,i  #aac? ,,congress  #a/ ,session  ,h4 
,r4 #bcjj  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,june #f1 #bjac ,mr4  
,price ( ,georgia introduc$ ! foll[+    
bill2 :i* 0 ref]r$ to ! ,committee on   
,en]gy & ,comm]ce1 & 9 addition to !    
,committees on ,education & ! ,work=ce1 
,ways & ,means1 ! ,judici>y1 ,natural   
,res\rces1 ,h\se ,adm9i/ration1 ,rules1 
,appropriations1 ! ,budget1 & ,ov]sight 
& ,gov]nm5t ,re=m1 = a p]iod to be      
subsequ5tly det]m9$ by ! ,speak]1 9 ea* 
case = consid]ation ( su* provisions z  
fall )9 ! jurisdiction ( ! committee    
conc]n$  ,a ,,bill  ,to provide =       
inc5tives to enc\rage heal? insurance   
cov]age1 & = o!r purposes4  #a4 ,%ort   
title2 table ( cont5ts  7a7 ,%ort title 
,?is ,act may be cit$ z ! ,emp[]+       
,pati5ts ,fir/ ,act ( #bjac4  7b7 ,table
 ( cont5ts ,! table ( cont5ts = ?is ,act
 is z foll[s3  ,sec4 #a4 ,%ort title2   
table ( cont5ts4 ,sec4 #b4 ,repeal (    
,,ppaca & heal? c>e-relat$ ,,hc]a       
provisions4 ,sec4 #c4 ,no m&ate (       

gu>ante$ issue or community rat+4 ,title
 ,i--,tax ,inc5tives = ,ma9ta9+ ,heal?  
,insurance ,cov]age ,sec4 #aja4         
,refundable tax cr$it = heal? insurance 
co/s ( l[-income individuals4 ,sec4     
#ajb4 ,advance paym5t ( cr$it z premium 
paym5t = qualifi$ heal? insurance4 ,sec4
 #ajc4 ,election ( tax cr$it in/ead (   
alt]native gov]nm5t or gr\p plan        
b5efits4 ,sec4 #ajd4 ,d$uction =        
qualifi$ heal? insurance co/s (         
individuals4 ,sec4 #aje4 ,limitation on 
abortion fund+4 ,sec4 #ajf4 ,no gov]nm5t
 discrim9ation aga9/ c]ta9 heal? c>e    
entities4 ,sec4 #ajg4 ,equal employ]    
contribution rule to promote *oice4     
,sec4 #ajh4 ,limitations on ,/ate       
re/rictions on employ] auto-enrollm5t4  
,sec4 #aji4 ,cr$it = small employ]s     
adopt+ auto-enrollm5t & def9$           
contribution options4 ,sec4 #aaj4 ,,hsa 
modifications & cl>ifications4 ,title   
,,ii--,heal? ,insurance ,pool+          
,me*anisms = ,individuals ,subtitle     
,a--,f$]al ,grants = ,/ate ,insurance   

,exp5ditures ,sec4 #bja4 ,f$]al grants =
 ,/ate insurance exp5ditures4 ,subtitle 
,b--,heal? ,c>e ,access & ,availability 
,sec4 #baa4 ,expansion ( access & *oice 
?r\gh individual & small employ]        
memb]%ip associations 7,i,m,as74        
,subtitle ,c--,small ,bus9ess ,heal?    
,fairness ,sec4 #bba4 ,%ort title4 ,sec4
 #bbb4 ,rules gov]n+ association heal?  
plans4 ,sec4 #bbc4 ,cl>ification (      
treatm5t ( s+le employ] arrangem5ts4    
,sec4 #bbd4 ,en=cem5t provisions relat+ 
to association heal? plans4 ,sec4 #bbe4 
,coop]ation betwe5 ,f$]al & ,/ate       
au?orities4 ,sec4 #bbf4 ,effective date 
& transitional & o!r rules4 ,title      
,,iii--,int]/ate ,m>ket = ,heal?        
,insurance ,sec4 #cja4 ,coop]ative      
gov]n+ ( individual heal? insurance     
cov]age4 ,title ,,iv--,safety ,net      
,re=ms ,sec4 #dja4 ,requir+ outrea* &   
cov]age be=e expansion ( eligibility4   
,sec4 #djb4 ,eas+ adm9i/rative b>ri]s to
 ,/ate coop]ation ) employ]-sponsor$    
insurance cov]age4 ,sec4 #djc4 ,improv+ 

b5efici>y *oice 9 ,,s*ip4 ,title        
,v--,lawsuit ,abuse ,re=ms ,sec4 #eja4  
,*ange 9 burd5 ( pro( bas$ on compliance
 ) be/ practice guidel9es4 ,sec4 #ejb4  
,/ate grants to create adm9i/rative     
heal? c>e tribunals4 ,sec4 #ejc4        
,au?orization ( paym5t ( future damages 
to claimants 9 heal? c>e lawsuits4 ,sec4
 #ejd4 ,def9itions4 ,sec4 #eje4 ,effect 
on o!r laws4 ,sec4 #ejf4 ,applicability2
 effective date4 ,title ,,vi--,wellness 
& ,prev5tion ,sec4 #fja4 ,provid+       
f9ancial inc5tives = treatm5t           
compliance4 ,title ,,vii--,transp>5cy & 
,insurance ,re=m ,measures ,sec4 #gja4  
,receipt & response to reque/s = claim  
in=mation4 ,title ,,viii--,quality ,sec4
 #hja4 ,prohibition on c]ta9 uses ( data
 obta9$ f comp>ative effectiv5ess rese>*
 or f pati5t-c5t]$ outcomes rese>*2     
acc\nt+ = p]sonaliz$ m$ic9e & diff]5ces 
9 pati5t treatm5t response4 ,sec4 #hjb4 
,e/abli%m5t ( p]=mance-bas$ quality     
measures4 ,title ,,ix--,/ate ,transp>5cy
 ,plan ,portal ,sec4 #ija4 ,provid+     

in=mation on heal? cov]age options &    
heal? c>e provid]s4 ,title ,x--,pati5t  
,fre$om ( ,*oice ,sec4 #ajja4 ,gu>antee+
 fre$om ( *oice & contract+ = pati5ts "u
 ,m$ic>e4 ,sec4 #ajjb4 ,preemption (    
,/ate laws limit+ *>ges = eligible      
pr(essional s]vices4 ,sec4 #ajjc4 ,heal?
 c>e provid] lic5sure _c be condition$  
on p>ticipation 9 a heal? plan4 ,sec4   
#ajjd4 ,bad debt d$uction = doctors to  
p>tially (fset ! co/ ( provid+          
uncomp5sat$ c>e requir$ to be provid$ "u
 am5dm5ts made by ! ,em]g5cy ,m$ical    
,treatm5t & ,labor ,act4 ,sec4 #ajje4   
,"r ( contract ) heal? c>e provid]s4    
,title ,,xi--,inc5tives to r$uce        
physician %ortages ,subtitle            
,a--,f$]ally ,support$ ,/ud5t ,loan     
,funds = ,m$ical ,/ud5ts ,sec4 #aaja4   
,f$]ally support$ /ud5t loan funds =    
m$ical /ud5ts4 ,subtitle ,b--,loan      
,=giv5ess = ,prim>y ,c>e ,provid]s ,sec4
 #aaaa4 ,loan =giv5ess = prim>y c>e     
provid]s4 ,title ,,xii--,quality ,heal? 
,c>e ,coalition ,sec4 #abja4 ,quality   

,heal? ,c>e ,coalition4 ,title          
,,xiii--,(fsets ,subtitle               
,a--,discretion>y sp5d+ limits ,sec4    
#acja4 ,discretion>y sp5d+ limits4      
,subtitle ,b--,sav+s f heal? c>e        
effici5cies ,sec4 #acaa4 ,m$ic>e ,,d%   
report & paym5t adju/m5ts 9 response to 
cov]age expansion4 ,sec4 #acab4         
,r$uction 9 ,m$icaid ,,d%4 ,subtitle    
,c--,fraud1 ,wa/e1 & ,abuse ,sec4 #acba4
 ,provide adequate fund+ to ,,hhs ,,oig 
& ,,hcfac4 ,sec4 #acbb4 ,improv$        
en=cem5t ( ! ,m$ic>e second>y payor     
provisions4 ,sec4 #acbc4 ,/r5g!n ,m$ic>e
 provid] enrollm5t /&>ds & safegu>ds4   
,sec4 #acbd4 ,track+ bann$ provid]s     
across ,/ate l9es4  #b4 ,repeal (       
,,ppaca & heal? c>e-relat$ ,,hc]a       
provisions  7a7 ,,ppaca ,effective z ( !
 enactm5t ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act 7,public ,law       
#aaa-adh71 su* ,act is repeal$1 & !     
provisions ( law am5d$ or repeal$ by su*
 ,act are re/or$ or reviv$ z if su* ,act
 _h n be5 enact$4  7b7 ,heal?           

,c>e-,relat$ ,provisions 9 ! ,heal? ,c>e
 & ,education ,reconciliation ,act (    
#bjaj ,effective z ( ! enactm5t ( !     
,heal? ,c>e & ,education ,reconciliation
 ,act ( #bjaj 7,public ,law #aaa-aeb71  
title ,i & subtitle ,b ( title ,,ii (   
su* ,act are repeal$1 & ! provisions (  
law am5d$ or repeal$ by su* title or    
subtitle1 respectively1 are re/or$ or   
reviv$ z if su* title & subtitle _h n   
be5 enact$4  #c4 ,no m&ate ( gu>ante$   
issue or community rat+ ,no?+ 9 ?is ,act
 %all be con/ru$ to provide a m&ate =   
gu>ante$ issue or community rat+ 9 !    
private insurance m>ket4  ,i ,tax       
,inc5tives = ,ma9ta9+ ,heal? ,insurance 
,cov]age  #aja4 ,refundable tax cr$it = 
heal? insurance co/s ( l[-income        
individuals  7a7 ,9 g5]al ,subp>t ,c (  
"p ,,iv ( sub*apt] ,a ( *apt] #a ( !    
,int]nal ,rev5ue ,code ( #aihf1 z am5d$ 
by section #b1 is am5d$ by ins]t+ aft]  
section #cf;,a ! foll[+ new section3    
#cf;,b4 ,heal? insurance co/s (         
l[-income individuals  7a7 ,9 g5]al ,9 !

 case ( an individual1 !re %all be all[$
 z a cr$it aga9/ ! tax impos$ by        
subtitle ,a ! aggregate am\nt paid by ! 
taxpay] = cov]age ( ! taxpay] & !       
taxpay]'s qualify+ family memb]s "u     
qualifi$ heal? insurance = eligible     
cov]age mon?s beg9n+ 9 ! taxable ye>4   
7b7 ,limitations  7#a7 ,9 g5]al ,! am\nt
 all[able z a cr$it "u subsection 7a7 = 
! taxable ye> %all n exce$ ! less] (--  
7,a7 ! sum ( ! mon?ly limitations =     
mon?s dur+ su* taxable ye> t ! taxpay]  
or ! taxpay]'s qualify+ family memb]s is
 an eligible individual1 &  7,b7 !      
aggregate premiums paid by ! taxpay] = !
 taxable ye> = cov]age describ$ 9       
subsection 7a74  7#b7 ,mon?ly limitation
 ,! mon?ly limitation = any mon? is !   
cr$it p]c5tage ( #a_/ab ( ! sum (--     
7,a7 #b1jjj = cov]age ( ! taxpay]       
7#d1jjj 9 ! case ( a jo9t return =      
cov]age ( ! taxpay] & ! taxpay]'s       
sp\se71 &  7,b7 #ejj = cov]age ( ea*    
dep5d5t ( ! taxpay]4  7#c7 ,cr$it       
p]c5tage  7,a7 ,9 g5]al ,= purposes (   

?is section1 ! t]m cr$it p]c5tage means 
#ajj p]c5t r$uc$ by #a p]c5tage po9t =  
ea* #a1jjj 7or fraction !re(7 by :i* !  
taxpay]'s adju/$ gross income = !       
taxable ye> exce$s ! ?re%old am\nt4     
7,b7 ,?re%old am\nt ,= purposes ( ?is   
p>agraph1 ! t]m ?re%old am\nt means1 )  
respect to any taxpay] = any taxable    
ye>1 #bjj p]c5t ( ! ,f$]al pov]ty       
guidel9e 7z det]m9$ by ! ,secret>y (    
,heal? & ,human ,s]vices = ! taxable    
ye>7 applicable to ! taxpay]4  7#d7     
,only #b dep5d5ts tak5 into acc\nt ,n m 
?an #b dep5d5ts ( ! taxpay] may be tak5 
into acc\nt "u p>agraphs 7#b77;,c7 &    
7#c77;,b74  7#e7 ,inflation adju/m5t ,9 
! case ( any taxable ye> beg9n+ 9 a     
cal5d> ye> aft] #bjac1 ea* doll> am\nt  
conta9$ 9 p>agraph 7#b7 %all be increas$
 by an am\nt equal to--  7,a7 su* doll> 
am\nt1 multipli$ by  7,b7 ! co/-(-liv+  
adju/m5t det]m9$ "u section #a7;f77#c7 =
 ! cal5d> ye> 9 :i* ! taxable ye> beg9s1
 det]m9$ by sub/itut+ cal5d> ye> #bjab =
 cal5d> ye> #aiib 9 subp>agraph 7,b7    

!re(4  ,any increase det]m9$ "u ! prec$+
 s5t5ce %all be r\nd$ to ! ne>e/        
multiple ( #ej4  7c7 ,eligible cov]age  
mon? ,= purposes ( ?is section1 ! t]m   
eligible cov]age mon? means1 ) respect  
to any individual1 any mon? if1 z ( !   
fir/ day ( su* mon?1 ! individual--     
7#a7 is cov]$ by qualifi$ heal?         
insurance1  7#b7 does n h o!r specifi$  
cov]age1 &  7#c7 is n imprison$ "u      
,f$]al1 ,/ate1 or local au?ority4  7d7  
,qualify+ family memb] ,= purposes ( ?is
 section1 ! t]m qualify+ family memb]   
means--  7#a7 9 ! case ( a jo9t return1 
! taxpay]'s sp\se1 &  7#b7 any dep5d5t (
 ! taxpay]4  7e7 ,qualifi$ heal?        
insurance ,= purposes ( ?is section1 !  
t]m qualifi$ heal? insurance means heal?
 insurance cov]age 7o!r ?an except$     
b5efits z def9$ 9 section #ihcb7;c77 :i*
 con/itutes m$ical c>e4  7f7 ,o!r       
specifi$ cov]age ,= purposes ( ?is      
section1 an individual has o!r specifi$ 
cov]age = any mon? if1 z ( ! fir/ day ( 
su* mon?--  7#a7 ,cov]age "u ,m$ic>e1   

,m$icaid1 or ,,s*ip ,su* individual--   
7,a7 is entitl$ to b5efits "u "p ,a (   
title ,,xviii ( ! ,social ,security ,act
 or is enroll$ "u "p ,b ( su* title1 or 
7,b7 is enroll$ 9 ! program "u title    
,,xix or ,,xxi ( su* ,act 7o!r ?an "u   
section #aibh ( su* ,act74  7#b7 ,c]ta9 
o!r cov]age ,su* individual--  7,a7 is  
enroll$ 9 a heal? b5efits plan "u *apt] 
#hi ( title #e1 ,unit$ ,/ates ,code1    
7,b7 is entitl$ to receive b5efits "u   
*apt] #ee ( title #aj1 ,unit$ ,/ates    
,code1  7,c7 is entitl$ to receive      
b5efits "u *apt] #ag ( title #ch1 ,unit$
 ,/ates ,code1  7,d7 is enroll$ 9 a gr\p
 heal? plan 7)9 ! mean+ ( section       
#ejjj7;b77#a77 :i* is subsidiz$ by !    
employ]1 or  7,e7 is a memb] ( a heal?  
c>e %>+ m9i/ry4  7#c7 ,heal? c>e %>+    
m9i/ry ,= purposes ( ?is subsection1 !  
t]m heal? c>e %>+ m9i/ry means an       
organization--  7,a7 :i* is describ$ 9  
section #eja7;c77#c7 & is exempt f      
taxation "u section #eja7;a71  7,b7     
memb]s ( :i* %>e a common set ( e?ical  

or religi\s beliefs & %>e m$ical exp5ses
 among memb]s 9 accordance ) ^? beliefs 
& )\t reg>d to ! ,/ate 9 :i* a memb]    
resides or is employ$1  7,c7 memb]s (   
:i* reta9 memb]%ip ev5 aft] !y develop a
 m$ical condition1  7,d7 :i* 7or a      
pr$ecessor ( :i*7 has be5 9 exi/5ce at  
all times s9ce ,decemb] #ca1 #aiii1 &   
m$ical exp5ses ( its memb]s h be5 %>$   
cont9u\sly & )\t int]ruption s9ce at    
lea/ ,decemb] #ca1 #aiii1 &  7,e7 :i*   
conducts an annual audit :i* is p]=m$ by
 an indep5d5t c]tifi$ public acc\nt+    
firm 9 accordance ) g5]ally accept$     
acc\nt+ pr9ciples & :i* is made         
available to ! public ^u reque/4  7g7   
,special rules  7#a7 ,coord9ation )     
advance paym5ts ( cr$it2 recapture (    
excess advance paym5ts ,) respect to any
 taxable ye>--  7,a7 ! am\nt :i* w\ld 7b
 = ?is subsection7 be all[$ z a cr$it to
 ! taxpay] "u subsection 7a7 %all be    
r$uc$ 7b n bel[ z]o7 by ! aggregate     
am\nt paid on behalf ( su* taxpay] "u   
section #gebi = mon?s beg9n+ 9 su*      

taxable ye>1 &  7,b7 ! tax impos$ by    
section #a = su* taxable ye> %all be    
increas$ by ! excess 7if any7 (--  7i7 !
 aggregate am\nt paid on behalf ( su*   
taxpay] "u section #gebi = mon?s beg9n+ 
9 su* taxable ye>1 ov]  7ii7 ! am\nt :i*
 w\ld 7b = ?is subsection7 be all[$ z a 
cr$it to ! taxpay] "u subsection 7a74   
7#b7 ,coord9ation ) o!r d$uctions       
,am\nts tak5 into acc\nt "u subsection  
7a7 %all n be tak5 into acc\nt 9        
det]m9+--  7,a7 any d$uction all[$ "u   
section #afb7l71 #bac1 or #bbd1 or  7,b7
 any cr$it all[$ "u section #ce4  7#c7  
,m$ical & heal? sav+s acc\nts ,am\nts   
di/ribut$ f an ,ar*] ,,msa 7z def9$ 9   
section #bbj7;d77 or f a heal? sav+s    
acc\nt 7z def9$ 9 section #bbc7;d77 %all
 n be tak5 into acc\nt "u subsection    
7a74  7#d7 ,d5ial ( cr$it to dep5d5ts & 
nonp]man5t resid5t ali5 individuals ,no 
cr$it %all be all[$ "u ?is section to   
any individual :o is--  7,a7 n a citiz5 
or lawful p]man5t resid5t ( ! ,unit$    
,/ates = ! cal5d> ye> 9 :i* ! taxable   

ye> beg9s1 or  7,b7 a dep5d5t ) respect 
to ano!r taxpay] = a taxable ye> beg9n+ 
9 ! cal5d> ye> 9 :i* su* individual's   
taxable ye> beg9s4  7#e7 ,insurance :i* 
cov]s o!r individuals ,= purposes ( ?is 
section1 rules simil> to ! rules (      
section #bac7;d77#f7 %all apply )       
respect to any contract = qualifi$ heal?
 insurance "u :i* am\nts are payable =  
cov]age ( an individual o!r ?an !       
taxpay] & qualify+ family memb]s4  7#f7 
,treatm5t ( paym5ts ,= purposes ( ?is   
section--  7,a7 ,paym5ts by secret>y    
,paym5ts made by ! ,secret>y on behalf (
 any individual "u section #gebi 7relat+
 to advance paym5t ( cr$it = heal?      
insurance co/s ( l[-income individuals7 
%all be treat$ z hav+ be5 made by !     
taxpay] on ! fir/ day ( ! mon? = :i* su*
 paym5t 0 made4  7,b7 ,paym5ts by       
taxpay] ,paym5ts made by ! taxpay] =    
eligible cov]age mon?s %all be treat$ z 
hav+ be5 made by ! taxpay] on ! fir/ day
 ( ! mon? = :i* su* paym5t 0 made4  7#g7
 ,regulations ,! ,secret>y may prescribe

 su* regulations & o!r guidance z may be
 necess>y or appropriate to c>ry out ?is
 section1 section #fjej,w1 & section    
#gebi4  4  7b7 ,con=m+ am5dm5ts  7#a7   
,p>agraph 7#b7 ( section #acbd7;b7 (    
title #ca1 ,unit$ ,/ates ,code1 z am5d$ 
by section #b1 is am5d$ by ins]t+       
#cf;,b1 aft] #cf;,a14  7#b7 ,! table (  
sections = subp>t ,c ( "p ,,iv (        
sub*apt] ,a ( *apt] #a ( ! ,int]nal     
,rev5ue ,code ( #aihf1 z am5d$ by       
section #b1 is am5d$ by ins]t+ aft] !   
item relat+ to section #cf;,a ! foll[+  
new item3  ,sec4 #cf;,b4 ,heal?         
insurance co/s ( l[-income individuals4 
4  7c7 ,effective date ,! am5dm5ts made 
by ?is section %all apply to taxable    
ye>s beg9n+ aft] ,decemb] #ca1 #bjac4   
7d7 ,s5se ( ,congress ,x is ! s5se (    
,congress t ! co/ ( ! advanceable       
refundable cr$it "u sections #cf;,b &   
#gebi ( ! ,int]nal ,rev5ue ,code (      
#aihf1 z add$ by ?is title1 w be (fset  
by sav+s d]iv$ f ! provisions ( title   
,,xiii4  #ajb4 ,advance paym5t ( cr$it z

 premium paym5t = qualifi$ heal?        
insurance  7a7 ,9 g5]al ,*apt] #gg ( !  
,int]nal ,rev5ue ,code ( #aihf 7relat+  
to miscellane\s provisions7 is am5d$ by 
add+ at ! end ! foll[+3  #gebi4 ,advance
 paym5t ( cr$it z premium paym5t =      
qualifi$ heal? insurance  7a7 ,g5]al    
rule ,n lat] ?an ,janu>y #a1 #bjad1 !   
,secret>y %all e/abli% a program = mak+ 
paym5ts to provid]s ( qualifi$ heal?    
insurance 7z def9$ 9 section #cf;,b7e77 
on behalf ( taxpay]s eligible = ! cr$it 
"u section #cf;,b4 ,except z o!rwise    
provid$ by ! ,secret>y1 su* paym5ts %all
 be made on ! basis ( ! adju/$ gross    
income ( ! taxpay] = ! prec$+ taxable   
ye>4  7b7 ,c]tification process & pro( (
 cov]age ,= purposes ( ?is section1     
paym5ts may be made pursuant to         
subsection 7a7 only ) respect to        
individuals = :om a qualifi$ heal?      
insurance co/s cr$it eligibility        
c]tificate is 9 effect4  4  7b7         
,disclosure ( return in=mation =        
purposes ( advance paym5t ( cr$it z     

premiums = qualifi$ heal? insurance     
7#a7 ,9 g5]al ,subsection 7l7 ( section 
#fajc ( su* ,code1 z am5d$ by section   
#b1 is am5d$ by add+ at ! end ! foll[+  
new p>agraph3  7#ba7 ,disclosure (      
return in=mation = purposes ( advance   
paym5t ( cr$it z premiums = qualifi$    
heal? insurance ,! ,secret>y may1 on    
behalf ( taxpay]s eligible = ! cr$it "u 
section #cf;,b1 disclose to a provid] ( 
qualifi$ heal? insurance 7z def9$ 9     
section #cf7;e771 & p]sons act+ on      
behalf ( su* provid]1 return in=mation )
 respect to any su* taxpay] only to !   
ext5t necess>y 7z prescrib$ by          
regulations issu$ by ! ,secret>y7 to    
c>ry out ! program e/abli%$ by section  
#gebi 7relat+ to advance paym5t ( cr$it 
z premium paym5t = qualifi$ heal?       
insurance74  4  7#b7 ,confid5tiality (  
in=mation ,p>agraph 7#c7 ( section      
#fajc7;a7 ( su* ,code1 z am5d$ by       
section #b1 is am5d$ by /rik+ or 7#bj7 &
 ins]t+ 7#bj71 or 7#ba74  7#c7          
,unau?oriz$ disclosure ,p>agraph 7#b7 ( 

section #gbac7;a7 ( su* ,code1 z am5d$  
by section #b1 is am5d$ by /rik+ or     
7#bj7 & ins]t+ 7#bj71 or 7#ba74  7c7    
,in=mation report+  7#a7 ,9 g5]al       
,subp>t ,b ( "p ,,iii ( sub*apt] ,a (   
*apt] #fa ( su* ,code 7relat+ to        
in=mation conc]n+ transactions ) o!r    
p]sons7 is am5d$ by add+ at ! end !     
foll[+ new section3  #fjej,x4 ,returns  
relat+ to cr$it = heal? insurance co/s (
 l[-income individuals  7a7 ,requirem5t 
( report+ ,e p]son :o is entitl$ to     
receive paym5ts = any mon? ( any cal5d> 
ye> "u section #gebi 7relat+ to advance 
paym5t ( cr$it z premium paym5t =       
qualifi$ heal? insurance7 ) respect to  
any individual %all1 at su* "t z !      
,secret>y may prescribe1 make ! return  
describ$ 9 subsection 7b7 ) respect to  
ea* su* individual4  7b7 ,=m & mann] (  
returns ,a return is describ$ 9 ?is     
subsection if su* return--  7#a7 is 9   
su* =m z ! ,secret>y may prescribe1 &   
7#b7 conta9s--  7,a7 ! "n1 address1 &   
,,t9 ( ea* individual ref]r$ to 9       

subsection 7a71  7,b7 ! numb] ( mon?s = 
:i* am\nts 7 entitl$ to be receiv$ )    
respect to su* individual "u section    
#gebi 7relat+ to advance paym5t ( cr$it 
z premium paym5t = qualifi$ heal?       
insurance71  7,c7 ! am\nt entitl$ to be 
receiv$ = ea* su* mon?1 &  7,d7 su* o!r 
in=mation z ! ,secret>y may prescribe4  
7c7 ,/atem5ts ,to be furni%$ to         
individuals ) respect to :om in=mation  
is requir$ ,e p]son requir$ to make a   
return "u subsection 7a7 %all furni% to 
ea* individual ^: "n is requir$ to be   
set =? 9 su* return a writt5 /atem5t    
%[+--  7#a7 ! "n & address ( ! p]son    
requir$ to make su* return & ! phone    
numb] ( ! in=mation contact = su* p]son1
 &  7#b7 ! in=mation requir$ to be %[n  
on ! return ) respect to su* individual4
  ,! writt5 /atem5t requir$ "u ! prec$+ 
s5t5ce %all be furni%$ on or be=e       
,janu>y #ca ( ! ye> foll[+ ! cal5d> ye> 
= :i* ! return "u subsection 7a7 is     
requir$ to be made4  4  7#b7 ,assessable
 p5alties  7,a7 ,subp>agraph 7,b7 (     

section #fgbd7;d77#a7 ( su* ,code1 z    
am5d$ by section #b1 is am5d$ by /rik+  
or at ! end ( clause 7xxii71 by /rik+ & 
at ! end ( clause 7xxiii7 & ins]t+ or1 &
 by ins]t+ aft] clause 7xxiii7 ! foll[+ 
new clause3  7xxiv7 section #fjej,x     
7relat+ to returns relat+ to cr$it =    
heal? insurance co/s ( l[-income        
individuals71 &  4  7,b7 ,p>agraph 7#b7 
( section #fgbd7;d7 ( su* ,code1 z am5d$
 by section #b1 is am5d$ by /rik+ or at 
! end ( subp>agraph 7,,ee71 by /rik+ !  
p]iod at ! end ( subp>agraph 7,,ff7 &   
ins]t+ 1 or1 & by add+ aft] subp>agraph 
7,,ff7 ! foll[+ new subp>agraph3  7,,gg7
 section #fjej,x 7relat+ to returns     
relat+ to cr$it = heal? insurance co/s (
 l[-income individuals74  4  7d7        
,cl]ical am5dm5ts  7#a7 ,! table (      
sections = *apt] #gg ( su* ,code is     
am5d$ by add+ at ! end ! foll[+ new     
item3  ,sec4 #gebi4 ,advance paym5t (   
cr$it z premium paym5t = qualifi$ heal? 
insurance4  4  7#b7 ,! table ( sections 
= subp>t ,b ( "p ,,iii ( sub*apt] ,a (  

*apt] #fa ( su* ,code is am5d$ by add+  
at ! end ! foll[+ new item3  ,sec4      
#fjej,x4 ,returns relat+ to cr$it =     
heal? insurance co/s ( l[-income        
individuals4  4  7e7 ,effective date ,! 
am5dm5ts made by ?is section %all take  
effect on ! date ( ! enactm5t ( ?is     
,act4  #ajc4 ,election ( tax cr$it      
in/ead ( alt]native gov]nm5t or gr\p    
plan b5efits  7a7 ,9 g5]al ,not)/&+ any 
o!r provision ( law1 an individual :o is
 o!rwise eligible = b5efits "u a heal?  
program 7z def9$ 9 subsection 7c77 may  
elect1 9 a =m & mann] specifi$ by !     
,secret>y ( ,heal? & ,human ,s]vices 9  
consultation ) ! ,secret>y ( !          
,treasury1 to receive a tax cr$it       
describ$ 9 section #cf;,b ( ! ,int]nal  
,rev5ue ,code ( #aihf 7:i* may be us$ = 
! purpose ( heal? insurance cov]age7 9  
lieu ( receiv+ any b5efits "u su*       
program4  7b7 ,effective date ,an       
election "u subsection 7a7 may fir/ be  
made = cal5d> ye> #bjad & any su*       
election %all be effective = su* p]iod  

7n less ?an "o cal5d> ye>7 z ! ,secret>y
 ( ,heal? & ,human ,s]vices %all        
specify1 9 consultation ) ! ,secret>y ( 
! ,treasury4  7c7 ,heal? program def9$  
,= purposes ( ?is section1 ! t]m heal?  
program means any ( ! foll[+3  7#a7     
,m$ic>e ,! ,m$ic>e program "u "p ,a (   
title ,,xviii ( ! ,social ,security     
,act4  7#b7 ,m$icaid ,! ,m$icaid program
 "u title ,,xix ( su* ,act 7includ+ su* 
a program op]at+ "u a ,/atewide waiv] "u
 section #aaae ( su* ,act74  7#c7 ,,s*ip
 ,! ,/ate *ildr5's heal? insurance      
program "u title ,,xxi ( su* ,act4  7#d7
 ,,tric>e ,! ,,tric>e program "u *apt]  
#ee ( title #aj1 ,unit$ ,/ates ,code4   
7#e7 ,vet]ans b5efits ,cov]age = b5efits
 "u *apt] #ag ( title #ch1 ,unit$ ,/ates
 ,code4  7#f7 ,,fehbp ,cov]age "u *apt] 
#hi ( title #e1 ,unit$ ,/ates ,code4    
7#g7 ,subsidiz$ gr\p heal? plans        
,cov]age "u a gr\p heal? plan 7)9 !     
mean+ ( section #ejjj7;b77#a77 :i* is   
subsidiz$ by ! employ]4  7d7 ,o!r       
,social ,security b5efits n waiv$ ,an   

election to waive ! b5efits describ$ 9  
subsection 7c77#a7 %all n result 9 !    
waiv] ( any o!r b5efits "u ! ,social    
,security ,act4  #ajd4 ,d$uction =      
qualifi$ heal? insurance co/s (         
individuals  7a7 ,9 g5]al ,"p ,,vii (   
sub*apt] ,b ( *apt] #a ( ! ,int]nal     
,rev5ue ,code ( #aihf 7relat+ to        
additional itemiz$ d$uctions7 is am5d$  
by r$esignat+ section #bbd z section    
#bbe & by ins]t+ aft] section #bbc !    
foll[+ new section3  #bbd4 ,co/s (      
qualifi$ heal? insurance  7a7 ,9 g5]al  
,9 ! case ( an individual1 !re %all be  
all[$ z a d$uction an am\nt equal to !  
am\nt paid dur+ ! taxable ye> = cov]age 
= ! taxpay]1 8 sp\se1 & dep5d5ts "u     
qualifi$ heal? insurance4  7b7          
,limitation ,9 ! case ( any taxpay] =   
any taxable ye>1 ! d$uction "u          
subsection 7a7 %all n exce$ an am\nt t  
w\ld cause ! taxpay]'s ,f$]al income tax
 liability to be r$uc$ by m ?an ! av]age
 value ( ! national heal? exclusion =   
employ]-sponsor$ insurance z det]m9$ by 

calculat+ ! value ( ! exclusion = ea*   
h\sehold foll[$ by calculat+ ! av]age ( 
^? values4  7c7 ,qualifi$ heal?         
insurance ,= purposes ( ?is section1 !  
t]m qualifi$ heal? insurance has ! mean+
 giv5 su* t]m by section #cf;,b7e74  7d7
 ,special rules  7#a7 ,coord9ation )    
m$ical d$uction1 etc ,any am\nt paid by 
a taxpay] = insurance to :i* subsection 
7a7 applies %all n be tak5 into acc\nt 9
 comput+ ! am\nt all[able to ! taxpay] z
 a d$uction "u section #afb7l7 or       
#bac7;a74 ,any am\nt tak5 into acc\nt 9 
det]m9+ ! cr$it all[$ "u section #ce or 
#cf;,b %all n be tak5 into acc\nt =     
purposes ( ?is section4  7#b7 ,d$uction 
n all[$ = self-employm5t tax purposes ,!
 d$uction all[able by reason ( ?is      
section %all n be tak5 into acc\nt 9    
det]m9+ an individual's net e>n+s f     
self-employm5t 7)9 ! mean+ ( section    
#adjb7;a77 = purposes ( *apt] #b4  4    
7b7 ,d$uction all[$ 9 comput+ adju/$    
gross income ,subsection 7a7 ( section  
#fb ( su* ,code is am5d$ by ins]t+ be=e 

! la/ s5t5ce ! foll[+ new p>agraph3     
7#bb7 ,co/s ( qualifi$ heal? insurance  
,! d$uction all[$ by section #bbd4  4   
7c7 ,cl]ical am5dm5t ,! table ( sections
 = "p ,,vii ( sub*apt] ,b ( *apt] #a (  
su* ,code is am5d$ by r$esignat+ ! item 
relat+ to section #bbd z an item relat+ 
to section #bbe & ins]t+ be=e su* item !
 foll[+ new item3  ,sec4 #bbd4 ,co/s (  
qualifi$ heal? insurance4  4  7d7       
,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ,decemb] #ca1 #bjac4  #aje4 
,limitation on abortion fund+ ,no funds 
au?oriz$ "u1 or cr$its or d$uctions     
all[$ "u ! ,int]nal ,rev5ue ,code (     
#aihf by reason (1 ?is ,act 7or any     
am5dm5t made by ?is ,act7 may be us$ to 
pay = any abortion or to cov] any "p ( !
 co/s ( any heal? plan t includes       
cov]age ( abortion1 except 9 ! case :]e 
a woman suff]s f a physical disord]1    
physical injury1 or physical illness t  
w\ld1 z c]tifi$ by a physician1 place ! 
woman 9 dang] ( dea? unless an abortion 

is p]=m$1 includ+ a life-endang]+       
physical condition caus$ by or aris+ f !
 pregnancy itself1 or unless ! pregnancy
 is ! result ( an act ( rape or ince/4  
#ajf4 ,no gov]nm5t discrim9ation aga9/  
c]ta9 heal? c>e entities  7a7           
,non-,discrim9ation ,a ,f$]al ag5cy or  
program1 & any ,/ate or local gov]nm5t t
 receives ,f$]al f9ancial assi/ance "u  
?is ,act or any am5dm5t made by ?is ,act
 7ei!r directly or indirectly71 may n   
subject any individual or in/itutional  
heal? c>e entity to discrim9ation on !  
basis t ! heal? c>e entity does n       
provide1 pay =1 provide cov]age (1 or   
ref] = abortions4  7b7 ,heal? c>e entity
 def9$ ,= purposes ( ?is section1 ! t]m 
heal? c>e entity includes an individual 
physician or o!r heal? c>e pr(essional1 
a hospital1 a provid]-sponsor$          
organization1 a heal? ma9t5ance         
organization1 a heal? insurance plan1 or
 any o!r k9d ( heal? c>e facility1      
organization1 or plan4  7c7 ,rem$ies    
7#a7 ,9 g5]al ,! c\rts ( ! ,unit$ ,/ates

 %all h jurisdiction to prev5t & r$ress 
actual or ?reat5$ violations ( ?is      
section by issu+ any =m ( legal or      
equitable relief1 includ+--  7,a7       
injunctions prohibit+ conduct t violates
 ?is section2 &  7,b7 ord]s prev5t+ !   
disbursem5t ( all or a portion ( ,f$]al 
f9ancial assi/ance to a ,/ate or local  
gov]nm5t1 or to a specific (f5d+ ag5cy  
or program ( a ,/ate or local gov]nm5t1 
until su* "t z ! conduct prohibit$ by   
?is section has ceas$4  7#b7 ,comm5cem5t
 ( action ,an action "u ?is subsection  
may be in/itut$ by--  7,a7 any heal? c>e
 entity t has /&+ to compla9 ( an actual
 or ?reat5$ violation ( ?is section2 or 
7,b7 ! ,attorney ,g5]al ( ! ,unit$      
,/ates4  7d7 ,adm9i/ration ,! ,secret>y 
( ,heal? & ,human ,s]vices %all         
designate ! ,director ( ! ,(fice =      
,civil ,rights ( ! ,dep>tm5t ( ,heal? & 
,human ,s]vices--  7#a7 to receive      
compla9ts alleg+ a violation ( ?is      
section2  7#b7 subject to p>agraph 7#c71
 to pursue ! inve/igation ( su*         

compla9ts 9 coord9ation ) ! ,attorney   
,g5]al2 &  7#c7 9 ! case ( a compla9t   
relat$ to a ,f$]al ag5cy 7o!r ?an )     
respect to ! ,dep>tm5t ( ,heal? & ,human
 ,s]vices7 or program adm9i/]$ ?r\gh su*
 o!r ag5cy or any ,/ate or local        
gov]nm5t receiv+ ,f$]al f9ancial        
assi/ance ?r\gh su* o!r ag5cy1 to ref] !
 compla9t to ! appropriate (fice ( su*  
o!r ag5cy4  #ajg4 ,equal employ]        
contribution rule to promote *oice  7a7 
,9 g5]al ,section #ejjj ( ! ,int]nal    
,rev5ue ,code ( #aihf is am5d$ by add+  
at ! end ! foll[+ new subsection3  7e7  
,heal? c>e contribution election  7#a7  
,9 g5]al ,subsection 7a7 %all n apply 9 
! case ( a gr\p heal? plan ) respect to 
:i* ! requirem5ts ( p>agraphs 7#b7 &    
7#c7 are met4  7#b7 ,contribution       
election ,! requirem5t ( ?is p>agraph is
 met ) respect to a gr\p heal? plan if  
any employee ( an employ] 7:o b = ?is   
p>agraph w\ld be cov]$ by su* plan7 may 
elect to h ! employ] or employee        
organization pay an am\nt :i* is n less 

?an ! contribution am\nt to any provid] 
( heal? insurance cov]age 7o!r ?an      
except$ b5efits z def9$ 9 section       
#ihcb7;c77 :i* con/itutes m$ical c>e ( !
 individual or individual's sp\se or    
dep5d5ts 9 lieu ( su* gr\p heal? plan   
cov]age o!rwise provid$ or contribut$ to
 by ! employ] ) respect to su* employee4
  7#c7 ,pre-exi/+ conditions  7,a7 ,9   
g5]al ,! requirem5t ( ?is p>agraph is   
met ) respect to heal? insurance cov]age
 provid$ to a p>ticipant or b5efici>y by
 any heal? insurance issu] if1 "u su*   
plan ! requirem5ts ( section #ihja are  
met ) respect to ! p>ticipant or        
b5efici>y4  7,b7 ,en=cem5t ) respect to 
individual election ,= purposes (       
subp>agraph 7,a71 any heal? insurance   
cov]age ) respect to ! p>ticipant or    
b5efici>y %all be treat$ z heal?        
insurance cov]age "u a gr\p heal? plan  
to :i* section #ihja applies4  7#d7     
,contribution am\nt ,= purposes ( ?is   
section1 ! t]m contribution am\nt means1
 ) respect to an individual "u a gr\p   

heal? plan1 ! portion ( ! applicable    
premium ( su* individual "u su* plan 7z 
det]m9$ "u section #dihj;,b7f77#d77 :i* 
is n paid by ! individual4 ,9 ! case t !
 employ] (f]s m ?an "o gr\p heal? plan1 
! contribution am\nt %all be ! av]age   
am\nt ( ! applicable premiums "u su*    
plans4  7#e7 ,gr\p heal? plan ,= purpose
 ( ?is subsection1 subsection 7d7 %all n
 apply4  7#f7 ,application to ,,fehbp   
,not)/&+ any o!r provision ( law1 !     
,(fice ( ,p]sonnel ,managem5t %all c>ry 
out ! heal? b5efits program "u *apt] #hi
 ( title #e1 ,unit$ ,/ates ,code1       
consi/5t ) ! requirem5ts ( ?is          
subsection4  4  7b7 ,requirem5t ( equal 
contributions to all ,,fehbp plans      
,section #hijf ( title #e1 ,unit$ ,/ates
 ,code1 is am5d$ by add+ at ! end !     
foll[+ new subsection3  7j7 ,not)/&+ !  
previ\s provisions ( ?is section !      
,(fice ( ,p]sonnel ,managem5t %all      
revise ! am\nt ( ! ,gov]nm5t            
contribution made "u ?is section 9 a    
mann] s t--  7#a7 ! am\nt ( su*         

contribution does n *ange bas$ on !     
heal? b5efits plan 9 :i* ! individual is
 enroll$2 &  7#b7 ! aggregate am\nt (   
su* contributions is e/imat$ to be equal
 to ! aggregate am\nt ( su*             
contributions if ?is subsection did n   
apply4  4  7c7 ,employee ,retirem5t     
,income ,security ,act ( #aigd con=m+   
am5dm5ts  7#a7 ,exception f ,,hipaa     
requirem5ts = b5efits provid$ "u heal?  
c>e contribution election ,section #gcb 
( ! ,employee ,retirem5t ,income        
,security ,act ( #aigd 7#bi ,u4,s4,c4   
#aaia;a7 is am5d$ by add+ at ! end !    
foll[+ new subsection3  7e7 ,heal? c>e  
contribution election  7#a7 ,9 g5]al ,! 
requirem5ts ( ?is "p %all n apply 9 !   
case ( heal? insurance cov]age 7o!r ?an 
except$ b5efits z def9$ 9 section       
#ihcb7;c7 ( ! ,int]nal ,rev5ue ,code (  
#aihf7--  7,a7 :i* is provid$ to a      
p>ticipant or b5efici>y by a heal?      
insurance issu] "u a gr\p heal? plan1 & 
7,b7 ) respect to :i* ! requirem5ts (   
p>agraphs 7#b7 & 7#c7 are met4  7#b7    

,contribution election ,! requirem5t (  
?is p>agraph is met ) respect to heal?  
insurance cov]age provid$ to a          
p>ticipant or b5efici>y by any heal?    
insurance issu] "u a gr\p heal? plan if1
 "u su* plan--  7,a7 ! p>ticipant may   
elect su* cov]age = any p]iod ( cov]age 
9 lieu ( heal? insurance cov]age o!rwise
 provid$ "u su* plan = su* p]iod1 &     
7,b7 9 ! case ( su* an election1 ! plan 
sponsor is requir$ to pay to su* issu] =
 ! elect$ cov]age = su* p]iod an am\nt  
:i* is n less ?an ! contribution am\nt =
 su* heal? insurance cov]age o!rwise    
provid$ "u su* plan = su* p]iod4  7#c7  
,pre-exi/+ conditions  7,a7 ,9 g5]al ,! 
requirem5t ( ?is p>agraph is met )      
respect to heal? insurance cov]age      
provid$ to a p>ticipant or b5efici>y by 
any heal? insurance issu] if1 "u su*    
plan ! requirem5ts ( section #gja are   
met ) respect to ! p>ticipant or        
b5efici>y4  7,b7 ,en=cem5t ) respect to 
individual election ,= purposes (       
subp>agraph 7,a71 any heal? insurance   

cov]age ) respect to ! p>ticipant or    
b5efici>y %all be treat$ z heal?        
insurance cov]age "u a gr\p heal? plan  
to :i* section #gja applies4  7#d7      
,contribution am\nt  7,a7 ,9 g5]al ,=   
purposes ( ?is section1 ! t]m           
contribution am\nt means1 ) respect to  
any p]iod ( heal? insurance cov]age (f]$
 to a p>ticipant or b5efici>y1 ! portion
 ( ! applicable premium ( su* p>ticipant
 or b5efici>y "u su* plan :i* is n paid 
by su* p>ticipant or b5efici>y4 ,9 !    
case t ! employ] (f]s m ?an "o gr\p     
heal? plan1 ! contribution am\nt %all be
 ! av]age am\nt ( ! applicable premiums 
"u su* plans4  7,b7 ,applicable premium 
,= purposes ( subp>agraph 7,a71 ! t]m   
applicable premium means1 ) respect to  
any p]iod ( heal? insurance cov]age ( a 
p>ticipant or b5efici>y "u a gr\p heal? 
plan1 ! co/ to ! plan = su* p]iod ( su* 
cov]age = simil>ly situat$ b5efici>ies  
7)\t reg>d to :e!r su* co/ is paid by ! 
plan sponsor or ! p>ticipant or         
b5efici>y74  4  7#b7 ,exemption f       

fiduci>y liability ,section #djd ( su*  
,act 7#bi ,u4,s4,c4 #aajd7 is am5d$ by  
add+ at ! end ! foll[+ new subsection3  
7e7 ,! plan sponsor ( a gr\p heal? plan 
7z def9$ 9 section #gcc7;a77 %all n be  
treat$ z brea*+ any ( !                 
responsibilities1 obligations1 or duties
 impos$ ^u fiduci>ies by ?is title 9 !  
case ( any individual :o is a p>ticipant
 or b5efici>y "u su* plan solely because
 ( ! ext5t to :i* ! plan sponsor        
provides1 9 ! case ( su* individual1 "s 
or all ( su* b5efits by means ( paym5t (
 contribution am\nts pursuant to a      
contribution election "u section        
#gcb7;e71 irrespective ( ! am\nt or type
 ( b5efits t w\ld o!rwise be provid$ to 
su* individual "u su* plan4  4  7d7     
,exception f ,,hipaa requirem5ts "u     
,,irc = b5efits provid$ "u heal? c>e    
contribution election ,section #ihca ( !
 ,int]nal ,rev5ue ,code ( #aihf 7relat+ 
to g5]al exceptions7 is am5d$ by add+ at
 ! end ! foll[+ new subsection3  7d7    
,heal? c>e contribution election  7#a7  

,9 g5]al ,! requirem5ts ( ?is *apt] %all
 n apply 9 ! case ( heal? insurance     
cov]age 7o!r ?an except$ b5efits z def9$
 9 section #ihcb7;c77--  7,a7 :i* is    
provid$ to a p>ticipant or b5efici>y by 
a heal? insurance issu] "u a gr\p heal? 
plan1 &  7,b7 ) respect to :i* !        
requirem5ts ( p>agraphs 7#b7 & 7#c7 are 
met4  7#b7 ,contribution election ,!    
requirem5t ( ?is p>agraph is met )      
respect to heal? insurance cov]age      
provid$ to a p>ticipant or b5efici>y by 
any heal? insurance issu] "u a gr\p     
heal? plan if1 "u su* plan--  7,a7 !    
p>ticipant may elect su* cov]age = any  
p]iod ( cov]age 9 lieu ( heal? insurance
 cov]age o!rwise provid$ "u su* plan =  
su* p]iod1 &  7,b7 9 ! case ( su* an    
election1 ! plan sponsor is requir$ to  
pay to su* issu] = ! elect$ cov]age =   
su* p]iod an am\nt :i* is n less ?an !  
contribution am\nt = su* heal? insurance
 cov]age o!rwise provid$ "u su* plan =  
su* p]iod4  7#c7 ,pre-exi/+ conditions  
7,a7 ,9 g5]al ,! requirem5t ( ?is       

p>agraph is met ) respect to heal?      
insurance cov]age provid$ to a          
p>ticipant or b5efici>y by any heal?    
insurance issu] if1 "u su* plan !       
requirem5ts ( section #ihja are met )   
respect to ! p>ticipant or b5efici>y4   
7,b7 ,en=cem5t ) respect to individual  
election ,= purposes ( subp>agraph 7,a71
 any heal? insurance cov]age ) respect  
to ! p>ticipant or b5efici>y %all be    
treat$ z heal? insurance cov]age "u a   
gr\p heal? plan to :i* section #ihja    
applies4  7#d7 ,contribution am\nt  7,a7
 ,9 g5]al ,= purposes ( ?is subsection1 
! t]m contribution am\nt means1 )       
respect to any p]iod ( heal? insurance  
cov]age (f]$ to a p>ticipant or         
b5efici>y1 ! portion ( ! applicable     
premium ( su* p>ticipant or b5efici>y "u
 su* plan :i* is n paid by su*          
p>ticipant or b5efici>y4 ,9 ! case t !  
employ] (f]s m ?an "o gr\p heal? plan1 !
 contribution am\nt %all be ! av]age    
am\nt ( ! applicable premiums "u su*    
plans4  7,b7 ,applicable premium ,=     

purposes ( subp>agraph 7,a71 ! t]m      
applicable premium means1 ) respect to  
any p]iod ( heal? insurance cov]age ( a 
p>ticipant or b5efici>y "u a gr\p heal? 
plan1 ! co/ to ! plan = su* p]iod ( su* 
cov]age = simil>ly situat$ b5efici>ies  
7)\t reg>d to :e!r su* co/ is paid by ! 
plan sponsor or ! p>ticipant or         
b5efici>y74  4  7e7 ,exception f ,,hipaa
 requirem5ts "u ! ,,phsa = b5efits      
provid$ "u heal? c>e contribution       
election ,section #bgba ( ! ,public     
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg-#ba7 is am5d$--  7#a7 by        
r$esignat+ subsection 7e7 z subsection  
7f72 &  7#b7 by ins]t+ aft] subsection  
7d7 ! foll[+ new subsection3  7e7 ,heal?
 c>e contribution election  7#a7 ,9     
g5]al ,! requirem5ts ( subp>ts #a ?r\gh 
#c %all n apply 9 ! case ( heal?        
insurance cov]age 7o!r ?an except$      
b5efits z def9$ 9 section #ihcb7;c7 ( ! 
,int]nal ,rev5ue ,code ( #aihf7--  7,a7 
:i* is provid$ to a p>ticipant or       
b5efici>y by a heal? insurance issu] "u 

a gr\p heal? plan1 &  7,b7 ) respect to 
:i* ! requirem5ts ( p>agraphs 7#b7 &    
7#c7 are met4  7#b7 ,contribution       
election ,! requirem5t ( ?is p>agraph is
 met ) respect to heal? insurance       
cov]age provid$ to a p>ticipant or      
b5efici>y by any heal? insurance issu]  
"u a gr\p heal? plan if1 "u su* plan--  
7,a7 ! p>ticipant may elect su* cov]age 
= any p]iod ( cov]age 9 lieu ( heal?    
insurance cov]age o!rwise provid$ "u su*
 plan = su* p]iod1 &  7,b7 9 ! case (   
su* an election1 ! plan sponsor is      
requir$ to pay to su* issu] = ! elect$  
cov]age = su* p]iod an am\nt :i* is n   
less ?an ! contribution am\nt = su*     
heal? insurance cov]age o!rwise provid$ 
"u su* plan = su* p]iod4  7#c7          
,pre-exi/+ conditions  7,a7 ,9 g5]al ,! 
requirem5t ( ?is p>agraph is met )      
respect to heal? insurance cov]age      
provid$ to a p>ticipant or b5efici>y by 
any heal? insurance issu] if1 "u su*    
plan ! requirem5ts ( section #bgja are  
met ) respect to ! p>ticipant or        

b5efici>y4  7,b7 ,en=cem5t ) respect to 
individual election ,= purposes (       
subp>agraph 7,a71 any heal? insurance   
cov]age ) respect to ! p>ticipant or    
b5efici>y %all be treat$ z heal?        
insurance cov]age "u a gr\p heal? plan  
to :i* section #bgja applies4  7#d7     
,contribution am\nt  7,a7 ,9 g5]al ,=   
purposes ( ?is section1 ! t]m           
contribution am\nt means1 ) respect to  
any p]iod ( heal? insurance cov]age (f]$
 to a p>ticipant or b5efici>y1 ! portion
 ( ! applicable premium ( su* p>ticipant
 or b5efici>y "u su* plan :i* is n paid 
by su* p>ticipant or b5efici>y4 ,9 !    
case t ! employ] (f]s m ?an "o gr\p     
heal? plan1 ! contribution am\nt %all be
 ! av]age am\nt ( ! applicable premiums 
"u su* plans4  7,b7 ,applicable premium 
,= purposes ( subp>agraph 7,a71 ! t]m   
applicable premium means1 ) respect to  
any p]iod ( heal? insurance cov]age ( a 
p>ticipant or b5efici>y "u a gr\p heal? 
plan1 ! co/ to ! plan = su* p]iod ( su* 
cov]age = simil>ly situat$ b5efici>ies  

7)\t reg>d to :e!r su* co/ is paid by ! 
plan sponsor or ! p>ticipant or         
b5efici>y74  4  #ajh4 ,limitations on   
,/ate re/rictions on employ]            
auto-enrollm5t  7a7 ,9 g5]al ,no ,/ate  
%all e/abli% a law t prev5ts an employ] 
t is all[$ an exclusion f gross income1 
a d$uction1 or a cr$it = ,f$]al income  
tax purposes = heal? b5efits furni%$ to 
a p>ticipant or b5efici>y f in/itut+    
auto-enrollm5t :i* meets ! requirem5ts (
 subsection 7b7 = cov]age ( a p>ticipant
 or b5efici>y "u a gr\p heal? plan1 or  
heal? insurance cov]age (f]$ 9          
connection ) su* a plan1 s long z !     
p>ticipant or b5efici>y has ! option (  
decl9+ su* cov]age4  7b7 ,automatic     
enrollm5t = employ]-,sponsor$ heal?     
b5efits  7#a7 ,9 g5]al ,! requirem5t (  
?is subsection ) respect to an employ] &
 an employee is t ! employ]             
automatically enroll su* employee into !
 employm5t-bas$ heal? b5efits plan =    
individual cov]age "u ! plan option ) ! 
l[e/ applicable employee premium4  7#b7 

,opt-out ,9 no case may an employ]      
automatically enroll an employee 9 a    
plan "u p>agraph 7#a7 if su* employee   
makes an affirmative election to opt-out
 ( su* plan or to elect cov]age "u an   
employm5t-bas$ heal? b5efits plan (f]$  
by su* employ]4 ,an employ] %all provide
 an employee ) a #cj-;day p]iod to make 
su* an affirmative election be=e !      
employ] may automatically enroll !      
employee 9 su* a plan4  7#c7 ,notice    
requirem5ts  7,a7 ,9 g5]al ,ea* employ] 
describ$ 9 p>agraph 7#a7 :o             
automatically enrolls an employee into a
 plan z describ$ 9 su* p>agraph %all    
provide ! employees1 )9 a reasonable    
p]iod be=e ! beg9n+ ( ea* plan ye> 7or1 
9 ! case ( new employees1 )9 a          
reasonable p]iod be=e ! end ( !         
enrollm5t p]iod = su* a new employee71  
writt5 notice ( ! employees' rights &   
obligations relat+ to ! automatic       
enrollm5t requirem5t "u su* p>agraph4   
,su* notice mu/ be compreh5sive &       
und]/ood by ! av]age employee to :om !  

automatic enrollm5t requirem5t applies4 
7,b7 ,inclusion ( specific in=mation ,! 
writt5 notice "u subp>agraph 7,a7 mu/   
expla9 an employee's "r to opt out ( be+
 automatically enroll$ 9 a plan & 9 !   
case t m ?an "o level ( b5efits or      
employee premium level is (f]$ by !     
employ] involv$1 ! notice mu/ expla9 :i*
 level ( b5efits & employee premium     
level ! employee w be automatically     
enroll$ 9 ! abs5ce ( an affirmative     
election by ! employee4  7c7            
,con/ruction ,no?+ 9 ?is section %all be
 con/ru$ to sup]s$e ,/ate law :i*       
e/abli%es1 implem5ts1 or cont9ues 9     
effect any /&>d or requirem5t relat+ to 
employ]s 9 connection ) payroll or !    
sponsor+ ( employ]-sponsor$ heal?       
insurance cov]age except to ! ext5t t   
su* /&>d or requirem5t prev5ts an       
employ] f in/itut+ ! auto-enrollm5t     
describ$ 9 subsection 7a74  7d7         
,non-,application to except$ b5efits ,= 
purposes ( ?is section1 ! t]m gr\p heal?
 plan does n include except$ b5efits 7z 

def9$ 9 section #bgha7;c7 ( ! ,public   
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg-#ia7;c7774  #aji4 ,cr$it = small
 employ]s adopt+ auto-enrollm5t & def9$ 
contribution options  7a7 ,9 g5]al      
,subp>t ,d ( "p ,,iv ( sub*apt] ,a (    
*apt] #a ( ! ,int]nal ,rev5ue ,code (   
#aihf1 z am5d$ by section #b1 is am5d$  
by add+ at ! end ! foll[+ new section3  
#de,r4 ,auto-enrollm5t & def9$          
contribution option = heal? b5efits     
plans ( small employ]s  7a7 ,9 g5]al ,= 
purposes ( section #ch1 9 ! case ( a    
small employ]1 ! heal? b5efits plan     
implem5tation cr$it det]m9$ "u ?is      
section = ! taxable ye> is an am\nt     
equal to #ajj p]c5t ( ! am\nt paid or   
incurr$ by ! taxpay] dur+ ! taxable ye> 
= qualifi$ heal? b5efits exp5ses4  7b7  
,limitation ,! cr$it det]m9$ "u         
subsection 7a7 ) respect to any taxpay] 
= any taxable ye> %all n exce$ ! excess 
(--  7#a7 #a1ejj1 ov]  7#b7 sum ( !     
cr$its det]m9$ "u subsection 7a7 )      
respect to su* taxpay] = all prec$+     

taxable ye>s4  7c7 ,qualifi$ heal?      
b5efits exp5ses ,= purposes ( ?is       
section1 ! t]m qualifi$ heal? b5efits   
auto-enrollm5t exp5ses means1 ) respect 
to any taxable ye>1 am\nts paid or      
incurr$ by ! taxpay] dur+ su* taxable   
ye> =--  7#a7 e/abli%+ auto-enrollm5t   
:i* meets ! requirem5ts ( section #ajg (
 ! ,emp[]+ ,pati5ts ,fir/ ,act ( #bjac =
 cov]age ( a p>ticipant or b5efici>y "u 
a gr\p heal? plan1 or heal? insurance   
cov]age (f]$ 9 connection ) su* a plan1 
&  7#b7 implem5t+ ! employ] contribution
 option = heal? insurance cov]age       
pursuant to section #ejjj7;e77#b74  7d7 
,qualifi$ small employ] ,= purposes (   
?is section1 ! t]m qualifi$ small       
employ] means any employ] = any taxable 
ye> if ! numb] ( employees employ$ by   
su* employ] dur+ su* taxable ye> does n 
exce$ #ej4 ,all employ]s treat$ z a s+le
 employ] "u section 7a7 or 7b7 ( section
 #eb %all be treat$ z a s+le employ] =  
purposes ( ?is section4  7e7 ,no d\ble  
b5efit ,no d$uction or cr$it %all be    

all[$ "u any o!r provision ( ?is *apt] )
 respect to ! am\nt ( ! cr$it det]m9$ "u
 ?is section4  7f7 ,t]m9ation           
,subsection 7a7 %all n apply to any     
taxable ye> beg9n+ aft] ! date :i* is #b
 ye>s aft] ! date ( ! enactm5t ( ?is    
section4  4  7b7 ,cr$it ,to be "p (     
g5]al bus9ess cr$it ,subsection 7b7 (   
section #ch ( su* ,code1 z am5d$ by     
section #b1 is am5d$ by /rik+ plus at ! 
end ( p>agraph 7#cd71 by /rik+ ! p]iod  
at ! end ( p>agraph 7#ce7 & ins]t+ 1    
plus1 & by add+ at ! end ! foll[+ new   
p>agraph3  7#cf7 9 ! case ( a small     
employ] 7z def9$ 9 section #de,r7d771 ! 
heal? b5efits plan implem5tation cr$it  
det]m9$ "u section #de,r7a74  4  7c7    
,cl]ical am5dm5t ,! table ( sections =  
subp>t ,d ( "p ,,iv ( sub*apt] ,a (     
*apt] #a ( su* ,code1 z am5d$ by section
 #b1 is am5d$ by ins]t+ aft] ! item     
relat+ to section #de,q ! foll[+ new    
item3  ,sec4 #de,r4 ,auto-enrollm5t &   
def9$ contribution option = heal?       
b5efits plans ( small employ]s4  4  7d7 

,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ! date ( ! enactm5t ( ?is   
,act4  #aaj4 ,,hsa modifications &      
cl>ifications  7a7 ,cl>ification (      
treatm5t ( capitat$ prim>y c>e paym5ts z
 am\nts paid = m$ical c>e ,section      
#bac7;d7 ( ! ,int]nal ,rev5ue ,code (   
#aihf 7relat+ to def9itions7 is am5d$ by
 add+ at ! end ! foll[+ new p>agraph3   
7#ab7 ,treatm5t ( capitat$ prim>y c>e   
paym5ts ,capitat$ prim>y c>e paym5ts    
%all be treat$ z am\nts paid = m$ical   
c>e4  4  7b7 ,special rule = individuals
 eligible = vet]ans or ,indian heal?    
b5efits ,section #bbc7;c77#a7 ( su*     
,code 7def9+ eligible individual7 is    
am5d$ by add+ at ! end ! foll[+ new     
subp>agraph3  7,c7 ,special rule =      
individuals eligible = vet]ans or       
,indian heal? b5efits ,= purposes (     
subp>agraph 7,a77ii71 an individual %all
 n be treat$ z cov]$ "u a heal? plan    
describ$ 9 su* subp>agraph m]ely because
 ! individual receives p]iodic hospital 

c>e or m$ical s]vices "u any law        
adm9i/]$ by ! ,secret>y ( ,vet]ans      
,affairs or ! ,bureau ( ,indian         
,affairs4  4  7c7 ,c]ta9 physician fees 
,to be treat$ z m$ical c>e ,section     
#bac7;d7 ( su* ,code is am5d$ by add+ at
 ! end ! foll[+ new p>agraph3  7#ac7    
,pre-paid physician fees ,! t]m m$ical  
c>e %all include am\nts paid by pati5ts 
to _! prim>y physician 9 advance = ! "r 
to receive m$ical s]vices on an z-ne$$  
basis4  4  7d7 ,application to heal? c>e
 %>+ m9i/ries ,section #bbc ( su* ,code 
is am5d$ by add+ at ! end ! foll[+ new  
subsection3  7i7 ,application to heal?  
c>e %>+ m9i/ries ,= purposes ( ?is      
section1 memb]%ip 9 a heal? c>e %>+     
m9i/ry 7z def9$ 9 section #cf;,b7f77#c77
 %all be treat$ z cov]age "u a high     
d$uctible heal? plan4  4  7e7 ,effective
 date ,! am5dm5t made by ?is section    
%all apply to taxable ye>s beg9n+ aft] !
 date ( ! enactm5t ( ?is ,act4  ,,ii    
,heal? ,insurance ,pool+ ,me*anisms =   
,individuals  ,a ,f$]al ,grants = ,/ate 

,insurance ,exp5ditures  #bja4 ,f$]al   
grants = ,/ate insurance exp5ditures    
7a7 ,9 ,g5]al ,subject to ! succe$+     
provisions ( ?is section1 ea* ,/ate %all
 receive f ! ,secret>y ( ,heal? & ,human
 ,s]vices 79 ?is subtitle ref]r$ to z ! 
,secret>y7 a grant = ! ,/ate's provid+ =
 ! use1 9 connection ) provid+ heal?    
b5efits cov]age1 ( a qualify+ high-risk 
pool or a re9surance pool or o!r        
risk-adju/m5t me*anism us$ = ! purpose (
 subsidiz+ ! pur*ase ( private heal?    
insurance4  7b7 ,fund+ am\nt  7#a7 ,9   
g5]al ,!re are h]eby appropriat$1 out ( 
any funds 9 ! ,treasury n o!rwise       
appropriat$1 #cjj1jjj1jjj = ea* ( fiscal
 ye>s #bjad1 #bjae1 & #bjaf = grants "u 
?is section4 ,su* am\nt %all be divid$  
among ! ,/ates z det]m9$ by ! ,secret>y4
  7#b7 ,con/ruction ,no?+ 9 ?is section 
%all be con/ru$ z prev5t+ a ,/ate f us+ 
fund+ "u section #bgde ( ! ,public      
,heal? ,s]vice ,act = purposes ( fund+  
re9surance or o!r risk me*anisms4  7c7  
,limitation ,fund+ "u subsection 7a7 may

 only be us$ = ! foll[+3  7#a7 ,qualify+
 high-risk pools  7,a7 ,curr5t pools ,a 
qualify+ high-risk pool creat$ be=e !   
date ( ! enactm5t ( ?is ,act t only cov]
 high-risk populations & individuals 7& 
_! sp\se & dep5d5ts7 receiv+ a heal? c>e
 tax cr$it "u section #ce ( ! ,int]nal  
,rev5ue ,code ( #aihf = a limit$ p]iod (
 "t z det]m9$ by ! ,secret>y or "u      
section #bgda ( ,public ,heal? ,s]vice  
,act4  7,b7 ,new pools ,a qualify+      
high-risk pool creat$ on or aft] su*    
date t only cov]s populations &         
individuals describ$ 9 subp>agraph 7,a7 
if ! pool--  7i7 (f]s at lea/ ! option (
 "o or m high-d$uctible plan options1 9 
comb9ation ) a contribution into a heal?
 sav+s acc\nt2  7ii7 (f]s multiple      
compet+ heal? plan options2 &  7iii7    
cov]s only high-risk populations4  7#b7 
,risk insurance pool or o!r             
risk-adju/m5t me*anisms  7,a7 ,curr5t   
re9surance ,a re9surance pool1 or o!r   
risk-adju/m5t me*anism1 creat$ be=e !   
date ( ! enactm5t ( ?is ,act t only     

cov]s populations & individuals describ$
 9 p>agraph 7#a77;,a74  7,b7 ,new pools 
,a re9surance pool or o!r risk-adju/m5t 
me*anism creat$ on or aft] su* date t   
provides re9surance only cov]s          
populations & individuals describ$ 9    
p>agraph 7#a77;,a7 & only on a          
prospective basis "u :i* a heal?        
insurance issu] c$es cov]$ lives to !   
pool 9 ex*ange = paym5t ( a re9surance  
premium4  7#c7 ,transition ,no?+ 9 ?is  
section %all be con/ru$ z prev5t+ a     
,/ate f us+ funds available to          
transition f an exi/+ high-risk pool to 
a re9surance pool4  7d7 ,bonus paym5ts  
,) respect to any am\nts made available 
to ! ,/ates "u ?is section1 ! ,secret>y 
%all set aside a portion ( su* am\nts t 
%all only be available = ! foll[+       
activities by su* ,/ates3  7#a7 ,provid+
 gu>ante$ availability ( individual     
heal? insurance cov]age to c]ta9        
individuals ) prior gr\p cov]age "u "p  
,b ( title ,,xxvii ( ! ,public ,heal?   
,s]vice ,act4  7#b7 ,a r$uction 9       

premium tr5ds1 actual premiums1 or o!r  
co/-%>+ requirem5ts4  7#c7 ,an expansion
 or broad5+ ( ! pool ( high-risk        
individuals eligible = cov]age4  7#d7   
,/ates t adopt ! ,model ,heal? ,plan =  
,un9surable ,individuals ,act ( !       
,national ,association ( ,insurance     
,commission]s 7if & :5 updat$ by su*    
,association74  ,! ,secret>y may reque/ 
su* ,association to update su* ,model   
,heal? ,plan z ne$$ by #bjae4  7e7      
,adm9i/ration ,! ,secret>y %all provide 
= ! adm9i/ration ( ?is section & may    
e/abli% su* t]ms & conditions1 includ+ !
 requirem5t ( an application1 z may be  
appropriate to c>ry out ?is section4    
7f7 ,con/ruction ,no?+ 9 ?is section    
%all be con/ru$ z requir+ a ,/ate to    
op]ate a re9surance pool 7or o!r        
risk-adju/m5t me*anism7 "u ?is section  
or z prev5t+ a ,/ate f op]at+ su* a pool
 or me*anism ?r\gh "o or m private      
entities4  7g7 ,def9itions ,9 ?is       
section3  7#a7 ,qualify+ high-risk pool 
,! t]m qualify+ high-risk pool means any

 qualifi$ high-risk pool 7z def9$ 9     
subsection 7g77#a77;,a7 ( section #bgde 
( ! ,public ,heal? ,s]vice ,act7 t meets
 ! conditions to receive a grant "u     
section 7b77#a7 ( su* section4  7#b7    
,re9surance pool or o!r risk-,adju/m5t  
me*anism def9$ ,! t]m re9surance pool or
 o!r risk-adju/m5t me*anism means any   
,/ate-bas$ risk spread+ me*anism to     
subsidize ! pur*ase ( private heal?     
insurance = ! high-risk population4     
7#c7 ,high-,risk population ,! t]m      
high-risk population means--  7,a7      
individuals :o1 by reason ( ! exi/5ce or
 hi/ory ( a m$ical condition1 are able  
to acquire heal? cov]age only at rates  
:i* are at lea/ #aej p]c5t ( ! /&>d risk
 rates = su* cov]age 79 a               
non-community-rat$ non-gu>ante$ issue   
,/ate71 &  7,b7 individuals :o are      
provid$ heal? cov]age by a high-risk    
pool4  7#d7 ,/ate def9$ ,! t]m ,/ate    
includes ! ,di/rict ( ,columbia1 ,pu]to 
,rico1 ! ,virg9 ,isl&s1 ,guam1 ,am]ican 
,samoa1 & ! ,nor!rn ,m>iana ,isl&s4  7h7

 ,ext5d+ fund+ ,section #bgde7;d77#b7 ( 
! ,public ,heal? ,s]vice ,act 7#db      
,u4,s4,c4 #cjj;gg-#de7;d77#b77 is       
am5d$--  7#a7 9 ! head+1 by ins]t+ &    
#bjad ?r\gh #bjaf aft] #bjaj2 &  7#b7 by
 ins]t+ & = ea* ( fiscal ye>s #bjad     
?r\gh #bjaf aft] = ea* ( fiscal ye>s    
#bjjg ?r\gh #bjaj4  7i7 ,sunset ,funds  
made available "u ?is section %all n be 
us$ = ! purpose ( subsidiz+ ! pur*ase ( 
private heal? insurance on or aft]      
,octob] #a1 #bjaf4  ,b ,heal? ,c>e      
,access & ,availability  #baa4          
,expansion ( access & *oice ?r\gh       
individual & small employ] memb]%ip     
associations 7,i,m,as7 ,! ,public ,heal?
 ,s]vice ,act1 z am5d$ by section #b1 is
 fur!r am5d$ by ins]t+ aft] title ,,xxx 
! foll[+ new title3  ,,xxxi ,individual 
& ,small ,employ] ,memb]%ip             
,associations  #caja4 ,def9ition (      
individual & small employ] memb]%ip     
association 7,,ima7  7a7 ,9 ,g5]al ,=   
purposes ( ?is title1 ! t]ms individual 
& small employ] memb]%ip association &  

,,ima mean a legal entity t meets !     
foll[+ requirem5ts3  7#a7 ,organization 
,! ,,ima is an organization op]at$ "u ! 
direction ( an association 7z def9$ 9   
section #cajd7a774  7#b7 ,(f]+ heal?    
b5efits cov]age  7,a7 ,diff]5t gr\ps ,! 
,,ima1 9 conjunction ) ^? heal?         
insurance issu]s t (f] heal? b5efits    
cov]age ?r\gh ! ,,ima1 makes available  
heal? b5efits cov]age 9 ! mann] describ$
 9 subsection 7b7 to all memb]s ( !     
,,ima & ! dep5d5ts ( su* memb]s 7&1 9 ! 
case ( small employ]s1 employees & _!   
dep5d5ts7 9 ! mann] describ$ 9          
subsection 7c77#b7 at rates t are       
e/abli%$ by ! heal? insurance issu] on a
 policy or product specific basis & t   
may v>y only z p]missible "u ,/ate law4 
7,b7 ,nondiscrim9ation 9 cov]age (f]$   
7i7 ,9 ,g5]al ,subject to clause 7ii71 !
 ,,ima may n (f] heal? b5efits cov]age  
to a memb] ( an ,,ima unless ! same     
cov]age is (f]$ to all su* memb]s ( !   
,,ima4  7ii7 ,con/ruction ,no?+ 9 ?is   
title %all be con/ru$ z requir+ or      

p]mitt+ a heal? insurance issu] to      
provide cov]age outside ! s]vice area ( 
! issu]1 z approv$ "u ,/ate law1 or     
requir+ a heal? insurance issu] f       
exclud+ or limit+ ! cov]age on any      
individual1 subject to ! requirem5t (   
section #bgda4  7,c7 ,no f9ancial       
und]writ+ ,! ,,ima provides heal?       
b5efits cov]age only ?r\gh contracts )  
heal? insurance issu]s & does n assume  
insurance risk ) respect to su* cov]age4
  7#c7 ,geographic areas ,no?+ 9 ?is    
title %all be con/ru$ z prev5t+ !       
e/abli%m5t & op]ation ( m ?an "o ,,ima 9
 a geographic area or z limit+ ! numb] (
 ,i,m,as t may op]ate 9 any area4  7#d7 
,provision ( adm9i/rative s]vices to    
pur*as]s  7,a7 ,9 ,g5]al ,! ,,ima may   
provide adm9i/rative s]vices = memb]s4  
,su* s]vices may include acc\nt+1 bill+1
 & enrollm5t in=mation4  7,b7           
,con/ruction ,no?+ 9 ?is subsection %all
 be con/ru$ z prev5t+ an ,,ima f s]v+ z 
an adm9i/rative s]vice organization to  
any entity4  7#e7 ,fil+ in=mation ,!    

,,ima files ) ! ,secret>y in=mation t   
demon/rates ! ,,ima's compliance ) !    
applicable requirem5ts ( ?is title4  7b7
 ,heal? b5efits cov]age requirem5ts     
7#a7 ,compliance ) consum] protection   
requirem5ts ,any heal? b5efits cov]age  
(f]$ ?r\gh an ,,ima %all--  7,a7 be     
und]writt5 by a heal? insurance issu]   
t--  7i7 is lic5s$ 7or o!rwise regulat$7
 "u ,/ate law1 &  7ii7 meets all        
applicable ,/ate /&>ds relat+ to consum]
 protection1 subject to section         
#cajb7;b71 &  7,b7 subject to p>agraph  
7#b71 be approv$ or o!rwise p]mitt$ to  
be (f]$ "u ,/ate law4  7#b7 ,examples ( 
types ( cov]age ,! b5efits cov]age made 
available ?r\gh an ,,ima may include1 b 
is n limit$ to1 any ( ! foll[+ if x     
meets ! o!r applicable requirem5ts ( ?is
 title3  7,a7 ,cov]age ?r\gh a heal?    
ma9t5ance organization4  7,b7 ,cov]age 9
 connection ) a pref]r$ provid]         
organization4  7,c7 ,cov]age 9          
connection ) a lic5s$ provid]-sponsor$  
organization4  7,d7 ,indemnity cov]age  

?r\gh an insurance company4  7,e7       
,cov]age (f]$ 9 connection ) a          
contribution into a m$ical sav+s acc\nt 
or flexible sp5d+ acc\nt4  7,f7 ,cov]age
 t includes a po9t-(-s]vice option4     
7,g7 ,any comb9ation ( su* types (      
cov]age4  7#c7 ,wellness bonuses = heal?
 promotion ,no?+ 9 ?is title %all be    
con/ru$ z preclud+ a heal? insurance    
issu] (f]+ heal? b5efits cov]age ?r\gh  
an ,,ima f e/abli%+ premium disc\nts or 
rebates = memb]s or f modify+ o!rwise   
applicable copaym5ts or d$uctibles 9    
return = adh]5ce to programs ( heal?    
promotion & disease prev5tion s long z  
su* programs are agre$ to 9 advance by !
 ,,ima & comply ) all o!r provisions (  
?is title & d n discrim9ate among       
simil>ly situat$ memb]s4  7c7 ,memb]s2  
heal? insurance issu]s  7#a7 ,memb]s    
7,a7 ,9 ,g5]al ,"u rules e/abli%$ to    
c>ry out ?is title1 ) respect to an     
individual or small employ] :o is a     
memb] ( an ,,ima1 ! individual may      
enroll = heal? b5efits cov]age 7includ+ 

cov]age = dep5d5ts ( su* individual7 or 
employ] may enroll employees = heal?    
b5efits cov]age 7includ+ cov]age =      
dep5d5ts ( su* employees7 (f]$ by a     
heal? insurance issu] ?r\gh ! ,,ima4    
7,b7 ,rules = enrollm5t ,no?+ 9 ?is     
p>agraph %all preclude an ,,ima f       
e/abli%+ rules ( enrollm5t & re5rollm5t 
( memb]s4 ,su* rules %all be appli$     
consi/5tly to all memb]s )9 ! ,,ima &   
%all n be bas$ 9 any mann] on heal?     
/atus-relat$ factors4  7#b7 ,heal?      
insurance issu]s ,! contract betwe5 an  
,,ima & a heal? insurance issu] %all    
provide1 ) respect to a memb] enroll$ ) 
heal? b5efits cov]age (f]$ by ! issu]   
?r\gh ! ,,ima1 = ! paym5t ( ! premiums  
collect$ by ! issu]4  #cajb4            
,application ( c]ta9 laws & requirem5ts 
,/ate laws ins(> z !y relate to any ( ! 
foll[+ are sup]s$$ & %all n apply to    
heal? b5efits cov]age made available    
?r\gh an ,,ima3  7#a7 ,b5efit           
requirem5ts = heal? b5efits cov]age (f]$
 ?r\gh an ,,ima1 includ+ 7b n limit$ to7

 requirem5ts relat+ to cov]age (        
specific provid]s1 specific s]vices or  
conditions1 or ! am\nt1 duration1 or    
scope ( b5efits1 b n includ+ requirem5ts
 to ! ext5t requir$ to implem5t title   
,,xxvii or o!r ,f$]al law & to ! ext5t !
 requirem5t prohibits an exclusion ( a  
specific disease f su* cov]age4  7#b7   
,any o!r requirem5ts 7includ+           
limitations on comp5sation arrangem5ts7 
t1 directly or indirectly1 preclude 7or 
h ! effect ( preclud+7 ! (f]+ ( su*     
cov]age ?r\gh an ,,ima1 if ! ,,ima meets
 ! requirem5ts ( ?is title4  ,any ,/ate 
law or regulation relat+ to !           
composition or organization ( an ,,ima  
is preempt$ to ! ext5t ! law or         
regulation is inconsi/5t ) ! provisions 
( ?is title4  #cajc4 ,adm9i/ration  7a7 
,9 ,g5]al ,! ,secret>y %all adm9i/] ?is 
title & is au?oriz$ to issue su*        
regulations z may be requir$ to c>ry out
 ?is title4 ,su* regulations %all be    
subject to ,congressional review "u !   
provisions ( *apt] #h ( title #e1 ,unit$

 ,/ates ,code4 ,! ,secret>y %all        
incorporate ! process ( deem$ file & use
 ) respect to ! in=mation fil$ "u       
section #caja7;a77#e77;,a7 & %all       
det]m9e :e!r in=mation fil$ by an ,,ima 
demon/rates compliance ) ! applicable   
requirem5ts ( ?is title4 ,! ,secret>y   
%all ex]cise au?ority "u ?is title 9 a  
mann] t fo/]s & promotes ! developm5t ( 
,i,m,as 9 ord] to improve access to     
heal? c>e cov]age & s]vices4  7b7       
,p]iodic reports ,! ,secret>y %all      
submit to ,congress a report e #cj      
mon?s1 dur+ ! #aj-ye> p]iod beg9n+ on ! 
effective date ( ! rules promulgat$ by !
 ,secret>y to c>ry out ?is title1 on !  
effectiv5ess ( ?is title 9 promot+      
cov]age ( un9sur$ individuals4 ,!       
,secret>y may provide = ! production (  
su* reports ?r\gh "o or m contracts )   
appropriate private entities4  #cajd4   
,def9itions ,= purposes ( ?is title3    
7#a7 ,association ,! t]m association    
means1 ) respect to heal? insurance     
cov]age (f]$ 9 a ,/ate1 a legal entity  

:i*--  7,a7 has be5 actively 9 exi/5ce =
 at lea/ #e ye>s2  7,b7 has be5 =m$ &   
ma9ta9$ 9 good fai? = purposes o!r ?an  
obta9+ insurance2  7,c7 does n condition
 memb]%ip 9 ! association on any heal?  
/atus-relat$ factor relat+ to an        
individual 7includ+ an employee ( an    
employ] or a dep5d5t ( an employee72 &  
7,d7 does n make heal? insurance cov]age
 (f]$ ?r\gh ! association available o!r 
?an 9 connection ) a memb] ( !          
association4  7#b7 ,dep5d5t ,! t]m      
dep5d5t1 z appli$ to heal? insurance    
cov]age (f]$ by a heal? insurance issu] 
lic5s$ 7or o!rwise regulat$7 9 a ,/ate1 
%all h ! mean+ appli$ to su* t]m )      
respect to su* cov]age "u ! laws ( !    
,/ate relat+ to su* cov]age & su* an    
issu]4 ,su* t]m may include ! sp\se &   
*ildr5 ( ! individual involv$4  7#c7    
,heal? b5efits cov]age ,! t]m heal?     
b5efits cov]age has ! mean+ giv5 ! t]m  
heal? insurance cov]age 9 section       
#bgia7;b77#a71 & does n include except$ 
b5efits 7z def9$ 9 section #bgia7;c774  

7#d7 ,heal? insurance issu] ,! t]m heal?
 insurance issu] has ! mean+ giv5 su*   
t]m 9 section #bgia7;b77#b74  7#e7      
,heal? /atus-relat$ factor ,! t]m heal? 
/atus-relat$ factor has ! mean+ giv5 su*
 t]m 9 section #bgia7;d77#i74  7#f7     
,,ima2 individual & small employ]       
memb]%ip association ,! t]ms ,,ima &    
individual & small employ] memb]%ip     
association are def9$ 9 section         
#caja7;a74  7#g7 ,memb] ,! t]m memb]    
means1 ) respect to an ,,ima1 an        
individual or small employ] :o is a     
memb] ( ! association to :i* ! ,,ima is 
(f]+ cov]age4  7#h7 ,small employ] ,!   
t]m small employ] has ! mean+ giv5 su*  
t]m 9 section #hab7;a77#ac7 ( !         
,employee ,retirem5t & ,income ,security
 ,act ( #aigd4  4  ,c ,small ,bus9ess   
,heal? ,fairness  #bba4 ,%ort title ,?is
 subtitle may be cit$ z ! ,small        
,bus9ess ,heal? ,fairness ,act ( #bjac4 
#bbb4 ,rules gov]n+ association heal?   
plans  7a7 ,9 ,g5]al ,subtitle ,b (     
title ,i ( ! ,employee ,retirem5t       

,income ,security ,act ( #aigd is am5d$ 
by add+ aft] "p #g ! foll[+ new "p3  #h 
,,rules ,,gov]n+ ,,association ,,heal?  
,,plans  #hja4 ,association heal? plans 
7a7 ,9 ,g5]al ,= purposes ( ?is "p1 !   
t]m association heal? plan means a gr\p 
heal? plan ^: sponsor is 7or is deem$ "u
 ?is "p to be7 describ$ 9 subsection    
7b74  7b7 ,sponsor%ip ,! sponsor ( a    
gr\p heal? plan is describ$ 9 ?is       
subsection if su* sponsor--  7#a7 is    
organiz$ & ma9ta9$ 9 good fai?1 ) a     
con/itution & bylaws specifically /at+  
its purpose & provid+ = p]iodic meet+s  
on at lea/ an annual basis1 z a bona    
fide trade association1 a bona fide     
indu/ry association 7includ+ a rural    
electric coop]ative association or a    
rural telephone coop]ative association71
 a bona fide pr(essional association1 or
 a bona fide *amb] ( comm]ce 7or simil> 
bona fide bus9ess association1 includ+ a
 corporation or simil> organization t   
op]ates on a coop]ative basis 7)9 !     
mean+ ( section #acha ( ! ,int]nal      

,rev5ue ,code ( #aihf771 = sub/antial   
purposes o!r ?an t ( obta9+ or provid+  
m$ical c>e2  7#b7 is e/abli%$ z a       
p]man5t entity :i* receives ! active    
support ( its memb]s & requires =       
memb]%ip paym5t on a p]iodic basis (    
dues or paym5ts necess>y to ma9ta9      
eligibility = memb]%ip 9 ! sponsor2 &   
7#c7 does n condition memb]%ip1 su* dues
 or paym5ts1 or cov]age "u ! plan on !  
basis ( heal? /atus-relat$ factors )    
respect to ! employees ( its memb]s 7or 
affiliat$ memb]s71 or ! dep5d5ts ( su*  
employees1 & does n condition su* dues  
or paym5ts on ! basis ( gr\p heal? plan 
p>ticipation4  ,any sponsor consi/+ ( an
 association ( entities :i* meet !      
requirem5ts ( p>agraphs 7#a71 7#b71 &   
7#c7 %all be deem$ to be a sponsor      
describ$ 9 ?is subsection4  #hjb4       
,c]tification ( association heal? plans 
7a7 ,9 ,g5]al ,! applicable au?ority    
%all prescribe by regulation a proc$ure 
"u :i*1 subject to subsection 7b71 !    
applicable au?ority %all c]tify         

association heal? plans :i* apply =     
c]tification z meet+ ! requirem5ts ( ?is
 "p4  7b7 ,/&>ds ,"u ! proc$ure         
prescrib$ pursuant to subsection 7a71 9 
! case ( an association heal? plan t    
provides at lea/ "o b5efit option :i*   
does n consi/ ( heal? insurance cov]age1
 ! applicable au?ority %all c]tify su*  
plan z meet+ ! requirem5ts ( ?is "p only
 if ! applicable au?ority is satisfi$ t 
! applicable requirem5ts ( ?is "p are   
met 7or1 ^u ! date on :i* ! plan is to  
comm5ce op]ations1 w be met7 ) respect  
to ! plan4  7c7 ,requirem5ts ,applicable
 to ,c]tifi$ ,plans ,an association     
heal? plan ) respect to :i* c]tification
 "u ?is "p is 9 effect %all meet !      
applicable requirem5ts ( ?is "p1        
effective on ! date ( c]tification 7or1 
if lat]1 on ! date on :i* ! plan is to  
comm5ce op]ations74  7d7 ,requirem5ts = 
,cont9u$ ,c]tification ,! applicable    
au?ority may provide by regulation =    
cont9u$ c]tification ( association heal?
 plans "u ?is "p4  7e7 ,class           

,c]tification = ,fully ,insur$ ,plans ,!
 applicable au?ority %all e/abli% a     
class c]tification proc$ure =           
association heal? plans "u :i* all      
b5efits consi/ ( heal? insurance        
cov]age4 ,"u su* proc$ure1 ! applicable 
au?ority %all provide = ! grant+ (      
c]tification "u ?is "p to ! plans 9 ea* 
class ( su* association heal? plans ^u  
appropriate fil+ "u su* proc$ure 9      
connection ) plans 9 su* class & paym5t 
( ! prescrib$ fee "u section #hjg7;a74  
7f7 ,c]tification ( ,self-,insur$       
,association ,heal? ,plans ,an          
association heal? plan :i* (f]s "o or m 
b5efit options :i* d n consi/ ( heal?   
insurance cov]age may be c]tifi$ "u ?is 
"p only if su* plan consi/s ( any ( !   
foll[+3  7#a7 a plan :i* (f]$ su*       
cov]age on ! date ( ! enactm5t ( !      
,small ,bus9ess ,heal? ,fairness ,act ( 
#bjac1  7#b7 a plan "u :i* ! sponsor    
does n re/rict memb]%ip to "o or m      
trades & bus9esses or indu/ries & ^:    
eligible p>ticipat+ employ]s repres5t a 

broad cross-section ( trades & bus9esses
 or indu/ries1 or  7#c7 a plan ^:       
eligible p>ticipat+ employ]s repres5t "o
 or m trades or bus9esses1 or "o or m   
indu/ries1 consi/+ ( any ( ! foll[+3    
agriculture2 equipm5t & automobile      
deal]%ips2 b>b]+ & cosmetology2 c]tifi$ 
public acc\nt+ practices2 *ild c>e2     
con/ruction2 dance1 !atrical & or*e/ra  
productions2 dis9fect+ & pe/ control2   
f9ancial s]vices2 fi%+2 food s]vice     
e/abli%m5ts2 hospitals2 labor           
organizations2 logg+2 manufactur+       
7metals72 m9+2 m$ical & d5tal practices2
 m$ical laboratories2 pr(essional       
consult+ s]vices2 sanit>y s]vices2      
transportation 7local & freight72       
w>eh\s+2 :olesal+_/di/ribut+2 or any o!r
 trade or bus9ess or indu/ry :i* has be5
 indicat$ z hav+ av]age or above-av]age 
risk or heal? claims exp]i5ce by reason 
( ,/ate rate fil+s1 d5ials ( cov]age1   
propos$ premium rate levels1 or o!r     
means demon/rat$ by su* plan 9          
accordance ) regulations4  #hjc4        

,requirem5ts relat+ to sponsors & bo>ds 
( tru/ees  7a7 ,sponsor ,! requirem5ts (
 ?is subsection are met ) respect to an 
association heal? plan if ! sponsor has 
met 7or is deem$ "u ?is "p to h met7 !  
requirem5ts ( section #hja7;b7 = a      
cont9u\s p]iod ( n less ?an #c ye>s end+
 ) ! date ( ! application = c]tification
 "u ?is "p4  7b7 ,bo>d ( ,tru/ees ,!    
requirem5ts ( ?is subsection are met )  
respect to an association heal? plan if 
! foll[+ requirem5ts are met3  7#a7     
,fiscal control ,! plan is op]at$1      
pursuant to a tru/ agreem5t1 by a bo>d (
 tru/ees :i* has complete fiscal control
 ov] ! plan & :i* is responsible = all  
op]ations ( ! plan4  7#b7 ,rules (      
op]ation & f9ancial controls ,! bo>d (  
tru/ees has 9 effect rules ( op]ation & 
f9ancial controls1 bas$ on a #c-ye> plan
 ( op]ation1 adequate to c>ry out ! t]ms
 ( ! plan & to meet all requirem5ts (   
?is title applicable to ! plan4  7#c7   
,rules gov]n+ relation%ip to p>ticipat+ 
employ]s & to contractors  7,a7 ,bo>d   

memb]%ip  7i7 ,9 g5]al ,except z provid$
 9 clauses 7ii7 & 7iii71 ! memb]s ( !   
bo>d ( tru/ees are individuals select$ f
 individuals :o are ! own]s1 (fic]s1    
directors1 or employees ( ! p>ticipat+  
employ]s or :o are p>tn]s 9 ! p>ticipat+
 employ]s & actively p>ticipate 9 !     
bus9ess4  7ii7 ,limitation  7,i7 ,g5]al 
rule ,except z provid$ 9 subclauses     
7,,ii7 & 7,,iii71 no su* memb] is an    
own]1 (fic]1 director1 or employee (1 or
 p>tn] 91 a contract adm9i/rator or o!r 
s]vice provid] to ! plan4  7,,ii7       
,limit$ exception = provid]s ( s]vices  
solely on behalf ( ! sponsor ,(fic]s or 
employees ( a sponsor :i* is a s]vice   
provid] 7o!r ?an a contract adm9i/rator7
 to ! plan may be memb]s ( ! bo>d if !y 
con/itute n m ?an #be p]c5t ( ! memb]%ip
 ( ! bo>d & !y d n provide s]vices to ! 
plan o!r ?an on behalf ( ! sponsor4     
7,,iii7 ,treatm5t ( provid]s ( m$ical   
c>e ,9 ! case ( a sponsor :i* is an     
association ^: memb]%ip consi/s prim>ily
 ( provid]s ( m$ical c>e1 subclause 7,i7

 %all n apply 9 ! case ( any s]vice     
provid] describ$ 9 subclause 7,i7 :o is 
a provid] ( m$ical c>e "u ! plan4  7iii7
 ,c]ta9 plans exclud$ ,clause 7i7 %all n
 apply to an association heal? plan :i* 
is 9 exi/5ce on ! date ( ! enactm5t ( ! 
,small ,bus9ess ,heal? ,fairness ,act ( 
#bjac4  7,b7 ,sole au?ority ,! bo>d has 
sole au?ority "u ! plan to approve      
applications = p>ticipation 9 ! plan &  
to contract ) a s]vice provid] to       
adm9i/] ! day-to-day affairs ( ! plan4  
7c7 ,treatm5t ( ,fran*ise ,networks ,9 !
 case ( a gr\p heal? plan :i* is        
e/abli%$ & ma9ta9$ by a fran*is] = a    
fran*ise network consi/+ ( its          
fran*isees--  7#a7 ! requirem5ts (      
subsection 7a7 & section #hja7;a7 %all  
be deem$ met if su* requirem5ts w\ld    
o!rwise be met if ! fran*is] 7 deem$ to 
be ! sponsor ref]r$ to 9 section        
#hja7;b71 su* network 7 deem$ to be an  
association describ$ 9 section #hja7;b71
 & ea* fran*isee 7 deem$ to be a memb]  
7( ! association & ! sponsor7 ref]r$ to 

9 section #hja7;b72 &  7#b7 !           
requirem5ts ( section #hjd7;a77#a7 %all 
be deem$ met4  ,! ,secret>y may by      
regulation def9e = purposes ( ?is       
subsection ! t]ms fran*is]1 fran*ise    
network1 & fran*isee4  #hjd4            
,p>ticipation & cov]age requirem5ts  7a7
 ,cov]$ ,employ]s & ,individuals ,!     
requirem5ts ( ?is subsection are met )  
respect to an association heal? plan if1
 "u ! t]ms ( ! plan--  7#a7 ea*         
p>ticipat+ employ] mu/ be--  7,a7 a     
memb] ( ! sponsor1  7,b7 ! sponsor1 or  
7,c7 an affiliat$ memb] ( ! sponsor )   
respect to :i* ! requirem5ts (          
subsection 7b7 are met1  except t1 9 !  
case ( a sponsor :i* is a pr(essional   
association or o!r individual-bas$      
association1 if at lea/ "o ( ! (fic]s1  
directors1 or employees ( an employ]1 or
 at lea/ "o ( ! individuals :o are      
p>tn]s 9 an employ] & :o actively       
p>ticipates 9 ! bus9ess1 is a memb] or  
su* an affiliat$ memb] ( ! sponsor1     
p>ticipat+ employ]s may also include su*

 employ]2 &  7#b7 all individuals       
comm5c+ cov]age "u ! plan aft]          
c]tification "u ?is "p mu/ be--  7,a7   
active or retir$ own]s 7includ+         
self-employ$ individuals71 (fic]s1      
directors1 or employees (1 or p>tn]s 91 
p>ticipat+ employ]s2 or  7,b7 !         
b5efici>ies ( individuals describ$ 9    
subp>agraph 7,a74  7b7 ,cov]age (       
,previ\sly ,un9sur$ ,employees ,9 ! case
 ( an association heal? plan 9 exi/5ce  
on ! date ( ! enactm5t ( ! ,small       
,bus9ess ,heal? ,fairness ,act ( #bjac1 
an affiliat$ memb] ( ! sponsor ( ! plan 
may be (f]$ cov]age "u ! plan z a       
p>ticipat+ employ] only if--  7#a7 !    
affiliat$ memb] 0 an affiliat$ memb] on 
! date ( c]tification "u ?is "p2 or     
7#b7 dur+ ! #ab-mon? p]iod prec$+ ! date
 ( ! (f]+ ( su* cov]age1 ! affiliat$    
memb] has n ma9ta9$ or contribut$ to a  
gr\p heal? plan ) respect to any ( its  
employees :o w\ld o!rwise be eligible to
 p>ticipate 9 su* association heal?     
plan4  7c7 ,individual ,m>ket ,unaffect$

 ,! requirem5ts ( ?is subsection are met
 ) respect to an association heal? plan 
if1 "u ! t]ms ( ! plan1 no p>ticipat+   
employ] may provide heal? insurance     
cov]age 9 ! individual m>ket = any      
employee n cov]$ "u ! plan :i* is simil>
 to ! cov]age contemporane\sly provid$  
to employees ( ! employ] "u ! plan1 if  
su* exclusion ( ! employee f cov]age "u 
! plan is bas$ on a heal? /atus-relat$  
factor ) respect to ! employee & su*    
employee w\ld1 b = su* exclusion on su* 
basis1 be eligible = cov]age "u ! plan4 
7d7 ,prohibition ( ,discrim9ation ,aga9/
 ,employ]s & ,employees ,eligible ,to   
,p>ticipate ,! requirem5ts ( ?is        
subsection are met ) respect to an      
association heal? plan if--  7#a7 "u !  
t]ms ( ! plan1 all employ]s meet+ !     
prec$+ requirem5ts ( ?is section are    
eligible to qualify z p>ticipat+        
employ]s = all geographically available 
cov]age options1 unless1 9 ! case ( any 
su* employ]1 p>ticipation or            
contribution requirem5ts ( ! type ref]r$

 to 9 section #bgaa ( ! ,public ,heal?  
,s]vice ,act are n met2  7#b7 ^u reque/1
 any employ] eligible to p>ticipate is  
furni%$ in=mation reg>d+ all cov]age    
options available "u ! plan2 &  7#c7 !  
applicable requirem5ts ( sections #gja1 
#gjb1 & #gjc are met ) respect to !     
plan4  #hje4 ,o!r requirem5ts relat+ to 
plan docum5ts1 contribution rates1 &    
b5efit options  7a7 ,9 ,g5]al ,!        
requirem5ts ( ?is section are met )     
respect to an association heal? plan if 
! foll[+ requirem5ts are met3  7#a7     
,cont5ts ( gov]n+ in/rum5ts ,! in/rum5ts
 gov]n+ ! plan include a writt5         
in/rum5t1 meet+ ! requirem5ts ( an      
in/rum5t requir$ "u section             
#djb7;a77#a71 :i*--  7,a7 provides t !  
bo>d ( tru/ees s]ves z ! nam$ fiduci>y  
requir$ = plans "u section #djb7;a77#a7 
& s]ves 9 ! capacity ( a plan           
adm9i/rator 7ref]r$ to 9 section        
#c7af77;,a772  7,b7 provides t ! sponsor
 ( ! plan is to s]ve z plan sponsor     
7ref]r$ to 9 section #c7af77;,b772 &    

7,c7 incorporates ! requirem5ts (       
section #hjf4  7#b7 ,contribution rates 
mu/ be nondiscrim9atory  7,a7 ,!        
contribution rates = any p>ticipat+     
small employ] d n v>y on ! basis ( any  
heal? /atus-relat$ factor 9 relation to 
employees ( su* employ] or _!           
b5efici>ies & d n v>y on ! basis ( !    
type ( bus9ess or indu/ry 9 :i* su*     
employ] is engag$4  7,b7 ,no?+ 9 ?is    
title or any o!r provision ( law %all be
 con/ru$ to preclude an association     
heal? plan1 or a heal? insurance issu]  
(f]+ heal? insurance cov]age 9          
connection ) an association heal? plan1 
f--  7i7 sett+ contribution rates bas$  
on ! claims exp]i5ce ( ! plan2 or  7ii7 
v>y+ contribution rates = small employ]s
 9 a ,/ate to ! ext5t t su* rates c\ld  
v>y us+ ! same me?odology employ$ 9 su* 
,/ate = regulat+ premium rates 9 ! small
 gr\p m>ket ) respect to heal? insurance
 cov]age (f]$ 9 connection ) bona fide  
associations 7)9 ! mean+ ( section      
#bgia7;d77#c7 ( ! ,public ,heal? ,s]vice

 ,act71  subject to ! requirem5ts (     
section #gjb7;b7 relat+ to contribution 
rates4  7#c7 ,floor = numb] ( cov]$     
individuals ) respect to c]ta9 plans ,if
 any b5efit option "u ! plan does n     
consi/ ( heal? insurance cov]age1 ! plan
 has z ( ! beg9n+ ( ! plan ye> n few]   
?an #a1jjj p>ticipants & b5efici>ies4   
7#d7 ,m>ket+ requirem5ts  7,a7 ,9 g5]al 
,if a b5efit option :i* consi/s ( heal? 
insurance cov]age is (f]$ "u ! plan1    
,/ate-lic5s$ insurance ag5ts %all be us$
 to di/ribute to small employ]s cov]age 
:i* does n consi/ ( heal? insurance     
cov]age 9 a mann] comp>able to ! mann] 9
 :i* su* ag5ts are us$ to di/ribute     
heal? insurance cov]age4  7,b7          
,/ate-lic5s$ insurance ag5ts ,= purposes
 ( subp>agraph 7,a71 ! t]m ,/ate-lic5s$ 
insurance ag5ts means "o or m ag5ts :o  
are lic5s$ 9 a ,/ate & are subject to ! 
laws ( su* ,/ate relat+ to lic5sure1    
qualification1 te/+1 exam9ation1 &      
cont9u+ education ( p]sons au?oriz$ to  
(f]1 sell1 or solicit heal? insurance   

cov]age 9 su* ,/ate4  7#e7 ,regulatory  
requirem5ts ,su* o!r requirem5ts z !    
applicable au?ority det]m9es are        
necess>y to c>ry out ! purposes ( ?is   
"p1 :i* %all be prescrib$ by !          
applicable au?ority by regulation4  7b7 
,ability ( ,association ,heal? ,plans   
,to ,design ,b5efit ,options ,subject to
 section #ead7;d71 no?+ 9 ?is "p or any 
provision ( ,/ate law 7z def9$ 9 section
 #ead7;c77#a77 %all be con/ru$ to       
preclude an association heal? plan1 or a
 heal? insurance issu] (f]+ heal?       
insurance cov]age 9 connection ) an     
association heal? plan1 f ex]cis+ its   
sole discretion 9 select+ ! specific    
items & s]vices consi/+ ( m$ical c>e to 
be includ$ z b5efits "u su* plan or     
cov]age1 except 7subject to section     
#ead7 9 ! case ( 7#a7 any law to ! ext5t
 t x is n preempt$ "u section           
#gca7;a77#a7 ) respect to matt]s gov]n$ 
by section #gaa1 #gab1 or #gac1 or 7#b7 
any law ( ! ,/ate ) :i* fil+ & approval 
( a policy type (f]$ by ! plan 0        

initially obta9$ to ! ext5t t su* law   
prohibits an exclusion ( a specific     
disease f su* cov]age4  #hjf4 ,ma9t5ance
 ( res]ves & provisions = solv5cy =     
plans provid+ heal? b5efits 9 addition  
to heal? insurance cov]age  7a7 ,9      
,g5]al ,! requirem5ts ( ?is section are 
met ) respect to an association heal?   
plan if--  7#a7 ! b5efits "u ! plan     
consi/ solely ( heal? insurance cov]age2
 or  7#b7 if ! plan provides any        
additional b5efit options :i* d n consi/
 ( heal? insurance cov]age1 ! plan--    
7,a7 e/abli%es & ma9ta9s res]ves )      
respect to su* additional b5efit        
options1 9 am\nts recomm5d$ by !        
qualifi$ heal? actu>y1 consi/+ (--  7i7 
a res]ve suffici5t = une>n$             
contributions2  7ii7 a res]ve suffici5t 
= b5efit liabilities :i* h be5 incurr$1 
:i* h n be5 satisfi$1 & = :i* risk (    
loss has n yet be5 transf]r$1 & =       
expect$ adm9i/rative co/s ) respect to  
su* b5efit liabilities2  7iii7 a res]ve 
suffici5t = any o!r obligations ( !     

plan2 &  7iv7 a res]ve suffici5t = a    
m>g9 ( error & o!r fluctuations1 tak+   
into acc\nt ! specific circum/ances ( ! 
plan2 &  7,b7 e/abli%es & ma9ta9s       
aggregate & specific excess_//op loss   
insurance & solv5cy indemnification1 )  
respect to su* additional b5efit options
 = :i* risk ( loss has n yet be5        
transf]r$1 z foll[s3  7i7 ,! plan %all  
secure aggregate excess_//op loss       
insurance = ! plan ) an atta*m5t po9t   
:i* is n great] ?an #abe p]c5t ( expect$
 gross annual claims4 ,! applicable     
au?ority may by regulation provide =    
upw>d adju/m5ts 9 ! am\nt ( su* p]c5tage
 9 specifi$ circum/ances 9 :i* ! plan   
specifically provides = & ma9ta9s       
res]ves 9 excess ( ! am\nts requir$ "u  
subp>agraph 7,a74  7ii7 ,! plan %all    
secure specific excess_//op loss        
insurance = ! plan ) an atta*m5t po9t   
:i* is at lea/ equal to an am\nt        
recomm5d$ by ! plan's qualifi$ heal?    
actu>y4 ,! applicable au?ority may by   
regulation provide = adju/m5ts 9 ! am\nt

 ( su* insurance 9 specifi$ circum/ances
 9 :i* ! plan specifically provides = & 
ma9ta9s res]ves 9 excess ( ! am\nts     
requir$ "u subp>agraph 7,a74  7iii7 ,!  
plan %all secure indemnification        
insurance = any claims :i* ! plan is    
unable to satisfy by reason ( a plan    
t]m9ation4  ,any p]son issu+ to a plan  
insurance describ$ 9 clause 7i71 7ii71  
or 7iii7 ( subp>agraph 7,b7 %all notify 
! ,secret>y ( any failure ( premium     
paym5t m]it+ cancellation ( ! policy    
prior to und]tak+ su* a cancellation4   
,any regulations prescrib$ by !         
applicable au?ority pursuant to clause  
7i7 or 7ii7 ( subp>agraph 7,b7 may all[ 
= su* adju/m5ts 9 ! requir$ levels (    
excess_//op loss insurance z ! qualifi$ 
heal? actu>y may recomm5d1 tak+ into    
acc\nt ! specific circum/ances ( ! plan4
  7b7 ,m9imum ,surplus 9 ,addition to   
,claims ,res]ves ,9 ! case ( any        
association heal? plan describ$ 9       
subsection 7a77#b71 ! requirem5ts ( ?is 
subsection are met if ! plan e/abli%es &

 ma9ta9s surplus 9 an am\nt at lea/     
equal to--  7#a7 #ejj1jjj1 or  7#b7 su* 
great] am\nt 7b n great] ?an #b1jjj1jjj7
 z may be set =? 9 regulations prescrib$
 by ! applicable au?ority1 consid]+ !   
level ( aggregate & specific excess_//op
 loss insurance provid$ ) respect to su*
 plan & o!r factors relat$ to solv5cy   
risk1 su* z ! plan's project$ levels (  
p>ticipation or claims1 ! nature ( !    
plan's liabilities1 & ! types ( assets  
available to assure t su* liabilities   
are met4  7c7 ,additional ,requirem5ts  
,9 ! case ( any association heal? plan  
describ$ 9 subsection 7a77#b71 !        
applicable au?ority may provide su*     
additional requirem5ts relat+ to        
res]ves1 excess_//op loss insurance1 &  
indemnification insurance z ! applicable
 au?ority consid]s appropriate4 ,su*    
requirem5ts may be provid$ by regulation
 ) respect to any su* plan or any class 
( su* plans4  7d7 ,adju/m5ts =          
,excess_/,/op ,loss ,insurance ,!       
applicable au?ority may provide =       

adju/m5ts to ! levels ( res]ves o!rwise 
requir$ "u subsections 7a7 & 7b7 )      
respect to any plan or class ( plans to 
take into acc\nt excess_//op loss       
insurance provid$ ) respect to su* plan 
or plans4  7e7 ,alt]native ,means (     
,compliance ,! applicable au?ority may  
p]mit an association heal? plan describ$
 9 subsection 7a77#b7 to sub/itute1 =   
all or "p ( ! requirem5ts ( ?is section 
7except subsection 7a77#b77;,b77iii771  
su* security1 gu>antee1 hold-h>mless    
arrangem5t1 or o!r f9ancial arrangem5t z
 ! applicable au?ority det]m9es to be   
adequate to enable ! plan to fully meet 
all its f9ancial obligations on a timely
 basis & is o!rwise no less protective (
 ! int]e/s ( p>ticipants & b5efici>ies  
?an ! requirem5ts = :i* x is sub/itut$4 
,! applicable au?ority may take into    
acc\nt1 = purposes ( ?is subsection1    
evid5ce provid$ by ! plan or sponsor :i*
 demon/rates an assumption ( liability )
 respect to ! plan4 ,su* evid5ce may be 
9 ! =m ( a contract ( indemnification1  

li51 bond+1 insurance1 lett] ( cr$it1   
rec\rse "u applicable t]ms ( ! plan 9 ! 
=m ( assessm5ts ( p>ticipat+ employ]s1  
security1 or o!r f9ancial arrangem5t4   
7f7 ,measures ,to ,ensure ,cont9u$      
,paym5t ( ,b5efits by ,c]ta9 ,plans 9   
,di/ress  7#a7 ,paym5ts by c]ta9 plans  
to association heal? plan fund  7,a7 ,9 
g5]al ,9 ! case ( an association heal?  
plan describ$ 9 subsection 7a77#b71 !   
requirem5ts ( ?is subsection are met if 
! plan makes paym5ts into ! ,association
 ,heal? ,plan ,fund "u ?is subp>agraph  
:5 !y are due4 ,su* paym5ts %all consi/ 
( annual paym5ts 9 ! am\nt ( #e1jjj1 &1 
9 addition to su* annual paym5ts1 su*   
supplem5tal paym5ts z ! ,secret>y may   
det]m9e to be necess>y "u p>agraph 7#b74
 ,paym5ts "u ?is p>agraph are payable to
 ! ,fund at ! "t det]m9$ by ! ,secret>y4
 ,initial paym5ts are due 9 advance (   
c]tification "u ?is "p4 ,paym5ts %all   
cont9ue to accrue until a plan's assets 
are di/ribut$ pursuant to a t]m9ation   
proc$ure4  7,b7 ,p5alties = failure to  

make paym5ts ,if any paym5t is n made by
 a plan :5 x is due1 a late paym5t *>ge 
( n m ?an #ajj p]c5t ( ! paym5t :i* 0 n 
timely paid %all be payable by ! plan to
 ! ,fund4  7,c7 ,cont9u$ duty ( !       
secret>y ,! ,secret>y %all n cease to   
c>ry out ! provisions ( p>agraph 7#b7 on
 acc\nt ( ! failure ( a plan to pay any 
paym5t :5 due4  7#b7 ,paym5ts by        
secret>y to cont9ue excess_//op loss    
insurance cov]age & indemnification     
insurance cov]age = c]ta9 plans ,9 any  
case 9 :i* ! applicable au?ority        
det]m9es t !re is1 or t !re is reason to
 believe t !re w be3 7,a7 a failure to  
take necess>y corrective actions "u     
section #hji7;a7 ) respect to an        
association heal? plan describ$ 9       
subsection 7a77#b72 or 7,b7 a t]m9ation 
( su* a plan "u section #hji7;b7 or     
#haj7;b77#h7 7&1 if ! applicable        
au?ority is n ! ,secret>y1 c]tifies su* 
det]m9ation to ! ,secret>y71 ! ,secret>y
 %all det]m9e ! am\nts necess>y to make 
paym5ts to an insur] 7designat$ by !    

,secret>y7 to ma9ta9 9 =ce excess_//op  
loss insurance cov]age or               
indemnification insurance cov]age = su* 
plan1 if ! ,secret>y det]m9es t !re is a
 reasonable expectation t1 )\t su*      
paym5ts1 claims w\ld n be satisfi$ by   
reason ( t]m9ation ( su* cov]age4 ,!    
,secret>y %all1 to ! ext5t provid$ 9    
advance 9 appropriation ,acts1 pay su*  
am\nts s det]m9$ to ! insur] designat$  
by ! ,secret>y4  7#c7 ,association heal?
 plan fund  7,a7 ,9 g5]al ,!re is       
e/abli%$ on ! books ( ! ,treasury a fund
 to be kn[n z ! ,association ,heal?     
,plan ,fund4 ,! ,fund %all be available 
= mak+ paym5ts pursuant to p>agraph     
7#b74 ,! ,fund %all be cr$it$ ) paym5ts 
receiv$ pursuant to p>agraph 7#a77;,a71 
p5alties receiv$ pursuant to p>agraph   
7#a77;,b71 & e>n+s on inve/m5ts ( am\nts
 ( ! ,fund "u subp>agraph 7,b74  7,b7   
,inve/m5t ,:5ev] ! ,secret>y det]m9es t 
! moneys ( ! fund are 9 excess ( curr5t 
ne$s1 ! ,secret>y may reque/ ! inve/m5t 
( su* am\nts z ! ,secret>y det]m9es     

advisable by ! ,secret>y ( ! ,treasury 9
 obligations issu$ or gu>ante$ by !     
,unit$ ,/ates4  7g7 ,excess_/,/op ,loss 
,insurance ,= purposes ( ?is section--  
7#a7 ,aggregate excess_//op loss        
insurance ,! t]m aggregate excess_//op  
loss insurance means1 9 connection ) an 
association heal? plan1 a contract--    
7,a7 "u :i* an insur] 7meet+ su* m9imum 
/&>ds z ! applicable au?ority may       
prescribe by regulation7 provides =     
paym5t to ! plan ) respect to aggregate 
claims "u ! plan 9 excess ( an am\nt or 
am\nts specifi$ 9 su* contract2  7,b7   
:i* is gu>ante$ r5ewable2 &  7,c7 :i*   
all[s = paym5t ( premiums by any ?ird   
p>ty on behalf ( ! insur$ plan4  7#b7   
,specific excess_//op loss insurance ,! 
t]m specific excess_//op loss insurance 
means1 9 connection ) an association    
heal? plan1 a contract--  7,a7 "u :i* an
 insur] 7meet+ su* m9imum /&>ds z !     
applicable au?ority may prescribe by    
regulation7 provides = paym5t to ! plan 
) respect to claims "u ! plan 9         

connection ) a cov]$ individual 9 excess
 ( an am\nt or am\nts specifi$ 9 su*    
contract 9 connection ) su* cov]$       
individual2  7,b7 :i* is gu>ante$       
r5ewable2 &  7,c7 :i* all[s = paym5t (  
premiums by any ?ird p>ty on behalf ( ! 
insur$ plan4  7h7 ,indemnification      
,insurance ,= purposes ( ?is section1 ! 
t]m indemnification insurance means1 9  
connection ) an association heal? plan1 
a contract--  7#a7 "u :i* an insur]     
7meet+ su* m9imum /&>ds z ! applicable  
au?ority may prescribe by regulation7   
provides = paym5t to ! plan ) respect to
 claims "u ! plan :i* ! plan is unable  
to satisfy by reason ( a t]m9ation      
pursuant to section #hji7;b7 7relat+ to 
m&atory t]m9ation72  7#b7 :i* is        
gu>ante$ r5ewable & noncancellable = any
 reason 7except z ! applicable au?ority 
may prescribe by regulation72 &  7#c7   
:i* all[s = paym5t ( premiums by any    
?ird p>ty on behalf ( ! insur$ plan4    
7i7 ,res]ves ,= purposes ( ?is section1 
! t]m res]ves means1 9 connection ) an  

association heal? plan1 plan assets :i* 
meet ! fiduci>y /&>ds "u "p #d & su*    
additional requirem5ts reg>d+ liquidity 
z ! applicable au?ority may prescribe by
 regulation4  7j7 ,solv5cy ,/&>ds ,work+
 ,gr\p  7#a7 ,9 g5]al ,)9 #ij days aft] 
! date ( ! enactm5t ( ! ,small ,bus9ess 
,heal? ,fairness ,act ( #bjac1 !        
applicable au?ority %all e/abli% a      
,solv5cy ,/&>ds ,work+ ,gr\p4 ,9        
prescrib+ ! initial regulations "u ?is  
section1 ! applicable au?ority %all take
 into acc\nt ! recomm5dations ( su*     
,work+ ,gr\p4  7#b7 ,memb]%ip ,! ,work+ 
,gr\p %all consi/ ( n m ?an #ae memb]s  
appo9t$ by ! applicable au?ority4 ,!    
applicable au?ority %all include among  
p]sons invit$ to memb]%ip on ! ,work+   
,gr\p at lea/ "o ( ea* ( ! foll[+3  7,a7
 ,a repres5tative ( ! ,national         
,association ( ,insurance ,commission]s4
  7,b7 ,a repres5tative ( ! ,am]ican    
,academy ( ,actu>ies4  7,c7 ,a          
repres5tative ( ! ,/ate gov]nm5ts1 or _!
 int]e/s4  7,d7 ,a repres5tative ( exi/+

 self-insur$ arrangem5ts1 or _! int]e/s4
  7,e7 ,a repres5tative ( associations (
 ! type ref]r$ to 9 section             
#hja7;b77#a71 or _! int]e/s4  7,f7 ,a   
repres5tative ( multiemploy] plans t are
 gr\p heal? plans1 or _! int]e/s4  #hjg4
 ,requirem5ts = application & relat$    
requirem5ts  7a7 ,fil+ ,fee ,"u !       
proc$ure prescrib$ pursuant to section  
#hjb7;a71 an association heal? plan %all
 pay to ! applicable au?ority at ! "t ( 
fil+ an application = c]tification "u   
?is "p a fil+ fee 9 ! am\nt ( #e1jjj1   
:i* %all be available 9 ! case ( !      
,secret>y1 to ! ext5t provid$ 9         
appropriation ,acts1 = ! sole purpose ( 
adm9i/]+ ! c]tification proc$ures       
applicable ) respect to association     
heal? plans4  7b7 ,in=mation ,to ,be    
,includ$ 9 ,application = ,c]tification 
,an application = c]tification "u ?is "p
 meets ! requirem5ts ( ?is section only 
if x includes1 9 a mann] & =m :i* %all  
be prescrib$ by ! applicable au?ority by
 regulation1 at lea/ ! foll[+ in=mation3

  7#a7 ,id5tify+ in=mation ,! names &   
addresses (--  7,a7 ! sponsor2 &  7,b7 !
 memb]s ( ! bo>d ( tru/ees ( ! plan4    
7#b7 ,/ates 9 :i* plan int5ds to d      
bus9ess ,! ,/ates 9 :i* p>ticipants &   
b5efici>ies "u ! plan are to be locat$ &
 ! numb] ( !m expect$ to be locat$ 9 ea*
 su* ,/ate4  7#c7 ,bond+ requirem5ts    
,evid5ce provid$ by ! bo>d ( tru/ees t !
 bond+ requirem5ts ( section #dab w be  
met z ( ! date ( ! application or 7if   
lat]7 comm5cem5t ( op]ations4  7#d7     
,plan docum5ts ,a copy ( ! docum5ts     
gov]n+ ! plan 7includ+ any bylaws & tru/
 agreem5ts71 ! summ>y plan description1 
& o!r mat]ial describ+ ! b5efits t w be 
provid$ to p>ticipants & b5efici>ies "u 
! plan4  7#e7 ,agreem5ts ) s]vice       
provid]s ,a copy ( any agreem5ts betwe5 
! plan & contract adm9i/rators & o!r    
s]vice provid]s4  7#f7 ,fund+ report ,9 
! case ( association heal? plans provid+
 b5efits options 9 addition to heal?    
insurance cov]age1 a report sett+ =?    
in=mation ) respect to su* additional   

b5efit options det]m9$ z ( a date )9 !  
#abj-;day p]iod end+ ) ! date ( !       
application1 includ+ ! foll[+3  7,a7    
,res]ves ,a /atem5t1 c]tifi$ by ! bo>d (
 tru/ees ( ! plan1 & a /atem5t (        
actu>ial op9ion1 sign$ by a qualifi$    
heal? actu>y1 t all applicable          
requirem5ts ( section #hjf are or w be  
met 9 accordance ) regulations :i* !    
applicable au?ority %all prescribe4     
7,b7 ,adequacy ( contribution rates ,a  
/atem5t ( actu>ial op9ion1 sign$ by a   
qualifi$ heal? actu>y1 :i* sets =? a    
description ( ! ext5t to :i*            
contribution rates are adequate to      
provide = ! paym5t ( all obligations & !
 ma9t5ance ( requir$ res]ves "u ! plan =
 ! #ab-mon? p]iod beg9n+ ) su* date )9  
su* #abj-;day p]iod1 tak+ into acc\nt ! 
expect$ cov]age & exp]i5ce ( ! plan4 ,if
 ! contribution rates are n fully       
adequate1 ! /atem5t ( actu>ial op9ion   
%all indicate ! ext5t to :i* ! rates are
 inadequate & ! *anges ne$$ to ensure   
adequacy4  7,c7 ,curr5t & project$ value

 ( assets & liabilities ,a /atem5t (    
actu>ial op9ion sign$ by a qualifi$     
heal? actu>y1 :i* sets =? ! curr5t value
 ( ! assets & liabilities accumulat$ "u 
! plan & a projection ( ! assets1       
liabilities1 income1 & exp5ses ( ! plan 
= ! #ab-mon? p]iod ref]r$ to 9          
subp>agraph 7,b74 ,! income /atem5t %all
 id5tify sep>ately ! plan's adm9i/rative
 exp5ses & claims4  7,d7 ,co/s ( cov]age
 to be *>g$ & o!r exp5ses ,a /atem5t ( !
 co/s ( cov]age to be *>g$1 includ+ an  
itemization ( am\nts = adm9i/ration1    
res]ves1 & o!r exp5ses associat$ ) !    
op]ation ( ! plan4  7,e7 ,o!r in=mation 
,any o!r in=mation z may be det]m9$ by !
 applicable au?ority1 by regulation1 z  
necess>y to c>ry out ! purposes ( ?is   
"p4  7c7 ,fil+ ,notice ( ,c]tification  
,) ,/ates ,a c]tification grant$ "u ?is 
"p to an association heal? plan %all n  
be effective unless writt5 notice ( su* 
c]tification is fil$ ) ! applicable     
,/ate au?ority ( ea* ,/ate 9 :i* at lea/
 #be p]c5t ( ! p>ticipants & b5efici>ies

 "u ! plan are locat$4 ,= purposes ( ?is
 subsection1 an individual %all be      
consid]$ to be locat$ 9 ! ,/ate 9 :i* a 
kn[n address ( su* individual is locat$ 
or 9 :i* su* individual is employ$4  7d7
 ,notice ( ,mat]ial ,*anges ,9 ! case ( 
any association heal? plan c]tifi$ "u   
?is "p1 descriptions ( mat]ial *anges 9 
any in=mation :i* 0 requir$ to be       
submitt$ ) ! application = !            
c]tification "u ?is "p %all be fil$ 9   
su* =m & mann] z %all be prescrib$ by ! 
applicable au?ority by regulation4 ,!   
applicable au?ority may require by      
regulation prior notice ( mat]ial *anges
 ) respect to specifi$ matt]s :i* might 
s]ve z ! basis = susp5sion or revocation
 ( ! c]tification4  7e7 ,report+        
,requirem5ts = ,c]ta9 ,association      
,heal? ,plans ,an association heal? plan
 c]tifi$ "u ?is "p :i* provides b5efit  
options 9 addition to heal? insurance   
cov]age = su* plan ye> %all meet !      
requirem5ts ( section #ajc by fil+ an   
annual report "u su* section :i* %all   

include in=mation describ$ 9 subsection 
7b77#f7 ) respect to ! plan ye> &1      
not)/&+ section #ajd7;a77#a77;,a71 %all 
be fil$ ) ! applicable au?ority n lat]  
?an #ij days aft] ! close ( ! plan ye>  
7or on su* lat] date z may be prescrib$ 
by ! applicable au?ority74 ,! applicable
 au?ority may require by regulation su* 
int]im reports z x consid]s appropriate4
  7f7 ,engagem5t ( ,qualifi$ ,heal?     
,actu>y ,! bo>d ( tru/ees ( ea*         
association heal? plan :i* provides     
b5efits options 9 addition to heal?     
insurance cov]age & :i* is apply+ =     
c]tification "u ?is "p or is c]tifi$ "u 
?is "p %all engage1 on behalf ( all     
p>ticipants & b5efici>ies1 a qualifi$   
heal? actu>y :o %all be responsible = ! 
prep>ation ( ! mat]ials compris+        
in=mation necess>y to be submitt$ by a  
qualifi$ heal? actu>y "u ?is "p4 ,!     
qualifi$ heal? actu>y %all utilize su*  
assumptions & te*niques z are necess>y  
to enable su* actu>y to =m an op9ion z  
to :e!r ! cont5ts ( ! matt]s report$ "u 

?is "p--  7#a7 are 9 ! aggregate        
reasonably relat$ to ! exp]i5ce ( ! plan
 & to reasonable expectations2 &  7#b7  
repres5t su* actu>y's be/ e/imate (     
anticipat$ exp]i5ce "u ! plan4  ,!      
op9ion by ! qualifi$ heal? actu>y %all  
be made ) respect to1 & %all be made a  
"p (1 ! annual report4  #hjh4 ,notice   
requirem5ts = volunt>y t]m9ation ,except
 z provid$ 9 section #hji7;b71 an       
association heal? plan :i* is or has be5
 c]tifi$ "u ?is "p may t]m9ate 7^u or at
 any "t aft] cessation ( accruals 9     
b5efit liabilities7 only if ! bo>d (    
tru/ees1 n less ?an #fj days be=e !     
propos$ t]m9ation date--  7#a7 provides 
to ! p>ticipants & b5efici>ies a writt5 
notice ( int5t to t]m9ate /at+ t su*    
t]m9ation is int5d$ & ! propos$         
t]m9ation date2  7#b7 develops a plan = 
w9d+ up ! affairs ( ! plan 9 connection 
) su* t]m9ation 9 a mann] :i* w result 9
 timely paym5t ( all b5efits = :i* !    
plan is obligat$2 &  7#c7 submits su*   
plan 9 writ+ to ! applicable au?ority4  

,actions requir$ "u ?is section %all be 
tak5 9 su* =m & mann] z may be prescrib$
 by ! applicable au?ority by regulation4
  #hji4 ,corrective actions & m&atory   
t]m9ation  7a7 ,actions ,to ,avoid      
,depletion ( ,res]ves ,an association   
heal? plan :i* is c]tifi$ "u ?is "p &   
:i* provides b5efits o!r ?an heal?      
insurance cov]age %all cont9ue to meet !
 requirem5ts ( section #hjf1            
irrespective ( :e!r su* c]tification    
cont9ues 9 effect4 ,! bo>d ( tru/ees (  
su* plan %all det]m9e qu>t]ly :e!r !    
requirem5ts ( section #hjf are met4 ,9  
any case 9 :i* ! bo>d det]m9es t !re is 
reason to believe t !re is or w be a    
failure to meet su* requirem5ts1 or !   
applicable au?ority makes su* a         
det]m9ation & s notifies ! bo>d1 ! bo>d 
%all imm$iately notify ! qualifi$ heal? 
actu>y engag$ by ! plan1 & su* actu>y   
%all1 n lat] ?an ! end ( ! next foll[+  
mon?1 make su* recomm5dations to ! bo>d 
= corrective action z ! actu>y det]m9es 
necess>y to ensure compliance ) section 

#hjf4 ,n lat] ?an #cj days aft] receiv+ 
f ! actu>y recomm5dations = corrective  
actions1 ! bo>d %all notify ! applicable
 au?ority 79 su* =m & mann] z !         
applicable au?ority may prescribe by    
regulation7 ( su* recomm5dations ( !    
actu>y = corrective action1 toge!r ) a  
description ( ! actions 7if any7 t !    
bo>d has tak5 or plans to take 9        
response to su* recomm5dations4 ,! bo>d 
%all !reaft] report to ! applicable     
au?ority1 9 su* =m & frequ5cy z !       
applicable au?ority may specify to !    
bo>d1 reg>d+ corrective action tak5 by !
 bo>d until ! requirem5ts ( section #hjf
 are met4  7b7 ,m&atory ,t]m9ation ,9   
any case 9 :i*--  7#a7 ! applicable     
au?ority has be5 notifi$ "u subsection  
7a7 7or by an issu] ( excess_//op loss  
insurance or indemnity insurance        
pursuant to section #hjf7;a77 ( a       
failure ( an association heal? plan :i* 
is or has be5 c]tifi$ "u ?is "p & is    
describ$ 9 section #hjf7;a77#b7 to meet 
! requirem5ts ( section #hjf & has n be5

 notifi$ by ! bo>d ( tru/ees ( ! plan t 
corrective action has re/or$ compliance 
) su* requirem5ts2 &  7#b7 ! applicable 
au?ority det]m9es t !re is a reasonable 
expectation t ! plan w cont9ue to fail  
to meet ! requirem5ts ( section #hjf1  !
 bo>d ( tru/ees ( ! plan %all1 at !     
direction ( ! applicable au?ority1      
t]m9ate ! plan &1 9 ! c\rse ( !         
t]m9ation1 take su* actions z !         
applicable au?ority may require1 includ+
 satisfy+ any claims ref]r$ to 9 section
 #hjf7;a77#b77;,b77iii7 & recov]+ = !   
plan any liability "u subsection        
7a77#b77;,b77iii7 or 7e7 ( section #hjf1
 z necess>y to ensure t ! affairs ( !   
plan w be1 to ! maximum ext5t possible1 
w\nd up 9 a mann] :i* w result 9 timely 
provision ( all b5efits = :i* ! plan is 
obligat$4  #haj4 ,tru/ee%ip by !        
,secret>y ( insolv5t association heal?  
plans provid+ heal? b5efits 9 addition  
to heal? insurance cov]age  7a7         
,appo9tm5t ( ,secret>y z ,tru/ee =      
,insolv5t ,plans ,:5ev] ! ,secret>y     

det]m9es t an association heal? plan :i*
 is or has be5 c]tifi$ "u ?is "p & :i*  
is describ$ 9 section #hjf7;a77#b7 w be 
unable to provide b5efits :5 due or is  
o!rwise 9 a f9ancially haz>d\s          
condition1 z %all be def9$ by !         
,secret>y by regulation1 ! ,secret>y    
%all1 ^u notice to ! plan1 apply to !   
appropriate ,unit$ ,/ates di/rict c\rt =
 appo9tm5t ( ! ,secret>y z tru/ee to    
adm9i/] ! plan = ! duration ( !         
insolv5cy4 ,! plan may appe> z a p>ty & 
o!r int]e/$ p]sons may int]v5e 9 !      
proce$+s at ! discretion ( ! c\rt4 ,!   
c\rt %all appo9t su* ,secret>y tru/ee if
 ! c\rt det]m9es t ! tru/ee%ip is       
necess>y to protect ! int]e/s ( !       
p>ticipants & b5efici>ies or provid]s ( 
m$ical c>e or to avoid any unreasonable 
det]ioration ( ! f9ancial condition ( ! 
plan4 ,! tru/ee%ip ( su* ,secret>y %all 
cont9ue until ! conditions describ$ 9 ! 
fir/ s5t5ce ( ?is subsection are rem$i$ 
or ! plan is t]m9at$4  7b7 ,p[]s z      
,tru/ee ,! ,secret>y1 ^u appo9tm5t z    

tru/ee "u subsection 7a71 %all h ! p[]--
  7#a7 to d any act au?oriz$ by ! plan1 
?is title1 or o!r applicable provisions 
( law to be done by ! plan adm9i/rator  
or any tru/ee ( ! plan2  7#b7 to require
 ! transf] ( all 7or any "p7 ( ! assets 
& records ( ! plan to ! ,secret>y z     
tru/ee2  7#c7 to inve/ any assets ( !   
plan :i* ! ,secret>y holds 9 accordance 
) ! provisions ( ! plan1 regulations    
prescrib$ by ! ,secret>y1 & applicable  
provisions ( law2  7#d7 to require !    
sponsor1 ! plan adm9i/rator1 any        
p>ticipat+ employ]1 & any employee      
organization repres5t+ plan p>ticipants 
to furni% any in=mation ) respect to !  
plan :i* ! ,secret>y z tru/ee may       
reasonably ne$ 9 ord] to adm9i/] ! plan2
  7#e7 to collect = ! plan any am\nts   
due ! plan & to recov] reasonable       
exp5ses ( ! tru/ee%ip2  7#f7 to comm5ce1
 prosecute1 or def5d on behalf ( ! plan 
any suit or proce$+ involv+ ! plan2     
7#g7 to issue1 publi%1 or file su*      
notices1 /atem5ts1 & reports z may be   

requir$ by ! ,secret>y by regulation or 
requir$ by any ord] ( ! c\rt2  7#h7 to  
t]m9ate ! plan 7or provide = its        
t]m9ation 9 accordance ) section        
#hji7;b77 & liquidate ! plan assets1 to 
re/ore ! plan to ! responsibility ( !   
sponsor1 or to cont9ue ! tru/ee%ip2     
7#i7 to provide = ! enrollm5t ( plan    
p>ticipants & b5efici>ies "u appropriate
 cov]age options2 &  7#aj7 to d su* o!r 
acts z may be necess>y to comply ) ?is  
title or any ord] ( ! c\rt & to protect 
! int]e/s ( plan p>ticipants &          
b5efici>ies & provid]s ( m$ical c>e4    
7c7 ,notice ( ,appo9tm5t ,z soon z      
practicable aft] ! ,secret>y's appo9tm5t
 z tru/ee1 ! ,secret>y %all give notice 
( su* appo9tm5t to--  7#a7 ! sponsor &  
plan adm9i/rator2  7#b7 ea* p>ticipant2 
7#c7 ea* p>ticipat+ employ]2 &  7#d7 if 
applicable1 ea* employee organization   
:i*1 = purposes ( collective b>ga9+1    
repres5ts plan p>ticipants4  7d7        
,additional ,duties ,except to ! ext5t  
inconsi/5t ) ! provisions ( ?is title1  

or z may be o!rwise ord]$ by ! c\rt1 !  
,secret>y1 ^u appo9tm5t z tru/ee "u ?is 
section1 %all be subject to ! same      
duties z ^? ( a tru/ee "u section #gjd (
 title #aa1 ,unit$ ,/ates ,code1 & %all 
h ! duties ( a fiduci>y = purposes ( ?is
 title4  7e7 ,o!r ,proce$+s ,an         
application by ! ,secret>y "u ?is       
subsection may be fil$ not)/&+ ! p5d5cy 
9 ! same or any o!r c\rt ( any          
bankruptcy1 mortgage =eclosure1 or      
equity receiv]%ip proce$+1 or any       
proce$+ to reorganize1 cons]ve1 or      
liquidate su* plan or its prop]ty1 or   
any proce$+ to en=ce a li5 aga9/ prop]ty
 ( ! plan4  7f7 ,jurisdiction ( ,c\rt   
7#a7 ,9 g5]al ,^u ! fil+ ( an           
application = ! appo9tm5t z tru/ee or ! 
issuance ( a decree "u ?is section1 !   
c\rt to :i* ! application is made %all h
 exclusive jurisdiction ( ! plan involv$
 & its prop]ty :]ev] locat$ ) ! p[]s1 to
 ! ext5t consi/5t ) ! purposes ( ?is    
section1 ( a c\rt ( ! ,unit$ ,/ates hav+
 jurisdiction ov] cases "u *apt] #aa (  

title #aa1 ,unit$ ,/ates ,code4 ,p5d+ an
 adjudication "u ?is section su* c\rt   
%all /ay1 & ^u appo9tm5t by x ( !       
,secret>y z tru/ee1 su* c\rt %all       
cont9ue ! /ay (1 any p5d+ mortgage      
=eclosure1 equity receiv]%ip1 or o!r    
proce$+ to reorganize1 cons]ve1 or      
liquidate ! plan1 ! sponsor1 or prop]ty 
( su* plan or sponsor1 & any o!r suit   
aga9/ any receiv]1 cons]vator1 or tru/ee
 ( ! plan1 ! sponsor1 or prop]ty ( !    
plan or sponsor4 ,p5d+ su* adjudication 
& ^u ! appo9tm5t by x ( ! ,secret>y z   
tru/ee1 ! c\rt may /ay any proce$+ to   
en=ce a li5 aga9/ prop]ty ( ! plan or ! 
sponsor or any o!r suit aga9/ ! plan or 
! sponsor4  7#b7 ,v5ue ,an action "u ?is
 section may be br\ght 9 ! judicial     
di/rict :]e ! sponsor or ! plan         
adm9i/rator resides or does bus9ess or  
:]e any asset ( ! plan is situat$4 ,a   
di/rict c\rt 9 :i* su* action is br\ght 
may issue process ) respect to su*      
action 9 any o!r judicial di/rict4  7g7 
,p]sonnel ,9 accordance ) regulations   

:i* %all be prescrib$ by ! ,secret>y1 ! 
,secret>y %all appo9t1 reta91 &         
comp5sate acc\ntants1 actu>ies1 & o!r   
pr(essional s]vice p]sonnel z may be    
necess>y 9 connection ) ! ,secret>y's   
s]vice z tru/ee "u ?is section4  #haa4  
,/ate assessm5t au?ority  7a7 ,9 ,g5]al 
,not)/&+ section #ead1 a ,/ate may      
impose by law a contribution tax on an  
association heal? plan describ$ 9       
section #hjf7;a77#b71 if ! plan comm5c$ 
op]ations 9 su* ,/ate aft] ! date ( !   
enactm5t ( ! ,small ,bus9ess ,heal?     
,fairness ,act ( #bjac4  7b7            
,contribution ,tax ,= purposes ( ?is    
section1 ! t]m contribution tax impos$  
by a ,/ate on an association heal? plan 
means any tax impos$ by su* ,/ate if--  
7#a7 su* tax is comput$ by apply+ a rate
 to ! am\nt ( premiums or contributions1
 ) respect to individuals cov]$ "u !    
plan :o are resid5ts ( su* ,/ate1 :i*   
are receiv$ by ! plan f p>ticipat+      
employ]s locat$ 9 su* ,/ate or f su*    
individuals2  7#b7 ! rate ( su* tax does

 n exce$ ! rate ( any tax impos$ by su* 
,/ate on premiums or contributions      
receiv$ by insur]s or heal? ma9t5ance   
organizations = heal? insurance cov]age 
(f]$ 9 su* ,/ate 9 connection ) a gr\p  
heal? plan2  7#c7 su* tax is o!rwise    
nondiscrim9atory2 &  7#d7 ! am\nt ( any 
su* tax assess$ on ! plan is r$uc$ by ! 
am\nt ( any tax or assessm5t o!rwise    
impos$ by ! ,/ate on premiums1          
contributions1 or bo? receiv$ by insur]s
 or heal? ma9t5ance organizations =     
heal? insurance cov]age1 aggregate      
excess_//op loss insurance 7z def9$ 9   
section #hjf7;g77#a771 specific         
excess_//op loss insurance 7z def9$ 9   
section #hjf7;g77#b771 o!r insurance    
relat$ to ! provision ( m$ical c>e "u ! 
plan1 or any comb9ation !re( provid$ by 
su* insur]s or heal? ma9t5ance          
organizations 9 su* ,/ate 9 connection )
 su* plan4  #hab4 ,def9itions & rules ( 
con/ruction  7a7 ,def9itions ,= purposes
 ( ?is "p--  7#a7 ,gr\p heal? plan ,!   
t]m gr\p heal? plan has ! mean+ provid$ 

9 section #gcc7;a77#a7 7aft] apply+     
subsection 7b7 ( ?is section74  7#b7    
,m$ical c>e ,! t]m m$ical c>e has !     
mean+ provid$ 9 section #gcc7;a77#b74   
7#c7 ,heal? insurance cov]age ,! t]m    
heal? insurance cov]age has ! mean+     
provid$ 9 section #gcc7;b77#a74  7#d7   
,heal? insurance issu] ,! t]m heal?     
insurance issu] has ! mean+ provid$ 9   
section #gcc7;b77#b74  7#e7 ,applicable 
au?ority ,! t]m applicable au?ority     
means ! ,secret>y1 except t1 9          
connection ) any ex]cise ( ! ,secret>y's
 au?ority reg>d+ :i* ! ,secret>y is     
requir$ "u section #ejf7;d7 to consult )
 a ,/ate1 su* t]m means ! ,secret>y1 9  
consultation ) su* ,/ate4  7#f7 ,heal?  
/atus-relat$ factor ,! t]m heal?        
/atus-relat$ factor has ! mean+ provid$ 
9 section #gcc7;d77#b74  7#g7           
,individual m>ket  7,a7 ,9 g5]al ,! t]m 
individual m>ket means ! m>ket = heal?  
insurance cov]age (f]$ to individuals   
o!r ?an 9 connection ) a gr\p heal?     
plan4  7,b7 ,treatm5t ( v small gr\ps   

7i7 ,9 g5]al ,subject to clause 7ii71   
su* t]m includes cov]age (f]$ 9         
connection ) a gr\p heal? plan t has    
few] ?an #b p>ticipants z curr5t        
employees or p>ticipants describ$ 9     
section #gcb7;d77#c7 on ! fir/ day ( !  
plan ye>4  7ii7 ,/ate exception ,clause 
7i7 %all n apply 9 ! case ( heal?       
insurance cov]age (f]$ 9 a ,/ate if su* 
,/ate regulates ! cov]age describ$ 9 su*
 clause 9 ! same mann] & to ! same ext5t
 z cov]age 9 ! small gr\p m>ket 7z def9$
 9 section #bgia7;e77#e7 ( ! ,public    
,heal? ,s]vice ,act7 is regulat$ by su* 
,/ate4  7#h7 ,p>ticipat+ employ] ,! t]m 
p>ticipat+ employ] means1 9 connection )
 an association heal? plan1 any employ]1
 if any individual :o is an employee (  
su* employ]1 a p>tn] 9 su* employ]1 or a
 self-employ$ individual :o is su*      
employ] 7or any dep5d5t1 z def9$ "u !   
t]ms ( ! plan1 ( su* individual7 is or 0
 cov]$ "u su* plan 9 connection ) !     
/atus ( su* individual z su* an         
employee1 p>tn]1 or self-employ$        

individual 9 relation to ! plan4  7#i7  
,applicable /ate au?ority ,! t]m        
applicable ,/ate au?ority means1 )      
respect to a heal? insurance issu] 9 a  
,/ate1 ! ,/ate insurance commission] or 
(ficial or (ficials designat$ by ! ,/ate
 to en=ce ! requirem5ts ( title ,,xxvii 
( ! ,public ,heal? ,s]vice ,act = !     
,/ate involv$ ) respect to su* issu]4   
7#aj7 ,qualifi$ heal? actu>y ,! t]m     
qualifi$ heal? actu>y means an          
individual :o is a memb] ( ! ,am]ican   
,academy ( ,actu>ies ) exp]tise 9 heal? 
c>e4  7#aa7 ,affiliat$ memb] ,! t]m     
affiliat$ memb] means1 9 connection ) a 
sponsor--  7,a7 a p]son :o is o!rwise   
eligible to be a memb] ( ! sponsor b :o 
elects an affiliat$ /atus ) ! sponsor1  
7,b7 9 ! case ( a sponsor ) memb]s :i*  
consi/ ( associations1 a p]son :o is a  
memb] ( any su* association & elects an 
affiliat$ /atus ) ! sponsor1 or  7,c7 9 
! case ( an association heal? plan 9    
exi/5ce on ! date ( ! enactm5t ( !      
,small ,bus9ess ,heal? ,fairness ,act ( 

#bjac1 a p]son eligible to be a memb] ( 
! sponsor or "o ( its memb]             
associations4  7#ab7 ,l>ge employ] ,!   
t]m l>ge employ] means1 9 connection ) a
 gr\p heal? plan ) respect to a plan    
ye>1 an employ] :o employ$ an av]age (  
at lea/ #ea employees on bus9ess days   
dur+ ! prec$+ cal5d> ye> & :o employs at
 lea/ #b employees on ! fir/ day ( !    
plan ye>4  7#ac7 ,small employ] ,! t]m  
small employ] means1 9 connection ) a   
gr\p heal? plan ) respect to a plan ye>1
 an employ] :o is n a l>ge employ]4  7b7
 ,rules ( ,con/ruction  7#a7 ,employ]s &
 employees ,= purposes ( det]m9+ :e!r a 
plan1 fund1 or program is an employee   
welf>e b5efit plan :i* is an association
 heal? plan1 & = purposes ( apply+ ?is  
title 9 connection ) su* plan1 fund1 or 
program s det]m9$ to be su* an employee 
welf>e b5efit plan--  7,a7 9 ! case ( a 
p>tn]%ip1 ! t]m employ] 7z def9$ 9      
section #c7e77 includes ! p>tn]%ip 9    
relation to ! p>tn]s1 & ! t]m employee  
7z def9$ 9 section #c7f77 includes any  

p>tn] 9 relation to ! p>tn]%ip2 &  7,b7 
9 ! case ( a self-employ$ individual1 ! 
t]m employ] 7z def9$ 9 section #c7e77 & 
! t]m employee 7z def9$ 9 section #c7f77
 %all include su* individual4  7#b7     
,plans1 funds1 & programs treat$ z      
employee welf>e b5efit plans ,9 ! case (
 any plan1 fund1 or program :i* 0       
e/abli%$ or is ma9ta9$ = ! purpose (    
provid+ m$ical c>e 7?r\gh ! pur*ase (   
insurance or o!rwise7 = employees 7or _!
 dep5d5ts7 cov]$ !reund] & :i*          
demon/rates to ! ,secret>y t all        
requirem5ts = c]tification "u ?is "p    
w\ld be met ) respect to su* plan1 fund1
 or program if su* plan1 fund1 or       
program 7 a gr\p heal? plan1 su* plan1  
fund1 or program %all be treat$ =       
purposes ( ?is title z an employee      
welf>e b5efit plan on & aft] ! date (   
su* demon/ration4  7#c7 ,exception =    
c]ta9 b5efits ,! requirem5ts ( ?is "p   
%all n apply to a gr\p heal? plan 9     
relation to its provision ( except$     
b5efits1 z def9$ 9 section #gjf7;c74  4 

7b7 ,con=m+ ,am5dm5ts to ,preemption    
,rules  7#a7 ,section #ead7;b77#f7 ( su*
 ,act 7#bi ,u4,s4,c4 #aadd7;b77#f77 is  
am5d$ by add+ at ! end ! foll[+ new     
subp>agraph3  7,e7 ,! prec$+            
subp>agraphs ( ?is p>agraph d n apply ) 
respect to any ,/ate law 9 ! case ( an  
association heal? plan :i* is c]tifi$ "u
 "p #h4  4  7#b7 ,section #ead ( su*    
,act 7#bi ,u4,s4,c4 #aadd7 is am5d$--   
7,a7 9 subsection 7b77#d71 by /rik+     
,subsection 7a7 & ins]t+ ,subsections   
7a7 & 7d72  7,b7 9 subsection 7b77#e71  
by /rik+ subsection 7a7 9 subp>agraph   
7,a7 & ins]t+ subsection 7a7 ( ?is      
section & subsections 7a77#b77;,b7 & 7b7
 ( section #hje1 & by /rik+ subsection  
7a7 9 subp>agraph 7,b7 & ins]t+         
subsection 7a7 ( ?is section or         
subsection 7a77#b77;,b7 or 7b7 ( section
 #hje2  7,c7 by r$esignat+ subsection   
7d7 z subsection 7e72 &  7,d7 by ins]t+ 
aft] subsection 7c7 ! foll[+ new        
subsection3  7d7  7#a7 ,except z provid$
 9 subsection 7b77#d71 ! provisions (   

?is title %all sup]s$e any & all ,/ate  
laws ins(> z !y may n[ or h]eaft]       
preclude1 or h ! effect ( preclud+1 a   
heal? insurance issu] f (f]+ heal?      
insurance cov]age 9 connection ) an     
association heal? plan :i* is c]tifi$ "u
 "p #h4  7#b7 ,except z provid$ 9       
p>agraphs 7#d7 & 7#e7 ( subsection 7b7 (
 ?is section--  7,a7 ,9 any case 9 :i*  
heal? insurance cov]age ( any policy    
type is (f]$ "u an association heal?    
plan c]tifi$ "u "p #h to a p>ticipat+   
employ] op]at+ 9 su* ,/ate1 ! provisions
 ( ?is title %all sup]s$e any & all laws
 ( su* ,/ate ins(> z !y may preclude a  
heal? insurance issu] f (f]+ heal?      
insurance cov]age ( ! same policy type  
to o!r employ]s op]at+ 9 ! ,/ate :i* are
 eligible = cov]age "u su* association  
heal? plan1 :e!r or n su* o!r employ]s  
are p>ticipat+ employ]s 9 su* plan4     
7,b7 ,9 any case 9 :i* heal? insurance  
cov]age ( any policy type is (f]$ 9 a   
,/ate "u an association heal? plan      
c]tifi$ "u "p #h & ! fil+1 ) !          

applicable ,/ate au?ority 7z def9$ 9    
section #hab7;a77#i771 ( ! policy =m 9  
connection ) su* policy type is approv$ 
by su* ,/ate au?ority1 ! provisions (   
?is title %all sup]s$e any & all laws ( 
any o!r ,/ate 9 :i* heal? insurance     
cov]age ( su* type is (f]$1 ins(> z !y  
may preclude1 ^u ! fil+ 9 ! same =m &   
mann] ( su* policy =m ) ! applicable    
,/ate au?ority 9 su* o!r ,/ate1 !       
approval ( ! fil+ 9 su* o!r ,/ate4  7#c7
 ,no?+ 9 subsection 7b77#f77;,e7 or !   
prec$+ provisions ( ?is subsection %all 
be con/ru$1 ) respect to heal? insurance
 issu]s or heal? insurance cov]age1 to  
sup]s$e or impair ! law ( any ,/ate--   
7,a7 provid+ solv5cy /&>ds or simil>    
/&>ds reg>d+ ! adequacy ( insur]        
capital1 surplus1 res]ves1 or           
contributions1 or  7,b7 relat+ to prompt
 paym5t ( claims4  7#d7 ,= additional   
provisions relat+ to association heal?  
plans1 see subsections 7a77#b77;,b7 &   
7b7 ( section #hje4  7#e7 ,= purposes ( 
?is subsection1 ! t]m association heal? 

plan has ! mean+ provid$ 9 section      
#hja7;a71 & ! t]ms heal? insurance      
cov]age1 p>ticipat+ employ]1 & heal?    
insurance issu] h ! mean+s provid$ su*  
t]ms 9 section #hab1 respectively4  4   
7#c7 ,section #ead7;b77#f77;,a7 ( su*   
,act 7#bi ,u4,s4,c4 #aadd7;b77#f77;,a77 
is am5d$--  7,a7 9 clause 7i77,,ii71 by 
/rik+ & at ! end2  7,b7 9 clause 7ii71  
by ins]t+ & :i* does n provide m$ical   
c>e 7)9 ! mean+ ( section #gcc7;a77#b771
 aft] arrangem5t11 & by /rik+ title4 &  
ins]t+ title1 &2 &  7,c7 by add+ at !   
end ! foll[+ new clause3  7iii7 subject 
to subp>agraph 7,e71 9 ! case ( any o!r 
employee welf>e b5efit plan :i* is a    
multiple employ] welf>e arrangem5t & :i*
 provides m$ical c>e 7)9 ! mean+ (      
section #gcc7;a77#b771 any law ( any    
,/ate :i* regulates insurance may apply4
  4  7#d7 ,section #ead7;e7 ( su* ,act  
7z r$esignat$ by p>agraph 7#b77;,c77 is 
am5d$--  7,a7 by /rik+ ,no?+ & ins]t+   
7#a7 ,except z provid$ 9 p>agraph 7#b71 
no?+2 &  7,b7 by add+ at ! end ! foll[+ 

new p>agraph3  7#b7 ,no?+ 9 any o!r     
provision ( law enact$ on or aft] ! date
 ( ! enactm5t ( ! ,small ,bus9ess ,heal?
 ,fairness ,act ( #bjac %all be con/ru$ 
to alt]1 am5d1 modify1 invalidate1      
impair1 or sup]s$e any provision ( ?is  
title1 except by specific cross-ref]5ce 
to ! affect$ section4  4  7c7 ,plan     
,sponsor ,section #c7af77;,b7 ( su* ,act
 7#bi ,u4,s4,c4 #ajb7af77;,b77 is am5d$ 
by add+ at ! end ! foll[+ new s5t5ce3   
,su* t]m also includes a p]son s]v+ z ! 
sponsor ( an association heal? plan "u  
"p #h44  7d7 ,disclosure ( ,solv5cy     
,protections ,relat$ to ,self-,insur$ & 
,fully ,insur$ ,options ,"u ,association
 ,heal? ,plans ,section #ajb7;b7 ( su*  
,act 7#bi ,u4,s4,c4 #ajb7;b77 is am5d$  
by add+ at ! end ! foll[+3 ,an          
association heal? plan %all include 9   
its summ>y plan description1 9          
connection ) ea* b5efit option1 a       
description ( ! =m ( solv5cy or gu>antee
 fund protection secur$ pursuant to ?is 
,act or applicable ,/ate law1 if any44  

7e7 ,sav+s ,clause ,section #gca7;c7 (  
su* ,act is am5d$ by ins]t+ or "p #h    
aft] ?is "p4  7f7 ,report to ! ,congress
 ,reg>d+ ,c]tification ( ,self-,insur$  
,association ,heal? ,plans ,n lat] ?an  
,janu>y #a1 #bjaf1 ! ,secret>y ( ,labor 
%all report to ! ,committee on          
,education & ! ,work=ce ( ! ,h\se (     
,repres5tatives & ! ,committee on       
,heal?1 ,education1 ,labor1 & ,p5sions (
 ! ,s5ate ! effect association heal?    
plans h _h1 if any1 on r$uc+ ! numb] (  
un9sur$ individuals4  7g7 ,cl]ical      
,am5dm5t ,! table ( cont5ts 9 section #a
 ( ! ,employee ,retirem5t ,income       
,security ,act ( #aigd is am5d$ by      
ins]t+ aft] ! item relat+ to section    
#gcd ! foll[+ new items3  ,"p #h--,rules
 ,gov]n+ ,association ,heal? ,plans     
#hja4 ,association heal? plans4 #hjb4   
,c]tification ( association heal? plans4
 #hjc4 ,requirem5ts relat+ to sponsors &
 bo>ds ( tru/ees4 #hjd4 ,p>ticipation & 
cov]age requirem5ts4 #hje4 ,o!r         
requirem5ts relat+ to plan docum5ts1    

contribution rates1 & b5efit options4   
#hjf4 ,ma9t5ance ( res]ves & provisions 
= solv5cy = plans provid+ heal? b5efits 
9 addition to heal? insurance cov]age4  
#hjg4 ,requirem5ts = application &      
relat$ requirem5ts4 #hjh4 ,notice       
requirem5ts = volunt>y t]m9ation4 #hji4 
,corrective actions & m&atory t]m9ation4
 #haj4 ,tru/ee%ip by ! ,secret>y (      
insolv5t association heal? plans provid+
 heal? b5efits 9 addition to heal?      
insurance cov]age4 #haa4 ,/ate assessm5t
 au?ority4 #hab4 ,def9itions & rules (  
con/ruction4  4  #bbc4 ,cl>ification (  
treatm5t ( s+le employ] arrangem5ts     
,section #c7dj77;,b7 ( ! ,employee      
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #ajjb7dj77;,b77 is 
am5d$--  7#a7 9 clause 7i71 by ins]t+   
aft] control gr\p1 ! foll[+3 except t1 9
 any case 9 :i* ! b5efit ref]r$ to 9    
subp>agraph 7,a7 consi/s ( m$ical c>e 7z
 def9$ 9 section #hab7;a77#b771 two or m
 trades or bus9esses1 :e!r or n         
incorporat$1 %all be deem$ a s+le       

employ] = any plan ye> ( su* plan1 or   
any fiscal ye> ( su* o!r arrangem5t1 if 
su* trades or bus9esses are )9 ! same   
control gr\p dur+ su* ye> or at any "t  
dur+ ! prec$+ #a-ye> p]iod12  7#b7 9    
clause 7iii71 by /rik+ 7iii7 !          
det]m9ation & ins]t+ ! foll[+3  7iii7   
7,i7 9 any case 9 :i* ! b5efit ref]r$ to
 9 subp>agraph 7,a7 consi/s ( m$ical c>e
 7z def9$ 9 section #hab7;a77#b771 !    
det]m9ation ( :e!r a trade or bus9ess is
 "u common control ) ano!r trade or     
bus9ess %all be det]m9$ "u regulations (
 ! ,secret>y apply+ pr9ciples consi/5t &
 coext5sive ) ! pr9ciples appli$ 9      
det]m9+ :e!r employees ( two or m trades
 or bus9esses are treat$ z employ$ by a 
s+le employ] "u section #djja7;b71      
except t1 = purposes ( ?is p>agraph1 an 
int]e/ ( great] ?an #be p]c5t may n be  
requir$ z ! m9imum int]e/ necess>y =    
common control1 or  7,,ii7 9 any o!r    
case1 ! det]m9ation  2  7#c7 by         
r$esignat+ clauses 7iv7 & 7v7 z clauses 
7v7 & 7vi71 respectively2 &  7#d7 by    

ins]t+ aft] clause 7iii7 ! foll[+ new   
clause3  7iv7 9 any case 9 :i* ! b5efit 
ref]r$ to 9 subp>agraph 7,a7 consi/s (  
m$ical c>e 7z def9$ 9 section           
#hab7;a77#b771 9 det]m9+1 aft] !        
application ( clause 7i71 :e!r b5efits  
are provid$ to employees ( two or m     
employ]s1 ! arrangem5t %all be treat$ z 
hav+ only "o p>ticipat+ employ] if1 aft]
 ! application ( clause 7i71 ! numb] (  
individuals :o are employees & =m]      
employees ( any "o p>ticipat+ employ] & 
:o are cov]$ "u ! arrangem5t is great]  
?an #ge p]c5t ( ! aggregate numb] ( all 
individuals :o are employees or =m]     
employees ( p>ticipat+ employ]s & :o are
 cov]$ "u ! arrangem5t1  4  #bbd4       
,en=cem5t provisions relat+ to          
association heal? plans  7a7 ,crim9al   
,p5alties = ,c]ta9 ,willful             
,misrepres5tations ,section #eja ( !    
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4 #aaca7 is   
am5d$--  7#a7 by ins]t+ 7a7 aft] ,sec4  
#eja42 &  7#b7 by add+ at ! end ! foll[+

 new subsection3  7b7 ,any p]son :o     
willfully falsely repres5ts1 to any     
employee1 any employee's b5efici>y1 any 
employ]1 ! ,secret>y1 or any ,/ate1 a   
plan or o!r arrangem5t e/abli%$ or      
ma9ta9$ = ! purpose ( (f]+ or provid+   
any b5efit describ$ 9 section #c7a7 to  
employees or _! b5efici>ies z--  7#a7   
be+ an association heal? plan :i* has   
be5 c]tifi$ "u "p #h2  7#b7 hav+ be5    
e/abli%$ or ma9ta9$ "u or pursuant to "o
 or m collective b>ga9+ agreem5ts :i*   
are rea*$ pursuant to collective b>ga9+ 
describ$ 9 section #h7;d7 ( ! ,national 
,labor ,relations ,act 7#bi ,u4,s4,c4   
#aeh7;d77 or p>agraph ,f\r? ( section #b
 ( ! ,railway ,labor ,act 7#de ,u4,s4,c4
 #aeb1 p>agraph ,f\r?7 or :i* are rea*$ 
pursuant to labor-managem5t negotiations
 "u simil> provisions ( ,/ate public    
employee relations laws2 or  7#c7 be+ a 
plan or arrangem5t describ$ 9 section   
#c7dj77;,a77i71  %all1 ^u conviction1 be
 imprison$ n m ?an #e ye>s1 be f9$ "u   
title #ah1 ,unit$ ,/ates ,code1 or bo?4 

4  7b7 ,cease ,activities ,ord]s        
,section #ejb ( su* ,act 7#bi ,u4,s4,c4 
#aacb7 is am5d$ by add+ at ! end !      
foll[+ new subsection3  7n7 ,association
 ,heal? ,plan ,cease & ,desi/ ,ord]s    
7#a7 ,9 g5]al ,subject to p>agraph 7#b71
 ^u application by ! ,secret>y %[+ !    
op]ation1 promotion1 or m>ket+ ( an     
association heal? plan 7or simil>       
arrangem5t provid+ b5efits consi/+ (    
m$ical c>e 7z def9$ 9 section           
#gcc7;a77#b777 t--  7,a7 is n c]tifi$ "u
 "p #h1 is subject "u section           
#ead7;b77#f7 to ! insurance laws ( any  
,/ate 9 :i* ! plan or arrangem5t (f]s or
 provides b5efits1 & is n lic5s$1       
regi/]$1 or o!rwise approv$ "u !        
insurance laws ( su* ,/ate2 or  7,b7 is 
an association heal? plan c]tifi$ "u "p 
#h & is n op]at+ 9 accordance ) !       
requirem5ts "u "p #h = su* c]tification1
  a di/rict c\rt ( ! ,unit$ ,/ates %all 
ent] an ord] requir+ t ! plan or        
arrangem5t cease activities4  7#b7      
,exception ,p>agraph 7#a7 %all n apply 9

 ! case ( an association heal? plan or  
o!r arrangem5t if ! plan or arrangem5t  
%[s t--  7,a7 all b5efits "u x ref]r$ to
 9 p>agraph 7#a7 consi/ ( heal?         
insurance cov]age2 &  7,b7 ) respect to 
ea* ,/ate 9 :i* ! plan or arrangem5t    
(f]s or provides b5efits1 ! plan or     
arrangem5t is op]at+ 9 accordance )     
applicable ,/ate laws t are n sup]s$$ "u
 section #ead4  7#c7 ,additional        
equitable relief ,! c\rt may grant su*  
additional equitable relief1 includ+ any
 relief available "u ?is title1 z x     
deems necess>y to protect ! int]e/s ( ! 
public & ( p]sons hav+ claims = b5efits 
aga9/ ! plan4  4  7c7 ,responsibility = 
,claims ,proc$ure ,section #ejc ( su*   
,act 7#bi ,u4,s4,c4 #aacc7 is am5d$ by  
ins]t+ 7a7 ,9 g5]al4-- be=e ,9          
accordance1 & by add+ at ! end ! foll[+ 
new subsection3  7b7 ,association ,heal?
 ,plans ,! t]ms ( ea* association heal? 
plan :i* is or has be5 c]tifi$ "u "p #h 
%all require ! bo>d ( tru/ees or ! nam$ 
fiduci>y 7z applicable7 to ensure t !   

requirem5ts ( ?is section are met 9     
connection ) claims fil$ "u ! plan4  4  
#bbe4 ,coop]ation betwe5 ,f$]al & ,/ate 
au?orities ,section #ejf ( ! ,employee  
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #aacf7 is am5d$ by 
add+ at ! end ! foll[+ new subsection3  
7d7 ,consultation ,) ,/ates ,) ,respect 
to ,association ,heal? ,plans  7#a7     
,agreem5ts ) /ates ,! ,secret>y %all    
consult ) ! ,/ate recogniz$ "u p>agraph 
7#b7 ) respect to an association heal?  
plan reg>d+ ! ex]cise (--  7,a7 !       
,secret>y's au?ority "u sections #ejb & 
#ejd to en=ce ! requirem5ts =           
c]tification "u "p #h2 &  7,b7 !        
,secret>y's au?ority to c]tify          
association heal? plans "u "p #h 9      
accordance ) regulations ( ! ,secret>y  
applicable to c]tification "u "p #h4    
7#b7 ,recognition ( prim>y domicile /ate
 ,9 c>ry+ out p>agraph 7#a71 ! ,secret>y
 %all ensure t only "o ,/ate w be       
recogniz$1 ) respect to any p>ticul>    
association heal? plan1 z ! ,/ate ) :i* 

consultation is requir$4 ,9 c>ry+ out   
?is p>agraph--  7,a7 9 ! case ( a plan  
:i* provides heal? insurance cov]age 7z 
def9$ 9 section #hab7;a77#c771 su* ,/ate
 %all be ! ,/ate ) :i* fil+ & approval (
 a policy type (f]$ by ! plan 0         
initially obta9$1 &  7,b7 9 any o!r     
case1 ! ,secret>y %all take into acc\nt 
! places ( resid5ce ( ! p>ticipants &   
b5efici>ies "u ! plan & ! ,/ate 9 :i* ! 
tru/ is ma9ta9$4  4  #bbf4 ,effective   
date & transitional & o!r rules  7a7    
,effective ,date ,! am5dm5ts made by ?is
 subtitle %all take effect #a ye> aft] !
 date ( ! enactm5t ( ?is ,act4 ,!       
,secret>y ( ,labor %all fir/ issue all  
regulations necess>y to c>ry out !      
am5dm5ts made by ?is subtitle )9 #a ye> 
aft] ! date ( ! enactm5t ( ?is ,act4    
7b7 ,treatm5t ( ,c]ta9 ,exi/+ ,heal?    
,b5efits ,programs  7#a7 ,9 g5]al ,9 any
 case 9 :i*1 z ( ! date ( ! enactm5t (  
?is ,act1 an arrangem5t is ma9ta9$ 9 a  
,/ate = ! purpose ( provid+ b5efits     
consi/+ ( m$ical c>e = ! employees &    

b5efici>ies ( its p>ticipat+ employ]s1  
at lea/ #bjj p>ticipat+ employ]s make   
contributions to su* arrangem5t1 su*    
arrangem5t has be5 9 exi/5ce = at lea/  
#aj ye>s1 & su* arrangem5t is lic5s$ "u 
! laws ( "o or m ,/ates to provide su*  
b5efits to its p>ticipat+ employ]s1 ^u !
 fil+ ) ! applicable au?ority 7z def9$ 9
 section #hab7;a77#e7 ( ! ,employee     
,retirem5t ,income ,security ,act (     
#aigd 7z am5d$ by ?is subtitle77 by !   
arrangem5t ( an application =           
c]tification ( ! arrangem5t "u "p #h (  
subtitle ,b ( title ,i ( su* ,act--     
7,a7 su* arrangem5t %all be deem$ to be 
a gr\p heal? plan = purposes ( title ,i 
( su* ,act2  7,b7 ! requirem5ts (       
sections #hja7;a7 & #hjc7;a7 ( !        
,employee ,retirem5t ,income ,security  
,act ( #aigd %all be deem$ met ) respect
 to su* arrangem5t2  7,c7 ! requirem5ts 
( section #hjc7;b7 ( su* ,act %all be   
deem$ met1 if ! arrangem5t is op]at$ by 
a bo>d ( directors :i*--  7i7 is elect$ 
by ! p>ticipat+ employ]s1 ) ea* employ] 

hav+ "o vote2 &  7ii7 has complete      
fiscal control ov] ! arrangem5t & :i* is
 responsible = all op]ations ( !        
arrangem5t2  7,d7 ! requirem5ts (       
section #hjd7;a7 ( su* ,act %all be     
deem$ met ) respect to su* arrangem5t2 &
  7,e7 ! arrangem5t may be c]tifi$ by   
any applicable au?ority ) respect to its
 op]ations 9 any ,/ate only if x op]ates
 9 su* ,/ate on ! date ( c]tification4  
,! provisions ( ?is subsection %all     
cease to apply ) respect to any su*     
arrangem5t at su* "t aft] ! date ( !    
enactm5t ( ?is ,act z ! applicable      
requirem5ts ( ?is subsection are n met )
 respect to su* arrangem5t4  7#b7       
,def9itions ,= purposes ( ?is           
subsection1 ! t]ms gr\p heal? plan1     
m$ical c>e1 & p>ticipat+ employ] %all h 
! mean+s provid$ 9 section #hab ( !     
,employee ,retirem5t ,income ,security  
,act ( #aigd1 except t ! ref]5ce 9      
p>agraph 7#g7 ( su* section to an       
association heal? plan %all be deem$ a  
ref]5ce to an arrangem5t ref]r$ to 9 ?is

 subsection4  ,,iii ,int]/ate ,m>ket =  
,heal? ,insurance  #cja4 ,coop]ative    
gov]n+ ( individual heal? insurance     
cov]age  7a7 ,9 ,g5]al ,title ,,xxvii ( 
! ,public ,heal? ,s]vice ,act 7#db      
,u4,s4,c4 #cjj;gg et seq471 z re/or$ by 
section #b1 is am5d$ by add+ at ! end ! 
foll[+ new "p3  ,d ,coop]ative ,gov]n+ (
 ,individual ,heal? ,insurance ,cov]age 
#bgie4 ,def9itions ,9 ?is "p3  7#a7     
,prim>y /ate ,! t]m prim>y ,/ate means1 
) respect to individual heal? insurance 
cov]age (f]$ by a heal? insurance issu]1
 ! ,/ate designat$ by ! issu] z ! ,/ate 
^: cov]$ laws %all gov]n ! heal?        
insurance issu] 9 ! sale ( su* cov]age  
"u ?is "p4 ,an issu]1 ) respect to a    
p>ticul> policy1 may only designate "o  
su* ,/ate z its prim>y ,/ate ) respect  
to all su* cov]age x (f]s4 ,su* an issu]
 may n *ange ! designat$ prim>y ,/ate ) 
respect to individual heal? insurance   
cov]age once ! policy is issu$1 except t
 su* a *ange may be made ^u r5ewal ( !  
policy4 ,) respect to su* designat$     

,/ate1 ! issu] is deem$ to be do+       
bus9ess 9 t ,/ate4  7#b7 ,second>y /ate 
,! t]m second>y ,/ate means1 ) respect  
to individual heal? insurance cov]age   
(f]$ by a heal? insurance issu]1 any    
,/ate t is n ! prim>y ,/ate4 ,9 ! case (
 a heal? insurance issu] t is sell+ a   
policy 91 or to a resid5t (1 a second>y 
,/ate1 ! issu] is deem$ to be do+       
bus9ess 9 t second>y ,/ate4  7#c7 ,heal?
 insurance issu] ,! t]m heal? insurance 
issu] has ! mean+ giv5 su* t]m 9 section
 #bgia7;b77#b71 except t su* an issu]   
mu/ be lic5s$ 9 ! prim>y ,/ate & be     
qualifi$ to sell individual heal?       
insurance cov]age 9 t ,/ate4  7#d7      
,individual heal? insurance cov]age ,!  
t]m individual heal? insurance cov]age  
means heal? insurance cov]age (f]$ 9 !  
individual m>ket1 z def9$ 9 section     
#bgia7;e77#a71 b does n include except$ 
b5efits describ$ 9 section #bgia7;c74   
7#e7 ,applicable /ate au?ority ,! t]m   
applicable ,/ate au?ority means1 )      
respect to a heal? insurance issu] 9 a  

,/ate1 ! ,/ate insurance commission] or 
(ficial or (ficials designat$ by ! ,/ate
 to en=ce ! requirem5ts ( ?is title = ! 
,/ate ) respect to ! issu]4  7#f7       
,haz>d\s f9ancial condition ,! t]m      
haz>d\s f9ancial condition means t1 bas$
 on its pres5t or reasonably anticipat$ 
f9ancial condition1 a heal? insurance   
issu] is unlikely to be able--  7,a7 to 
meet obligations to policyhold]s )      
respect to kn[n claims & reasonably     
anticipat$ claims2 or  7,b7 to pay o!r  
obligations 9 ! normal c\rse ( bus9ess4 
7#g7 ,cov]$ laws  7,a7 ,9 g5]al ,! t]m  
cov]$ laws means ! laws1 rules1         
regulations1 agreem5ts1 & ord]s gov]n+ !
 insurance bus9ess p]ta9+ to--  7i7     
individual heal? insurance cov]age issu$
 by a heal? insurance issu]2  7ii7 !    
(f]1 sale1 rat+ 7includ+ m$ical         
und]writ+71 r5ewal1 & issuance (        
individual heal? insurance cov]age to an
 individual2  7iii7 ! provision to an   
individual 9 relation to individual     
heal? insurance cov]age ( heal? c>e &   

insurance relat$ s]vices2  7iv7 !       
provision to an individual 9 relation to
 individual heal? insurance cov]age (   
managem5t1 op]ations1 & inve/m5t        
activities ( a heal? insurance issu]2 & 
7v7 ! provision to an individual 9      
relation to individual heal? insurance  
cov]age ( loss control & claims         
adm9i/ration = a heal? insurance issu] )
 respect to liability = :i* ! issu]     
provides insurance4  7,b7 ,exception    
,su* t]m does n include any law1 rule1  
regulation1 agreem5t1 or ord] gov]n+ !  
use ( c>e or co/ managem5t te*niques1   
includ+ any requirem5t relat$ to provid]
 contract+1 network access or adequacy1 
heal? c>e data collection1 or quality   
assurance4  7#h7 ,/ate ,! t]m ,/ate     
means only ! #ej ,/ates & ! ,di/rict (  
,columbia4  7#i7 ,unfair claims         
settlem5t practices ,! t]m unfair claims
 settlem5t practices means only ! foll[+
 practices3  7,a7 ,kn[+ly misrepres5t+  
to claimants & insur$ individuals       
relevant facts or policy provisions     

relat+ to cov]age at issue4  7,b7 ,fail+
 to ackn[l$ge ) reasonable promptness   
p]t95t communications ) respect to      
claims aris+ "u policies4  7,c7 ,fail+  
to adopt & implem5t reasonable /&>ds = !
 prompt inve/igation & settlem5t (      
claims aris+ "u policies4  7,d7 ,fail+  
to effectuate prompt1 fair1 & equitable 
settlem5t ( claims submitt$ 9 :i*       
liability has become reasonably cle>4   
7,e7 ,refus+ to pay claims )\t conduct+ 
a reasonable inve/igation4  7,f7 ,fail+ 
to affirm or d5y cov]age ( claims )9 a  
reasonable p]iod ( "t aft] hav+ complet$
 an inve/igation relat$ to ^? claims4   
7,g7 ,a patt]n or practice ( compell+   
insur$ individuals or _! b5efici>ies to 
in/itute suits to recov] am\nts due "u  
its policies by (f]+ sub/antially less  
?an ! am\nts ultimately recov]$ 9 suits 
br\ght by !m4  7,h7 ,a patt]n or        
practice ( attempt+ to settle or settl+ 
claims = less ?an ! am\nt t a reasonable
 p]son w\ld believe ! insur$ individual 
or 8 or h] b5efici>y 0 entitl$ by       

ref]5ce to writt5 or pr9t$ adv]tis+     
mat]ial accompany+ or made "p ( an      
application4  7,i7 ,attempt+ to settle  
or settl+ claims on ! basis ( an        
application t 0 mat]ially alt]$ )\t     
notice to1 or k or cons5t (1 ! insur$4  
7,j7 ,fail+ to provide =ms necess>y to  
pres5t claims )9 #ae cal5d> days ( a    
reque/s ) reasonable explanations reg>d+
 _! use4  7,k7 ,attempt+ to cancel a    
policy 9 less "t ?an t prescrib$ 9 !    
policy or by ! law ( ! prim>y ,/ate4    
7#aj7 ,fraud & abuse ,! t]m fraud &     
abuse means an act or omission committ$ 
by a p]son :o1 kn[+ly & ) int5t to      
defraud1 commits1 or conceals any       
mat]ial in=mation conc]n+1 "o or m ( !  
foll[+3  7,a7 ,pres5t+1 caus+ to be     
pres5t$ or prep>+ ) k or belief t x w be
 pres5t$ to or by an insur]1 a re9sur]1 
brok] or its ag5t1 false in=mation z "p 
(1 9 support ( or conc]n+ a fact mat]ial
 to "o or m ( ! foll[+3  7i7 ,an        
application = ! issuance or r5ewal ( an 
insurance policy or re9surance contract4

  7ii7 ,! rat+ ( an insurance policy or 
re9surance contract4  7iii7 ,a claim =  
paym5t or b5efit pursuant to an         
insurance policy or re9surance contract4
  7iv7 ,premiums paid on an insurance   
policy or re9surance contract4  7v7     
,paym5ts made 9 accordance ) ! t]ms ( an
 insurance policy or re9surance         
contract4  7vi7 ,a docum5t fil$ ) !     
commission] or ! *ief insurance         
regulatory (ficial ( ano!r jurisdiction4
  7vii7 ,! f9ancial condition ( an      
insur] or re9sur]4  7viii7 ,! =mation1  
acquisition1 m]g]1 reconsolidation1     
dissolution or )drawal f "o or m l9es ( 
insurance or re9surance 9 all or "p ( a 
,/ate by an insur] or re9sur]4  7ix7 ,! 
issuance ( writt5 evid5ce ( insurance4  
7x7 ,! re9/atem5t ( an insurance policy4
  7,b7 ,solicitation or acceptance ( new
 or r5ewal insurance risks on behalf (  
an insur]1 re9sur]1 or o!r p]son engag$ 
9 ! bus9ess ( insurance by a p]son :o   
kn[s or %\ld "k t ! insur] or o!r p]son 
responsible = ! risk is insolv5t at ! "t

 ( ! transaction4  7,c7 ,transaction ( !
 bus9ess ( insurance 9 violation ( laws 
requir+ a lic5se1 c]tificate ( au?ority 
or o!r legal au?ority = ! transaction ( 
! bus9ess ( insurance4  7,d7 ,attempt to
 commit1 aid+ or abett+ 9 ! commission  
(1 or conspiracy to commit ! acts or    
omissions specifi$ 9 ?is p>agraph4      
#bgif4 ,application ( law  7a7 ,9 ,g5]al
 ,! cov]$ laws ( ! prim>y ,/ate %all    
apply to individual heal? insurance     
cov]age (f]$ by a heal? insurance issu] 
9 ! prim>y ,/ate & 9 any second>y ,/ate1
 b only if ! cov]age & issu] comply ) ! 
conditions ( ?is section ) respect to ! 
(f]+ ( cov]age 9 any second>y ,/ate4    
7b7 ,exemptions ,f ,cov]$ ,laws 9 a     
,second>y ,/ate ,except z provid$ 9 ?is 
section1 a heal? insurance issu] )      
respect to its (f]1 sale1 rat+ 7includ+ 
m$ical und]writ+71 r5ewal1 & issuance ( 
individual heal? insurance cov]age 9 any
 second>y ,/ate is exempt f any cov]$   
laws ( ! second>y ,/ate 7& any rules1   
regulations1 agreem5ts1 or ord]s s\ght  

or issu$ by su* ,/ate "u or relat$ to   
su* cov]$ laws7 to ! ext5t t su* laws   
w\ld--  7#a7 make unlawful1 or regulate1
 directly or indirectly1 ! op]ation ( ! 
heal? insurance issu] op]at+ 9 !        
second>y ,/ate1 except t any second>y   
,/ate may require su* an issu]--  7,a7  
to pay1 on a nondiscrim9atory basis1    
applicable premium & o!r taxes 7includ+ 
high-risk pool assessm5ts7 :i* are levi$
 on insur]s & surplus l9es insur]s1     
brok]s1 or policyhold]s "u ! laws ( !   
,/ate2  7,b7 to regi/] ) & designate !  
,/ate insurance commission] z its ag5t  
solely = ! purpose ( receiv+ s]vice (   
legal docum5ts or process2  7,c7 to     
submit to an exam9ation ( its f9ancial  
condition by ! ,/ate insurance          
commission] 9 any ,/ate 9 :i* ! issu] is
 do+ bus9ess to det]m9e ! issu]'s       
f9ancial condition1 if--  7i7 ! ,/ate   
insurance commission] ( ! prim>y ,/ate  
has n done an exam9ation )9 ! p]iod     
recomm5d$ by ! ,national ,association ( 
,insurance ,commission]s2 &  7ii7 any   

su* exam9ation is conduct$ 9 accordance 
) ! exam9]s' h&book ( ! ,national       
,association ( ,insurance ,commission]s 
& is coord9at$ to avoid unju/ifi$       
duplication & unju/ifi$ repetition2     
7,d7 to comply ) a lawful ord] issu$--  
7i7 9 a del9qu5cy proce$+ comm5c$ by !  
,/ate insurance commission] if !re has  
be5 a f9d+ ( f9ancial impairm5t "u      
subp>agraph 7,c72 or  7ii7 9 a volunt>y 
dissolution proce$+2  7,e7 to comply )  
an injunction issu$ by a c\rt ( compet5t
 jurisdiction1 ^u a petition by ! ,/ate 
insurance commission] alleg+ t ! issu]  
is 9 haz>d\s f9ancial condition2  7,f7  
to p>ticipate1 on a nondiscrim9atory    
basis1 9 any insurance insolv5cy gu>anty
 association or simil> association to   
:i* a heal? insurance issu] 9 ! ,/ate is
 requir$ to belong2  7,g7 to comply )   
any ,/ate law reg>d+ fraud & abuse 7z   
def9$ 9 section #bgie7aj771 except t if 
! ,/ate seeks an injunction reg>d+ !    
conduct describ$ 9 ?is subp>agraph1 su* 
injunction mu/ be obta9$ f a c\rt (     

compet5t jurisdiction2  7,h7 to comply )
 any ,/ate law reg>d+ unfair claims     
settlem5t practices 7z def9$ 9 section  
#bgie7i772 or  7,i7 to comply ) !       
applicable requirem5ts = indep5d5t      
review "u section #bgih ) respect to    
cov]age (f]$ 9 ! ,/ate2  7#b7 require   
any individual heal? insurance cov]age  
issu$ by ! issu] to be c\nt]sign$ by an 
insurance ag5t or brok] resid+ 9 t      
,second>y ,/ate2 or  7#c7 o!rwise       
discrim9ate aga9/ ! issu] issu+         
insurance 9 bo? ! prim>y ,/ate & 9 any  
second>y ,/ate4  7c7 ,cle> & ,conspicu\s
 ,disclosure ,a heal? insurance issu]   
%all provide ! foll[+ notice1 9 #ab-po9t
 bold type1 9 any insurance cov]age (f]$
 9 a second>y ,/ate "u ?is "p by su* a  
heal? insurance issu] & at r5ewal ( !   
policy1 ) ! #e blank spaces !re9 be+    
appropriately fill$ ) ! "n ( ! heal?    
insurance issu]1 ! "n ( prim>y ,/ate1 ! 
"n ( ! second>y ,/ate1 ! "n ( ! second>y
 ,/ate1 & ! "n ( ! second>y ,/ate1      
respectively1 = ! cov]age conc]n$3 ,?is 

policy is issu$ by  & is gov]n$ by !    
laws & regulations ( ! ,/ate ( 1 & x has
 met all ! laws ( t ,/ate z det]m9$ by t
 ,/ate's ,dep>tm5t ( ,insurance4 ,?is   
policy may be less exp5sive ?an o!rs    
because x is n subject to all ( !       
insurance laws & regulations ( ! ,/ate (
 1 includ+ cov]age ( "s s]vices or      
b5efits m&at$ by ! law ( ! ,/ate ( 4    
,additionally1 ?is policy is n subject  
to all ( ! consum] protection laws or   
re/rictions on rate *anges ( ! ,/ate ( 4
 ,z ) all insurance products1 be=e      
pur*as+ ?is policy1 y %\ld c>efully     
review ! policy & det]m9e :at heal? c>e 
s]vices ! policy cov]s & :at b5efits x  
provides1 includ+ any exclusions1       
limitations1 or conditions = su* s]vices
 or b5efits4  7d7 ,prohibition on ,c]ta9
 ,reclassifications & ,premium          
,increases  7#a7 ,9 g5]al ,= purposes ( 
?is section1 a heal? insurance issu] t  
provides individual heal? insurance     
cov]age to an individual "u ?is "p 9 a  
prim>y or second>y ,/ate may n ^u       

r5ewal--  7,a7 move or reclassify !     
individual insur$ "u ! heal? insurance  
cov]age f ! class su* individual is 9 at
 ! "t ( issue ( ! contract bas$ on !    
heal?-/atus relat$ factors ( !          
individual2 or  7,b7 increase ! premiums
 assess$ ! individual = su* cov]age bas$
 on a heal? /atus-relat$ factor or *ange
 ( a heal? /atus-relat$ factor or ! pa/ 
or prospective claim exp]i5ce ( ! insur$
 individual4  7#b7 ,con/ruction ,no?+ 9 
p>agraph 7#a7 %all be con/ru$ to        
prohibit a heal? insurance issu]--  7,a7
 f t]m9at+ or discont9u+ cov]age or a   
class ( cov]age 9 accordance )          
subsections 7b7 & 7c7 ( section #bgdb2  
7,b7 f rais+ premium rates = all policy 
hold]s )9 a class bas$ on claims        
exp]i5ce2  7,c7 f *ang+ premiums or (f]+
 disc\nt$ premiums to individuals :o    
engage 9 wellness activities at int]vals
 prescrib$ by ! issu]1 if su* premium   
*anges or inc5tives--  7i7 are disclos$ 
to ! consum] 9 ! insurance contract2    
7ii7 are bas$ on specific wellness      

activities t are n applicable to all    
individuals2 &  7iii7 are n obta9able by
 all individuals to :om cov]age is (f]$2
  7,d7 f re9/at+ laps$ cov]age2 or  7,e7
 f retroactively adju/+ ! rates *>g$ an 
insur$ individual if ! initial rates 7  
set bas$ on mat]ial misrepres5tation by 
! individual at ! "t ( issue4  7e7      
,prior ,(f]+ ( ,policy 9 ,prim>y ,/ate  
,a heal? insurance issu] may n (f] =    
sale individual heal? insurance cov]age 
9 a second>y ,/ate unless t cov]age is  
curr5tly (f]$ = sale 9 ! prim>y ,/ate4  
7f7 ,lic5s+ ( ,ag5ts or ,brok]s = ,heal?
 ,insurance ,issu]s ,any ,/ate may      
require t a p]son act+1 or (f]+ to act1 
z an ag5t or brok] = a heal? insurance  
issu] ) respect to ! (f]+ ( individual  
heal? insurance cov]age obta9 a lic5se f
 t ,/ate1 ) commissions or o!r          
comp5sation subject to ! provisions ( ! 
laws ( t ,/ate1 except t a ,/ate may n  
impose any qualification or requirem5t  
:i* discrim9ates aga9/ a nonresid5t ag5t
 or brok]4  7g7 ,docum5ts = ,submission 

to ,/ate ,insurance ,commission] ,ea*   
heal? insurance issu] issu+ individual  
heal? insurance cov]age 9 bo? prim>y &  
second>y ,/ates %all submit--  7#a7 to !
 insurance commission] ( ea* ,/ate 9 :i*
 x int5ds to (f] su* cov]age1 be=e x may
 (f] individual heal? insurance cov]age 
9 su* ,/ate--  7,a7 a copy ( ! plan (   
op]ation or feasibility /udy or any     
simil> /atem5t ( ! policy be+ (f]$ & its
 cov]age 7:i* %all include ! "n ( its   
prim>y ,/ate & its pr9cipal place (     
bus9ess72  7,b7 writt5 notice ( any     
*ange 9 its designation ( its prim>y    
,/ate2 &  7,c7 writt5 notice f ! issu] (
 ! issu]'s compliance ) all ! laws ( !  
prim>y ,/ate2 &  7#b7 to ! insurance    
commission] ( ea* second>y ,/ate 9 :i* x
 (f]s individual heal? insurance        
cov]age1 a copy ( ! issu]'s qu>t]ly     
f9ancial /atem5t submitt$ to ! prim>y   
,/ate1 :i* /atem5t %all be c]tifi$ by an
 indep5d5t public acc\ntant & conta9 a  
/atem5t ( op9ion on loss & loss adju/m5t
 exp5se res]ves made by--  7,a7 a memb] 

( ! ,am]ican ,academy ( ,actu>ies2 or   
7,b7 a qualifi$ loss res]ve speciali/4  
7h7 ,p[] ( ,c\rts ,to ,enjo9 ,conduct   
,no?+ 9 ?is section %all be con/ru$ to  
affect ! au?ority ( any ,f$]al or ,/ate 
c\rt to enjo9--  7#a7 ! solicitation or 
sale ( individual heal? insurance       
cov]age by a heal? insurance issu] to   
any p]son or gr\p :o is n eligible = su*
 insurance2 or  7#b7 ! solicitation or  
sale ( individual heal? insurance       
cov]age t violates ! requirem5ts ( ! law
 ( a second>y ,/ate :i* are describ$ 9  
subp>agraphs 7,a7 ?r\gh 7,h7 ( section  
#bgif7;b77#a74  7i7 ,p[] ( ,second>y    
,/ates ,to ,take ,adm9i/rative ,action  
,no?+ 9 ?is section %all be con/ru$ to  
affect ! au?ority ( any ,/ate to enjo9  
conduct 9 violation ( t ,/ate's laws    
describ$ 9 section #bgif7;b77#a74  7j7  
,/ate ,p[]s ,to ,en=ce ,/ate ,laws  7#a7
 ,9 g5]al ,subject to ! provisions (    
subsection 7b77#a77;,g7 7relat+ to      
injunctions7 & p>agraph 7#b71 no?+ 9 ?is
 section %all be con/ru$ to affect !    

au?ority ( any ,/ate to make use ( any (
 its p[]s to en=ce ! laws ( su* ,/ate ) 
respect to :i* a heal? insurance issu]  
is n exempt "u subsection 7b74  7#b7    
,c\rts ( compet5t jurisdiction ,if a    
,/ate seeks an injunction reg>d+ !      
conduct describ$ 9 p>agraphs 7#a7 & 7#b7
 ( subsection 7h71 su* injunction mu/ be
 obta9$ f a ,f$]al or ,/ate c\rt (      
compet5t jurisdiction4  7k7 ,/ates'     
,au?ority ,to ,sue ,no?+ 9 ?is section  
%all affect ! au?ority ( any ,/ate to   
br+ action 9 any ,f$]al or ,/ate c\rt4  
7l7 ,g5]ally ,applicable ,laws ,no?+ 9  
?is section %all be con/ru$ to affect ! 
applicability ( ,/ate laws g5]ally      
applicable to p]sons or corporations4   
7m7 ,gu>ante$ ,availability ( ,cov]age  
to ,,hipaa ,eligible ,individuals ,to ! 
ext5t t a heal? insurance issu] is (f]+ 
cov]age 9 a prim>y ,/ate t does n       
accommodate resid5ts ( second>y ,/ates  
or does n provide a work+ me*anism =    
resid5ts ( a second>y ,/ate1 & ! issu]  
is (f]+ cov]age "u ?is "p 9 su* second>y

 ,/ate :i* has n adopt$ a qualifi$      
high-risk pool z its acceptable         
alt]native me*anism 7z def9$ 9 section  
#bgdd7;c77#b771 ! issu] %all1 ) respect 
to any individual heal? insurance       
cov]age (f]$ 9 a second>y ,/ate "u ?is  
"p1 comply ) ! gu>ante$ availability    
requirem5ts = eligible individuals 9    
section #bgda4  #bgig4 ,prim>y ,/ate mu/
 meet ,f$]al floor be=e issu] may sell  
into second>y ,/ates ,a heal? insurance 
issu] may n (f]1 sell1 or issue         
individual heal? insurance cov]age 9 a  
second>y ,/ate if ! ,/ate insurance     
commission] does n use a risk-bas$      
capital =mula = ! det]m9ation ( capital 
& surplus requirem5ts = all heal?       
insurance issu]s4  #bgih4 ,limitation on
 individual pur*ase 9 second>y ,/ate    
,effective beg9n+ two ye>s aft] ! date (
 enactm5t ( ?is "p1 an individual 9 a   
,/ate may n buy individual heal?        
insurance cov]age 9 a second>y ,/ate if 
! premium = individual heal? insurance 9
 ! prim>y ,/ate 7) respect to !         

individual7 exce$s ! national av]age    
premium by #aj p]c5t or m4  #bgii4      
,indep5d5t ext]nal appeals proc$ures    
7a7 ,"r to ,ext]nal ,appeal ,a heal?    
insurance issu] may n (f]1 sell1 or     
issue individual heal? insurance cov]age
 9 a second>y ,/ate "u ! provisions (   
?is title unless--  7#a7 bo? ! second>y 
,/ate & ! prim>y ,/ate h legislation or 
regulations 9 place e/abli%+ an         
indep5d5t review process = individuals  
:o are cov]$ by individual heal?        
insurance cov]age1 or  7#b7 9 any case 9
 :i* ! requirem5ts ( subp>agraph 7,a7   
are n met ) respect to ! ei!r ( su*     
,/ates1 ! issu] provides an indep5d5t   
review me*anism sub/antially id5tical 7z
 det]m9$ by ! applicable ,/ate au?ority 
( su* ,/ate7 to t prescrib$ 9 ! ,heal?  
,c>ri] ,ext]nal ,review ,model ,act ( ! 
,national ,association ( ,insurance     
,commission]s = all individuals :o      
pur*ase insurance cov]age "u ! t]ms (   
?is "p1 except t1 "u su* me*anism1 !    
review is conduct$ by an indep5d5t      

m$ical review]1 or a panel ( su*        
review]s1 ) respect to :om ! requirem5ts
 ( subsection 7b7 are met4  7b7         
,qualifications ( ,indep5d5t ,m$ical    
,review]s ,9 ! case ( any indep5d5t     
review me*anism ref]r$ to 9 subsection  
7a77#b7--  7#a7 ,9 g5]al ,9 ref]r+ a    
d5ial ( a claim to an indep5d5t m$ical  
review]1 or to any panel ( su* review]s1
 to conduct indep5d5t m$ical review1 !  
issu] %all ensure t--  7,a7 ea*         
indep5d5t m$ical review] meets !        
qualifications describ$ 9 p>agraphs 7#b7
 & 7#c72  7,b7 ) respect to ea* review1 
ea* review] meets ! requirem5ts (       
p>agraph 7#d7 & ! review]1 or at lea/ #a
 review] on ! panel1 meets ! requirem5ts
 describ$ 9 p>agraph 7#e72 &  7,c7      
comp5sation provid$ by ! issu] to ea*   
review] is consi/5t ) p>agraph 7#f74    
7#b7 ,lic5sure & exp]tise ,ea* indep5d5t
 m$ical review] %all be a physician     
7allopa?ic or o/eopa?ic7 or heal? c>e   
pr(essional :o--  7,a7 is appropriately 
cr$5tial$ or lic5s$ 9 "o or m ,/ates to 

deliv] heal? c>e s]vices2 &  7,b7       
typically treats ! condition1 makes !   
diagnosis1 or provides ! type ( treatm5t
 "u review4  7#c7 ,indep5d5ce  7,a7 ,9  
g5]al ,subject to subp>agraph 7,b71 ea* 
indep5d5t m$ical review] 9 a case %all--
  7i7 n be a relat$ p>ty 7z def9$ 9     
p>agraph 7#g772  7ii7 n h a mat]ial     
familial1 f9ancial1 or pr(essional      
relation%ip ) su* a p>ty2 &  7iii7 n    
o!rwise h a conflict ( int]e/ ) su* a   
p>ty 7z det]m9$ "u regulations74  7,b7  
,exception ,no?+ 9 subp>agraph 7,a7 %all
 be con/ru$ to--  7i7 prohibit an       
individual1 solely on ! basis (         
affiliation ) ! issu]1 f s]v+ z an      
indep5d5t m$ical review] if--  7,i7 a   
non-affiliat$ individual is n reasonably
 available2  7,,ii7 ! affiliat$         
individual is n involv$ 9 ! provision ( 
items or s]vices 9 ! case "u review2    
7,,iii7 ! fact ( su* an affiliation is  
disclos$ to ! issu] & ! enrollee 7or    
au?oriz$ repres5tative7 & nei!r p>ty    
objects2 &  7,,iv7 ! affiliat$          

individual is n an employee ( ! issu] & 
does n provide s]vices exclusively or   
prim>ily to or on behalf ( ! issu]2     
7ii7 prohibit an individual :o has /aff 
privileges at ! in/itution :]e !        
treatm5t involv$ takes place f s]v+ z an
 indep5d5t m$ical review] m]ely on !    
basis ( su* affiliation if ! affiliation
 is disclos$ to ! issu] & ! enrollee 7or
 au?oriz$ repres5tative71 & nei!r p>ty  
objects2 or  7iii7 prohibit receipt (   
comp5sation by an indep5d5t m$ical      
review] f an entity if ! comp5sation is 
provid$ consi/5t ) p>agraph 7#f74  7#d7 
,practic+ heal? c>e pr(essional 9 same  
field  7,a7 ,9 g5]al ,9 a case involv+  
treatm5t1 or ! provision ( items or     
s]vices--  7i7 by a physician1 a review]
 %all be a practic+ physician 7allopa?ic
 or o/eopa?ic7 ( ! same or simil>       
specialty1 z a physician :o1 act+ )9 !  
appropriate scope ( practice )9 ! ,/ate 
9 :i* ! s]vice is provid$ or r5d]$1     
typically treats ! condition1 makes !   
diagnosis1 or provides ! type ( treatm5t

 "u review2 or  7ii7 by a non-physician 
heal? c>e pr(essional1 ! review]1 or at 
lea/ #a memb] ( ! review panel1 %all be 
a practic+ non-physician heal? c>e      
pr(essional ( ! same or simil> specialty
 z ! non-physician heal? c>e pr(essional
 :o1 act+ )9 ! appropriate scope (      
practice )9 ! ,/ate 9 :i* ! s]vice is   
provid$ or r5d]$1 typically treats !    
condition1 makes ! diagnosis1 or        
provides ! type ( treatm5t "u review4   
7,b7 ,practic+ def9$ ,= purposes ( ?is  
p>agraph1 ! t]m practic+ means1 )       
respect to an individual :o is a        
physician or o!r heal? c>e pr(essional1 
t ! individual provides heal? c>e       
s]vices to individual pati5ts on av]age 
at lea/ #b days p] week4  7#e7 ,p$iatric
 exp]tise ,9 ! case ( an ext]nal review 
relat+ to a *ild1 a review] %all h      
exp]tise "u p>agraph 7#b7 9 p$iatrics4  
7#f7 ,limitations on review] comp5sation
 ,comp5sation provid$ by ! issu] to an  
indep5d5t m$ical review] 9 connection ) 
a review "u ?is section %all--  7,a7 n  

exce$ a reasonable level2 &  7,b7 n be  
cont+5t on ! decision r5d]$ by !        
review]4  7#g7 ,relat$ p>ty def9$ ,=    
purposes ( ?is section1 ! t]m relat$    
p>ty means1 ) respect to a d5ial ( a    
claim "u a cov]age relat+ to an         
enrollee1 any ( ! foll[+3  7,a7 ,! issu]
 involv$1 or any fiduci>y1 (fic]1       
director1 or employee ( ! issu]4  7,b7  
,! enrollee 7or au?oriz$ repres5tative74
  7,c7 ,! heal? c>e pr(essional t       
provides ! items or s]vices involv$ 9 ! 
d5ial4  7,d7 ,! in/itution at :i* !     
items or s]vices 7or treatm5t7 involv$ 9
 ! d5ial are provid$4  7,e7 ,!          
manufactur] ( any drug or o!r item t is 
includ$ 9 ! items or s]vices involv$ 9 !
 d5ial4  7,f7 ,any o!r p>ty det]m9$ "u  
any regulations to h a sub/antial int]e/
 9 ! d5ial involv$4  7#h7 ,def9itions ,=
 purposes ( ?is subsection3  7,a7       
,enrollee ,! t]m enrollee means1 )      
respect to heal? insurance cov]age (f]$ 
by a heal? insurance issu]1 an          
individual enroll$ ) ! issu] to receive 

su* cov]age4  7,b7 ,heal? c>e           
pr(essional ,! t]m heal? c>e pr(essional
 means an individual :o is lic5s$1      
accr$it$1 or c]tifi$ "u ,/ate law to    
provide specifi$ heal? c>e s]vices & :o 
is op]at+ )9 ! scope ( su* lic5sure1    
accr$itation1 or c]tification4  #bhjj4  
,en=cem5t  7a7 ,9 ,g5]al ,subject to    
subsection 7b71 ) respect to specific   
individual heal? insurance cov]age !    
prim>y ,/ate = su* cov]age has sole     
jurisdiction to en=ce ! prim>y ,/ate's  
cov]$ laws 9 ! prim>y ,/ate & any       
second>y ,/ate4  7b7 ,second>y ,/ate's  
,au?ority ,no?+ 9 subsection 7a7 %all be
 con/ru$ to affect ! au?ority ( a       
second>y ,/ate to en=ce its laws z set  
=? 9 ! exception specifi$ 9 section     
#bgif7;b77#a74  7c7 ,c\rt ,int]pretation
 ,9 review+ action initiat$ by !        
applicable second>y ,/ate au?ority1 !   
c\rt ( compet5t jurisdiction %all apply 
! cov]$ laws ( ! prim>y ,/ate4  7d7     
,notice ( ,compliance ,failure ,9 ! case
 ( individual heal? insurance cov]age   

(f]$ 9 a second>y ,/ate t fails to      
comply ) ! cov]$ laws ( ! prim>y ,/ate1 
! applicable ,/ate au?ority ( ! second>y
 ,/ate may notify ! applicable ,/ate    
au?ority ( ! prim>y ,/ate4  4  7b7      
,effective ,date ,! am5dm5t made by     
subsection 7a7 %all apply to individual 
heal? insurance cov]age (f]$1 issu$1 or 
sold aft] ! date t is "o ye> aft] ! date
 ( ! enactm5t ( ?is ,act4  7c7 ,,gao    
,ongo+ ,/udy & ,reports  7#a7 ,/udy ,!  
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all conduct an ongo+ /udy conc]n+ !    
effect ( ! am5dm5t made by subsection   
7a7 on--  7,a7 ! numb] ( un9sur$ &      
"u-insur$2  7,b7 ! availability & co/ ( 
heal? insurance policies = individuals )
 pre-exi/+ m$ical conditions2  7,c7 !   
availability & co/ ( heal? insurance    
policies g5]ally2  7,d7 ! elim9ation or 
r$uction ( diff]5t types ( b5efits "u   
heal? insurance policies (f]$ 9 diff]5t 
,/ates2 &  7,e7 cases ( fraud or abuse  
relat+ to heal? insurance cov]age (f]$  
"u su* am5dm5t & ! resolution ( su*     

cases4  7#b7 ,annual reports ,!         
,comptroll] ,g5]al %all submit to       
,congress an annual report1 aft] ! end (
 ea* ( ! #e ye>s foll[+ ! effective date
 ( ! am5dm5t made by subsection 7a71 on 
! ongo+ /udy conduct$ "u p>agraph 7#a74 
7d7 ,sev]ability ,if any provision ( !  
section or ! application ( su* provision
 to any p]son or circum/ance is held to 
be uncon/itutional1 ! rema9d] ( ?is     
section & ! application ( ! provisions (
 su* to any o!r p]son or circum/ance    
%all n be affect$4  ,,iv ,safety ,net   
,re=ms  #dja4 ,requir+ outrea* & cov]age
 be=e expansion ( eligibility  7a7 ,/ate
 *ild heal? plan requir$ ,to specify h[ 
x w a*ieve cov]age = #ij p]c5t ( t>get$ 
l[-,income *ildr5  7#a7 ,9 g5]al        
,section #bajb7;a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acig;bb7a77 is    
am5d$--  7,a7 9 p>agraph 7#f71 by /rik+ 
& at ! end2  7,b7 9 p>agraph 7#g71 by   
/rik+ ! p]iod at ! end & ins]t+ 2 &2 &  
7,c7 by add+ at ! end ! foll[+ new      
p>agraph3  7#h7 h[ ! eligibility &      

b5efits provid$ = "u ! plan = ea* fiscal
 ye> 7beg9n+ ) fiscal ye> #bjae7 w all[ 
= ! ,/ate's annual fund+ allotm5t to    
cov] at lea/ #ij p]c5t ( ! eligible     
t>get$ l[-income *ildr5 9 ! ,/ate4  4   
7#b7 ,effective date ,! am5dm5ts made by
 p>agraph 7#a7 %all apply to ,/ate *ild 
heal? plans = fiscal ye>s beg9n+ )      
fiscal ye> #bjae4  7b7 ,limitation on   
program expansions until l[e/ income    
eligible individuals enroll$ ,section   
#baje7;c7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #acig;dd7c77 is am5d$ by 
add+ at ! end ! foll[+ new p>agraph3    
7#ab7 ,limitation on increas$ cov]age ( 
high] income *ildr5  7,a7 ,9 g5]al ,=   
*ild heal? assi/ance furni%$ 9 a fiscal 
ye> beg9n+ ) fiscal ye> #bjae3  7i7 ,no 
paym5t = *ildr5 ) family income above   
#cjj p]c5t ( pov]ty l9e ,paym5t %all n  
be made "u ?is section = *ild heal?     
assi/ance = a t>get$ l[-income *ild 9 a 
family ! income ( :i* exce$s #cjj p]c5t 
( ! pov]ty l9e applicable to a family ( 
! size involv$4  7ii7 ,special rules =  

paym5t = *ildr5 ) family income above   
#bjj p]c5t ( pov]ty l9e ,9 ! case ( *ild
 heal? assi/ance = a t>get$ l[-income   
*ild 9 a family ! income ( :i* exce$s   
#bjj p]c5t 7b does n exce$ #cjj p]c5t7 (
 ! pov]ty l9e applicable to a family ( !
 size involv$ no paym5t %all be made "u 
?is section = su* assi/ance unless !    
,/ate demon/rates to ! satisfaction ( ! 
,secret>y t--  7,i7 ! ,/ate has met !   
#ij p]c5t retrospective cov]age te/     
specifi$ 9 subp>agraph 7,b77i7 = !      
previ\s fiscal ye>2 &  7,,ii7 ! ,/ate w 
meet ! #ij p]c5t prospective cov]age te/
 specifi$ 9 subp>agraph 7,b77ii7 = !    
fiscal ye>4  7,b7 #ij p]c5t cov]age te/s
  7i7 ,retrospective te/ ,! #ij p]c5t   
retrospective cov]age te/ specifi$ 9 ?is
 clause is1 = a ,/ate = a fiscal ye>1 t 
on av]age dur+ ! fiscal ye>1 ! ,/ate has
 enroll$ "u ?is title or title ,,xix at 
lea/ #ij p]c5t ( ! individuals resid+ 9 
! ,/ate :o--  7,i7 are *ildr5 "u #ai    
ye>s ( age 7or are pregnant wom57 & are 
eligible = m$ical assi/ance "u title    

,,xix2 or  7,,ii7 are t>get$ l[-income  
*ildr5 ^: family income does n exce$    
#bjj p]c5t ( ! pov]ty l9e & :o are      
eligible = *ild heal? assi/ance "u ?is  
title4  7ii7 ,prospective te/ ,! #ij    
p]c5t prospective te/ specifi$ 9 ?is    
clause is1 = a ,/ate = a fiscal ye>1 t  
on av]age dur+ ! fiscal ye>1 ! ,/ate w  
enroll "u ?is title or title ,,xix at   
lea/ #ij p]c5t ( ! individuals resid+ 9 
! ,/ate :o--  7,i7 are *ildr5 "u #ai    
ye>s ( age 7or are pregnant wom57 & are 
eligible = m$ical assi/ance "u title    
,,xix2 or  7,,ii7 are t>get$ l[-income  
*ildr5 ^: family income does n exce$ su*
 p]c5t ( ! pov]ty l9e 79 excess ( #bjj  
p]c5t7 z ! ,/ate elects consi/5t ) ?is  
p>agraph & :o are eligible = *ild heal? 
assi/ance "u ?is title4  7,c7 ,gr&fa!r  
,clauses 7i7 & 7ii7 ( subp>agraph 7,a7  
%all n apply to ! provision ( *ild heal?
 assi/ance--  7i7 to a t>get$ l[-income 
*ild :o is enroll$ = *ild heal?         
assi/ance "u ?is title z ( ,septemb]    
#cj1 #bjab2  7ii7 to a pregnant woman :o

 is enroll$ = assi/ance "u ?is title z (
 ,septemb] #cj1 #bjac1 ?r\gh !          
completion ( ! po/-p>tum p]iod foll[+   
completion ( h] pregnancy2 &  7iii7 =   
items & s]vices furni%$ be=e ,octob] #a1
 #bjad1 to an individual :o is n a      
t>get$ l[-income *ild & :o is enroll$ = 
assi/ance "u ?is title z ( ,septemb]    
#cj1 #bjac4  7,d7 ,treatm5t ( pregnant  
wom5 ,9 ?is p>agraph & sections         
#bajb7;a77#h7 & #bajd7;a77#b71 ! t]m    
t>get$ l[-income *ild includes an       
individual "u age #ai1 includ+ ! p]iod f
 conception to bir?1 :o is eligible =   
*ild heal? assi/ance "u ?is title by    
virtue ( ! def9ition ( ! t]m *ild "u    
section #deg4aj ( title #db1 ,code (    
,f$]al ,regulations4  4  7c7            
,/&>dization ( income det]m9ations  7#a7
 ,9 g5]al ,section #baaj ( ! ,social    
,security ,act 7#db ,u4,s4,c4 #acig;jj7 
is am5d$ by add+ at ! end ! foll[+ new  
subsection3  7d7 ,/&>dization ( income  
det]m9ations ,9 det]m9+ family income "u
 ?is title 7includ+ 9 ! case ( a ,/ate  

*ild heal? plan t provides heal? b5efits
 cov]age 9 ! mann] describ$ 9 section   
#baja7;a77#b771 a ,/ate %all base su*   
det]m9ation on gross income 7includ+    
am\nts t w\ld be includ$ 9 gross income 
if !y 7 n exempt f income taxation7 &   
may only take into consid]ation su*     
income disreg>ds z ! ,secret>y %all     
develop4  4  7#b7 ,effective date  7,a7 
,subject to subp>agraph 7,b71 ! am5dm5t 
made by p>agraph 7#a7 %all apply to     
det]m9ations 7& r$et]m9ations7 ( income 
made on or aft] ,april #a1 #bjab4  7,b7 
,9 ! case ( a ,/ate *ild heal? plan "u  
title ,,xxi ( ! ,social ,security ,act  
:i* ! ,secret>y ( ,heal? & ,human       
,s]vices det]m9es requires ,/ate        
legislation 7o!r ?an legislation        
appropriat+ funds7 9 ord] = ! plan to   
meet ! additional requirem5t impos$ by !
 am5dm5t made by p>agraph 7#a71 ! ,/ate 
*ild heal? plan %all n be reg>d$ z fail+
 to comply ) ! requirem5ts ( su* title  
solely on ! basis ( its failure to meet 
?is additional requirem5t be=e ! fir/   

day ( ! fir/ cal5d> qu>t] beg9n+ aft] ! 
close ( ! fir/ regul> session ( ! ,/ate 
legislature t beg9s aft] ! date ( !     
enactm5t ( ?is ,act4 ,= purposes ( !    
previ\s s5t5ce1 9 ! case ( a ,/ate t has
 a #b-ye> legislative session1 ea* ye> (
 su* session %all be deem$ to be a      
sep>ate regul> session ( ! ,/ate        
legislature4  #djb4 ,eas+ adm9i/rative  
b>ri]s to ,/ate coop]ation )            
employ]-sponsor$ insurance cov]age  7a7 
,requir+ "s cov]age = employ]-,sponsor$ 
insurance "u ,,*ip ,section #bajb7;a7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acig;b7a771 z am5d$ by section         
#dja7;a71 is am5d$--  7#a7 9 p>agraph   
7#g71 by /rik+ & at ! end2  7#b7 9      
p>agraph 7#h71 by /rik+ ! p]iod at ! end
 & ins]t+ 2 &2 &  7#c7 by add+ at ! end 
! foll[+ new p>agraph3  7#i7 effective =
 plan ye>s beg9n+ on or aft] ,octob] #a1
 #bjad1 h[ ! plan w provide = *ild heal?
 assi/ance ) respect to t>get$ l[-income
 *ildr5 cov]$ "u a gr\p heal? plan4  4  
7b7 ,f$]al f9ancial p>ticipation =      

employ]-,sponsor$ insurance ,section    
#baje ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acig;d7 is am5d$--  7#a7 9   
subsection 7a77#a77;,c71 by ins]t+ be=e 
! semicolon at ! end ! foll[+3 &1       
subject to p>agraph 7#c77;,c71 9 ! =m ( 
paym5t ( ! premiums = cov]age "u a gr\p 
heal? plan t includes cov]age ( t>get$  
l[-income *ildr5 & b5efits supplem5tal  
to su* cov]age2 &  7#b7 by am5d+        
p>agraph 7#c7 ( subsection 7c7 to read z
 foll[s3  7#c7 ,pur*ase (               
employ]-sponsor$ insurance  7,a7 ,9     
g5]al ,paym5t may be made to a ,/ate "u 
subsection 7a77#a77;,c71 subject to !   
provisions ( ?is p>agraph1 = ! pur*ase (
 family cov]age "u a gr\p heal? plan t  
includes cov]age ( t>get$ l[-income     
*ildr5 unless su* cov]age w\ld o!rwise  
sub/itute = cov]age t w\ld be provid$ to
 su* *ildr5 b = ! pur*ase ( family      
cov]age4  7,b7 ,waiv] ( c]ta9 provisions
 ,) respect to cov]age describ$ 9       
subp>agraph 7,a7--  7i7 not)/&+ section 
#bajb1 no m9imum b5efits requirem5t 7o!r

 ?an ^? o!rwise applicable ) respect to 
s]vices ref]r$ to 9 section             
#bajb7;a77#g77 "u ?is title %all apply2 
&  7ii7 no limitation on b5efici>y      
co/-%>+ o!rwise applicable "u ?is title 
or title ,,xix %all apply4  7,c7        
,requir$ provision ( supplem5tal b5efits
 ,if ! cov]age describ$ 9 subp>agraph   
7,a7 does n provide cov]age = ! s]vices 
ref]r$ to 9 section #bajb7;a77#g71 !    
,/ate *ild heal? plan %all provide      
cov]age ( su* s]vices z supplem5tal     
b5efits4  7,d7 ,limitation on ,,ffp ,!  
am\nt ( ! paym5t "u p>agraph 7#a77;,c7 =
 cov]age describ$ 9 subp>agraph 7,a7 7& 
supplem5tal b5efits "u subp>agraph 7,c7 
= individuals s cov]$7 dur+ a fiscal ye>
 may n exce$ ! product (--  7i7 !       
national p] capita exp5diture "u ?is    
title 7tak+ into acc\nt bo? ,f$]al &    
,/ate exp5ditures7 = ! previ\s fiscal   
ye> 7z det]m9$ by ! ,secret>y us+ ! be/ 
available data72  7ii7 ! enhanc$ ,,fmap 
= ! ,/ate & fiscal ye> involv$2 &  7iii7
 ! numb] ( t>get$ l[-income *ildr5 = :om

 su* cov]age is provid$4  7,e7 ,volunt>y
 enrollm5t ,a ,/ate *ild heal? plan--   
7i7 may n require a t>get$ l[-income    
*ild to enroll 9 cov]age describ$ 9     
subp>agraph 7,a7 9 ord] to obta9 *ild   
heal? assi/ance "u ?is title2  7ii7 be=e
 provid+ su* *ild heal? assi/ance = su* 
cov]age ( a *ild1 %all make available   
7:i* may be ?r\gh an ,int]net ,web site 
or o!r means includ+ ! ,/ate transp>5cy 
plan portal e/abli%$ "u section #ija ( !
 ,emp[]+ ,pati5ts ,fir/ ,act ( #bjac7 to
 ! p>5t or gu>dian ( ! *ild in=mation on
 ! cov]age available "u ?is title1      
includ+ b5efits & co/-%>+2 &  7iii7 %all
 provide at lea/ "o opportunity p]      
fiscal ye> = b5efici>ies to swit*       
cov]age "u ?is title f cov]age describ$ 
9 subp>agraph 7,a7 to ! cov]age t is    
o!rwise made available "u ?is title4    
7,f7 ,in=mation on cov]age options ,a   
,/ate *ild heal? plan %all--  7i7       
describe h[ ! ,/ate w notify pot5tial   
b5efici>ies ( cov]age describ$ 9        
subp>agraph 7,a72  7ii7 provide su*     

notification 9 writ+ at lea/ dur+ !     
initial application = enrollm5t "u ?is  
title & dur+ r$et]m9ations ( eligibility
 if ! individual 0 enroll$ be=e ,octob] 
#a1 #bjad2 &  7iii7 po/ a description ( 
^! cov]age options on any (ficial ,web  
site t may be e/abli%$ by ! ,/ate 9     
connection ) ! plan1 includ+ ! ,/ate    
transp>5cy plan portal e/abli%$ "u      
section #ija ( ! ,emp[]+ ,pati5ts ,fir/ 
,act ( #bjac4  7,g7 ,semiannual         
v]ification ( cov]age ,if cov]age       
describ$ 9 subp>agraph 7,a7 is provid$  
"u a gr\p heal? plan ) respect to a     
t>get$ l[-income *ild1 ! ,/ate *ild     
heal? plan %all provide = ! collection1 
at lea/ once e six mon?s1 ( pro( f !    
plan t ! *ild is enroll$ 9 su* cov]age4 
7,h7 ,rule ( con/ruction ,no?+ 9 ?is    
section is to be con/ru$ to prohibit a  
,/ate f--  7i7 (f]+ wrap ar\nd b5efits 9
 ord] = a gr\p heal? plan to meet any   
,/ate-e/abli%$ m9imum b5efit            
requirem5ts2  7ii7 e/abli%+ a           
co/-effectiv5ess te/ to qualify =       

cov]age "u su* a plan2  7iii7 e/abli%+  
limits on b5efici>y co/-%>+ "u su* a    
plan2  7iv7 pay+ all or "p ( a          
b5efici>y's co/-%>+ requirem5ts "u su* a
 plan2  7v7 pay+ less ?an ! full co/ ( !
 employee's %>e ( ! premium "u su* a    
plan1 includ+ prorat+ ! co/ ( ! premium 
to pay = only :at ! ,/ate det]m9es is ! 
portion ( ! premium t cov]s t>get$      
l[-income *ildr52  7vi7 us+ ,/ate funds 
to pay = b5efits above ! ,f$]al upp]    
limit e/abli%$ "u subp>agraph 7,c72     
7vii7 all[+ b5efici>ies enroll$ 9 gr\p  
heal? plans f *ang+ plans to ano!r      
cov]age option available "u ?is title at
 any "t2 or  7viii7 provid+ any guidance
 or in=mation x deems appropriate 9 ord]
 to help b5efici>ies make an in=m$      
decision reg>d+ ! option to enroll 9    
cov]age describ$ 9 subp>agraph 7,a74    
7,i7 ,gr\p heal? plan def9$ ,9 ?is      
p>agraph1 ! t]m gr\p heal? plan has !   
mean+ giv5 su* t]m 9 section            
#bgia7;a77#a7 ( ! ,public ,heal? ,s]vice
 ,act 7#db ,u4,s4,c4                    

#cjj;gg-#ia7;a77#a774  4  7c7           
,application "u ,m$icaid ,! ,secret>y ( 
,heal? & ,human ,s]vices %all provide = 
! application ( ! am5dm5ts made by      
subsections 7a7 & 7b7 "u ! ,m$icaid     
program "u title ,,xix ( ! ,social      
,security ,act 9 ! same mann] z su*     
am5dm5ts apply to ,,s*ip "u title ,,xxi 
( su* ,act4  #djc4 ,improv+ b5efici>y   
*oice 9 ,,s*ip  7a7 ,requir+ (f]+ (     
alt]native cov]age options ,section     
#bajb ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acig;b71 z am5d$ by sections 
#dja7;a7 & #djb7;a71 is am5d$--  7#a7 9 
subsection 7a7--  7,a7 9 p>agraph 7#h71 
by /rik+ & at ! end2  7,b7 9 p>agraph   
7#i71 by /rik+ ! p]iod at ! end & ins]t+
 2 &2 &  7,c7 by add+ at ! end ! foll[+ 
new p>agraph3  7#aj7 effective = plan   
ye>s beg9n+ on or aft] ,octob] #a1      
#bjad1 h[ ! plan w provide = *ild heal? 
assi/ance ) respect to t>get$ l[-income 
*ildr5 ?r\gh alt]native cov]age options 
9 accordance ) subsection 7e74  2 &     
7#b7 by add+ at ! end ! foll[+ new      

subsection3  7d7 ,alt]native cov]age    
options  7#a7 ,9 g5]al ,effective       
,octob] #a1 #bjad1 a ,/ate *ild heal?   
plan %all provide = ! (f]+ ( any        
qualifi$ alt]native cov]age t a qualifi$
 entity seeks to (f] to t>get$ l[-income
 *ildr5 ?r\gh ! plan 9 ! ,/ate4  7#b7   
,application ( uni=m f9ancial limitation
 = all alt]native cov]age options ,)    
respect to all qualifi$ alt]native      
cov]age (f]$ 9 a ,/ate1 ! ,/ate *ild    
heal? plan %all e/abli% a uni=m doll>   
limitation on ! p] capita mon?ly am\nt t
 w be paid by ! ,/ate to ! qualifi$     
entity ) respect to su* cov]age provid$ 
to a t>get$ l[-income *ild4 ,su*        
limitation may n be less ?an #ij p]c5t (
 ! p] capita mon?ly paym5t made =       
cov]age (f]$ "u ! ,/ate *ild heal? plan 
t is n 9 ! =m ( an alt]native cov]age   
option4 ,no?+ 9 ?is p>agraph %all be    
con/ru$--  7,a7 z requir+ a ,/ate to    
provide = ! full paym5t ( premiums =    
qualifi$ alt]native cov]age2  7,b7 z    
prev5t+ a ,/ate f *>g+ additional       

premiums to cov] ! diff]5ce betwe5 ! co/
 ( qualifi$ alt]native cov]age & ! am\nt
 ( su* paym5t limitation2 or  7,c7 z    
prev5t+ a ,/ate f us+ its own funds to  
provide a doll> limitation t exce$s !   
,f$]al f9ancial p>ticipation z limit$ "u
 section #baje7;c77#aj74  7#c7 ,treatm5t
 ( l[ co/ cov]age  7,a7 ,9 g5]al ,except
 z provid$ 9 subp>agraph 7,b71 if !     
uni=m doll> limitation "u p>agraph 7#b7 
exce$s ! premium = qualifi$ alt]native  
cov]age = an enrollee1 !n su* excess    
%all be refund$ to ! ,f$]al & ,/ate     
gov]nm5ts 9 ! same proportion z is      
o!rwise applicable to recov]$ funds "u  
?is title4  7,b7 ,exception =           
high-d$uctible heal? plans ,9 ! case (  
cov]age "u a high-d$uctible heal? plan1 
! excess describ$ 9 subp>agraph 7,a7    
%all be deposit$ into a heal? sav+s     
acc\nt e/abli%$ ) respect to su* plan4  
7#d7 ,exemption ,a ,/ate is n subject to
 ! requirem5t ( p>agraph 7#a7 if ! ,/ate
 *ild heal? plan provides1 z ( ! date ( 
! enactm5t ( ?is subsection1 = a ca% out

 or heal? sav+s acc\nt type option = ^? 
enroll$ "u ! plan4  7#e7 ,qualifi$      
alt]native cov]age def9$ ,9 ?is section1
 ! t]m qualifi$ alt]native cov]age means
 heal? insurance cov]age t--  7,a7 meets
 ! cov]age requirem5ts ( section #bajc  
7o!r ?an co/-%>+ requirem5ts ( su*      
section72 &  7,b7 is (f]$ by a qualifi$ 
insur]1 & n directly by ! ,/ate4  7#f7  
,qualifi$ insur] def9$ ,9 ?is section1 !
 t]m qualifi$ insur] means1 ) respect to
 a ,/ate1 an entity t is lic5s$ to (f]  
heal? insurance cov]age 9 ! ,/ate4  4   
7b7 ,f$]al f9ancial p>ticipation =      
qualifi$ alt]native cov]age ,section    
#baje ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acig;d7 is am5d$--  7#a7 9   
subsection 7a77#a77;,c71 z am5d$ by     
section #djb7;b71 by ins]t+ be=e !      
semicolon at ! end ! foll[+3 &1 subject 
to p>agraph 7#ac77;,c71 9 ! =m ( paym5t 
( ! premiums = cov]age = qualifi$       
alt]native cov]age2 &  7#b7 9 subsection
 7c71 z am5d$ by section #dja7;b7 by    
add+ at ! end ! foll[+ new p>agraph3    

7#ac7 ,pur*ase ( qualifi$ alt]native    
cov]age  7,a7 ,9 g5]al ,paym5t may be   
made to a ,/ate "u subsection           
7a77#a77;,c71 subject to ! provisions ( 
?is p>agraph1 = ! pur*ase ( qualifi$    
alt]native cov]age4  7,b7 ,waiv] ( c]ta9
 provisions ,) respect to cov]age       
describ$ 9 subp>agraph 7,a71 no         
limitation on b5efici>y co/-%>+ o!rwise 
applicable "u ?is title or title ,,xix  
%all apply4  7,c7 ,limitation on ,,ffp  
,! am\nt ( ! paym5t "u p>agraph         
7#a77;,c7 = cov]age describ$ 9          
subp>agraph 7,a7 dur+ a fiscal ye> 9 !  
aggregate = all su* cov]age 9 ! ,/ate   
may n exce$ ! product (--  7i7 !        
national p] capita exp5diture "u ?is    
title 7tak+ into acc\nt bo? ,f$]al &    
,/ate exp5ditures7 = ! previ\s fiscal   
ye> 7z det]m9$ by ! ,secret>y us+ ! be/ 
available data72  7ii7 ! enhanc$ ,,fmap 
= ! ,/ate & fiscal ye> involv$2 &  7iii7
 ! numb] ( t>get$ l[-income *ildr5 = :om
 su* cov]age is provid$4  7,d7 ,volunt>y
 enrollm5t ,a ,/ate *ild heal? plan--   

7i7 may n require a t>get$ l[-income    
*ild to enroll 9 cov]age describ$ 9     
subp>agraph 7,a7 9 ord] to obta9 *ild   
heal? assi/ance "u ?is title2  7ii7 be=e
 provid+ su* *ild heal? assi/ance = su* 
cov]age ( a *ild1 %all make available   
7:i* may be ?r\gh an ,int]net ,web site 
or o!r means7 to ! p>5t or gu>dian ( !  
*ild in=mation on ! cov]age available "u
 ?is title1 includ+ b5efits & co/-%>+2 &
  7iii7 %all provide at lea/ "o         
opportunity p] fiscal ye> = b5efici>ies 
to swit* cov]age "u ?is title f cov]age 
describ$ 9 subp>agraph 7,a7 to ! cov]age
 t is o!rwise made available "u ?is     
title4  7,e7 ,in=mation on cov]age      
options ,a ,/ate *ild heal? plan %all-- 
7i7 describe h[ ! ,/ate w notify        
pot5tial b5efici>ies ( cov]age describ$ 
9 subp>agraph 7,a72  7ii7 provide su*   
notification 9 writ+ at lea/ dur+ !     
initial application = enrollm5t "u ?is  
title & dur+ r$et]m9ations ( eligibility
 if ! individual 0 enroll$ be=e ,octob] 
#a1 #bjad2 &  7iii7 po/ a description ( 

^! cov]age options on any (ficial ,web  
site t may be e/abli%$ by ! ,/ate 9     
connection ) ! plan4  7,f7 ,rule (      
con/ruction ,no?+ 9 ?is section is to be
 con/ru$ to prohibit a ,/ate f--  7i7   
e/abli%+ limits on b5efici>y co/-%>+ "u 
su* alt]native cov]age2  7ii7 pay+ all  
or "p ( a b5efici>y's co/-%>+           
requirem5ts "u su* cov]age2  7iii7 pay+ 
less ?an ! full co/ ( a *ild's %>e ( !  
premium "u su* cov]age1 ins(> z !       
premium = su* cov]age exce$s !          
limitation e/abli%$ by ! ,/ate "u       
subp>agraph 7,c72  7iv7 us+ ,/ate funds 
to pay = b5efits above ! ,f$]al upp]    
limit e/abli%$ "u subp>agraph 7,c72 or  
7v7 provid+ any guidance or in=mation x 
deems appropriate 9 ord] to help        
b5efici>ies make an in=m$ decision      
reg>d+ ! option to enroll 9 cov]age     
describ$ 9 subp>agraph 7,a74  4  7c7    
,application "u ,m$icaid ,! ,secret>y ( 
,heal? & ,human ,s]vices %all provide = 
! application ( ! am5dm5ts made by      
subsections 7a7 & 7b7 "u ! ,m$icaid     

program "u title ,,xix ( ! ,social      
,security ,act 9 ! same mann] z su*     
am5dm5ts apply to ,,s*ip "u title ,,xxi 
( su* ,act4  ,v ,lawsuit ,abuse ,re=ms  
#eja4 ,*ange 9 burd5 ( pro( bas$ on     
compliance ) be/ practice guidel9es  7a7
 ,selection & issuance ( be/ practices  
guidel9es  7#a7 ,9 g5]al ,! ,secret>y ( 
,heal? & ,human ,s]vices 79 ?is section 
ref]r$ to z ! ,secret>y7 %all provide = 
! selection & issuance ( be/ practice   
guidel9es = treatm5t ( m$ical conditions
 7ea* 9 ?is subsection ref]r$ to z a    
guidel9e7 9 accordance ) p>agraphs 7#b7 
& 7#c74  7#b7 ,developm5t process ,n    
lat] ?an #ij days aft] ! date ( enactm5t
 ( ?is title1 ! ,secret>y %all ent] into
 a contract ) a qualifi$ physician      
cons5sus-build+ organization 7su* z !   
,physician ,consortium = ,p]=mance      
,improvem5t71 9 conc]t & agreem5t )     
physician specialty organizations1 to   
develop guidel9es4 ,! contract %all     
require t ! organization submit         
guidel9es to ! ag5cy n lat] ?an #ah     

mon?s aft] ! date ( ! enactm5t ( ?is    
title4  7#c7 ,issuance  7,a7 ,9 g5]al ,n
 lat] ?an #b ye>s aft] ! date ( !       
enactm5t ( ?is title1 ! ,secret>y %all1 
aft] notice & opportunity = public      
comm5t1 make a rule t provides = !      
issuance ( ! guidel9es submitt$ "u      
p>agraph 7#b74  7,b7 ,limitation ,!     
,secret>y may n make a rule t includes  
guidel9es o!r ?an ^? submitt$ "u        
p>agraph 7#b74  7,c7 ,dissem9ation ,!   
,secret>y %all po/ su* guidel9es on !   
public ,int]net ,web page ( ! ,dep>tm5t 
( ,heal? & ,human ,s]vices4  7#d7       
,ma9t5ance ,n lat] ?an #d ye>s aft] !   
date ( enactm5t ( ?is title1 & e #b ye>s
 !reaft]1 ! ,secret>y %all review !     
guidel9es & %all1 z necess>y1 ent] into 
contracts simil> to ! contract describ$ 
9 p>agraph 7#b71 & issue guidel9es 9 a  
mann] simil> to ! issuance ( guidel9es  
"u p>agraph 7#c74  7b7 ,use  7#a7 ,use  
by def5dant to *ange ! burd5 ( pro( ,if 
a def5dant 9 a heal? c>e lawsuit relat+ 
to treatm5t ( an individual e/abli%es by

 a prepond]ance ( ! evid5ce t ! treatm5t
 0 provid$ 9 a mann] consi/5t ) an      
applicable guidel9e issu$ "u subsection 
7a71 ! def5dant may n be held liable    
unless ! pla9tiff e/abli%es ! liability 
( ! def5dant by cle> & conv9c+ evid5ce4 
7#b7 ,limitation on introduction z      
evid5ce aga9/ a def5dant ,guidel9es     
issu$ "u subsection 7a7 may n be        
introduc$ z evid5ce ( neglig5ce or      
deviation 9 ! /&>d ( c>e 9 any heal? c>e
 lawsuit unless !y h previ\sly be5      
introduc$ by ! def5dant4  7#c7 ,no      
presumption ( neglig5ce aga9/ a def5dant
 ,!re %all be no presumption ( neglig5ce
 ) respect to treatm5t if a heal? c>e   
provid] provides ! treatm5t 9 a mann]   
inconsi/5t ) su* guidel9es4  7c7        
,con/ruction ,no?+ 9 ?is section %all be
 con/ru$ z prev5t+ a ,/ate f--  7#a7    
replac+ _! curr5t m$ical malpractice    
rules ) rules t rely1 z a def5se1 ^u a  
heal? c>e provid]'s compliance ) a      
guidel9e issu$ "u subsection 7a72 or    
7#b7 apply+ additional guidel9es or     

limitations on liability t are 9        
addition to1 b n 9 lieu (1 ! guidel9es  
issu$ "u subsection 7a74  #ejb4 ,/ate   
grants to create adm9i/rative heal? c>e 
tribunals ,"p ,p ( title ,,iii ( !      
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #bhj;g et seq47 is am5d$ by   
add+ at ! end ! foll[+3  #cii,t4 ,/ate  
grants to create adm9i/rative heal? c>e 
tribunals  7a7 ,9 g5]al ,! ,secret>y may
 aw>d grants to ,/ates = ! developm5t1  
implem5tation1 & evaluation (           
adm9i/rative heal? c>e tribunals t      
comply ) ?is section1 = ! resolution (  
disputes conc]n+ injuries alleg$ly caus$
 by heal? c>e provid]s4  7b7 ,conditions
 = demon/ration grants ,to be eligible  
to receive a grant "u ?is section1 a    
,/ate %all submit to ! ,secret>y an     
application at su* "t1 9 su* mann]1 &   
conta9+ su* in=mation z may be requir$  
by ! ,secret>y4 ,a grant %all be aw>d$  
"u ?is section on su* t]ms & conditions 
z ! ,secret>y det]m9es appropriate4  7c7
 ,repres5tation by c\nsel ,a ,/ate t    

receives a grant "u ?is section may n   
preclude any p>ty to a dispute be=e an  
adm9i/rative heal? c>e tribunal op]at$  
"u su* grant f obta9+ legal             
repres5tation dur+ any review by ! exp]t
 panel "u subsection 7d71 ! adm9i/rative
 heal? c>e tribunal "u subsection 7e71  
or a ,/ate c\rt "u subsection 7f74  7d7 
,exp]t panel review & e>ly (f] guidel9es
  7#a7 ,9 g5]al ,prior to ! submission (
 any dispute conc]n+ injuries alleg$ly  
caus$ by heal? c>e provid]s to an       
adm9i/rative heal? c>e tribunal "u ?is  
section1 su* allegations %all fir/ be   
review$ by an exp]t panel4  7#b7        
,composition  7,a7 ,9 g5]al ,! memb]s ( 
ea* exp]t panel "u ?is subsection %all  
be appo9t$ by ! head ( ! ,/ate ag5cy    
responsible = heal?4 ,ea* exp]t panel   
%all be compos$ ( no few] ?an #c memb]s 
& n m ?an #g memb]s4 ,at lea/ "o-half ( 
su* memb]s %all be m$ical exp]ts 7ei!r  
physicians or heal? c>e pr(essionals74  
7,b7 ,lic5sure & exp]tise ,ea* physician
 or heal? c>e pr(essional appo9t$ to an 

exp]t panel "u subp>agraph 7,a7 %all--  
7i7 be appropriately cr$5tial$ or lic5s$
 9 "o or m ,/ates to deliv] heal? c>e   
s]vices2 &  7ii7 typically treat !      
condition1 make ! diagnosis1 or provide 
! type ( treatm5t t is "u review4  7,c7 
,indep5d5ce  7i7 ,9 g5]al ,subject to   
clause 7ii71 ea* individual appo9t$ to  
an exp]t panel "u ?is p>agraph %all--   
7,i7 n h a mat]ial familial1 f9ancial1  
or pr(essional relation%ip ) a p>ty     
involv$ 9 ! dispute review$ by ! panel2 
&  7,,ii7 n o!rwise h a conflict (      
int]e/ ) su* a p>ty4  7ii7 ,exception   
,no?+ 9 clause 7i7 %all be con/ru$ to   
prohibit an individual :o has /aff      
privileges at an in/itution :]e !       
treatm5t involv$ 9 ! dispute 0 provid$ f
 s]v+ z a memb] ( an exp]t panel m]ely  
on ! basis ( su* affiliation1 if !      
affiliation is disclos$ to ! p>ties &   
nei!r p>ty objects4  7,d7 ,practic+     
heal? c>e pr(essional 9 same field  7i7 
,9 g5]al ,9 a dispute be=e an exp]t     
panel t involves treatm5t1 or !         

provision ( items or s]vices--  7,i7 by 
a physician1 ! m$ical exp]ts on ! exp]t 
panel %all be practic+ physicians       
7allopa?ic or o/eopa?ic7 ( ! same or    
simil> specialty z a physician :o       
typically treats ! condition1 makes !   
diagnosis1 or provides ! type ( treatm5t
 "u review2 or  7,,ii7 by a heal? c>e   
pr(essional o!r ?an a physician1 at lea/
 two m$ical exp]ts on ! exp]t panel %all
 be practic+ physicians 7allopa?ic or   
o/eopa?ic7 ( ! same or simil> specialty 
z ! heal? c>e pr(essional :o typically  
treats ! condition1 makes ! diagnosis1  
or provides ! type ( treatm5t "u review1
 &1 if det]m9$ appropriate by ! ,/ate   
ag5cy1 an additional m$ical exp]t %all  
be a practic+ heal? c>e pr(essional 7o!r
 ?an su* a physician7 ( su* a same or   
simil> specialty4  7ii7 ,practic+ def9$ 
,9 ?is p>agraph1 ! t]m practic+ means1 )
 respect to an individual :o is a       
physician or o!r heal? c>e pr(essional1 
t ! individual provides heal? c>e       
s]vices to individual pati5ts on av]age 

at lea/ #b days a week4  7,e7 ,p$iatric 
exp]tise ,9 ! case ( dispute relat+ to a
 *ild1 at lea/ #a m$ical exp]t on !     
exp]t panel %all h exp]tise describ$ 9  
subp>agraph 7,d77i7 9 p$iatrics4  7#c7  
,det]m9ation ,aft] a review "u p>agraph 
7#a71 an exp]t panel %all make a        
det]m9ation z to ! liability ( ! p>ties 
involv$ & comp5sation4  7#d7 ,acceptance
 ,if ! p>ties to a dispute be=e an exp]t
 panel "u ?is subsection accept !       
det]m9ation ( ! exp]t panel conc]n+     
liability & comp5sation1 su* comp5sation
 %all be paid to ! claimant & ! claimant
 %all agree to =go any fur!r action     
aga9/ ! heal? c>e provid]s involv$4     
7#e7 ,failure to accept ,if any p>ty    
decides n to accept ! exp]t panel's     
det]m9ation1 ! matt] %all be ref]r$ to  
an adm9i/rative heal? c>e tribunal      
creat$ pursuant to ?is section4  7e7    
,adm9i/rative heal? c>e tribunals  7#a7 
,9 g5]al ,^u ! failure ( any p>ty to    
accept ! det]m9ation ( an exp]t panel "u
 subsection 7d71 ! p>ties %all h ! "r to

 reque/ a he>+ conc]n+ ! liability or   
comp5sation involv$ by an adm9i/rative  
heal? c>e tribunal e/abli%$ by ! ,/ate  
involv$4  7#b7 ,requirem5ts ,9 e/abli%+ 
an adm9i/rative heal? c>e tribunal "u   
?is section1 a ,/ate %all--  7,a7 ensure
 t su* tribunals are presid$ ov] by     
special judges ) heal? c>e exp]tise2    
7,b7 provide au?ority to su* judges to  
make b9d+ rul+s1 r5d]$ 9 writt5         
decisions1 on /&>ds ( c>e1 causation1   
comp5sation1 & relat$ issues ) reliance 
on indep5d5t exp]t witnesses commission$
 by ! tribunal2  7,c7 e/abli% gross     
neglig5ce z ! legal /&>d = ! tribunal2  
7,d7 all[ ! admission into evid5ce ( !  
recomm5dation made by ! exp]t panel "u  
subsection 7d72 &  7,e7 provide = an    
appeals process to all[ = review (      
decisions by ,/ate c\rts4  7f7 ,review  
by ,/ate c\rt aft] exhau/ion (          
adm9i/rative rem$ies  7#a7 ,"r to file  
,if any p>ty to a dispute be=e a heal?  
c>e tribunal "u subsection 7e7 is n     
satisfi$ ) ! det]m9ations ( ! tribunal1 

! p>ty %all h ! "r to file _! claim 9 a 
,/ate c\rt ( compet5t jurisdiction4     
7#b7 ,=feit ( aw>ds ,any p>ty fil+ an   
action 9 a ,/ate c\rt 9 accordance )    
p>agraph 7#a7 %all =feit any comp5sation
 aw>d made "u subsection 7e74  7#c7     
,admissibility ,! det]m9ations ( ! exp]t
 panel & ! adm9i/rative heal? c>e       
tribunal pursuant to subsections 7d7 &  
7e7 ) respect to a ,/ate c\rt proce$+ "u
 p>agraph 7#a7 %all be admissible into  
evid5ce 9 any su* ,/ate c\rt proce$+4   
7g7 ,def9ition ,9 ?is section1 ! t]m    
heal? c>e provid] means any p]son or    
entity requir$ by ,/ate or ,f$]al laws  
or regulations to be lic5s$1 regi/]$1 or
 c]tifi$ to provide heal? c>e s]vices1 &
 be+ ei!r s lic5s$1 regi/]$1 or c]tifi$1
 or exempt$ f su* requirem5t by o!r     
/atute or regulation4  7h7 ,au?orization
 ( appropriations ,!re are au?oriz$ to  
be appropriat$ = any fiscal ye> su* sums
 z may be necess>y = purposes ( mak+    
grants to ,/ates "u ?is section4  4     
#ejc4 ,au?orization ( paym5t ( future   

damages to claimants 9 heal? c>e        
lawsuits  7a7 ,9 g5]al ,9 any heal? c>e 
lawsuit1 if an aw>d ( future damages1   
)\t r$uction to pres5t value1 equal+ or 
exce$+ #ej1jjj is made aga9/ a p>ty )   
suffici5t insurance or o!r assets to    
fund a p]iodic paym5t ( su* a judgm5t1 !
 c\rt %all1 at ! reque/ ( any p>ty1 ent]
 a judgm5t ord]+ t ! future damages be  
paid by p]iodic paym5ts1 9 accordance ) 
! ,uni=m ,p]iodic ,paym5t ( ,judgm5ts   
,act promulgat$ by ! ,national ,conf]5ce
 ( ,commission]s on ,uni=m ,/ate ,laws4 
7b7 ,applicability ,?is section applies 
to all actions :i* h n be5 fir/ set =   
trial or retrial be=e ! effective date (
 ?is title4  #ejd4 ,def9itions ,9 ?is   
title3  7#a7 ,alt]native dispute        
resolution sy/em2 ,,adr ,! t]m          
alt]native dispute resolution sy/em or  
,,adr means a sy/em t provides = !      
resolution ( heal? c>e lawsuits 9 a     
mann] o!r ?an ?r\gh a civil action      
br\ght 9 a ,/ate or ,f$]al c\rt4  7#b7  
,claimant ,! t]m claimant means any     

p]son :o br+s a heal? c>e lawsuit1      
includ+ a p]son :o ass]ts or claims a "r
 to legal or equitable contribution1    
indemnity1 or subrogation1 aris+ out ( a
 heal? c>e liability claim or action1 & 
any p]son on ^: behalf su* a claim is   
ass]t$ or su* an action is br\ght1 :e!r 
deceas$1 incompet5t1 or a m9or4  7#c7   
,f$]al tax b5efit ,a claimant %all be   
treat$ z receiv+ a ,f$]al tax b5efit )  
respect to paym5t = items or s]vices    
if--  7,a7 su* paym5t is comp5sation by 
insurance--  7i7 :i* con/itutes m$ical  
c>e1 &  7ii7 ) respect to ! paym5t (    
premiums = :i* ! claimant1 or ! employ] 
( ! claimant1 0 all[$ an exclusion f    
gross income1 a d$uction1 or a cr$it =  
,f$]al income tax purposes1  7,b7 a     
d$uction 0 all[$ ) respect to su* paym5t
 = ,f$]al income tax purposes1 or  7,c7 
su* paym5t 0 f an ,ar*] ,,msa 7z def9$ 9
 section #bbj7;d7 ( ! ,int]nal ,rev5ue  
,code ( #aihf71 a heal? sav+s acc\nt 7z 
def9$ 9 section #bbc7;d7 ( su* ,code71 a
 flexible sp5d+ arrangem5t 7z def9$ 9   

section #ajf7;c77#b7 ( su* ,code71 or a 
heal? reimbursem5t arrangem5t :i* is    
treat$ z employ]-provid$ cov]age "u an  
accid5t or heal? plan = purposes (      
section #ajf ( su* ,code4  7#d7 ,heal?  
c>e lawsuit ,! t]m heal? c>e lawsuit    
means any heal? c>e liability claim     
conc]n+ ! provision ( heal? c>e goods or
 s]vices br\ght 9 a ,f$]al c\rt or 9 a  
,/ate c\rt or pursuant to an alt]native 
dispute resolution sy/em1 if su* claim  
conc]ns items or s]vices = :i* cov]age  
is provid$ "u title ,,xviii1 ,,xix1 or  
,,xxi ( ! ,social ,security ,act or =   
:i* ! claimant receives a ,f$]al tax    
b5efit1 aga9/ a heal? c>e provid]1 a    
heal? c>e organization1 or !            
manufactur]1 di/ributor1 suppli]1       
m>ket]1 promot]1 or sell] ( a m$ical    
product1 reg>dless ( ! !ory ( liability 
on :i* ! claim is bas$1 or ! numb] (    
claimants1 pla9tiffs1 def5dants1 or o!r 
p>ties1 or ! numb] ( claims or causes ( 
action1 9 :i* ! claimant alleges a heal?
 c>e liability claim4 ,su* t]m does n   

include a claim or action :i* is bas$ on
 crim9al liability2 :i* seeks civil f9es
 or p5alties paid to ,f$]al gov]nm5t2 or
 :i* is gr\nd$ 9 antitru/4  7#e7 ,heal? 
c>e liability action ,! t]m heal? c>e   
liability action means a civil action   
br\ght 9 a ,/ate or ,f$]al c\rt or      
pursuant to an alt]native dispute       
resolution sy/em1 aga9/ a heal? c>e     
provid]1 a heal? c>e organization1 or ! 
manufactur]1 di/ributor1 suppli]1       
m>ket]1 promot]1 or sell] ( a m$ical    
product1 reg>dless ( ! !ory ( liability 
on :i* ! claim is bas$1 or ! numb] (    
pla9tiffs1 def5dants1 or o!r p>ties1 or 
! numb] ( causes ( action1 9 :i* !      
claimant alleges a heal? c>e liability  
claim4  7#f7 ,heal? c>e liability claim 
,! t]m heal? c>e liability claim means a
 dem& by any p]son1 :e!r or n pursuant  
to ,,adr1 aga9/ a heal? c>e provid]1    
heal? c>e organization1 or !            
manufactur]1 di/ributor1 suppli]1       
m>ket]1 promot]1 or sell] ( a m$ical    
product1 includ+1 b n limit$ to1        

?ird-p>ty claims1 cross-claims1         
c\nt]-claims1 or contribution claims1   
:i* are bas$ ^u ! provision (1 use (1 or
 paym5t = 7or ! failure to provide1 use1
 or pay =7 heal? c>e s]vices or m$ical  
products1 reg>dless ( ! !ory ( liability
 on :i* ! claim is bas$1 or ! numb] (   
pla9tiffs1 def5dants1 or o!r p>ties1 or 
! numb] ( causes ( action4  7#g7 ,heal? 
c>e organization ,! t]m heal? c>e       
organization means any p]son or entity  
:i* is obligat$ to provide or pay =     
heal? b5efits "u any heal? plan1 includ+
 any p]son or entity act+ "u a contract 
or arrangem5t ) a heal? c>e organization
 to provide or adm9i/] any heal? b5efit4
  7#h7 ,heal? c>e provid] ,! t]m heal?  
c>e provid] means any p]son or entity   
requir$ by ,/ate or ,f$]al laws or      
regulations to be lic5s$1 regi/]$1 or   
c]tifi$ to provide heal? c>e s]vices1 & 
be+ ei!r s lic5s$1 regi/]$1 or c]tifi$1 
or exempt$ f su* requirem5t by o!r      
/atute or regulation4  7#i7 ,heal? c>e  
goods or s]vices ,! t]m heal? c>e goods 

or s]vices means any goods or s]vices   
provid$ by a heal? c>e organization1    
provid]1 or by any individual work+ "u !
 sup]vision ( a heal? c>e provid]1 t    
relates to ! diagnosis1 prev5tion1 or   
treatm5t ( any human disease or         
impairm5t1 or ! assessm5t or c>e ( !    
heal? ( human be+s4  7#aj7 ,m$ical      
product ,! t]m m$ical product means a   
drug1 device1 or biological product     
int5d$ = humans1 & ! t]ms drug1 device1 
& biological product h ! mean+s giv5 su*
 t]ms 9 sections #bja7;g77#a7 & #bja7;h7
 ( ! ,f$]al ,food1 ,drug & ,cosmetic    
,act 7#ba ,u4,s4,c4 #cba7;g77#a7 & 7h77 
& section #cea7;a7 ( ! ,public ,heal?   
,s]vice ,act 7#db ,u4,s4,c4 #bfb7;a771  
respectively1 includ+ any compon5t or   
raw mat]ial us$ !re91 b exclud+ heal?   
c>e s]vices4  7#aa7 ,m$ical treatm5t ,! 
t]m m$ical treatm5t means ! provision ( 
any goods or s]vices by a heal? c>e     
provid] or by any individual work+ "u ! 
sup]vision ( a heal? c>e provid]1 t     
relates to ! diagnosis1 prev5tion1 or   

treatm5t ( any human disease or         
impairm5t1 or ! assessm5t or c>e ( !    
heal? ( human be+s4  7#ab7 ,recov]y ,!  
t]m recov]y means ! net sum recov]$ aft]
 d$uct+ any disbursem5ts or co/s incurr$
 9 connection ) prosecution or settlem5t
 ( ! claim1 includ+ all co/s paid or    
advanc$ by any p]son4 ,co/s ( heal? c>e 
incurr$ by ! pla9tiff & ! attorneys'    
(fice ov]head co/s or *>ges = legal     
s]vices are n d$uctible disbursem5ts or 
co/s = su* purpose4  7#ac7 ,/ate ,! t]m 
,/ate means ea* ( ! sev]al ,/ates1 !    
,di/rict ( ,columbia1 ! ,commonweal? (  
,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1   
,am]ican ,samoa1 ! ,nor!rn ,m>iana      
,isl&s1 ! ,tru/ ,t]ritory ( ! ,pacific  
,isl&s1 & any o!r t]ritory or possession
 ( ! ,unit$ ,/ates1 or any political    
subdivision !re(4  #eje4 ,effect on o!r 
laws  7a7 ,vacc9e ,injury  7#a7 ,to !   
ext5t t title ,,xxi ( ! ,public ,heal?  
,s]vice ,act e/abli%es a ,f$]al rule (  
law applicable to a civil action br\ght 
= a vacc9e-relat$ injury or dea?--  7,a7

 ?is title does n affect ! application (
 ! rule ( law to su* an action2 &  7,b7 
any rule ( law prescrib$ by ?is title 9 
conflict ) a rule ( law ( su* title     
,,xxi %all n apply to su* action4  7#b7 
,if !re is an aspect ( a civil action   
br\ght = a vacc9e-relat$ injury or dea? 
to :i* a ,f$]al rule ( law "u title     
,,xxi ( ! ,public ,heal? ,s]vice ,act   
does n apply1 !n ?is title or o!rwise   
applicable law 7z det]m9$ "u ?is title7 
w apply to su* aspect ( su* action4  7b7
 ,o!r f$]al law ,except z provid$ 9 ?is 
section1 no?+ 9 ?is title %all be deem$ 
to affect any def5se available to a     
def5dant 9 a heal? c>e lawsuit or action
 "u any o!r provision ( ,f$]al law4     
#ejf4 ,applicability2 effective date    
,?is title %all apply to any heal? c>e  
lawsuit br\ght 9 a ,f$]al or ,/ate c\rt1
 or subject to an alt]native dispute    
resolution sy/em1 t is initiat$ on or   
aft] ! date ( ! enactm5t ( ?is title1   
except t any heal? c>e lawsuit aris+ f  
an injury occurr+ prior to ! date ( !   

enactm5t ( ?is title %all be gov]n$ by !
 applicable /atute ( limitations        
provisions 9 effect at ! "t ! injury    
occurr$4  ,,vi ,wellness & ,prev5tion   
#fja4 ,provid+ f9ancial inc5tives =     
treatm5t compliance  7a7 ,limitation on 
exception = wellness programs "u ,,hipaa
 discrim9ation rules  7#a7 ,employee    
,retirem5t ,income ,security ,act (     
#aigd am5dm5t ,section #gjb7;b77#b7 ( ! 
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4             
#aahb7;b77#b77 is am5d$ by add+ aft] &  
bel[ subp>agraph 7,b7 ! foll[+3  ,9     
apply+ subp>agraph 7,b71 a gr\p heal?   
plan 7or a heal? insurance issu] )      
respect to heal? insurance cov]age7 may 
v>y premiums & co/-%>+ by up to #ej     
p]c5t ( ! value ( ! b5efits "u ! plan   
7or cov]age7 bas$ on p>ticipation 7or   
lack ( p>ticipation7 9 a /&>ds-bas$     
wellness program4 4  7#b7 ,,phsa am5dm5t
 ,section #bgjb7;b77#b7 ( ! ,public     
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg-#a7;b77#b77 is am5d$ by add+    

aft] & bel[ subp>agraph 7,b7 ! foll[+3  
,9 apply+ subp>agraph 7,b71 a gr\p heal?
 plan 7or a heal? insurance issu] )     
respect to heal? insurance cov]age7 may 
v>y premiums & co/-%>+ by up to #ej     
p]c5t ( ! value ( ! b5efits "u ! plan   
7or cov]age7 bas$ on p>ticipation 7or   
lack ( p>ticipation7 9 a /&>ds-bas$     
wellness program4 4  7#c7 ,,irc am5dm5t 
,section #ihjb7;b77#b7 ( ! ,int]nal     
,rev5ue ,code ( #aihf is am5d$ by add+  
aft] & bel[ subp>agraph 7,b7 ! foll[+3  
,9 apply+ subp>agraph 7,b71 a gr\p heal?
 plan may v>y premiums & co/-%>+ by up  
to #ej p]c5t ( ! value ( ! b5efits "u ! 
plan bas$ on p>ticipation 7or lack (    
p>ticipation7 9 a /&>ds-bas$ wellness   
program4 4  7b7 ,effective date ,!      
am5dm5ts made by subsection 7a7 %all    
apply to plan ye>s beg9n+ m ?an #a ye>  
aft] ! date ( ! enactm5t ( ?is ,act4    
,,vii ,transp>5cy & ,insurance ,re=m    
,measures  #gja4 ,receipt & response to 
reque/s = claim in=mation  7a7 ,9 g5]al 
,title ,,xxvii ( ! ,public ,heal?       

,s]vice ,act is am5d$ by ins]t+ aft]    
section #bgac ! foll[+ new section3     
#bgad4 ,receipt & response to reque/s = 
claim in=mation  7a7 ,requirem5t  7#a7  
,9 g5]al ,9 ! case ( heal? insurance    
cov]age (f]$ 9 connection ) a gr\p heal?
 plan1 n lat] ?an ! #cj? day aft] ! date
 a heal? insurance issu] receives a     
writt5 reque/ = a writt5 report ( claim 
in=mation f ! plan1 plan sponsor1 or    
plan adm9i/rator1 ! heal? insurance     
issu] %all provide ! reque/+ p>ty !     
report1 subject to ! succe$+ provisions 
( ?is section4  7#b7 ,exception ,! heal?
 insurance issu] is n obligat$ to       
provide a report "u ?is subsection      
reg>d+ a p>ticul> employ] or gr\p heal? 
plan m ?an twice 9 any #ab-mon? p]iod & 
is n obligat$ to provide su* a report 9 
! case ( an employ] ) few] ?an #ej      
employees4  7#c7 ,deadl9e ,a plan1 plan 
sponsor1 or plan adm9i/rator mu/ reque/ 
a report "u ?is subsection be=e or on ! 
second anniv]s>y ( ! date ( t]m9ation ( 
cov]age "u a gr\p heal? plan issu$ by ! 

heal? insurance issu]4  7b7 ,=m (       
report2 in=mation ,to be includ$  7#a7  
,9 g5]al ,a heal? insurance issu] %all  
provide ! report ( claim in=mation "u   
subsection 7a7--  7,a7 9 a writt5       
report2  7,b7 ?r\gh an electronic file  
transmitt$ by secure electronic mail or 
a file transf] protocol site2 or  7,c7  
by mak+ ! requir$ in=mation available   
?r\gh a secure ,web site or ,web portal 
accessible by ! reque/+ plan1 plan      
sponsor1 or plan adm9i/rator4  7#b7     
,in=mation to be includ$ ,a report (    
claim in=mation provid$ "u subsection   
7a7 %all conta9 all in=mation available 
to ! heal? insurance issu] t is         
responsive to ! reque/ made "u su*      
subsection1 includ+1 subject to         
subsection 7c71 protect$ heal?          
in=mation1 = ! #cf-mon? p]iod prec$+ !  
date ( ! report or ! p]iod specifi$ by  
subp>agraphs 7,d71 7,e71 & 7,f7 (       
p>agraph 7#c71 if applicable1 or = !    
entire p]iod ( cov]age1 :i*ev] p]iod is 
%ort]4  7#c7 ,requir$ in=mation ,subject

 to subsection 7c71 a report provid$ "u 
subsection 7a7 %all include ! foll[+3   
7,a7 ,aggregate paid claims exp]i5ce by 
mon?1 includ+ claims exp]i5ce = m$ical1 
d5tal1 & ph>macy b5efits1 z applicable4 
7,b7 ,total premium paid by mon?4  7,c7 
,total numb] ( cov]$ employees on a     
mon?ly basis by cov]age ti]1 includ+    
:e!r cov]age 0 =--  7i7 an employee     
only2  7ii7 an employee ) dep5d5ts only2
  7iii7 an employee ) a sp\se only2 or  
7iv7 an employee ) a sp\se & dep5d5ts4  
7,d7 ,! total doll> am\nt ( claims p5d+ 
z ( ! date ( ! report4  7,e7 ,a sep>ate 
description & individual claims report =
 any individual ^: total paid claims    
exce$ #ae1jjj dur+ ! #ab-mon? p]iod     
prec$+ ! date ( ! report1 includ+ !     
foll[+ in=mation relat$ to ! claims = t 
individual--  7i7 a unique id5tify+     
numb]1 *>act]i/ic1 or code = !          
individual2  7ii7 ! am\nts paid2  7iii7 
dates ( s]vice2 &  7iv7 applicable      
proc$ure codes & diagnosis codes4  7,f7 
,= claims t are n "p ( ! in=mation      

describ$ 9 a previ\s subp>agraph1 a     
/atem5t describ+ prec]tification reque/s
 = hospital /ays ( #e days or long] t 7 
made dur+ ! #cj-;day p]iod prec$+ ! date
 ( ! report4  7c7 ,limitations on       
disclosure  7#a7 ,9 g5]al ,a heal?      
insurance issu] may n disclose protect$ 
heal? in=mation 9 a report ( claim      
in=mation provid$ "u ?is section if !   
heal? insurance issu] is prohibit$ f    
disclos+ t in=mation "u ano!r ,/ate or  
,f$]al law t imposes m /r+5t privacy    
re/rictions ?an ^? impos$ "u ,f$]al law 
"u ! ,,hipaa privacy regulations4 ,to   
)hold in=mation 9 accordance ) ?is      
subsection1 ! heal? insurance issu]     
mu/--  7,a7 notify ! plan1 plan sponsor1
 or plan adm9i/rator reque/+ ! report t 
in=mation is be+ )held2 &  7,b7 provide 
to ! plan1 plan sponsor1 or plan        
adm9i/rator a li/ ( categories ( claim  
in=mation t ! heal? insurance issu] has 
det]m9$ are subject to ! m /r+5t privacy
 re/rictions "u ano!r ,/ate or ,f$]al   
law4  7#b7 ,protection ,a plan sponsor  

is entitl$ to receive protect$ heal?    
in=mation "u subp>agraph 7,e7 & 7,f7 (  
subsection 7b77#c7 & subsection 7d7 only
 aft] an appropriately au?oriz$         
repres5tative ( ! plan sponsor makes to 
! heal? insurance issu] a c]tification  
sub/antially simil> to ! foll[+         
c]tification3 ,i h]eby c]tify t ! plan  
docum5ts comply ) ! requirem5ts (       
section #afd4ejd7;f77#b7 ( title #de1   
,code ( ,f$]al ,regulations1 & t ! plan 
sponsor w safegu>d & limit ! use &      
disclosure ( protect$ heal? in=mation t 
! plan sponsor may receive f ! gr\p     
heal? plan to p]=m ! plan adm9i/ration  
functions44  7#c7 ,results ,a plan      
sponsor t does n provide ! c]tification 
requir$ by p>agraph 7#b7 is n entitl$ to
 receive ! protect$ heal? in=mation     
describ$ by subp>agraphs 7,e7 & 7,f7 (  
subsection 7b77#c7 & subsection 7d71 b  
is entitl$ to receive a report ( claim  
in=mation t includes ! in=mation        
describ$ by subp>agraphs 7,a7 ?r\gh 7,d7
 ( subsection 7b77#c74  7#d7 ,in=mation 

,9 ! case ( a reque/ made "u subsection 
7a7 aft] ! date ( t]m9ation ( cov]age1 !
 report mu/ conta9 all in=mation        
available to ! heal? insurance issu] z (
 ! date ( ! report t is responsive to ! 
reque/1 includ+ protect$ heal?          
in=mation1 & includ+ ! in=mation        
describ$ by subsection 7b77#c71 = !     
p]iod describ$ by subsection 7b77#b7    
prec$+ ! date ( t]m9ation ( cov]age or =
 ! entire policy p]iod1 :i*ev] p]iod is 
%ort]4 ,not)/&+ ?is subsection1 ! report
 may n include ! protect$ heal?         
in=mation describ$ by subp>agraphs 7,e7 
& 7,f7 ( subsection 7b77#c7 unless a    
c]tification has be5 provid$ 9          
accordance ) p>agraph 7#b74  7d7 ,reque/
 = additional in=mation  7#a7 ,review   
,on receipt ( ! report requir$ by       
subsection 7a71 ! plan1 plan sponsor1 or
 plan adm9i/rator may review ! report &1
 n lat] ?an ! #aj? day aft] ! date !    
report is receiv$1 may make a writt5    
reque/ to ! heal? insurance issu] =     
additional in=mation 9 accordance ) ?is 

subsection = specifi$ individuals4  7#b7
 ,reque/ ,) respect to a reque/ =       
additional in=mation conc]n+ specifi$   
individuals = :om claims in=mation has  
be5 provid$ "u subsection 7b77#c77;,e71 
! heal? insurance issu] %all provide    
additional in=mation on ! prognosis or  
recov]y if available &1 = individuals 9 
active case managem5t1 ! mo/ rec5t case 
managem5t in=mation1 includ+ any future 
expect$ co/s & treatm5t plan1 t relate  
to ! claims = t individual4  7#c7       
,response ,! heal? insurance issu] mu/  
respond to ! reque/ = additional        
in=mation "u ?is subsection n lat] ?an !
 #ae? day aft] ! date ( su* reque/      
unless ! reque/+ plan1 plan sponsor1 or 
plan adm9i/rator agrees to a reque/ =   
additional "t4  7#d7 ,limitation ,!     
heal? insurance issu] is n requir$ to   
produce ! report describ$ by ?is        
subsection unless a c]tification has be5
 provid$ 9 accordance ) subsection      
7c77#b74  7#e7 ,compliance ) section    
does n create liability ,a heal?        

insurance issu] t releases in=mation1   
includ+ protect$ heal? in=mation1 9     
accordance ) ?is subsection has n       
violat$ a /&>d ( c>e & is n liable =    
civil damages result+ f1 & is n subject 
to crim9al prosecution =1 releas+ t     
in=mation4  7e7 ,limitation on          
preemption ,no?+ 9 ?is section is meant 
to limit ,/ates f enact+ additional laws
 9 addition to ! provisions ( ?is       
section1 b n 9 lieu ( su* provisions4   
7f7 ,def9itions ,9 ?is section3  7#a7 ,!
 t]ms employ]1 plan adm9i/rator1 & plan 
sponsor h ! mean+s giv5 su* t]ms 9      
section #c ( ! ,employee ,retirem5t     
,income ,security ,act ( #aigd4  7#b7 ,!
 t]m ,,hipaa privacy regulations has !  
mean+ giv5 su* t]m 9 section            
#aahj7;b77#c7 ( ! ,social ,security     
,act4  7#c7 ,! t]m protect$ heal?       
in=mation has ! mean+ giv5 su* t]m "u ! 
,,hipaa privacy regulations4  4  7b7    
,effective date ,! am5dm5t made by      
subsection 7a7 %all take effect on !    
date ( ! enactm5t ( ?is ,act4  ,,viii   

,quality  #hja4 ,prohibition on c]ta9   
uses ( data obta9$ f comp>ative         
effectiv5ess rese>* or f pati5t-c5t]$   
outcomes rese>*2 acc\nt+ = p]sonaliz$   
m$ic9e & diff]5ces 9 pati5t treatm5t    
response  7a7 ,9 g5]al ,not)/&+ any o!r 
provision ( law1 ! ,secret>y ( ,heal? & 
,human ,s]vices--  7#a7 %all n use data 
obta9$ f ! conduct ( comp>ative         
effectiv5ess rese>* or pati5t-c5t]$     
outcomes rese>*1 includ+ su* rese>* t is
 conduct$ or support$ us+ funds         
appropriat$ "u ! ,am]ican ,recov]y &    
,re9ve/m5t ,act ( #bjji 7,public ,law   
#aaa-e71 to d5y cov]age ( an item or    
s]vice "u a ,f$]al heal? c>e program 7z 
def9$ 9 section #aabh;,b7f7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acbj;a-#g;b7f7772 &  7#b7 %all ensure t
 comp>ative effectiv5ess rese>* &       
pati5t-c5t]$ outcomes rese>* conduct$ or
 support$ by ! ,f$]al ,gov]nm5t acc\nts 
= factors contribut+ to diff]5ces 9 !   
treatm5t response & treatm5t pref]5ces (
 pati5ts1 includ+ pati5t-report$        

outcomes1 g5omics & p]sonaliz$ m$ic9e1 !
 unique ne$s ( heal? disp>ity           
populations1 & indirect pati5t b5efits4 
7b7 ,consultation & approval requir$    
,no?+ ! ,f$]al ,coord9at+ ,c\ncil =     
,comp>ative ,effectiv5ess ,rese>* f9ds c
 be releas$ 9 f9al =m until aft]        
consultation ) & approv$ by relevant    
physician specialty organizations4  7c7 
,rule ( con/ruction ,no?+ 9 ?is section 
%all be con/ru$ z affect+ ! au?ority ( !
 ,commission] ( ,food & ,drugs "u !     
,f$]al ,food1 ,drug1 & ,cosmetic ,act or
 ! ,public ,heal? ,s]vice ,act4  #hjb4  
,e/abli%m5t ( p]=mance-bas$ quality     
measures ,n lat] ?an ,janu>y #a1 #bjad1 
! ,secret>y ( ,heal? & ,human ,s]vices  
%all submit to ,congress a proposal = a 
=maliz$ process = ! developm5t (        
p]=mance-bas$ quality measures t c\ld be
 appli$ to physicians' s]vices "u !     
,m$ic>e program "u title ,,xviii ( !    
,social ,security ,act4 ,su* proposal   
%all be 9 conc]t & agreem5t ) !         
,physician ,consortium = ,p]=mance      

,improvem5t & %all only utilize measures
 agre$ ^u by ea* physician specialty    
organization4  ,,ix ,/ate ,transp>5cy   
,plan ,portal  #ija4 ,provid+ in=mation 
on heal? cov]age options & heal? c>e    
provid]s  7a7 ,/ate-,bas$ portal ,a     
,/ate 7by itself or jo9tly ) o!r ,/ates7
 may contract ) a private entity to     
e/abli% a ,heal? ,plan & ,provid]       
,portal ,web site 7ref]r$ to 9 ?is      
section z a plan portal7 = ! purposes ( 
provid+ /&>diz$ in=mation--  7#a7 on    
heal? insurance plans t h be5 c]tifi$ to
 be available = pur*ase 9 t ,/ate2 &    
7#b7 on price & quality in=mation on    
heal? c>e provid]s 7includ+ physicians1 
hospitals1 & o!r heal? c>e in/itutions74
  7b7 ,prohibitions  7#a7 ,direct       
,enrollm5t ,a plan portal may n directly
 enroll individuals 9 heal? insurance   
plans or "u a ,/ate ,m$icaid plan or a  
,/ate *ildr5's heal? insurance plan4    
7#b7 ,conflicts ( int]e/  7,a7          
,companies ,a heal? insurance issu] (f]+
 a heal? insurance plan ?r\gh a plan    

portal may n--  7i7 be ! private entity 
develop+ & ma9ta9+ a plan portal "u ?is 
section2 or  7ii7 h an own]%ip int]e/ 9 
su* private entity or 9 ! plan portal4  
7,b7 ,individuals ,an individual employ$
 by a heal? insurance issu] (f]+ a heal?
 insurance plan ?r\gh a plan portal may 
n s]ve z a director or (fic] =--  7i7 ! 
private entity develop+ & ma9ta9+ a plan
 portal "u ?is section2 or  7ii7 ! plan 
portal4  7c7 ,con/ruction ,no?+ 9 ?is   
section %all be con/ru$ to prohibit     
heal? insurance brok]s & ag5ts f--  7#a7
 utiliz+ ! plan portal = any purpose2 or
  7#b7 m>ket+ or (f]+ heal? insurance   
products4  7d7 ,/ate def9$ ,9 ?is       
section1 ! t]m ,/ate has ! mean+ giv5   
su* t]m = purposes ( title ,,xix ( !    
,social ,security ,act4  7e7 ,heal?     
insurance plans ,= purposes ( ?is       
section1 ! t]m heal? insurance plan does
 n include cov]age ( except$ b5efits1 z 
def9$ 9 section #bgia7;c7 ( ! ,public   
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg-#ia7;c774  ,x ,pati5t ,fre$om ( 

,*oice  #ajja4 ,gu>antee+ fre$om ( *oice
 & contract+ = pati5ts "u ,m$ic>e  7a7  
,9 g5]al ,section #ahjb ( ! ,social     
,security ,act 7#db ,u4,s4,c4 #acie;a7  
is am5d$ to read z foll[s3  #ahjb4      
,fre$om ( *oice & contract+ by pati5t   
gu>ante$  7a7 ,basic fre$om ( *oice ,any
 individual entitl$ to insurance b5efits
 "u ?is title may obta9 heal? s]vices f 
any in/itution1 ag5cy1 or p]son qualifi$
 to p>ticipate "u ?is title if su*      
in/itution1 ag5cy1 or p]son und]takes to
 provide t individual su* s]vices4  7b7 
,fre$om ,to contract by ,m$ic>e         
b5efici>ies  7#a7 ,9 g5]al ,subject to !
 provisions ( ?is subsection1 no?+ 9 ?is
 title %all prohibit a ,m$ic>e b5efici>y
 f ent]+ into a contract ) an eligible  
pr(essional 7:e!r or n ! pr(essional is 
a p>ticipat+ or non-p>ticipat+ physician
 or practition]7 = any item or s]vice   
cov]$ "u ?is title4  7#b7 ,submission ( 
claims ,any ,m$ic>e b5efici>y t ent]s   
into a contract "u ?is section ) an     
eligible pr(essional %all be p]mitt$ to 

submit a claim = paym5t "u ?is title =  
s]vices furni%$ by su* pr(essional1 &   
su* paym5t %all be made 9 ! am\nt t w\ld
 o!rwise apply to su* pr(essional "u ?is
 title except t :]e su* pr(essional is  
consid]$ to be non-p>ticipat+1 paym5t   
%all be paid z if ! pr(essional 7       
p>ticipat+4 ,paym5t made "u ?is title = 
any item or s]vice provid$ "u ! contract
 %all n r5d] ! pr(essional a p>ticipat+ 
or non-p>ticipat+ physician or          
practition]1 & z su*1 requirem5ts ( ?is 
title t may o!rwise apply to a          
p>ticipat+ or non-p>ticipat+ physician  
or practition] w\ld n apply ) respect to
 any items or s]vices furni%$ "u !      
contract4  7#c7 ,b5efici>y protections  
7,a7 ,9 g5]al ,p>agraph 7#a7 %all n     
apply to any contract unless--  7i7 !   
contract is 9 writ+1 is sign$ by !      
,m$ic>e b5efici>y & ! eligible          
pr(essional1 & e/abli%es all t]ms ( !   
contract 7includ+ specific paym5t =     
items & s]vices cov]$ by ! contract7    
be=e any item or s]vice is provid$      

pursuant to ! contract1 & ! b5efici>y   
%all be held h>mless = any subsequ5t    
paym5t *>g$ = an item or s]vice 9 excess
 ( ! am\nt e/abli%$ "u ! contract dur+ !
 p]iod ! contract is 9 effect2  7ii7 !  
contract conta9s ! items describ$ 9     
subp>agraph 7,b72 &  7iii7 ! contract is
 n ent]$ into at a "t :5 ! ,m$ic>e      
b5efici>y is fac+ an em]g5cy m$ical     
condition or urg5t heal? c>e situation4 
7,b7 ,items requir$ to be includ$ 9     
contract ,any contract to provide items 
& s]vices to :i* p>agraph 7#a7 applies  
%all cle>ly indicate to ! ,m$ic>e       
b5efici>y t by sign+ su* contract !     
b5efici>y--  7i7 agrees to be           
responsible = paym5t to su* eligible    
pr(essional = su* items or s]vices "u ! 
t]ms ( & am\nts e/abli%$ "u ! contract2 
7ii7 agrees to be responsible = submitt+
 claims "u ?is title to ! ,secret>y1 &  
to any o!r supplem5tal insurance plan t 
may provide supplem5tal insurance1 = su*
 items or s]vices furni%$ "u ! contract 
if su* items or s]vices are cov]$ by ?is

 title1 unless o!rwise provid$ 9 !      
contract "u subp>agraph 7,c77i72 &      
7iii7 ackn[l$ges t no limits or o!r     
paym5t inc5tives t may o!rwise apply "u 
?is title 7su* z ! limits "u subsection 
7g7 ( section #ahdh or inc5tives "u     
subsection 7a77#e71 7m71 7q71 & 7p7 (   
su* section7 %all apply to am\nts t may 
be *>g$1 or paid to a b5efici>y =1 su*  
items or s]vices4  ,su* contract %all   
also cle>ly indicate :e!r ! eligible    
pr(essional is exclud$ f p>ticipation "u
 ! ,m$ic>e program "u section #aabh4    
7,c7 ,b5efici>y elections "u ! contract 
,any ,m$ic>e b5efici>y t ent]s into a   
contract "u ?is section may elect to    
negotiate1 z a t]m ( ! contract1 a      
provision "u :i*--  7i7 ! eligible      
pr(essional %all file claims on behalf (
 ! b5efici>y ) ! ,secret>y & any        
supplem5tal insurance plan = items or   
s]vices furni%$ "u ! contract if su*    
items or s]vices are cov]$ "u ?is title 
or "u ! plan2 &  7ii7 ! b5efici>y       
assigns paym5t to ! eligible pr(essional

 = any claims fil$ by1 or on behalf (1 !
 b5efici>y ) ! ,secret>y & any          
supplem5tal insurance plan = items or   
s]vices furni%$ "u ! contract4  7,d7    
,exclusion ( dual eligible individuals  
,p>agraph 7#a7 %all n apply to any      
contract if a b5efici>y :o is eligible =
 m$ical assi/ance "u title ,,xix is a   
p>ty to ! contract4  7#d7 ,limitation on
 actual *>ge & claim submission         
requirem5t n applicable ,section        
#ahdh7;g7 %all n apply ) respect to any 
item or s]vice provid$ to a ,m$ic>e     
b5efici>y "u a contract describ$ 9      
p>agraph 7#a74  7#e7 ,con/ruction ,no?+ 
9 ?is section %all be con/ru$--  7,a7 to
 prohibit any eligible pr(essional f    
ma9ta9+ an election & act+ z a          
p>ticipat+ or non-p>ticipat+ physician  
or practition] ) respect to any pati5t n
 cov]$ "u a contract e/abli%$ "u ?is    
section2 &  7,b7 z *ang+ ! items &      
s]vices = :i* an eligible pr(essional   
may bill "u ?is title4  7#f7 ,def9itions
 ,9 ?is subsection3  7,a7 ,m$ic>e       

b5efici>y ,! t]m ,m$ic>e b5efici>y means
 an individual :o is entitl$ to b5efits 
"u "p ,a or enroll$ "u "p ,b4  7,b7     
,eligible pr(essional ,! t]m eligible   
pr(essional has ! mean+ giv5 su* t]m 9  
section #ahdh7k77#c77;,b74  7,c7        
,em]g5cy m$ical condition ,! t]m em]g5cy
 m$ical condition means a m$ical        
condition manife/+ itself by acute      
symptoms ( suffici5t sev]ity 7includ+   
sev]e pa97 su* t a prud5t layp]son1 ) an
 av]age k ( heal? & m$ic9e1 c\ld        
reasonably expect ! abs5ce ( imm$iate   
m$ical att5tion to result 9--  7i7 s]i\s
 jeop>dy to ! heal? ( ! individual or1 9
 ! case ( a pregnant woman1 ! heal? ( ! 
woman or h] unborn *ild2  7ii7 s]i\s    
impairm5t to bodily functions2 or  7iii7
 s]i\s dysfunction ( any bodily organ or
 "p4  7,d7 ,urg5t heal? c>e situation ,!
 t]m urg5t heal? c>e situation means    
s]vices furni%$ to an individual :o     
requires s]vices to be furni%$ )9 #ab   
h\rs 9 ord] to avoid ! likely onset ( an
 em]g5cy m$ical condition4  4  #ajjb4   

,preemption ( ,/ate laws limit+ *>ges = 
eligible pr(essional s]vices  7a7 ,9    
g5]al ,no ,/ate may impose a limit on ! 
am\nt ( *>ges = s]vices1 furni%$ by an  
eligible pr(essional 7z def9$ 9         
subsection 7k77#c77;,b7 ( section #ahdh 
( ! ,social ,security ,act1 #db         
,u4,s4,c4 #aciew-#d71 = :i* paym5t is   
made "u su* section1 & any su* limit is 
h]eby preempt$4  7b7 ,/ate ,9 ?is       
section1 ! t]m ,/ate includes ! ,di/rict
 ( ,columbia1 ,pu]to ,rico1 ! ,virg9    
,isl&s1 ,guam1 & ,am]ican ,samoa4       
#ajjc4 ,heal? c>e provid] lic5sure _c be
 condition$ on p>ticipation 9 a heal?   
plan  7a7 ,9 g5]al ,! ,secret>y ( ,heal?
 & ,human ,s]vices & any ,/ate 7z a     
condition ( receiv+ ,f$]al f9ancial     
p>ticipation "u title ,,xix ( ! ,social 
,security ,act7 may n require any heal? 
c>e provid] to p>ticipate 9 any heal?   
plan z a condition ( lic5sure ( !       
provid] 9 any ,/ate4  7b7 ,def9itions ,9
 ?is section3  7#a7 ,heal? plan ,! t]m  
heal? plan has ! mean+ giv5 su* t]m 9   

section #aaga7e7 ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #acbj;d7#e774  7#b7 
,heal? c>e provid] ,! t]m heal? c>e     
provid] means any p]son or entity t is  
requir$ by ,/ate or ,f$]al laws or      
regulations to be lic5s$1 regi/]$1 or   
c]tifi$ to provide heal? c>e s]vices &  
is s lic5s$1 regi/]$1 or c]tifi$1 or    
exempt$ f su* requirem5t by o!r /atute  
or regulation4  7#c7 ,/ate ,! t]m ,/ate 
has ! mean+ giv5 su* t]m = purposes (   
title ,,xix ( ! ,social ,security ,act4 
#ajjd4 ,bad debt d$uction = doctors to  
p>tially (fset ! co/ ( provid+          
uncomp5sat$ c>e requir$ to be provid$ "u
 am5dm5ts made by ! ,em]g5cy ,m$ical    
,treatm5t & ,labor ,act  7a7 ,9 g5]al   
,section #aff ( ! ,int]nal ,rev5ue ,code
 ( #aihf 7relat+ to bad debts7 is am5d$ 
by r$esignat+ subsection 7f7 z          
subsection 7g7 & by ins]t+ aft]         
subsection 7e7 ! foll[+ new subsection3 
7f7 ,bad debt treatm5t = doctors ,to    
p>tially (fset co/ ( provid+ uncomp5sat$
 c>e requir$ ,to be provid$  7#a7 ,am\nt

 ( d$uction  7,a7 ,9 g5]al ,= purposes (
 subsection 7a71 ! basis = det]m9+ !    
am\nt ( any d$uction = an eligible      
,,emtala debt %all be treat$ z be+ equal
 to ! ,m$ic>e paym5t am\nt4  7,b7       
,m$ic>e paym5t am\nt ,= purposes (      
subp>agraph 7,a71 ! ,m$ic>e paym5t am\nt
 ) respect to an eligible ,,emtala debt 
is ! fee s*$ule am\nt e/abli%$ "u       
section #ahdh ( ! ,social ,security ,act
 = ! physicians' s]vice 7to :i* su* debt
 relates7 z if ! s]vice 7 provid$ to an 
individual enroll$ "u "p ,b ( title     
,,xviii ( su* ,act4  7#b7 ,eligible     
,,emtala debt ,= purposes ( ?is section1
 ! t]m eligible ,,emtala debt means any 
debt if--  7,a7 su* debt arose z a      
result ( physicians' s]vices--  7i7 :i* 
7 p]=m$ 9 an ,,emtala hospital by a     
bo>d-c]tifi$ physician 7:e!r z "p (     
m$ical scre5+ or necess>y /abiliz+      
treatm5t & :e!r z an em]g5cy dep>tm5t   
physician1 z an on-call physician1 or   
o!rwise71 &  7ii7 :i* 7 requir$ to be   
provid$ "u section #ahfg ( ! ,social    

,security ,act 7#db ,u4,s4,c4 #acie;dd71
 &  7,b7 su* debt is ow$--  7i7 to su*  
physician1 or  7ii7 to an entity if--   
7,i7 su* entity is a corporation & !    
sole %>ehold] ( su* corporation is su*  
physician1 or  7,,ii7 su* entity is a   
p>tn]%ip & any d$uction "u ?is          
subsection ) respect to su* debt is     
allocat$ to su* physician or to an      
entity describ$ 9 subclause 7,i74  7#c7 
,bo>d-c]tifi$ physician ,= purposes (   
?is subsection1 ! t]m bo>d-c]tifi$      
physician means any physician 7z def9$ 9
 section #ahfa7r7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciex7r777 :o is   
c]tifi$ by ! ,am]ican ,bo>d ( ,em]g5cy  
,m$ic9e or o!r appropriate m$ical       
specialty bo>d = ! specialty 9 :i* !    
physician practices1 or :o meets        
comp>able requirem5ts1 z id5tifi$ by !  
,secret>y ( ! ,treasury 9 consultation )
 ,secret>y ( ,heal? & ,human ,s]vices4  
7#d7 ,o!r def9itions ,= purposes ( ?is  
subsection--  7,a7 ,,emtala hospital ,! 
t]m ,,emtala hospital means any hospital

 hav+ a hospital em]g5cy dep>tm5t :i* is
 requir$ to comply ) section #ahfg ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acie;dd7 7relat+ to exam9ation &       
treatm5t = em]g5cy m$ical conditions &  
wom5 9 labor74  7,b7 ,physicians'       
s]vices ,! t]m physicians' s]vices has !
 mean+ giv5 su* t]m 9 section #ahfa7q7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #aciex7q774  4  7b7 ,effective date ,! 
am5dm5ts made by ?is section %all apply 
to debts aris+ f s]vices p]=m$ 9 taxable
 ye>s beg9n+ aft] ! date ( ! enactm5t ( 
?is ,act4  #ajje4 ,"r ( contract ) heal?
 c>e provid]s  7a7 ,9 g5]al ,! ,secret>y
 ( ,heal? & ,human ,s]vices %all n      
preclude an enrollee1 p>ticipant1 or    
b5efici>y 9 a heal? b5efits plan f ent]+
 into any contract or arrangem5t = heal?
 c>e ) any heal? c>e provid]4  7b7      
,heal? b5efits plan def9$  7#a7 ,9 g5]al
 ,9 ?is section1 subject to p>agraph    
7#b71 ! t]m heal? b5efits plan means any
 ( ! foll[+3  7,a7 ,gr\p heal? plan 7z  
def9$ 9 section #bgia ( ! ,public ,heal?

 ,s]vice ,act74  7,b7 ,heal? insurance  
cov]age 7z def9$ 9 section #bgia ( su*  
,act74  7,c7 ,a heal? b5efits plan "u   
*apt] #hi ( title #e1 ,unit$ ,/ates     
,code4  7#b7 ,exclusion ( ,m$icaid &    
,tric>e ,su* t]m does n include a heal? 
plan p>ticipat+ 9--  7,a7 ! ,m$icaid    
program "u title ,,xix ( ! ,social      
,security ,act2 or  7,b7 ! ,,tric>e     
program "u *apt] #ee ( title #aj1 ,unit$
 ,/ates ,code4  7c7 ,heal? c>e provid]  
def9$ ,9 ?is section1 ! t]m heal? c>e   
provid] means--  7#a7 a physician1 z    
def9$ 9 p>agraphs 7#a71 7#b71 7#c71 &   
7#d7 ( section #ahfa7r7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#aciex7r772 &  7#b7 a heal? c>e         
practition] describ$ 9 section          
#ahdb7;b77#ah77;,c7 ( su* ,act 7#db     
,u4,s4,c4 #acieu7b77#ah77;,c774  ,,xi   
,inc5tives to r$uce physician %ortages  
,a ,f$]ally ,support$ ,/ud5t ,loan      
,funds = ,m$ical ,/ud5ts  #aaja4        
,f$]ally support$ /ud5t loan funds =    
m$ical /ud5ts  7a7 ,prim>y heal? c>e    

m$ical /ud5ts ,subp>t ,,ii ( "p ,a ( !  
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #bibq et seq47 is am5d$--     
7#a7 by r$esignat+ section #gce z       
section #gbi2 &  7#b7 9 subsection 7f7 (
 section #gbi 7z s r$esignat$71 by /rik+
 is au?oriz$ to be appropriat$          
#aj1jjj1jjj = ea* ( ! fiscal ye>s #aiid 
?r\gh #aiif & ins]t+ are au?oriz$ to be 
appropriat$ su* sums z may be necess>y =
 fiscal ye> #bjad & ea* fiscal ye>      
!reaft]4  7b7 ,o!r m$ical /ud5ts ,"p ,a 
( title ,,vii ( ! ,public ,heal? ,s]vice
 ,act 7#db ,u4,s4,c4 #bib et seq47 is   
am5d$ by add+ at ! end ! foll[+3  ,,iii 
,f$]ally ,support$ ,/ud5t ,loan ,funds =
 ,c]ta9 ,m$ical ,/ud5ts  #gcj4 ,s*ool   
loan funds = c]ta9 m$ical /ud5ts  7a7   
,fund agreem5ts ,= ! purpose describ$ 9 
subsection 7b71 ! ,secret>y is au?oriz$ 
to ent] into an agreem5t = ! e/abli%m5t 
& op]ation ( a /ud5t loan fund ) any    
public or nonpr(it s*ool ( m$ic9e or    
o/eopa?ic m$ic9e4  7b7 ,purpose ,!      
purpose ( ?is subp>t is to provide =    

loans to m$ical /ud5ts :o w\ld be       
eligible = a loan "u subp>t ,,ii1 except
 = ! /ud5t's decision to ent] a resid5cy
 tra9+ program 9 a field o!r ?an prim>y 
heal? c>e4  7c7 ,comm5cem5t ( repaym5t  
p]iod ,! repaym5t p]iod = a loan "u ?is 
section %all n beg9 be=e ! end ( any    
p]iod dur+ :i* ! /ud5t is p>ticipat+ 9  
an int]n%ip1 resid5cy1 or fell[%ip tra9+
 program directly relat$ to ! field (   
m$ic9e :i* ! /ud5t agrees to ent]       
pursuant to subsection 7d74  7d7        
,requirem5ts = /ud5ts ,ea* agreem5t "u  
?is section = ! e/abli%m5t ( a /ud5t    
loan fund %all provide t ! s*ool (      
m$ic9e or o/eopa?ic m$ic9e w make a loan
 to a /ud5t f su* fund only if ! /ud5t  
agrees--  7#a7 to ent] & complete a     
resid5cy tra9+ program 79 a field (     
m$ic9e o!r ?an prim>y heal? c>e7 n lat] 
?an a p]iod det]m9$ by ! ,secret>y to be
 reasonable aft] ! date on :i* ! /ud5t  
graduates f su* s*ool2 &  7#b7 to       
practice m$ic9e ?r\gh ! date on :i* !   
loan is repaid 9 full4  7e7 ,requirem5ts

 = s*ools ,! provisions ( section       
#gbc7;b7 7reg>d+ graduates 9 prim>y     
heal? c>e7 %all n apply to a /ud5t loan 
fund e/abli%$ "u ?is section4  7f7      
,applicability ( o!r provisions ,except 
z inconsi/5t ) ?is section1 ! provisions
 ( subp>t ,,ii %all apply to ! program (
 /ud5t loan funds e/abli%$ "u ?is       
section to ! same ext5t & 9 ! same mann]
 z su* provisions apply to ! program (  
/ud5t loan funds e/abli%$ "u subp>t     
,,ii4  7g7 ,au?orization (              
appropriations ,to c>ry out ?is section1
 !re are au?oriz$ to be appropriat$ su* 
sums z may be necess>y = fiscal ye>     
#bjad & ea* fiscal ye> !reaft]4  4  ,b  
,loan ,=giv5ess = ,prim>y ,c>e ,provid]s
  #aaaa4 ,loan =giv5ess = prim>y c>e    
provid]s  7a7 ,9 g5]al ,! ,secret>y (   
,heal? & ,human ,s]vices %all c>ry out a
 program ( ent]+ into contracts )       
eligible individuals "u :i*--  7#a7 !   
individual agrees to s]ve = a p]iod ( n 
less ?an #e ye>s z a prim>y c>e provid]2
 &  7#b7 9 consid]ation ( su* s]vice1 ! 

,secret>y agrees to pay n m ?an #ej1jjj 
on ! pr9cipal & int]e/ on ! individual's
 graduate educational loans4  7b7       
,eligibility ,to be eligible to ent]    
into a contract "u subsection 7a71 an   
individual mu/--  7#a7 h a graduate     
degree 9 m$ic9e1 o/eopa?ic m$ic9e1 or   
ano!r heal? pr(ession f an accr$it$ 7z  
det]m9$ by ! ,secret>y ( ,heal? & ,human
 ,s]vices7 in/itution ( high] education2
 &  7#b7 h practic$ z a prim>y c>e      
provid] = a p]iod 7exclud+ any resid5cy 
or fell[%ip tra9+ p]iod7 ( n less ?an-- 
7,a7 #e ye>s2 or  7,b7 #c ye>s 9 a      
m$ically und]s]v$ community 7z def9$ 9  
section #gii;,b ( ! ,public ,heal?      
,s]vice ,act 7#db ,u4,s4,c4 #biep774    
7c7 ,in/allm5ts ,paym5ts "u ?is section 
may be made 9 in/allm5ts ( n m ?an      
#aj1jjj = ea* ye> ( s]vice describ$ 9   
subsection 7a77#a74  7d7 ,applicability 
( c]ta9 provisions ,! provisions (      
subp>t ,,iii ( "p ,d ( title ,,iii ( !  
,public ,heal? ,s]vice ,act %all1 except
 z inconsi/5t ) ?is section1 apply to ! 

program e/abli%$ "u ?is section 9 ! same
 mann] & to ! same ext5t z su*          
provisions apply to ! ,national ,heal?  
,s]vice ,corps ,loan ,repaym5t ,program 
e/abli%$ 9 su* subp>t4  ,,xii ,quality  
,heal? ,c>e ,coalition  #abja4 ,quality 
,heal? ,c>e ,coalition  7a7 ,application
 ( ! ,f$]al antitru/ laws to heal? c>e  
pr(essionals negotiat+ ) heal? plans    
7#a7 ,9 g5]al ,any heal? c>e            
pr(essionals :o are engag$ 9            
negotiations ) a heal? plan reg>d+ !    
t]ms ( any contract "u :i* !            
pr(essionals provide heal? c>e items or 
s]vices = :i* b5efits are provid$ "u su*
 plan %all1 9 connection ) su*          
negotiations1 be exempt f ! ,f$]al      
antitru/ laws4  7#b7 ,limitation  7,a7  
,no new "r = collective cessation (     
s]vice ,! exemption provid$ 9 p>agraph  
7#a7 %all n conf] any new "r to         
p>ticipate 9 any collective cessation ( 
s]vice to pati5ts n already p]mitt$ by  
exi/+ law4  7,b7 ,no *ange 9 ,national  
,labor ,relations ,act ,?is section     

applies only to heal? c>e pr(essionals  
exclud$ f ! ,national ,labor ,relations 
,act4 ,no?+ 9 ?is section %all be       
con/ru$ z *ang+ or am5d+ any provision (
 ! ,national ,labor ,relations ,act1 or 
z affect+ ! /atus ( any gr\p ( p]sons "u
 t ,act4  7#c7 ,no application to ,f$]al
 programs ,no?+ 9 ?is section %all apply
 to negotiations betwe5 heal? c>e       
pr(essionals & heal? plans p]ta9+ to    
b5efits provid$ "u any ( ! foll[+3  7,a7
 ,! ,m$ic>e ,program "u title ,,xviii ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acie et seq474  7,b7 ,! ,m$icaid       
program "u title ,,xix ( ! ,social      
,security ,act 7#db ,u4,s4,c4 #acif et  
seq474  7,c7 ,! ,,s*ip program "u title 
,,xxi ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acig;aa et seq474  7,d7      
,*apt] #ee ( title #aj1 ,unit$ ,/ates   
,code 7relat+ to m$ical & d5tal c>e =   
memb]s ( ! uni=m$ s]vices74  7,e7 ,*apt]
 #ag ( title #ch1 ,unit$ ,/ates ,code   
7relat+ to ,vet]ans' m$ical c>e74  7,f7 
,*apt] #hi ( title #e1 ,unit$ ,/ates    

,code 7relat+ to ! ,f$]al employees'    
heal? b5efits program74  7,g7 ,! ,indian
 ,heal? ,c>e ,improvem5t ,act 7#be      
,u4,s4,c4 #afja et seq474  7b7          
,def9itions ,9 ?is section1 ! foll[+    
def9itions %all apply3  7#a7 ,antitru/  
laws ,! t]m antitru/ laws--  7,a7 has ! 
mean+ giv5 x 9 subsection 7a7 ( ! fir/  
section ( ! ,clayton ,act 7#ae ,u4,s4,c4
 #ab7;a771 except t su* t]m includes    
section #e ( ! ,f$]al ,trade ,commission
 ,act 7#ae ,u4,s4,c4 #de7 to ! ext5t su*
 section applies to unfair me?ods (     
competition2 &  7,b7 includes any ,/ate 
law simil> to ! laws ref]r$ to 9        
subp>agraph 7,a74  7#b7 ,gr\p heal? plan
 ,! t]m gr\p heal? plan means an        
employee welf>e b5efit plan to ! ext5t t
 ! plan provides m$ical c>e 7includ+    
items & s]vices paid = z m$ical c>e7 to 
employees or _! dep5d5ts 7z def9$ "u !  
t]ms ( ! plan7 directly or ?r\gh        
insurance1 reimbursem5t1 or o!rwise4    
7#c7 ,gr\p heal? plan1 heal? insurance  
issu] ,! t]ms gr\p heal? plan & heal?   

insurance issu] include a ?ird-p>ty     
adm9i/rator or o!r p]son act+ = or on   
behalf ( su* plan or issu]4  7#d7 ,heal?
 c>e s]vices ,! t]m heal? c>e s]vices   
means any s]vices = :i* paym5t may be   
made "u a heal? plan1 includ+ s]vices   
relat$ to ! deliv]y or adm9i/ration (   
su* s]vices4  7#e7 ,heal? c>e           
pr(essional ,! t]m heal? c>e pr(essional
 means any individual or entity t       
provides heal? c>e items or s]vices1    
treatm5t1 assi/ance ) activities ( daily
 liv+1 or m$ications to pati5ts & :o1 to
 ! ext5t requir$ by ,/ate or ,f$]al law1
 possesses specializ$ tra9+ t conf]s    
exp]tise 9 ! provision ( su* items or   
s]vices1 treatm5t1 assi/ance1 or        
m$ications4  7#f7 ,heal? insurance      
cov]age ,! t]m heal? insurance cov]age  
means b5efits consi/+ ( m$ical c>e      
7provid$ directly1 ?r\gh insurance or   
reimbursem5t1 or o!rwise & includ+ items
 & s]vices paid = z m$ical c>e7 "u any  
hospital or m$ical s]vice policy or     
c]tificate1 hospital or m$ical s]vice   

plan contract1 or heal? ma9t5ance       
organization contract (f]$ by a heal?   
insurance issu]4  7#g7 ,heal? insurance 
issu] ,! t]m heal? insurance issu] means
 an insurance company1 insurance s]vice1
 or insurance organization 7includ+ a   
heal? ma9t5ance organization7 t is      
lic5s$ to engage 9 ! bus9ess ( insurance
 9 a ,/ate & t is subject to ,/ate law  
regulat+ insurance4 ,su* t]m does n     
include a gr\p heal? plan4  7#h7 ,heal? 
ma9t5ance organization ,! t]m heal?     
ma9t5ance organization means--  7,a7 a  
f$]ally qualifi$ heal? ma9t5ance        
organization 7z def9$ 9 section         
#acja7;a7 ( ! ,public ,heal? ,s]vice    
,act 7#db ,u4,s4,c4 #cjj;e7a7772  7,b7  
an organization recogniz$ "u ,/ate law z
 a heal? ma9t5ance organization2 or     
7,c7 a simil> organization regulat$ "u  
,/ate law = solv5cy 9 ! same mann] & to 
! same ext5t z su* a heal? ma9t5ance    
organization4  7#i7 ,heal? plan ,! t]m  
heal? plan means a gr\p heal? plan or a 
heal? insurance issu] t is (f]+ heal?   

insurance cov]age4  7#aj7 ,m$ical c>e ,!
 t]m m$ical c>e means am\nts paid =--   
7,a7 ! diagnosis1 cure1 mitigation1     
treatm5t1 or prev5tion ( disease1 or    
am\nts paid = ! purpose ( affect+ any   
/ructure or function ( ! body2 &  7,b7  
transportation prim>ily = & ess5tial to 
receiv+ items & s]vices ref]r$ to 9     
subp>agraph 7,a74  7#aa7 ,p]son ,! t]m  
p]son includes a ,/ate or unit ( local  
gov]nm5t4  7#ab7 ,/ate ,! t]m ,/ate     
includes ! sev]al ,/ates1 ! ,di/rict (  
,columbia1 ,pu]to ,rico1 ! ,virg9 ,isl&s
 ( ! ,unit$ ,/ates1 ,guam1 ,am]ican     
,samoa1 & ! ,commonweal? ( ! ,nor!rn    
,m>iana ,isl&s4  7c7 ,effective date    
,?is section %all take effect on ! date 
( ! enactm5t ( ?is ,act & %all n apply )
 respect to conduct occurr+ be=e su*    
date4  ,,xiii ,(fsets  ,a ,discretion>y 
sp5d+ limits  #acja4 ,discretion>y sp5d+
 limits ,! ,balanc$ ,budget & ,em]g5cy  
,deficit ,control ,act ( #aihe1 z am5d$ 
by section #aja ( ! ,budget ,control    
,act ( #bjaa1 is am5d$--  7#a7 9 section

 #bea7;c7 7#b ,u4,s4,c4 #ija7;c77--     
7,a7 by /rik+ & at ! end ( p>agraph     
7#i72 &  7,b7 by ins]t+ aft] p>agraph   
7#aj7 ! foll[+3  7#aa7 ) respect to     
fiscal ye> #bjbb--  7,a7 = ! security   
category1 #ffb1efb1eaj1jjj 9 budget     
au?ority2 &  7,b7 = ! nonsecurity       
category1 #dif1gbg1dij1jjj 9 budget     
au?ority2 &  7#ab7 ) respect to fiscal  
ye> #bjbc--  7,a7 = ! security category1
 #fhi1gjd1bij1jjj 9 budget au?ority2 &  
7,b7 = ! nonsecurity category1          
#die1cbe1gaj1jjj2  2 &  7#b7 9 section  
#bea;,a7#b7 7#b ,u4,s4,c4 #ija;a7#b77-- 
7,a7 9 subp>agraph 7,b77ii71 by /rik+   
#eaj1jjj1jjj1jjj & ins]t+               
#daj1bca1bej1jjj2  7,b7 9 subp>agraph   
7,c77ii71 by /rik+ #ebj1jjj1jjj1jjj &   
ins]t+ #dbd1cgg1cfj1jjj2  7,c7 9        
subp>agraph 7,d77ii71 by /rik+          
#ecj1jjj1jjj1jjj & ins]t+               
#dcd1dfd1dgj1jjj2  7,d7 9 subp>agraph   
7,e77ii71 by /rik+ #eda1jjj1jjj1jjj &   
ins]t+ #dde1cfh1jjj1jjj2  7,e7 9        
subp>agraph 7,f77ii71 by /rik+          

#eec1jjj1jjj1jjj & ins]t+               
#deg1fdi1bhj1jjj2  7,f7 9 subp>agraph   
7,g77ii71 by /rik+ #eff1jjj1jjj1jjj &   
ins]t+ #dgb1jih1cfj1jjj2  7,g7 9        
subp>agraph 7,h77ii71 by /rik+          
#egh1jjj1jjj1jjj & ins]t+               
#dhe1dff1cjj1jjj2 &  7,h7 9 subp>agraph 
7,i77ii71 by /rik+ #eij1jjj1jjj1jjj &   
ins]t+ #dih1jid1gdj1jjj4  ,b ,sav+s f   
heal? c>e effici5cies  #acaa4 ,m$ic>e   
,,d% report & paym5t adju/m5ts 9        
response to cov]age expansion  7a7 ,,d% 
report  7#a7 ,9 g5]al ,n lat] ?an       
,janu>y #a1 #bjah1 ! ,secret>y ( ,heal? 
& ,human ,s]vices %all submit to        
,congress a report on ,m$ic>e ,,d% tak+ 
into acc\nt ! impact ( ! heal? c>e re=ms
 c>ri$ out "u ?is ,act 9 r$uc+ ! numb] (
 un9sur$ individuals4 ,! report %all    
include recomm5dations relat+ to !      
foll[+3  7,a7 ,! appropriate am\nt1     
t>get+1 & di/ribution ( ,m$ic>e ,,d% to 
comp5sate = high] ,m$ic>e co/s associat$
 ) s]v+ l[-income b5efici>ies 7tak+ into
 acc\nt v>iations 9 ! empirical         

ju/ification = ,m$ic>e ,,d% attributable
 to hospital *>act]i/ics1 includ+ b$    
size71 consi/5t ) ! orig9al int5t (     
,m$ic>e ,,d%4  7,b7 ,! appropriate      
am\nt1 t>get+1 & di/ribution ( ,m$ic>e  
,,d% to hospitals giv5 _! cont9u$       
uncomp5sat$ c>e co/s1 to ! ext5t su*    
co/s rema94  7#b7 ,coord9ation )        
,m$icaid ,,d% report ,! ,secret>y %all  
coord9ate ! report "u ?is subsection ) !
 report on ,m$icaid ,,d% "u section     
#acbb7;a74  7b7 ,paym5t adju/m5ts 9     
response to cov]age expansion  7#a7 ,9  
g5]al ,if !re is a significant decrease 
9 ! national rate ( un9surance z a      
result ( ?is ,act 7z det]m9$ "u p>agraph
 7#b77;,a771 !n ! ,secret>y ( ,heal? &  
,human ,s]vices %all1 beg9n+ 9 fiscal   
ye> #bjai1 implem5t ! foll[+ adju/m5ts  
to ,m$ic>e ,,d%3  7,a7 ,9 lieu ( ! am\nt
 ( ,m$ic>e ,,d% paym5t t w\ld o!rwise be
 made "u section #ahhf7;d77#e77;,f7 ( ! 
,social ,security ,act1 ! am\nt (       
,m$ic>e ,,d% paym5t %all be an am\nt    
bas$ on ! recomm5dations ( ! report "u  

subsection 7a77#a77;,a7 & %all take into
 acc\nt v>iations 9 ! empirical         
ju/ification = ,m$ic>e ,,d% attributable
 to hospital *>act]i/ics1 includ+ b$    
size4  7,b7 ,subject to p>agraph 7#c71  
make an additional paym5t to a hospital 
by an am\nt t is e/imat$ bas$ on ! am\nt
 ( uncomp5sat$ c>e provid$ by ! hospital
 bas$ on crit]ia = uncomp5sat$ c>e z    
det]m9$ by ! ,secret>y1 :i* %all exclude
 bad debt4  7#b7 ,significant decrease 9
 national rate ( un9surance z a result (
 ?is ,act ,= purposes ( ?is subsection--
  7,a7 ,9 g5]al ,!re is a significant   
decrease 9 ! national rate ( un9surance 
z a result ( ?is ,act if !re is a       
decrease 9 ! national rate ( un9surance 
7z def9$ 9 subp>agraph 7,b77 f #bjad to 
#bjaf t exce$s #h p]c5tage po9ts4  7,b7 
,national rate ( un9surance def9$ ,! t]m
 national rate ( un9surance means1 = a  
ye>1 su* rate = ! "u-#fe population = ! 
ye> z det]m9$ & publi%$ by ! ,bureau ( !
 ,c5sus 9 its ,curr5t ,population       
,survey 9 or ab\t ,septemb] ( ! succe$+ 

ye>4  7#c7 ,uncomp5sat$ c>e increase    
7,a7 ,computation ( ,,d% sav+s ,= ea*   
fiscal ye> 7beg9n+ ) fiscal ye> #bjag71 
! ,secret>y %all e/imate ! aggregate    
r$uction 9 ,m$ic>e ,,d% t w result f !  
adju/m5t "u p>agraph 7#a77;,a74  7,b7   
,/ructure ( paym5t increase ,! ,secret>y
 %all compute ! increase 9 ,m$ic>e ,,d% 
"u p>agraph 7#a77;,b7 = a fiscal ye> 9  
accordance ) a =mula e/abli%$ by !      
,secret>y t provides t--  7i7 !         
aggregate am\nt ( su* increase = !      
fiscal ye> does n exce$ #ej p]c5t ( !   
aggregate r$uction 9 ,m$ic>e ,,d%       
e/imat$ by ! ,secret>y = su* fiscal ye>2
 &  7ii7 hospitals ) high] levels (     
uncomp5sat$ c>e receive a great]        
increase4  7c7 ,m$ic>e ,,d% ,9 ?is      
section1 ! t]m ,m$ic>e ,,d% means       
adju/m5ts 9 paym5ts "u section          
#ahhf7;d77#e77;,f7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acieww7d77#e77;,f77 = inpati5t hospital
 s]vices furni%$ by disproportionate %>e
 hospitals4  #acab4 ,r$uction 9 ,m$icaid

 ,,d%  7a7 ,report  7#a7 ,9 g5]al ,n    
lat] ?an ,janu>y #a1 #bjah1 ! ,secret>y 
( ,heal? & ,human ,s]vices 79 ?is title 
ref]r$ to z ! ,secret>y7 %all submit to 
,congress a report conc]n+ ! ext5t to   
:i*1 bas$ ^u ! impact ( ! heal? c>e     
re=ms c>ri$ out "u ?is ,act 9 r$uc+ !   
numb] ( un9sur$ individuals1 !re is a   
cont9u$ role = ,m$icaid ,,d%4 ,9 prep>+ 
! report1 ! ,secret>y %all consult )    
community-bas$ heal? c>e networks s]v+  
l[-income b5efici>ies4  7#b7 ,matt]s to 
be includ$ ,! report %all include !     
foll[+3  7,a7 ,recomm5dations           
,recomm5dations reg>d+--  7i7 !         
appropriate t>get+ ( ,m$icaid ,,d% )9   
,/ates2 &  7ii7 ! di/ribution ( ,m$icaid
 ,,d% among ! ,/ates4  7,b7             
,specification ( ,,d% ,heal? ,re=m      
me?odology ,! ,,d% ,heal? ,re=m         
me?odology describ$ 9 p>agraph 7#b7 (   
subsection 7b7 = purposes ( implem5t+ ! 
requirem5ts ( su* subsection4  7#c7     
,coord9ation ) ,m$ic>e ,,d% report ,!   
,secret>y %all coord9ate ! report "u ?is

 subsection ) ! report on ,m$ic>e ,,d%  
"u section #acba4  7#d7 ,m$icaid ,,d% ,9
 ?is section1 ! t]m ,m$icaid ,,d% means 
adju/m5ts 9 paym5ts "u section #aibc ( !
 ,social ,security ,act = inpati5t      
hospital s]vices furni%$ by             
disproportionate %>e hospitals4  7b7    
,m$icaid ,,d% r$uctions  7#a7 ,9 g5]al  
,if !re is a significant decrease 9 !   
national rate ( un9surance z a result ( 
?is ,act 7z det]m9$ "u section          
#acba7;a77#b77;,a771 !n ! ,secret>y (   
,heal? & ,human ,s]vices %all r$uce     
,m$icaid ,,d% s z to r$uce total ,f$]al 
paym5ts to all ,/ates = su* purpose by  
#a1ejj1jjj1jjj 9 fiscal ye> #bjai1      
#b1ejj1jjj1jjj 9 fiscal ye> #bjbj1 &    
#f1jjj1jjj1jjj 9 fiscal ye> #bjba4  7#b7
 ,,d% ,heal? ,re=m me?odology ,!        
,secret>y %all c>ry out p>agraph 7#a7   
?r\gh use ( a ,,d% ,heal? ,re=m         
me?odology issu$ by ! ,secret>y t       
imposes ! l>ge/ p]c5tage r$uctions on ! 
,/ates t--  7,a7 h ! l[e/ p]c5tages (   
un9sur$ individuals 7det]m9$ on ! basis 

( audit$ hospital co/ reports7 dur+ !   
mo/ rec5t ye> = :i* su* data are        
available2 or  7,b7 d n t>get _! ,,d%   
paym5ts on--  7i7 hospitals ) high      
volumes ( ,m$icaid inpati5ts 7z def9$ 9 
section #aibc7;b77#a77;,a7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#acifr-#d7;b77#a77;,a7772 &  7ii7       
hospitals t h high levels ( uncomp5sat$ 
c>e 7exclud+ bad debt74  7#c7 ,,d%      
allotm5t publications  7,a7 ,9 g5]al ,n 
lat] ?an ! publication deadl9e specifi$ 
9 subp>agraph 7,b71 ! ,secret>y %all    
publi% 9 ! ,f$]al ,regi/] a notice      
specify+ ! ,,d% allotm5t to ea* ,/ate "u
 #aibc7;f7 ( ! ,social ,security ,act = 
! respective fiscal ye> specifi$ 9 su*  
subp>agraph1 consi/5t ) ! application ( 
! ,,d% ,heal? ,re=m me?odology describ$ 
9 p>agraph 7#b74  7,b7 ,publication     
deadl9e ,! publication deadl9e specifi$ 
9 ?is subp>agraph is--  7i7 ,janu>y #a1 
#bjah1 ) respect to ,,d% allotm5ts      
describ$ 9 subp>agraph 7,a7 = fiscal ye>
 #bjai2  7ii7 ,janu>y #a1 #bjai1 )      

respect to ,,d% allotm5ts describ$ 9    
subp>agraph 7,a7 = fiscal ye> #bjbj2 &  
7iii7 ,janu>y #a1 #bjbj1 ) respect to   
,,d% allotm5ts describ$ 9 subp>agraph   
7,a7 = fiscal ye> #bjba4  7c7 ,con=m+   
am5dm5ts  7#a7 ,section #aibc7;f7 ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#acifr-#d7;f77 is am5d$--  7,a7 by      
r$esignat+ p>agraph 7#g7 z p>agraph     
7#h72 &  7,b7 by ins]t+ aft] p>agraph   
7#f7 ! foll[+ new p>agraph3  7#g7       
,special rule = fiscal ye>s #bjai1      
#bjbj1 & #bjba ,not)/&+ p>agraph 7#b71  
if ! ,secret>y makes a r$uction "u      
section #acbb7;b77#a7 ( ! ,emp[]+       
,pati5ts ,fir/ ,act ( #bjac1 ! total    
,,d% allotm5ts = all ,/ates =--  7,a7   
fiscal ye> #bjai1 %all be ! total ,,d%  
allotm5ts t w\ld o!rwise be det]m9$ "u  
?is subsection = su* fiscal ye> decreas$
 by #a1ejj1jjj1jjj2  7,b7 fiscal ye>    
#bjbj1 %all be ! total ,,d% allotm5ts t 
w\ld o!rwise be det]m9$ "u ?is          
subsection = su* fiscal ye> decreas$ by 
#b1ejj1jjj1jjj2 &  7,c7 fiscal ye>      

#bjba1 %all be ! total ,,d% allotm5ts t 
w\ld o!rwise be det]m9$ "u ?is          
subsection = su* fiscal ye> decreas$ by 
#f1jjj1jjj1jjj4  4  7#b7 ,section       
#aibc7;b77#d7 ( su* ,act 7#db ,u4,s4,c4 
#acifr-#d7;b77#d77 is am5d$ by add+ be=e
 ! p]iod ! foll[+3 or to affect !       
au?ority ( ! ,secret>y to issue &       
implem5t ! ,,d% ,heal? ,re=m me?odology 
"u section #acbb7;b77#b7 ( ! ,emp[]+    
,pati5ts ,fir/ ,act ( #bjac4  7d7       
,disproportionate %>e hospitals 7,,d%7 &
 ess5tial access hospital 7,,eah7       
non-,discrim9ation  7#a7 ,9 g5]al       
,section #aibc7;d7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acifr-#d7 is am5d$
 by add+ at ! end ! foll[+ new p>agraph3
  7#d7 ,no hospital may be def9$ or     
deem$ z a disproportionate %>e hospital1
 or z an ess5tial access hospital 7=    
purposes ( subsection 7f77#f77;,a77iv771
 "u a ,/ate plan "u ?is title or        
subsection 7b7 ( ?is section 7includ+   
any waiv] "u section #aaae7 unless !    
hospital--  7,a7 provides s]vices to    

b5efici>ies "u ?is title )\t            
discrim9ation on ! gr\nd ( race1 color1 
national orig91 cre$1 s\rce ( paym5t1   
/atus z a b5efici>y "u ?is title1 or any
 o!r gr\nd unrelat$ to su* b5efici>y's  
ne$ = ! s]vices or ! availability ( !   
ne$$ s]vices 9 ! hospital2 &  7,b7 makes
 arrangem5ts =1 & accepts1 reimbursem5t 
"u ?is title = s]vices provid$ to       
eligible b5efici>ies "u ?is title4  4   
7#b7 ,effective date ,! am5dm5t made by 
subsection 7a7 %all be apply to         
exp5ditures made on or aft] ,july #a1   
#bjad4  ,c ,fraud1 ,wa/e1 & ,abuse      
#acba4 ,provide adequate fund+ to ,,hhs 
,,oig & ,,hcfac  7a7 ,,hcfac fund+      
,section #ahag7k77#c77;,a7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#acie;i7k77#c77;,a77 is am5d$--  7#a7 9 
clause 7i7--  7,a7 9 subclause 7,,iii71 
by /rik+ at ! end &2  7,b7 9 subclause  
7,,iv7--  7i7 by ins]t+ & be=e fiscal   
ye> #bjad aft] = ea* fiscal ye> aft]    
fiscal ye> #bjjf2 &  7ii7 by /rik+ !    
p]iod at ! end & ins]t+ 2 &2 &  7,c7 by 

add+ at ! end ! foll[+ new subclause3   
7,v7 = ea* fiscal ye> aft] fiscal ye>   
#bjac1 #cjj1jjj1jjj4  2 &  7#b7 9 clause
 7ii7--  7,a7 9 subclause 7,,viii71 by  
/rik+ at ! end &2  7,b7 9 subclause     
7,,ix7--  7i7 by ins]t+ & be=e fiscal   
ye> #bjad aft] = ea* fiscal ye> aft]    
fiscal ye> #bjjg2 &  7ii7 by /rik+ !    
p]iod at ! end & ins]t+ 2 &2 &  7,c7 by 
add+ at ! end ! foll[+ new subclause3   
7,x7 = ea* fiscal ye> aft] fiscal ye>   
#bjac1 n less ?an ! am\nt requir$ "u ?is
 clause = fiscal ye> #bjac1 plus ! am\nt
 by :i* ! am\nt made available "u clause
 7i77,v7 = fiscal ye> #bjad exce$s !    
am\nt made available "u clause 7i77,,iv7
 = fiscal ye> #bjac4  4  7b7 ,,oig fund+
 ,!re are au?oriz$ to be appropriat$ =  
ea* ( fiscal ye>s #bjad ?r\gh #bjbc     
#ajj1jjj1jjj = ! ,(fice ( ! ,inspector  
,g5]al ( ! ,dep>tm5t ( ,heal? & ,human  
,s]vices = fraud prev5tion activities "u
 ! ,m$ic>e & ,m$icaid programs4  #acbb4 
,improv$ en=cem5t ( ! ,m$ic>e second>y  
payor provisions  7a7 ,9 g5]al ,!       

,secret>y1 9 coord9ation ) ! ,inspector 
,g5]al ( ! ,dep>tm5t ( ,heal? & ,human  
,s]vices1 %all provide ?r\gh !          
,coord9ation ( ,b5efits ,contractor = ! 
id5tification ( in/ances :]e ! ,m$ic>e  
program %\ld be1 b is n1 act+ z a       
second>y pay] to an individual's private
 heal? b5efits cov]age "u section       
#ahfb7;b7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciey7b774  7b7 ,updat+ 
proc$ures ,! ,secret>y %all update      
proc$ures = id5tify+ & resolv+ cr$it    
balance situations :i* occur "u !       
,m$ic>e program :5 paym5t "u su* title &
 f o!r heal? b5efit plans exce$ !       
provid]s' *>ges or ! all[$ am\nt4  7c7  
,report on improv$ en=cem5t ,n lat] ?an 
#a ye> aft] ! date ( ! enactm5t ( ?is   
,act1 ! ,secret>y %all submit a report  
to ,congress on progress made 9 improv$ 
en=cem5t ( ! ,m$ic>e second>y payor     
provisions1 includ+ rec\pm5t ( cr$it    
balances4  #acbc4 ,/r5g!n ,m$ic>e       
provid] enrollm5t /&>ds & safegu>ds  7a7
 ,/r5g!n+ ,m$ic>e provid] numb]s  7#a7  

,scre5+ new provid]s ,z a condition ( a 
provid] ( s]vices or a suppli]1 includ+ 
durable m$ical equipm5t suppli]s & home 
heal? ag5cies1 apply+ = ! fir/ "t = a   
provid] numb] "u ! ,m$ic>e program "u   
title ,,xviii ( ! ,social ,security ,act
 & be=e grant+ bill+ privileges "u su*  
title1 ! ,secret>y ( ,heal? & ,human    
,s]vices 7ref]r$ to 9 ?is section z !   
,secret>y7 %all scre5 ! provid] or      
suppli] = a crim9al backgr\nd or o!r    
f9ancial or op]ational irregul>ities    
?r\gh f+]pr9t+1 lic5sure *ecks1         
site-visits1 & o!r database *ecks4  7#b7
 ,application fees ,! ,secret>y %all    
impose an application *>ge on su* a     
provid] or suppli] 9 ord] to cov] !     
,secret>y's co/s 9 p]=m+ ! scre5+       
requir$ "u p>agraph 7#a74  7#c7         
,provisional approval ,dur+ an initial1 
provisional p]iod 7specifi$ by !        
,secret>y7 9 :i* su* a provid] or       
suppli] has be5 issu$ su* a numb]1 !    
,secret>y %all provide enhanc$ ov]sight 
( ! activities ( su* provid] or suppli] 

"u ! ,m$ic>e program1 su* z ?r\gh       
prepaym5t review & paym5t limitations4  
7#d7 ,p5alties = false /atem5ts ,9 !    
case ( a provid] or suppli] t kn[+ly    
makes a false /atem5t 9 an application =
 su* a numb]1 ! ,secret>y may exclude ! 
provid] or suppli] f p>ticipation "u !  
,m$ic>e program1 or may impose a civil  
money p5alty 79 ! am\nt describ$ 9      
section #aabh;,a7a77#d7 ( ! ,social     
,security ,act71 9 ! same mann] z !     
,secret>y may impose su* an exclusion or
 p5alty "u sections #aabh & #aabh;,a1   
respectively1 ( su* ,act 9 ! case ( kn[+
 pres5tation ( a false claim describ$ 9 
section #aabh;,a7a77#a77;,a7 ( su* ,act4
  7#e7 ,disclosure requirem5ts ,)       
respect to approval ( su* an            
application1 ! ,secret>y--  7,a7 %all   
require applicants to disclose previ\s  
affiliation ) enroll$ entities t h      
uncollect$ debt relat$ to ! ,m$ic>e or  
,m$icaid programs2  7,b7 may d5y        
approval if ! ,secret>y det]m9es t ^!   
affiliations pose undue risk to !       

,m$ic>e or ,m$icaid program1 subject to 
an appeals process = ! applicant z      
det]m9$ by ! ,secret>y2 &  7,c7 may     
implem5t enhanc$ safegu>ds 7su* z surety
 bonds74  7b7 ,moratoria ,! ,secret>y   
may impose moratoria on approval (      
provid] & suppli] numb]s "u ! ,m$ic>e   
program = new provid]s ( s]vices &      
suppli]s z det]m9$ necess>y to prev5t or
 combat fraud a p]iod ( delay = any "o  
applicant _c exce$ #cj days unless cause
 is %[n by ! ,secret>y4  7c7 ,fund+ ,!re
 are au?oriz$ to be appropriat$ to c>ry 
out ?is section su* sums z may be       
necess>y4  #acbd4 ,track+ bann$ provid]s
 across ,/ate l9es  7a7 ,great]         
coord9ation ,! ,secret>y ( ,heal? &     
,human ,s]vices 79 ?is section ref]r$ to
 z ! ,secret>y7 %all provide = increas$ 
coord9ation betwe5 ! ,adm9i/rator ( !   
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices 79  
?is section ref]r$ to z ,,cms7 & its    
regional (fices to ensure t provid]s (  
s]vices & suppli]s t h op]at$ 9 "o ,/ate
 & are exclud$ f p>ticipation 9 !       

,m$ic>e program are unable to beg9      
op]ation & p>ticipation 9 ! ,m$ic>e     
program 9 ano!r ,/ate4  7b7 ,improv$    
in=mation sy/ems  7#a7 ,9 g5]al ,!      
,secret>y %all improve in=mation sy/ems 
to all[ great] integration betwe5       
databases "u ! ,m$ic>e program s t--    
7,a7 ,m$ic>e adm9i/rative contractors1  
fiscal int]m$i>ies1 & c>ri]s h imm$iate 
access to in=mation id5tify+ provid]s & 
suppli]s exclud$ f p>ticipation 9 !     
,m$ic>e & ,m$icaid program & o!r ,f$]al 
heal? c>e programs2 &  7,b7 su*         
in=mation c be %>$ across ,f$]al heal?  
c>e programs & ag5cies1 includ+ betwe5 !
 ,dep>tm5ts ( ,heal? & ,human ,s]vices1 
! ,social ,security ,adm9i/ration1 !    
,dep>tm5t ( ,vet]ans ,affairs1 !        
,dep>tm5t ( ,def5se1 ! ,dep>tm5t (      
,ju/ice1 & ! ,(fice ( ,p]sonnel         
,managem5t4  7c7 ,m$ic>e_/,m$icaid ,"o  
,,pi database ,! ,secret>y %all implem5t
 a database t includes claims & paym5t  
data = all compon5ts ( ! ,m$ic>e program
 & ! ,m$icaid program4  7d7 ,au?oriz+   

exp&$ data mat*+ ,not)/&+ any provision 
( ! ,comput] ,mat*+ & ,privacy          
,protection ,act ( #aihh to ! contr>y-- 
7#a7 ! ,secret>y & ! ,inspector ,g5]al 9
 ! ,dep>tm5t ( ,heal? & ,human ,s]vices 
may p]=m data mat*+ ( data f ! ,m$ic>e  
program ) data f ! ,m$icaid program2 &  
7#b7 ! ,commission] ( ,social ,security 
& ! ,secret>y may p]=m data mat*+ ( data
 ( ! ,social ,security ,adm9i/ration )  
data f ! ,m$ic>e & ,m$icaid programs4   
7e7 ,consolidation ( databases ,!       
,secret>y %all consolidate & exp& into a
 c5traliz$ database = individuals &     
entities t h be5 exclud$ f ,f$]al heal? 
c>e programs ! ,heal?c>e ,integrity &   
,protection ,data ,bank1 ! ,national    
,practition] ,data ,bank1 ! ,li/ (      
,exclud$ ,individuals_/,entities1 & a   
national pati5t abuse_/neglect regi/ry4 
7f7 ,compreh5sive provid] database  7#a7
 ,e/abli%m5t ,! ,secret>y %all e/abli% a
 compreh5sive database t includes       
in=mation on provid]s ( s]vices1        
suppli]s1 & relat$ entities p>ticipat+ 9

 ! ,m$ic>e program1 ! ,m$icaid program1 
or bo?4 ,su* database %all include1     
in=mation on own]%ip & bus9ess          
relation%ips1 hi/ory ( adv]se actions1  
results ( site visits or o!r monitor+ by
 any program4  7#b7 ,use ,prior to issu+
 a provid] or suppli] numb] = an entity 
"u ! ,m$ic>e program1 ! ,secret>y %all  
obta9 in=mation on ! entity f su*       
database to assure ! entity qualifies = 
! issuance ( su* a numb]4  7g7          
,compreh5sive sanctions database ,!     
,secret>y %all e/abli% a compreh5sive   
sanctions database on sanctions impos$  
on provid]s ( s]vices1 suppli]s1 &      
relat$ entities4 ,su* database %all be  
ov]se5 by ! ,inspector ,g5]al ( !       
,dep>tm5t ( ,heal? & ,human ,s]vices &  
%all be l9k$ to relat$ databases ma9ta9$
 by ,/ate lic5sure bo>ds & by ,f$]al or 
,/ate law en=cem5t ag5cies4  7h7 ,access
 to claims & paym5t databases ,!        
,secret>y %all ensure t ! ,inspector    
,g5]al ( ! ,dep>tm5t ( ,heal? & ,human  
,s]vices & ,f$]al law en=cem5t ag5cies h

 direct access to all claims & paym5t   
databases ( ! ,secret>y "u ! ,m$ic>e or 
,m$icaid programs4  7i7 ,civil money    
p5alties = submission ( errone\s        
in=mation ,9 ! case ( a provid] (       
s]vices1 suppli]1 or o!r entity t kn[+ly
 submits errone\s in=mation t s]ves z a 
basis = paym5t ( any entity "u ! ,m$ic>e
 or ,m$icaid program1 ! ,secret>y may   
impose a civil money p5alty ( n to exce$
 #ej1jjj = ea* su* errone\s submission4 
,a civil money p5alty "u ?is subsection 
%all be impos$ & collect$ 9 ! same mann]
 z a civil money p5alty "u subsection   
7a7 ( section #aabh;,a ( ! ,social      
,security ,act is impos$ & collect$ "u t
 section4