,i #aac? ,,congress #a/ ,session ,h4 ,r4 #cafe ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,septemb] #bj1 #bjac,mr4 ,la?am introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,ways & ,means1 ,education & ! ,work=ce1 ,natural ,res\rces1 ! ,judici>y1 ,h\se ,adm9i/ration1 ,rules1 & ,appropriations1 = 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 repeal ! ,pati5t ,protection & ,af=dable ,c>e ,act & to take mean+ful /eps to l[] heal? c>e co/s & increase access to heal? insurance cov]age )\t rais+ taxes1 cutt+ ,m$ic>e b5efits = s5iors1 add+ to ! national deficit1 int]v5+ 9 ! doctor-pati5t relation%ip1 or in/itut+ a gov]nm5t takeov] ( heal? c>e4 #a4 ,%ort title2 purpose2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,common ,s5se ,heal? ,re=m ,am]icans ,actually ,want ,act4 7b7 ,purpose ,! purpose ( ?is ,act is to take mean+ful /eps to l[] heal? c>e co/s & increase access to heal? insurance cov]age 7especially = individuals ) preexi/+ conditions7 )\t-- 7#a7 rais+ taxes2 7#b7 cutt+ ,m$ic>e b5efits = s5iors2 7#c7 add+ to ! national deficit2 7#d7 int]v5+ 9 ! doctor-pati5t relation%ip2 or 7#e7 in/itut+ a gov]nm5t takeov] ( heal? c>e4 7c7 ,table ( cont5ts ,! table ( cont5ts ( ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 purpose2 table ( cont5ts4,sec4 #b4 ,repeal ( ! ,pati5t ,protection & ,af=dable ,c>e ,act & ! ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj4;,division ,a--,ensur+ cov]age = individuals ) preexi/+ conditions & multiple heal? c>e needs,sec4 #aja4 ,e/abli% univ]sal access programs to improve high risk pools & re9surance m>kets4,sec4 #ajb4 ,no annual or lifetime sp5d+ caps4,sec4 #ajc4 ,prev5t+ unju/ cancellation ( insurance cov]age4,division ,b--,r$uc+ ,heal? ,c>e ,premiums & ! ,numb] ( ,un9sur$ ,americans,title ,i--,exp&+ ,access & ,l[]+ ,co/s = ,small ,businesses,subtitle ,a--,enhanc$ ,m>ketplace ,pools,sec4 #bja4 ,rules gov]n+ enhanc$ m>ketplace pools4,sec4 #bjb4 ,coop]ation betwe5 ,f$]al & ,/ate au?orities4,sec4 #bjc4 ,effective date & transitional & o!r rules4,subtitle ,b--,m>ket ,relief,sec4 #bjd4 ,m>ket relief4,title ,,ii--,t>get$ ,ef=ts to ,exp& ,access,sec4 #baa4 ,ext5d+ cov]age ( dep5d5ts4,sec4 #bab4 ,prohibit+ preexi/+ condition exclusions = enrollees "u age #ai4,sec4 #bac4 ,heal? plan f9d]s4,title ,,iii--,exp&+ ,*oices by ,all[+ ,am]icans to ,buy ,heal? ,c>e ,cov]age ,across ,/ate ,lines,sec4 #bba4 ,int]/ate pur*as+ ( heal? insurance4,title ,,iv--,improv+ ,heal? ,sav+s ,accounts,sec4 #bca4 ,,hsa funds = premiums = high d$uctible heal? plans4,sec4 #bcb4 ,requir+ great] coord9ation betwe5 ,,hdhp adm9i/rators & ,,hsa acc\nt adm9i/rators s t enrollees c enroll 9 bo? at ! same "t4,sec4 #bcc4 ,special rule = c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt4,title ,v--,tax-,relat$ ,heal? ,incentives,sec4 #bda4 ,,seca tax d$uction = heal? insurance co/s4,sec4 #bdb4 ,d$uction = qualifi$ heal? insurance co/s ( individuals4,division ,c--,enact+ ,real ,m$ical ,liability ,reform,sec4 #cja4 ,cap on non-economic damages aga9/ heal? c>e practition]s4,sec4 #cjb4 ,cap on non-economic damages aga9/ heal? c>e in/itutions4,sec4 #cjc4 ,cap1 9 wrongful dea? cases1 on total damages aga9/ any s+le heal? c>e practition]4,sec4 #cjd4 ,limitation ( insur] liability :5 insur] rejects c]ta9 settlem5t (f]s4,sec4 #cje4 ,m&atory jury in/ruction on cap on damages4,sec4 #cjf4 ,det]m9ation ( neglig5ce2 m&atory jury in/ruction4,sec4 #cjg4 ,exp]t reports requir$ to be s]v$ 9 civil actions4,sec4 #cjh4 ,exp]t op9ions relat+ to physicians may be provid$ only by actively practic+ physicians4,sec4 #cji4 ,paym5t ( future damages on p]iodic or accrual basis4,sec4 #caj4 ,unanim\s jury requir$ = punitive or exempl>y damages4,sec4 #caa4 ,proportionate liability4,sec4 #cab4 ,def5se-initiat$ settlem5t process4,sec4 #cac4 ,/atute ( limitations2 /atute ( repose4,sec4 #cad4 ,limitation on liability = ,good ,sam>itans provid+ em]g5cy heal? c>e4,sec4 #cae4 ,def9itions4,division ,d--,protect+ ! ,doctor-,pati5t ,relationship,sec4 #dja4 ,rule ( con/ruction4,sec4 #djb4 ,repeal ( ,f$]al ,coord9at+ ,c\ncil = ,comp>ative ,effectiv5ess ,rese>*4,division ,e--,inc5tiviz+ ,wellness & ,quality ,improvements,sec4 #eja4 ,inc5tives = prev5tion & wellness programs4,division ,f--,protect+ ,taxpayers,sec4 #fja4 ,p]man5tly prohibit+ taxpay] fund$ abortions & ensur+ consci5ce protections4,sec4 #fjb4 ,improv$ en=cem5t ( ! ,m$ic>e & ,m$icaid second>y pay] provisions4,sec4 #fjc4 ,/r5g!n ,m$ic>e provid] enrollm5t /&>ds & safegu>ds4,sec4 #fjd4 ,track+ bann$ provid]s across ,/ate l9es4 #b4 ,repeal ( ! ,pati5t ,protection & ,af=dable ,c>e ,act & ! ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj 7a7 ,pati5t ,protection & ,af=dable ,c>e ,act ,! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh7 is repeal$ & ! provisions ( law am5d$ or repeal$ by su* ,act are re/or$ or reviv$ z if su* ,act _h n be5 enact$4 7b7 ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj ,! ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj 7,public ,law #aaa-aeb7 is repeal$ & ! provisions ( law am5d$ or repeal$ by su* ,act are re/or$ or reviv$ z if su* ,act _h n be5 enact$4 ,a ,ensur+ cov]age = individuals ) preexi/+ conditions & multiple heal? c>e ne$s #aja4 ,e/abli% univ]sal access programs to improve high risk pools & re9surance m>kets 7a7 ,/ate requirem5t 7#a7 ,9 g5]al ,n lat] ?an #ij days aft] ! date ( ! enactm5t ( ?is ,act1 ea* ,/ate %all-- 7,a7 subject to p>agraph 7#c71 op]ate a qualify+ ,/ate high risk pool describ$ 9 subsection 7b77#a72 & 7,b7 subject to p>agraph 7#c71 apply to ! op]ation ( su* a program f ,/ate funds an am\nt equival5t to ! portion ( ,/ate funds d]iv$ f ,/ate premium assessm5ts 7z def9$ by ! ,secret>y7 t are n o!rwise us$ on ,/ate heal? c>e programs4 7#b7 ,relation to curr5t qualifi$ high risk pool program 7,a7 ,/ates n op]at+ a qualifi$ high risk pool ,9 ! case ( a ,/ate t is n op]at+ a curr5t section #bgde qualifi$ high risk pool z ( ! date ( ! enactm5t ( ?is ,act1 ! ,/ate's op]ation ( a qualify+ ,/ate high risk pool describ$ 9 subsection 7b77#a7 %all be treat$1 = purposes ( section #bgde ( ! ,public ,heal? ,s]vice ,act1 z ! op]ation ( a qualifi$ high risk pool describ$ 9 su* section4 7,b7 ,/ate op]at+ a qualifi$ high risk pool ,9 ! case ( a ,/ate t is op]at+ a curr5t section #bgde qualifi$ high risk pool z ( ! date ( ! enactm5t ( ?is ,act1 z ( ! date t is #ij days aft] ! date ( ! enactm5t ( ?is ,act1 su* a pool %all n be treat$ z a qualifi$ high risk pool "u section #bgde ( ! ,public ,heal? ,s]vice ,act unless ! pool is a qualify+ ,/ate high risk pool describ$ 9 subsection 7b77#a74 7#c7 ,application ( funds ,if ! pool op]at$ "u p>agraph 7#a77;,a7 is 9 /rong fiscal heal?1 z det]m9$ 9 accordance ) /&>ds e/abli%$ by ! ,national ,association ( ,insurance ,commission]s & z approv$ by ! ,/ate ,insurance ,commission] involv$1 ! requirem5t ( p>agraph 7#a77;,b7 %all be deem$ to be met4 7b7 ,qualify+ ,/ate high risk pool 7#a7 ,9 g5]al ,a qualify+ ,/ate high risk pool describ$ 9 ?is subsection means a curr5t section #bgde qualifi$ high risk pool t meets ! foll[+ requirem5ts3 7,a7 ,! pool mu/ be fund$ ) a /able fund+ s\rce4 7,b7 ,! pool mu/ elim9ate any wait+ li/s s t all eligible resid5ts :o are seek+ cov]age ?r\gh ! pool %\ld be all[$ to receive cov]age ?r\gh ! pool4 7,c7 ,! pool mu/ all[ = cov]age ( individuals :o1 b = ! #bd-mon? disability wait+ p]iod "u section #bbf7;b7 ( ! ,social ,security ,act1 w\ld be eligible = ,m$ic>e dur+ ! p]iod ( su* wait+ p]iod4 7,d7 ,! pool mu/ limit ! pool premiums to no m ?an #aej p]c5t ( ! av]age premium = applicable /&>d risk rates 9 t ,/ate4 7,e7 ,! pool mu/ conduct education & outrea* initiatives s t resid5ts & brok]s und]/& t ! pool is available to eligible resid5ts4 7,f7 ,! pool mu/ provide cov]age = prev5tive s]vices & disease managem5t = *ronic diseases4 7,g7 ,subject to subp>agraph 7,c71 an individual may only be eligible = cov]age ?r\gh ! pool if ! individual has a pre-exi/+ condition1 z det]m9$ 9 a mann] consi/5t ) guidance uss$ by ! ,secret>y ( ,heal? & ,human ,s]vices &-- 7i7 0 d5i$ heal? insurance cov]age 9 ! individual m>ket because ( a pre-exi/+ condition or heal? /atus2 or 7ii7 0 (f]$ su* cov]age-- 7,i7 "u t]ms t limit ! cov]age = su* a pre-exi/+ condition2 or 7,,ii7 at a premium rate t is above ! premium rate = cov]age ?r\gh ! pool pursuant to ?is section4 7,h7 ,no pre-exi/+ condition exclusion p]iod may be impos$ on cov]age ?r\gh ! pool4 7,i7 ,! pool %all n require an individual to be un9sur$ = any p]iod z a condition ( eligibility to receive cov]age ?r\gh ! pool4 7#b7 ,v]ification ( citiz5%ip or ali5 qualification 7,a7 ,9 g5]al ,not)/&+ any o!r provision ( law1 only citiz5s & nationals ( ! ,unit$ ,/ates %all be eligible to p>ticipate 9 a qualify+ ,/ate high risk pool t receives funds "u section #bgde ( ! ,public ,heal? ,s]vice ,act or ?is section4 7,b7 ,condition ( p>ticipation ,z a condition ( a ,/ate receiv+ su* funds1 ! ,secret>y %all require ! ,/ate to c]tify1 to ! satisfaction ( ! ,secret>y1 t su* ,/ate requires all applicants = cov]age 9 ! qualify+ ,/ate high risk pool to provide satisfactory docum5tation ( citiz5%ip or nationality 9 a mann] consi/5t ) section #aijc7x7 ( ! ,social ,security ,act4 7,c7 ,records ,! ,secret>y %all keep suffici5t records su* t a det]m9ation ( citiz5%ip or nationality only has to be made once = any individual "u ?is p>agraph4 7#c7 ,relation to section #bgde ,z ( ,janu>y #a1 #bjab1 a pool %all n qualify z qualifi$ high risk pool "u section #bgde ( ! ,public ,heal? ,s]vice ,act unless ! pool is a qualify+ ,/ate high risk pool describ$ 9 p>agraph 7#a74 7c7 ,waiv]s ,9 ord] to accommodate new & innovative programs1 ! ,secret>y may waive su* requirem5ts ( ?is section = qualify+ ,/ate high risk pools z ! ,secret>y deems appropriate4 7d7 ,fund+ ,9 addition to any o!r am\nts appropriat$1 !re is appropriat$ to c>ry out section #bgde ( ! ,public ,heal? ,s]vice ,act 7includ+ ?r\gh a pool describ$ 9 subsection 7a77#a77-- 7#a7 #ae1jjj1jjj1jjj = ! p]iod ( fiscal ye>s #bjaa ?r\gh #bjba2 & 7#b7 an additional #aj1jjj1jjj1jjj = ! p]iod ( fiscal ye>s #bjag ?r\gh #bjba4 7e7 ,def9itions ,9 ?is section3 7#a7 ,heal? insurance cov]age2 heal? insurance issu] ,! t]ms heal? insurance cov]age & heal? insurance issu] h ! mean+s giv5 su* t]ms 9 section #bgia ( ! ,public ,heal? ,s]vice ,act4 7#b7 ,curr5t section #bgde qualifi$ high risk pool ,! t]m curr5t section #bgde qualifi$ high risk pool has ! mean+ giv5 ! t]m qualifi$ high risk pool "u section #bgde7;g7 ( ! ,public ,heal? ,s]vice ,act z 9 effect z ( ! date ( ! enactm5t ( ?is ,act4 7#c7 ,secret>y ,! t]m ,secret>y means ,secret>y ( ,heal? & ,human ,s]vices4 7#d7 ,/&>d risk rate ,! t]m /&>d risk rate means a rate t-- 7,a7 is det]m9$ "u ! ,/ate high risk pool by consid]+ ! premium rates *>g$ by o!r heal? insurance issu]s (f]+ heal? insurance cov]age to individuals 9 ! insurance m>ket s]v$2 7,b7 is e/abli%$ us+ reasonable actu>ial te*niques2 & 7,c7 reflects anticipat$ claims exp]i5ce & exp5ses = ! cov]age involv$4 7#e7 ,/ate ,! t]m ,/ate means any ( ! #ej ,/ates or ! ,di/rict ( ,columbia4 #ajb4 ,no annual or lifetime sp5d+ caps ,not)/&+ any o!r provision ( law1 a heal? insurance issu] 7includ+ an entity lic5s$ to sell insurance ) respect to a ,/ate or gr\p heal? plan7 may n apply an annual or lifetime aggregate sp5d+ cap on any heal? insurance cov]age or plan (f]$ by su* issu]4 #ajc4 ,prev5t+ unju/ cancellation ( insurance cov]age 7a7 ,cl>ification reg>d+ application ( gu>ante$ r5ewability ( individual heal? insurance cov]age ,section #bgdb ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#db71 z re/or$ by section #b1 is am5d$-- 7#a7 9 its head+1 by ins]t+ 1 cont9uation 9 =ce1 includ+ prohibition ( rescission1 aft] ,gu>ante$ r5ewability2 7#b7 9 subsection 7a71 by ins]t+ 1 includ+ )\t rescission1 aft] cont9ue 9 =ce2 & 7#c7 9 subsection 7b77#b71 by ins]t+ be=e ! p]iod at ! end ! foll[+3 1 includ+ int5tional concealm5t ( mat]ial facts reg>d+ a heal? condition relat$ to ! condition = :i* cov]age is be+ claim$4 7b7 ,opportunity = indep5d5t1 ext]nal ?ird p>ty review 9 c]ta9 cases ,subp>t #a ( "p ,b ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act1 z re/or$ by section #b1 is am5d$ by add+ at ! end ! foll[+ new section3 #bgdf4 ,opportunity = indep5d5t1 ext]nal ?ird p>ty review 9 c]ta9 cases 7a7 ,notice & review "r ,if a heal? insurance issu] det]m9es to nonr5ew or n cont9ue 9 =ce1 includ+ resc9d1 heal? insurance cov]age = an individual 9 ! individual m>ket on ! basis describ$ 9 section #bgdb7;b77#b7 be=e su* nonr5ewal1 discont9uation1 or rescission1 may take effect ! issu] %all provide ! individual ) notice ( su* propos$ nonr5ewal1 discont9uation1 or rescission & an opportunity = a review ( su* det]m9ation by an indep5d5t1 ext]nal ?ird p>ty "u proc$ures specifi$ by ! ,secret>y4 7b7 ,indep5d5t det]m9ation ,if ! individual reque/s su* review by an indep5d5t1 ext]nal ?ird p>ty ( a nonr5ewal1 discont9uation1 or rescission ( heal? insurance cov]age1 ! cov]age %all rema9 9 effect until su* ?ird p>ty det]m9es t ! cov]age may be nonr5ew$1 discont9u$1 or resc9d$ "u section #bgdb7;b77#b74 4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply aft] ! date ( ! enactm5t ( ?is ,act ) respect to heal? insurance cov]age issu$ be=e1 on1 or aft] su* date4 ,b ,r$uc+ ,heal? ,c>e ,premiums & ! ,numb] ( ,un9sur$ ,am]icans ,i ,exp&+ ,access & ,l[]+ ,co/s = ,small ,bus9esses ,a ,enhanc$ ,m>ketplace ,pools #bja4 ,rules gov]n+ enhanc$ m>ketplace pools 7a7 ,9 g5]al ,subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z re/or$ by section #b1 is am5d$ by add+ aft] "p #g ! foll[+ new "p3 #h ,rules gov]n+ enhanc$ m>ketplace pools #hja4 ,small bus9ess heal? plans 7a7 ,9 g5]al ,= purposes ( ?is "p1 ! t]m small bus9ess heal? plan means a fully insur$ 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+ 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]%ip2 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>ticipation2 & 7#d7 does n condition memb]%ip on ! basis ( a m9imum gr\p size4 ,any sponsor consi/+ ( an association ( entities :i* meet ! requirem5ts ( p>agraphs 7#a71 7#b71 7#c71 & 7#d7 %all be deem$ to be a sponsor describ$ 9 ?is subsection4 #hjb4 ,alt]native ,m>ket ,pool+ ,organizations 7a7 ,9 g5]al ,! ,secret>y1 n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is "p1 %all promulgate regulations t apply ! rules & /&>ds ( ?is "p1 z necess>y1 to circum/ances 9 :i* a pool+ entity o!r 7h]e9aft] ,alt]native ,m>ket ,pool+ ,organizations7 is n made up pr9cipally ( employ]s & _! employees1 or n a pr(essional organization or su* small bus9ess heal? plan entity id5tifi$ 9 section #hja4 7b7 ,adaption ( /&>ds ,9 develop+ & promulgat+ regulations pursuant to subsection 7a71 ! ,secret>y1 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices1 small bus9ess heal? plans1 small & l>ge employ]s1 l>ge & small insurance issu]s1 consum] repres5tatives1 & /ate insurance commission]s1 %all-- 7#a7 adapt ! /&>ds ( ?is "p1 to ! maximum degree practicable1 to assure balanc$ & comp>able ov]sight /&>ds = bo? small bus9ess heal? plans & alt]native m>ket pool+ organizations2 7#b7 p]mit ! p>ticipation z alt]native m>ket pool+ organizations unions1 *ur*es & o!r fai?-bas$ organizations1 or o!r organizations compos$ ( individuals & gr\ps :i* may h little or no association ) employm5t1 provid$ h[ev]1 t su* alt]native m>ket pool+ organizations meet1 & cont9ue meet+ on an ongo+ basis1 to satisfy /&>ds1 rules1 & requirem5ts mat]ially equival5t to ^? set =? 9 ?is "p ) respect to small bus9ess heal? plans2 7#c7 conduct p]iodic v]ification ( su* compliance by alt]native m>ket pool+ organizations1 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,national ,association ( ,insurance ,commission]s1 except t su* p]iodic v]ification %all n mat]ially imp$e m>ket entry or p>ticipation z pool+ entities comp>able to t ( small bus9ess heal? plans2 7#d7 assure t consi/5t1 cle>1 & regul>ly monitor$ /&>ds are appli$ ) respect to alt]native m>ket pool+ organizations to av]t mat]ial risk-selection )9 or among ! composition ( su* organizations2 7#e7 ! exp$it$ & deem$ c]tification proc$ures provid$ 9 section #hje7;d7 %all n apply to alt]native m>ket pool+ organizations until soon] ( ! promulgation ( regulations "u ?is subsection or ! expiration ( "o ye> foll[+ enactm5t ( ?is ,act2 & 7#f7 make su* o!r appropriate adju/m5ts to ! requirem5ts ( ?is "p z ! ,secret>y may reasonably deem appropriate to fit ! circum/ances ( an individual alt]native m>ket pool+ organization or category ( su* organization1 includ+ b n limit$ to ! application ( ! memb]%ip paym5t requirem5ts ( section #hja7;b77#b7 to alt]native m>ket pool+ organizations compos$ prim>ily ( *ur*- or fai?-bas$ memb]%ip4 #hjc4 ,c]tification ( small bus9ess heal? plans 7a7 ,9 g5]al ,n lat] ?an #f mon?s aft] ! date ( enactm5t ( ?is "p1 ! applicable au?ority %all prescribe by int]im f9al rule a proc$ure "u :i* ! applicable au?ority %all c]tify small bus9ess heal? plans :i* apply = c]tification z meet+ ! requirem5ts ( ?is "p4 7b7 ,requirem5ts applicable to c]tifi$ plans ,a small bus9ess 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 7c7 ,requirem5ts = cont9u$ c]tification ,! applicable au?ority may provide by regulation = cont9u$ c]tification ( small bus9ess heal? plans "u ?is "p4 ,su* regulation %all provide = ! revocation ( a c]tification if ! applicable au?ority f9ds t ! small bus9ess heal? plan involv$ is fail+ to comply ) ! requirem5ts ( ?is "p4 7d7 ,exp$it$ & deem$ c]tification 7#a7 ,9 g5]al ,if ! ,secret>y fails to act on an application = c]tification "u ?is section )9 #ij days ( receipt ( su* application1 ! apply+ small bus9ess heal? plan %all be deem$ c]tifi$ until su* "t z ! ,secret>y may d5y = cause ! application = c]tification4 7#b7 ,civil p5alty ,! ,secret>y may assess a civil p5alty aga9/ ! bo>d ( tru/ees & plan sponsor 7jo9tly & sev]ally7 ( a small bus9ess heal? plan t is deem$ c]tifi$ "u p>agraph 7#a7 ( up to #ejj1jjj 9 ! ev5t ! ,secret>y det]m9es t ! application = c]tification ( su* small bus9ess heal? plan 0 willfully or ) gross neglig5ce incomplete or inaccurate4 #hjd4 ,requirem5ts relat+ to sponsors & bo>ds ( tru/ees 7a7 ,sponsor ,! requirem5ts ( ?is subsection are met ) respect to a small bus9ess 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 a small bus9ess heal? plan if ! foll[+ requirem5ts are met3 7#a7 ,fiscal control ,! plan is op]at$1 pursuant to a plan docum5t1 by a bo>d ( tru/ees :i* pursuant to a tru/ agreem5t has complete fiscal control ov] ! plan & :i* is responsible = all op]ations ( ! plan4 7#b7 ,rules ( op]ation & f9ancial controls ,! bo>d ( tru/ees has 9 effect rules ( op]ation & f9ancial controls1 bas$ 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 a small bus9ess heal? plan :i* is 9 exi/5ce on ! date ( ! enactm5t ( ?is "p4 7,b7 ,sole au?ority ,! bo>d has sole au?ority "u ! plan to approve applications = p>ticipation 9 ! plan & to contract ) insur]s4 7c7 ,treatm5t ( fran*ises ,9 ! case ( a gr\p heal? plan :i* is e/abli%$ & ma9ta9$ by a fran*is] = a fran*isor or = 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*isor 7 deem$ to be ! sponsor ref]r$ to 9 section #hja7;b7 & ea* fran*isee 7 deem$ to be a memb] 7( ! sponsor7 ref]r$ to 9 section #hja7;b72 & 7#b7 ! requirem5ts ( section #hjd7;a77#a7 %all be deem$ met4 ,= purposes ( ?is subsection ! t]ms fran*isor & fran*isee %all h ! mean+s giv5 su* t]ms = purposes ( sections #dcf4b7;a7 ?r\gh #dcf4b7;c7 ( title #af1 ,code ( ,f$]al ,regulations 7includ+ any su* am5dm5ts to su* regulation aft] ! date ( enactm5t ( ?is "p74 #hje4 ,p>ticipation & cov]age requirem5ts 7a7 ,cov]$ employ]s & individuals ,! requirem5ts ( ?is subsection are met ) respect to a small bus9ess heal? plan if1 "u ! t]ms ( ! plan-- 7#a7 ea* p>ticipat+ employ] mu/ be-- 7,a7 a memb] ( ! sponsor2 7,b7 ! sponsor2 or 7,c7 an affiliat$ memb] ( ! sponsor1 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 ! dep5d5ts ( individuals describ$ 9 subp>agraph 7,a74 7b7 ,individual m>ket unaffect$ ,! requirem5ts ( ?is subsection are met ) respect to a small bus9ess 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 7c7 ,prohibition ( discrim9ation aga9/ employ]s & employees eligible ,to p>ticipate ,! requirem5ts ( ?is subsection are met ) respect to a small bus9ess 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 in=mation reg>d+ all cov]age options available "u ! plan is made readily available to any employ] eligible to p>ticipate2 & 7#c7 ! applicable requirem5ts ( sections #gja1 #gjb1 & #gjc are met ) respect to ! plan4 #hjf4 ,o!r requirem5ts relat+ to plan docum5ts1 contribution rates1 & b5efit options 7a7 ,9 g5]al ,! requirem5ts ( ?is section are met ) respect to a small bus9ess heal? plan if ! foll[+ requirem5ts are met3 7#a7 ,cont5ts ( gov]n+ in/rum5ts 7,a7 ,9 g5]al ,! in/rum5ts gov]n+ ! plan include a writt5 in/rum5t1 meet+ ! requirem5ts ( an in/rum5t requir$ "u section #djb7;a77#a71 :i*-- 7i7 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 & 7ii7 provides t ! sponsor ( ! plan is to s]ve z plan sponsor 7ref]r$ to 9 section #c7af77;,b774 7,b7 ,description ( mat]ial provisions ,! t]ms ( ! heal? insurance cov]age 7includ+ ! t]ms ( any individual c]tificates t may be (f]$ to individuals 9 connection ) su* cov]age7 describe ! mat]ial b5efit & rat+1 & o!r provisions set =? 9 ?is section & su* mat]ial provisions are includ$ 9 ! summ>y plan description4 7#b7 ,contribution rates mu/ be nondiscrim9atory 7,a7 ,9 g5]al ,! contribution rates = any p>ticipat+ small employ] %all n v>y on ! basis ( any heal? /atus-relat$ factor 9 relation to employees ( su* employ] or _! b5efici>ies & %all n v>y on ! basis ( ! type ( bus9ess or indu/ry 9 :i* su* employ] is engag$1 subject to subp>agraph 7,b7 & ! t]ms ( ?is title4 7,b7 ,effect ( title ,no?+ 9 ?is title or any o!r provision ( law %all be con/ru$ to preclude a heal? insurance issu] (f]+ heal? insurance cov]age 9 connection ) a small bus9ess heal? plan t meets ! requirem5ts ( ?is "p1 & at ! reque/ ( su* small bus9ess heal? plan1 f-- 7i7 sett+ contribution rates = ! small bus9ess heal? plan bas$ on ! claims exp]i5ce ( ! small bus9ess heal? plan s long z any v>iation 9 su* rates = p>ticipat+ small employ]s complies ) ! requirem5ts ( clause 7ii71 except t small bus9ess heal? plans %all n be subject1 9 non-adopt+ /ates1 to subp>agraphs 7,a77ii7 & 7,c7 ( section #biab7;a77#b7 ( ! ,public ,heal? ,s]vice ,act1 & 9 adopt+ /ates1 to any ,/ate law t w\ld h ! effect ( impos+ requirem5ts z outl9$ 9 su* subp>agraphs 7,a77ii7 & 7,c72 or 7ii7 v>y+ contribution rates = p>ticipat+ small employ]s 9 a small bus9ess heal? plan 9 a ,/ate to ! ext5t t su* rates c\ld v>y us+ ! same me?odology employ$ 9 su* ,/ate = regulat+ small gr\p premium rates1 subject to ! t]ms ( "p ,i ( subtitle ,a ( title ,,xxxi ( ! ,public ,heal? ,s]vice ,act 7relat+ to rat+ requirem5ts71 z add$ by subtitle ,b ( title ,,ii ( ! ,heal? ,security = ,all ,am]icans ,act ( #bjaj4 7#c7 ,exceptions reg>d+ self-employ$ & l>ge employ]s 7,a7 ,self-employ$ 7i7 ,9 g5]al ,small bus9ess heal? plans ) p>ticipat+ employ]s :o are self-employ$ individuals 7& _! dep5d5ts7 %all enroll su* self-employ$ p>ticipat+ employ]s 9 accordance ) rat+ rules t d n violate ! rat+ rules = self-employ$ individuals 9 ! ,/ate 9 :i* su* self-employ$ p>ticipat+ employ]s are locat$4 7ii7 ,gu>antee issue ,small bus9ess heal? plans ) p>ticipat+ employ]s :o are self-employ$ individuals 7& _! dep5d5ts7 may decl9e to gu>antee issue to su* p>ticipat+ employ]s 9 ,/ates 9 :i* gu>antee issue is n o!rwise requir$ = ! self-employ$ 9 t ,/ate4 7,b7 ,l>ge employ]s ,small bus9ess heal? plans ) p>ticipat+ employ]s t are l>g] ?an small employ]s 7z def9$ 9 section #hjh7;a77#aj77 %all enroll su* l>ge p>ticipat+ employ]s 9 accordance ) rat+ rules t d n violate ! rat+ rules = l>ge employ]s 9 ! ,/ate 9 :i* su* l>ge p>ticipat+ employ]s are locat$4 7#d7 ,regulatory requirem5ts ,su* o!r requirem5ts z ! applicable au?ority det]m9es are necess>y to c>ry out ! purposes ( ?is "p1 :i* %all be prescrib$ by ! applicable au?ority by regulation4 7b7 ,ability ( small bus9ess heal? plans ,to design b5efit options ,no?+ 9 ?is "p or any provision ( ,/ate law 7z def9$ 9 section #ead7;c77#a77 %all be con/ru$ to preclude a small bus9ess heal? plan or a heal? insurance issu] (f]+ heal? insurance cov]age 9 connection ) a small bus9ess heal? plan f ex]cis+ its sole discretion 9 select+ ! specific b5efits & s]vices consi/+ ( m$ical c>e to be includ$ z b5efits "u su* plan or cov]age1 except t su* b5efits & s]vices mu/ meet ! t]ms & specifications ( "p ,,ii ( subtitle ,a ( title ,,xxxi ( ! ,public ,heal? ,s]vice ,act 7relat+ to l[] co/ plans71 z add$ by subtitle ,b ( title ,,ii ( ! ,heal? ,security = ,all ,am]icans ,act ( #bjaj4 7c7 ,domicile & non-,domicile ,/ates 7#a7 ,domicile /ate ,cov]age %all be issu$ to a small bus9ess heal? plan 9 ! ,/ate 9 :i* ! sponsor's pr9cipal place ( bus9ess is locat$4 7#b7 ,non-domicile /ates ,) respect to a ,/ate 7o!r ?an ! domicile ,/ate7 9 :i* p>ticipat+ employ]s ( a small bus9ess heal? plan are locat$ b 9 :i* ! insur] ( ! small bus9ess heal? plan 9 ! domicile ,/ate is n yet lic5s$1 ! foll[+ %all apply3 7,a7 ,tempor>y preemption ,if1 ^u ! expiration ( ! #ij-;day p]iod foll[+ ! submission ( a lic5sure application by su* insur] 7t includes a c]tifi$ copy ( an approv$ lic5sure application z submitt$ by su* insur] 9 ! domicile ,/ate7 to su* ,/ate1 su* ,/ate has n approv$ or d5i$ su* application1 su* ,/ate's heal? insurance lic5sure laws %all be tempor>ily preempt$ & ! insur] %all be p]mitt$ to op]ate 9 su* ,/ate1 subject to ! foll[+ t]ms3 7i7 ,application ( non-domicile ,/ate law ,except ) respect to lic5sure & ) respect to ! t]ms ( subtitle ,a ( title ,,xxxi ( ! ,public ,heal? ,s]vice ,act 7relat+ to rat+ & b5efits z add$ by subtitle ,b ( title ,,ii ( ! ,heal? ,security = ,all ,am]icans ,act ( #bjaj71 ! laws & au?ority ( ! non-domicile ,/ate %all rema9 9 full =ce & effect4 7ii7 ,revocation ( preemption ,! preemption ( a non-domicile ,/ate's heal? insurance lic5sure laws pursuant to ?is subp>agraph1 %all be t]m9at$ ^u ! occurr5ce ( ei!r ( ! foll[+3 7,i7 ,approval or d5ial ( application ,! approval ( d5ial ( an insur]'s lic5sure application1 foll[+ ! laws & regulations ( ! non-domicile ,/ate ) respect to lic5sure4 7,,ii7 ,det]m9ation ( mat]ial violation ,a det]m9ation by a non-domicile ,/ate t an insur] op]at+ 9 a non-domicile ,/ate pursuant to ! preemption provid$ = 9 ?is subp>agraph is 9 mat]ial violation ( ! insurance laws 7o!r ?an lic5sure & ) respect to ! t]ms ( subtitle ,a ( title ,,xxxi ( ! ,public ,heal? ,s]vice ,act 7relat+ to rat+ & b5efits add$ by subtitle ,b ( title ,,ii ( ! ,heal? ,security = ,all ,am]icans ,act ( #bjaj77 ( su* ,/ate4 7,b7 ,no prohibition on promotion ,no?+ 9 ?is p>agraph %all be con/ru$ to prohibit a small bus9ess heal? plan or an insur] f promot+ cov]age prior to ! expiration ( ! #ij-;day p]iod provid$ = 9 subp>agraph 7,a71 except t no enrollm5t or collection ( contributions %all occur be=e ! expiration ( su* #ij-;day p]iod4 7,c7 lic5sure ,except ) respect to ! application ( ! tempor>y preemption provision ( ?is p>agraph1 no?+ 9 ?is "p %all be con/ru$ to limit ! requirem5t t insur]s issu+ cov]age to small bus9ess heal? plans %all be lic5s$ 9 ea* ,/ate 9 :i* ! small bus9ess heal? plans op]ate4 7,d7 ,s]vic+ by lic5s$ insur]s ,not)/&+ subp>agraph 7,c71 ! requirem5ts ( ?is subsection may also be satisfi$ if ! p>ticipat+ employ]s ( a small bus9ess heal? plan are s]vic$ by a lic5s$ insur] 9 t ,/ate1 ev5 :]e su* insur] is n ! insur] ( su* small bus9ess heal? plan 9 ! ,/ate 9 :i* su* small bus9ess heal? plan is domicil$4 #hjg4 ,requirem5ts = application & relat$ requirem5ts 7a7 ,fil+ fee ,"u ! proc$ure prescrib$ pursuant to section #hjb7;a71 a small bus9ess 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$ures applicable ) respect to small bus9ess heal? plans4 7b7 ,in=mation ,to be includ$ 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 ! plan1 heal? insurance issu]1 & contract adm9i/rators & o!r s]vice provid]s4 7c7 ,fil+ notice ( c]tification ) ,/ates ,a c]tification grant$ "u ?is "p to a small bus9ess heal? plan %all n be effective unless writt5 notice ( su* c]tification is fil$ ) ! applicable ,/ate au?ority ( ea* ,/ate 9 :i* ! small bus9ess heal? plans op]ate4 7d7 ,notice ( mat]ial *anges ,9 ! case ( any small bus9ess 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 #hjh4 ,notice requirem5ts = volunt>y t]m9ation ,a small bus9ess 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 ,implem5tation & application au?ority by ,secret>y ,! ,secret>y %all1 ?r\gh promulgation & implem5tation ( su* regulations z ! ,secret>y may reasonably det]m9e necess>y or appropriate1 & 9 consultation ) a balanc$ spectrum ( effect$ entities & p]sons1 modify ! implem5tation & application ( ?is "p to accommodate ) m9imum disruption su* *anges to ,/ate or ,f$]al law provid$ 9 ?is "p & ! 7& ! am5dm5ts made by su* ,act7 or 9 regulations issu$ !reto4 #haj4 ,def9itions & rules ( con/ruction 7a7 ,def9itions ,= purposes ( ?is "p-- 7#a7 ,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 or 7,b7 9 ! case ( a sponsor ) memb]s :i* consi/ ( associations1 a p]son :o is a memb] or employee ( any su* association & elects an affiliat$ /atus ) ! sponsor4 7#b7 ,applicable au?ority ,! t]m applicable au?ority means ! ,secret>y ( ,labor1 except t1 9 connection ) any ex]cise ( ! ,secret>y's au?ority ) respect to :i* ! ,secret>y is requir$ "u section #ejf7;d7 to consult ) a ,/ate1 su* t]m means ! ,secret>y1 9 consultation ) su* ,/ate4 7#c7 ,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#d7 ,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#e7 ,heal? insurance cov]age ,! t]m heal? insurance cov]age has ! mean+ provid$ 9 section #gcc7;b77#a71 except t su* t]m %all n include except$ b5efits 7z def9$ 9 section #gcc7;c774 7#f7 ,heal? insurance issu] ,! t]m heal? insurance issu] has ! mean+ provid$ 9 section #gcc7;b77#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 ,m$ical c>e ,! t]m m$ical c>e has ! mean+ provid$ 9 section #gcc7;a77#b74 7#i7 ,p>ticipat+ employ] ,! t]m p>ticipat+ employ] means1 9 connection ) a small bus9ess 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#aj7 ,small employ] ,! t]m small employ] means1 9 connection ) a gr\p heal? plan ) respect to a plan ye>1 a small employ] z def9$ 9 section #bgia7;e77#d74 7#aa7 ,trade association & pr(essional association ,! t]ms trade association & pr(essional association mean an entity t meets ! requirem5ts ( section #a4eja7;c77#f7-a ( title #bf1 ,code ( ,f$]al ,regulations 7z 9 effect on ! date ( enactm5t ( ?is ,act74 7b7 ,rule ( con/ruction ,= purposes ( det]m9+ :e!r a plan1 fund1 or program is an employee welf>e b5efit plan :i* is a small bus9ess heal? plan1 & = purposes ( apply+ ?is title 9 connection ) su* plan1 fund1 or program s det]m9$ 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 7c7 ,r5ewal ,not)/&+ any provision ( law to ! contr>y1 a p>ticipat+ employ] 9 a small bus9ess heal? plan %all n be deem$ to be a plan sponsor 9 apply+ requirem5ts relat+ to cov]age r5ewal4 7d7 ,heal? sav+s acc\nts ,no?+ 9 ?is "p %all be con/ru$ to create any m&ates = cov]age ( b5efits = ,,hsa-qualifi$ heal? plans t w\ld require reimbursem5ts 9 violation ( section #bbc7;c77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf4 4 7b7 ,con=m+ am5dm5ts to preemption rules 7#a7 ,section #ead7;b77#f7 ( su* ,act 7#bi ,u4,s4,c4 #aadd7;b77#f771 z re/or$ by section #b1 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,! prec$+ subp>agraphs ( ?is p>agraph d n apply ) respect to any ,/ate law 9 ! case ( a small bus9ess heal? plan :i* is c]tifi$ "u "p #h4 4 7#b7 ,section #ead ( su* ,act 7#bi ,u4,s4,c4 #aadd71 z re/or$ by section #b1 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$e any & all ,/ate laws ins(> z !y may n[ or h]eaft] preclude a heal? insurance issu] f (f]+ heal? insurance cov]age 9 connection ) a small bus9ess heal? plan :i* is c]tifi$ "u "p #h4 7#b7 ,9 any case 9 :i* heal? insurance cov]age ( any policy type is (f]$ "u a small bus9ess heal? plan c]tifi$ "u "p #h to a p>ticipat+ employ] op]at+ 9 su* ,/ate1 ! provisions ( ?is title %all sup]s$e any & all laws ( su* ,/ate ins(> z !y may e/abli% rat+ & b5efit requirem5ts t w\ld o!rwise apply to su* cov]age1 provid$ ! requirem5ts ( subtitle ,a ( title ,,xxxi ( ! ,public ,heal? ,s]vice ,act 7z add$ by title ,,ii ( ! ,heal? ,security = ,all ,am]icans ,act ( #bjaj7 7conc]n+ heal? plan rat+ & b5efits7 are met4 4 7c7 ,plan sponsor ,section #c7af77;,b7 ( su* ,act 7#bi ,u4,s4,c4 #ajb7af77;,b771 z re/or$ by section #b1 is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,su* t]m also includes a p]son s]v+ z ! sponsor ( a small bus9ess heal? plan "u "p #h44 7d7 ,sav+s clause ,section #gca7;c7 ( su* ,act1 z re/or$ by section #b1 is am5d$ by ins]t+ or "p #h aft] ?is "p4 7e7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z re/or$ by section #b1 is am5d$ by ins]t+ aft] ! item relat+ to section #gcd ! foll[+ new items3 ,"p #h--,rules gov]n+ small bus9ess heal? plans#hja4 ,small bus9ess heal? plans4#hjb4 ,alt]native m>ket pool+ organizations4#hjc4 ,c]tification ( small bus9ess heal? plans4#hjd4 ,requirem5ts relat+ to sponsors & bo>ds ( tru/ees4#hje4 ,p>ticipation & cov]age requirem5ts4#hjf4 ,o!r requirem5ts relat+ to plan docum5ts1 contribution rates1 & b5efit options4#hjg4 ,requirem5ts = application & relat$ requirem5ts4#hjh4 ,notice requirem5ts = volunt>y t]m9ation4#hji4 ,implem5tation & application au?ority by ,secret>y4#haj4 ,def9itions & rules ( con/ruction4 4 #bjb4 ,coop]ation betwe5 ,f$]al & ,/ate au?orities ,section #ejf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aacf71 z re/or$ by section #b1 is am5d$ by add+ at ! end ! foll[+ new subsection3 7d7 ,consultation ) ,/ates ) respect to small bus9ess heal? plans 7#a7 ,agreem5ts ) ,/ates ,! ,secret>y %all consult ) ! ,/ate recogniz$ "u p>agraph 7#b7 ) respect to a small bus9ess 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 small bus9ess heal? plans "u "p #h 9 accordance ) regulations ( ! ,secret>y applicable to c]tification "u "p #h4 7#b7 ,recognition ( 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> small bus9ess heal? plan1 z ! ,/ate ) :i* consultation is requir$4 ,9 c>ry+ out ?is p>agraph su* ,/ate %all be ! domicile ,/ate1 z def9$ 9 section #hje7;c74 4 #bjc4 ,effective date & transitional & o!r rules 7a7 ,effective date ,! am5dm5ts made by ?is subtitle %all take effect #ab mon?s 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 #f mon?s 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 #hjh7;a77#b7 ( ! ,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 ( tru/ees :i* has control ov] ! 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* arrangem5t or at su* "t t ! arrangem5t provides cov]age to p>ticipants & b5efici>ies 9 any ,/ate o!r ?an ! ,/ates 9 :i* cov]age is provid$ on su* date ( enactm5t4 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 #hjh ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 except t ! ref]5ce 9 p>agraph 7#g7 ( su* section to an small bus9ess heal? plan %all be deem$ a ref]5ce to an arrangem5t ref]r$ to 9 ?is subsection4 ,b ,m>ket ,relief #bjd4 ,m>ket relief ,! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bja et seq471 z re/or$ by section #b1 is am5d$ by ins]t+ aft] title ,,xxx ! foll[+3 ,,xxxi ,heal? c>e insurance m>ketplace mod]nization #caja4 ,g5]al insurance def9itions ,9 ?is title1 ! t]ms heal? insurance cov]age1 heal? insurance issu]1 gr\p heal? plan1 & individual heal? insurance %all h ! mean+s giv5 su* t]ms 9 section #bgia4 #cajb4 ,implem5tation & application au?ority by ,secret>y ,! ,secret>y %all1 ?r\gh promulgation & implem5tation ( su* regulations z ! ,secret>y may reasonably det]m9e necess>y or appropriate1 & 9 consultation ) a balanc$ spectrum ( effect$ entities & p]sons1 modify ! implem5tation & application ( ?is title to accommodate ) m9imum disruption su* *anges to ,/ate or ,f$]al law provid$ 9 ?is title & ! 7& ! am5dm5ts made by su* ,act7 or 9 regulations issu$ !reto4 ,a ,m>ket relief ,i ,rat+ requirem5ts #caaa4 ,def9itions ,9 ?is "p3 7#a7 ,adopt+ /ate ,! t]m adopt+ ,/ate means a ,/ate t1 ) respect to ! small gr\p m>ket1 has enact$ small gr\p rat+ rules t meet ! m9imum /&>ds set =? 9 section #caab7;a77#a7 or1 z applicable1 transitional small gr\p rat+ rules set =? 9 section #caab7;b74 7#b7 ,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 ! insurance laws ( su* ,/ate4 7#c7 ,base premium rate ,! t]m base premium rate means1 = ea* class ( bus9ess ) respect to a rat+ p]iod1 ! l[e/ premium rate *>g$ or t c\ld h be5 *>g$ "u a rat+ sy/em = t class ( bus9ess by ! small employ] c>ri] to small employ]s ) simil> case *>act]i/ics = heal? b5efit plans ) ! same or simil> cov]age4 7#d7 ,eligible insur] ,! t]m eligible insur] means a heal? insurance issu] t is lic5s$ 9 a ,/ate & t-- 7,a7 notifies ! ,secret>y1 n lat] ?an #cj days prior to ! (f]+ ( cov]age describ$ 9 ?is subp>agraph1 t ! issu] int5ds to (f] heal? insurance cov]age consi/5t ) ! ,model ,small ,gr\p ,rat+ ,rules or1 z applicable1 transitional small gr\p rat+ rules 9 a ,/ate2 7,b7 notifies ! insurance dep>tm5t ( a nonadopt+ ,/ate 7or o!r ,/ate ag5cy71 n lat] ?an #cj days prior to ! (f]+ ( cov]age describ$ 9 ?is subp>agraph1 t ! issu] int5ds to (f] small gr\p heal? insurance cov]age 9 t ,/ate consi/5t ) ! ,model ,small ,gr\p ,rat+ ,rules1 & provides ) su* notice a copy ( any insurance policy t x int5ds to (f] 9 ! ,/ate1 its mo/ rec5t annual & qu>t]ly f9ancial reports1 & any o!r in=mation requir$ to be fil$ ) ! insurance dep>tm5t ( ! ,/ate 7or o!r ,/ate ag5cy72 & 7,c7 includes 9 ! t]ms ( ! heal? insurance cov]age (f]$ 9 nonadopt+ ,/ates 7includ+ 9 ! t]ms ( any individual c]tificates t may be (f]$ to individuals 9 connection ) su* gr\p heal? cov]age7 & fil$ ) ! ,/ate pursuant to subp>agraph 7,b71 a description 9 ! insur]'s contract ( ! ,model ,small ,gr\p ,rat+ ,rules & an affirmation t su* ,rules are includ$ 9 ! t]ms ( su* contract4 7#e7 ,heal? insurance cov]age ,! t]m heal? insurance cov]age means any cov]age issu$ 9 ! small gr\p heal? insurance m>ket1 except t su* t]m %all n include except$ b5efits 7z def9$ 9 section #bgia7;c774 7#f7 ,index rate ,! t]m index rate means = ea* class ( bus9ess ) respect to ! rat+ p]iod = small employ]s ) simil> case *>act]i/ics1 ! ari?metic av]age ( ! applicable base premium rate & ! correspond+ highe/ premium rate4 7#g7 ,model ,small ,gr\p ,rat+ ,rules ,! t]m ,model ,small ,gr\p ,rat+ ,rules means ! rules set =? 9 section #caab7;a77#b74 7#h7 ,nonadopt+ /ate ,! t]m nonadopt+ ,/ate means a ,/ate t is n an adopt+ ,/ate4 7#i7 ,small gr\p insurance m>ket ,! t]m small gr\p insurance m>ket %all h ! mean+ giv5 ! t]m small gr\p m>ket 9 section #bgia7;e77#e74 7#aj7 ,/ate law ,! t]m ,/ate law means all laws1 decisions1 rules1 regulations1 or o!r ,/ate actions 7includ+ actions by a ,/ate ag5cy7 hav+ ! effect ( law1 ( any ,/ate4 7#aa7 ,v>iation limits 7,a7 ,composite v>iation limit 7i7 ,9 g5]al ,! t]m composite v>iation limit means ! total v>iation 9 premium rates *>g$ by a heal? insurance issu] 9 ! small gr\p m>ket z p]mitt$ "u applicable ,/ate law bas$ on ! foll[+ factors or case *>act]i/ics3 7,i7 ,age4 7,,ii7 ,duration ( cov]age4 7,,iii7 ,claims exp]i5ce4 7,,iv7 ,heal? /atus4 7ii7 ,use ( factors ,) respect to ! use ( ! factors describ$ 9 clause 7i7 9 sett+ premium rates1 a heal? insurance issu] %all use "o or bo? ( ! factors describ$ 9 subclauses 7,i7 or 7,,iv7 ( su* clause & may use ! factors describ$ 9 subclauses 7,,ii7 or 7,,iii7 ( su* clause4 7,b7 ,total v>iation limit ,! t]m total v>iation limit means ! total v>iation 9 premium rates *>g$ by a heal? insurance issu] 9 ! small gr\p m>ket z p]mitt$ "u applicable ,/ate law bas$ on all factors & case *>act]i/ics 7z describ$ 9 section #caab7;a77#a774 #caab4 ,rat+ rules 7a7 ,e/abli%m5t ( m9imum /&>ds = premium v>iations & model small gr\p rat+ rules ,n lat] ?an #f mon?s aft] ! date ( enactm5t ( ?is title1 ! ,secret>y %all promulgate regulations e/abli%+ ! foll[+ ,m9imum ,/&>ds & ,model ,small ,gr\p ,rat+ ,rules3 7#a7 ,m9imum /&>ds = premium v>iations 7,a7 ,composite v>iation limit ,! composite v>iation limit %all n be less ?an #c3a4 7,b7 ,total v>iation limit ,! total v>iation limit %all n be less ?an #e3a4 7,c7 ,prohibition on use ( c]ta9 case *>act]i/ics ,= purposes ( ?is p>agraph1 9 calculat+ ! total v>iation limit1 ! ,/ate %all n use case *>act]i/ics o!r ?an ^? us$ 9 calculat+ ! composite v>iation limit & indu/ry1 geographic area1 gr\p size1 p>ticipation rate1 class ( bus9ess1 & p>ticipation 9 wellness programs4 7#b7 ,model ,small ,gr\p ,rat+ ,rules ,! foll[+ apply to an eligible insur] 9 a non-adopt+ ,/ate3 7,a7 ,premium rates ,premium rates = small gr\p heal? b5efit plans to :i* ?is title applies %all comply ) ! foll[+ provisions relat+ to premiums1 except z provid$ = "u subsection 7b73 7i7 ,v>iation 9 premium rates ,! plan may n v>y premium rates by m ?an ! m9imum /&>ds provid$ = "u p>agraph 7#a74 7ii7 ,index rate ,! index rate = a rat+ p]iod = any class ( bus9ess %all n exce$ ! index rate = any o!r class ( bus9ess by m ?an #bj p]c5t1 exclud+ ^? classes ( bus9ess relat$ to association gr\ps "u ?is title4 7iii7 ,class ( bus9esses ,) respect to a class ( bus9ess1 ! premium rates *>g$ dur+ a rat+ p]iod to small employ]s ) simil> case *>act]i/ics = ! same or simil> cov]age or ! rates t c\ld be *>g$ to su* employ]s "u ! rat+ sy/em = t class ( bus9ess1 %all n v>y f ! index rate by m ?an #be p]c5t ( ! index rate "u clause 7ii74 7iv7 ,increases = new rat+ p]iods ,! p]c5tage increase 9 ! premium rate *>g$ to a small employ] = a new rat+ p]iod may n exce$ ! sum ( ! foll[+3 7,i7 ,! p]c5tage *ange 9 ! new bus9ess premium rate measur$ f ! fir/ day ( ! prior rat+ p]iod to ! fir/ day ( ! new rat+ p]iod4 ,9 ! case ( a heal? b5efit plan into :i* ! small employ] c>ri] is no long] enroll+ new small employ]s1 ! small employ] c>ri] %all use ! p]c5tage *ange 9 ! base premium rate1 except t su* *ange %all n exce$1 on a p]c5tage basis1 ! *ange 9 ! new bus9ess premium rate = ! mo/ simil> heal? b5efit plan into :i* ! small employ] c>ri] is actively enroll+ new small employ]s4 7,,ii7 ,any adju/m5t1 n to exce$ #ae p]c5t annually & adju/$ pro rata = rat+ p]iods ( less !n #a ye>1 due to ! claim exp]i5ce1 heal? /atus or duration ( cov]age ( ! employees or dep5d5ts ( ! small employ] z det]m9$ f ! small employ] c>ri]'s rate manual = ! class ( bus9ess involv$4 7,,iii7 ,any adju/m5t due to *ange 9 cov]age or *ange 9 ! case *>act]i/ics ( ! small employ] z det]m9$ f ! small employ] c>ri]'s rate manual = ! class ( bus9ess4 7v7 ,uni=m application ( adju/m5ts ,adju/m5ts 9 premium rates = claim exp]i5ce1 heal? /atus1 or duration ( cov]age %all n be *>g$ to individual employees or dep5d5ts4 ,any su* adju/m5t %all be appli$ uni=mly to ! rates *>g$ = all employees & dep5d5ts ( ! small employ]4 7vi7 ,prohibition on use ( c]ta9 case *>act]i/ic ,a small employ] c>ri] %all n utilize case *>act]i/ics1 o!r ?an ^? p]mitt$ "u p>agraph 7#a77;,c71 )\t ! prior approval ( ! applicable ,/ate au?ority4 7vii7 ,consi/5t application ( factors ,small employ] c>ri]s %all apply rat+ factors1 includ+ case *>act]i/ics1 consi/5tly ) respect to all small employ]s 9 a class ( bus9ess4 ,rat+ factors %all produce premiums = id5tical gr\ps :i* diff] only by ! am\nts attributable to plan design & d n reflect diff]5ces due to ! nature ( ! gr\ps assum$ to select p>ticul> heal? b5efit plans4 7viii7 ,treatm5t ( plans z hav+ same rat+ p]iod ,a small employ] c>ri] %all treat all heal? b5efit plans issu$ or r5ew$ 9 ! same cal5d> mon? z hav+ ! same rat+ p]iod4 7ix7 ,require compliance ,premium rates = small bus9ess heal? b5efit plans %all comply ) ! requirem5ts ( ?is subsection not)/&+ any assessm5ts paid or payable by a small employ] c>ri] z requir$ by a ,/ate's small employ] c>ri] re9surance program4 7,b7 ,e/abli%m5t ( sep>ate class ( bus9ess ,subject to subp>agraph 7,c71 a small employ] c>ri] may e/abli% a sep>ate class ( bus9ess only to reflect sub/antial diff]5ces 9 expect$ claims exp]i5ce or adm9i/rative co/s relat$ to ! foll[+3 7i7 ,! small employ] c>ri] uses m ?an "o type ( sy/em = ! m>ket+ & sale ( heal? b5efit plans to small employ]s4 7ii7 ,! small employ] c>ri] has acquir$ a class ( bus9ess f ano!r small employ] c>ri]4 7iii7 ,! small employ] c>ri] provides cov]age to "o or m association gr\ps t meet ! requirem5ts ( ?is title4 7,c7 ,limitation ,a small employ] c>ri] may e/abli% up to #i sep>ate classes ( bus9ess "u subp>agraph 7,b71 exclud+ ^? classes ( bus9ess relat$ to association gr\ps "u ?is title4 7,d7 ,limitation on transf]s ,a small employ] c>ri] %all n transf] a small employ] involunt>ily into or out ( a class ( bus9ess4 ,a small employ] c>ri] %all n (f] to transf] a small employ] into or out ( a class ( bus9ess unless su* (f] is made to transf] all small employ]s 9 ! class ( bus9ess )\t reg>d to case *>act]i/ics1 claim exp]i5ce1 heal? /atus or duration ( cov]age s9ce issue4 7b7 ,transitional ,model ,small ,gr\p ,rat+ ,rules 7#a7 ,9 g5]al ,n lat] ?an #f mon?s aft] ! date ( enactm5t ( ?is title & to ! ext5t necess>y to provide = a graduat$ transition to ! m9imum /&>ds = premium v>iation z provid$ = 9 subsection 7a77#a71 ! ,secret>y1 9 consultation ) ! ,national ,association ( ,insurance ,commission]s 7,,naic71 %all promulgate ,/ate-specific transitional small gr\p rat+ rules 9 accordance ) ?is subsection1 :i* %all be applicable ) respect to non-adopt+ ,/ates & eligible insur]s op]at+ 9 su* ,/ates = a p]iod ( n to exce$ #c ye>s f ! date ( ! promulgation ( ! m9imum /&>ds = premium v>iation pursuant to subsection 7a74 7#b7 ,compliance ) transitional model small gr\p rat+ rules ,dur+ ! transition p]iod describ$ 9 p>agraph 7#a71 a ,/ate t1 on ! date ( enactm5t ( ?is title1 has 9 effect a small gr\p rat+ rules me?odology t all[s = a v>iation t is less ?an ! v>iation provid$ = "u subsection 7a77#a7 7conc]n+ m9imum /&>ds = premium v>iation71 %all be deem$ to be an adopt+ ,/ate if ! ,/ate complies ) ! transitional small gr\p rat+ rules z promulgat$ by ! ,secret>y pursuant to p>agraph 7#a74 7#c7 ,transition+ ( old bus9ess 7,a7 ,9 g5]al ,9 develop+ ! transitional small gr\p rat+ rules "u p>agraph 7#a71 ! ,secret>y %all1 aft] consultation ) ! ,national ,association ( ,insurance ,commission]s & repres5tatives ( insur]s op]at+ 9 ! small gr\p heal? insurance m>ket 9 non-adopt+ ,/ates1 promulgate special transition /&>ds ) respect to indep5d5t rat+ classes = old & new bus9ess1 to ! ext5t reasonably necess>y to protect heal? insurance consum]s & to ensure a /able & fair transition = old & new m>ket entrants4 7,b7 ,p]iod = op]ation ( indep5d5t rat+ classes ,9 develop+ ! special transition /&>ds pursuant to subp>agraph 7,a71 ! ,secret>y %all p]mit a c>ri] 9 a non-adopt+ ,/ate1 at its option1 to ma9ta9 indep5d5t rat+ classes = old & new bus9ess = a p]iod ( up to #e ye>s1 ) ! comm5cem5t ( su* #e-ye> p]iod to beg9 at su* "t1 b n lat] ?an ! date t is #c ye>s aft] ! date ( enactm5t ( ?is title1 z ! c>ri] (f]s a book ( bus9ess meet+ ! m9imum /&>ds = premium v>iation provid$ = 9 subsection 7a77#a7 or ! transitional small gr\p rat+ rules "u p>agraph 7#a74 7#d7 ,o!r transitional au?ority ,9 develop+ ! transitional small gr\p rat+ rules "u p>agraph 7#a71 ! ,secret>y %all provide = ! application ( ! transitional small gr\p rat+ rules 9 transition ,/ates z ! ,secret>y may det]m9e necess>y = a an effective transition4 7c7 ,m>ket re-,entry 7#a7 ,9 g5]al ,not)/&+ any o!r provision ( law1 a heal? insurance issu] t has volunt>ily )drawn f provid+ cov]age 9 ! small gr\p m>ket prior to ! date ( enactm5t ( ?is title %all n be exclud$ f re-ent]+ su* m>ket on a date t is m ?an #ahj days aft] su* date ( enactm5t4 7#b7 ,t]m9ation ,! provision ( ?is subsection %all t]m9ate on ! date t is #bd mon?s aft] ! date ( enactm5t ( ?is title4 #caac4 ,application & preemption 7a7 ,sup]s$+ ( /ate law 7#a7 ,9 g5]al ,?is "p %all sup]s$e any & all ,/ate laws ( a non-adopt+ ,/ate ins(> z su* ,/ate laws 7:e!r enact$ prior to or aft] ! date ( enactm5t ( ?is subtitle7 relate to rat+ 9 ! small gr\p insurance m>ket z appli$ to an eligible insur]1 or small gr\p heal? insurance cov]age issu$ by an eligible insur]1 includ+ ) respect to cov]age issu$ to a small employ] ?r\gh a small bus9ess heal? plan1 9 a ,/ate4 7#b7 ,nonadopt+ /ates ,?is "p %all sup]s$e any & all ,/ate laws ( a nonadopt+ ,/ate ins(> z su* ,/ate laws 7:e!r enact$ prior to or aft] ! date ( enactm5t ( ?is subtitle7-- 7,a7 prohibit an eligible insur] f (f]+1 m>ket+1 or implem5t+ small gr\p heal? insurance cov]age consi/5t ) ! ,model ,small ,gr\p ,rat+ ,rules or transitional model small gr\p rat+ rules2 or 7,b7 h ! effect ( retaliat+ aga9/ or o!rwise puni%+ 9 any respect an eligible insur] = (f]+1 m>ket+1 or implem5t+ small gr\p heal? insurance cov]age consi/5t ) ! ,model ,small ,gr\p ,rat+ ,rules or transitional model small gr\p rat+ rules4 7b7 ,sav+s clause & con/ruction 7#a7 ,nonapplication to adopt+ /ates ,subsection 7a7 %all n apply ) respect to adopt+ /ates4 7#b7 ,nonapplication to c]ta9 insur]s ,subsection 7a7 %all n apply ) respect to insur]s t d n qualify z eligible insur]s t (f] small gr\p heal? insurance cov]age 9 a nonadopt+ ,/ate4 7#c7 ,nonapplication :]e obta9+ relief "u /ate law ,subsection 7a77#a7 %all n sup]c$e any ,/ate law 9 a nonadopt+ ,/ate to ! ext5t necess>y to p]mit individuals or ! insurance dep>tm5t ( ! ,/ate 7or o!r ,/ate ag5cy7 to obta9 relief "u ,/ate law to require an eligible insur] to comply ) ! ,model ,small ,gr\p ,rat+ ,rules or transitional model small gr\p rat+ rules4 7#d7 ,no effect on preemption ,9 no case %all ?is "p be con/ru$ to limit or affect 9 any mann] ! preemptive scope ( sections #ejb & #ead ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd4 ,9 no case %all ?is "p be con/ru$ to create any cause ( action "u ,f$]al or ,/ate law or enl>ge or affect any rem$y available "u ! ,employee ,retirem5t ,income ,security ,act ( #aigd4 7#e7 ,preemption limit$ to rat+ ,subsection 7a7 %all n preempt any ,/ate law t does n h a ref]5ce to or a connection ) ,/ate rat+ rules t w\ld o!rwise apply to eligible insur]s4 7c7 ,effective date ,?is section %all apply1 at ! election ( ! eligible insur]1 beg9n+ 9 ! fir/ plan ye> or ! fir/ cal5d> ye> foll[+ ! issuance ( ! f9al rules by ! ,secret>y "u ! ,model ,small ,gr\p ,rat+ ,rules or1 z applicable1 ! ,transitional ,model ,small ,gr\p ,rat+ ,rules1 b 9 no ev5t e>li] ?an ! date t is #ab mon?s aft] ! date ( enactm5t ( ?is title4 #caad4 ,civil actions & jurisdiction 7a7 ,9 g5]al ,! c\rts ( ! ,unit$ ,/ates %all h exclusive jurisdiction ov] civil actions involv+ ! int]pretation ( ?is "p4 7b7 ,actions ,an eligible insur] may br+ an action 9 ! di/rict c\rts ( ! ,unit$ ,/ates = injunctive or o!r equitable relief aga9/ any (ficials or ag5ts ( a nonadopt+ ,/ate 9 connection ) any conduct or action1 or propos$ conduct or action1 by su* (ficials or ag5ts :i* violates1 or :i* w\ld if und]tak5 violate1 section #caac4 7c7 ,direct fil+ 9 ,c\rt ( ,appeals ,at ! election ( ! eligible insur]1 an action may be br\ght "u subsection 7b7 directly 9 ! ,unit$ ,/ates ,c\rt ( ,appeals = ! circuit 9 :i* ! nonadopt+ ,/ate is locat$ by ! fil+ ( a petition = review 9 su* ,c\rt4 7d7 ,exp$it$ review 7#a7 ,di/rict c\rt ,9 ! case ( an action br\ght 9 a di/rict c\rt ( ! ,unit$ ,/ates "u subsection 7b71 su* c\rt %all complete su* action1 includ+ ! issuance ( a judgm5t1 prior to ! end ( ! #abj-;day p]iod beg9n+ on ! date on :i* su* action is fil$1 unless all p>ties to su* proce$+ agree to an ext5sion ( su* p]iod4 7#b7 ,c\rt ( ,appeals ,9 ! case ( an action br\ght directly 9 a ,unit$ ,/ates ,c\rt ( ,appeal "u subsection 7c71 or 9 ! case ( an appeal ( an action br\ght 9 a di/rict c\rt "u subsection 7b71 su* ,c\rt %all complete all action on ! petition1 includ+ ! issuance ( a judgm5t1 prior to ! end ( ! #fj-;day p]iod beg9n+ on ! date on :i* su* petition is fil$ ) ! ,c\rt1 unless all p>ties to su* proce$+ agree to an ext5sion ( su* p]iod4 7e7 ,/&>d ( review ,a c\rt 9 an action fil$ "u ?is section1 %all r5d] a judgm5t bas$ on a review ( ! m]its ( all que/ions pres5t$ 9 su* action & %all n def] to any conduct or action1 or propos$ conduct or action1 ( a nonadopt+ ,/ate4 #caae4 ,ongo+ review ,n lat] ?an #e ye>s aft] ! date on :i* ! ,model ,small ,gr\p ,rat+ ,rules are issu$ "u ?is "p1 & e #e ye>s !reaft]1 ! ,secret>y1 9 consultation ) ! ,national ,association ( ,insurance ,commission]s1 %all prep>e & submit to ! appropriate committees ( ,congress a report t assesses ! effect ( ! ,model ,small ,gr\p ,rat+ ,rules on access1 co/1 & m>ket function+ 9 ! small gr\p m>ket4 ,su* report may1 if ! ,secret>y1 9 consultation ) ! ,national ,association ( ,insurance ,commission]s1 det]m9es su* is appropriate = improv+ access1 co/s1 & m>ket function+1 conta9 legislative proposals = recomm5d$ modification to su* ,model ,small ,gr\p ,rat+ ,rules4 ,,ii ,af=dable ,plans #caba4 ,def9itions ,9 ?is "p3 7#a7 ,adopt+ /ate ,! t]m adopt+ ,/ate means a ,/ate t has enact$ a law provid+ t small gr\p1 individual1 & l>ge gr\p heal? insur]s 9 su* ,/ate may (f] & sell products 9 accordance ) ! ,li/ ( ,requir$ ,b5efits & ! ,t]ms ( ,application z provid$ = 9 section #cabb7;b74 7#b7 ,eligible insur] ,! t]m eligible insur] means a heal? insurance issu] t is lic5s$ 9 a nonadopt+ ,/ate & t-- 7,a7 notifies ! ,secret>y1 n lat] ?an #cj days prior to ! (f]+ ( cov]age describ$ 9 ?is subp>agraph1 t ! issu] int5ds to (f] heal? insurance cov]age consi/5t ) ! ,li/ ( ,requir$ ,b5efits & ,t]ms ( ,application 9 a nonadopt+ ,/ate2 7,b7 notifies ! insurance dep>tm5t ( a nonadopt+ ,/ate 7or o!r applicable ,/ate ag5cy71 n lat] ?an #cj days prior to ! (f]+ ( cov]age describ$ 9 ?is subp>agraph1 t ! issu] int5ds to (f] heal? insurance cov]age 9 t ,/ate consi/5t ) ! ,li/ ( ,requir$ ,b5efits & ,t]ms ( ,application1 & provides ) su* notice a copy ( any insurance policy t x int5ds to (f] 9 ! ,/ate1 its mo/ rec5t annual & qu>t]ly f9ancial reports1 & any o!r in=mation requir$ to be fil$ ) ! insurance dep>tm5t ( ! ,/ate 7or o!r ,/ate ag5cy7 by ! ,secret>y 9 regulations2 & 7,c7 includes 9 ! t]ms ( ! heal? insurance cov]age (f]$ 9 nonadopt+ ,/ates 7includ+ 9 ! t]ms ( any individual c]tificates t may be (f]$ to individuals 9 connection ) su* gr\p heal? cov]age7 & fil$ ) ! ,/ate pursuant to subp>agraph 7,b71 a description 9 ! insur]'s contract ( ! ,li/ ( ,requir$ ,b5efits & a description ( ! ,t]ms ( ,application1 includ+ a description ( ! b5efits to be provid$1 & t adh]5ce to su* /&>ds is includ$ z a t]m ( su* contract4 7#c7 ,heal? insurance cov]age ,! t]m heal? insurance cov]age means any cov]age issu$ 9 ! small gr\p1 individual1 or l>ge gr\p heal? insurance m>kets1 includ+ ) respect to small bus9ess heal? plans1 except t su* t]m %all n include except$ b5efits 7z def9$ 9 section #bgia7;c774 7#d7 ,li/ ( ,requir$ ,b5efits ,! t]m ,li/ ( ,requir$ ,b5efits means ! ,li/ issu$ "u section #cabb7;a74 7#e7 ,nonadopt+ /ate ,! t]m nonadopt+ ,/ate means a ,/ate t is n an adopt+ ,/ate4 7#f7 ,/ate law ,! t]m ,/ate law means all laws1 decisions1 rules1 regulations1 or o!r ,/ate actions 7includ+ actions by a ,/ate ag5cy7 hav+ ! effect ( law1 ( any ,/ate4 7#g7 ,/ate ,provid] ,fre$om ( ,*oice ,law ,! t]m ,/ate ,provid] ,fre$om ( ,*oice ,law means a ,/ate law requir+ t a heal? insurance issu]1 ) respect to heal? insurance cov]age1 n discrim9ate ) respect to p>ticipation1 reimbursem5t1 or indemnification z to any provid] :o is act+ )9 ! scope ( ! provid]'s lic5se or c]tification "u applicable ,/ate law4 7#h7 ,t]ms ( ,application ,! t]m ,t]ms ( ,application means t]ms provid$ "u section #cabb7;a74 #cabb4 ,(f]+ af=dable plans 7a7 ,li/ ( ,requir$ ,b5efits ,n lat] ?an #c mon?s aft] ! date ( enactm5t ( ?is title1 ! ,secret>y1 9 consultation ) ! ,national ,association ( ,insurance ,commission]s1 %all issue by int]im f9al rule a li/ 7to be kn[n z ! ,li/ ( ,requir$ ,b5efits7 ( cov]$ b5efits1 s]vices1 or categories ( provid]s t are requir$ to be provid$ by heal? insurance issu]s1 9 ea* ( ! small gr\p1 individual1 & l>ge gr\p m>kets1 9 at lea/ #bf ,/ates z a result ( ! application ( ,/ate cov]$ b5efit1 s]vice1 & category ( provid] m&ate laws4 ,) respect to plans sold to or ?r\gh small bus9ess heal? plans1 ! ,li/ ( ,requir$ ,b5efits applicable to ! small gr\p m>ket %all apply4 7b7 ,t]ms ( ,application 7#a7 ,/ate ) m&ates ,) respect to a ,/ate t has a cov]$ b5efit1 s]vice1 or category ( provid] m&ate 9 effect t is cov]$ "u ! ,li/ ( ,requir$ ,b5efits "u subsection 7a71 su* ,/ate m&ate %all1 subject to p>agraph 7#c7 7conc]n+ uni=m application71 apply to a cov]age plan or plan 91 z applicable1 ! small gr\p1 individual1 or l>ge gr\p m>ket or ?r\gh a small bus9ess heal? plan 9 su* ,/ate4 7#b7 ,/ates )\t m&ates ,) respect to a ,/ate t does n h a cov]$ b5efit1 s]vice1 or category ( provid] m&ate 9 effect t is cov]$ "u ! ,li/ ( ,requir$ ,b5efits "u subsection 7a71 su* m&ate %all n apply1 z applicable1 to a cov]age plan or plan 9 ! small gr\p1 individual1 or l>ge gr\p m>ket or ?r\gh a small bus9ess heal? plan 9 su* ,/ate4 7#c7 ,uni=m application ( laws 7,a7 ,9 g5]al ,) respect to a ,/ate describ$ 9 p>agraph 7#a71 9 apply+ a cov]$ b5efit1 s]vice1 or category ( provid] m&ate t is on ! ,li/ ( ,requir$ ,b5efits "u subsection 7a7 ! ,/ate %all p]mit a cov]age plan or plan (f]$ 9 ! small gr\p1 individual1 or l>ge gr\p m>ket or ?r\gh a small bus9ess heal? plan 9 su* ,/ate to apply su* b5efit1 s]vice1 or category ( provid] cov]age 9 a mann] consi/5t ) ! mann] 9 :i* su* cov]age is appli$ "u "o ( ! ?ree mo/ heavily subscrib$ national heal? plans (f]$ "u ! ,f$]al ,employee ,heal? ,b5efits ,program "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code 7z det]m9$ by ! ,secret>y 9 consultation ) ! ,director ( ! ,(fice ( ,p]sonnel ,managem5t71 & consi/5t ) ! ,publication ( ,b5efit ,applications "u subsection 7c74 ,9 ! ev5t a cov]$ b5efit1 s]vice1 or category ( provid] appe>+ 9 ! ,li/ ( ,requir$ ,b5efits is n (f]$ 9 "o ( ! ?ree mo/ heavily subscrib$ national heal? plans (f]$ "u ! ,f$]al ,employees ,heal? ,b5efits ,program1 su* cov]$ b5efit1 s]vice1 or category ( provid] requirem5t %all be appli$ 9 a mann] consi/5t ) ! mann] 9 :i* su* cov]age is (f]$ 9 ! rema9+ mo/ heavily subscrib$ plan ( ! rema9+ ,f$]al ,employees ,heal? ,b5efits ,program plans1 z det]m9$ by ! ,secret>y1 9 consultation ) ! ,director ( ! ,(fice ( ,p]sonnel ,managem5t4 7,b7 ,exception reg>d+ ,/ate provid] fre$om ( *oice laws ,not)/&+ subp>agraph 7,a71 9 ! ev5t a category ( provid] m&ate is includ$ 9 ! ,li/ ( ,cov]$ ,b5efits1 any ,/ate ,provid] ,fre$om ( ,*oice ,law 7z def9$ 9 section #caba7g77 t is 9 effect 9 any ,/ate 9 :i* su* category ( provid] m&ate is 9 effect %all n be preempt$1 ) respect to t category ( provid]1 by ?is "p4 7c7 ,publication ( b5efit applications ,n lat] ?an #c mon?s aft] ! date ( enactm5t ( ?is title1 & on ! fir/ day ( e cal5d> ye> !reaft]1 ! ,secret>y1 9 consultation ) ! ,director ( ! ,(fice ( ,p]sonnel ,managem5t1 %all publi% 9 ! ,f$]al ,regi/] a description ( su* cov]$ b5efits1 s]vices1 & categories ( provid]s cov]$ 9 t cal5d> ye> by ea* ( ! ?ree mo/ heavily subscrib$ nationally available ,f$]al ,employee ,heal? ,b5efits ,plan options :i* are also includ$ on ! ,li/ ( ,requir$ ,b5efits4 7d7 ,effective dates 7#a7 ,small bus9ess heal? plans ,) respect to heal? insurance provid$ to p>ticipat+ employ]s ( small bus9ess heal? plans1 ! requirem5ts ( ?is "p 7conc]n+ l[] co/ plans7 %all apply beg9n+ on ! date t is #ab mon?s aft] ! date ( enactm5t ( ?is title4 7#b7 ,non-association cov]age ,) respect to heal? insurance provid$ to gr\ps or individuals o!r ?an p>ticipat+ employ]s ( small bus9ess heal? plans1 ! requirem5ts ( ?is "p %all apply beg9n+ on ! date t is #ae mon?s aft] ! date ( enactm5t ( ?is title4 7e7 ,updat+ ( li/ ( requir$ b5efits ,n lat] ?an #b ye>s aft] ! date on :i* ! li/ ( requir$ b5efits is issu$ "u subsection 7a71 & e #b ye>s !reaft]1 ! ,secret>y1 9 consultation ) ! ,national ,association ( ,insurance ,commission]s1 %all update ! li/ bas$ on *anges 9 ! laws & regulations ( ! ,/ates4 ,! ,secret>y %all issue ! updat$ li/ by regulation1 & su* updat$ li/ %all be effective ^u ! fir/ plan ye> foll[+ ! issuance ( su* regulation4 #cabc4 ,application & preemption 7a7 ,sup]c$+ ( /ate law 7#a7 ,9 g5]al ,?is "p %all sup]s$e any & all ,/ate laws ins(> z su* laws relate to m&ates relat+ to cov]$ b5efits1 s]vices1 or categories ( provid] 9 ! heal? insurance m>ket z appli$ to an eligible insur]1 or heal? insurance cov]age issu$ by an eligible insur]1 includ+ ) respect to cov]age issu$ to a small bus9ess heal? plan1 9 a nonadopt+ ,/ate4 7#b7 ,nonadopt+ /ates ,?is "p %all sup]s$e any & all ,/ate laws ( a nonadopt+ ,/ate 7:e!r enact$ prior to or aft] ! date ( enactm5t ( ?is title7 ins(> z su* laws-- 7,a7 prohibit an eligible insur] f (f]+1 m>ket+1 or implem5t+ heal? insurance cov]age consi/5t ) ! ,b5efit ,*oice ,/&>ds1 z provid$ = 9 section #cabb7;a72 or 7,b7 h ! effect ( retaliat+ aga9/ or o!rwise puni%+ 9 any respect an eligible insur] = (f]+1 m>ket+1 or implem5t+ heal? insurance cov]age consi/5t ) ! ,b5efit ,*oice ,/&>ds4 7b7 ,sav+s clause & con/ruction 7#a7 ,nonapplication to adopt+ /ates ,subsection 7a7 %all n apply ) respect to adopt+ ,/ates4 7#b7 ,nonapplication to c]ta9 insur]s ,subsection 7a7 %all n apply ) respect to insur]s t d n qualify z eligible insur]s :o (f] heal? insurance cov]age 9 a nonadopt+ ,/ate4 7#c7 ,nonapplication :]e obta9+ relief "u /ate law ,subsection 7a77#a7 %all n sup]c$e any ,/ate law ( a nonadopt+ ,/ate to ! ext5t necess>y to p]mit individuals or ! insurance dep>tm5t ( ! ,/ate 7or o!r ,/ate ag5cy7 to obta9 relief "u ,/ate law to require an eligible insur] to comply ) ! ,b5efit ,*oice ,/&>ds4 7#d7 ,no effect on preemption ,9 no case %all ?is "p be con/ru$ to limit or affect 9 any mann] ! preemptive scope ( sections #ejb & #ead ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd4 ,9 no case %all ?is "p be con/ru$ to create any cause ( action "u ,f$]al or ,/ate law or enl>ge or affect any rem$y available "u ! ,employee ,retirem5t ,income ,security ,act ( #aigd4 7#e7 ,preemption limit$ to b5efits ,subsection 7a7 %all n preempt any ,/ate law t does n h a ref]5ce to or a connection ) ,/ate m&ates reg>d+ cov]$ b5efits1 s]vices1 or categories ( provid]s t w\ld o!rwise apply to eligible insur]s4 #cabd4 ,civil actions & jurisdiction 7a7 ,9 g5]al ,! c\rts ( ! ,unit$ ,/ates %all h exclusive jurisdiction ov] civil actions involv+ ! int]pretation ( ?is "p4 7b7 ,actions ,an eligible insur] may br+ an action 9 ! di/rict c\rts ( ! ,unit$ ,/ates = injunctive or o!r equitable relief aga9/ any (ficials or ag5ts ( a nonadopt+ ,/ate 9 connection ) any conduct or action1 or propos$ conduct or action1 by su* (ficials or ag5ts :i* violates1 or :i* w\ld if und]tak5 violate1 section #cabc4 7c7 ,direct fil+ 9 ,c\rt ( ,appeals ,at ! election ( ! eligible insur]1 an action may be br\ght "u subsection 7b7 directly 9 ! ,unit$ ,/ates ,c\rt ( ,appeals = ! circuit 9 :i* ! nonadopt+ ,/ate is locat$ by ! fil+ ( a petition = review 9 su* ,c\rt4 7d7 ,exp$it$ review 7#a7 ,di/rict c\rt ,9 ! case ( an action br\ght 9 a di/rict c\rt ( ! ,unit$ ,/ates "u subsection 7b71 su* c\rt %all complete su* action1 includ+ ! issuance ( a judgm5t1 prior to ! end ( ! #abj-;day p]iod beg9n+ on ! date on :i* su* action is fil$1 unless all p>ties to su* proce$+ agree to an ext5sion ( su* p]iod4 7#b7 ,c\rt ( ,appeals ,9 ! case ( an action br\ght directly 9 a ,unit$ ,/ates ,c\rt ( ,appeal "u subsection 7c71 or 9 ! case ( an appeal ( an action br\ght 9 a di/rict c\rt "u subsection 7b71 su* ,c\rt %all complete all action on ! petition1 includ+ ! issuance ( a judgm5t1 prior to ! end ( ! #fj-;day p]iod beg9n+ on ! date on :i* su* petition is fil$ ) ! ,c\rt1 unless all p>ties to su* proce$+ agree to an ext5sion ( su* p]iod4 7e7 ,/&>d ( review ,a c\rt 9 an action fil$ "u ?is section1 %all r5d] a judgm5t bas$ on a review ( ! m]its ( all que/ions pres5t$ 9 su* action & %all n def] to any conduct or action1 or propos$ conduct or action1 ( a nonadopt+ ,/ate4 #cabe4 ,rules ( con/ruction 7a7 ,9 g5]al ,not)/&+ any o!r provision ( ,f$]al or ,/ate law1 a heal? insurance issu] 9 an adopt+ ,/ate or an eligible insur] 9 a non-adopt+ ,/ate may am5d its exi/+ policies to be consi/5t ) ! t]ms ( ?is subtitle 7conc]n+ rat+ & b5efits74 7b7 ,heal? sav+s acc\nts ,no?+ 9 ?is subtitle %all be con/ru$ to create any m&ates = cov]age ( b5efits = ,,hsa-qualifi$ heal? plans t w\ld require reimbursem5ts 9 violation ( section #bbc7;c77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf4 4 ,,ii ,t>get$ ,ef=ts to ,exp& ,access #baa4 ,ext5d+ cov]age ( dep5d5ts 7a7 ,employee ,retirem5t ,income ,security ,act ( #aigd 7#a7 ,9 g5]al ,"p #g ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by ins]t+ aft] section #gad ! foll[+ new section3 #gae4 ,ext5d+ cov]age ( dep5d5ts 7a7 ,9 g5]al ,9 ! case ( a gr\p heal? plan1 or heal? insurance cov]age (f]$ 9 connection ) a gr\p heal? plan1 t treats z a b5efici>y "u ! plan an individual :o is a dep5d5t *ild ( a p>ticipant or b5efici>y "u ! plan1 ! plan or cov]age %all cont9ue to treat ! individual z a dep5d5t *ild )\t reg>d to ! individual's age until ! individual turns #bf ye>s ( age4 7b7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$ z requir+ a gr\p heal? plan to provide b5efits = dep5d5t *ildr5 z b5efici>ies "u ! plan or to require a p>ticipant to elect cov]age ( dep5d5t *ildr54 4 7#b7 ,cl]ical am5dm5t ,! table ( cont5ts ( su* ,act is am5d$ by ins]t+ aft] ! item relat+ to section #gad ! foll[+ new item3 ,sec4 #gae4 ,ext5d+ cov]age ( dep5d5ts4 4 7b7 ,,phsa ,title ,,xxvii ( ! ,public ,heal? ,s]vice ,act1 z re/or$ by section #b1 is am5d$ by ins]t+ aft] section #bgjg ! foll[+ new section3 #bgjh4 ,ext5d+ cov]age ( dep5d5ts 7a7 ,9 g5]al ,9 ! case ( a gr\p heal? plan1 or heal? insurance cov]age (f]$ 9 connection ) a gr\p heal? plan1 t treats z a b5efici>y "u ! plan an individual :o is a dep5d5t *ild ( a p>ticipant or b5efici>y "u ! plan1 ! plan or cov]age %all cont9ue to treat ! individual z a dep5d5t *ild )\t reg>d to ! individual's age until ! individual turns #bf ye>s ( age4 7b7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$ z requir+ a gr\p heal? plan to provide b5efits = dep5d5t *ildr5 z b5efici>ies "u ! plan or to require a p>ticipant to elect cov]age ( dep5d5t *ildr54 4 7c7 ,,irc 7#a7 ,9 g5]al ,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new section3 #ihad4 ,ext5d+ cov]age ( dep5d5ts 7a7 ,9 g5]al ,9 ! case ( a gr\p heal? plan t treats z a b5efici>y "u ! plan an individual :o is a dep5d5t *ild ( a p>ticipant or b5efici>y "u ! plan1 ! plan %all cont9ue to treat ! individual z a dep5d5t *ild )\t reg>d to ! individual's age until ! individual turns #bf ye>s ( age4 7b7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$ z requir+ a gr\p heal? plan to provide cov]age = dep5d5t *ildr5 z b5efici>ies "u ! plan or to require a p>ticipant to elect cov]age ( dep5d5t *ildr54 4 7#b7 ,cl]ical am5dm5t ,! table ( sections 9 su* sub*apt] is am5d$ by add+ at ! end ! foll[+ new item3 ,sec4 #ihad4 ,ext5d+ cov]age ( dep5d5ts4 4 7d7 ,effective date ,! am5dm5ts made by subsections 7a71 7b71 & 7c7 %all apply to gr\p heal? plans = plan ye>s beg9n+ m ?an #c mon?s aft] ! date ( ! enactm5t ( ?is ,act & %all apply to individuals :o are dep5d5t *ildr5 "u a gr\p heal? plan1 or heal? insurance cov]age (f]$ 9 connection ) su* a plan1 on or aft] su* date4 7e7 ,adult dep5d5ts 7#a7 ,exclusion ( am\nts exp5d$ = m$ical c>e ,! fir/ s5t5ce ( section #aje7;b7 ( ! ,int]nal ,rev5ue ,code ( #aihf 7relat+ to am\nts exp5d$ = m$ical c>e7 is am5d$-- 7,a7 by /rik+ & 8 dep5d5ts & ins]t+ 8 dep5d5ts2 & 7,b7 by ins]t+ be=e ! p]iod ! foll[+3 1 & any *ild 7z def9$ 9 section #aeb7;f77#a77 ( ! taxpay] :o z ( ! end ( ! taxable ye> has n atta9$ age #bg4 7#b7 ,self-employ$ heal? insurance d$uction ,section #afb7l77#a7 ( su* ,code is am5d$ to read z foll[s3 7#a7 ,all[ance ( d$uction ,9 ! case ( a taxpay] :o is an employee )9 ! mean+ ( section #dja7;c77#a71 !re %all be all[$ z a d$uction "u ?is section an am\nt equal to ! am\nt paid dur+ ! taxable ye> = insurance :i* con/itutes m$ical c>e = 7,a7 ! taxpay]1 7,b7 ! taxpay]'s sp\se1 7,c7 ! taxpay]'s dep5d5ts1 & 7,d7 any *ild 7z def9$ 9 section #aeb7;f77#a77 ( ! taxpay] :o z ( ! end ( ! taxable ye> has n atta9$ age #bg4 4 7#c7 ,cov]age "u self-employ$ d$uction ,section #afb7l77#b77;,b7 ( su* ,code is am5d$ by ins]t+ 1 or any dep5d5t1 or individual describ$ 9 subp>agraph 7,d7 ( p>agraph 7#a7 ) respect to1 aft] sp\se (4 7#d7 ,sick & accid5t b5efits provid$ to memb]s ( a volunt>y employees' b5efici>y association & _! dep5d5ts ,section #eja7;c77#i7 ( su* ,code is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,= purposes ( provid+ = ! paym5t ( sick & accid5t b5efits to memb]s ( su* an association & _! dep5d5ts1 ! t]m dep5d5t %all include any individual :o is a *ild 7z def9$ 9 section #aeb7;f77#a77 ( a memb] :o z ( ! end ( ! cal5d> ye> has n atta9$ age #bg44 7#e7 ,m$ical & o!r b5efits = retir$ employees ,section #dja7;h7 ( su* ,code is am5d$ by add+ at ! end ! foll[+3 ,= purposes ( ?is subsection1 ! t]m dep5d5t %all include any individual :o is a *ild 7z def9$ 9 section #aeb7;f77#a77 ( a retir$ employee :o z ( ! end ( ! cal5d> ye> has n atta9$ age #bg44 #bab4 ,prohibit+ preexi/+ condition exclusions = enrollees "u age #ai 7a7 ,,phsa ,section #bgja7;a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg7a771 z re/or$ by section #b1 is am5d$-- 7#a7 9 ! matt] prec$+ p>agraph 7#a71 by ins]t+ & ! la/ s5t5ce ( ?is subsection aft] subsection 7d72 & 7#b7 by add+ at ! end ! foll[+ new s5t5ce3 ,9 ! case ( a p>ticipant or b5efici>y :o is "u #ai ye>s ( age1 a gr\p heal? plan & a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age may n impose any preexi/+ condition exclusion ) respect to su* plan or cov]age4 4 7b7 ,,erisa ,section #gja7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z re/or$ by section #b1 is am5d$-- 7#a7 9 ! matt] prec$+ p>agraph 7#a71 by ins]t+ & ! la/ s5t5ce ( ?is subsection aft] subsection 7d72 & 7#b7 by add+ at ! end ! foll[+ new s5t5ce3 ,9 ! case ( a p>ticipant or b5efici>y :o is "u #ai ye>s ( age1 a gr\p heal? plan & a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age may n impose any preexi/+ condition exclusion ) respect to su* plan or cov]age4 4 7c7 ,,irc ,section #ihja ( ! ,int]nal ,rev5ue ,code ( #aihf1 z re/or$ by section #b1 is am5d$-- 7#a7 9 ! matt] prec$+ p>agraph 7#a71 by ins]t+ & ! la/ s5t5ce ( ?is subsection aft] subsection 7d72 & 7#b7 by add+ at ! end ! foll[+ new s5t5ce3 ,9 ! case ( a p>ticipant or b5efici>y :o is "u #ai ye>s ( age1 a gr\p heal? plan may n impose any preexi/+ condition exclusion ) respect to su* plan4 4 #bac4 ,heal? plan f9d]s 7a7 ,/ate plan f9d]s ,n lat] ?an #ab mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ea* ,/ate may contract ) a private entity to develop & op]ate a plan f9d] website 7ref]r$ to 9 ?is section z a ,/ate plan f9d]7 :i* %all provide in=mation to individuals 9 su* ,/ate on plans ( heal? insurance cov]age t are available to individuals 9 su* ,/ate 79 ?is section ref]r$ to z a heal? insurance plan7 4 ,su* ,/ate may n op]ate a plan f9d] itself4 7b7 ,multi-,/ate plan f9d]s 7#a7 ,9 g5]al ,a private entity may op]ate a multi-,/ate f9d] t op]ates "u ?is section 9 ! ,/ates involv$ 9 ! same mann] z a ,/ate plan f9d] w\ld op]ate 9 a s+le ,/ate4 7#b7 ,%>+ ( in=mation ,/ates %all regulate ! mann] 9 :i* data is %>$ betwe5 plan f9d]s to ensure consi/5cy & accuracy 9 ! in=mation ab\t heal? insurance plans conta9$ 9 su* f9d]s4 7c7 ,requirem5ts = plan f9d]s ,ea* plan f9d] %all meet ! foll[+ requirem5ts3 7#a7 ,! plan f9d] %all ensure t ea* heal? insurance plan 9 ! plan f9d] meets ! requirem5ts = su* plans "u subsection 7d74 7#b7 ,! plan f9d] %all pres5t complete in=mation on ! co/s & b5efits ( heal? insurance plans 7includ+ in=mation on mon?ly premium1 copaym5ts1 & d$uctibles7 9 a uni=m mann] t-- 7,a7 uses ! /&>d def9itions develop$ "u p>agraph 7#c72 & 7,b7 is design$ to all[ consum]s to easily comp>e su* plans4 7#c7 ,! plan f9d] %all be available on ! ,int]net & accessible to all individuals 9 ! ,/ate or1 9 ! case ( a multi-,/ate plan f9d]1 9 all ,/ates cov]$ by ! multi-,/ate plan f9d]4 7#d7 ,! plan f9d] %all all[ consum]s to se>* & sort data on ! heal? insurance plans 9 ! plan f9d] on crit]ia su* z cov]age ( specific b5efits 7su* z cov]age ( disease managem5t s]vices or p$iatric c>e s]vices71 z well z data available on quality4 7#e7 ,! plan f9d] %all meet all relevant ,/ate laws & regulations1 includ+ laws & regulations relat$ to ! m>ket+ ( insurance products4 ,9 ! case ( a multi-,/ate plan f9d]1 ! f9d] %all meet su* laws & regulations = all ( ! ,/ates involv$4 7#f7 ,! plan f9d] %all meet solv5cy1 f9ancial1 & privacy requirem5ts e/abli%$ by ! ,/ate or ,/ates 9 :i* ! plan f9d] op]ates or ! ,secret>y = multi-,/ate f9d]s4 7#g7 ,! plan f9d] & ! employees ( ! plan f9d] %all be appropriately lic5s$ 9 ! ,/ate or ,/ates 9 :i* ! plan f9d] op]ates1 if su* lic5sure is requir$ by su* ,/ate or ,/ates4 7#h7 ,not)/&+ subsection 7f77#a71 ! plan f9d] %all assi/ individuals :o are eligible = ! ,m$icaid program "u title ,,xix ( ! ,social ,security ,act or ,/ate ,*ildr5's ,heal? ,insurance ,program "u title ,,xxi ( su* ,act by includ+ in=mation on ,m$icaid options1 eligibility1 & h[ to enroll4 7d7 ,requirem5ts = plans p>ticipat+ 9 a plan f9d] 7#a7 ,9 g5]al ,ea* ,/ate %all ensure t heal? insurance plans p>ticipat+ 9 ! ,/ate plan f9d] or 9 a multi-,/ate plan f9d] meet ! requirem5ts ( p>agraph 7#b7 7relat+ to adequacy ( insurance cov]age1 consum] protection1 & f9ancial /r5g?74 7#b7 ,specific requirem5ts ,9 ord] to p>ticipate 9 a plan f9d]1 a heal? insurance plan mu/ meet all ( ! foll[+ requirem5ts1 z det]m9$ by ea* ,/ate 9 :i* su* plan op]ates3 7,a7 ,! heal? insurance plan %all be actu>ially s\nd4 7,b7 ,! heal? insurance plan may n h a hi/ory ( abusive policy rescissions4 7,c7 ,! heal? insurance plan %all meet f9ancial & solv5cy requirem5ts4 7,d7 ,! heal? insurance plan %all disclose-- 7i7 all f9ancial arrangem5ts involv+ ! sale & pur*ase ( heal? insurance1 su* z ! paym5t ( fees & commissions2 & 7ii7 su* arrangem5ts may n be abusive4 7,e7 ,! heal? insurance plan %all ma9ta9 electronic heal? records t comply ) ! requirem5ts ( ! ,am]ican ,recov]y & ,re9ve/m5t ,act ( #bjji 7,public ,law #aaa-e7 relat$ to electronic heal? records4 7,f7 ,! heal? insurance plan %all make available to plan enrollees via ! f9d]1 :e!r by in=mation provid$ to ! f9d] or by a website l9k direct+ ! enrollee f ! f9d] to ! heal? insurance plan website1 data t includes ! price & co/ to ! individual ( s]vices (f]$ by a provid] accord+ to ! t]ms & conditions ( ! heal? plan4 ,data describ$ 9 ?is p>agraph is n made public by ! f9d]1 only made available to ! individual once enroll$ 9 ! heal? plan4 7e7 ,prohibitions 7#a7 ,direct ,enrollm5t ,! ,/ate plan f9d] may n directly enroll individuals 9 heal? insurance plans4 7#b7 ,conflicts ( int]e/ 7,a7 ,companies ,a heal? insurance issu] (f]+ a heal? insurance plan ?r\gh a plan f9d] may n-- 7i7 be ! private entity develop+ & ma9ta9+ a plan f9d] "u subsections 7a7 & 7b72 or 7ii7 h an own]%ip int]e/ 9 su* private entity or 9 ! plan f9d]4 7,b7 ,individuals ,an individual employ$ by a heal? insurance issu] (f]+ a heal? insurance plan ?r\gh a plan f9d] may n s]ve z a director or (fic] =-- 7i7 ! private entity develop+ & ma9ta9+ a plan f9d] "u subsections 7a7 & 7b72 or 7ii7 ! plan f9d]4 7f7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$ to all[ ! ,secret>y au?ority to regulate b5efit packages or to prohibit heal? insurance brok]s & ag5ts f-- 7#a7 utiliz+ ! plan f9d] = any purpose2 or 7#b7 m>ket+ or (f]+ heal? insurance products4 7g7 ,plan f9d] def9$ ,= purposes ( ?is section1 ! t]m plan f9d] means a ,/ate plan f9d] "u subsection 7a7 or a multi-,/ate plan f9d] "u subsection 7b74 7h7 ,/ate def9$ ,9 ?is section1 ! t]m ,/ate has ! mean+ giv5 su* t]m = purposes ( title ,,xix ( ! ,social ,security ,act4 ,,iii ,exp&+ ,*oices by ,all[+ ,am]icans to ,buy ,heal? ,c>e ,cov]age ,across ,/ate ,l9es #bba4 ,int]/ate pur*as+ ( heal? insurance 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#a74 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 ! #ej ,/ates & includes ! ,di/rict ( ,columbia1 ,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1 ,am]ican ,samoa1 & ! ,nor!rn ,m>iana ,isl&s4 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] re9sur] 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 4 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 ,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 #a 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$itation1 or c]tification4 #bgii4 ,en=cem5t 7a7 ,9 ,g5]al ,subject to subsection 7b71 ) respect to specific individual heal? insurance cov]age ! prim>y ,/ate = su* cov]age has sole jurisdiction to en=ce ! prim>y ,/ate's cov]$ 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$2 7,b7 ! availability & co/ ( heal? insurance policies = individuals ) preexi/+ m$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 ,,iv ,improv+ ,heal? ,sav+s ,acc\nts #bca4 ,,hsa funds = premiums = high d$uctible heal? plans 7a7 ,9 g5]al ,subp>agraph 7,c7 ( section #bbc7;d77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z re/or$ by section #b1 is am5d$ by /rik+ or at ! end ( clause 7iii71 by /rik+ ! p]iod at ! end ( clause 7iv7 & ins]t+ 1 or1 & by add+ at ! end ! foll[+3 7v7 a high d$uctible heal? plan if-- 7,i7 su* plan is n (f]$ 9 connection ) a gr\p heal? plan1 7,,ii7 no portion ( any premium 7)9 ! mean+ ( applicable premium "u section #dihj;,b7f77#d77 = su* plan is excludable f gross income "u section #ajf1 & 7,,iii7 ! acc\nt b5efici>y demon/rates1 us+ proc$ures deem$ appropriate by ! ,secret>y1 t aft] paym5t ( ! premium = su* insurance ! balance 9 ! heal? sav+s acc\nt is at lea/ twice ! m9imum d$uctible 9 effect "u subsection 7c77#b77;,a77i7 :i* is applicable to su* plan4 4 7b7 ,effective ,date ,! am5dm5t made by subsection 7a7 %all apply to premiums = a high d$uctible heal? plan = p]iods beg9n+ aft] ,decemb] #ca1 #bjaa4 #bcb4 ,requir+ great] coord9ation betwe5 ,,hdhp adm9i/rators & ,,hsa acc\nt adm9i/rators s t enrollees c enroll 9 bo? at ! same "t ,! ,secret>y ( ! ,treasury1 ?r\gh ! issuance ( regulations or o!r guidance1 %all enc\rage adm9i/rators ( heal? plans & tru/ees ( heal? sav+s acc\nts to provide = simultane\s enrollm5t 9 high d$uctible heal? plans & setup ( heal? sav+s acc\nts4 #bcc4 ,special rule = c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt 7a7 ,9 g5]al ,subsection 7d7 ( section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf1 z re/or$ by section #b1 is am5d$ by r$esignat+ p>agraph 7#d7 z p>agraph 7#e7 & by ins]t+ aft] p>agraph 7#c7 ! foll[+ new p>agraph3 7#d7 ,c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt treat$ z qualifi$ 7,a7 ,9 g5]al ,= purposes ( p>agraph 7#b71 an exp5se %all n fail to be treat$ z a qualifi$ m$ical exp5se solely because su* exp5se 0 incurr$ be=e ! e/abli%m5t ( ! heal? sav+s acc\nt if su* exp5se 0 incurr$ dur+ ! #fj-;day p]iod beg9n+ on ! date on :i* ! high d$uctible heal? plan is fir/ effective4 7,b7 ,special rules ,= purposes ( subp>agraph 7,a7-- 7i7 an individual %all be treat$ z an eligible individual = any portion ( a mon? = :i* ! individual is describ$ 9 subsection 7c77#a71 det]m9$ )\t reg>d to :e!r ! individual is cov]$ "u a high d$uctible heal? plan on ! #a/ day ( su* mon?1 & 7ii7 ! effective date ( ! heal? sav+s acc\nt is deem$ to be ! date on :i* ! high d$uctible heal? plan is fir/ effective aft] ! date ( ! enactm5t ( ?is p>agraph4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply ) respect to insurance pur*as$ aft] ! date ( ! enactm5t ( ?is ,act 9 taxable ye>s beg9n+ aft] su* date4 ,v ,tax-,relat$ ,heal? ,inc5tives #bda4 ,,seca tax d$uction = heal? insurance co/s 7a7 ,9 ,g5]al ,subsection 7l7 ( section #afb ( ! ,int]nal ,rev5ue ,code ( #aihf 7relat+ to special rules = heal? insurance co/s ( self-employ$ individuals7 is am5d$ by /rik+ p>agraph 7#d7 & by r$esignat+ p>agraph 7#e7 z p>agraph 7#d74 7b7 ,effective ,date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjaj4 #bdb4 ,d$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$uctions = individuals7 is am5d$ 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 ,qualifi$ ,heal? ,insurance ,= purposes ( ?is section1 ! t]m qualifi$ heal? insurance means insurance :i* con/itutes m$ical c>e1 o!r ?an insurance sub/antially all ( ! cov]age ( :i* is ( except$ b5efits describ$ 9 section #ihcb7;c74 7c7 ,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 %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 #bjaj4 ,c ,enact+ ,real ,m$ical ,liability ,re=m #cja4 ,cap on non-economic damages aga9/ heal? c>e practition]s ,:5 an individual is injur$ or dies z ! result ( heal? c>e1 a p]son entitl$ to non-economic damages may n recov]1 f ! class ( liable heal? c>e practition]s 7reg>dless ( ! !ory ( liability71 m ?an #bej1jjj su* damages4 #cjb4 ,cap on non-economic damages aga9/ heal? c>e in/itutions ,:5 an individual is injur$ or dies z ! result ( heal? c>e1 a p]son entitl$ to non-economic damages may n recov]-- 7#a7 f any s+le liable heal? c>e in/itution 7reg>dless ( ! !ory ( liability71 m ?an #bej1jjj su* damages2 & 7#b7 f ! class ( liable heal? c>e in/itutions 7reg>dless ( ! !ory ( liability71 m ?an #ejj1jjj su* damages4 #cjc4 ,cap1 9 wrongful dea? cases1 on total damages aga9/ any s+le heal? c>e practition] 7a7 ,9 g5]al ,:5 an individual dies z ! result ( heal? c>e1 a p]son entitl$ to damages may n recov]1 f any s+le liable heal? c>e practition] 7reg>dless ( ! !ory ( liability71 m ?an #a1djj1jjj 9 total damages4 7b7 ,total damages def9$ ,9 ?is section1 ! t]m total damages includes comp5satory damages1 punitive damages1 /atutory damages1 & any o!r type ( damages4 7c7 ,adju/m5t = inflation ,= ea* cal5d> ye> aft] ! cal5d> ye> ( ! enactm5t ( ?is ,act1 ! doll> am\nt ref]r$ to 9 subsection 7a7 %all be adju/$ to reflect *anges 9 ! ,consum] ,price ,index ( ! ,bureau ( ,labor ,/ati/ics ( ! ,dep>tm5t ( ,labor4 ,! adju/m5t %all be bas$ on ! relation%ip betwe5-- 7#a7 ! ,consum] ,price ,index data mo/ rec5tly publi%$ z ( ,janu>y #a ( ! cal5d> ye> ( ! enactm5t ( ?is ,act2 & 7#b7 ! ,consum] ,price ,index data mo/ rec5tly publi%$ z ( ,janu>y #a ( ! cal5d> ye> conc]n$4 7d7 ,applicability ( adju/m5t ,! doll> am\nt t applies to a recov]y is ! doll> am\nt = ! cal5d> ye> dur+ :i* ! am\nt ( ! recov]y is made f9al4 #cjd4 ,limitation ( insur] liability :5 insur] rejects c]ta9 settlem5t (f]s ,9 a civil action1 to ! ext5t ! civil action seeks damages = ! injury or dea? ( an individual z ! result ( heal? c>e1 :5 ! insur] ( a heal? c>e practition] or heal? c>e in/itution rejects a reasonable settlem5t (f] )9 policy limits1 ! insur] is n1 by reason ( t rejection1 liable = damages 9 an am\nt t exce$s ! liability ( ! insur$4 #cje4 ,m&atory jury in/ruction on cap on damages ,9 a civil action tri$ to a jury1 to ! ext5t ! civil action seeks damages = ! injury or dea? ( an individual z ! result ( heal? c>e1 ! c\rt %all in/ruct ! jury t ! jury is n to consid] :e!r1 or to :at ext5t1 a limitation on damages applies4 #cjf4 ,det]m9ation ( neglig5ce2 m&atory jury in/ruction 7a7 ,9 g5]al ,:5 an individual is injur$ or dies z ! result ( heal? c>e1 liability = neglig5ce may n be bas$ solely on a bad result4 7b7 ,m&atory jury in/ruction ,9 a civil action tri$ to a jury1 to ! ext5t ! civil action seeks damages = ! injury or dea? ( an individual z ! result ( heal? c>e & alleges liability = neglig5ce1 ! c\rt %all in/ruct ! jury z provid$ 9 subsection 7a74 #cjg4 ,exp]t reports requir$ to be s]v$ 9 civil actions 7a7 ,s]vice requir$ ,to ! ext5t a plead+ fil$ 9 a civil action seeks damages aga9/ a heal? c>e practition] = ! injury or dea? ( an individual z ! result ( heal? c>e1 ! p>ty fil+ ! plead+ %all1 n lat] ?an #abj days aft] ! date on :i* ! plead+ 0 fil$1 s]ve on ea* p>ty aga9/ :om su* damages are s\ght a qualifi$ exp]t report4 7b7 ,qualifi$ exp]t report ,z us$ 9 subsection 7a71 a qualifi$ exp]t report is a writt5 report ( a qualifi$ heal? c>e exp]t t-- 7#a7 includes a curriculum vitae = t exp]t2 & 7#b7 sets =? a summ>y ( ! exp]t op9ion ( t exp]t z to-- 7,a7 ! /&>d ( c>e applicable to t practition]2 7,b7 h[ t practition] fail$ to meet t /&>d ( c>e2 & 7,c7 ! causal relation%ip betwe5 t failure & ! injury or dea? ( ! individual4 7c7 ,motion ,to en=ce ,a p>ty n s]v$ z requir$ by subsection 7a7 may move ! c\rt to en=ce t subsection4 ,on su* a motion1 ! c\rt-- 7#a7 %all dismiss1 ) prejudice1 ! plead+ z x relates to t p>ty2 & 7#b7 %all aw>d to t p>ty ! attorney fees reasonably incurr$ by t p>ty to respond to t plead+4 7d7 ,use ( exp]t report 7#a7 ,9 g5]al ,except z o!rwise provid$ 9 ?is section1 a qualifi$ exp]t report s]v$ "u subsection 7a7 may n1 9 t civil action-- 7,a7 be (f]$ by any p>ty z evid5ce2 7,b7 be us$ by any p>ty 9 discov]y or any o!r pretrial proce$+2 or 7,c7 be ref]r$ to by any p>ty at trial4 7#b7 ,violations 7,a7 ,by o!r p>ty ,if p>agraph 7#a7 is violat$ by a p>ty o!r ?an ! p>ty :o s]v$ ! report1 ! c\rt %all1 on motion ( any p>ty or on its own motion1 take su* measures z ! c\rt consid]s appropriate1 :i* may include ! imposition ( sanctions4 7,b7 ,by s]v+ p>ty ,if p>agraph 7#a7 is violat$ by ! p>ty :o s]v$ ! report1 p>agraph 7#a7 %all no long] apply to any p>ty4 #cjh4 ,exp]t op9ions relat+ to physicians may be provid$ only by actively practic+ physicians 7a7 ,9 g5]al ,a physician-relat$ op9ion may be provid$ only by an actively practic+ physician :o is det]m9$ by ! c\rt to be qualifi$ on ! basis ( tra9+ & exp]i5ce to r5d] t op9ion4 7b7 ,consid]ations requir$ ,9 det]m9+ :e!r an actively practic+ physician is qualifi$ "u subsection 7a71 ! c\rt %all1 except on good cause %[n1 consid] :e!r t physician is bo>d-c]tifi$1 or has o!r sub/antial tra9+1 9 an area ( m$ical practice relevant to ! heal? c>e to :i* ! op9ion relates4 7c7 ,def9itions ,9 ?is section3 7#a7 ,! t]m actively practic+ physician means an individual :o-- 7,a7 is lic5s$ to practice m$ic9e 9 ! ,unit$ ,/ates or1 if ! individual is a def5dant provid+ a physician-relat$ op9ion ) respect to ! heal? c>e provid$ by t def5dant1 is a graduate ( a m$ical s*ool accr$it$ by ! ,liaison ,committee on ,m$ical ,education or ! ,am]ican ,o/eopa?ic ,association2 7,b7 is practic+ m$ic9e :5 ! op9ion is r5d]$1 or 0 practic+ m$ic9e :5 ! heal? c>e 0 provid$2 & 7,c7 has k ( ! accept$ /&>ds ( c>e = ! heal? c>e to :i* ! op9ion relates4 7#b7 ,! t]m physician-relat$ op9ion means an exp]t op9ion z to any "o or m ( ! foll[+3 7,a7 ,! /&>d ( c>e applicable to a physician4 7,b7 ,:e!r a physician fail$ to meet su* a /&>d ( c>e4 7,c7 ,:e!r !re 0 a causal relation%ip betwe5 su* a failure by a physician & ! injury or dea? ( an individual4 7#c7 ,! t]m practic+ m$ic9e includes tra9+ resid5ts or /ud5ts at an accr$it$ s*ool ( m$ic9e or o/eopa?y1 & s]v+ z a consult+ physician to o!r physicians :o provide direct pati5t c>e4 #cji4 ,paym5t ( future damages on p]iodic or accrual basis 7a7 ,9 g5]al ,:5 future damages are aw>d$ aga9/ a heal? c>e practition] to a p]son = ! injury or dea? ( an individual z a result ( heal? c>e1 & ! pres5t value ( ^? future damages is #ajj1jjj or m1 t heal? c>e practition] may move t ! c\rt ord] paym5t on a p]iodic or accrual basis ( ^? damages4 ,on su* a motion1 ! c\rt-- 7#a7 %all ord] t paym5t be made on an accrual basis ( future damages describ$ 9 subsection 7b77#a72 & 7#b7 may ord] t paym5t be made on a p]iodic or accrual basis ( any o!r future damages t ! c\rt consid]s appropriate4 7b7 ,future damages def9$ ,9 ?is section1 ! t]m future damages means-- 7#a7 ! future co/s ( m$ical1 heal? c>e1 or cu/odial s]vices2 7#b7 noneconomic damages1 su* z pa9 & suff]+ or loss ( consortium2 7#c7 loss ( future e>n+s2 & 7#d7 any o!r damages incurr$ aft] ! aw>d is made4 #caj4 ,unanim\s jury requir$ = punitive or exempl>y damages ,:5 an individual is injur$ or dies z ! result ( heal? c>e1 a jury may n aw>d punitive or exempl>y damages aga9/ a heal? c>e practition] or heal? c>e in/itution unless ! jury is unanim\s ) reg>d to bo? ! liability ( t p>ty = su* damages & ! am\nt ( ! aw>d ( su* damages4 #caa4 ,proportionate liability ,:5 an individual is injur$ or dies z ! result ( heal? c>e & a p]son is entitl$ to damages = t injury or dea?1 ea* p]son responsible is liable only = a proportionate %>e ( ! total damages t directly corresponds to t p]son's proportionate %>e ( ! total responsibility4 #cab4 ,def5se-initiat$ settlem5t process 7a7 ,9 g5]al ,9 a civil action1 to ! ext5t ! civil action seeks damages = ! injury or dea? ( an individual z ! result ( heal? c>e1 a heal? c>e practition] or heal? c>e in/itution aga9/ :i* su* damages are s\ght may s]ve "o or m qualifi$ settlem5t (f]s "u ?is section to a p]son seek+ su* damages4 ,if ! p]son seek+ su* damages does n accept su* an (f]1 t p]son may !reaft] s]ve "o or m qualifi$ settlem5t (f]s "u ?is section to ! p>ty ^: (f] 0 n accept$4 7b7 ,qualifi$ settlem5t (f] ,a qualifi$ settlem5t (f] "u ?is section is an (f]1 9 writ+1 to settle ! matt] z betwe5 ! (f]or & ! (f]ee1 :i*-- 7#a7 specifies t x is made "u ?is section2 7#b7 /ates ! t]ms ( settlem5t2 & 7#c7 /ates ! deadl9e )9 :i* ! (f] mu/ be accept$4 7c7 ,effect ( (f] ,if ! (f]ee ( a qualifi$ settlem5t (f] does n accept t (f]1 & !reaft] receives a judgm5t at trial t1 z betwe5 ! (f]or & ! (f]ee1 is significantly less favorable ?an ! t]ms ( settlem5t 9 t (f]1 t (f]ee is responsible = ^? litigation co/s reasonably incurr$1 aft] ! deadl9e /at$ 9 ! (f]1 by ! (f]or to respond to ! claims ( ! (f]ee4 7d7 ,litigation co/s def9$ ,9 ?is section1 ! t]m litigation co/s include c\rt co/s1 fil+ fees1 exp]t witness fees1 attorney fees1 & any o!r co/s directly relat$ to c>ry+ out ! litigation4 7e7 ,significantly less favorable def9$ ,= purposes ( ?is section1 a judgm5t is significantly less favorable ?an ! t]ms ( settlem5t if-- 7#a7 9 ! case ( an (f]ee seek+ damages1 ! (f]ee's aw>d at trial is less ?an #hj p]c5t ( ! value ( ! t]ms ( settlem5t2 & 7#b7 9 ! case ( an (f]ee aga9/ :om damages are s\ght1 ! (f]or's aw>d at trial is m ?an #abj p]c5t ( ! value ( ! t]ms ( settlem5t4 #cac4 ,/atute ( limitations2 /atute ( repose 7a7 ,/atute ( limitations ,:5 an individual is injur$ or dies z ! result ( heal? c>e1 ! /atute ( limitations %all be z foll[s3 7#a7 ,individuals ( age #ab & ov] ,if ! individual has atta9$ ! age ( #ab ye>s1 ! claim mu/ be br\ght ei!r-- 7,a7 )9 #b ye>s aft] ! neglig5ce occurr$2 or 7,b7 )9 #b ye>s aft] ! heal? c>e on :i* ! claim is bas$ is complet$4 7#b7 ,individuals "u age #ab ,if ! individual has n atta9$ ! age ( #ab ye>s1 ! claim mu/ be br\ght be=e ! individual atta9s ! age ( #ad ye>s4 7b7 ,/atute ( repose ,:5 an individual is injur$ or dies z ! result ( heal? c>e1 ! /atute ( repose %all be z foll[s3 ,! claim mu/ be br\ght )9 #aj ye>s aft] ! act or omission on :i* ! claim is bas$ is complet$4 7c7 ,toll+ 7#a7 ,/atute ( limitations ,! /atute ( limitations requir$ by subsection 7a7 may be toll$ if applicable law s provides1 except t x may n be toll$ on ! basis ( m9ority4 7#b7 ,/atute ( repose ,! /atute ( repose requir$ by subsection 7b7 may n be toll$ = any reason4 #cad4 ,limitation on liability = ,good ,sam>itans provid+ em]g5cy heal? c>e 7a7 ,willful or wanton neglig5ce requir$ ,a heal? c>e practition] or heal? c>e in/itution t provides em]g5cy heal? c>e on a ,good ,sam>itan basis is n liable = damages caus$ by t c>e except = willful or wanton neglig5ce or m culpable misconduct4 7b7 ,good ,sam>itan basis ,= purposes ( ?is section1 c>e is provid$ on a ,good ,sam>itan basis if x is n provid$ = or 9 expectation ( remun]ation4 ,be+ entitl$ to remun]ation is relevant to1 b is n det]m9ative (1 :e!r x is provid$ = or 9 expectation ( remun]ation4 #cae4 ,def9itions ,9 ?is division3 7#a7 ,heal? c>e in/itution ,! t]m heal? c>e in/itution includes in/itutions su* z-- 7,a7 an ambulatory surgical c5t]2 7,b7 an assi/$ liv+ facility2 7,c7 an em]g5cy m$ical s]vices provid]2 7,d7 a home heal? ag5cy2 7,e7 a hospice2 7,f7 a hospital2 7,g7 a hospital sy/em2 7,h7 an int]m$iate c>e facility = ! m5tally ret>d$2 7,i7 a nurs+ home2 & 7,j7 an end /age r5al disease facility4 7#b7 ,heal? c>e practition] ,! t]m heal? c>e practition] includes a physician & a physician entity4 7#c7 ,physician entity ,! t]m physician entity includes-- 7,a7 a p>tn]%ip or limit$ liability p>tn]%ip creat$ by a gr\p ( physicians2 7,b7 a company creat$ by physicians2 & 7,c7 a nonpr(it heal? corporation ^: bo>d is compos$ ( physicians4 ,d ,protect+ ! ,doctor-,pati5t ,relation%ip #dja4 ,rule ( con/ruction ,no?+ 9 ?is ,act %all be con/ru$ to int]f]e ) ! doctor-pati5t relation%ip or ! practice ( m$ic9e4 #djb4 ,repeal ( ,f$]al ,coord9at+ ,c\ncil = ,comp>ative ,effectiv5ess ,rese>* ,effective on ! date ( ! enactm5t ( ?is ,act1 section #hjd ( ! ,am]ican ,recov]y & ,re9ve/m5t ,act ( #bjji is repeal$4 ,e ,inc5tiviz+ ,wellness & ,quality ,improvem5ts #eja4 ,inc5tives = prev5tion & wellness programs 7a7 ,employee ,retirem5t ,income ,security ,act ( #aigd limitation on exception = wellness programs "u ,,hipaa discrim9ation rules 7#a7 ,9 g5]al ,section #gjb7;b77#b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahb7;b77#b771 z re/or$ by section #b1 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 9 a /&>ds-bas$ wellness program4 4 7#b7 ,effective date ,! am5dm5t made by p>agraph 7#a7 %all apply to plan ye>s beg9n+ m ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act4 7b7 ,con=m+ am5dm5ts to ,,phsa 7#a7 ,gr\p m>ket rules 7,a7 ,9 g5]al ,section #bgjb7;b77#b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#a7;b77#b771 z re/or$ by section #b1 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 9 a /&>ds-bas$ wellness program4 4 7,b7 ,effective date ,! am5dm5t made by subp>agraph 7,a7 %all apply to plan ye>s beg9n+ m ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act4 7#b7 ,individual m>ket rules relat+ to gu>ante$ availability 7,a7 ,9 g5]al ,section #bgda7;f7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#a7;b77#b771 z re/or$ by section #b1 is am5d$ by add+ aft] & bel[ p>agraph 7#a7 ! foll[+3 ,9 apply+ p>agraph 7#b71 a heal? insurance issu] may v>y premiums & co/-%>+ "u heal? insurance cov]age by up to #ej p]c5t ( ! value ( ! b5efits "u ! cov]age bas$ on p>ticipation 9 a /&>ds-bas$ wellness program4 4 7,b7 ,effective date ,! am5dm5t made by p>agraph 7#a7 %all apply to heal? insurance cov]age (f]$ or r5ew$ on & aft] ! date t is #a ye> aft] ! date ( ! enactm5t ( ?is ,act4 7c7 ,con=m+ am5dm5ts to ,,irc 7#a7 ,9 g5]al ,section #ihjb7;b77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf1;z re/or$ by section #b1 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 9 a /&>ds-bas$ wellness program4 4 7#b7 ,effective date ,! am5dm5t made by p>agraph 7#a7 %all apply to plan ye>s beg9n+ m ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act4 ,f ,protect+ ,taxpay]s #fja4 ,p]man5tly prohibit+ taxpay] fund$ abortions & ensur+ consci5ce protections ,title #a ( ! ,unit$ ,/ates ,code is am5d$ by add+ at ! end ! foll[+ new *apt]3 #d ,p]man5tly prohibit+ taxpay] fund$ abortions & ensur+ consci5ce protections #cja4 ,prohibition on fund+ = abortions ,no funds au?oriz$ or appropriat$ by ,f$]al law1 & none ( ! funds 9 any tru/ fund to :i* funds are au?oriz$ or appropriat$ by ,f$]al law1 %all be exp5d$ = any abortion4 #cjb4 ,prohibition on fund+ = heal? b5efits plans t cov] abortion ,none ( ! funds au?oriz$ or appropriat$ by f$]al law1 & none ( ! funds 9 any tru/ fund to :i* funds are au?oriz$ or appropriat$ by f$]al law1 %all be exp5d$ = a heal? b5efits plan t includes cov]age ( abortion4 #cjc4 ,treatm5t ( abortions relat$ to rape1 ince/1 or pres]v+ ! life ( ! "m ,! limitations e/abli%$ 9 sections #cja & #cjb %all n apply to an abortion-- 7#a7 if ! pregnancy is ! result ( an act ( rape or ince/2 or 7#b7 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 itself4 #cjd4 ,con/ruction relat+ to supplem5tal cov]age ,no?+ 9 ?is *apt] %all be con/ru$ z prohibit+ any individual1 entity1 or ,/ate or locality f pur*as+ sep>ate supplem5tal abortion plan or cov]age t includes abortion s long z su* plan or cov]age is paid = entirely us+ only funds n au?oriz$ or appropriat$ by f$]al law & su* plan or cov]age %all n be pur*as$ us+ mat*+ funds requir$ = a f$]ally subsidiz$ program1 includ+ a ,/ate's or locality's contribution ( ,m$icaid mat*+ funds4 #cje4 ,con/ruction relat+ to ! use ( non-,f$]al funds = heal? cov]age ,no?+ 9 ?is *apt] %all be con/ru$ z re/rict+ ! ability ( any manag$ c>e provid] or o!r organization f (f]+ abortion cov]age or ! ability ( a ,/ate to contract sep>ately ) su* a provid] or organization = su* cov]age ) funds n au?oriz$ or appropriat$ by f$]al law & su* plan or cov]age %all n be pur*as$ us+ mat*+ funds requir$ = a f$]ally subsidiz$ program1 includ+ a ,/ate's or locality's contribution ( ,m$icaid mat*+ funds4 #cjf4 ,no gov]nm5t discrim9ation aga9/ c]ta9 heal? c>e entities 7a7 ,9 g5]al ,no funds au?oriz$ or appropriat$ by f$]al law may be made available to a ,f$]al ag5cy or program1 or to a ,/ate or local gov]nm5t1 if su* ag5cy1 program1 or gov]nm5t subjects any in/itutional or individual 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 4 #fjb4 ,improv$ en=cem5t ( ! ,m$ic>e & ,m$icaid second>y pay] provisions 7a7 ,m$ic>e 7#a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices1 9 coord9ation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 %all provide ?r\gh ! ,coord9ation ( ,b5efits ,contractor = ! id5tification ( in/ances :]e ! ,m$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 7#b7 ,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 7#c7 ,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$ic>e second>y pay] provisions1 includ+ rec\pm5t ( cr$it balances4 7b7 ,m$icaid ,section #aijc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7aa7 ,en=cem5t ( pay] ( la/ resort provisions 7#a7 ,submission ( /ate plan am5dm5t ,ea* ,/ate %all submit1 n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is subsection1 a ,/ate plan am5dm5t t details h[ ! ,/ate w become fully compliant ) ! requirem5ts ( section #aijb7;a77#be74 7#b7 ,bonus = compliance ,if a ,/ate submits a timely ,/ate plan am5dm5t "u p>agraph 7#a7 t ! ,secret>y det]m9es provides = full compliance ( ! ,/ate ) ! requirem5ts ( section #aijb7;a77#be71 ! ,secret>y %all provide = an additional paym5t to ! ,/ate ( #a1jjj1jjj4 ,if a ,/ate c]tifies1 to ! ,secret>y's satisfaction1 t x is already fully compliant ) su* requirem5ts1 su* am\nt %all be increas$ to #b1jjj1jjj4 7#c7 ,r$uction = noncompliance ,if a ,/ate does n submit su* an am5dm5t1 ! ,secret>y %all r$uce ! ,f$]al m$ical assi/ance p]c5tage o!rwise applicable "u ?is title by #a p]c5tage po9t until ! ,/ate submits su* an am5dm5t4 7#d7 ,ongo+ r$uction ,if at any "t ! ,secret>y det]m9es t a ,/ate is n 9 compliance ) section #aijb7;a77#be71 reg>dless ( ! /atus ( ! ,/ate's submission ( a ,/ate plan am5dm5t "u ?is subsection or previ\s det]m9ations ( compliance su* requirem5ts1 ! ,secret>y %all r$uce ! ,f$]al m$ical assi/ance p]c5tage o!rwise applicable "u ?is title = ! ,/ate by #a p]c5tage po9t dur+ ! p]iod ( non-compliance z det]m9$ by ! ,secret>y4 4 #fjc4 ,/r5g!n ,m$ic>e provid] enrollm5t /&>ds & safegu>ds 7a7 ,protect+ aga9/ ! fraudul5t use ( ,m$ic>e provid] numb]s ,subject to subsection 7c77#b7-- 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 %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#a7 & t is rev5ue neutral to ! ,f$]al gov]nm5t4 7#c7 ,provisional approval ,dur+ an initial1 provisional p]iod 7specifi$ 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$ic>e program1 su* z ?r\gh prepaym5t review & paym5t limitations4 7#d7 ,p5alties = false /atem5ts ,9 ! case ( a provid] or suppli] t makes a false /atem5t 9 an application = su* a numb]1 ! ,secret>y may exclude ! provid] or suppli] f p>ticipation "u ! ,m$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 ( ,heal? & ,human ,s]vices 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+ 7#a7 ,9 g5]al ,!re are au?oriz$ to be appropriat$ to c>ry out ?is section su* sums z may be necess>y4 7#b7 ,condition ,! provisions ( p>agraphs 7#a7 & 7#b7 ( subsection 7a7 %all n apply unless & until funds are appropriat$ to c>ry out su* provisions4 #fjd4 ,track+ bann$ provid]s across ,/ate l9es 7a7 ,great] coord9ation ,! ,secret>y ( ,heal? & ,human ,s]vices %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 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