,i #aacth ,,congress #ast ,session ,h4 ,r4 #bijj ,,in ,,the ,,house ,,of ,,representatives ,august #a1 #bjac ,mr4 ,broun of ,georgia introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means1 ,education and the ,workforce1 ,natural ,resources1 the ,judiciary1 ,house ,administration1 ,appropriations1 and ,rules1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to repeal the ,patient ,protection and ,affordable ,care ,act and the ,health ,care and ,education ,reconciliation ,act of #bjaj2 to amend the ,internal ,revenue ,code of #aihf to repeal the percentage floor on medical expense deductions1 expand the use of tax-preferred health care accounts1 and establish a charity care credit2 to amend the ,social ,security ,act to create a ,medicare ,premium ,assistance ,program1 reform ,,emtala requirements1 and to replace the ,medicaid program and the ,children's ,health ,insurance program with a block grant to the ,states2 to amend the ,public ,health ,service ,act to provide for cooperative governing of individual and group health insurance coverage offered in interstate commerce2 and for other purposes4 #a4 ,short title2 table of contents2 construction 7a7 ,short title ,this ,act may be cited as the ,offering ,patients ,true ,individualized ,options ,now ,act of #bjac or the ,,option ,act of #bjac4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents2 construction4 ,title ,i--,repeal of ,,ppaca and ,,hcera ,sec4 #aja4 ,repeal of ,,ppaca and ,,hcera4 ,title ,,ii--,health ,care ,tax ,reform ,subtitle ,a--,,hsa ,reform ,sec4 #bja4 ,repeal of high deductible health plan requirement4 ,sec4 #bjb4 ,increase in deductible ,,hsa contribution limitations4 ,sec4 #bjc4 ,medicare eligible individuals eligible to contribute to ,,hsa4 ,sec4 #bjd4 ,,hsa ,rollover to ,medicare ,advantage ,,msa4 ,sec4 #bje4 ,repeal of additional tax on distributions not used for qualified medical expenses4 ,subtitle ,b--,other ,health ,care ,tax ,reform ,sec4 #bjf4 ,elimination of #aj-percent floor on medical expense deductions4 ,sec4 #bjg4 ,repeal of prescribed drug limitation on certain tax benefits for medical expenses4 ,sec4 #bjh4 ,repeal of #b-percent miscellaneous itemized deduction floor for medical expense deductions4 ,sec4 #bji4 ,charity care credit4 ,sec4 #baj4 ,credit for contributions made for purpose of providing medical care to the indigent4 ,sec4 #baa4 ,,cobra continuation coverage extended4 ,sec4 #bab4 ,,hsa charitable contributions4 ,title ,,iii--,medicare ,premium ,assistance ,program ,sec4 #cja4 ,replacement of ,medicare part ,a entitlement with ,medicare ,reform ,premium ,assistance ,program4 ,sec4 #cjb4 ,gradual phasing out of ,,cms and transfer of functions to ,department of the ,treasury4 ,title ,,iv--,,emtala ,reforms ,sec4 #dja4 ,,emtala reforms4 ,title ,v--,cooperative ,governing of ,individual and ,group ,health ,insurance ,coverage ,sec4 #eja4 ,cooperative governing of individual and group health insurance coverage4 ,sec4 #ejb4 ,continuing ,state authority4 ,title ,,vi--,state ,health ,flexibility ,sec4 #fja4 ,short title4 ,sec4 #fjb4 ,health grants to the ,states for health care services to indigent individuals4 ,sec4 #fjc4 ,repeal of ,federal requirements of ,medicaid and ,,chip4 ,sec4 #fjd4 ,severability4 ,sec4 #fje4 ,effective date4 7c7 ,construction ,nothing in this ,act shall be construed to preclude or prohibit a health care provider or health insurance issuer from publicly disclosing any pricing of services provided or covered4 ,i ,repeal of ,,ppaca and ,,hcera #aja4 ,repeal of ,,ppaca and ,,hcera ,the ,patient ,protection and ,affordable ,care ,act and the ,health ,care and ,education ,reconciliation ,act of #bjaj are each repealed1 effective as of the respective date of enactment of each such ,act1 and the provisions of law amended or repealed by such ,acts are restored or revived as if such ,acts had not been enacted4 ,,ii ,health ,care ,tax ,reform ,a ,,hsa ,reform #bja4 ,repeal of high deductible health plan requirement 7a7 ,in general ,section #bbc of the ,internal ,revenue ,code of #aihf is amended by striking subsection 7c7 and redesignating subsections 7d7 through 7h7 as subsections 7c7 through 7g71 respectively4 7b7 ,conforming amendments 7#a7 ,subsection 7a7 of section #bbc of such ,code is amended to read as follows3 7a7 ,deduction allowed ,in the case of an individual1 there shall be allowed as a deduction for a taxable year an amount equal to the aggregate amount paid in cash during such taxable year by or on behalf of such individual to a health savings account of such individual4 4 7#b7 ,subsection 7b7 of section #bbc of such ,code is amended by striking paragraph 7#h74 7#c7 ,subparagraph 7,a7 of section #bbc7;c77#a7 of the ,internal ,revenue ,code of #aihf 7as redesignated by subsection 7b77#a77 is amended-- 7,a7 by striking subsection 7f77#e7 and inserting subsection 7e77#e71 and 7,b7 in clause 7ii7-- 7i7 by striking the sum of-- and all that follows and inserting the dollar amount in effect under subsection 7b77#a744 7#d7 ,section #bbc7;f77#a7 of such ,code 7as redesignated by subsection 7b77#a77 is amended by striking ,each dollar amount in subsections 7b77#b7 and 7c77#b77;,a7 and inserting ,in the case of a taxable year beginning after ,december #ca1 #bjaj1 each dollar amount in subsection 7b77#a74 7#e7 ,section #bf7;b77,u7 of such ,code is amended by striking section #bbc7;f77#d7 and inserting section #bbc7;e77#d74 7#f7 ,sections #ce7;g77#c71 #bbj7;f77#e77;,a71 #hdh7;e77#a77v71 #digc7;a77#e71 and #fjea7;a77#ab7 of such ,code are each amended by striking section #bbc7;d7 each place it appears and inserting section #bbc7;c74 7#g7 ,section #ajf7;d77#a7 of such ,code is amended-- 7,a7 by striking who is an eligible individual 7as defined in section #bbc7;c77#a771 and 7,b7 by striking section #bbc7;d7 and inserting section #bbc7;c74 7#h7 ,section #djh7;d77#i7 of such ,code is amended-- 7,a7 in subparagraph 7,a7 by striking who is an eligible individual 7as defined in section #bbc7;c77 and1 and 7,b7 in subparagraph 7,c7 by striking computed on the basis of the type of coverage under the high deductible health plan covering the individual at the time of the qualified ,,hsa funding distribution4 7#i7 ,section #hgg;,a7g77#f7 of such ,code is amended by striking #bbc7;f77#d7 and inserting #bbc7;e77#d74 7#aj7 ,section #digc7;g7 of such ,code is amended-- 7,a7 by striking section #bbc7;d7 and inserting section #bbc7;c71 7,b7 in paragraph 7#b71 by striking section #bbc7;f77#b7 and inserting section #bbc7;e77#b71 and 7,c7 by striking section #bbc7;f77#c7 and inserting section #bbc7;e77#c74 7#aa7 ,section #dige of such ,code is amended-- 7,a7 in subsection 7c77#f7-- 7i7 by striking section #bbc7;d7 and inserting section #bbc7;c71 and 7ii7 by striking section #bbc7;e77#b7 and inserting section #bbc7;d77#b71 and 7,b7 in subsection 7e77#a77;,e71 by striking section #bbc7;d7 and inserting section #bbc7;c74 7#ab7 ,section #ffic7;a77#b77;,c7 of such ,code is amended by striking section #bbc7;h7 and inserting section #bbc7;g74 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjab4 #bjb4 ,increase in deductible ,,hsa contribution limitations 7a7 ,in general ,paragraph 7#a7 of section #bbc7;b7 of the ,internal ,revenue ,code of #aihf is amended by striking the sum of the monthly and all that follows through eligible individual and inserting #aj1jjj 7#bj1jjj in the case of a joint return74 7b7 ,conforming amendments 7#a7 ,subsection 7b7 of such ,code is amended by striking paragraphs 7#b71 7#c71 and 7#e7 and by redesignating paragraphs 7#d71 7#f71 and 7#g7 as paragraphs 7#b71 7#c71 and 7#d71 respectively4 7#b7 ,paragraph 7#b7 of section #bbc7;b7 of such ,code 7as redesignated by paragraph 7#a77 is amended by striking the last sentence4 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjab4 #bjc4 ,medicare eligible individuals eligible to contribute to ,,hsa 7a7 ,subsection 7b7 of section #bbc of the ,internal ,revenue ,code of #aihf is amended by striking paragraph 7#g74 7b7 ,paragraph 7#a7 of section #bbc7;c7 of such ,code is amended by adding at the end the following new subparagraph3 7,c7 ,special rule for individuals entitled to benefits under medicare ,in the case of an individual-- 7i7 who is entitled to benefits under title ,,xviii of the ,social ,security ,act1 and 7ii7 with respect to whom a health savings account is established in a month before the first month such individual is entitled to such benefits1 such individual shall be deemed to be an eligible individual4 4 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjab4 #bjd4 ,,hsa ,rollover to ,medicare ,advantage ,,msa 7a7 ,in general ,paragraph 7#b7 of section #ach7;b7 of the ,internal ,revenue ,code of #aihf is amended by striking or at the end of subparagraph 7,a71 by adding or at the end of subparagraph 7,c71 and by adding at the end the following new subparagraph3 7,c7 a ,,hsa rollover contribution described in subsection 7d77#e71 4 7b7 ,,hsa rollover contribution ,subsection 7c7 of section #ach of such ,code is amended by adding at the end the following new paragraph3 7#e7 ,rollover contribution ,an amount is described in this paragraph as a rollover contribution if it meets the requirement of subparagraphs 7,a7 and 7,b74 7,a7 ,in general ,the requirements of this subparagraph are met in the case of an amount paid or distributed from a health savings to the account beneficiary to the extent the amount is received is paid into a ,medicare ,advantage ,,msa of such beneficiary not later than the #fjth day after the day on which the beneficiary receives the payment or distribution4 7,b7 ,limitation ,this paragraph shall not apply to any amount described in subparagraph 7,a7 received by an individual from a health savings account if1 at any time during the #a-year period ending on the day of such receipt1 such individual received any other amount described in subparagraph 7,a7 from a health savings account which was not includible in the individual's gross income because of the application of section #bbc7;f77#e77;,a74 4 7c7 ,conforming amendment ,subparagraph 7,a7 of section #bbc7;f77#e7 of such ,code is amended by inserting or ,medicare ,advantage ,,msa after into a health savings account4 7d7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjab4 #bje4 ,repeal of additional tax on distributions not used for qualified medical expenses 7a7 ,in general ,subsection 7f7 of section #bbc of the ,internal ,revenue ,code of #aihf is amended by striking paragraph 7#d7 and redesignating paragraphs 7#e71 7#f71 and 7#g7 and paragraphs 7#d71 7#e71 and 7#f71 respectively4 7b7 ,conforming amendments 7#a7 ,paragraph 7#b7 of section #be7;b7 of such ,code is amended by striking subparagraph 7,u7 and by redesignating subparagraphs 7,v71 7,w71 and 7,x7 as subparagraphs 7,u71 7,v71 and 7,w74 7#b7 ,subparagraph 7,c7 of section #ajf7;e77#d7 of such ,code is amended by striking #bbc7;f77#e7 and inserting #bbc7;f77#d74 7#c7 ,paragraph 7#f7 of section #hgg;,a7g7 of such ,code is amended by striking #bbc7;f77#d714 7#d7 ,paragraph 7#a7 of section #digc7;g7 of such ,code is amended by striking #bbc7;f77#e7 and inserting #bbc7;f77#d74 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjab4 ,b ,other ,health ,care ,tax ,reform #bjf4 ,elimination of #aj-percent floor on medical expense deductions 7a7 ,in general ,subsection 7a7 of section #bac of the ,internal ,revenue ,code of #aihf is amended by striking 1 to the extent that such expenses exceed #aj percent of adjusted gross income4 7b7 ,conforming amendment ,paragraph 7#a7 of section #ef7;b7 of such ,code is amended by striking subparagraph 7,b74 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjab4 #bjg4 ,repeal of prescribed drug limitation on certain tax benefits for medical expenses 7a7 ,deduction for medical expenses 7#a7 ,in general ,section #bac of the ,internal ,revenue ,code of #aihf is amended by striking subsection 7b74 7#b7 ,conforming amendment ,subsection 7d7 of section #bac of such ,code is amended by striking paragraph 7#c74 7b7 ,treatment of reimbursements under accident or health plans ,section #ajf of such ,code is amended by striking subsection 7f74 7c7 ,health savings accounts ,subparagraph 7,a7 of section #bbc7;d77#b7 of such ,code is amended by striking the last sentence thereof4 7d7 ,archer ,m,s,as ,subparagraph 7,a7 of section #bbj7;d77#b7 of such ,code is amended by striking the last sentence thereof4 7e7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjab4 #bjh4 ,repeal of #b-percent miscellaneous itemized deduction floor for medical expense deductions 7a7 ,in general ,subsection 7b7 of section #fg of the ,internal ,revenue ,code of #aihf is amended by striking paragraph 7#e74 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after the ,december #ca1 #bjab4 #bji4 ,charity care credit 7a7 ,in general ,subpart ,a of part ,,iv of subchapter ,a of chapter #a of the ,internal ,revenue ,code of #aihf 7relating to nonrefundable personal credits7 is amended by inserting after section #be;,d the following new section3 #be;,e4 ,charity care credit 7a7 ,allowance of credit ,in the case of a physician1 there shall be allowed as a credit against the tax imposed by this chapter for a taxable year the amount determined in accordance with the following table3 ,if the physician has provided during such taxable year3,the amount of the credit is3 ,at least #be but less than #cj qualified hours of charity care#b1jjj4 ,at least #cj but less than #ce qualified hours of charity care#b1djj4 ,at least #ce but less than #dj qualified hours of charity care#b1hjj4 ,at least #dj but less than #de qualified hours of charity care#c1bjj4 ,at least #de but less than #ej qualified hours of charity care#c1fjj4 ,at least #ej but less than #ee qualified hours of charity care#d1jjj4 ,at least #ee but less than #fj qualified hours of charity care#d1djj4 ,at least #fj but less than #fe qualified hours of charity care#d1hjj4 ,at least #fe but less than #gj qualified hours of charity care#e1bjj4 ,at least #gj but less than #ge qualified hours of charity care#e1fjj4 ,at least #ge but less than #hj qualified hours of charity care#f1jjj4 ,at least #hj but less than #he qualified hours of charity care#f1djj4 ,at least #he but less than #ij qualified hours of charity care#f1hjj4 ,at least #ij but less than #ie qualified hours of charity care#g1bjj4 ,at least #ie but less than #ajj qualified hours of charity care#g1fjj4 ,at least #ajj hours of charity care#h1jjj4 7b7 ,qualified hours of charity care ,for purposes of this section-- 7#a7 ,qualified hours of charity care ,the term qualified hours of charity care means the hours that a physician provides medical care 7as defined in section #bac7;d77#a77;,a77 on a volunteer or pro bono basis4 7#b7 ,physician ,the term physician has the meaning given to such term in section #ahfa7r7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7r774 4 7b7 ,conforming amendment ,the table of sections for subpart ,a of part ,,iv of subchapter ,a of chapter #a of such ,code is amended by inserting after the item relating to section #be;,d the following new item3 ,sec4 #be;,e4 ,charity care credit4 4 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjab4 #baj4 ,credit for contributions made for purpose of providing medical care to the indigent 7a7 ,in general ,subpart ,b of part ,,iv of subchapter ,a of chapter #a of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new section3 #cj;,e4 ,contributions for providing medical care to the indigent 7a7 ,in general ,there shall be allowed as a credit against the tax imposed by this chapter for the taxable year an amount equal to the indigent care contributions made by the taxpayer during the taxable year4 7b7 ,indigent care contribution ,for purposes of this section1 the term indigent care contribution means any contribution or gift of money or other property to or for the use of any person if such contribution or gift is used 7or the proceeds from which are used7 by such person for the purpose of providing medical care to indigent individuals in the ,united ,states4 7c7 ,valuation and substantiation of contributions1 etc ,rules similar to the rules of subsections 7e7 and 7f7 of section #agj shall apply for purposes of this section4 7d7 ,application with other credits 7#a7 ,business credit treated as part of general business credit ,so much of the credit which would be allowed under subsection 7a7 for any taxable year 7determined without regard to this subsection7 that is attributable to indigent care contributions made by-- 7,a7 any corporation or partnership1 or 7,b7 any other person if such contribution was made in connection with a trade or business carried on by such person1 shall be treated as a credit listed in section #ch7;b7 for such taxable year 7and not allowed under subsection 7a774 7#b7 ,personal credit ,for purposes of this title1 the credit allowed under subsection 7a7 for any taxable year 7determined after application of paragraph 7#a77 shall be treated as a credit allowable under subpart ,a for such taxable year4 7e7 ,denial of double benefit ,the amount of any deduction or other credit allowable under this chapter for any indigent care contribution shall be reduced by the amount of credit allowable under this section for such contribution4 4 7b7 ,conforming amendments 7#a7 ,section #ch7;b7 of such ,code is amended by striking plus at the end of paragraph 7#ce71 by striking the period at the end of paragraph 7#cf7 and inserting 1 plus1 and by adding at the end the following new paragraph3 7#cg7 the portion of the credit described in section #cj;,e7d77#a7 7relating to credit for contributions for providing medical care to the indigent74 4 7#b7 ,section #ch7;c77#d77;,b7 of such ,code is amended by striking and at the end of clause 7viii71 by striking the period at the end of clause 7ix7 and inserting 1 and1 and by adding at the end the following new clause3 7x7 the portion of the credit described in section #cj;,e7d77#a7 7relating to credit for contributions for providing medical care to the indigent74 4 7#c7 ,the table of sections for subpart ,b of part ,,iv of subchapter ,a of chapter #a of such ,code is amended by adding at the end the following new item3 ,sec4 #cj;,e4 ,contributions for providing medical care to the indigent4 4 7c7 ,effective date ,the amendments made by this section shall apply to contributions made after the date of the enactment of this ,act4 #baa4 ,,cobra continuation coverage extended 7a7 ,under ,,irc ,subparagraph 7,b7 of section #dihj;,b7f77#b7 of the ,internal ,revenue ,code of #aihf is amended by striking clauses 7i7 and 7v7 and by redesignating clauses 7ii71 7iii71 and 7iv7 as clauses 7i71 7ii71 and 7iii71 respectively4 7b7 ,under ,,erisa ,paragraph 7#b7 of section #fjb of the ,employee ,retirement ,income ,security ,act of #bjji 7#bi ,u4,s4,c4 #aafb7 is amended by striking subparagraphs 7,a7 and 7,e7 and by redesignating subparagraphs 7,b71 7,c71 and 7,d7 as subparagraphs 7,a71 7,b71 and 7,c71 respectively4 7c7 ,under ,,phsa ,paragraph 7#b7 of section #bbjb7b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;bb-#b7b77 is amended by striking subparagraphs 7,a7 and 7,e7 and by redesignating subparagraphs 7,b71 7,c71 and 7,d7 as subparagraphs 7,a71 7,b71 and 7,c71 respectively4 7d7 ,effective date ,the amendments made by this section shall apply with respect to group health plans1 and health insurance coverage offered in connection with group health plans1 for plan years beginning after the date of the enactment of this ,act4 #bab4 ,,hsa charitable contributions 7a7 ,in general ,subsection 7f7 of section #bbc of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#i7 ,distributions for charitable purposes ,for purposes of this subsection-- 7,a7 ,in general ,paragraph 7#b7 shall not apply to any qualified charitable distributions with respect to a taxpayer made during any taxable year4 7,b7 ,qualified charitable distribution ,for purposes of this paragraph1 the term qualified charitable distribution means any distribution from a health savings account which is made directly by the trustee to an organization described in section #agj7;b77#a77;,a7 7other than any organization described in section #eji7;a77#c7 or any fund or account described in section #diff7;d77#b774 ,a distribution shall be treated as a qualified charitable distribution only to the extent that the distribution would be includible in gross income without regard to subparagraph 7,a74 7,c7 ,contributions must be otherwise deductible ,for purposes of this paragraph1 a distribution to an organization described in subparagraph 7,b7 shall be treated as a qualified charitable distribution only if a deduction for the entire distribution would be allowable under section #agj 7determined without regard to subsection 7b7 thereof and this paragraph74 7,d7 ,denial of deduction ,qualified charitable distributions which are not includible in gross income pursuant to subparagraph 7,a7 shall not be taken into account in determining the deduction under section #agj4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjab4 ,,iii ,medicare ,premium ,assistance ,program #cja4 ,replacement of ,medicare part ,a entitlement with ,medicare ,reform ,premium ,assistance ,program 7a7 ,in general ,section #bbf of the ,social ,security ,act 7#db ,u4,s4,c4 #dbf7 is amended by adding at the end the following new subsections3 7k7 ,replacement of entitlement with premium assistance program 7#a7 ,in general ,notwithstanding the previous provisions of this section1 beginning the first ,january #a after the date of the enactment of the ,offering ,patients ,true ,individualized ,options ,now ,act of #bjac1 the ,secretary shall establish procedures under which-- 7,a7 in the case of an individual who1 but for the application of this paragraph1 would otherwise become entitled under subsection 7a7 on or after such ,january #a to benefits under part ,a of title ,,xviii1 subject to paragraph 7#d71 the individual shall in lieu of such entitlement be automatically enrolled in the ,medicare ,reform ,premium ,assistance ,program established under subsection 7l72 and 7,b7 in the case of an individual who before such ,january #a is entitled under subsection 7a7 to benefits under part ,a of title ,,xviii1 the individual may in lieu of such entitlement elect on or after such ,january #a to enroll in the ,medicare ,reform ,premium ,assistance ,program established under subsection 7l74 7#b7 ,treatment under the ,internal ,revenue ,code of #aihf ,an individual who is enrolled under the ,medicare ,reform ,premium ,assistance ,program under paragraph 7#a7 shall not be treated as entitled to benefits under title ,,xviii for purposes of section #bbc7;b77#g7 of the ,internal ,revenue ,code of #aihf4 7#c7 ,ineligibility for part ,b or ,d benefits ,an individual shall not be eligible for benefits under part ,b or ,d of title ,,xviii once the individual is enrolled in the ,medicare ,reform ,premium ,assistance ,program under paragraph 7#a74 7#d7 ,opt out 7,a7 ,in general ,any individual who is otherwise eligible for automatic enrollment in the ,medicare ,reform ,premium ,assistance ,program under paragraph 7#a77;,a7 may elect 7in such form and manner as may be specified by the ,secretary of ,health and ,human ,services7 to not be so enrolled4 7,b7 ,individuals electing to opt out not treated as entitled to ,medicare benefits ,in the case of an individual who makes an election under subparagraph 7,a7-- 7i7 such individual shall not be eligible for benefits under part ,a of title ,,xviii2 and 7ii7 the provisions of paragraphs 7#b7 and 7#c7 shall apply to such individual in the same manner as such paragraphs apply to an individual enrolled under the ,medicare ,reform ,premium ,assistance ,program under paragraph 7#a74 7l7 ,medicare ,reform ,premium ,assistance 7#a7 ,establishment of premium assistance program ,the ,secretary shall establish a program to be known as the ,medicare ,reform ,premium ,assistance ,program 7in this subsection referred to as the premium assistance program7 consistent with this subsection4 7#b7 ,automatic enrollment ,an individual otherwise entitled under subsection 7a7 to benefits under part ,a of title ,,xviii shall1 subject to subsection 7k77#d71 be enrolled in the premium assistance program for the period during which such individual would otherwise be so entitled to benefits4 7#c7 ,amount of premium assistance 7,a7 ,in general ,subject to clause 7ii71 for each year that an individual is enrolled in the premium assistance program1 the ,secretary shall provide premium assistance to such individual in an amount determined by the ,secretary that is based on the geographic location of the individual and the cost of applicable health insurance coverage and benefits in such area4 7,b7 ,computation of premium assistance amounts ,the amount of premium assistance provided to an individual located in a geographic area for a year shall be computed at #ajj percent of the sum of the median premium and median deductible payment for such year for all health insurance coverage offered by health insurance issuers in the individual market serving such area4 7#d7 ,permissible use of premium assistance ,premium assistance under paragraph 7#c7 may be used only for the following purposes3 7,a7 ,for payment of premiums1 deductibles1 copayments1 or other cost-sharing for enrollment of such individual for health insurance coverage offered by health insurance issuers in the individual market4 7,b7 ,as a contribution into a ,,msa plan established by such individual1 as defined in section #ach7;b77#b7 of the ,internal ,revenue ,code of #aihf4 7#e7 ,,msa deposits ,the amount of the premium assistance received by an individual under this subsection shall be deposited1 on behalf of such individual1 into the ,,msa plan of such individual4 4 7b7 ,effective date ,the amendment made by this section shall take effect on the first ,january #a after the date of the enactment of this ,act4 #cjb4 ,gradual phasing out of ,,cms and transfer of functions to ,department of the ,treasury 7a7 ,in general ,beginning on ,january #a of the first year beginning after the date of the enactment of this ,act1 the ,secretary shall provide for the gradual phasing out over a period 7not to exceed #aj years7 of the ,office of the ,administrator of the ,centers for ,medicare ,medicaid ,services and such ,centers and the transfer of the duties and responsibilities of such ,administrator and ,centers to such an office and official within the ,department of the ,treasury as the ,secretary of the ,treasury shall specify4 7b7 ,references ,any reference in law to the ,administrator of the ,centers for ,medicare ,medicaid ,services1 or to such ,centers1 is deemed to include a reference to such official and office1 respectively1 within the ,department of the ,treasury as is specified under subsection 7a74 ,,iv ,,emtala ,reforms #dja4 ,,emtala reforms 7a7 ,use of qualified emergency department personnel in performing initial screening ,subsection 7a7 of section #ahfg of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;dd7 is amended-- 7#a7 by designating the sentence beginning with ,in the case of as paragraph 7#a71 with the heading ,in general4-- and appropriate indentation2 and 7#b7 by adding at the end the following new paragraph3 7#b7 ,permitting application of ,,er triage 7,a7 ,in general ,the requirement of paragraph 7#a7 that a hospital conduct an appropriate medical screening examination of an individual is deemed to be satisfied if a qualified emergency screener 7as defined in subparagraph 7,b77 performs a preliminary triage-type screening in which the personnel-- 7i7 assesses the nature and extent of the individual's illness or injury2 and 7ii7 determines1 based on such assessment1 that an emergency medical condition does not exist4 7,b7 ,qualified emergency screener defined ,in this paragraph1 the term qualified emergency screener means a physician1 licensed practical nurse or registered nurse1 qualified emergency medical technician1 or other individual with basic1 health care education that meets standards specified by the ,secretary as being sufficient to perform the screening described in subparagraph 7,a74 4 7b7 ,revision of emergency medical condition definition ,subsection 7e77#a77;,a7 of such section is amended to read as follows3 7,a7 a medical condition manifesting itself by symptoms of sufficient severity 7including severe pain7 and with an onset or of a course such that the absence of immediate medical attention could reasonably be expected to pose an immediate risk to life or long-term health of the individual 7or1 with respect to a pregnant woman1 the life or long-term health of the woman or her unborn child72 or 4 7c7 ,effective date ,the amendments made by this section shall take effect on the date of the enactment of this ,act and shall apply to individuals who come to an emergency room on or after the date that is #cj days after the date of the enactment of this ,act4 ,v ,cooperative ,governing of ,individual and ,group ,health ,insurance ,coverage #eja4 ,cooperative governing of individual and group health insurance coverage 7a7 ,in general ,title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 is amended by adding at the end the following new part3 ,d ,cooperative ,governing of ,individual and ,group ,health ,insurance ,coverage #bgie4 ,definitions ,in this part3 7#a7 ,primary state ,the term primary ,state means1 with respect to individual or group health insurance coverage offered by a health insurance issuer1 the ,state designated by the issuer as the ,state whose covered laws shall govern the health insurance issuer in the sale of such coverage under this part4 ,an issuer1 with respect to a particular policy1 may only designate one such ,state as its primary ,state with respect to all such coverage it offers4 ,such an issuer may not change the designated primary ,state with respect to individual or group health insurance coverage once the policy is issued1 except that such a change may be made upon renewal of the policy4 ,with respect to such designated ,state1 the issuer is deemed to be doing business in that ,state4 7#b7 ,secondary state ,the term secondary ,state means1 with respect to individual or group health insurance coverage offered by a health insurance issuer1 any ,state that is not the primary ,state4 ,in the case of a health insurance issuer that is selling a policy in1 or to a resident of1 a secondary ,state1 the issuer is deemed to be doing business in that secondary ,state4 7#c7 ,health insurance issuer ,the term health insurance issuer has the meaning given such term in section #bgia7;b77#b71 except that such an issuer must be licensed in the primary ,state and be qualified to sell individual health insurance coverage in that ,state4 7#d7 ,individual health insurance coverage ,the term individual health insurance coverage means health insurance coverage offered in the individual market1 as defined in section #bgia7;e77#a74 7#e7 ,group health insurance coverage ,the term group health insurance coverage has the meaning given such term in #bgia7;b77#d74 7#f7 ,applicable state authority ,the term applicable ,state authority means1 with respect to a health insurance issuer in a ,state1 the ,state insurance commissioner or official or officials designated by the ,state to enforce the requirements of this title for the ,state with respect to the issuer4 7#g7 ,hazardous financial condition ,the term hazardous financial condition means that1 based on its present or reasonably anticipated financial condition1 a health insurance issuer is unlikely to be able-- 7,a7 to meet obligations to policyholders with respect to known claims and reasonably anticipated claims2 or 7,b7 to pay other obligations in the normal course of business4 7#h7 ,covered laws 7,a7 ,in general ,the term covered laws means the laws1 rules1 regulations1 agreements1 and orders governing the insurance business pertaining to-- 7i7 individual or group health insurance coverage issued by a health insurance issuer2 7ii7 the offer1 sale1 rating 7including medical underwriting71 renewal1 and issuance of individual or group health insurance coverage to an individual2 7iii7 the provision to an individual in relation to individual or group health insurance coverage of health care and insurance related services2 7iv7 the provision to an individual in relation to individual or group health insurance coverage of management1 operations1 and investment activities of a health insurance issuer2 and 7v7 the provision to an individual in relation to individual or group health insurance coverage of loss control and claims administration for a health insurance issuer with respect to liability for which the issuer provides insurance4 7,b7 ,exception ,such term does not include any law1 rule1 regulation1 agreement1 or order governing the use of care or cost management techniques1 including any requirement related to provider contracting1 network access or adequacy1 health care data collection1 or quality assurance4 7#i7 ,state ,the term ,state means the #ej ,states and includes the ,district of ,columbia1 ,puerto ,rico1 the ,virgin ,islands1 ,guam1 ,american ,samoa1 and the ,northern ,mariana ,islands4 7#aj7 ,unfair claims settlement practices ,the term unfair claims settlement practices means only the following practices3 7,a7 ,knowingly misrepresenting to claimants and insured individuals relevant facts or policy provisions relating to coverage at issue4 7,b7 ,failing to acknowledge with reasonable promptness pertinent communications with respect to claims arising under policies4 7,c7 ,failing to adopt and implement reasonable standards for the prompt investigation and settlement of claims arising under policies4 7,d7 ,failing to effectuate prompt1 fair1 and equitable settlement of claims submitted in which liability has become reasonably clear4 7,e7 ,refusing to pay claims without conducting a reasonable investigation4 7,f7 ,failing to affirm or deny coverage of claims within a reasonable period of time after having completed an investigation related to those claims4 7,g7 ,a pattern or practice of compelling insured individuals or their beneficiaries to institute suits to recover amounts due under its policies by offering substantially less than the amounts ultimately recovered in suits brought by them4 7,h7 ,a pattern or practice of attempting to settle or settling claims for less than the amount that a reasonable person would believe the insured individual or his or her beneficiary was entitled by reference to written or printed advertising material accompanying or made part of an application4 7,i7 ,attempting to settle or settling claims on the basis of an application that was materially altered without notice to1 or knowledge or consent of1 the insured4 7,j7 ,failing to provide forms necessary to present claims within #ae calendar days of a requests with reasonable explanations regarding their use4 7,k7 ,attempting to cancel a policy in less time than that prescribed in the policy or by the law of the primary ,state4 7#aa7 ,fraud and abuse ,the term fraud and abuse means an act or omission committed by a person who1 knowingly and with intent to defraud1 commits1 or conceals any material information concerning1 one or more of the following3 7,a7 ,presenting1 causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer1 a reinsurer1 broker or its agent1 false information as part of1 in support of or concerning a fact material to one or more of the following3 7i7 ,an application for the issuance or renewal of an insurance policy or reinsurance contract4 7ii7 ,the rating of an insurance policy or reinsurance contract4 7iii7 ,a claim for payment or benefit pursuant to an insurance policy or reinsurance contract4 7iv7 ,premiums paid on an insurance policy or reinsurance contract4 7v7 ,payments made in accordance with the terms of an insurance policy or reinsurance contract4 7vi7 ,a document filed with the commissioner or the chief insurance regulatory official of another jurisdiction4 7vii7 ,the financial condition of an insurer or reinsurer4 7viii7 ,the formation1 acquisition1 merger1 reconsolidation1 dissolution or withdrawal from one or more lines of insurance or reinsurance in all or part of a ,state by an insurer or reinsurer4 7ix7 ,the issuance of written evidence of insurance4 7x7 ,the reinstatement of an insurance policy4 7,b7 ,solicitation or acceptance of new or renewal insurance risks on behalf of an insurer reinsurer or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction4 7,c7 ,transaction of the business of insurance in violation of laws requiring a license1 certificate of authority or other legal authority for the transaction of the business of insurance4 7,d7 ,attempt to commit1 aiding or abetting in the commission of1 or conspiracy to commit the acts or omissions specified in this paragraph4 #bgif4 ,application of law 7a7 ,in general ,the covered laws of the primary ,state shall apply to individual and group health insurance coverage offered by a health insurance issuer in the primary ,state and in any secondary ,state1 but only if the coverage and issuer comply with the conditions of this section with respect to the offering of coverage in any secondary ,state4 7b7 ,exemptions from covered laws in a secondary state ,except as provided in this section1 a health insurance issuer with respect to its offer1 sale1 rating 7including medical underwriting71 renewal1 and issuance of individual or group health insurance coverage in any secondary ,state is exempt from any covered laws of the secondary ,state 7and any rules1 regulations1 agreements1 or orders sought or issued by such ,state under or related to such covered laws7 to the extent that such laws would-- 7#a7 make unlawful1 or regulate1 directly or indirectly1 the operation of the health insurance issuer operating in the secondary ,state1 except that any secondary ,state may require such an issuer-- 7,a7 to pay1 on a nondiscriminatory basis1 applicable premium and other taxes 7including high risk pool assessments7 which are levied on insurers and surplus lines insurers1 brokers1 or policyholders under the laws of the ,state2 7,b7 to register with and designate the ,state insurance commissioner as its agent solely for the purpose of receiving service of legal documents or process2 7,c7 to submit to an examination of its financial condition by the ,state insurance commissioner in any ,state in which the issuer is doing business to determine the issuer's financial condition1 if-- 7i7 the ,state insurance commissioner of the primary ,state has not done an examination within the period recommended by the ,national ,association of ,insurance ,commissioners2 and 7ii7 any such examination is conducted in accordance with the examiners' handbook of the ,national ,association of ,insurance ,commissioners and is coordinated to avoid unjustified duplication and unjustified repetition2 7,d7 to comply with a lawful order issued-- 7i7 in a delinquency proceeding commenced by the ,state insurance commissioner if there has been a finding of financial impairment under subparagraph 7,c72 or 7ii7 in a voluntary dissolution proceeding2 7,e7 to comply with an injunction issued by a court of competent jurisdiction1 upon a petition by the ,state insurance commissioner alleging that the issuer is in hazardous financial condition2 7,f7 to participate1 on a nondiscriminatory basis1 in any insurance insolvency guaranty association or similar association to which a health insurance issuer in the ,state is required to belong2 7,g7 to comply with any ,state law regarding fraud and abuse 7as defined in section #bgie7aj771 except that if the ,state seeks an injunction regarding the conduct described in this subparagraph1 such injunction must be obtained from a court of competent jurisdiction2 7,h7 to comply with any ,state law regarding unfair claims settlement practices 7as defined in section #bgie7i772 or 7,i7 to comply with the applicable requirements for independent review under section #bgih with respect to coverage offered in the ,state2 7#b7 require any individual or group health insurance coverage issued by the issuer to be countersigned by an insurance agent or broker residing in that ,secondary ,state2 or 7#c7 otherwise discriminate against the issuer issuing insurance in both the primary ,state and in any secondary ,state4 7c7 ,clear and conspicuous disclosure ,a health insurance issuer shall provide the following notice1 in #ab-point bold type1 in any insurance coverage offered in a secondary ,state under this part by such a health insurance issuer and at renewal of the policy1 with the #e blank spaces therein being appropriately filled with the name of the health insurance issuer1 the name of primary ,state1 the name of the secondary ,state1 the name of the secondary ,state1 and the name of the secondary ,state1 respectively1 for the coverage concerned3 ,notice3 ,this policy is issued by and is governed by the laws and regulations of the ,state of 1 and it has met all the laws of that ,state as determined by that ,state's ,department of ,insurance4 ,this policy may be less expensive than others because it is not subject to all of the insurance laws and regulations of the ,state of 1 including coverage of some services or benefits mandated by the law of the ,state of 4 ,additionally1 this policy is not subject to all of the consumer protection laws or restrictions on rate changes of the ,state of 4 ,as with all insurance products1 before purchasing this policy1 you should carefully review the policy and determine what health care services the policy covers and what benefits it provides1 including any exclusions1 limitations1 or conditions for such services or benefits44 7d7 ,prohibition on certain reclassifications and premium increases 7#a7 ,in general ,for purposes of this section1 a health insurance issuer that provides individual or group health insurance coverage to an individual under this part in a primary or secondary ,state may not upon renewal-- 7,a7 move or reclassify the individual insured under the health insurance coverage from the class such individual is in at the time of issue of the contract based on the health status-related factors of the individual2 or 7,b7 increase the premiums assessed the individual for such coverage based on a health status-related factor or change of a health status-related factor or the past or prospective claim experience of the insured individual4 7#b7 ,construction ,nothing in paragraph 7#a7 shall be construed to prohibit a health insurance issuer-- 7,a7 from terminating or discontinuing coverage or a class of coverage in accordance with subsections 7b7 and 7c7 of section #bgdb2 7,b7 from raising premium rates for all policy holders within a class based on claims experience2 7,c7 from changing premiums or offering discounted premiums to individuals who engage in wellness activities at intervals prescribed by the issuer1 if such premium changes or incentives-- 7i7 are disclosed to the consumer in the insurance contract2 7ii7 are based on specific wellness activities that are not applicable to all individuals2 and 7iii7 are not obtainable by all individuals to whom coverage is offered2 7,d7 from reinstating lapsed coverage2 or 7,e7 from retroactively adjusting the rates charged an insured individual if the initial rates were set based on material misrepresentation by the individual at the time of issue4 7e7 ,prior offering of policy in primary state ,a health insurance issuer may not offer for sale individual or group health insurance coverage in a secondary ,state unless that coverage is currently offered for sale in the primary ,state4 7f7 ,licensing of agents or brokers for health insurance issuers ,any ,state may require that a person acting1 or offering to act1 as an agent or broker for a health insurance issuer with respect to the offering of individual or group health insurance coverage obtain a license from that ,state1 with commissions or other compensation subject to the provisions of the laws of that ,state1 except that a ,state may not impose any qualification or requirement which discriminates against a nonresident agent or broker4 7g7 ,documents for submission to state insurance commissioner ,each health insurance issuer issuing individual or group health insurance coverage in both primary and secondary ,states shall submit-- 7#a7 to the insurance commissioner of each ,state in which it intends to offer such coverage1 before it may offer individual or group health insurance coverage in such ,state-- 7,a7 a copy of the plan of operation or feasibility study or any similar statement of the policy being offered and its coverage 7which shall include the name of its primary ,state and its principal place of business72 7,b7 written notice of any change in its designation of its primary ,state2 and 7,c7 written notice from the issuer of the issuer's compliance with all the laws of the primary ,state2 and 7#b7 to the insurance commissioner of each secondary ,state in which it offers individual or group health insurance coverage1 a copy of the issuer's quarterly financial statement submitted to the primary ,state1 which statement shall be certified by an independent public accountant and contain a statement of opinion on loss and loss adjustment expense reserves made by-- 7,a7 a member of the ,american ,academy of ,actuaries2 or 7,b7 a qualified loss reserve specialist4 7h7 ,power of courts ,to enjoin conduct ,nothing in this section shall be construed to affect the authority of any ,federal or ,state court to enjoin-- 7#a7 the solicitation or sale of individual or group health insurance coverage by a health insurance issuer to any person or group who is not eligible for such insurance2 or 7#b7 the solicitation or sale of individual or group health insurance coverage that violates the requirements of the law of a secondary ,state which are described in subparagraphs 7,a7 through 7,h7 of section #bgif7;b77#a74 7i7 ,power of ,secondary ,states ,to ,take ,administrative ,action ,nothing in this section shall be construed to affect the authority of any ,state to enjoin conduct in violation of that ,state's laws described in section #bgif7;b77#a74 7j7 ,state powers ,to enforce state laws 7#a7 ,in general ,subject to the provisions of subsection 7b77#a77;,g7 7relating to injunctions7 and paragraph 7#b71 nothing in this section shall be construed to affect the authority of any ,state to make use of any of its powers to enforce the laws of such ,state with respect to which a health insurance issuer is not exempt under subsection 7b74 7#b7 ,courts of competent jurisdiction ,if a ,state seeks an injunction regarding the conduct described in paragraphs 7#a7 and 7#b7 of subsection 7h71 such injunction must be obtained from a ,federal or ,state court of competent jurisdiction4 7k7 ,states' authority ,to sue ,nothing in this section shall affect the authority of any ,state to bring action in any ,federal or ,state court4 7l7 ,generally applicable laws ,nothing in this section shall be construed to affect the applicability of ,state laws generally applicable to persons or corporations4 7m7 ,guaranteed ,availability of ,coverage to ,,hipaa ,eligible ,individuals ,to the extent that a health insurance issuer is offering coverage in a primary ,state that does not accommodate residents of secondary ,states or does not provide a working mechanism for residents of a secondary ,state1 and the issuer is offering coverage under this part in such secondary ,state which has not adopted a qualified high risk pool as its acceptable alternative mechanism 7as defined in section #bgdd7;c77#b771 the issuer shall1 with respect to any individual or group health insurance coverage offered in a secondary ,state under this part1 comply with the guaranteed availability requirements for eligible individuals in section #bgda4 #bgig4 ,primary ,state must meet ,federal floor before issuer may sell into secondary ,states ,a health insurance issuer may not offer1 sell1 or issue individual or group health insurance coverage in a secondary ,state if the ,state insurance commissioner does not use a risk-based capital formula for the determination of capital and surplus requirements for all health insurance issuers4 #bgih4 ,independent external appeals procedures 7a7 ,right to ,external ,appeal ,a health insurance issuer may not offer1 sell1 or issue individual or group health insurance coverage in a secondary ,state under the provisions of this title unless-- 7#a7 both the secondary ,state and the primary ,state have legislation or regulations in place establishing an independent review process for individuals who are covered by individual health insurance coverage or group health insurance offered by a health insurance issuer1 respectively1 or 7#b7 in any case in which the requirements of subparagraph 7,a7 are not met with respect to the either of such ,states1 the issuer provides an independent review mechanism substantially identical 7as determined by the applicable ,state authority of such ,state7 to that prescribed in the ,health ,carrier ,external ,review ,model ,act of the ,national ,association of ,insurance ,commissioners for all individuals who purchase insurance coverage under the terms of this part1 except that1 under such mechanism1 the review is conducted by an independent medical reviewer1 or a panel of such reviewers1 with respect to whom the requirements of subsection 7b7 are met4 7b7 ,qualifications of ,independent ,medical ,reviewers ,in the case of any independent review mechanism referred to in subsection 7a77#b73 7#a7 ,in general ,in referring a denial of a claim to an independent medical reviewer1 or to any panel of such reviewers1 to conduct independent medical review1 the issuer shall ensure that-- 7,a7 each independent medical reviewer meets the qualifications described in paragraphs 7#b7 and 7#c72 7,b7 with respect to each review1 each reviewer meets the requirements of paragraph 7#d7 and the reviewer1 or at least #a reviewer on the panel1 meets the requirements described in paragraph 7#e72 and 7,c7 compensation provided by the issuer to each reviewer is consistent with paragraph 7#f74 7#b7 ,licensure and expertise ,each independent medical reviewer shall be a physician 7allopathic or osteopathic7 or health care professional who-- 7,a7 is appropriately credentialed or licensed in #a or more ,states to deliver health care services2 and 7,b7 typically treats the condition1 makes the diagnosis1 or provides the type of treatment under review4 7#c7 ,independence 7,a7 ,in general ,subject to subparagraph 7,b71 each independent medical reviewer in a case shall-- 7i7 not be a related party 7as defined in paragraph 7#g772 7ii7 not have a material familial1 financial1 or professional relationship with such a party2 and 7iii7 not otherwise have a conflict of interest with such a party 7as determined under regulations74 7,b7 ,exception ,nothing in subparagraph 7,a7 shall be construed to-- 7i7 prohibit an individual1 solely on the basis of affiliation with the issuer1 from serving as an independent medical reviewer if-- 7,i7 a non-affiliated individual is not reasonably available2 7,,ii7 the affiliated individual is not involved in the provision of items or services in the case under review2 7,,iii7 the fact of such an affiliation is disclosed to the issuer and the enrollee 7or authorized representative7 and neither party objects2 and 7,,iv7 the affiliated individual is not an employee of the issuer and does not provide services exclusively or primarily to or on behalf of the issuer2 7ii7 prohibit an individual who has staff privileges at the institution where the treatment involved takes place from serving as an independent medical reviewer merely on the basis of such affiliation if the affiliation is disclosed to the issuer and the enrollee 7or authorized representative71 and neither party objects2 or 7iii7 prohibit receipt of compensation by an independent medical reviewer from an entity if the compensation is provided consistent with paragraph 7#f74 7#d7 ,practicing health care professional in same field 7,a7 ,in general ,in a case involving treatment1 or the provision of items or services-- 7i7 by a physician1 a reviewer shall be a practicing physician 7allopathic or osteopathic7 of the same or similar specialty1 as a physician who1 acting within the appropriate scope of practice within the ,state in which the service is provided or rendered1 typically treats the condition1 makes the diagnosis1 or provides the type of treatment under review2 or 7ii7 by a non-physician health care professional1 the reviewer1 or at least #a member of the review panel1 shall be a practicing non-physician health care professional of the same or similar specialty as the non-physician health care professional who1 acting within the appropriate scope of practice within the ,state in which the service is provided or rendered1 typically treats the condition1 makes the diagnosis1 or provides the type of treatment under review4 7,b7 ,practicing defined ,for purposes of this paragraph1 the term practicing means1 with respect to an individual who is a physician or other health care professional1 that the individual provides health care services to individual patients on average at least #b days per week4 7#e7 ,pediatric expertise ,in the case of an external review relating to a child1 a reviewer shall have expertise under paragraph 7#b7 in pediatrics4 7#f7 ,limitations on reviewer compensation ,compensation provided by the issuer to an independent medical reviewer in connection with a review under this section shall-- 7,a7 not exceed a reasonable level2 and 7,b7 not be contingent on the decision rendered by the reviewer4 7#g7 ,related party defined ,for purposes of this section1 the term related party means1 with respect to a denial of a claim under a coverage relating to an enrollee1 any of the following3 7,a7 ,the issuer involved1 or any fiduciary1 officer1 director1 or employee of the issuer4 7,b7 ,the enrollee 7or authorized representative74 7,c7 ,the health care professional that provides the items or services involved in the denial4 7,d7 ,the institution at which the items or services 7or treatment7 involved in the denial are provided4 7,e7 ,the manufacturer of any drug or other item that is included in the items or services involved in the denial4 7,f7 ,any other party determined under any regulations to have a substantial interest in the denial involved4 7#h7 ,definitions ,for purposes of this subsection3 7,a7 ,enrollee ,the term enrollee means1 with respect to health insurance coverage offered by a health insurance issuer1 an individual enrolled with the issuer to receive such coverage4 7,b7 ,health care professional ,the term health care professional means an individual who is licensed1 accredited1 or certified under ,state law to provide specified health care services and who is operating within the scope of such licensure1 accreditation1 or certification4 #bgii4 ,enforcement 7a7 ,in general ,subject to subsection 7b71 with respect to specific individual or group health insurance coverage the primary ,state for such coverage has sole jurisdiction to enforce the primary ,state's covered laws in the primary ,state and any secondary ,state4 7b7 ,secondary state's authority ,nothing in subsection 7a7 shall be construed to affect the authority of a secondary ,state to enforce its laws as set forth in the exception specified in section #bgif7;b77#a74 7c7 ,court interpretation ,in reviewing action initiated by the applicable secondary ,state authority1 the court of competent jurisdiction shall apply the covered laws of the primary ,state4 7d7 ,notice of compliance failure ,in the case of individual health insurance coverage offered in a secondary ,state1 or group health insurance coveraged offered by a health insurance issuer in a secondary ,state1 that fails to comply with the covered laws of the primary ,state1 the applicable ,state authority of the secondary ,state may notify the applicable ,state authority of the primary ,state4 4 7b7 ,effective date ,the amendment made by subsection 7a7 shall apply to health insurance coverage offered1 issued1 or sold after the date that is one year after the date of the enactment of this ,act4 7c7 ,,gao ongoing study and reports 7#a7 ,study ,the ,comptroller ,general of the ,united ,states shall conduct an ongoing study concerning the effect of the amendment made by subsection 7a7 on-- 7,a7 the number of uninsured and under-insured2 7,b7 the availability and cost of health insurance policies for individuals with pre-existing medical conditions2 7,c7 the availability and cost of health insurance policies generally2 7,d7 the elimination or reduction of different types of benefits under health insurance policies offered in different ,states2 and 7,e7 cases of fraud or abuse relating to health insurance coverage offered under such amendment and the resolution of such cases4 7#b7 ,annual reports ,the ,comptroller ,general shall submit to ,congress an annual report1 after the end of each of the #e years following the effective date of the amendment made by subsection 7a71 on the ongoing study conducted under paragraph 7#a74 #ejb4 ,continuing ,state authority ,nothing in this title1 or the amendments made by this title1 shall be construed as preventing a ,state-- 7#a7 from permitting residents of the ,state to purchase of health insurance offered by a health insurance issuer located outside the ,state2 or 7#b7 from permitting groups to directly obtain1 through an association health plan or otherwise1 health insurance coverage for their members4 ,,vi ,state ,health ,flexibility #fja4 ,short title ,this title may be cited as the ,state ,health ,flexibility ,act of #bjac4 #fjb4 ,health grants to the ,states for health care services to indigent individuals 7a7 ,health care block grant to ,states ,the ,social ,security ,act is amended by adding at the end the following new title3 ,,xxii ,,block ,,grants ,,to ,,states ,,for ,,health ,,care ,,services ,,to ,,indigent ,,individuals #bbja4 ,purpose ,the purpose of this title is to provide ,federal financial assistance to the ,states1 in the form of a single grant1 to allow the ,states maximum flexibility in providing1 and financing the provision of1 health-care-related items and services to indigent individuals4 #bbjb4 ,grants to ,states 7a7 ,in general ,subject to the requirements of this title1 each ,state is entitled to receive from the ,secretary of the ,treasury a grant for each quarter of fiscal years #bjad1 #bjae1 #bjaf1 #bjag1 #bjah1 #bjai1 #bjbj1 #bjba1 #bjbb1 and #bjbc1 in an amount that is equal to #be percent of the total amount received by a ,state under title ,,xix and title ,,xxi for fiscal year #bjab4 7b7 ,appropriation ,out of any money in the ,treasury of the ,united ,states not otherwise appropriated1 there are appropriated for fiscal years #bjad1 #bjae1 #bjaf1 #bjag1 #bjah1 #bjai1 #bjbj1 #bjba1 #bjbb1 and #bjbc such sums as are necessary for grants under this section4 7c7 ,requirements relating to intergovernmental financing ,the ,secretary of the ,treasury shall make the transfer of funds under grants under subsection 7a7 directly to each ,state in accordance with the requirements of section #fejc of title #ca1 ,united ,states ,code4 7d7 ,expenditure of funds 7#a7 ,in general ,except as provided in paragraph 7#b71 amounts received by a ,state under this title for any fiscal year shall be expended by the ,state in such fiscal year or in the succeeding fiscal year4 7#b7 ,use of rainy day fund permitted ,of the amounts received by a ,state under this title1 the ,state may set aside1 in a separate account1 such amounts as the ,state deems necessary to provide1 without fiscal limitation1 health-care-related items and services for indigent individuals during-- 7,a7 periods of unexpectedly high rates of unemployment2 or 7,b7 periods related to circumstances that are not described in subparagraph 7,a7 and that cause unexpected increases in the need for such items and services for such individuals4 7#c7 ,funds remaining after fiscal year #bjbb ,if1 after fiscal year #bjbc1 a ,state has funds in the account under paragraph 7#b71 the ,state may only expend such funds if such funds are used in a manner that is permitted under subsection 7e71 as such subsection is in effect on ,september #cj1 #bjbc4 7e7 ,use of funds ,a ,state may only use the amounts received under subsection 7a7 as follows3 7#a7 ,general purpose ,for the purpose under section #bbja1 including the provision of health-care-related items and services as required under section #bbje4 ,nothing in this title shall be construed as limiting the flexibility of a ,state to determine which providers of such items and services qualify to receive payment from a grant made to the ,state under this title4 7#b7 ,funding for risk adjustment mechanisms ,to fund qualified high risk pools1 reinsurance pools1 or other risk-adjustment mechanisms used for the purpose of subsidizing the purchase of private health insurance for the high-risk population4 7#c7 ,authority to use portion of ,federal assistance for other welfare-related programs 7,a7 ,in general ,subject to the limit under subparagraph 7,b71 to carry out a ,state program pursuant to any or all of the following provisions of law3 7i7 ,part ,a of title ,,iv of this ,act4 7ii7 ,section #afaf of this ,act4 7iii7 ,the ,food and ,nutrition ,act of #bjjh4 7,b7 ,limitation ,a ,state may not use more than #cj percent of the amount received under subsection 7a7 for a fiscal year to carry out a ,state program1 or programs1 under subparagraph 7,a74 7,c7 ,requirements on funds ,any amounts that are used under subparagraph 7,a7-- 7i7 shall not be subject to any of the requirements of subsection 7d71 subsection 7f71 section #bbjd1 or section #bbje2 and 7ii7 shall be subject to-- 7,i7 the audit requirements under section #bbjc2 and 7,,ii7 any requirements that apply to ,federal funds provided directly for such ,state program4 7f7 ,maintenance of current law restrictions on use of federal funds 7#a7 ,in general 7,a7 ,no funding for abortions ,none of the funds appropriated in this title shall be expended for any abortion4 7,b7 ,no funds for coverage of abortion ,none of the funds appropriated in this title shall be expended for health benefits coverage that includes coverage of abortion4 7,c7 ,health benefits coverage defined ,for purposes of this subsection1 the term health benefits coverage means the package of services covered by a managed care provider or organization pursuant to a contract or other arrangement4 7#b7 ,exceptions ,the limitations established in paragraph 7#a7 shall not apply to an abortion in the case where a woman suffers from a physical disorder1 physical injury1 or physical illness that would1 as certified by a physician1 place the woman in danger of death unless an abortion is performed1 including a life-endangering physical condition caused by or arising from the pregnancy itself4 7#c7 ,state funds used in conjunction with ,federal funds ,the limitations established in paragraph 7#a7 shall apply to any ,state funds used in conjunction with ,federal funds appropriated under this title to provide1 or finance the provision of1 health-care-related items and services to indigent individuals pursuant to section #bbja or subsections 7d77#b71 7e77#a71 or 7e77#b7 of this section4 7#d7 ,option to purchase separate coverage or plan ,nothing in this subsection shall be construed as prohibiting a ,state from purchasing separate coverage for abortions for which funding is prohibited under this subsection1 or a health plan that includes such abortions1 so long as such coverage or plan is paid for entirely using funds not provided by this title4 7#e7 ,option to offer coverage or plan ,nothing in this subsection shall restrict any health insurance issuer from offering separate coverage for abortions for which funding is prohibited under this subsection1 or a health plan that includes such abortions1 so long as-- 7,a7 premiums for such separate coverage or plan are paid entirely with funds not provided by this title2 and 7,b7 administrative costs and all services offered through such separate coverage or plan are paid for using only premiums collected for such coverage or plan4 7#f7 ,conscience protections 7,a7 ,none of the funds appropriated in this ,act may be made available to a ,federal agency or program1 or to a ,state or local government1 if such agency1 program1 or government subjects any institutional or individual health care entity to discrimination on the basis that the health care entity does not provide1 pay for1 provide coverage of1 or refer for abortions4 7,b7 ,in this paragraph1 the term health care entity includes an individual physician1 pharmacist1 or other health care professional1 a hospital1 a provider-sponsored organization1 a health maintenance organization1 a health insurance plan1 or any other kind of health care facility1 organization1 or plan4 7g7 ,no funding for illegal aliens ,except as provided under this section and section #bbje1 no funds appropriated in this title may be used to provide health-care-related items and services to an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the ,united ,states under color of law4 7h7 ,nonentitlement ,nothing in this title shall be construed as providing an individual with an entitlement to health-care-related items and services under this title4 #bbjc4 ,administrative and fiscal accountability 7a7 ,audits 7#a7 ,contract with approved auditing entity ,not later than ,october #a1 #bjad1 and annually thereafter1 a ,state shall contract with an approved auditing entity 7as defined under paragraph 7#c77;,b77 for purposes of conducting an audit under paragraph 7#b7 7with respect to the fiscal year ending ,september #cj of such year74 7#b7 ,audit requirement ,under a contract under paragraph 7#a71 an approved auditing entity shall conduct an audit of the expenditures or transfers made by a ,state from amounts received under a grant under this title1 or from ,state funds described in section #bbjb7;f77#c71 with respect to the fiscal year which such audit covers1 to determine the extent to which such expenditures and transfers were expended in accordance with this title4 7#c7 ,entity conducting audit 7,a7 ,in general ,with respect to a ,state1 the audit under paragraph 7#b7 shall be conducted by an approved auditing entity in accordance with generally accepted auditing principles4 7,b7 ,approved auditing entity ,for purposes of this section1 the term approved auditing entity means1 with respect to a ,state1 an entity that is-- 7i7 approved by the ,secretary of the ,treasury2 7ii7 approved by the chief executive officer of the ,state2 and 7iii7 independent of any ,federal1 ,state1 or local agency4 7#d7 ,submission of audit ,not later than ,december #ca1 #bjad1 and annually thereafter1 a ,state shall submit the results of the audit under paragraph 7#b7 7with respect to the fiscal year ending on ,september #cj of such year7 to the ,state legislature and to the ,secretary of the ,treasury4 7#e7 ,additional accounting requirements ,the provisions of chapter #ge of title #ca1 ,united ,states ,code1 shall apply to the audit requirements of this section4 7b7 ,reimbursement and penalty 7#a7 ,in general ,if1 through an audit conducted under subsection 7a71 an approved auditing entity finds that any amounts paid to a ,state under a grant under this title were not expended in accordance with this title-- 7,a7 the ,state shall pay to the ,treasury of the ,united ,states any such amount1 plus #aj percent of such amount as a penalty2 or 7,b7 the ,secretary of the ,treasury shall offset such amount plus the #aj percent penalty against any other amount in any other fiscal year that the ,state may be entitled to receive under a grant under this title4 7#b7 ,misuse of ,state funds ,if1 through an audit conducted under subsection 7a71 an approved auditing entity finds that a ,state violated the requirements of section #bbjb7;f77#c71 the ,state shall pay to the ,treasury of the ,united ,states #ajj percent of the amount of ,state funds that were used in violation of section #bbjb7;f77#c7 as a penalty4 ,insofar as a ,state fails to pay any such penalty1 the ,secretary of the ,treasury shall offset the amount not so paid against the amount of any grant otherwise payable to the ,state under this title4 7c7 ,annual reporting requirements 7#a7 ,in general ,not later than ,january #ca1 #bjae1 and annually thereafter1 each ,state shall submit to the ,secretary of the ,treasury and the ,state legislature a report on the activities carried out by the ,state during the most recently completed fiscal year with funds received by the ,state under a grant under this title for such fiscal year4 7#b7 ,content ,a report under paragraph 7#a7 shall1 with respect to a fiscal year-- 7,a7 contain the results of the audit conducted by an approved auditing entity for a ,state for such fiscal year1 in accordance with the requirements of subsection 7a7 of this section2 7,b7 specify the amount of the grant made to the ,state under this title that is used to carry out a program under section #bbjb7;e77#c72 and 7,c7 be in such form and contain such other information as the ,state determines is necessary to provide-- 7i7 an accurate description of the activities conducted by the ,state for the purpose described under section #bbja and any other use of funds permitted under subsections 7d7 and 7e7 of section #bbjb2 and 7ii7 a complete record of the purposes for which amounts were expended in accordance with this title4 7#c7 ,conformity with accounting principals ,any financial information in the report under paragraph 7#a7 shall be prepared and reported in accordance with generally accepted accounting principles1 including the provisions of chapter #ge of title #ca1 ,united ,states ,code4 7#d7 ,public availability ,a ,state shall make copies of the reports required under this section available on a public ,web site and shall make copies available in other formats upon request4 7d7 ,failure ,to comply with requirements ,the ,secretary of the ,treasury shall not make any payment to a ,state under a grant authorized by section #bbjb7;a7-- 7#a7 if an audit for a ,state is not submitted as required under subsection 7a71 during the period between the date such audit is due and the date on which such audit is submitted2 7#b7 if a ,state fails to submit a report as required under subsection 7c71 during the period between the date such report is due and the date on which such report is submitted2 or 7#c7 if a ,state violates a requirement of section #bbjb7;f71 during the period beginning on the date the ,secretary becomes aware of such violation and the date on which such violation is corrected by the ,state4 7e7 ,administrative supervision and oversight 7#a7 ,limited role for ,secretary of ,treasury and the ,attorney general 7,a7 ,treasury ,the authority of the ,secretary of the ,treasury under this title is limited to-- 7i7 promulgating regulations1 issuing rules1 or publishing guidance documents to the extent necessary for purposes of implementing subsection 7a77#c77;,b71 subsection 7b71 and subsection 7d72 7ii7 making quarterly payments to the ,states under grants under this title in accordance with section #bbjb7;a72 7iii7 approving entities under subsection 7a77#c77;,b7 for purposes of the audits required under subsection 7a72 7iv7 withholding payment to a ,state of a grant under subsection 7d7 or offsetting a payment of such a grant to a ,state under subsection 7b72 and 7v7 exercising the authority relating to nondiscrimination that is specified in section #bbjd7;b74 7,b7 ,attorney general ,the authority of the ,attorney ,general to supervise the amounts received by a ,state under this title is limited to the authority under section #bbjd7;c74 7#b7 ,federal supervision 7,a7 ,in general ,except as provided under paragraph 7#a71 an administrative officer1 employee1 department1 or agency of the ,united ,states 7including the ,secretary of ,health and ,human ,services7 may not-- 7i7 supervise-- 7,i7 the amounts received by the ,states under this title2 or 7,,ii7 the use of such amounts by the ,states2 or 7ii7 promulgate regulations or issue rules in accordance with this title4 7,b7 ,limitation on ,secretary of ,health and ,human ,services ,the ,secretary of ,health and ,human ,services shall have no authority over any provision of this title4 7f7 ,reservation of ,state powers ,nothing in this section shall be construed to limit the power of a ,state1 including the power of a ,state to pursue civil and criminal penalties under ,state law against any individual or entity that misuses1 or engages in fraud or abuse related to1 the funds provided to a ,state under this title4 #bbjd4 ,nondiscrimination provisions 7a7 ,no discrimination against individuals ,no individual shall be excluded from participation in1 denied the benefits of1 or subjected to discrimination under1 any program or activity funded in whole or in part with amounts paid to a ,state under this title on the basis of such individual's-- 7#a7 disability under section #ejd of the ,rehabilitation ,act of #aigc 7#bi ,u4,s4,c4 #gid72 7#b7 sex under title ,,ix of the ,education ,amendments of #aigb 7#bj ,u4,s4,c4 #afha et seq472 or 7#c7 race1 color1 or national origin under title ,,vi of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;d et seq474 7b7 ,compliance 7#a7 ,if the ,secretary of the ,treasury determines that a ,state or an entity that has received funds from amounts paid to a ,state under a grant under this title has failed to comply with a provision of law referred to in subsection 7a71 the ,secretary of the ,treasury shall notify the chief executive officer of the ,state of such failure to comply and shall request that such chief executive officer secure such compliance4 7#b7 ,if1 not later than #fj days after receiving notification under paragraph 7#a71 the chief executive officer of a ,state fails or refuses to secure compliance with the provision of law referred to in such notification1 the ,secretary of the ,treasury may-- 7,a7 refer the matter to the ,attorney ,general with a recommendation that an appropriate civil action be instituted2 or 7,b7 exercise the powers and functions provided under section #eje of the ,rehabilitation ,act of #aigc 7#bi ,u4,s4,c4 #gid;a71 title ,,ix of the ,education ,amendments of #aigb 7#bj ,u4,s4,c4 #afha et seq471 or title ,,vi of the ,civil ,rights ,act of #aifd 7#db ,u4,s4,c4 #bjjj;d et seq47 7as applicable74 7c7 ,civil actions ,if a matter is referred to the ,attorney ,general under subsection 7b77#b77;,a71 or the ,attorney ,general has reason to believe that a ,state or entity has failed to comply with a provision of law referred to in subsection 7a71 the ,attorney ,general may bring a civil action in an appropriate district court of the ,united ,states for such relief as may be appropriate1 including injunctive relief4 #bbje4 ,emergency assistance 7a7 ,in general ,a ,state that receives a grant under this title for a fiscal year shall provide payment for health-care-related items and services provided to a citizen1 legal resident1 or an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the ,united ,states under color of law1 consistent with the requirements of section #ahfg1 if-- 7#a7 such health-care-related items and services are-- 7,a7 necessary for the treatment of an emergency medical condition2 and 7,b7 health-care-related items and services that such ,state would provide payment for under this title1 if provided to an indigent individual2 7#b7 the individual meets all necessary eligibility requirements for health-care-related items and services under the ,state program funded under this title1 except for any requirement related to immigration status2 and 7#c7 such items and services are not related to an organ transplant procedure4 7b7 ,emergency medical condition ,for purposes of this section1 the term emergency medical condition means a medical condition 7including emergency labor and delivery7 manifesting itself by acute symptoms of sufficient severity 7including severe pain7 such that the absence of immediate medical attention could reasonably be expected to result in-- 7#a7 placing the patient's health in serious jeopardy2 7#b7 serious impairment to bodily functions2 or 7#c7 serious dysfunction of any bodily organ or part4 #bbjf4 ,definitions ,for purposes of this title3 7#a7 ,health-care-related items and services ,the term health-care-related items and services shall be defined by a ,state with respect to use of such term for purposes of the application of this title to the ,state4 7#b7 ,high-,risk ,population ,the term high-risk population means individuals who are described in one of the following subparagraphs3 7,a7 ,individuals who1 by reason of the existence or history of a medical condition1 are able to acquire health coverage only at rates which are at least #aej percent of the standard risk rates for such coverage4 7,b7 ,individuals who are provided health coverage by a qualified high risk pool4 7#c7 ,indigent individual ,the term indigent individual shall be defined by a ,state with respect to use of such term for purposes of the application of this title to the ,state4 7#d7 ,qualified high risk pool ,the term qualified high risk pool has the meaning given such term in section #bgde7;g77#a77;,a7 of the ,public ,health ,service ,act4 7#e7 ,risk-,adjustment ,mechanism ,defined ,for purposes of this section1 the term risk-adjustment mechanism means any risk-spreading mechanism to subsidize the purchase of private health insurance for the high-risk population1 including a qualified high risk pool4 4 7b7 ,report on reduction of ,federal administrative expenditures ,beginning not later than ,october #ca1 #bjad1 and annually thereafter until ,october #ca1 #bjbc1 the ,secretary of ,health and ,human ,services1 in consultation with the ,secretary of the ,treasury1 shall submit a report to the ,committee on ,energy and ,commerce in the ,house of ,representatives and the ,finance ,committee in the ,senate containing a description of the total reduction in ,federal expenditures required to administer and provide oversight for the programs to provide health-care-related items and services to indigent individuals under this ,act1 compared to the expenditures required to administer and provide oversight for the programs under titles ,,xix and ,,xxi of the ,social ,security ,act1 as in effect on ,september #cj1 #bjab4 7c7 ,state defined ,section #aaja7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acja7;a77#a77 is amended-- 7#a7 in the first sentence1 by striking and ,,xxi and inserting ,,xxi1 and ,,xxii2 and 7#b7 in the fourth sentence1 by striking and ,,xxi and inserting 1 ,,xxi1 and ,,xxii4 #fjc4 ,repeal of ,federal requirements of ,medicaid and ,,chip ,titles ,,xix and ,,xxi of the ,social ,security ,act are repealed4 #fjd4 ,severability ,if any provision of this title1 or the application of such provision to any person or circumstance1 is found to be unconstitutional1 the remainder of this title1 or the application of that provision to other persons or circumstances1 shall not be affected4 #fje4 ,effective date ,this title and the amendments made by this title shall take effect with respect to items and services furnished on or after ,october #a1 #bjac4