of the individual harmed by the health care professional; or “(2) the health care professional rendered the health care services under the influence (as determined pursuant to applicable State law) of intoxicating alcohol or an intoxicating drug. “(c) Standard of proof.—In any civil action or proceeding against a health care professional claiming that the limitation in subsection (a) applies, the plaintiff shall have the burden of proving by clear and convincing evidence the extent to which limitation does not apply. “(d) Preemption.— “(1) IN GENERAL.—This section preempts the laws of a State or any political subdivision of a State to the extent that such laws are inconsistent with this section, unless such laws provide greater protection from liability. “(2) VOLUNTEER PROTECTION ACT.—Protections afforded by this section are in addition to those provided by the Volunteer Protection Act of 1997. “(e) Definitions.—In this section: “(1) The term ‘disaster’ means— “(A) a national emergency declared by the President under the National Emergencies Act; “(B) an emergency or major disaster declared by the President under the Robert T. Stafford Disaster Relief and Emergency Assistance Act; or “(C) a public health emergency determined by the Secretary under section 319 of this Act. “(2) The term ‘harm’ includes physical, nonphysical, economic, and noneconomic losses. “(3) The term ‘health care professional’ means an individual who is licensed, certified, or authorized in one or more States to practice a health care profession. “(4) The term ‘State’ includes each of the several States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, and any other territory or possession of the United States. “(5) (A) The term ‘volunteer’ means a health care professional who, with respect to the health care services rendered, does not receive— “(i) compensation; or “(ii) any other thing of value in lieu of compensation, in excess of $500 per year. “(B) For purposes of subparagraph (A), the term ‘compensation’— “(i) includes payment under any insurance policy or health plan, or under any Federal or State health benefits program; and “(ii) excludes— “(I) reasonable reimbursement or allowance for expenses actually incurred; “(II) receipt of paid leave; and “(III) receipt of items to be used exclusively for rendering the health services in the health care professional’s capacity as a volunteer described in subsection (a)(1).”. (b) Effective date.— (1) IN GENERAL.—This Act and the amendment made by subsection (a) shall take effect 90 days after the date of the enactment of this Act. (2) APPLICATION.—This Act applies to any claim for harm caused by an act or omission of a health care professional where the claim is filed on or after the effective date of this Act, but only if the harm that is the subject of the claim or the conduct that caused such harm occurred on or after such effective date. Subtitle C—Pandemic recovery Sec. 521. Renaming of the COVID-19 pandemic. The official name of the epidemic of the novel Coronavirus discovered in the year 2019 which occurred in the United States and internationally during the year 2020 is the Chinavirus epidemic of 2020, and the disease and virus which caused it shall be officially known in the United States as the Chinavirus disease (or Chinavirus) and the Chinavirus. The Delta variant shall henceforth be referred to as the Londonized Chinavirus and the Omnicron variant shall henceforth be named the South African Nu-Xi Chinavirus. Sec. 522. Authorization of imposition of sanctions. (a) In general.—The President may impose the sanctions described in subsection (b) with respect to any foreign person the President determines, based on credible evidence— (1) is a government official, or a senior associate of such an official, that is responsible for, or complicit in, ordering, controlling, or otherwise directing, or financially benefits from, acts intended to deliberately conceal or distort information about a public health emergency of international concern, including coronavirus disease 2019 (commonly known as “COVID–19”); or (2) has materially assisted, sponsored, or provided financial, material, or technological support for, or goods or services in support of, an act described in paragraph (1). (b) Sanctions described.—The sanctions described in this subsection are the following: (1) INADMISSIBILITY TO UNITED STATES.—In the case of a foreign person who is an individual— (A) ineligibility to receive a visa to enter the United States or to be admitted to the United States; or (B) if the individual has been issued a visa or other documentation, revocation, in accordance with section 221(i) of the Immigration and Nationality Act (8 U.S.C. 1201(i)), of the visa or other documentation. (2) BLOCKING OF PROPERTY.—The blocking, in accordance with the International Emergency Economic Powers Act (50 U.S.C. 1701 et seq.), of all transactions in all property and interests in property of a foreign person if such property and interests in property are in the United States, come within the United States, or are or come within the possession or control of a United States person. (3) CANCELLATION OF FOREIGN ASSETS.—In the case of a foreign person who possesses any United States currency or any form of debt including any bond of the United States, or anything else the United States may be able to confiscate, the revocation, nullification, voidance, and confiscation of such assets by the United States Government. (4) TARIFFS.—The imposition by the President of the United States or any delegated officer of the United States of tariffs, imposed at a rate of up to 100%, on foreign goods, which would be paid by confiscation of assets of a foreign person or otherwise. (5) LETTERS OF MARQUE.—The issuance of letters of marque to enforce restitutions due to the United States, to the States thereof, and to United States citizens and nationals for the damages caused by public health emergencies. (6) SEIZURE OF OCEANIC, ARCHIPELAGIC, AND ISLANDIC TERRITORY.—In the case of a foreign person which occupies any territory which is an island or which is maritime, the United States may seize such territories. (c) Consideration of certain information in imposing sanctions.—In determining whether to impose sanctions under subsection (a), the President shall consider— (1) information provided jointly by the chairperson and ranking member of each of the appropriate congressional committees; and (2) credible information obtained by other countries and nongovernmental organizations that monitor violations of human rights and global health issues, including issues related to infectious disease. (d) Requests by appropriate congressional committees.— (1) IN GENERAL.—Not later than 120 days after receiving a request that meets the requirements of paragraph (2) with respect to whether a foreign person is described in subsection (a), the President shall— (A) determine if that person is so described; and (B) submit a classified or unclassified report to the chairperson and ranking member of the committee or committees that submitted the request with respect to that determination that includes— (i) a statement of whether or not the President imposed or intends to impose sanctions with respect to the person; and (ii) if the President imposed or intends to impose sanctions, a description of those sanctions. (2) REQUIREMENTS.—A request under paragraph (1) with respect to whether a foreign person is described in subsection (a) shall be submitted to the President in writing jointly by the chairperson and ranking member of one of the appropriate congressional committees. (e) Exception To comply with United Nations headquarters agreement and law enforcement objectives.—Sanctions under subsection (b)(1) shall not apply to an individual if admitting the individual into the United States— (1) would further important law enforcement objectives; or (2) is necessary to permit the United States to comply with the Agreement regarding the Headquarters of the United Nations, signed at Lake Success June 26, 1947, and entered into force November 21, 1947, between the United Nations and the United States, or other applicable international obligations of the United States. (f) Enforcement of blocking of property.—A person that violates, attempts to violate, conspires to violate, or causes a violation of subsection (b)(2) or any regulation, license, or order issued to carry out that subsection shall be subject to the penalties set forth in subsections (b) and (c) of section 206 of the International Emergency Economic Powers Act (50 U.S.C. 1705) to the same extent as a person that commits an unlawful act described in subsection (a) of that section. (g) Reports required.—Not later than 120 days after the date of the enactment of this Act, and annually thereafter, the President shall submit to the appropriate congressional committees a report that includes— (1) a list of each foreign person with respect to which the President imposed sanctions under subsection (b) during the year preceding the submission of the report; (2) a description of the type of sanctions imposed with respect to each such person; (3) the number of foreign persons with respect to which the President— (A) imposed sanctions under subsection (b) during that year; or (B) terminated sanctions under subsection (h) during that year; (4) the dates on which such sanctions were imposed or terminated, as the case may be; (5) the reasons for imposing or terminating such sanctions; and (6) a description of the efforts of the President to encourage the governments of other countries to impose sanctions that are similar to the sanctions authorized by this section. (h) Termination of sanctions.—The President may terminate the application of sanctions under this section with respect to a person if the President determines and reports to the appropriate congressional committees not later than 15 days before the termination of the sanctions that— (1) credible information exists that the person did not engage in the activity for which sanctions were imposed; (2) the person has been prosecuted appropriately for the activity for which sanctions were imposed; or (3) the termination of the sanctions is in the national security interests of the United States. (i) Regulatory authority.—The President shall issue such regulations, licenses, and orders as are necessary to carry out this section. (j) Definitions.—In this section: (1) APPROPRIATE CONGRESSIONAL COMMITTEES.—The term “appropriate congressional committees” means— (A) the Committee on Banking, Housing, and Urban Affairs and the Committee on Foreign Relations of the Senate; and (B) the Committee on Financial Services and the Committee on Foreign Affairs of the House of Representatives. (2) FOREIGN PERSON.—The term “foreign person” means a person that is not a United States person. (3) PERSON.—The term “person” means an individual or entity. (4) PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN.—The term “public health emergency of international concern” means a public health emergency determined to be a public health emergency of international concern by the Secretary of State on the advice of the Secretary of Health and Human Services or by the World Health Organization concerning any pandemic which was declared by such Organization during the year 2020. (5) UNITED STATES PERSON.—The term “United States person” means— (A) an individual who is a United States citizen or an alien lawfully admitted for permanent residence to the United States; (B) an entity organized under the laws of the United States or any jurisdiction within the United States, including a foreign branch of such an entity; or (C) any person in the United States. Sec. 523. Post-lockdown health recovery. (a) No weight loss procedure or procedure including a liposuction shall be considered an applicable healthcare associated product (as defined by the Internal Revenue Code of 1986) during the fiscal years of 2030 or 2031. (b) Notwithstanding the Public Health Service Act and Federal Food, Drug, and Cosmetic Act, weight-loss medications may be distributed over-the-counter from the first month after this Act shall enter into force through the end of 2031; the Secretary of Health and Human Services shall establish a program to monitor the effects of over-the-counter weight-loss medications. (c) There are authorized to be appropriated to the Secretary of Health and Human Services to carry out subsection (a) $15,000,000 for each of the fiscal years 2028 through 2031, subject to the availability of appropriations. Sec. 524. Lockdowns ended. Any law, ordinance, or emegency order which implemented any curfew, stay-at-home order, vaccination mandate, facial covering mandate, or restraint of commerce in response to the 2020 Chinavirus pandemic or any subsequent Chinavirus outbreak or the Monkeypox epidemic is hereby preempted immediately upon the enactment of this Act. All mandates for the use of masks or for the use of any vaccine or test are hereby preempted upon the enactment of this Act. Any unobligated funds from Acts preceding the beginning of fiscal year 2027 are rescinded, unless otherwise reappropriated by this Act. Sec. 525. Investigation of VAERS. (a) In General.—The Inspector General of the Department of Health and Human Services shall investigate the Vaccine Adverse Event Reporting System of the Centers for Disease Control and Prevention and Food and Drug Administration. (b) Required Questions.— (1) INDIVIDUALS.— (A) In conducting the investigation under subsection (a), the Inspector General of the Department of Health and Human Services shall ask every individual who reported an adverse event to a COVID–19 vaccine at a minimum the following questions: (i) Which COVID–19 vaccine did you receive? (ii) Which vaccine did you receive as a booster shot? (iii) Do you have any allergies or preexisting conditions? (iv) Was the adverse event mild, such as minor pain or swelling, or severe, such as leading to hospitalization, disability, or death? (v) Can you describe in detail the symptoms of the adverse event? (vi) In detail, can you describe any health problems you believe were caused by the adverse event? (vii) Are you aware of any other individuals within your community who had a similar adverse event? (viii) When receiving a vaccination did you notice anything suspicious regarding how the vaccination was administered? (ix) How soon after the adverse event did you report it to the Vaccine Adverse Event Reporting System? (x) Did you seek compensation for the adverse event through the Countermeasures Injury Compensation Program? (xi) Would you be willing to testify under oath to a congressional committee? (B) If an individual described in subparagraph (A) is deceased, the Inspector General of the Department of Health and Human Services shall ask one or more of the individual’s immediate family members to answer (on the individual’s behalf) the questions listed in subparagraph (A). (2) MANUFACTURERS.—In conducting the investigation under subsection (a), the Inspector General of the Department of Health and Human Services shall ask each manufacturer of a COVID–19 vaccine that is distributed in the United States, at a minimum, the following questions and requests: (A) What are the ingredients in your COVID–19 vaccine or vaccines distributed in the United States? (B) Can you provide all information relating to your manufacturing methods and your data on the stability and safety of the product? (C) What is the address of each of your locations involved in the manufacture of the vaccines? (D) Did you include labeling of the vaccine or vaccines containing a specific statement describing how suspected adverse events can be reported? (E) Can you provide substantive evidence you have followed all Food and Drug Administration guidance regarding product safety? (F) How many adverse events did you report to the Vaccine Adverse Event Reporting System pursuant to section 2125 of the Public Health Service Act (42 U.S.C. 300aa–25) or other applicable law? (G) Are you conducting your own internal review of any adverse events caused by the vaccine or vaccines? (H) Are you ensuring that all public statements regarding vaccine safety are accurate? (I) Are you limiting reporting data regarding adverse events? (J) Would you be willing to direct representatives to testify under oath to a congressional committee? (3) HEALTH CARE PROVIDERS.—In conducting the investigation under subsection (a), the Inspector General of the Department of Health and Human Services shall ask a representative sample of health care providers, at a minimum, the following questions: (A) How many adverse events did you report to the Vaccine Adverse Event Reporting System pursuant to section 2125 of the Public Health Service Act (42 U.S.C. 300aa–25) or other applicable law? (B) What kind of compensation does your facility receive for vaccine administration and from which source or sources? (C) Is your facility keeping a record of any increase in hospitalization rates for individuals with adverse events following vaccination? (D) How many severe adverse events has your facility encountered? (E) How many mild adverse events has your facility encountered? (F) Has your facility determined if adverse events are caused by an immune response to the vaccine? (G) Is your facility keeping a record of any problems with vaccine administration? (H) Is your facility keeping a record of all breakthrough cases of COVID–19 in fully vaccinated patients? (I) Has your facility terminated any health care professionals who are opposed to vaccine mandates or who have raised questions regarding adverse events? (J) Would you be willing to direct representatives of your facility to testify under oath to a congressional committee? (c) Reports.— (1) REPORT ON VAERS.— (A) IN GENERAL.—Not later than 3 months after the date of enactment of this Act, the Inspector General of the Department of Health and Human Services shall— (i) complete the investigation under subsection (a); and (ii) publish a report on the results of such investigation. (B) CONTENTS.—The report under subparagraph (A)(ii) shall include the following: (i) A list of all reported COVID–19 vaccine related deaths and injuries in chronological order. (ii) Transcripts of all interviews conducted by the Inspector General pursuant to this section with an individual described in subsection (b)(1), a manufacturer described in subsection (b)(2), or a health care provider described in subsection (b)(3). (iii) A list of recommendations on how the Centers for Disease Control and Prevention and the Food and Drug Administration can strengthen the Vaccine Adverse Event Reporting System to be a more reliable method of obtaining information about adverse events. (iv) A determination on whether the Centers for Disease Control and Prevention or the Food and Drug Administration is hiding data regarding adverse events. (v) A determination on whether the Food and Drug Administration is suppressing data on the effectiveness of monoclonal antibodies that are used to treat COVID–19. (vi) Recommendations on further actions the Congress can take when conducting oversight regarding data collection by the Centers for Disease Control and Prevention and the Food and Drug Administration. (vii) A determination on whether adverse events are common or rare following administration of a COVID–19 vaccine. (viii) A determination of any causal relationship between any COVID–19 vaccine and specific adverse events using clinical, laboratory, or epidemiologic evidence. (ix) A determination on whether adverse events are intrinsic to the COVID–19 vaccine (meaning provoked by the immune response caused by the vaccine) or related to faulty production or administration of the COVID–19 vaccine. (2) REPORT ON INVESTIGATION.— (A) IN GENERAL.—Not later than 6 months after publishing the report required by paragraph (1)(A)(ii), the Inspector General of the Department of Health and Human Services shall submit to the relevant congressional committees a report on the implementation of this section. (B) CONTENTS.—The report under subparagraph (A) shall— (i) specify, of the amount authorized by subsection (c)(1) to be appropriated to carry out this section, the total amount obligated and expended; and (ii) describe how such amount was used. (d) Subpoena Power.—The Inspector General of the Department of Health and Human Services may, pursuant to authorities vested in the Inspector General by other applicable law, issue subpoenas requiring the attendance and testimony of witnesses and the production of any evidence relating to any matter under investigation pursuant to this section. (e) Authorization Of Appropriations.— (1) IN GENERAL.—To carry out this section, there is authorized to be appropriated $100,000,000 for the period beginning on the date of enactment of this Act and ending on the date of submission of the report required by subsection (b)(2). (2) OFFSET.— (A) REPEAL OF DEDUCTION FOR CERTAIN STATE AND LOCAL, ETC., TAXES OF INDIVIDUALS.—Section 164(b)(6) of the Internal Revenue Code of 1986 is amended by— (i) striking “and before January 1, 2030—” and all that follows through “a separate return).” and inserting “paragraphs (1), (2), and (3) of subsection (a) and paragraph (5) of this subsection shall not apply.”; and (ii) by striking “FOR TAXABLE YEARS 2018 THROUGH 2029” in the heading thereof. (B) EFFECTIVE DATE.—The amendments made by this paragraph shall apply to taxable years beginning after the date of the enactment of this Act. Sec. 526. Civil Rights Act Improvement. (a) Section 2000e(k) of title 42, United States Code is amended by striking the last instance of the article “an” and all that follows and inserting “any action with a potential basis that could be related to sexually transmitted diseases or risk of child abuse, including any action against persons with paraphilias which have been interpreted by the judicial or executive branches at any times as protected under this subsection, particularly homosexual, bisexual, and transsexual persons and persons who are designated or identified as paraphiliacs by Diagnostic and Statistical Manual of Mental Disorders, Third Edition.” in place of such wording. (b) A new subsection (o) is added to section 2000e of title 42 of the United States Code as follows: “The term “vaccine or lockdown status” means any use or disuse of a face covering, vaccine, or other preventative against any disease: Provided, That nothing herein shall preclude any measure that discourages or punishes sexually promiscuous behaviors or the use of applicable healthcare associated products as defined by section 5792 of the Internal Revenue Code.”. (c) 42 U.S. Code § 2000e–2, 42 U.S. Code § 2000e–3, 42 U.S. Code § 2000e–16, 42 U.S. Code § 2000e–16a, and 42 U.S. Code § 2000e–16b are amended by inserting “vaccine or lockdown status” after each mention of “sex,”. (d) 42 U.S. Code § 2000a, 42 U.S. Code § 2000a–1, 42 U.S. Code § 2000b, 42 U.S. Code § 2000c, 42 U.S. Code § 2000d, 42 U.S. Code § 2000f, 42 U.S. Code § 2000g–1, and 42 U.S. Code § 2000h–2 are amended by inserting “vaccine or lockdown status” after each mention of “color,”. Sec. 527. Post-Lockdown Education. (a) In General.—Except as provided in subsection (b), no funds shall be made available under any applicable program to any institution of higher education unless— (1) in-person instruction is available to all students at such institution; and (2) a student may opt-out of any requirement of the institution to wear a face covering, to be vaccinated against COVID–19, or to take a COVID–19 test. (b) Exceptions.—The requirement of subsection (a)(1) shall not apply to a course or program of study that an institution offers via distance education for reasons unrelated to COVID–19, unless restrictions on distance learning may be used to prevent the graduation of students. (c) Definitions.—In this section: (1) APPLICABLE PROGRAM.—The term “applicable program” has the meaning given the term in section 400(c) of the General Education Provisions Act (20 U.S.C. 1221(c)). (2) INSTITUTION OF HIGHER EDUCATION.—The term “institution of higher education” has the meaning given that term in section 102 of the Higher Education Act of 1965 (20 U.S.C. 1002). (3) OTHER DEFINITIONS.—The terms “child”, “elementary school”, “parent”, “secondary school”, and “State” have the meanings given those terms in section 8101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801). (d) Grants For Students.—From amounts made available under subsection (h), the Secretary of Education shall carry out a program under which the parent of a child who has an application approved by the Secretary under subsection (f) shall receive a grant to pay certain educational expenses on behalf of such child. (e) Application.—To be eligible to receive grant under this section, the parent of a child shall submit an application to the Secretary of Education at such time, in such manner, and containing such information as the Secretary may require. (f) Approval.—Subject to the availability of funds to carry out this section, the Secretary of Education shall make a grant under subsection (a) to the parent of a child if the parent— (1) submits a true and correct application under subsection (e); and (2) provides an assurance that the parent will use the grant only for the purposes authorized under this section. (g) Use Of Funds.—A parent who receives grant under this section on behalf of a child may use the grant to pay the following educational expenses: (1) Costs of attendance for the child at a private elementary school or private secondary school. (2) Costs incurred by the parent to homeschool the child. (3) Such other educational expenses as may be approved by the Secretary for purposes of this subsection. (h) Funding.—Notwithstanding any other provision of law, this section shall be carried out using amounts made available to the Secretary of Education under Acts providing funding for fiscal years prior to 2027 that are unobligated as of the date of the enactment of this Act and no additional amounts are authorized to be appropriated to carry out this section. (i) Preemption.—No State or Territory (including the District of Columbia) shall prohibit any accredited private elementary school or private secondary school or in any way restrict the practice of homeschooling. Sec. 528. Ketogenic diet deregulation. 21 U.S. Code § 342(a)(2)(A) is amended by inserting “(except a product useful for ketogenic or weight-loss dieting or for increasing high-density lipoprotein, in the case that a product is designated as unsafe due to increased cholesterol or risk of heart disease)” after “unsafe”. 21 U.S. Code § 342(a)(2)(C)(i) is amended by inserting “(except a product useful for ketogenic or weight-loss dieting or for increasing high-density lipoprotein, in the case that a product is designated as unsafe due to increased cholesterol or risk of heart disease)” after “unsafe”. TITLE VI—Veterans Sec. 601. Department of Energy veterans health research and development. (a) In general.—The Secretary shall establish and carry out a research program in artificial intelligence and high-performance computing, focused on the development of tools to solve big data challenges associated with veteran’s healthcare, and to support the efforts of the Department of Veterans Affairs to identify potential health risks and challenges utilizing data on long-term healthcare, health risks, and genomic data collected from veteran populations. The Secretary shall carry out this program through a competitive, merit-reviewed process, and consider applications from National Laboratories, institutions of higher education, multi-institutional collaborations, and other appropriate entities. (b) Program components.—In carrying out the program established under subsection (a), the Secretary may— (1) conduct basic research in modeling and simulation, machine learning, large-scale data analytics, and predictive analysis in order to develop novel or optimized algorithms for prediction of disease treatment and recovery; (2) develop methods to accommodate large data sets with variable quality and scale, and to provide insight and models for complex systems; (3) develop new approaches and maximize the use of algorithms developed through artificial intelligence, machine learning, data analytics, natural language processing, modeling and simulation, and develop new algorithms suitable for high-performance computing systems and large biomedical data sets; (4) advance existing and construct new data enclaves capable of securely storing data sets provided by the Department of Veterans Affairs, Department of Defense, and other sources; and (5) promote collaboration and data sharing between National Laboratories, research entities, and user facilities of the Department by providing the necessary access and secure data transfer capabilities. (c) Coordination.—In carrying out the program required under subsection (a), the Secretary is authorized to— (1) enter into memoranda of understanding in order to carry out reimbursable agreements with the Department of Veterans Affairs and other entities in order to maximize the effectiveness of Department of Energy research and development to improve veterans’ healthcare; (2) consult with the Department of Veterans Affairs and other Federal agencies as appropriate; and (3) ensure that data storage meets all privacy and security requirements established by the Department of Veterans Affairs, and that access to data is provided in accordance with relevant Department of Veterans Affairs data access policies, including informed consent. (d) Report.—Not later than 2 years after the date of the enactment of this Act, the Secretary shall submit to the Committee on Science, Space, and Technology and the Committee on Veterans’ Affairs of the House of Representatives, and the Committee on Energy and Natural Resources and the Committee on Veterans’ Affairs of the Senate, a report detailing the effectiveness of— (1) the interagency coordination between each Federal agency involved in the research program carried out under this section; (2) collaborative research achievements of the program; and (3) potential opportunities to expand the technical capabilities of the Department. (e) Funding.—There are authorized to be appropriated to the Secretary of Veterans Affairs to carry out this section $27,000,000 during the period of fiscal years 2028 through 2032, subject to the availability of appropriations. Sec. 602. Interagency collaboration. (a) In general.—The Secretary is authorized to carry out research, development, and demonstration activities to develop tools to apply to big data that enable Federal agencies, institutions of higher education, nonprofit research organizations, and industry to better leverage the capabilities of the Department to solve complex, big data challenges. The Secretary shall carry out these activities through a competitive, merit-reviewed process, and consider applications from National Laboratories, institutions of higher education, multi-institutional collaborations, and other appropriate entities. (b) Activities.—In carrying out the research, development, and demonstration activities authorized under subsection (a), the Secretary may— (1) utilize all available mechanisms to prevent duplication and coordinate research efforts across the Department; (2) establish multiple user facilities to serve as data enclaves capable of securely storing data sets created by Federal agencies, institutions of higher education, nonprofit organizations, or industry at National Laboratories; and (3) promote collaboration and data sharing between National Laboratories, research entities, and user facilities of the Department by providing the necessary access and secure data transfer capabilities. (c) Report.—Not later than 2 years after the date of the enactment of this Act, the Secretary shall submit to the Committee on Science, Space, and Technology of the House of Representatives and the Committee on Energy and Natural Resources of the Senate a report evaluating the effectiveness of the activities authorized under subsection (a). (d) Funding.—There are authorized to be appropriated to the Secretary of Energy to carry out subsection (a) $15,000,000 for each of the fiscal years 2028 through 2031, subject to the availability of appropriations. Sec. 603. Pilot program on posttraumatic growth. (a) Program.—The Secretary of Veterans Affairs shall conduct a pilot program to study the effectiveness and benefits of nonprofit posttraumatic growth programs to determine— (1) the outcomes of such programs in contrast to traditional models of mental health care; (2) the possible integration of such nonprofit programs into the mental health care programs provided by the Secretary; and (3) the budgetary impacts of such integration. (b) Review and evaluation.—In developing the pilot program under subsection (a), the Secretary shall— (1) review relevant literature to summarize the existing knowledge regarding posttraumatic growth programs; and (2) evaluate such programs. (c) Duration.—The Secretary shall carry out the pilot program under subsection (a) for a two-year period beginning on the date that is 180 days after the date of the enactment of this Act. (d) Locations.—The Secretary shall select more than one location at which to carry out the pilot program under subsection (a), of which at least one location shall include a rural area. (e) Participants.— (1) ELIGIBILITY.—A veteran is eligible to participate in the pilot program under subsection (a) if the Secretary determines that the veteran is— (A) not at known immediate risk of attempting suicide; and (B) not participating in traditional mental health treatment. (2) FEMALE VETERANS.—Not fewer than four groups of veterans participating in the pilot program under subsection (a) shall consist only of female veterans. (3) MALE VETERANS.—Not fewer than four groups of veterans participating in the pilot program under subsection (a) shall consist only of male veterans. (4) MIXED GROUPS.—Not fewer than four groups of veterans participating in the pilot program under subsection (a) shall consist of both female veterans and male veterans. (f) Nonprofit organizations.—The Secretary shall carry out the pilot program under subsection (a) by entering into an agreement with one or more nonprofit organizations that— (1) have staff with expertise in evidence-based care and experience working with veterans; (2) have experience in the science of posttraumatic growth; and (3) use a standardized, evaluated, and comprehensive curriculum. (g) Report.—Not later than one year after the date on which the pilot program under subsection (a) is completed, the Secretary shall submit to Congress a report on the pilot program, including a comparison of the care provided under the pilot program and the clinical care model of the Department. (h) Definitions.— (1) FEMALE VETERANS.—A person who is a veteran and is biologically female. (2) MALE VETERANS.—A person who is a veteran and is biologically male. Sec. 604. Financial assistance to certain entities to provide and coordinate the provision of suicide prevention services for veterans at risk of suicide and veteran families. (a) Distribution of financial assistance.—The Secretary of Veterans Affairs shall provide financial assistance to eligible entities approved under this section through the award of grants to such entities to provide and coordinate the provision services to veterans and veteran families to reduce the risk of suicide. (b) Award of grants.— (1) IN GENERAL.—The Secretary shall award a grant to each eligible entity for which the Secretary has approved an application under subsection (e) to provide or coordinate the provision of suicide prevention services under this section. (2) GRANT AMOUNTS, INTERVALS OF PAYMENT, AND MATCHING FUNDS.—In accordance with the services being provided under a grant under this section and the duration of those services, the Secretary may establish— (A) a maximum amount to be awarded under the grant; (B) intervals of payment for the administration of the grant; and (C) a requirement for the recipient of the grant to provide matching funds in a specified percentage. (c) Distribution of financial assistance and preference.— (1) DISTRIBUTION.— (A) GEOGRAPHIC.—The Secretary shall ensure that, to the extent practicable and in compliance with subparagraph (B), financial assistance under this section is equitably distributed across geographic regions, including rural communities and Tribal land. (B) AREAS WITH NEED.—The Secretary shall ensure that, to the extent practicable, financial assistance under this section is distributed— (i) to provide services in areas of the United States that have experienced high rates or a high burden of veteran suicide; and (ii) to eligible entities that can assist veterans at risk of suicide that are not currently receiving health care furnished by the Department of Veterans Affairs. (2) PREFERENCE.—The Secretary shall give preference in the provision of financial assistance under this section to eligible entities providing or coordinating, or who have demonstrated the ability to provide or coordinate, suicide prevention services or other services that improve the quality of life of veterans and their families and reduce the factors that contribute to veteran suicide. (3) NO DISCRIMINATION.—The Secretary shall not deny or grant preference in the distribution of financial assistance on the basis of race, religion, or national origin. (d) Requirements for receipts of financial assistance.— (1) NOTIFICATION THAT SERVICES ARE FROM DEPARTMENT.—Each entity receiving financial assistance under this section to provide suicide prevention services to veterans at risk of suicide and veteran families shall notify the recipients of such services that such services are being paid for, in whole or in part, by the Department. (2) DEVELOPMENT OF PLAN WITH BENEFICIARIES.— (A) IN GENERAL.—If an entity receiving financial assistance under this section provides temporary cash assistance under subsection (k)(5)(K), the entity shall develop a plan to ensure that any beneficiary of such temporary cash assistance is self-sustaining at the end of the period of eligibility for such temporary cash assistance. (B) CONSULTATION WITH BENEFICIARY.—Any plan developed under subparagraph (A) with respect to a beneficiary shall be developed in consultation with the beneficiary. (3) REPORTS.—The Secretary— (A) shall require each entity receiving financial assistance under this section to submit to the Secretary an annual report that describes the projects carried out with such financial assistance during the year covered by the report; (B) shall specify to each such entity the evaluation criteria and data and information, which shall include a mental health measurement of each veteran served, to be submitted in such report; and (C) may require such entities to submit to the Secretary such additional reports as the Secretary considers appropriate. (e) Application for financial assistance.— (1) IN GENERAL.—An eligible entity seeking financial assistance under this section shall submit to the Secretary an application therefor in such form, in such manner, and containing such commitments and information as the Secretary considers necessary to carry out this section. (2) MATTERS TO BE INCLUDED.—Each application submitted by an eligible entity under paragraph (1) shall contain the following: (A) A description of the suicide prevention services proposed to be provided by the eligible entity and the identified need for those services. (B) A detailed plan describing how the eligible entity proposes to coordinate and deliver suicide prevention services to veterans not currently receiving care furnished by the Department, including— (i) an identification of the community partners with which the eligible entity proposes to work in delivering such services; (ii) a description of the arrangements currently in place between the eligible entity and such partners; and (iii) an identification of how long such arrangements have been in place. (C) A description of the types of veterans at risk of suicide and veteran families proposed to be provided suicide prevention services. (D) An estimate of the number of veterans at risk of suicide and veteran families proposed to be provided suicide prevention services and the basis for such estimate, including the percentage of those veterans who are not currently receiving care furnished by the Department. (E) Evidence of the experience of the eligible entity (and the proposed partners of the entity) in providing suicide prevention services to individuals at risk of suicide, particularly to veterans at risk of suicide and veteran families. (F) A description of the managerial and technological capacity of the eligible entity— (i) to coordinate the provision of suicide prevention services with the provision of other services; (ii) to assess continuously the needs of veterans at risk of suicide and veteran families for suicide prevention services; (iii) to coordinate the provision of suicide prevention services with the services of the Department for which the beneficiaries are eligible; (iv) to tailor suicide prevention services to the needs of veterans at risk of suicide and veteran families; (v) to continuously seek new sources of assistance to ensure the continuity of suicide prevention services for veterans at risk of suicide and veteran families as long as the veteran is determined to be at risk of suicide; and (vi) to measure, over a long-term period, the improved mental resiliency and mental outlook of the veteran served. (G) Such additional application criteria as the Secretary considers appropriate. (f) Technical assistance.— (1) IN GENERAL.—The Secretary shall provide training and technical assistance to eligible entities in receipt of financial assistance under this section regarding— (A) the data required to be collected and shared with the Department; (B) the means of data collection and sharing; (C) familiarization with and appropriate use of any tool to be used to measure the effectiveness of the use of the financial assistance provided; and (D) the requirements for reporting under subsection (d)(3) on services provided via such financial assistance. (2) PROVISION OF TRAINING AND TECHNICAL ASSISTANCE.—The Secretary may provide the training and technical assistance described in paragraph (1) directly or through grants or contracts with appropriate public or nonprofit entities. (g) Administration of grant program.— (1) SELECTION CRITERIA.—The Secretary, in consultation with entities specified in paragraph (3), shall establish criteria for the selection of eligible entities that have submitted applications under subsection (e). (2) DEVELOPMENT OF MEASURES AND METRICS.—The Secretary shall develop, in consultation with entities specified in paragraph (3), the following: (A) A framework for collecting and sharing information about entities in receipt of financial assistance under this section for purposes of improving the discovery of services available for veterans at risk of suicide and veteran families, set forth by service type, locality, and eligibility criteria. (B) The measures to be used by each entity in receipt of financial assistance under this section to determine the effectiveness of the programming being provided by such entity in improving mental resiliency and mental outlook of veterans at risk of suicide and veteran families. (C) Metrics for measuring the effectiveness of the provision of financial assistance under this section. (3) COORDINATION.—In developing a plan for the design and implementation of the provision of financial assistance under this section, including criteria for the award of grants, the Secretary shall consult with the following: (A) Veterans service organizations. (B) National organizations representing potential community partners of eligible entities in providing supportive services to address the needs of veterans at risk of suicide and their families, including national organizations that— (i) advocate for the needs of individuals with or at risk of behavioral health conditions; (ii) represent mayors; (iii) represent first responders; or (iv) represent chiefs of police and sheriffs. (C) Organizations with which the Department has a current memoranda of agreement or understanding related to mental health or suicide prevention. (D) State departments of veterans affairs. (E) National organizations representing members of the reserve components of the Armed Forces. (F) Veteran Centers. (G) Organizations with experience in creating measurement tools for purposes of determining programmatic effectiveness. (H) Such other organizations as the Secretary considers appropriate. (4) REPORT ON GRANT CRITERIA.—Before notifying eligible entities of the availability of funding under this section, the Secretary shall submit to Congress a report containing— (A) criteria for the award of a grant under this section; (B) the tool to be used by the Department to measure the effectiveness of the use of financial assistance provided under this section; and (C) a framework for the sharing of information about entities in receipt of financial assistance under this section. (h) Information on potential beneficiaries.— (1) IN GENERAL.—The Secretary may make available to recipients of financial assistance under this section certain information regarding potential beneficiaries of services for which such financial assistance is provided. (2) INFORMATION INCLUDED.—The information made available under paragraph (1) with respect to potential beneficiaries may include the following: (A) Confirmation of the status of a potential beneficiary as a veteran. (B) Confirmation of whether a potential beneficiary is currently receiving care furnished by the Department or has recently received such care. (i) Duration.—The authority of the Secretary to provide financial assistance under this section shall terminate on the date that is three years after the date on which the first grant is awarded under this section. (j) Reporting.— (1) INTERIM REPORT.— (A) IN GENERAL.—Not later than 18 months after the date on which the first grant is awarded under this section, the Secretary shall submit to the appropriate committees of Congress a report on the provision of financial assistance under this section. (B) ELEMENTS.—The report submitted under subparagraph (A) shall include the following: (i) An assessment of the effectiveness of the provision of financial assistance under this section, including the effectiveness of community partners in conducting outreach to veterans at risk of suicide and veteran families. (ii) A list of grant recipients and their partner organizations that delivered services funded by the grant and the amount of such grant received by each recipient and partner organization. (iii) The number of veterans supported by each grant recipient, including through services provided to family members. (iv) The number of veterans supported by financial assistance under this section, including through services provided to family members. (v) The number of veterans supported by financial assistance under this section, including through services provided to family members, who were not previously receiving care furnished by the Department. (vi) The number of veterans whose mental resiliency and mental outlook received a baseline measurement assessment under this section and the number of such veterans whose mental resiliency and mental outlook will be measured by the Department or a community partner over a period of time. (vii) The types of data the Department was able to collect and share with partners, including a characterization of the benefits of that data. (2) FINAL REPORT.—Not later than three years after the date on which the first grant is awarded under this section, the Secretary shall submit to the appropriate committees of Congress— (A) a follow-up on the interim report submitted under paragraph (1) containing the elements set forth in subparagraph (B) of such paragraph; and (B) a report on— (i) the effectiveness of the provision of financial assistance under this section, including the effectiveness of community partners in conducting outreach to veterans at risk of suicide and veteran families; (ii) an assessment of the increased capacity of the Department to provide services to veterans at risk of suicide and veteran families, set forth by State, as a result of the provision of financial assistance under this section; and (iii) the feasibility and advisability of extending or expanding the provision of financial assistance under this section. (k) Definitions.—In this section: (1) APPROPRIATE COMMITTEES OF CONGRESS.—The term “appropriate committees of Congress” means— (A) the Committee on Veterans’ Affairs and the Subcommittee on Military Construction, Veterans Affairs, and Related Agencies of the Committee on Appropriations of the Senate; and (B) the Committee on Veterans’ Affairs and the Subcommittee on Military Construction, Veterans Affairs, and Related Agencies of the Committee on Appropriations of the House of Representatives. (2) ELIGIBLE ENTITY.—The term “eligible entity” means— (A) an incorporated private institution or foundation— (i) no part of the net earnings of which incurs to the benefit of any member, founder, contributor, or individual; (ii) that has a governing board that would be responsible for the operation of the suicide prevention services provided under this section; and (iii) that is approved by the Secretary as to financial responsibility; (B) a corporation wholly owned and controlled by an organization meeting the requirements of clauses (i), (ii), and (iii) of subparagraph (A); (C) a tribally designated housing entity (as defined in section 4 of the Native American Housing Assistance and Self-Determination Act of 1996 (25 U.S.C. 4103)); or (D) a community-based organization that is physically based in the targeted community and that can effectively network with local civic organizations, regional health systems, and other settings where veterans at risk of suicide and the families of such veterans are likely to have contact. (3) PEER SPECIALIST.—The term “peer specialist” means a person eligible to be appointed as a peer specialist under section 7402(b)(13) of title 38, United States Code. (4) RISK OF SUICIDE.—The term “risk of suicide” means exposure to or the existence of any of the following: (A) Health risk factors, including the following: (i) Mental health challenges. (ii) Substance abuse. (iii) Serious or chronic health conditions or pain. (iv) Traumatic brain injury. (B) Environmental risk factors, including the following: (i) Access to lethal means (such as drugs, firearms, etc.). (ii) Prolonged stress. (iii) Stressful life events. (iv) Exposure to the suicide of another person or to graphic or sensationalized accounts of suicide. (v) Unemployment. (vi) Homelessness. (vii) Recent loss. (viii) Legal or financial challenges. (C) Historical risk factors, including the following: (i) Previous suicide attempts. (ii) Family history of suicide. (iii) History of abuse, neglect, or trauma. (5) SUICIDE PREVENTION SERVICES.—The term “suicide prevention services” means services to address the needs of veterans at risk of suicide and veteran families and includes the following: (A) Outreach to identify veterans at risk of suicide, with an emphasis on veterans who are at highest risk or not receiving health care or other services furnished by the Department. (B) A baseline mental health assessment for risk screening and referral to care. (C) Education on suicide risk and prevention to families and communities. (D) Direct treatment. (E) Medication management. (F) Individual and group therapy. (G) Case management services. (H) Peer support services. (I) Assistance in obtaining any benefits from the Department that the veteran at risk of suicide or veteran family may be eligible to receive, including— (i) vocational and rehabilitation counseling; (ii) supportive services for homeless veterans; (iii) employment and training services; (iv) educational assistance; and (v) health care services. (J) Assistance in obtaining and coordinating the provision of other benefits provided by the Federal Government, a State or local government, or an eligible entity. (K) Temporary cash assistance (not to exceed 6 months) to assist with emergent needs relating to— (i) health care services; (ii) daily living services; (iii) personal financial planning; (iv) transportation services; (v) temporary income support services; (vi) fiduciary and representative payee services; (vii) legal services to assist the veteran family with issues that may contribute to the risk of suicide of the veteran; and (viii) child care (not to exceed $5,000 per veteran family per fiscal year). (L) Such other services necessary for improving the resiliency of veterans at risk of suicide and veteran families as the Secretary considers appropriate, which may include— (i) adaptive sports or in-place recreational therapy; (ii) substance use reduction programming; (iii) individual, group, or family counseling; and (iv) relationship coaching. (6) VETERAN CENTER.—The term “Veteran Center” means a center for readjustment counseling and related mental health services for veterans under section 1712A of title 38, United States Code. (7) VETERAN.—The term “veteran” has the meaning given that term in section 101 of title 38, United States Code. (8) VETERAN FAMILY.—The term “veteran family” means, with respect to a veteran at risk of suicide, any of the following: (A) A parent. (B) A spouse. (C) A child. (D) A sibling. (E) A step-family member. (F) An extended family member. (G) Any other individual who lives with the veteran. (l) CONSTITUTIONAL RIGHTS.—The Secretary shall respect the preferences of veterans who may choose to legally possess firearms or legally exercise any other constitutional right, including the rights of free speech and free exercise of religion. (m) FUNDING.—There is appropriated an amount of $20,000,000 to provide financial assistance under this section, excluding such funds otherwise appropriated. Sec. 605. Veterinary insurance for veterans. Chapter 17 of Title 38 of the United States Code is amended by adding, between subchapters VI and VIII, a new subchapter VII as follows— “Subchapter VI—Veterinary care “§1771. Providence of veterinary insurance. “Pursuant to— “(a) a diagnosis with any physical or mental condition which necessitates a service animal, “(b) entrustment of an animal from prior service in the military, or “(c) a diagnosis with a condition for which an animal companion may be helpful, “a veteran may receive veterinary insurance unless such veteran has a history of animal abuse or is barred from owning an animal, provided the cost of such insurance does not exceed $2000 per year and includes all services which may be necessary to ensure the mental health of a veteran insofar as it relates to an animal. The Secretary, in consultation with the Attorney General or the Secretary of Defense, may impose additional restrictions related to the animals in question to protect human and animal health.” Sec. 606. Cooperation between Department of Veterans Affairs and the Department of the Interior. A new subsection (j) is added at the end of section X as follows— “(j) The Indian Health Service and Veteran Health Service shall cooperate to enhance access to care for both of their patient groups, including by making their medical facilities mutually accessible, while separating patient costs in accordance with a formula to be devised by the Department of the Treasury, by 2029. Furthermore, the two Departments as a whole shall investigate further means to cooperate for mutual improvement and submit a report to Congress on the matter by 2030, and are authorized to undertake any cooperation they see as beneficial otherwise.” Sec. 607. Wheelchairs for veterans with service-connected disabilities. (a) Definition.—Section 1701 of title 38, United States Code, is amended by adding at the end the following new paragraph: “(11) The term ‘wheelchair’ includes enhanced power wheelchairs, multi-environmental wheelchairs, track wheelchairs, stair-climbing wheelchairs, and other power-driven mobility devices.”. (b) Enhanced wheelchairs.—Section 1712(c) of title 38, United States Code, is amended— (1) by striking “Dental” and inserting “(1) Dental”; (2) by striking “section” and inserting “title”; and (3) by adding at the end the following new paragraph: “(2) The Secretary shall ensure that each wheelchair, furnished under this title to a veteran because of a service-connected disability, restores the maximum achievable mobility and function in the activities of daily life, employment, and recreation. The Secretary may furnish a wheelchair to a veteran because the wheelchair restores an ability that relates exclusively to participation in a recreational activity.”. Sec. 608. Discharge treatment. (a) Any veteran who commits a crime against another veteran or otherwise commits a Federal crime as a means to infringe upon the rights guaranteed by the United States Constitution or by an Act of Congress intended to further those rights guaranteed by the United States Constitution shall be treated as dishonorably discharged, even if an initial discharge from the military was not dishonorable, for veteran affairs purposes. (b) Any veteran who was given a discharge that was not an honorable discharge as a victim of a crime committed under subsection (a) or as a victim of collusion between perpetrators and the Department of Veterans Affairs, Department of Defense, or any other agency of the United States Government shall be eligible for a change in discharge type to honorable, provided that no reason exists for such veteran to have a discharge that was not honorable. (c) The Secretary of Veterans Affairs may establish administrative procedures for the implementation of this section, including requirements to prove action by Federal, State, tribal, or other judicial authorities, in accordance with the necessary need to do so in accordance with the Fifth and Fourteenth Amendments to the Constitution of the United States. Sec. 609. Third-party review of appointees in Veterans Health Administration. (a) Third-party review.— (1) IN GENERAL.—Not later than 180 days after the date of the enactment of this Act, the Secretary of Veterans Affairs shall enter into a contract or other agreement with an organization that is not part of the Federal Government to conduct a clinical review for quality management of hospital care or medical services furnished by covered providers. (2) QUALIFICATIONS.—The Secretary shall ensure that each review of a covered provider under this subsection is performed by an individual who is licensed in the same specialty as the covered provider. (b) Notice to patients treated by covered providers.—With respect to hospital care or medical services furnished by a covered provider under the laws administered by the Secretary, if a clinical review for quality management under subsection (a) determines that the standard of care was not met during an episode of care, the Secretary shall notify the individual who received such care or services from the covered provider as described in applicable policy of the Veterans Heath Administration. (c) Covered provider.—For purposes of this section, a covered provider is an individual who— (1) was appointed to the Veterans Health Administration under section 7401 of title 38, United States Code; and (2) had a license terminated for cause by a State licensing board for hospital care or medical services provided in a facility that is not a facility of the Veterans Health Administration. (d) Hospital care or medical services defined.—In this section, the terms “hospital care” and “medical services” have the meanings given those terms in section 1701 of title 38, United States Code. Sec. 610. Unionization of the Veterans Health Administration. No employee of the Veterans Health Administration shall be a member of any labor union. Sec. 611. Deeming certain State Veterans homes as meeting Medicare skilled nursing facilities conditions and requirements. Section 1865(a) of the Social Security Act (42 U.S.C. 1395bb(a)) is amended— (1) in paragraph (1), by inserting “, subject to paragraph (5),” after “If the Secretary”; and (2) by adding at the end the following new subsection: “(5) In the case of a provider entity described in paragraph (3)(B) that the Secretary of Veterans Affairs inspects as a State home under section 1742 of title 38, United States Code, and determines meets such standards as the Secretary of Veterans Affairs shall prescribe pursuant to such section, the Secretary of Health and Human Services shall— “(A) treat such provider entity as meeting all conditions and requirements under sections 1819 and 1861(j) for the period for which such determination is in effect; and “(B) for purposes of subsection (g)(5)(E) of section 1819 and other related purposes for posting information on the Nursing Home Compare website under subsection (i) of such section, in lieu of the information described in the first sentence of such subsection (g)(5)(E), use the information described in the inspections of the Secretary of Veterans Affairs conducted under such section 1742 with respect to such provider entity for such period.”. Sec. 612. Hyperbaric oxygen therapy. (a) In General.—Chapter 17 of title 38, United States Code, is amended by inserting after section 1710E the following new section: “§ 1710F. Traumatic brain injury and post-traumatic stress disorder: hyperbaric oxygen therapy “(a) Authority.—The Secretary shall furnish hyperbaric oxygen therapy to a veteran who has a condition specified in subsection (b) through a health care provider described in section 1703(c)(5) of this title. “(b) Covered Conditions.—The conditions specified in this subsection are the following: “(1) Traumatic brain injury. “(2) Post-traumatic stress disorder (provided that the Secretary has found that hyperbaric oxygen therapy is an effective treatment).”. (b) Clerical Amendment.—The table of sections at the beginning of such chapter is amended by inserting after the item relating to section 1710E the following new item: “1710F. Traumatic brain injury and post-traumatic stress disorder: hyperbaric oxygen therapy.”. TITLE VII—Education Sec. 701. Clarification of Title IX. Section 909 of Title IX of the Education Amendments of 1972 is amended by— (a) striking “Nothing in this section” and all that follows from section 909, and (b) striking “or prohibit” from section 909. Sec. 702. Sports rules. Section 901 of the Education Amendments of 1972 (20 U.S.C. 1681) is amended by adding at the end the following: “(d) “Sex” defined The word “sex” includes only male and female, and does not include sexual orientation or gender identity.” “(e) (1) It shall be a violation of subsection (a) for a recipient of Federal financial assistance who operates, sponsors, or facilitates athletic programs or activities to permit a person whose sex is not matching the designated sex for an athletic program or activity to participate in an athletic program or activity that is designed to be for only one sex. “(2) For the purposes of this subsection, sex shall be recognized based solely on a person’s reproductive biology and genetics at birth. “(3) For the purposes of this subsection, the term ‘athletic programs and activities’ includes, but is not limited to, all programs or activities that are provided conditional upon participation with any athletic team. “(4) Nothing in this subsection shall be construed to prohibit a recipient from permitting males to train or practice with an athletic program or activity that is designated for women or girls so long as no male receives a roster spot on a team or sport, opportunity to participate in a practice or competition, scholarship, admission to an educational institution, or any other benefit that accompanies participating in the athletic program or activity, except that a male may participate in a supporting role as a manager, coach, or other helper. “(f) The Comptroller General shall carry out a study to determine the meaning of the phrases ‘any other benefit’ and ‘supporting role’ as used in subsection (d)(4) as used in subsection (d)(4) by looking at benefits to women or girls of participating in single sex sports that would be lost by allowing males to participate. The study shall document the adverse psychological, developmental, participatory, and sociological results to girls of allowing males to compete, be members of a sports team, or participants in athletic programs, that are designed for girls, including displacement or discouragement from sports participation, deprivation of a roster spot on a team or sport, loss of the opportunity to participate in a practice or competition, loss of a scholarship or scholarship opportunities, loss or displacement of admission to an educational institution, deprivation of the benefit of an environment free of hostility based on sexual assault or harassment, or any other benefit that accompanies participating in the athletics program or activity. Further, the Comptroller General shall submit to the Committee on Education and the Workforce of the House of Representatives and the Committee on Health, Education, Labor, and Pensions of the Senate a report that contains the results of such study no later than January 1, 2027, with further studies authorized as the Comptroller General may deem necessary.”. Sec. 703. Reduction of regulatory burdens for universities. Title IX of the Education Amendments of 1972 is amended by inserting a new section 910 at the end as follows— “Reduction of regulatory burdens for universities.” “(a) The Secretary of Education is authorized to reduce excessive regulatory burdens under this Title. “(b) No student-on-student harassment which is not prohibited by disciplinary rules of an educational program or activity receiving Federal financial assistance may be considered discriminatory unless it violates a Federal, State, or local law. “(c) No educational program or activity receiving Federal financial assistance shall be required by this Title to establish any new athletic team under after July 1, 2027. This date may be delayed up to two years at the discretion of the Secretary of Education. “(d) No project subject to section 110 of this Title shall be in violation of such section on the basis of refusal of acceptance of students of one particular sex, provided that— “(1) Such project is not intended to train clergy who belong to only one sex; or “(2) Such project rejects students purely on the basis of sex, provided that such project has a sister or brother school of the opposite sex within an appropriate distance prescribed by the Secretary of Education, with the same cost of attendance, offering courses and opportunities to avoid violation of this Title, and has programs to assist students in meeting people of the opposite sex for the intent of marriage.” Sec. 704. Living facility equality under Title IX. Section 907 of Title IX of the Education Amendments of 1972 is amended as follows— “(a) Notwithstanding anything to the contrary contained in this chapter, no educational program or activity receiving Federal financial assistance shall be permitted to maintain non-separated living facilities (including changing rooms, restrooms, bedrooms, and other facilities where a person may not be fully clothed) for the two sexes. “(b) The Secretary of Education shall have the authority to resolve issues related to persons with chromosomal and genital abnormalities. “(c) The Secretary of Education shall have the authority to issue regulations to ensure that living facilities for parents are kept adequate to the needs of such persons.” “(d) The Secretary of Education may issue transitional waivers to ensure that this section does not increase costs of education. “(e) Subsection (a) does not prevent the separation of persons who may sexually harass or violate persons of the same sex from potential victims of harassment or violation by persons of the same sex.” Sec. 705. Repeal of SAFRA Act. All amendments to the Higher Education Act of 1965 under sections 2201, 2202, 2203, 2204, 2205, 2206, 2207, and 2208 of the Health Care and Education Reconciliation Act of 2010 are repealed. Sec. 706. High demand skillset education loans. The Higher Education Act of 1965 is amended by adding a new section 437A after section 437 as follows— “437A. High demand skillset education loans.” “(a) In general.—It is the purpose of this section to authorize insured loans for United States citizens who are attending a university with the intent to enter one of the following professions— “(1) Health care for organisms of the species homo sapiens; “(2) Health care for organisms of other species which are endangered or displayed in zoos, aquariums, insectariums, or similar facilities; “(3) Healthcare administration; or “(4) Legal work relevant to other professions defined under this subsection. “(b) Eligible borrowers.—Any student with a GPA of at least 3.2 shall qualify for a loan under this section. “(c) Determination of amount of loan.—The determination of the amount of a loan by an eligible institution under subsection (b) shall be calculated by subtracting from the estimated cost of attendance at the eligible institution any estimated financial assistance reasonably available to such student. An eligible institution may not, in carrying out the provisions of subsection (b) of this section, provide a statement which certifies the eligibility of any student to receive any loan under this section in excess of the amount calculated under the preceding sentence. “(d) Loan limits “(1) In general.—The aggregate limit for loans under this section shall be $200,000. “(2) Limits for new students.—In a student's first year receiving a loan under this section, a limit of $5,000 may be borrowed. “(3) Subsequent annual limits.—For each subsequent year, an annual limit equal to one-fifth of the amount found by substracting the limit described by paragraph (2) from the limit described by paragraph (1) shall apply. “(5) Capitalized interest.—Interest capitalized shall not be deemed to exceed a maximum aggregate amount determined under this section. “(e) Payment of principal and interest “(1) Commencement of repayment.—Repayment of principal on loans made under this section shall begin at the beginning of the repayment period described in section 1078(b)(7) of this title. Not less than 30 days prior to the anticipated commencement of such repayment period, the holder of such loan shall provide notice to the borrower that interest will accrue before repayment begins and of the borrower's option to begin loan repayment at an earlier date. “(2) Capitalization of interest “(A) Except as provided in subparagraph (C), interest on loans made under this section for which payments of principal are not required during the in“school and grace periods or for which payments are deferred under sections 1077(a)(2)(C) and 1078(b)(1)(M) of this title shall, if agreed upon by the borrower and the lender“ “(i) be paid monthly or quarterly; or “(ii) be added to the principal amount of the loan by the lender only“ “(I) when the loan enters repayment; “(II) at the expiration of a grace period, in the case of a loan that qualifies for a grace period; “(III) at the expiration of a period of deferment or forbearance; or “(IV) when the borrower defaults. “(B) The capitalization of interest described in subparagraph (A) shall not be deemed to exceed the annual insurable limit on account of the student. “(C) Interest shall not accrue on a loan deferred under section 1078(b)(1)(M)(v) or 1077(a)(2)(C)(iv) of this title. “(3) Subsidies prohibited.—No payments to reduce interest costs shall be paid pursuant to section 1078(a) of this title on loans made pursuant to this section. “(4) Applicable rates of interest.—Interest on loans made pursuant to this section shall be at the applicable rate of interest provided in section 1077a of this title. “(5) Amortization.—The amount of the periodic payment and the repayment schedule for any loan made pursuant to this section shall be established by assuming an interest rate equal to the applicable rate of interest at the time the repayment of the principal amount of the loan commences. At the option of the lender, the note or other written evidence of the loan may require that— “(A) the amount of the periodic payment will be adjusted annually; or “(B) the period of repayment of principal will be lengthened or shortened, in order to reflect adjustments in interest rates occurring as a consequence of section 1077a(c)(4) of this title. “(6) Repayment period.—For purposes of calculating the repayment period under section 1078(b)(9) of this title, such period shall commence at the time the first payment of principal is due from the borrower. “(7) Qualification for forbearance.—A lender may grant the borrower of a loan under this section a forbearance for a period not to exceed 60 days if the lender reasonably determines that such a forbearance from collection activity is warranted following a borrower's request for forbearance, deferment, or a change in repayment plan, or a request to consolidate loans in order to collect or process appropriate supporting documentation related to the request. During any such period, interest on the loan shall accrue but not be capitalized. “(f) Interest rate.—A loan issued under this section shall accrue interest at a rate of 4% per year, and the rate at issuance shall not be increased. “(g) Single application form and loan repayment schedule.—A guaranty agency shall use a single application form and a single repayment schedule for subsidized Federal Stafford loans made pursuant to section 1078 of this title and for unsubsidized Federal Stafford loans made pursuant to this section. “(h) Insurance premium.—Each State or private institution or organization having an agreement with the Secretary under section 1078(b)(1) of this title may charge a borrower under this section an insurance premium equal to not more than 1.0 percent of the principal amount of the loan, if such premium will not be used for incentive payments to lenders. In lieu of the insurance premium authorized under the preceding sentence, each State or private institution or organization having an agreement with the Secretary under section 1078(b)(1) of this title shall collect and deposit into the Federal Student Loan Reserve Fund under section 1072a of this title, a Federal default fee of an amount equal to 1.0 percent of the principal amount of the loan, which fee shall be collected either by deduction from the proceeds of the loan or by payment from other non“Federal sources. The Federal default fee shall not be used for incentive payments to lenders.” Sec. 707. Improvement of secondary education. (a) 20 U.S.C. 1001(a)(4) is amended by striking “is a public or other nonprofit institution” and inserting “awards only degrees which provide opportunities for gainful employment”. (b) 20 U.S.C. 1001(a)(1) is amended by inserting “(unless it is a secondary school)” after “this title”. (c) 20 U.S.C. 1001(a)(2) is amended by inserting “(unless it is a secondary school)” after “secondary education”. (d) 20 U.S.C. 1091(a)(1) is amended by inserting “(unless enrolled or accepted at such an institute of higher education that is also a secondary school)” and striking “(including a program of study abroad approved for credit by the eligible institution at which such student is enrolled)”. (e) A new subparagraph 20 U.S.C. 1091(d)(1)(C) is inserted as follows— “(C) The student is enrolled in an institute of higher education which is a secondary school.” (f) A new section 1011n is inserted at the end of Part B of Subchapter I of Chapter 28 of Title 20 U.S.c. as follows— “The Secretary of Education may establish regulations and exemptions for secondary schools which are treated as institutes of higher education.”. (g) 20 U.S.C. 1091(a)(5) is amended by striking “, a permanent resident of the United States” and all that follows and inserting “ who resides in the United States; and”. (h) 20 U.S.C. 1091(a)(1) is amended Sec. 708. Territorial application. (a) Notwithstanding any prior Act, proclamation, order, ruling, or other item to the contrary, no territory of the United States may be considered a State for purposes of the Higher Education Act or Title 20 U.S.C. (b) 20 U.S.C. 1011b is amended by inserting “Puerto Rico,” before “Guam”. Sec. 709. Clarification of school authority. (a) 20 U.S.C. 1011a(b)(1) is amended by— (1) striking the word “liquor,” (2) by striking the word “alcohol” and inserting “substance” in its place, (3) striking “date” before “rape”, (4) inserting “to enforce a code of morals which shall not discriminate against any student on the basis of race, protected association, or protected speech,” after “to prevent hazing”, and (5) by striking “or”. (b) 20 U.S.C. 1011a(b)(2) is amended by striking the period at the end and inserting “; or” at the end. (c) A new paragraph 20 U.S.C. 1011a(b)(3) is inserted as follows— “(3) as permitting an institution of higher education to establish safe spaces, permit of violations of any Federal law, comply with or participate in any plot, action, or conspiracy which involves the violation of Federal law, or censor anything which does not involve the direct and unpermitted disruption of a lecture, violation of academic honesty policies, a presentation of genital or nipple, or in the case of a nonpublic and explicitly religious institution, enforcement of religious uniformity.” (d) A new paragraph 20 U.S.C. 1011a(c)(4) is inserted as follows— “(4) The term “safe space” means any restriction of protected speech within any area other than temporarily for the purpose of educational enhancement in which speech may be limited to that which is on-topic to course materials or to that which does not interfere with the lecturings of a professor, for the purpose of protecting protected association by actual associations known to an institution of higher education, for the purpose of ensuring that such institutions are capable of privately conducting administrative activities, or for the purpose of permitting a peaceful assembly.” Sec. 710. Rules regarding seminaries 20 U.S.C. 1062(c)(1) is amended by inserting “, unless its students receive training in emergency medical services and legal services relating to marriage and funerals” preceding the period at the end of its first sentence. Sec. 711. Educational status of child sexual mutilation. (a) Prohibition On Institutions Of Higher Education.—Section 487(a) of the Higher Education Act of 1965 (20 U.S.C. 1094(a)) is amended by adding at the end the following: “(30) The institution will not offer instruction in child sexual mutilation (as defined in section 2260B(d) of title 18, United States Code).”. (b) Prohibition On Accrediting Agencies Or Associations.—Section 496(a) of the Higher Education Act of 1965 (20 U.S.C. 1099b(a)) is amended— (1) by striking “and” at the end of paragraph (7); (2) by striking the period at the end of paragraph (8) and inserting “; and”; and (3) by adding at the end the following: “(9) such agency or association does not accredit any institution that offers instruction in child sexual mutilation (as defined in section 2260B(d) of title 18, United States Code).”.