SB3391 (Accountability for Better Care Act of 2025) amends Internal Revenue Code section 36B and Affordable Care Act section 1402 to extend and reshape the enhanced premium tax credits and to reauthorize reduced-cost-sharing payments. The bill pushes the statutory timeframe past 2025, raises the upper income threshold used in subsidy calculations to 600 percent of the federal poverty level for years beginning after December 31, 2026, revises the sliding-scale premium percentages that determine enrollee contributions, and adds a rule that ensures enrollees pay at least $5 of the monthly premium.
It also changes eligibility language to limit credits and cost-sharing reductions to U.S. citizens and bars qualified health plans from covering abortions except to save the mother's life or in cases of rape or incest.
Why this matters: the bill expands premium assistance for higher-income marketplace shoppers, creates new federal outlays through an open-ended appropriation for cost-sharing payments, tightens access for lawfully present noncitizens, and forces issuers and state exchanges to alter plan benefits and certification practices. Those moves will change premium math, enrollment incentives, administrative workloads for exchanges and the IRS, and legal exposure around plan coverage rules and state laws on reproductive care.
At a Glance
What It Does
Modifies IRC section 36B and ACA section 1402 to extend enhanced marketplace subsidies, substitutes a 600% FPL upper cutoff for the current 400% cutoff (for years after 2026), revises the percentage schedule that sets enrollee premium shares, imposes a rule that assistance cannot exceed premium minus $5, restricts subsidy and CSR eligibility to citizens, and prohibits QHP abortion coverage except for life, rape, or incest.
Who It Affects
Directly affects individual marketplace enrollees—especially households with incomes between 400% and 600% of FPL—health insurers and plan issuers that certify qualified health plans, state-based and federally facilitated exchanges that compute eligibility, the IRS for tax-credit administration, and the Treasury due to the appropriation for cost-sharing reductions.
Why It Matters
It changes who can get financial help and how much they pay, shifts recurring fiscal exposure to the federal budget via an unspecified appropriation, and forces plan design changes that may collide with state reproductive-health rules and with existing policy toward lawfully present immigrants.
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What This Bill Actually Does
The bill keeps the 'enhanced' marketplace premium tax credit regime in statutory text beyond the end of 2025 and then changes how that regime operates for later years. For taxable years beginning after December 31, 2026, it raises the income cutoff used in subsidy calculations so that the statute treats households up to 600 percent of the federal poverty level as part of the sliding scale, instead of stopping at 400 percent.
At the same time it rewrites the table of applicable percentages that determines the share of household income an enrollee must pay toward premiums, so higher-income households will face higher calculated contribution rates under the revised schedule.
The bill also inserts an express floor on enrollee liability: premium assistance cannot exceed the monthly premium amount minus $5, which effectively guarantees each enrollee pays at least $5 per month for coverage. That rule will change the mechanics of zero-premium plan outcomes and interacts with the revised percentage table when premiums are very low.
Separately, the bill narrows eligibility language so that both the premium tax credits and the cost-sharing reduction rules apply only to U.S. citizens for taxable years or plan years after December 31, 2025; lawfully present noncitizens who previously could qualify will generally be excluded under the new statutory text.On benefits, SB3391 adds a certification rule: a health plan that provides any abortion coverage cannot qualify as a qualified health plan (QHP) for premium tax-credit purposes, with narrow exceptions limited to life endangerment and pregnancies resulting from rape or incest. Finally, the bill adds an open-ended appropriation to the ACA cost-sharing reduction provision to make payments for plan years beginning January 1, 2027, and directs exchanges and the IRS to apply the new citizenship standard when administering CSRs.
Taken together these changes alter subsidy reach and size, change benefit certification standards, and create fresh administrative and fiscal tasks for federal and state agencies and for plan issuers.
The Five Things You Need to Know
For taxable years beginning after December 31, 2026, the bill substitutes a 600% of FPL cutoff for the previous 400% cutoff to determine the enhanced premium tax credit sliding scale.
The amended applicable-percentage schedule in section 36B sets enrollee contribution rates that start at 8.5% for incomes just above 400% FPL and rise to 16.5% at 600% FPL (the bill inserts explicit percentage rows for 400–450%, 450–500%, 500–550%, 550–600%, and 600%+).
The bill adds a minimum-monthly-payment rule: premium assistance may not exceed the monthly premium reduced by $5—so every enrollee must pay at least $5 of the monthly premium.
SB3391 changes eligibility language so credits and cost-sharing reductions apply only to U.S. citizens for taxable and plan years after December 31, 2025, excluding many lawfully present noncitizen categories previously eligible.
The bill prohibits a qualified health plan from providing any abortion coverage except when the mother's life is endangered or the pregnancy results from rape or incest, and it appropriates 'such sums as may be necessary' to fund cost-sharing reduction payments for plan years beginning January 1, 2027.
Section-by-Section Breakdown
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Short title
Formally names the bill the 'Accountability for Better Care Act of 2025.' This is a housekeeping provision but signals the package ties subsidy and plan-certification changes together under one banner, which matters for legislative drafting and for how other agencies will refer to the amendments in guidance.
Extend and change 36B threshold language
Amends IRC section 36B(c)(1)(E) to move the statutory reference dates and to add a clause that, for years beginning after December 31, 2026, replaces the prior 400% FPL cap with a 600% FPL cap. Practically, that changes which households are mapped into the enhanced sliding scale. Exchanges and the IRS will need to change eligibility logic, verification flows, and outreach materials to reflect that broader income band.
Rewrites the applicable-percentage table
Replaces the existing percentage table in 36B(b)(3)(A)(iii) with a five‑tier schedule that imposes higher percentage contributions as income rises between 400% and 600% of FPL and sets a top percentage (16.5%) at 600% FPL. The practical effect is to increase the statutory required contribution for higher‑income enrollees compared with the current text. Carriers and actuaries will need to re-run premium‑sharing projections because the modified percentages change who qualifies for full or partial credits and by how much.
Minimum monthly enrollee payment
Adds a rule directing that the initial and final premium percentages be adjusted so that premium assistance never exceeds the monthly premium reduced by $5. This guarantees enrollees pay at least $5 per month. It affects how exchanges compute net premium due, may eliminate zero-dollar premium outcomes in some designs, and creates edge cases when plan premiums are under $5 (the statute's language leaves ambiguity about assistance in those instances).
Citizenship test for tax credits
Changes the statutory eligibility phrase in 36B(e) so that for taxable years after 2025 the relevant test is whether individuals 'are not citizens of the United States' rather than the current 'not lawfully present' formulation. That is a substantive narrowing: many lawfully present noncitizens who previously qualified (DACA recipients, certain visa holders, LPRs in some interpretations) would be excluded under the new text, shifting both coverage outcomes and verification burdens for exchanges and the IRS.
Prohibits QHPs from covering abortion (limited exceptions)
Adds a new clause to 36B(c)(3) that disqualifies any plan that provides abortion coverage from being a qualified health plan, subject only to life‑of‑mother and rape/incest exceptions. The provision operates at the plan-certification level: issuers that want their plans to remain QHPs and therefore eligible for premium tax-credit eligibility must remove abortion benefits (except in the enumerated exceptions). That will trigger benefit redesign in some markets and may create tension with state laws that require or permit abortion coverage.
Effective date for tax-credit amendments
Specifies that the IRC amendments apply to taxable years beginning after December 31, 2025. Agencies must interpret how those taxable-year rules align with plan-year administration and with exchange open-enrollment periods; the statutory dating will drive transitional guidance.
Appropriation for cost‑sharing reductions
Amends ACA section 1402 to add an open-ended appropriation—'such sums as may be necessary'—to pay cost‑sharing reduction (CSR) payments for plan years beginning on or after January 1, 2027. That removes the previous reliance on reconciliation or litigation outcomes and places recurring fiscal responsibility for CSRs explicitly in appropriations law, increasing federal budget exposure and requiring Treasury/OMB planning.
Citizenship rule for cost‑sharing reductions
Mirrors the tax‑credit citizenship change in the CSR context by amending ACA section 1402(e) so that, for plan years after December 31, 2025, the eligibility test for CSRs uses 'is not a citizen of the United States' instead of 'is not lawfully present.' Exchanges will need to update verification and attestations for CSR eligibility and reconcile those processes with state‑level residency or ID requirements.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Households between 400% and 600% of FPL — will become newly mapped into the enhanced sliding scale and can receive some level of premium tax credit that did not exist under the 400% statutory cap.
- Some marketplace enrollees previously exposed to steep premium cliffs — the revised percentage schedule smooths support for higher incomes (albeit at higher enrollee share rates), reducing the abrupt loss of assistance for certain households.
- Insurers with large individual-market blocks — may see enrollment stability or growth in certain markets as more people remain eligible for partial subsidies, which can lower uncompensated-care risk and improve risk pools in some rating areas.
- State exchanges and federally facilitated exchanges — gain statutory authorization for CSR payments starting in 2027, which reduces the funding uncertainty that has complicated plan pricing and reconciliation in prior years.
Who Bears the Cost
- Federal Treasury / taxpayers — face increased budgetary outlays from expanded premium tax credits across more households and from the 'such sums as may be necessary' appropriation for CSRs.
- Lawfully present noncitizens who previously qualified — will generally lose access to premium tax credits and CSRs under the new 'citizen' eligibility standard, increasing uninsured risk for that population.
- Plan issuers and carriers — must redesign benefit packages and plan certification processes if they want to retain QHP status but also meet state mandates on reproductive services, and they will absorb compliance and communications costs.
- State regulators and exchanges — will need to revise certification, eligibility, and verification systems and face operational burdens and potential legal questions when state reproductive-health requirements conflict with the QHP abortion ban.
- The IRS and HHS — will need to rewrite guidance, update calculation routines, and manage appeals and reconciliation changes tied to the new percentage schedule and the $5 minimum rule.
Key Issues
The Core Tension
The central trade-off is stark: the bill expands financial help to higher‑income marketplace shoppers (broadening the subsidy ladder up to 600% FPL) while simultaneously narrowing who may receive that help (limiting eligibility to citizens and excluding lawfully present noncitizens) and restricting plan benefits (barring most abortion coverage in QHPs). That mixes an expansionary fiscal policy with exclusionary eligibility and coverage rules, forcing policymakers and implementers to balance coverage reach, federal cost, and conflicting state and provider obligations.
SB3391 pulls multiple levers at once, and several drafting and implementation issues jump out. First, the replacement of the 400% cutoff with 600% changes broad categories of eligibility but also interacts awkwardly with the inserted percentage table and the minimum‑$5 rule.
Those three mechanics together can produce surprising edge cases—for example, when a benchmark plan premium is close to $5, the 'assistance may not exceed premium minus $5' language could produce zero or negative allowable assistance unless administrative guidance clarifies intent. Second, the citizenship language is a substantive eligibility change: swapping 'lawfully present' for 'citizen' excludes groups that reviews and prior policy treated as eligible.
That narrowing will require exchanges to change verification flows and will likely increase appeals and requests for individualized relief.
Third, the abortion‑coverage restriction operates at plan certification; in states that require insurers to offer or cover abortion services, issuers face a binary choice—remove coverage to stay a QHP (and preserve eligibility for premium tax-credit recipients) or keep coverage and forfeit QHP status with predictable marketplace consequences. That creates a direct federal‑state conflict over plan design that could invite litigation.
Finally, the appropriation language—'such sums as may be necessary' for CSRs beginning in 2027—eliminates one source of uncertainty but also introduces open‑ended fiscal exposure without a specified offset. Combined, these elements make the bill fiscally meaningful but administratively complex and legally vulnerable in several respects, especially where state law and federal plan‑certification rules collide.
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