,i #aac? ,,congress #a/ ,session ,h4 ,r4 #cfbb ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,novemb] #bb1 #bjac,mr4 ,duffy introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,ways & ,means1 ,education & ! ,work=ce1 ! ,judici>y1 ,natural ,res\rces1 ,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 & provide = compreh5sive heal? re=m1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,pati5t ,c5t]$ ,heal?c>e ,sav+s ,act ( #bjac4 7b7 ,table ( cont5ts ,! table ( cont5ts ( ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4,title ,i--,repeal+ ( ,p,p,a,c,a,sec4 #aja4 ,repeal ( ! heal? c>e re=m package4,title ,,ii--,m$ical ,liability ,reform,sec4 #bja4 ,f9d+s & purpose4,sec4 #bjb4 ,enc\rag+ spe$y resolution ( claims4,sec4 #bjc4 ,comp5sat+ pati5t injury4,sec4 #bjd4 ,maximiz+ pati5t recov]y4,sec4 #bje4 ,punitive damages4,sec4 #bjf4 ,au?orization ( paym5t ( future damages to claimants 9 ,,heal? c>e lawsuits4,sec4 #bjg4 ,def9itions4,sec4 #bjh4 ,effect on o!r laws4,sec4 #bji4 ,/ate flexibility & protection ( ,/ates' rights4,sec4 #baj4 ,applicability2 effective date4,title ,,iii--,all[+ ,p ,to ,pur*ase ,heal? ,insurance ,across ,/ate ,lines,sec4 #cja4 ,specification ( con/itutional au?ority = enactm5t ( law4,sec4 #cjb4 ,f9d+s4,sec4 #cjc4 ,coop]ative gov]n+ ( individual heal? insurance cov]age4,sec4 #cjd4 ,sev]ability4,title ,,iv--,increas+ ,transp>5cy & ,competition 9 ,healthcare,sec4 #dja4 ,exp&+ availability ( ,m$ic>e data4,title ,v--,exp&+ ! ,effectiv5ess ( ,heal? ,sav+s ,accounts,sec4 #eja4 ,am5dm5t ( #aihf ,code4,subtitle ,a--,provisions relat+ to tax-,pref]r$ heal? accounts,sec4 #eaa4 ,all[ bo? sp\ses to make cat*-up contributions to ! same ,,hsa acc\nt4,sec4 #eab4 ,provisions relat+ to ,m$ic>e4,sec4 #eac4 ,individuals eligible = vet]ans b5efits = a s]vice-connect$ disability4,sec4 #ead4 ,individuals eligible = ,indian ,heal? ,s]vice assi/ance4,sec4 #eae4 ,individuals eligible = ,,tric>e cov]age4,sec4 #eaf4 ,heal? ,,fsa c>ry=w>ds4,sec4 #eag4 ,,fsa & ,,hra int]action ) ,h,s,as4,sec4 #eah4 ,all[ance ( di/ributions = prescription & ov]-!-c\nt] m$ic9es & drugs4,sec4 #eai4 ,pur*ase ( heal? insurance f ,,hsa acc\nt4,sec4 #ebj4 ,special rule = c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt4,sec4 #eba4 ,prev5tive c>e prescription drug cl>ification4,sec4 #ebb4 ,equival5t bankruptcy protections = heal? sav+s acc\nts z retirem5t funds4,sec4 #ebc4 ,adm9i/rative error correction be=e due date ( return4,sec4 #ebd4 ,reau?orization ( m$icaid heal? opportunity acc\nts4,subtitle ,b--,o!r provisions,sec4 #eca4 ,c]ta9 ex]cise equipm5t & physical fitness programs treat$ z m$ical c>e4,sec4 #ecb4 ,c]ta9 nutritional & diet>y supplem5ts to be treat$ z m$ical c>e4,sec4 #ecc4 ,c]ta9 provid] fees to be treat$ z m$ical c>e4,title ,,vi--,cov]+ ,p ) ,pre-,exi/+ ,conditions1 ,remov+ ,annual & ,lifetime ,cov]age ,caps1 & ,exp&+ ,access to ,care,subtitle ,a--,mak+ ,heal? ,c>e ,cov]age ,af=dable = ,e ,am]ican ,*apt] #a--;,ensur+ cov]age = individuals ) preexi/+ conditions & multiple heal? c>e needs,sec4 #fja4 ,e/abli% univ]sal access programs to improve high risk pools & re9surance m>kets4,sec4 #fjb4 ,elim9ation ( c]ta9 requirem5ts = gu>ante$ availability 9 individual m>ket4,sec4 #fjc4 ,no annual or lifetime sp5d+ caps4,sec4 #fjd4 ,prev5t+ unju/ cancellation ( insurance cov]age4,*apt] #b--,r$uc+ heal? c>e premiums & ! numb] ( un9sur$ ,americans,sec4 #faa4 ,/ate innovation programs4,sec4 #fab4 ,heal? plan f9d]s4,sec4 #fac4 ,adm9i/rative simplification4,subtitle ,b--,improv+ ,access to ,heal? ,c>e ,*apt] #a--;,exp&+ ,access & ,l[]+ ,co/s = ,small ,businesses,sec4 #fbj4 ,%ort title4,sec4 #fba4 ,rules gov]n+ association heal? plans4,sec4 #fbb4 ,cl>ification ( treatm5t ( s+le employ] arrangem5ts4,sec4 #fbc4 ,en=cem5t provisions relat+ to association heal? plans4,sec4 #fbd4 ,coop]ation betwe5 ,f$]al & ,/ate au?orities4,sec4 #fbe4 ,effective date & transitional & o!r rules4,*apt] #b--,t>get$ ,ef=ts ,to ,exp& ,access,sec4 #fca4 ,ext5d+ cov]age ( dep5d5ts4,sec4 #fcb4 ,all[+ auto-enrollm5t = employ] sponsor$ cov]age4,title ,,vii--,/opp+ ,m$ic>e1 ,wa/e1 ,fraud1 & ,abuse & ,increas+ ,p5alties = ,abusers,sec4 #gja4 ,increas$ civil money p5alties & crim9al f9es = ,m$ic>e fraud & abuse4,sec4 #gjb4 ,increas$ s5t5ces = felonies involv+ ,m$ic>e fraud & abuse4,sec4 #gjc4 ,o!r ,,dme suppli] anti-fraud & abuse provisions4,sec4 #gjd4 ,ret5tion ( c]ta9 fraud & abuse provisions4,sec4 #gje4 ,ensur+ timely en=cem5t ( ,m$ic>e second>y pay] requirem5ts 9 liability cases4 ,i ,repeal+ ( ,,ppaca #aja4 ,repeal ( ! heal? c>e re=m package 7a7 ,,ppaca ,! ,pati5t ,protection & ,af=dable ,c>e ,act is repeal$1 & ! provisions ( law am5d$ or repeal$ by su* ,act are re/or$ or reviv$ z if su* ,act _h n be5 enact$4 7b7 ,,hc]a ,title ,i & subtitle ,b ( title ,,ii ( ! ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj are repeal$1 & ! provisions ( law am5d$ or repeal$ by su* title or subtitle are re/or$ or reviv$ z if su* title or subtitle _h n be5 enact$4 ,,ii ,m$ical ,liability ,re=m #bja4 ,f9d+s & purpose 7a7 ,f9d+s 7#a7 ,effect on heal? c>e access & co/s ,congress f9ds t our curr5t civil ju/ice sy/em is adv]sely affect+ pati5t access to heal? c>e s]vices1 bett] pati5t c>e1 & co/-effici5t heal? c>e1 9 t ! heal? c>e liability sy/em is a co/ly & ineffective me*anism = resolv+ claims ( heal? c>e liability & comp5sat+ injur$ pati5ts1 & is a det]r5t to ! %>+ ( in=mation among heal? c>e pr(essionals :i* imp$es ef=ts to improve pati5t safety & quality ( c>e4 7#b7 ,effect on f$]al sp5d+ ,congress f9ds t ! heal? c>e liability litigation sy/ems exi/+ ?r\gh\t ! ,unit$ ,/ates h a significant effect on ! am\nt1 di/ribution1 & use ( ,f$]al funds because (-- 7,a7 ! l>ge numb] ( individuals :o receive heal? c>e b5efits "u programs op]at$ or f9anc$ by ! ,f$]al ,gov]nm5t2 7,b7 ! l>ge numb] ( individuals :o b5efit because ( ! exclusion f ,f$]al taxes ( ! am\nts sp5t to provide !m ) heal? insurance b5efits2 & 7,c7 ! l>ge numb] ( heal? c>e provid]s :o provide items or s]vices = :i* ! ,f$]al ,gov]nm5t makes paym5ts4 7b7 ,purpose ,x is ! purpose ( ?is title to implem5t reasonable1 compreh5sive1 & effective heal? c>e liability re=ms design$ to-- 7#a7 improve ! availability ( heal? c>e s]vices 9 cases 9 :i* heal? c>e liability actions h be5 %[n to be a factor 9 ! decreas$ availability ( s]vices2 7#b7 r$uce ! incid5ce ( def5sive m$ic9e & l[] ! co/ ( heal? c>e liability insurance1 all ( :i* contribute to ! escalation ( heal? c>e co/s2 7#c7 ensure t p]sons ) m]itori\s heal? c>e injury claims receive fair & adequate comp5sation1 includ+ reasonable noneconomic damages2 7#d7 improve ! fairness & co/-effectiv5ess ( our curr5t heal? c>e liability sy/em to resolve disputes ov]1 & provide comp5sation =1 heal? c>e liability by r$uc+ unc]ta9ty 9 ! am\nt ( comp5sation provid$ to injur$ individuals2 & 7#e7 provide an increas$ %>+ ( in=mation 9 ! heal? c>e sy/em :i* w r$uce un9t5d$ injury & improve pati5t c>e4 #bjb4 ,enc\rag+ spe$y resolution ( claims ,! "t = ! comm5cem5t ( a heal? c>e lawsuit %all be #c ye>s aft] ! date ( manife/ation ( injury or #a ye> aft] ! claimant discov]s1 or ?r\gh ! use ( reasonable dilig5ce %\ld h discov]$1 ! injury1 :i*ev] occurs fir/4 ,9 no ev5t %all ! "t = comm5cem5t ( a heal? c>e lawsuit exce$ #c ye>s aft] ! date ( manife/ation ( injury unless toll$ = any ( ! foll[+-- 7#a7 ^u pro( ( fraud2 7#b7 int5tional concealm5t2 or 7#c7 ! pres5ce ( a =eign body1 :i* has no !rapeutic or diagno/ic purpose or effect1 9 ! p]son ( ! injur$ p]son4 ,actions by a m9or %all be comm5c$ )9 #c ye>s f ! date ( ! alleg$ manife/ation ( injury except t actions by a m9or "u ! full age ( #f ye>s %all be comm5c$ )9 #c ye>s ( manife/ation ( injury or prior to ! m9or's #h? bir?day1 :i*ev] provides a long] p]iod4 ,su* "t limitation %all be toll$ = m9ors = any p]iod dur+ :i* a p>5t or gu>dian & a heal? c>e provid] or heal? c>e organization h committ$ fraud or collusion 9 ! failure to br+ an action on behalf ( ! injur$ m9or4 #bjc4 ,comp5sat+ pati5t injury 7a7 ,unlimit$ ,am\nt ( ,damages = ,actual ,economic ,losses 9 ,heal? ,c>e ,lawsuits ,9 any heal? c>e lawsuit1 no?+ 9 ?is title %all limit a claimant's recov]y ( ! full am\nt ( ! available economic damages1 not)/&+ ! limitation 9 subsection 7b74 7b7 ,additional ,noneconomic ,damages ,9 any heal? c>e lawsuit1 ! am\nt ( noneconomic damages1 if available1 may be z mu* z #bej1jjj1 reg>dless ( ! numb] ( p>ties aga9/ :om ! action is br\ght or ! numb] ( sep>ate claims or actions br\ght ) respect to ! same injury4 7c7 ,no ,disc\nt ( ,aw>d = ,noneconomic ,damages ,= purposes ( apply+ ! limitation 9 subsection 7b71 future noneconomic damages %all n be disc\nt$ to pres5t value4 ,! jury %all n be in=m$ ab\t ! maximum aw>d = noneconomic damages4 ,an aw>d = noneconomic damages 9 excess ( #bej1jjj %all be r$uc$ ei!r be=e ! entry ( judgm5t1 or by am5dm5t ( ! judgm5t aft] entry ( judgm5t1 & su* r$uction %all be made be=e acc\nt+ = any o!r r$uction 9 damages requir$ by law4 ,if sep>ate aw>ds are r5d]$ = pa/ & future noneconomic damages & ! comb9$ aw>ds exce$ #bej1jjj1 ! future noneconomic damages %all be r$uc$ fir/4 7d7 ,fair ,%>e ,rule ,9 any heal? c>e lawsuit1 ea* p>ty %all be liable = t p>ty's sev]al %>e ( any damages only & n = ! %>e ( any o!r p]son4 ,ea* p>ty %all be liable only = ! am\nt ( damages allocat$ to su* p>ty 9 direct proportion to su* p>ty's p]c5tage ( responsibility4 ,:5ev] a judgm5t ( liability is r5d]$ z to any p>ty1 a sep>ate judgm5t %all be r5d]$ aga9/ ea* su* p>ty = ! am\nt allocat$ to su* p>ty4 ,= purposes ( ?is section1 ! tri] ( fact %all det]m9e ! proportion ( responsibility ( ea* p>ty = ! claimant's h>m4 #bjd4 ,maximiz+ pati5t recov]y 7a7 ,c\rt ,sup]vision ( ,%>e ( ,damages ,actually ,paid to ,claimants ,9 any heal? c>e lawsuit1 ! c\rt %all sup]vise ! arrangem5ts = paym5t ( damages to protect aga9/ conflicts ( int]e/ t may h ! effect ( r$uc+ ! am\nt ( damages aw>d$ t are actually paid to claimants4 ,9 p>ticul>1 9 any heal? c>e lawsuit 9 :i* ! attorney = a p>ty claims a f9ancial /ake 9 ! outcome by virtue ( a cont+5t fee1 ! c\rt %all h ! p[] to re/rict ! paym5t ( a claimant's damage recov]y to su* attorney1 & to r$irect su* damages to ! claimant bas$ ^u ! int]e/s ( ju/ice & pr9ciples ( equity4 ,9 no ev5t %all ! total ( all cont+5t fees = repres5t+ all claimants 9 a heal? c>e lawsuit exce$ ! foll[+ limits3 7#a7 ,=ty p]c5t ( ! fir/ #ej1jjj recov]$ by ! claimant7s74 7#b7 ,?irty-?ree & "o-?ird p]c5t ( ! next #ej1jjj recov]$ by ! claimant7s74 7#c7 ,tw5ty-five p]c5t ( ! next #ejj1jjj recov]$ by ! claimant7s74 7#d7 ,fifte5 p]c5t ( any am\nt by :i* ! recov]y by ! claimant7s7 is 9 excess ( #fjj1jjj4 7b7 ,applicability ,! limitations 9 ?is section %all apply :e!r ! recov]y is by judgm5t1 settlem5t1 m$iation1 arbitration1 or any o!r =m ( alt]native dispute resolution4 ,9 a heal? c>e lawsuit involv+ a m9or or incompet5t p]son1 a c\rt reta9s ! au?ority to au?orize or approve a fee t is less ?an ! maximum p]mitt$ "u ?is section4 ,! requirem5t = c\rt sup]vision 9 ! fir/ two s5t5ces ( subsection 7a7 applies only 9 civil actions4 #bje4 ,punitive damages 7a7 ,9 ,g5]al ,punitive damages may1 if o!rwise p]mitt$ by applicable ,/ate or ,f$]al law1 be aw>d$ aga9/ any p]son 9 a heal? c>e lawsuit only if x is prov5 by cle> & conv9c+ evid5ce t su* p]son act$ ) malici\s int5t to injure ! claimant1 or t su* p]son delib]ately fail$ to avoid unnecess>y injury t su* p]son knew ! claimant 0 sub/antially c]ta9 to suff]4 ,9 any heal? c>e lawsuit :]e no judgm5t = comp5satory damages is r5d]$ aga9/ su* p]son1 no punitive damages may be aw>d$ ) respect to ! claim 9 su* lawsuit4 ,no dem& = punitive damages %all be includ$ 9 a heal? c>e lawsuit z initially fil$4 ,a c\rt may all[ a claimant to file an am5d$ plead+ = punitive damages only ^u a motion by ! claimant & aft] a f9d+ by ! c\rt1 ^u review ( support+ & oppos+ affidavits or aft] a he>+1 aft] weigh+ ! evid5ce1 t ! claimant has e/abli%$ by a sub/antial probability t ! claimant w prevail on ! claim = punitive damages4 ,at ! reque/ ( any p>ty 9 a heal? c>e lawsuit1 ! tri] ( fact %all consid] 9 a sep>ate proce$+-- 7#a7 :e!r punitive damages are to be aw>d$ & ! am\nt ( su* aw>d2 & 7#b7 ! am\nt ( punitive damages foll[+ a det]m9ation ( punitive liability4 ,if a sep>ate proce$+ is reque/$1 evid5ce relevant only to ! claim = punitive damages1 z det]m9$ by applicable ,/ate law1 %all be inadmissible 9 any proce$+ to det]m9e :e!r comp5satory damages are to be aw>d$4 7b7 ,det]m9+ ,am\nt ( ,punitive ,damages 7#a7 ,factors consid]$ ,9 det]m9+ ! am\nt ( punitive damages1 if aw>d$1 9 a heal? c>e lawsuit1 ! tri] ( fact %all consid] only ! foll[+-- 7,a7 ! sev]ity ( ! h>m caus$ by ! conduct ( su* p>ty2 7,b7 ! duration ( ! conduct or any concealm5t ( x by su* p>ty2 7,c7 ! pr(itability ( ! conduct to su* p>ty2 7,d7 ! numb] ( products sold or m$ical proc$ures r5d]$ = comp5sation1 z ! case may be1 by su* p>ty1 ( ! k9d caus+ ! h>m compla9$ ( by ! claimant2 7,e7 any crim9al p5alties impos$ on su* p>ty1 z a result ( ! conduct compla9$ ( by ! claimant2 & 7,f7 ! am\nt ( any civil f9es assess$ aga9/ su* p>ty z a result ( ! conduct compla9$ ( by ! claimant4 7#b7 ,maximum aw>d ,! am\nt ( punitive damages1 if aw>d$1 9 a heal? c>e lawsuit may be z mu* z #bej1jjj or z mu* z two times ! am\nt ( economic damages aw>d$1 :i*ev] is great]4 ,! jury %all n be in=m$ ( ?is limitation4 7c7 ,no ,punitive ,damages = ,products ,t ,comply ,) ,,fda ,/&>ds 7#a7 ,9 g5]al 7,a7 ,no punitive damages may be aw>d$ aga9/ ! manufactur] or di/ributor ( a m$ical product1 or a suppli] ( any compon5t or raw mat]ial ( su* m$ical product1 bas$ on a claim t su* product caus$ ! claimant's h>m :]e-- 7i7 7,i7 su* m$ical product 0 subject to prem>ket approval1 cle>ance1 or lic5sure by ! ,food & ,drug ,adm9i/ration ) respect to ! safety ( ! =mulation or p]=mance ( ! aspect ( su* m$ical product :i* caus$ ! claimant's h>m or ! adequacy ( ! packag+ or label+ ( su* m$ical product2 & 7,,ii7 su* m$ical product 0 s approv$1 cle>$1 or lic5s$2 or 7ii7 su* m$ical product is g5]ally recogniz$ among qualifi$ exp]ts z safe & effective pursuant to conditions e/abli%$ by ! ,food & ,drug ,adm9i/ration & applicable ,food & ,drug ,adm9i/ration regulations1 includ+ )\t limitation ^? relat$ to packag+ & label+1 unless ! ,food & ,drug ,adm9i/ration has det]m9$ t su* m$ical product 0 n manufactur$ or di/ribut$ 9 sub/antial compliance ) applicable ,food & ,drug ,adm9i/ration /atutes & regulations4 7,b7 ,rule ( con/ruction ,subp>agraph 7,a7 may n be con/ru$ z e/abli%+ ! obligation ( ! ,food & ,drug ,adm9i/ration to demon/rate affirmatively t a manufactur]1 di/ributor1 or suppli] ref]r$ to 9 su* subp>agraph meets any ( ! conditions describ$ 9 su* subp>agraph4 7#b7 ,liability ( heal? c>e provid]s ,a heal? c>e provid] :o prescribes1 or :o disp5ses pursuant to a prescription1 a m$ical product approv$1 lic5s$1 or cle>$ by ! ,food & ,drug ,adm9i/ration %all n be nam$ z a p>ty to a product liability lawsuit involv+ su* product & %all n be liable to a claimant 9 a class action lawsuit aga9/ ! manufactur]1 di/ributor1 or sell] ( su* product4 ,no?+ 9 ?is p>agraph prev5ts a c\rt f consolidat+ cases involv+ heal? c>e provid]s & cases involv+ products liability claims aga9/ ! manufactur]1 di/ributor1 or product sell] ( su* m$ical product4 7#c7 ,packag+ ,9 a heal? c>e lawsuit = h>m :i* is alleg$ to relate to ! adequacy ( ! packag+ or label+ ( a drug :i* is requir$ to h tamp]-resi/ant packag+ "u regulations ( ! ,secret>y ( ,heal? & ,human ,s]vices 7includ+ label+ regulations relat$ to su* packag+71 ! manufactur] or product sell] ( ! drug %all n be held liable = punitive damages unless su* packag+ or label+ is f\nd by ! tri] ( fact by cle> & conv9c+ evid5ce to be sub/antially out ( compliance ) su* regulations4 7#d7 ,exception ,p>agraph 7#a7 %all n apply 9 any heal? c>e lawsuit 9 :i*-- 7,a7 a p]son1 be=e or aft] prem>ket approval1 cle>ance1 or lic5sure ( su* m$ical product1 kn[+ly misrepres5t$ to or )held f ! ,food & ,drug ,adm9i/ration in=mation t is requir$ to be submitt$ "u ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cja et seq47 or section #cea ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bfb7 t is mat]ial & is causally relat$ to ! h>m :i* ! claimant alleg$ly suff]$2 or 7,b7 a p]son made an illegal paym5t to an (ficial ( ! ,food & ,drug ,adm9i/ration = ! purpose ( ei!r secur+ or ma9ta9+ approval1 cle>ance1 or lic5sure ( su* m$ical product4 #bjf4 ,au?orization ( paym5t ( future damages to claimants 9 ,,heal? c>e lawsuits 7a7 ,9 ,g5]al ,9 any heal? c>e lawsuit1 if an aw>d ( future damages1 )\t r$uction to pres5t value1 equal+ or exce$+ #ej1jjj is made aga9/ a p>ty ) suffici5t insurance or o!r assets to fund a p]iodic paym5t ( su* a judgm5t1 ! c\rt %all1 at ! reque/ ( any p>ty1 ent] a judgm5t ord]+ t ! future damages be paid by p]iodic paym5ts1 9 accordance ) ! ,uni=m ,p]iodic ,paym5t ( ,judgm5ts ,act promulgat$ by ! ,national ,conf]5ce ( ,commission]s on ,uni=m ,/ate ,laws4 7b7 ,applicability ,?is section applies to all actions :i* h n be5 fir/ set = trial or retrial be=e ! effective date ( ?is ,act4 #bjg4 ,def9itions ,9 ?is title3 7#a7 ,alt]native dispute resolution sy/em2 ,,adr ,! t]m alt]native dispute resolution sy/em or ,,adr means a sy/em t provides = ! resolution ( heal? c>e lawsuits 9 a mann] o!r ?an ?r\gh a civil action br\ght 9 a ,/ate or ,f$]al c\rt4 7#b7 ,claimant ,! t]m claimant means any p]son :o br+s a heal? c>e lawsuit1 includ+ a p]son :o ass]ts or claims a "r to legal or equitable contribution1 indemnity1 or subrogation1 aris+ out ( a heal? c>e liability claim or action1 & any p]son on ^: behalf su* a claim is ass]t$ or su* an action is br\ght1 :e!r deceas$1 incompet5t1 or a m9or4 7#c7 ,comp5satory damages ,! t]m comp5satory damages means objectively v]ifiable monet>y losses incurr$ z a result ( ! provision (1 use (1 or paym5t = 7or failure to provide1 use1 or pay =7 heal? c>e s]vices or m$ical products1 su* z pa/ & future m$ical exp5ses1 loss ( pa/ & future e>n+s1 co/ ( obta9+ dome/ic s]vices1 loss ( employm5t1 & loss ( bus9ess or employm5t opportunities1 damages = physical & emotional pa91 suff]+1 inconv5i5ce1 physical impairm5t1 m5tal angui%1 disfigurem5t1 loss ( enjoym5t ( life1 loss ( society & companion%ip1 loss ( consortium 7o!r ?an loss ( dome/ic s]vice71 h$onic damages1 injury to reputation1 & all o!r nonpecuni>y losses ( any k9d or nature4 ,! t]m comp5satory damages includes economic damages & noneconomic damages1 z su* t]ms are def9$ 9 ?is section4 7#d7 ,cont+5t fee ,! t]m cont+5t fee includes all comp5sation to any p]son or p]sons :i* is payable only if a recov]y is effect$ on behalf ( "o or m claimants4 7#e7 ,economic damages ,! t]m economic damages means objectively v]ifiable monet>y losses incurr$ z a result ( ! provision (1 use (1 or paym5t = 7or failure to provide1 use1 or pay =7 heal? c>e s]vices or m$ical products1 su* z pa/ & future m$ical exp5ses1 loss ( pa/ & future e>n+s1 co/ ( obta9+ dome/ic s]vices1 loss ( employm5t1 & loss ( bus9ess or employm5t opportunities4 7#f7 ,heal? c>e lawsuit ,! t]m heal? c>e lawsuit means any heal? c>e liability claim conc]n+ ! provision ( heal? c>e goods or s]vices or any m$ical product affect+ int]/ate comm]ce1 or any heal? c>e liability action conc]n+ ! provision ( heal? c>e goods or s]vices or any m$ical product affect+ int]/ate comm]ce1 br\ght 9 a ,/ate or ,f$]al c\rt or pursuant to an alt]native dispute resolution sy/em1 aga9/ a heal? c>e provid]1 a heal? c>e organization1 or ! manufactur]1 di/ributor1 suppli]1 m>ket]1 promot]1 or sell] ( a m$ical product1 reg>dless ( ! !ory ( liability on :i* ! claim is bas$1 or ! numb] ( claimants1 pla9tiffs1 def5dants1 or o!r p>ties1 or ! numb] ( claims or causes ( action1 9 :i* ! claimant alleges a heal? c>e liability claim4 ,su* t]m does n include a claim or action :i* is bas$ on crim9al liability2 :i* seeks civil f9es or p5alties paid to ,f$]al1 ,/ate1 or local gov]nm5t2 or :i* is gr\nd$ 9 antitru/4 7#g7 ,heal? c>e liability action ,! t]m heal? c>e liability action means a civil action br\ght 9 a ,/ate or ,f$]al c\rt or pursuant to an alt]native dispute resolution sy/em1 aga9/ a heal? c>e provid]1 a heal? c>e organization1 or ! manufactur]1 di/ributor1 suppli]1 m>ket]1 promot]1 or sell] ( a m$ical product1 reg>dless ( ! !ory ( liability on :i* ! claim is bas$1 or ! numb] ( pla9tiffs1 def5dants1 or o!r p>ties1 or ! numb] ( causes ( action1 9 :i* ! claimant alleges a heal? c>e liability claim4 7#h7 ,heal? c>e liability claim ,! t]m heal? c>e liability claim means a dem& by any p]son1 :e!r or n pursuant to ,,adr1 aga9/ a heal? c>e provid]1 heal? c>e organization1 or ! manufactur]1 di/ributor1 suppli]1 m>ket]1 promot]1 or sell] ( a m$ical product1 includ+1 b n limit$ to1 ?ird-p>ty claims1 cross-claims1 c\nt]-claims1 or contribution claims1 :i* are bas$ ^u ! provision (1 use (1 or paym5t = 7or ! failure to provide1 use1 or pay =7 heal? c>e s]vices or m$ical products1 reg>dless ( ! !ory ( liability on :i* ! claim is bas$1 or ! numb] ( pla9tiffs1 def5dants1 or o!r p>ties1 or ! numb] ( causes ( action4 7#i7 ,heal? c>e organization ,! t]m heal? c>e organization means any p]son or entity :i* is obligat$ to provide or pay = heal? b5efits "u any heal? plan1 includ+ any p]son or entity act+ "u a contract or arrangem5t ) a heal? c>e organization to provide or adm9i/] any heal? b5efit4 7#aj7 ,heal? c>e provid] ,! t]m heal? c>e provid] means any p]son or entity requir$ by ,/ate or ,f$]al laws or regulations to be lic5s$1 regi/]$1 or c]tifi$ to provide heal? c>e s]vices1 & be+ ei!r s lic5s$1 regi/]$1 or c]tifi$1 or exempt$ f su* requirem5t by o!r /atute or regulation4 7#aa7 ,heal? c>e goods or s]vices ,! t]m heal? c>e goods or s]vices means any goods or s]vices provid$ by a heal? c>e organization1 provid]1 or by any individual work+ "u ! sup]vision ( a heal? c>e provid]1 t relates to ! diagnosis1 prev5tion1 or treatm5t ( any human disease or impairm5t1 or ! assessm5t or c>e ( ! heal? ( human be+s4 7#ab7 ,malici\s int5t to injure ,! t]m malici\s int5t to injure means int5tionally caus+ or attempt+ to cause physical injury o!r ?an provid+ heal? c>e goods or s]vices4 7#ac7 ,m$ical product ,! t]m m$ical product means a drug1 device1 or biological product int5d$ = humans1 & ! t]ms drug1 device1 & biological product h ! mean+s giv5 su* t]ms 9 sections #bja7;g77#a7 & #bja7;h7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cba7;g77#a7 & 7h77 & section #cea7;a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bfb7;a771 respectively1 includ+ any compon5t or raw mat]ial us$ !re91 b exclud+ heal? c>e s]vices4 7#ad7 ,noneconomic damages ,! t]m noneconomic damages means damages = physical & emotional pa91 suff]+1 inconv5i5ce1 physical impairm5t1 m5tal angui%1 disfigurem5t1 loss ( enjoym5t ( life1 loss ( society & companion%ip1 loss ( consortium 7o!r ?an loss ( dome/ic s]vice71 h$onic damages1 injury to reputation1 & all o!r nonpecuni>y losses ( any k9d or nature4 7#ae7 ,punitive damages ,! t]m punitive damages means damages aw>d$1 = ! purpose ( puni%m5t or det]r5ce1 & n solely = comp5satory purposes1 aga9/ a heal? c>e provid]1 heal? c>e organization1 or a manufactur]1 di/ributor1 or suppli] ( a m$ical product4 ,punitive damages are nei!r economic nor noneconomic damages4 7#af7 ,recov]y ,! t]m recov]y means ! net sum recov]$ aft] d$uct+ any disbursem5ts or co/s incurr$ 9 connection ) prosecution or settlem5t ( ! claim1 includ+ all co/s paid or advanc$ by any p]son4 ,co/s ( heal? c>e incurr$ by ! pla9tiff & ! attorneys' (fice ov]head co/s or *>ges = legal s]vices are n d$uctible disbursem5ts or co/s = su* purpose4 7#ag7 ,/ate ,! t]m ,/ate means ea* ( ! sev]al ,/ates1 ! ,di/rict ( ,columbia1 ! ,commonweal? ( ,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1 ,am]ican ,samoa1 ! ,nor!rn ,m>iana ,isl&s1 ! ,tru/ ,t]ritory ( ! ,pacific ,isl&s1 & any o!r t]ritory or possession ( ! ,unit$ ,/ates1 or any political subdivision !re(4 #bjh4 ,effect on o!r laws 7a7 ,vacc9e ,injury 7#a7 ,to ! ext5t t title ,,xxi ( ! ,public ,heal? ,s]vice ,act e/abli%es a ,f$]al rule ( law applicable to a civil action br\ght = a vacc9e-relat$ injury or dea?-- 7,a7 ?is title does n affect ! application ( ! rule ( law to su* an action2 & 7,b7 any rule ( law prescrib$ by ?is title 9 conflict ) a rule ( law ( su* title ,,xxi %all n apply to su* action4 7#b7 ,if !re is an aspect ( a civil action br\ght = a vacc9e-relat$ injury or dea? to :i* a ,f$]al rule ( law "u title ,,xxi ( ! ,public ,heal? ,s]vice ,act does n apply1 !n ?is title or o!rwise applicable law 7z det]m9$ "u ?is title7 w apply to su* aspect ( su* action4 7b7 ,o!r ,f$]al ,law ,except z provid$ 9 ?is section1 no?+ 9 ?is title %all be deem$ to affect any def5se available to a def5dant 9 a heal? c>e lawsuit or action "u any o!r provision ( ,f$]al law4 #bji4 ,/ate flexibility & protection ( ,/ates' rights 7a7 ,heal? ,c>e ,lawsuits ,! provisions gov]n+ heal? c>e lawsuits set =? 9 ?is title preempt1 subject to subsections 7b7 & 7c71 ,/ate law to ! ext5t t ,/ate law prev5ts ! application ( any provisions ( law e/abli%$ by or "u ?is title4 ,! provisions gov]n+ heal? c>e lawsuits set =? 9 ?is title sup]s$e *apt] #aga ( title #bh1 ,unit$ ,/ates ,code1 to ! ext5t t su* *apt]-- 7#a7 provides = a great] am\nt ( damages or cont+5t fees1 a long] p]iod 9 :i* a heal? c>e lawsuit may be comm5c$1 or a r$uc$ applicability or scope ( p]iodic paym5t ( future damages1 ?an provid$ 9 ?is title2 or 7#b7 prohibits ! introduction ( evid5ce reg>d+ collat]al s\rce b5efits1 or m&ates or p]mits subrogation or a li5 on collat]al s\rce b5efits4 7b7 ,protection ( ,/ates' ,rights & ,o!r ,laws 7#a7 ,any issue t is n gov]n$ by any provision ( law e/abli%$ by or "u ?is title 7includ+ ,/ate /&>ds ( neglig5ce7 %all be gov]n$ by o!rwise applicable ,/ate or ,f$]al law4 7#b7 ,?is title %all n preempt or sup]s$e any ,/ate or ,f$]al law t imposes great] proc$ural or sub/antive protections = heal? c>e provid]s & heal? c>e organizations f liability1 loss1 or damages ?an ^? provid$ by ?is title or create a cause ( action4 7c7 ,/ate ,flexibility ,no provision ( ?is title %all be con/ru$ to preempt-- 7#a7 any ,/ate law 7:e!r effective be=e1 on1 or aft] ! date ( ! enactm5t ( ?is ,act7 t specifies a p>ticul> monet>y am\nt ( comp5satory or punitive damages 7or ! total am\nt ( damages7 t may be aw>d$ 9 a heal? c>e lawsuit1 reg>dless ( :e!r su* monet>y am\nt is great] or less] ?an is provid$ = "u ?is title1 not)/&+ section #bjd7;a72 or 7#b7 any def5se available to a p>ty 9 a heal? c>e lawsuit "u any o!r provision ( ,/ate or ,f$]al law4 #baj4 ,applicability2 effective date ,?is title %all apply to any heal? c>e lawsuit br\ght 9 a ,f$]al or ,/ate c\rt1 or subject to an alt]native dispute resolution sy/em1 t is initiat$ on or aft] ! date ( ! enactm5t ( ?is ,act1 except t any heal? c>e lawsuit aris+ f an injury occurr+ prior to ! date ( ! enactm5t ( ?is ,act %all be gov]n$ by ! applicable /atute ( limitations provisions 9 effect at ! "t ! injury occurr$4 ,,iii ,all[+ ,p ,to ,pur*ase ,heal? ,insurance ,across ,/ate ,l9es #cja4 ,specification ( con/itutional au?ority = enactm5t ( law ,?is title is enact$ pursuant to ! p[] grant$ ,congress "u article ,i1 section #h1 clause #c1 ( ! ,unit$ ,/ates ,con/itution4 #cjb4 ,f9d+s ,congress f9ds ! foll[+3 7#a7 ,! application ( num]\s & significant v>iations 9 ,/ate law & ! implem5tation ( ! ,pati5t ,protection & ,af=dable ,c>e ,act impacts ! ability ( insur]s to (f]1 & individuals to obta91 af=dable individual heal? insurance cov]age1 !reby imp$+ comm]ce 9 individual heal? insurance cov]age4 7#b7 ,m&ates = heal? c>e cov]age e/abli%$ by title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act w significantly elevate heal? insurance co/s beyond ,/ate & ,f$]al ability to pay4 7#c7 ,individual heal? insurance cov]age is increas+ly (f]$ ?r\gh ! ,int]net1 o!r electronic means1 & by mail1 all ( :i* are inh]5tly "p ( int]/ate comm]ce4 7#d7 ,9 response to ^! issues1 x is appropriate to enc\rage increas$ effici5cy 9 ! (f]+ ( individual heal? insurance cov]age ?r\gh a collaborative approa* by ! ,/ates 9 regulat+ ?is cov]age4 7#e7 ,! e/abli%m5t ( risk-ret5tion gr\ps has provid$ a successful model = ! sale ( insurance across ,/ate l9es1 z ! acts e/abli%+ ^? gr\ps all[ insurance to be sold 9 multiple ,/ates b regulat$ by a s+le ,/ate4 #cjc4 ,coop]ative gov]n+ ( individual heal? insurance cov]age 7a7 ,9 ,g5]al ,title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 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$3 ,notice ,?is policy is issu$ 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$2 7,b7 ! availability & co/ ( heal? insurance policies = individuals ) pre-exi/+ m$ical conditions2 7,c7 ! availability & co/ ( heal? insurance policies g5]ally2 7,d7 ! elim9ation or r$uction ( diff]5t types ( b5efits "u heal? insurance policies (f]$ 9 diff]5t ,/ates2 & 7,e7 cases ( fraud or abuse relat+ to heal? insurance cov]age (f]$ "u su* am5dm5t & ! resolution ( su* cases4 7#b7 ,annual reports ,! ,comptroll] ,g5]al %all submit to ,congress an annual report1 aft] ! end ( ea* ( ! #e ye>s foll[+ ! effective date ( ! am5dm5t made by subsection 7a71 on ! ongo+ /udy conduct$ "u p>agraph 7#a74 #cjd4 ,sev]ability ,if any provision ( ?is title or ! application ( su* provision to any p]son or circum/ance is held to be uncon/itutional1 ! rema9d] ( ?is title & ! application ( ! provisions ( su* to any o!r p]son or circum/ance %all n be affect$4 ,,iv ,increas+ ,transp>5cy & ,competition 9 ,heal?c>e #dja4 ,exp&+ availability ( ,m$ic>e data 7a7 ,exp&+ uses ( ,m$ic>e data by qualifi$ entities 7#a7 ,9 g5]al ,to ! ext5t consi/5t ) applicable in=mation1 privacy1 security1 & disclosure laws1 beg9n+ ) #bjad1 not)/&+ p>agraph 7#d77;,b7 ( section #ahgd7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77 & ! second s5t5ce ( p>agraph 7#d77;,d7 ( su* section1 a qualifi$ entity may use data receiv$ by su* entity "u su* section1 & in=mation d]iv$ f ! evaluation describ$ 9 su* p>agraph 7#d77;,d71 = additional non-public analyses 7z det]m9$ appropriate by ! ,secret>y ( ,heal? & ,human ,s]vices7 or provide or sell su* data to regi/]$ or au?oriz$ us]s & subscrib]s1 includ+ to provid]s ( s]vices & suppli]s1 = non-public use 7includ+ = ! purposes ( assi/+ provid]s ( s]vices & suppli]s to develop & p>ticipate 9 quality & pati5t c>e improvem5t activities1 includ+ develop+ new models ( c>e74 7#b7 ,def9itions ,9 ?is section3 7,a7 ,! t]m qualifi$ entity has ! mean+ giv5 su* t]m 9 section #ahgd7;e77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e774 7,b7 ,! t]ms suppli] & provid] ( s]vices h ! mean+s giv5 su* t]ms 9 subsections 7d7 & 7u71 respectively1 ( section #ahfa ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex74 7b7 ,access to ,m$ic>e data to provid]s ( s]vices & suppli]s ,to facilitate developm5t ( alt]native paym5t models & to qualifi$ cl9ical data regi/ries ,to facilitate quality improvem5t ,consi/5t ) applicable laws & regulations ) respect to privacy & o!r relevant matt]s1 ! ,secret>y %all provide ,m$ic>e claims data 79 a =m & mann] det]m9$ to be appropriate7 to-- 7#a7 qualifi$ entities1 t may %>e ) provid]s ( s]vices & suppli]s t are regi/]$ or au?oriz$ us]s or subscrib]s1 = non-public use includ+ to facilitate ! developm5t ( new models ( c>e 7includ+ developm5t ( ,alt]nate ,paym5t ,models "u section #ahdh;,a ( ! ,social ,security ,act1 models = small gr\p specialty practices1 & c>e coord9ation models72 & 7#b7 qualifi$ cl9ical data regi/ries "u section #ahdh7m77#c77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,e77 = purposes ( l9k+ su* data ) cl9ical outcomes data & p]=m+ & dissem9at+ risk-adju/$1 sci5tifically valid analysis & rese>* to support quality improvem5t or pati5t safety1 provid$ t any public report+ ( id5tifiable provid] data %all only be conduct$ ) prior cons5t ( su* provid]4 ,v ,exp&+ ! ,effectiv5ess ( ,heal? ,sav+s ,acc\nts #eja4 ,am5dm5t ( #aihf ,code ,except z o!rwise expressly provid$1 :5ev] 9 ?is title an am5dm5t or repeal is express$ 9 t]ms ( an am5dm5t to1 or repeal (1 a section or o!r provision1 ! ref]5ce %all be consid]$ to be made to a section or o!r provision ( ! ,int]nal ,rev5ue ,code ( #aihf4 ,a ,provisions relat+ to tax-,pref]r$ heal? acc\nts #eaa4 ,all[ bo? sp\ses to make cat*-up contributions to ! same ,,hsa acc\nt 7a7 ,9 g5]al ,p>agraph 7#c7 ( section #bbc7;b7 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,special rule :]e bo? sp\ses are eligible individuals ) #a acc\nt ,if-- 7i7 an individual & ! individual's sp\se h bo? atta9$ age #ee be=e ! close ( ! taxable ye>1 & 7ii7 ! sp\se is n an acc\nt b5efici>y ( a heal? sav+s acc\nt z ( ! close ( su* ye>1 ! additional contribution am\nt %all be #bjj p]c5t ( ! am\nt o!rwise det]m9$ "u subp>agraph 7,b74 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #eab4 ,provisions relat+ to ,m$ic>e 7a7 ,individuals ov] age #fe only enroll$ 9 ,m$ic>e ,"p ,a ,p>agraph 7#g7 ( section #bbc7;b7 is am5d$ by add+ at ! end ! foll[+3 ,?is p>agraph %all n apply to any individual dur+ any p]iod = :i* ! individual's only entitlem5t to su* b5efits is an entitlem5t to hospital insurance b5efits "u "p ,a ( title ,,xviii ( su* ,act pursuant to an enrollm5t = su* hospital insurance b5efits "u section #bbf7;a77#a7 ( su* ,act44 7b7 ,m$ic>e b5efici>ies p>ticipat+ 9 ,m$ic>e advantage ,,msa may contribute _! own money to _! ,,msa ,subsection 7b7 ( section #ach is am5d$ by /rik+ p>agraph 7#b7 & by r$esignat+ p>agraphs 7#c7 & 7#d7 z p>agraphs 7#b7 & 7#c71 respectively4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #eac4 ,individuals eligible = vet]ans b5efits = a s]vice-connect$ disability 7a7 ,9 g5]al ,p>agraph 7#a7 ( section #bbc7;c7 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,special rule = individuals eligible = c]ta9 vet]ans b5efits ,= purposes ( subp>agraph 7,a77ii71 an individual %all n be treat$ z cov]$ "u a heal? plan describ$ 9 su* subp>agraph m]ely because ! individual receives p]iodic hospital c>e or m$ical s]vices = a s]vice-connect$ disability "u any law adm9i/]$ by ! ,secret>y ( ,vet]ans ,affairs b only if ! individual is n eligible to receive su* c>e or s]vices = any condition o!r ?an a s]vice-connect$ disability4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #ead4 ,individuals eligible = ,indian ,heal? ,s]vice assi/ance 7a7 ,9 g5]al ,p>agraph 7#a7 ( section #bbc7;c71 z am5d$ by section #fab1 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,special rule = individuals eligible = assi/ance "u ,indian ,heal? ,s]vice programs ,= purposes ( subp>agraph 7,a77ii71 an individual %all n be treat$ z cov]$ "u a heal? plan describ$ 9 su* subp>agraph m]ely because ! individual receives hospital c>e or m$ical s]vices "u a m$ical c>e program ( ! ,indian ,heal? ,s]vice or ( a tribal organization4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #eae4 ,individuals eligible = ,,tric>e cov]age 7a7 ,9 g5]al ,p>agraph 7#a7 ( section #bbc7;c71 z am5d$ by sections #fac & #fad1 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,special rule = individuals eligible = assi/ance "u tric>e ,= purposes ( subp>agraph 7,a77ii71 an individual %all n be treat$ z cov]$ "u a heal? plan describ$ 9 su* subp>agraph m]ely because ! individual is eligible to receive hospital c>e1 m$ical s]vices1 or prescription drugs "u ,,tric>e ,extra or ,,tric>e ,/&>d & su* individual is n enroll$ 9 ,,tric>e ,prime4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #eaf4 ,heal? ,,fsa c>ry=w>ds 7a7 ,9 g5]al ,section #abe is am5d$ by r$esignat+ subsections 7i7 & 7j7 z subsections 7j7 & 7k71 respectively1 & by ins]t+ aft] subsection 7h7 ! foll[+ new subsection3 7i7 ,special rules applicable to heal? flexible sp5d+ arrangem5ts 7#a7 ,9 g5]al ,= purposes ( ?is title1 a plan or o!r arrangem5t %all n fail to be treat$ z a heal? flexible sp5d+ or simil> arrangem5t solely because "u ! plan or arrangem5t a p>ticipant is p]mitt$ access to any unus$ balance 9 ! p>ticipant's acc\nts "u su* plan or arrangem5t 9 ! mann] provid$ "u p>agraph 7#b74 7#b7 ,c>ry=w>d ( unus$ b5efits 9 heal? arrangem5ts 7,a7 ,9 g5]al ,a plan or arrangem5t may p]mit a p>ticipant 9 a heal? flexible sp5d+ arrangem5t to elect to c>ry =w>d any aggregate unus$ balances 9 ! p>ticipant's acc\nts "u su* arrangem5t z ( ! close ( any ye> to ! succe$+ ye>4 ,su* c>ry=w>d %all be treat$ z hav+ occurr$ )9 #cj days ( ! close ( ! ye>4 7,b7 ,doll> limit on c>ry=w>ds 7i7 ,9 g5]al ,! am\nt :i* a p>ticipant may elect to c>ry =w>d "u subp>agraph 7,a7 f any ye> %all n exce$ #ejj4 ,= purposes ( ?is p>agraph1 all plans & arrangem5ts ma9ta9$ by an employ] or any relat$ p]son %all be treat$ z #a plan4 7ii7 ,co/-(-liv+ adju/m5t ,9 ! case ( any taxable ye> beg9n+ 9 a cal5d> ye> aft] #bjac1 ! #ejj am\nt "u clause 7i7 %all be increas$ by an am\nt equal to-- 7,i7 #ejj1 multipli$ by 7,,ii7 ! co/-(-liv+ adju/m5t det]m9$ "u section #a7;f77#c7 = su* cal5d> ye>1 det]m9$ by sub/itut+ #bjab = #aiib 9 subp>agraph 7,b7 !re(4 ,if any doll> am\nt z increas$ "u ?is clause is n a multiple ( #ajj1 su* am\nt %all be r\nd$ to ! next l[e/ multiple ( #ajj4 7,c7 ,exclusion f gross income ,no am\nt %all be requir$ to be includ$ 9 gross income "u ?is *apt] by reason ( any c>ry=w>d "u ?is p>agraph4 7,d7 ,coord9ation ) limits ,! maximum am\nt :i* may be contribut$ to a heal? flexible sp5d+ arrangem5t = any ye> to :i* an unus$ am\nt is c>ri$ "u ?is p>agraph %all be r$uc$ by su* am\nt4 7#c7 ,t]ms relat+ to flexible sp5d+ arrangem5ts 7,a7 ,flexible sp5d+ arrangem5ts ,= purposes ( ?is subsection1 a flexible sp5d+ arrangem5t is a b5efit program :i* provides employees ) cov]age "u :i* specifi$ incurr$ exp5ses may be reimburs$ 7subject to reimbursem5t maximums & o!r reasonable conditions74 7,b7 ,heal? arrangem5ts ,! t]m heal? flexible sp5d+ arrangem5t means any flexible sp5d+ arrangem5t 7or portion !re(7 :i* provides paym5ts = exp5ses incurr$ = m$ical c>e 7z def9$ 9 section #bac7;d774 4 7b7 ,con=m+ am5dm5ts 7#a7 ,! head+ = section #abe ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by ins]t+ & heal? flexible sp5d+ arrangem5ts aft] plans4 7#b7 ,! item relat+ to section #abe 9 ! table ( sections = "p ,,iii ( sub*apt] ,b ( *apt] #a ( su* ,code is am5d$ by ins]t+ & heal? flexible sp5d+ arrangem5ts aft] plans4 7c7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ! date ( ! enactm5t ( ?is ,act4 #eag4 ,,fsa & ,,hra int]action ) ,h,s,as 7a7 ,eligible individuals include ,,fsa & ,,hra p>ticipants ,subp>agraph 7,b7 ( section #bbc7;c77#a7 is am5d$-- 7#a7 by /rik+ & at ! end ( clause 7ii71 7#b7 by /rik+ ! p]iod at ! end ( clause 7iii7 & ins]t+ 1 &1 & 7#c7 by ins]t+ aft] clause 7iii7 ! foll[+ new clause3 7iv7 cov]age "u a heal? flexible sp5d+ arrangem5t or a heal? reimbursem5t arrangem5t 9 ! plan ye> a qualifi$ ,,hsa di/ribution z describ$ 9 section #ajf7;e7 is made on behalf ( ! individual if aft] ! qualifi$ ,,hsa di/ribution is made & = ! rema9+ duration ( ! plan ye>1 ! cov]age provid$ "u ! heal? flexible sp5d+ arrangem5t or heal? reimbursem5t arrangem5t is conv]t$ to-- 7,i7 cov]age t does n pay or reimburse any m$ical exp5se incurr$ be=e ! m9imum annual d$uctible "u p>agraph 7#b77;,a77i7 7prorat$ = ! p]iod occurr+ aft] ! qualifi$ ,,hsa di/ribution is made7 is satisfi$1 7,,ii7 cov]age t1 aft] ! qualifi$ ,,hsa di/ribution is made1 does n pay or reimburse any m$ical exp5se incurr$ aft] ! qualifi$ ,,hsa di/ribution is made o!r ?an prev5tive c>e z def9$ 9 p>agraph 7#b77;,c71 7,,iii7 cov]age t1 aft] ! qualifi$ ,,hsa di/ribution is made1 pays or reimburses b5efits = cov]age describ$ 9 clause 7ii7 7b n ?r\gh insurance or = long-t]m c>e s]vices71 7,,iv7 cov]age t1 aft] ! qualifi$ ,,hsa di/ribution is made1 pays or reimburses b5efits = p]mitt$ insurance or cov]age describ$ 9 clause 7ii7 7b n = long-t]m c>e s]vices71 7,v7 cov]age t1 aft] ! qualifi$ ,,hsa di/ribution is made1 pays or reimburses only ^? m$ical exp5ses incurr$ aft] an individual's retirem5t 7& no exp5ses incurr$ be=e retirem5t71 or 7,,vi7 cov]age t1 aft] ! qualifi$ ,,hsa di/ribution is made1 is susp5d$1 pursuant to an election made on or be=e ! date ! individual elects a qualifi$ ,,hsa di/ribution or1 if lat]1 on ! date ( ! individual enrolls 9 a high d$uctible heal? plan1 t does n pay or reimburse1 at any "t1 any m$ical exp5se incurr$ dur+ ! susp5sion p]iod except z def9$ 9 ! prec$+ subclauses ( ?is clause4 4 7b7 ,qualifi$ ,,hsa di/ribution %all n affect flexible sp5d+ arrangem5t ,p>agraph 7#a7 ( section #ajf7;e7 is am5d$ to read z foll[s3 7#a7 ,9 g5]al ,a plan %all n fail to be treat$ z a heal? flexible sp5d+ arrangem5t "u ?is section1 section #aje1 or section #abe1 or z a heal? reimbursem5t arrangem5t "u ?is section or section #aje1 m]ely because su* plan provides = a qualifi$ ,,hsa di/ribution4 4 7c7 ,,fsa balances at ye> end %all n =feit ,p>agraph 7#b7 ( section #abe7;d7 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,exception = qualifi$ ,,hsa di/ributions ,subp>agraph 7,a7 %all n apply to ! ext5t t !re is an am\nt rema9+ 9 a heal? flexible sp5d+ acc\nt at ! end ( a plan ye> t an individual elects to contribute to a heal? sav+s acc\nt pursuant to a qualifi$ ,,hsa di/ribution 7z def9$ 9 section #ajf7;e77#b774 4 7d7 ,simplification ( limitations on ,,fsa & ,,hra rollov]s ,p>agraph 7#b7 ( section #ajf7;e7 is am5d$ to read z foll[s3 7#b7 ,qualifi$ ,,hsa di/ribution 7,a7 ,9 g5]al ,! t]m qualifi$ ,,hsa di/ribution means a di/ribution f a heal? flexible sp5d+ arrangem5t or heal? reimbursem5t arrangem5t to ! ext5t t su* di/ribution does n exce$ ! less] (-- 7i7 ! balance 9 su* arrangem5t z ( ! date ( su* di/ribution1 or 7ii7 ! am\nt det]m9$ "u subp>agraph 7,b74 ,su* t]m %all n include m ?an #a di/ribution ) respect to any arrangem5t4 7,b7 ,doll> limitations 7i7 ,di/ributions f a heal? flexible sp5d+ arrangem5t ,a qualifi$ ,,hsa di/ribution f a heal? flexible sp5d+ arrangem5t %all n exce$ ! applicable am\nt4 7ii7 ,di/ributions f a heal? reimbursem5t arrangem5t ,a qualifi$ ,,hsa di/ribution f a heal? reimbursem5t arrangem5t %all n exce$-- 7,i7 ! applicable am\nt divid$ by #ab1 multipli$ by 7,,ii7 ! numb] ( mon?s dur+ :i* ! individual is a p>ticipant 9 ! heal? reimbursem5t arrangem5t4 7iii7 ,applicable am\nt ,= purposes ( ?is subp>agraph1 ! applicable am\nt is-- 7,i7 #b1bej 9 ! case ( an eligible individual :o has self-only cov]age "u a high d$uctible heal? plan at ! "t ( su* di/ribution1 & 7,,ii7 #d1ejj 9 ! case ( an eligible individual :o has family cov]age "u a high d$uctible heal? plan at ! "t ( su* di/ribution4 4 7e7 ,elim9ation ( additional tax = failure ,to ma9ta9 high d$uctible heal? plan cov]age ,subsection 7e7 ( section #ajf is am5d$-- 7#a7 by /rik+ p>agraph 7#c7 & r$esignat+ p>agraphs 7#d7 & 7#e7 z p>agraphs 7#c7 & 7#d71 respectively1 & 7#b7 by /rik+ subp>agraph 7,a7 ( p>agraph 7#c71 z s r$esignat$1 & r$esignat+ subp>agraphs 7,b7 & 7,c7 ( su* p>agraph z subp>agraphs 7,a7 & 7,b7 !re(1 respectively4 7f7 ,limit$ purpose ,f,s,as & ,h,r,as ,subsection 7e7 ( section #ajf1 z am5d$ by ?is section1 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#e7 ,limit$ purpose ,f,s,as & ,h,r,as ,a plan %all n fail to be a heal? flexible sp5d+ arrangem5t or heal? reimbursem5t arrangem5t "u ?is section or section #aje m]ely because ! plan conv]ts cov]age = individuals :o enroll 9 a high d$uctible heal? plan describ$ 9 section #bbc7;c77#b7 to cov]age describ$ 9 section #bbc7;c77#a77;,b77iv74 ,cov]age = su* individuals may be conv]t$ z ( ! date ( enrollm5t 9 ! high d$uctible heal? plan1 )\t reg>d to ! p]iod ( cov]age "u ! heal? flexible sp5d+ arrangem5t or heal? reimbursem5t arrangem5t1 & )\t requir+ any *ange 9 cov]age to individuals :o d n enroll 9 a high d$uctible heal? plan4 4 7g7 ,di/ribution am\nts adju/$ = co/-(-,liv+ ,subsection 7e7 ( section #ajf1 z am5d$ by ?is section1 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,co/-(-liv+ adju/m5t 7,a7 ,9 g5]al ,9 ! case ( any taxable ye> beg9n+ aft] ,decemb] #ca1 #bjac1 ea* ( ! doll> am\nts 9 p>agraph 7#b77;,b77iii7 %all be increas$ by an am\nt equal to su* doll> am\nt1 multipli$ by ! co/-(-liv+ adju/m5t det]m9$ "u section #a7;f77#c7 = ! cal5d> ye> 9 :i* su* taxable ye> beg9s by sub/itut+ cal5d> ye> #bjab = cal5d> ye> #aiib 9 subp>agraph 7,b7 !re(4 7,b7 ,r\nd+ ,if any increase "u p>agraph 7#a7 is n a multiple ( #ej1 su* increase %all be r\nd$ to ! ne>e/ multiple ( #ej4 4 7h7 ,disclaim] ( disqualify+ cov]age ,subp>agraph 7,b7 ( section #bbc7;c77#a71 z am5d$ by ?is section1 is am5d$-- 7#a7 by /rik+ & at ! end ( clause 7iii71 7#b7 by /rik+ ! p]iod at ! end ( clause 7iv7 & ins]t+ 1 &1 & 7#c7 by ins]t+ aft] clause 7iv7 ! foll[+ new clause3 7v7 any cov]age 7includ+ prospective cov]age7 "u a heal? plan t is n a high d$uctible heal? plan :i* is disclaim$ 9 writ+1 at ! "t ( ! creation or organization ( ! heal? sav+s acc\nt1 includ+ by execution ( a tru/ describ$ 9 subsection 7d77#a7 ?r\gh a gov]n+ in/rum5t t includes su* a disclaim]1 or by acceptance ( an am5dm5t to su* a tru/ t includes su* a disclaim]4 4 7i7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #eah4 ,all[ance ( di/ributions = prescription & ov]-!-c\nt] m$ic9es & drugs 7a7 ,ref]5ce ,to repeal ( di/ributions = m$ic9e qualifi$ only if = prescrib$ drug or insul9 ,section #aja ( ?is ,act provides = ! repeal ( section #ijjc ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh7 & ! am5dm5ts made by su* section4 ,! ,int]nal ,rev5ue ,code ( #aihf %all be appli$ z if su* section #ijjc & am5dm5ts _h nev] be5 enact$4 7b7 ,all[ance ( di/ributions = all m$ic9es & drugs 7#a7 ,h,s,as ,subp>agraph 7,a7 ( section #bbc7;d77#b7 is am5d$ by add+ at ! end ! foll[+3 ,su* t]m %all include an am\nt paid = any prescription or ov]-!-c\nt] m$ic9e or drug44 7#b7 ,ar*] ,m,s,as ,subp>agraph 7,a7 ( section #bbj7;d77#b7 is am5d$ by add+ at ! end ! foll[+3 ,su* t]m %all include an am\nt paid = any prescription or ov]-!-c\nt] m$ic9e or drug44 7#c7 ,heal? flexible sp5d+ arrangem5ts & heal? reimbursem5t arrangem5ts ,section #ajf is am5d$ by add+ at ! end ! foll[+ new subsection3 7f7 ,reimbursem5ts = all m$ic9es & drugs ,= purposes ( ?is section & section #aje1 reimbursem5t = exp5ses incurr$ = any prescription or ov]-!-c\nt] m$ic9e or drug %all be treat$ z a reimbursem5t = m$ical exp5ses4 4 7#d7 ,effective dates 7,a7 ,di/ributions f sav+s acc\nts ,! am5dm5ts made by p>agraphs 7#a7 & 7#b7 %all apply to am\nts paid ) respect to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjac4 7,b7 ,reimbursem5ts ,! am5dm5t made by p>agraph 7#c7 %all apply to exp5ses incurr$ ) respect to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjac4 #eai4 ,pur*ase ( heal? insurance f ,,hsa acc\nt 7a7 ,9 g5]al ,p>agraph 7#b7 ( section #bbc7;d7 is am5d$ to read z foll[s3 7#b7 ,qualifi$ m$ical exp5ses 7,a7 ,9 g5]al ,! t]m qualifi$ m$ical exp5ses means1 ) respect to an acc\nt b5efici>y1 am\nts paid by su* b5efici>y = m$ical c>e 7z def9$ 9 section #bac7;d77 = any individual cov]$ by a high d$uctible heal? plan ( ! acc\nt b5efici>y1 b only to ! ext5t su* am\nts are n comp5sat$ = by insurance or o!rwise4 7,b7 ,heal? insurance may n be pur*as$ f acc\nt ,except z provid$ 9 subp>agraph 7,c71 subp>agraph 7,a7 %all n apply to any paym5t = insurance4 7,c7 ,exceptions ,subp>agraph 7,b7 %all n apply to any exp5se = cov]age "u-- 7i7 a heal? plan dur+ any p]iod ( cont9uation cov]age requir$ "u any ,f$]al law1 7ii7 a qualifi$ long-t]m c>e insurance contract 7z def9$ 9 section #ggjb;,b7b771 7iii7 a heal? plan dur+ any p]iod 9 :i* ! individual is receiv+ unemploym5t comp5sation "u any ,f$]al or ,/ate law1 7iv7 a high d$uctible heal? plan1 or 7v7 any heal? insurance "u title ,,xviii ( ! ,social ,security ,act1 o!r ?an a ,m$ic>e supplem5tal policy 7z def9$ 9 section #ahhb ( su* ,act74 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 #ebj4 ,special rule = c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt 7a7 ,9 g5]al ,p>agraph 7#b7 ( section #bbc7;d71 z am5d$ by section #fai1 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt treat$ z qualifi$ ,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$-- 7i7 dur+ ei!r-- 7,i7 ! taxable ye> 9 :i* ! heal? sav+s acc\nt 0 e/abli%$1 or 7,,ii7 ! prec$+ taxable ye> 9 ! case ( a heal? sav+s acc\nt e/abli%$ aft] ! taxable ye> 9 :i* su* exp5se 0 incurr$ b be=e ! "t prescrib$ by law = fil+ ! return = su* taxable ye> 7n includ+ ext5sions !re(71 & 7ii7 = m$ical c>e ( an individual dur+ a p]iod t su* individual 0 cov]$ by a high d$uctible heal? plan & met ! requirem5ts ( subsection 7c77#a77;,a77ii7 7aft] application ( subsection 7c77#a77;,b774 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #eba4 ,prev5tive c>e prescription drug cl>ification 7a7 ,cl>ify use ( drugs 9 prev5tive c>e ,subp>agraph 7,c7 ( section #bbc7;c77#b7 is am5d$ by add+ at ! end ! foll[+3 ,prev5tive c>e %all include prescription & ov]-!-c\nt] drugs & m$ic9es :i* h ! prim>y purpose ( prev5t+ ! onset (1 fur!r det]ioration f1 or complications associat$ ) *ronic conditions1 illnesses1 or diseases44 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjjc4 #ebb4 ,equival5t bankruptcy protections = heal? sav+s acc\nts z retirem5t funds 7a7 ,9 g5]al ,section #ebb ( title #aa1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+ new subsection3 7r7 ,treatm5t ( heal? sav+s acc\nts ,= purposes ( ?is section1 any heal? sav+s acc\nt 7z describ$ 9 section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf7 %all be treat$ 9 ! same mann] z an individual retirem5t acc\nt describ$ 9 section #djh ( su* ,code4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to cases comm5c+ "u title #aa1 ,unit$ ,/ates ,code1 aft] ! date ( ! enactm5t ( ?is ,act4 #ebc4 ,adm9i/rative error correction be=e due date ( return 7a7 ,9 g5]al ,p>agraph 7#d7 ( section #bbc7;f7 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,exception = adm9i/rative errors correct$ be=e due date ( return ,subp>agraph 7,a7 %all n apply if any paym5t or di/ribution is made to correct an adm9i/rative1 cl]ical or payroll contribution error & if-- 7i7 su* di/ribution is receiv$ by ! individual on or be=e ! la/ day prescrib$ by law 7includ+ ext5sions ( "t7 = fil+ su* individual's return = su* taxable ye>1 & 7ii7 su* di/ribution is accompani$ by ! am\nt ( net income attributable to su* contribution4 ,any net income describ$ 9 clause 7ii7 %all be includ$ 9 ! gross income ( ! individual = ! taxable ye> 9 :i* x is receiv$4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all take effect on ! date ( ! enactm5t ( ?is ,act4 #ebd4 ,reau?orization ( m$icaid heal? opportunity acc\nts 7a7 ,9 g5]al ,section #aich ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#h7 is am5d$-- 7#a7 9 subsection 7a7-- 7,a7 by /rik+ p>agraph 7#b7 & ins]t+ ! foll[+3 7#b7 ,initial demon/ration ,! demon/ration program "u ?is section %all beg9 #ij days aft] ! date ( ! enactm5t ( ?is p>agraph4 ,! ,secret>y %all approve ,/ates to conduct demon/ration programs "u ?is section = a #e-ye> p]iod1 ) ea* ,/ate demon/ration program cov]+ #a or m geographic areas specifi$ by ! ,/ate4 ,) respect to a ,/ate1 aft] ! initial #e-ye> p]iod ( any demon/ration program conduct$ "u ?is section by ! ,/ate1 unless ! ,secret>y f9ds1 tak+ into acc\nt co/-effectiv5ess & quality ( c>e1 t ! ,/ate demon/ration program has be5 unsuccessful1 ! demon/ration program may be ext5d$ or made p]man5t 9 ! ,/ate4 2 & 7,b7 9 p>agraph 7#c71 9 ! matt] prec$+ subp>agraph 7,a7-- 7i7 by /rik+ n2 & 7ii7 by /rik+ unless & ins]t+ if 2 7#b7 9 subsection 7b7-- 7,a7 9 p>agraph 7#c71 by ins]t+ clauses 7i7 ?r\gh 7vii71 7viii7 7)\t reg>d to ! am5dm5t made by section #bjjd7;c77#b7 ( ,public ,law #aaa-adh71 7x71 or 7xi7 ( aft] describ$ 9 2 & 7,b7 by /rik+ p>agraphs 7#d71 7#e71 & 7#f72 7#c7 9 subsection 7c7-- 7,a7 by /rik+ p>agraphs 7#c7 & 7#d72 7,b7 by r$esignat+ p>agraphs 7#e7 ?r\gh 7#h7 z p>agraphs 7#c7 ?r\gh 7#f71 respectively2 & 7,c7 9 p>agraph 7#d7 7z r$esignat$ by subp>agraph 7,b771 by /rik+ ,subject to subp>agraphs 7,d7 & 7,e7 & ins]t+ ,subject to subp>agraph 7,d72 & 7#d7 9 subsection 7d7-- 7,a7 9 p>agraph 7#b71 by /rik+ subp>agraph 7,e72 & 7,b7 9 p>agraph 7#c7-- 7i7 9 subp>agraph 7,a77ii71 by /rik+ ,subject to subp>agraph 7,b77ii71 9 & ins]t+ ,92 & 7ii7 by /rik+ subp>agraph 7,b7 & ins]t+ ! foll[+3 7,b7 ,ma9t5ance ( heal? opportunity acc\nt aft] becom+ ineligible = public b5efit ,not)/&+ any o!r provision ( law1 if an acc\nt hold] ( a heal? opportunity acc\nt becomes ineligible = b5efits "u ?is title because ( an increase 9 income or assets-- 7i7 no additional contribution %all be made into ! acc\nt "u p>agraph 7#b77;,a77i72 & 7ii7 ! acc\nt %all rema9 available to ! acc\nt hold] = #c ye>s aft] ! date on :i* ! individual becomes ineligible = su* b5efits = )drawals "u ! same t]ms & conditions z if ! acc\nt hold] rema9$ eligible = su* b5efits1 & su* )drawals %all be treat$ z m$ical assi/ance 9 accordance ) subsection 7c77#d74 4 7b7 ,con=m+ am5dm5t ,section #fac ( ,public ,law #aaa-c is repeal$4 ,b ,o!r provisions #eca4 ,c]ta9 ex]cise equipm5t & physical fitness programs treat$ z m$ical c>e 7a7 ,9 g5]al ,subsection 7d7 ( section #bac is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ab7 ,ex]cise equipm5t & physical fitness programs 7,a7 ,9 g5]al ,! t]m m$ical c>e %all include am\nts paid-- 7i7 to pur*ase or use equipm5t us$ 9 a program 7includ+ a self-direct$ program7 ( physical ex]cise1 7ii7 to p>ticipate1 or receive in/ruction1 9 a program ( physical ex]cise1 & 7iii7 = memb]%ip dues 9 a fitness club ! prim>y purpose ( :i* is to provide access to equipm5t & facilities = physical ex]cise4 7,b7 ,limitation ,am\nts treat$ z m$ical c>e "u subp>agraph 7,a7 %all n exce$ #a1jjj ) respect to any individual = any taxable ye>4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #ecb4 ,c]ta9 nutritional & diet>y supplem5ts to be treat$ z m$ical c>e 7a7 ,9 g5]al ,subsection 7d7 ( section #bac1 z am5d$ by section #fca1 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ac7 ,nutritional & diet>y supplem5ts 7,a7 ,9 g5]al ,! t]m m$ical c>e %all include am\nts paid to pur*ase h]bs1 vitam9s1 m9]als1 homeopa?ic rem$ies1 meal replacem5t products1 & o!r diet>y & nutritional supplem5ts4 7,b7 ,limitation ,am\nts treat$ z m$ical c>e "u subp>agraph 7,a7 %all n exce$ #a1jjj ) respect to any individual = any taxable ye>4 7,c7 ,meal replacem5t product ,= purposes ( ?is p>agraph1 ! t]m meal replacem5t product means any product t-- 7i7 is p]mitt$ to be> label+ mak+ a claim describ$ 9 section #djc7r77#c7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act1 & 7ii7 is p]mitt$ to claim "u su* section t su* product is l[ 9 fat & is a good s\rce ( prote91 fib]1 & multiple ess5tial vitam9s & m9]als4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #ecc4 ,c]ta9 provid] fees to be treat$ z m$ical c>e 7a7 ,9 g5]al ,subsection 7d7 ( section #bac1 z am5d$ by sections #fca & #fcb1 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ad7 ,p]iodic provid] fees ,! t]m m$ical c>e %all include p]iodic fees paid to a prim>y physician1 physician assi/ant1 or nurse practition] = ! "r to receive m$ical s]vices on an z-ne$$ basis4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 ,,vi ,cov]+ ,p ) ,pre-,exi/+ ,conditions1 ,remov+ ,annual & ,lifetime ,cov]age ,caps1 & ,exp&+ ,access to ,c>e ,a ,mak+ ,heal? ,c>e ,cov]age ,af=dable = ,e ,am]ican #a ,ensur+ cov]age = individuals ) preexi/+ conditions & multiple heal? c>e ne$s #fja4 ,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 ,janu>y #a1 #bjad1 ea* ,/ate %all-- 7,a7 subject to p>agraph 7#c71 op]ate-- 7i7 a qualifi$ ,/ate re9surance program describ$ 9 subsection 7b72 or 7ii7 qualify+ ,/ate high risk pool describ$ 9 subsection 7c77#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 ,act-- 7i7 ! ,/ate may only meet ! requirem5t ( p>agraph 7#a7 ?r\gh ! op]ation ( a qualifi$ ,/ate re9surance program describ$ 9 subsection 7b72 & 7ii7 ! ,/ate's op]ation ( su* a re9surance program %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 ,act-- 7i7 z ( ,janu>y #a1 #bjad1 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 7c77#a72 & 7ii7 ! ,/ate may use premium assessm5t funds describ$ 9 p>agraph 7#a77;,b7 to transition f op]ation ( su* a pool to op]ation ( a qualifi$ ,/ate re9surance program describ$ 9 subsection 7b74 7#c7 ,application ( funds ,if ! program or 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 ,qualifi$ ,/ate re9surance program 7#a7 ,9 g5]al ,= purposes ( ?is section1 a qualifi$ ,/ate re9surance program means a program op]at$ by a ,/ate program t provides re9surance = heal? insurance cov]age (f]$ 9 ! small gr\p m>ket 9 accordance ) ! model = su* a program e/abli%$ 7z ( ! date ( ! enactm5t ( ?is ,act74 7#b7 ,=m ( program ,a qualifi$ ,/ate re9surance program may provide re9surance-- 7,a7 on a prospective or retrospective basis2 & 7,b7 on a basis t protects heal? insurance issu]s aga9/ ! annual aggregate sp5d+ ( _! enrollees z well z pur*ase protection aga9/ individual cata/rophic co/s4 7#c7 ,satisfaction ( ,,hipaa requirem5t ,a qualifi$ ,/ate re9surance program %all be deem$1 = purposes ( section #bgde ( ! ,public ,heal? ,s]vice ,act1 to be a qualifi$ high risk pool "u su* section4 7c7 ,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/ provide at lea/ two cov]age options1 "o ( :i* mu/ be a high d$uctible heal? plan c\pl$ ) a heal? sav+s acc\nt4 7,b7 ,! pool mu/ be fund$ ) a /able fund+ s\rce4 7,c7 ,! 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,d7 ,! 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,e7 ,! pool mu/ limit ! pool premiums to no m ?an #aej p]c5t ( ! av]age premium = applicable /&>d risk rates 9 t ,/ate4 7,f7 ,! pool mu/ conduct education & outrea* initiatives s t resid5ts & brok]s und]/& t ! pool is available to eligible resid5ts4 7,g7 ,! pool mu/ provide cov]age = prev5tive s]vices & disease managem5t = *ronic diseases4 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 #bjad1 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 7d7 ,waiv]s ,9 ord] to accommodate new & innovative programs1 ! ,secret>y may waive su* requirem5ts ( ?is section = qualifi$ ,/ate re9surance programs & = qualify+ ,/ate high risk pools z ! ,secret>y deems appropriate4 7e7 ,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 program or pool describ$ 9 subsection 7a77#a77-- 7#a7 #ae1jjj1jjj1jjj = ! p]iod ( fiscal ye>s #bjad ?r\gh #bjbc2 & 7#b7 an additional #aj1jjj1jjj1jjj = ! p]iod ( fiscal ye>s #bjai ?r\gh #bjbc4 7f7 ,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 #fjb4 ,elim9ation ( c]ta9 requirem5ts = gu>ante$ availability 9 individual m>ket 7a7 ,9 g5]al ,section #bgda7;b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#da7;b77 is am5d$-- 7#a7 9 p>agraph 7#a7-- 7,a7 by /rik+ 7#a77;,a7 & ins]t+ 7#a72 & 7,b7 by /rik+ & 7,b7 & all t foll[s up to ! semicolon at ! end2 7#b7 by add+ & at ! end ( p>agraph 7#b72 7#c7 9 p>agraph 7#c7-- 7,a7 by /rik+ 7#a77;,a7 & ins]t+ 7#a72 & 7,b7 by /rik+ ! semicolon at ! end & ins]t+ a p]iod2 & 7#d7 by /rik+ p>agraphs 7#d7 & 7#e74 7b7 ,effective date ,! am5dm5ts made by subsection 7a7 %all take effect on ! date ( ! enactm5t ( ?is ,act4 #fjc4 ,no annual or lifetime sp5d+ caps 7a7 ,9 g5]al ,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 ,! re/riction ( ! previ\s s5t5ce %all n apply ) respect to a heal? insurance cov]age or plan if1 z ( ! date ( ! enactm5t ( ?is ,act1 x w\ld result 9 a significant decrease 9 access to b5efits "u ! plan or w\ld significantly increase premiums "u ! plan4 7b7 ,application ,subsection 7a7 %all be en=c$ z if x 7 includ$ z a provision 9 p>ts ,a & ,b ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7z su* title is 9 effect aft] ! date ( repeal ( ,public ,law #aaa-adh "u section #aja74 #fjd4 ,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-#db7 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 ,act 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 #faa4 ,/ate innovation programs 7a7 ,programs t r$uce ! co/ ( heal? insurance premiums 7#a7 ,paym5ts to ,/ates 7,a7 ,= premium r$uctions 9 ! small gr\p m>ket ,if ! ,secret>y det]m9es t a ,/ate has r$uc$ ! av]age p] capita premium = heal? insurance cov]age 9 ! small gr\p m>ket 9 ye> #c1 9 ye> #f1 or ye> #i 7z def9$ 9 subsection 7c77 bel[ ! premium basel9e = su* ye> 7z def9$ p>agraph 7#b771 ! ,secret>y %all pay ! ,/ate an am\nt equal to ! product (-- 7i7 bonus premium p]c5tage 7z def9$ 9 p>agraph 7#c77 = ! ,/ate1 m>ket1 & ye>2 & 7ii7 ! maximum ,/ate premium paym5t am\nt 7z def9$ 9 p>agraph 7#d77 = ! ,/ate1 m>ket1 & ye>4 7,b7 ,= premium r$uctions 9 ! individual m>ket ,if ! ,secret>y det]m9es t a ,/ate has r$uc$ ! av]age p] capita premium = heal? insurance cov]age 9 ! individual m>ket 9 ye> #c1 9 ye> #f1 or 9 ye> #i bel[ ! premium basel9e = su* ye>1 ! ,secret>y %all pay ! ,/ate an am\nt equal to ! product (-- 7i7 bonus premium p]c5tage = ! ,/ate1 m>ket1 & ye>2 & 7ii7 ! maximum ,/ate premium paym5t am\nt = ! ,/ate1 m>ket1 & ye>4 7#b7 ,premium basel9e ,= purposes ( ?is subsection1 ! t]m premium basel9e means1 = a m>ket 9 a ,/ate-- 7,a7 = ye> #a1 ! av]age p] capita premiums = heal? insurance cov]age 9 su* m>ket 9 ! ,/ate 9 su* ye>2 or 7,b7 = a subsequ5t ye>1 ! basel9e = ! m>ket 9 ! ,/ate = ! previ\s ye> "u ?is p>agraph increas$ by a p]c5tage specifi$ 9 accordance ) a =mula e/abli%$ by ! ,secret>y1 9 consultation ) ! ,congressional ,budget ,(fice & ! ,bureau ( ! ,c5sus1 t takes into acc\nt at lea/ ! foll[+3 7i7 ,gr[? factor ,! inflation 9 ! co/s ( inputs to heal? c>e s]vices 9 ! ye>4 7ii7 ,hi/oric premium gr[? rates ,hi/oric gr[? rates1 dur+ ! #aj ye>s be=e ye> #a1 ( p] capita premiums = heal? insurance cov]age4 7iii7 ,demographic consid]ations ,hi/oric av]age *anges 9 ! demographics ( ! population cov]$ t impact on ! rate ( gr[? ( p] capita heal? c>e co/s4 7#c7 ,bonus premium p]c5tage def9$ 7,a7 ,9 g5]al ,= purposes ( ?is subsection1 ! t]m bonus premium p]c5tage means1 = ! small gr\p m>ket or individual m>ket 9 a ,/ate = a ye>1 su* p]c5tage z det]m9$ 9 accordance ) ! foll[+ table bas$ on ! ,/ate's premium p]=mance level 7z def9$ 9 subp>agraph 7,b77 = su* m>ket & ye>3 ,! bonus premium p]c5tage = a ,/ate is--,= ye> #c if ! premium p]=mance level ( ! ,/ate is--,= ye> #f if ! premium p]=mance level ( ! ,/ate is--,= ye> #i if ! premium p]=mance level ( ! ,/ate is--#ajj p]c5t at lea/ #h4e at lea/ #aa;at lea/ #ac4e #ej p]c5t at lea/ #f4ch1 b less ?an #h4e;at lea/ #aj4ch1 b less ?an #aa;at lea/ #ab4hh1 b less ?an #ac4e #be p]c5t at lea/ #d4be1 b less ?an #f4ch at lea/ #i4ge1 b less ?an #aj4ch at lea/ #ab4be1 b less ?an #ab4hh #j p]c5tless ?an #d4beless ?an #i4geless ?an #ab4be4 7,b7 ,premium p]=mance level ,= purposes ( ?is subsection1 ! t]m premium p]=mance level means1 = a ,/ate1 m>ket1 & ye>1 ! p]c5tage r$uction 9 ! av]age p] capita premiums = heal? insurance cov]age = ! ,/ate1 m>ket1 & ye>1 z comp>$ to ! premium basel9e = su* ,/ate1 m>ket1 & ye>4 7#d7 ,maximum ,/ate premium paym5t am\nt def9$ ,= purposes ( ?is subsection1 ! t]m maximum ,/ate premium paym5t am\nt means1 = a ,/ate = ! small gr\p m>ket or ! individual m>ket = a ye>1 ! product (-- 7,a7 ! proportion 7z det]m9$ by ! ,secret>y71 ( ! numb] ( noneld]ly individuals lawfully resid+ 9 all ! ,/ates :o are enroll$ 9 heal? insurance cov]age 9 ! respective m>ket 9 ! ye>1 :o are resid5ts ( ! ,/ate2 & 7,b7 ! am\nt available = obligation f am\nts appropriat$ "u subsection 7d7 = su* m>ket ) respect to p]=mance 9 su* ye>4 7#e7 ,me?odology = calculat+ av]age p] capita premiums 7,a7 ,e/abli%m5t ,! ,secret>y %all e/abli%1 by rule & consi/5t ) ?is subsection1 a me?odology = comput+ ! av]age p] capita premiums = heal? insurance cov]age = ! small gr\p m>ket & = ! individual m>ket 9 ea* ,/ate = ea* ye> beg9n+ ) ye> #a4 7,b7 ,adju/m5ts ,"u su* me?odology1 ! ,secret>y %all provide = ! foll[+ adju/m5ts 79 a mann] det]m9$ appropriate by ! ,secret>y73 7i7 ,exclusion ( illegal ali5s ,an adju/m5t s z n to take into acc\nt enrollees :o are n lawfully pres5t 9 ! ,unit$ ,/ates & _! premium co/s4 7ii7 ,treat+ ,/ate premium subsidies z premium co/s ,an adju/m5t s z to increase p] capita premiums to remove ! impact ( premium subsidies made directly by a ,/ate to r$uce heal? insurance premiums4 7#f7 ,conditions ( paym5t ,z a condition ( receiv+ a paym5t "u p>agraph 7#a71 a ,/ate mu/ agree to submit aggregate1 non-individually id5tifiable data to ! ,secret>y1 9 a =m & mann] specifi$ by ! ,secret>y1 = use by ! ,secret>y to det]m9e ! ,/ate's premium basel9e & premium p]=mance level = purposes ( ?is subsection4 7b7 ,programs t r$uce ! numb] ( un9sur$ 7#a7 ,9 g5]al ,if ! ,secret>y det]m9es t a ,/ate has r$uc$ ! p]c5tage ( un9sur$ noneld]ly resid5ts 9 ye> #e1 ye> #g1 or ye> #i1 bel[ ! un9sur$ basel9e 7z def9$ 9 p>agraph 7#b77 = ! ,/ate = ! ye>1 ! ,secret>y %all pay ! ,/ate an am\nt equal to ! product (-- 7,a7 bonus un9sur$ p]c5tage 7z def9$ 9 p>agraph 7#c77 = ! ,/ate & ye>2 & 7,b7 ! maximum un9sur$ paym5t am\nt 7z def9$ 9 p>agraph 7#d77 = ! ,/ate & ye>4 7#b7 ,un9sur$ basel9e 7,a7 ,9 g5]al ,= purposes ( ?is subsection1 & subject to subp>agraph 7,b71 ! t]m un9sur$ basel9e means1 = a ,/ate1 ! p]c5tage ( noneld]ly resid5ts 9 ! ,/ate :o are un9sur$ 9 ye> #a4 7,b7 ,adju/m5t ,! ,secret>y may1 at ! writt5 reque/ ( a ,/ate1 adju/ ! un9sur$ basel9e = ,/ates = a ye> to take into acc\nt unanticipat$ & exceptional *anges1 su* z an unanticipat$ migration1 ( noneld]ly individuals into1 or out (1 ,/ates 9 a mann] t does n reflect sub/antially ! proportion ( un9sur$ noneld]ly resid5ts 9 ! ,/ates involv$ 9 ye> #a4 ,any su* adju/m5t %all only be done 9 a mann] t does n result 9 ! av]age ( ! un9sur$ basel9es = noneld]ly resid5ts = all ,/ates be+ *ang$4 7#c7 ,bonus un9sur$ p]c5tage 7,a7 ,bonus un9sur$ p]c5tage ,= purposes ( ?is subsection1 ! t]m bonus un9sur$ p]c5tage means1 = a ,/ate = a ye>1 su* p]c5tage z det]m9$ 9 accordance ) ! foll[+ table1 bas$ on ! un9sur$ p]=mance level 7z def9$ 9 subp>agraph 7,b77 = su* ,/ate & ye>3 ,! bonus un9sur$ p]c5tage = a ,/ate is--,= ye> #e if ! un9sur$ p]=mance level ( ! ,/ate is--,= ye> #g if ! un9sur$ p]=mance level ( ! ,/ate is--,= ye> #i if ! un9sur$ p]=mance level ( ! ,/ate is--#ajj p]c5t at lea/ #aj at lea/ #ae;at lea/ #bj #ej p]c5t at lea/ #g4e b less ?an #aj;at lea/ #ac4ge b less ?an #ae at lea/ #ah4ge b less ?an #bjbe p]c5t at lea/ #e b less ?an #g4e;at lea/ #ab4e b less ?an #ac4ge;at lea/ #ag4e b less ?an #ah4gej p]c5tless ?an #eless ?an #ab4eless ?an #ag4e4 7,b7 ,un9sur$ p]=mance level ,= purposes ( ?is subsection1 ! t]m un9sur$ p]=mance level means1 = a ,/ate = a ye>1 ! r$uction 7express$ z a p]c5tage7 9 ! p]c5tage ( un9sur$ noneld]ly resid5ts 9 su* ,/ate 9 ! ye> z comp>$ to ! un9sur$ basel9e = su* ,/ate = su* ye>4 7#d7 ,maximum ,/ate un9sur$ paym5t am\nt def9$ ,= purposes ( ?is subsection1 ! t]m maximum ,/ate un9sur$ paym5t am\nt means1 = a ,/ate = a ye>1 ! product (-- 7,a7 ! proportion 7z det]m9$ by ! ,secret>y71 ( ! numb] ( un9sur$ noneld]ly individuals lawfully resid+ 9 all ! ,/ates 9 ! ye>1 :o are resid5ts ( ! ,/ate2 & 7,b7 ! am\nt available = obligation "u ?is subsection f am\nts appropriat$ "u subsection 7d7 ) respect to p]=mance 9 su* ye>4 7#e7 ,me?odology = comput+ ! p]c5tage ( un9sur$ noneld]ly resid5ts 9 a ,/ate 7,a7 ,e/abli%m5t ,! ,secret>y %all e/abli%1 by rule & consi/5t ) ?is subsection1 a me?odology = comput+ ! p]c5tage ( noneld]ly resid5ts 9 a ,/ate :o are un9sur$ 9 ea* ye> beg9n+ ) ye> #a4 7,b7 ,rules 7i7 ,treatm5t ( un9sur$ ,su* me?odology %all treat z un9sur$ ^? resid5ts :o d n h heal? insurance cov]age or o!r cr$itable cov]age 7z def9$ 9 section #ihja7;c77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf71 except t su* me?odology %all rely ^u data on ! noneld]ly & un9sur$ populations )9 ea* ,/ate 9 su* ye> provid$ ?r\gh population surveys conduct$ by f$]al ag5cies4 7ii7 ,limitation to noneld]ly ,su* me?odology %all exclude individuals :o are #fe ye>s ( age or old]4 7iii7 ,exclusion ( illegal ali5s ,su* me?odology %all exclude individuals n lawfully pres5t 9 ! ,unit$ ,/ates4 7#f7 ,conditions ( paym5t ,z a condition ( receiv+ a paym5t "u p>agraph 7#a71 a ,/ate mu/ agree to submit aggregate1 non-individually id5tifiable data to ! ,secret>y1 9 a =m & mann] specifi$ by ! ,secret>y1 = use by ! ,secret>y 9 det]m9+ ! ,/ate's un9sur$ basel9e & un9sur$ p]=mance level = purposes ( ?is subsection4 7c7 ,def9itions ,= purposes ( ?is section3 7#a7 ,gr\p heal? plan ,! t]m gr\p heal? plan has ! mean+ giv5 su* t]m 9 section #ihcb7;a7 ( ! ,int]nal ,rev5ue ,code ( #aihf4 7#b7 ,heal? insurance cov]age ,! t]m heal? insurance cov]age has ! mean+ giv5 su* t]m 9 section #ihcb7;b77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf4 7#c7 ,individual m>ket ,except z ! ,secret>y may o!rwise provide 9 ! case ( gr\p heal? plans t h few] ?an #b p>ticipants z curr5t employees on ! fir/ day ( a plan ye>1 ! 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#d7 ,secret>y ,! t]m ,secret>y means ! ,secret>y ( ,heal? & ,human ,s]vices4 7#e7 ,small gr\p m>ket ,! t]m small gr\p m>ket means ! m>ket = heal? insurance cov]age "u :i* individuals obta9 heal? insurance cov]age 7directly or ?r\gh any arrangem5t7 on behalf ( !mselves 7& _! dep5d5ts7 ?r\gh a gr\p heal? plan ma9ta9$ by an employ] :o employ$ on av]age at lea/ #b b n m ?an #ej employees on bus9ess days dur+ a cal5d> ye>4 7#f7 ,/ate ,! t]m ,/ate means any ( ! #ej ,/ates & ! ,di/rict ( ,columbia4 7#g7 ,ye>s ,! t]ms ye> #a1 ye> #b1 ye> #c1 & simil> subsequ5tly numb]$ ye>s mean #bjad1 #bjae1 #bjaf1 & subsequ5t sequ5tially numb]$ ye>s4 7d7 ,appropriations2 paym5ts 7#a7 ,paym5ts = r$uctions 9 co/ ( heal? insurance cov]age 7,a7 ,small gr\p m>ket 7i7 ,9 g5]al ,f any funds 9 ! ,treasury n o!rwise appropriat$1 !re is appropriat$ = paym5ts "u subsection 7a77#a77;,a7-- 7,i7 #ah1jjj1jjj1jjj ) respect to p]=mance 9 ye> #c2 7,,ii7 #e1jjj1jjj1jjj ) respect to p]=mance 9 ye> #f2 & 7,,iii7 #b1jjj1jjj1jjj ) respect to p]=mance 9 ye> #i4 7ii7 ,availability ( appropriat$ funds ,funds appropriat$ "u clause 7i7 %all rema9 available until exp5d$4 7,b7 ,individual m>ket 7i7 ,9 g5]al ,subject to clause 7ii71 f any funds 9 ! ,treasury n o!rwise appropriat$1 !re is appropriat$ = paym5ts "u subsection 7a77#a77;,b7-- 7,i7 #g1jjj1jjj1jjj ) respect to p]=mance 9 ye> #c2 7,,ii7 #b1jjj1jjj1jjj ) respect to p]=mance 9 ye> #f2 & 7,,iii7 #a1jjj1jjj1jjj ) respect to p]=mance 9 ye> #i4 7ii7 ,availability ( appropriat$ funds ,( ! funds appropriat$ "u clause 7i7 t are n exp5d$ or obligat$ by ! end ( ! ye> foll[+ ! ye> = :i* ! funds are appropriat$-- 7,i7 #ge p]c5t %all rema9 available until exp5d$ = paym5ts "u subsection 7a77#a77;,b72 & 7,,ii7 #be p]c5t %all rema9 available until exp5d$ = paym5ts "u subsection 7a77#a77;,a74 7#b7 ,paym5ts = r$uctions 9 ! p]c5tage ( un9sur$ 7,a7 ,9 g5]al ,f any funds 9 ! ,treasury n o!rwise appropriat$1 !re is appropriat$ = paym5ts "u subsection 7b77#a7-- 7i7 #aj1jjj1jjj1jjj ) respect to p]=mance 9 ye> #e2 7ii7 #c1jjj1jjj1jjj ) respect to p]=mance 9 ye> #g2 & 7iii7 #b1jjj1jjj1jjj ) respect to p]=mance 9 ye> #i4 7,b7 ,availability ( appropriat$ funds ,funds appropriat$ "u subp>agraph 7,a7 %all rema9 available until exp5d$4 7#c7 ,paym5t tim+ ,paym5ts "u ?is section %all be made 9 a =m & mann] specifi$ by ! ,secret>y 9 ! ye> aft] ! p]=mance ye> involv$4 #fab4 ,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 plan74 ,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 #fac4 ,adm9i/rative simplification 7a7 ,op]at+ ,rules = ,heal? ,in=mation ,transactions 7#a7 ,def9ition ( op]at+ rules ,section #aaga ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d7 is am5d$ by add+ at ! end ! foll[+3 7#i7 ,op]at+ rules ,! t]m op]at+ rules means ! necess>y bus9ess rules & guidel9es = ! electronic ex*ange ( in=mation t are n def9$ by a /&>d or its implem5tation specifications z adopt$ = purposes ( ?is "p4 4 7#b7 ,op]at+ rules & compliance ,section #aagc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d-#b7 is am5d$-- 7,a7 9 subsection 7a77#b71 by add+ at ! end ! foll[+ new subp>agraph3 7,j7 ,electronic funds transf]s4 2 & 7,b7 by add+ at ! end ! foll[+ new subsections3 7g7 ,op]at+ rules 7#a7 ,9 g5]al ,! ,secret>y %all adopt a s+le set ( op]at+ rules = ea* transaction describ$ 9 subsection 7a77#b7 ) ! goal ( creat+ z mu* uni=mity 9 ! implem5tation ( ! electronic /&>ds z possible4 ,su* op]at+ rules %all be cons5sus-bas$ & reflect ! necess>y bus9ess rules affect+ heal? plans & heal? c>e provid]s & ! mann] 9 :i* !y op]ate pursuant to /&>ds issu$ "u ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif4 7#b7 ,op]at+ rules developm5t ,9 adopt+ op]at+ rules "u ?is subsection1 ! ,secret>y %all rely on recomm5dations = op]at+ rules develop$ by a qualifi$ nonpr(it entity1 z select$ by ! ,secret>y1 t meets ! foll[+ requirem5ts3 7,a7 ,! entity focuses its mission on adm9i/rative simplification4 7,b7 ,! entity demon/rates an e/abli%$ multi-/akehold] & cons5sus-bas$ process = developm5t ( op]at+ rules1 includ+ repres5tation by or p>ticipation f heal? plans1 heal? c>e provid]s1 v5dors1 relevant ,f$]al ag5cies1 & o!r /&>d developm5t organizations4 7,c7 ,! entity has e/abli%$ a public set ( guid+ pr9ciples t ensure ! op]at+ rules & process are op5 & transp>5t4 7,d7 ,! entity coord9ates its activities ) ! ,,hit ,policy ,committee & ! ,,hit ,/&>ds ,committee 7z e/abli%$ "u title ,,xxx ( ! ,public ,heal? ,s]vice ,act7 & complem5ts ! ef=ts ( ! ,(fice ( ! ,national ,heal?c>e ,coord9ator & its relat$ heal? in=mation ex*ange goals4 7,e7 ,! entity incorporates national /&>ds1 includ+ ! transaction /&>ds issu$ "u ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif4 7,f7 ,! entity supports nondiscrim9ation & conflict ( int]e/ policies t demon/rate a commitm5t to op51 fair1 & nondiscrim9atory practices4 7,g7 ,! entity all[s = public review & updates ( ! op]at+ rules4 7#c7 ,review & recomm5dations ,! ,national ,committee on ,vital & ,heal? ,/ati/ics %all-- 7,a7 review ! op]at+ rules develop$ by a nonpr(it entity describ$ "u p>agraph 7#b72 7,b7 det]m9e :e!r su* rules repres5t a cons5sus view ( ! heal? c>e indu/ry & are consi/5t ) & d n alt] curr5t /&>ds2 7,c7 evaluate :e!r su* rules are consi/5t ) electronic /&>ds adopt$ = heal? in=mation te*nology2 & 7,d7 submit to ! ,secret>y a recomm5dation z to :e!r ! ,secret>y %\ld adopt su* rules4 7#d7 ,implem5tation 7,a7 ,9 g5]al ,! ,secret>y %all adopt op]at+ rules "u ?is subsection1 by regulation 9 accordance ) subp>agraph 7,c71 foll[+ consid]ation ( ! rules develop$ by ! non-pr(it entity describ$ 9 p>agraph 7#b7 & ! recomm5dation submitt$ by ! ,national ,committee on ,vital & ,heal? ,/ati/ics "u p>agraph 7#c77;,d7 & hav+ ensur$ consultation ) provid]s4 7,b7 ,adoption requirem5ts2 effective dates 7i7 ,eligibility = a heal? plan & heal? claim /atus ,! set ( op]at+ rules = transactions = eligibility = a heal? plan & heal? claim /atus %all be adopt$ n lat] ?an ,july #a1 #bjae1 9 a mann] ensur+ t su* rules are effective n lat] ?an ,janu>y #a1 #bjag1 & may all[ = ! use ( a ma*9e readable id5tification c>d4 7ii7 ,electronic funds transf]s & heal? c>e paym5t & remittance advice ,! set ( op]at+ rules = electronic funds transf]s & heal? c>e paym5t & remittance advice %all be adopt$ n lat] ?an ,july #a1 #bjaf1 9 a mann] ensur+ t su* rules are effective n lat] ?an ,janu>y #a1 #bjah4 7iii7 ,o!r complet$ transactions ,! set ( op]at+ rules = ! rema9d] ( ! complet$ transactions describ$ 9 subsection 7a77#b71 includ+ heal? claims or equival5t enc\nt] in=mation1 enrollm5t & dis5rollm5t 9 a heal? plan1 heal? plan premium paym5ts1 & ref]ral c]tification & au?orization1 %all be adopt$ n lat] ?an ,july #a1 #bjah1 9 a mann] ensur+ t su* rules are effective n lat] ?an ,janu>y #a1 #bjbj4 7,c7 ,exp$it$ rulemak+ ,! ,secret>y %all promulgate an int]im f9al rule apply+ any /&>d or op]at+ rule recomm5d$ by ! ,national ,committee on ,vital & ,heal? ,/ati/ics pursuant to p>agraph 7#c74 ,! ,secret>y %all accept public comm5ts on any int]im f9al rule publi%$ "u ?is subp>agraph = #fj days aft] ! date ( su* publication4 7h7 ,compliance 7#a7 ,heal? plan c]tification 7,a7 ,eligibility = a heal? plan1 heal? claim /atus1 electronic funds transf]s1 heal? c>e paym5t & remittance advice ,n lat] ?an ,decemb] #ca1 #bjag1 a heal? plan %all file a /atem5t ) ! ,secret>y1 9 su* =m z ! ,secret>y may require1 c]tify+ t ! data & in=mation sy/ems = su* plan are 9 compliance ) any applicable /&>ds 7z describ$ "u p>agraph 7#g7 ( section #aaga7 & op]at+ rules 7z describ$ "u p>agraph 7#i7 ( su* section7 = electronic funds transf]s1 eligibility = a heal? plan1 heal? claim /atus1 & heal? c>e paym5t & remittance advice1 respectively4 7,b7 ,o!r complet$ transactions ,n lat] ?an ,decemb] #ca1 #bjai1 a heal? plan %all file a /atem5t ) ! ,secret>y1 9 su* =m z ! ,secret>y may require1 c]tify+ t ! data & in=mation sy/ems = su* plan are 9 compliance ) any applicable /&>ds & op]at+ rules = ! rema9d] ( ! complet$ transactions describ$ 9 subsection 7a77#b71 includ+ heal? claims or equival5t enc\nt] in=mation1 enrollm5t & dis5rollm5t 9 a heal? plan1 heal? plan premium paym5ts1 & ref]ral c]tification & au?orization1 respectively4 ,a heal? plan %all provide ! same level ( docum5tation to c]tify compliance ) su* transactions z is requir$ to c]tify compliance ) ! transactions specifi$ 9 subp>agraph 7,a74 7#b7 ,docum5tation ( compliance ,a heal? plan %all provide ! ,secret>y1 9 su* =m z ! ,secret>y may require1 ) adequate docum5tation ( compliance ) ! /&>ds & op]at+ rules describ$ "u p>agraph 7#a74 ,a heal? plan %all n be consid]$ to h provid$ adequate docum5tation & %all n be c]tifi$ z be+ 9 compliance ) su* /&>ds1 unless ! heal? plan-- 7,a7 demon/rates to ! ,secret>y t ! plan conducts ! electronic transactions specifi$ 9 p>agraph 7#a7 9 a mann] t fully complies ) ! regulations ( ! ,secret>y2 & 7,b7 provides docum5tation %[+ t ! plan has complet$ end-to-end te/+ = su* transactions ) _! p>tn]s1 su* z hospitals & physicians4 7#c7 ,s]vice contracts ,a heal? plan %all be requir$ to comply ) any applicable c]tification & compliance requirem5ts 7& provide ! ,secret>y ) adequate docum5tation ( su* compliance7 "u ?is subsection = any entities t provide s]vices pursuant to a contract ) su* heal? plan4 7#d7 ,c]tification by outside entity ,! ,secret>y may contract ) an indep5d5t1 outside entity to c]tify t a heal? plan has compli$ ) ! requirem5ts "u ?is subsection1 provid$ t ! c]tification /&>ds employ$ by su* entities are 9 accordance ) any /&>ds or rules issu$ by ! ,secret>y4 7#e7 ,compliance ) revis$ /&>ds & rules ,a heal? plan 7includ+ entities describ$ "u p>agraph 7#c77 %all comply ) ! c]tification & docum5tation requirem5ts "u ?is subsection = any int]im f9al rule promulgat$ by ! ,secret>y "u subsection 7i7 t am5ds any /&>d or op]at+ rule describ$ "u p>agraph 7#a7 ( ?is subsection4 ,a heal? plan %all comply ) su* requirem5ts n lat] ?an ! effective date ( ! applicable int]im f9al rule4 7#f7 ,audits ( heal? plans ,! ,secret>y %all conduct p]iodic audits to ensure t heal? plans 7includ+ entities describ$ "u p>agraph 7#c77 are 9 compliance ) any /&>ds & op]at+ rules t are describ$ "u p>agraph 7#a74 7i7 ,review & am5dm5t ( /&>ds & rules 7#a7 ,e/abli%m5t ,n lat] ?an ,janu>y #a1 #bjah1 ! ,secret>y %all e/abli% a review committee 7z describ$ "u p>agraph 7#d774 7#b7 ,evaluations & ,reports 7,a7 ,he>+s ,n lat] ?an ,april #a1 #bjah1 & n less ?an bi5nially !reaft]1 ! ,secret>y1 act+ ?r\gh ! review committee1 %all conduct he>+s to evaluate & review ! exi/+ /&>ds & op]at+ rules e/abli%$ "u ?is section4 7,b7 ,report ,n lat] ?an ,july #a1 #bjah1 & n less ?an bi5nially !reaft]1 ! review committee %all provide recomm5dations = updat+ & improv+ su* /&>ds & rules4 ,! review committee %all recomm5d a s+le set ( op]at+ rules p] transaction /&>d & ma9ta9 ! goal ( creat+ z mu* uni=mity z possible 9 ! implem5tation ( ! electronic /&>ds4 7#c7 ,int]im f9al rulemak+ 7,a7 ,9 g5]al ,any recomm5dations to am5d exi/+ /&>ds & op]at+ rules t h be5 approv$ by ! review committee & report$ to ! ,secret>y "u p>agraph 7#b77;,b7 %all be adopt$ by ! ,secret>y ?r\gh promulgation ( an int]im f9al rule n lat] ?an #ij days aft] receipt ( ! committee's report4 7,b7 ,public comm5t 7i7 ,public comm5t p]iod ,! ,secret>y %all accept public comm5ts on any int]im f9al rule publi%$ "u ?is p>agraph = #fj days aft] ! date ( su* publication4 7ii7 ,effective date ,! effective date ( any am5dm5t to exi/+ /&>ds or op]at+ rules t is adopt$ ?r\gh an int]im f9al rule publi%$ "u ?is p>agraph %all be #be mon?s foll[+ ! close ( su* public comm5t p]iod4 7#d7 ,review committee 7,a7 ,def9ition ,= ! purposes ( ?is subsection1 ! t]m review committee means a committee )9 ! ,dep>tm5t ( ,heal? & ,human s]vices t has be5 designat$ by ! ,secret>y to c>ry out ?is subsection1 includ+-- 7i7 ! ,national ,committee on ,vital & ,heal? ,/ati/ics2 or 7ii7 any appropriate committee z det]m9$ by ! ,secret>y4 7,b7 ,coord9ation ( ,,hit ,/&>ds ,9 develop+ recomm5dations "u ?is subsection1 ! review committee %all consid] ! /&>ds approv$ by ! ,(fice ( ! ,national ,coord9ator = ,heal? ,in=mation ,te*nology4 7j7 ,p5alties 7#a7 ,p5alty fee 7,a7 ,9 g5]al ,n lat] ?an ,april #a1 #bjah1 & annually !reaft]1 ! ,secret>y %all assess a p5alty fee 7z det]m9$ "u subp>agraph 7,b77 aga9/ a heal? plan t has fail$ to meet ! requirem5ts "u subsection 7h7 ) respect to c]tification & docum5tation ( compliance ) ! /&>ds 7& _! op]at+ rules7 z describ$ "u p>agraph 7#a7 ( su* subsection4 7,b7 ,fee am\nt ,subject to subp>agraphs 7,c71 7,d71 & 7,e71 ! ,secret>y %all assess a p5alty fee aga9/ a heal? plan 9 ! am\nt ( #a p] cov]$ life until c]tification is complete4 ,! p5alty %all be assess$ p] p]son cov]$ by ! plan = :i* its data sy/ems = major m$ical policies are n 9 compliance & %all be impos$ aga9/ ! heal? plan = ea* day t ! plan is n 9 compliance ) ! requirem5ts "u subsection 7h74 7,c7 ,additional p5alty = misrepres5tation ,a heal? plan t kn[+ly provides inaccurate or incomplete in=mation 9 a /atem5t ( c]tification or docum5tation ( compliance "u subsection 7h7 %all be subject to a p5alty fee t is d\ble ! am\nt t w\ld o!rwise be impos$ "u ?is subsection4 7,d7 ,annual fee increase ,! am\nt ( ! p5alty fee impos$ "u ?is subsection %all be increas$ on an annual basis by ! annual p]c5tage increase 9 total national heal? c>e exp5ditures1 z det]m9$ by ! ,secret>y4 7,e7 ,p5alty limit ,a p5alty fee assess$ aga9/ a heal? plan "u ?is subsection %all n exce$1 on an annual basis-- 7i7 an am\nt equal to #bj p] cov]$ life "u su* plan2 or 7ii7 an am\nt equal to #dj p] cov]$ life "u ! plan if su* plan has kn[+ly provid$ inaccurate or incomplete in=mation 7z describ$ "u subp>agraph 7,c774 7,f7 ,det]m9ation ( cov]$ individuals ,! ,secret>y %all det]m9e ! numb] ( cov]$ lives "u a heal? plan bas$ ^u ! mo/ rec5t /atem5ts & fil+s t h be5 submitt$ by su* plan to ! ,securities & ,ex*ange ,commission4 7#b7 ,notice & ,dispute ,proc$ure ,! ,secret>y %all e/abli% a proc$ure = assessm5t ( p5alty fees "u ?is subsection t provides a heal? plan ) reasonable notice & a dispute resolution proc$ure prior to provision ( a notice ( assessm5t by ! ,secret>y ( ! ,treasury 7z describ$ "u p>agraph 7#d77;,b774 7#c7 ,p5alty fee report ,n lat] ?an ,may #a1 #bjah1 & annually !reaft]1 ! ,secret>y %all provide ! ,secret>y ( ! ,treasury ) a report id5tify+ ^? heal? plans t h be5 assess$ a p5alty fee "u ?is subsection4 7#d7 ,collection ( p5alty fee 7,a7 ,9 ,g5]al ,! ,secret>y ( ! ,treasury1 act+ ?r\gh ! ,f9ancial ,managem5t ,s]vice1 %all adm9i/] ! collection ( p5alty fees f heal? plans t h be5 id5tifi$ by ! ,secret>y 9 ! p5alty fee report provid$ "u p>agraph 7#c74 7,b7 ,notice ,n lat] ?an ,augu/ #a1 #bjah1 & annually !reaft]1 ! ,secret>y ( ! ,treasury %all provide notice to ea* heal? plan t has be5 assess$ a p5alty fee by ! ,secret>y "u ?is subsection4 ,su* notice %all include ! am\nt ( ! p5alty fee assess$ by ! ,secret>y & ! due date = paym5t ( su* fee to ! ,secret>y ( ! ,treasury 7z describ$ 9 subp>agraph 7,c774 7,c7 ,paym5t due date ,paym5t by a heal? plan = a p5alty fee assess$ "u ?is subsection %all be made to ! ,secret>y ( ! ,treasury n lat] ?an ,novemb] #a1 #bjah1 & annually !reaft]4 7,d7 ,unpaid p5alty fees ,any am\nt ( a p5alty fee assess$ aga9/ a heal? plan "u ?is subsection = :i* paym5t has n be5 made by ! due date provid$ "u subp>agraph 7,c7 %all be-- 7i7 increas$ by ! int]e/ accru$ on su* am\nt1 z det]m9$ pursuant to ! und]paym5t rate e/abli%$ "u section #ffja ( ! ,int]nal ,rev5ue ,code ( #aihf2 & 7ii7 treat$ z a pa/-due1 legally en=ceable debt ow$ to a ,f$]al ag5cy = purposes ( section #fdjb7;d7 ( ! ,int]nal ,rev5ue ,code ( #aihf4 7,e7 ,adm9i/rative fees ,any fee *>g$ or allocat$ = collection activities conduct$ by ! ,f9ancial ,managem5t ,s]vice w be pass$ on to a heal? plan on a pro-rata basis & add$ to any p5alty fee collect$ f ! plan4 4 7b7 ,promulgation ( rules 7#a7 ,unique heal? plan id5tifi] ,! ,secret>y %all promulgate a f9al rule to e/abli% a unique heal? plan id5tifi] 7z describ$ 9 section #aagc7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d-#b7;b777 bas$ on ! input ( ! ,national ,committee ( ,vital & ,heal? ,/ati/ics4 ,! ,secret>y may d s on an int]im f9al basis & su* rule %all be effective n lat] ?an ,octob] #a1 #bjaf4 7#b7 ,electronic funds transf] ,! ,secret>y %all promulgate a f9al rule to e/abli% a /&>d = electronic funds transf]s 7z describ$ 9 section #aagc7;a77#b77;,j7 ( ! ,social ,security ,act1 z add$ by subsection 7a77#b77;,a774 ,! ,secret>y may d s on an int]im f9al basis & %all adopt su* /&>d n lat] ?an ,janu>y #a1 #bjaf1 9 a mann] ensur+ t su* /&>d is effective n lat] ?an ,janu>y #a1 #bjah4 7c7 ,expansion ( electronic transactions 9 ,m$ic>e ,section #ahfb7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77 is am5d$-- 7#a7 9 p>agraph 7#bc71 by /rik+ ! or at ! end2 7#b7 9 p>agraph 7#bd71 by /rik+ ! p]iod & ins]t+ 2 or2 & 7#c7 by ins]t+ aft] p>agraph 7#bd7 ! foll[+ new p>agraph3 7#be7 n lat] ?an ,janu>y #a1 #bjah1 = :i* ! paym5t is o!r ?an by electronic funds transf] 7,,eft7 or an electronic remittance 9 a =m z specifi$ 9 ,,asc ,x#ab #hce ,heal? ,c>e ,paym5t & ,remittance ,advice or subsequ5t /&>d4 4 7d7 ,m$ic>e & m$icaid compliance reports ,n lat] ?an ,july #a1 #bjag1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit a report to ! *airs & rank+ memb]s ( ! ,committee on ,ways & ,means & ! ,committee on ,en]gy & ,comm]ce ( ! ,h\se ( ,repres5tatives & ! *airs & rank+ memb]s ( ! ,committee on ,heal?1 ,education1 ,labor1 & ,p5sions & ! ,committee on ,f9ance ( ! ,s5ate on ! ext5t to :i* ! ,m$ic>e program & provid]s t s]ve b5efici>ies "u t program1 & ,/ate ,m$icaid programs & provid]s t s]ve b5efici>ies "u ^? programs1 transact electronically 9 accordance ) transaction /&>ds issu$ "u ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 "p ,c ( title ,,xi ( ! ,social ,security ,act1 & regulations promulgat$ "u su* ,acts4 ,b ,improv+ ,access to ,heal? ,c>e #a ,exp&+ ,access & ,l[]+ ,co/s = ,small ,bus9esses #fbj4 ,%ort title ,?is *apt] may be cit$ z ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjac4 #fba4 ,rules gov]n+ association heal? plans 7a7 ,9 ,g5]al ,subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by add+ aft] "p #g ! foll[+ new "p3 #h ,,rules ,,gov]n+ ,,association ,,heal? ,,plans #hja4 ,association heal? plans 7a7 ,9 ,g5]al ,= purposes ( ?is "p1 ! t]m association heal? plan means a gr\p heal? plan ^: sponsor is 7or is deem$ "u ?is "p to be7 describ$ 9 subsection 7b74 7b7 ,sponsor%ip ,! sponsor ( a gr\p heal? plan is describ$ 9 ?is subsection if su* sponsor-- 7#a7 is organiz$ & ma9ta9$ 9 good fai?1 ) a con/itution & bylaws specifically /at+ its purpose & provid+ = p]iodic meet+s on at lea/ an annual basis1 z a bona fide trade association1 a bona fide indu/ry association 7includ+ a rural electric coop]ative association or a rural telephone coop]ative association71 a bona fide pr(essional association1 or a bona fide *amb] ( comm]ce 7or simil> bona fide bus9ess association1 includ+ a corporation or simil> organization t op]ates on a coop]ative basis 7)9 ! mean+ ( section #acha ( ! ,int]nal ,rev5ue ,code ( #aihf771 = sub/antial purposes o!r ?an t ( obta9+ or provid+ m$ical c>e2 7#b7 is e/abli%$ z a p]man5t entity :i* receives ! active support ( its memb]s & requires = memb]%ip paym5t on a p]iodic basis ( dues or paym5ts necess>y to ma9ta9 eligibility = memb]%ip 9 ! sponsor2 & 7#c7 does n condition memb]%ip1 su* dues or paym5ts1 or cov]age "u ! plan on ! basis ( heal? /atus-relat$ factors ) respect to ! employees ( its memb]s 7or affiliat$ memb]s71 or ! dep5d5ts ( su* employees1 & does n condition su* dues or paym5ts on ! basis ( gr\p heal? plan p>ticipation4 ,any sponsor consi/+ ( an association ( entities :i* meet ! requirem5ts ( p>agraphs 7#a71 7#b71 & 7#c7 %all be deem$ to be a sponsor describ$ 9 ?is subsection4 #hjb4 ,c]tification ( association heal? plans 7a7 ,9 ,g5]al ,! applicable au?ority %all prescribe by regulation a proc$ure "u :i*1 subject to subsection 7b71 ! applicable au?ority %all c]tify association heal? plans :i* apply = c]tification z meet+ ! requirem5ts ( ?is "p4 7b7 ,/&>ds ,"u ! proc$ure prescrib$ pursuant to subsection 7a71 9 ! case ( an association heal? plan t provides at lea/ "o b5efit option :i* does n consi/ ( heal? insurance cov]age1 ! applicable au?ority %all c]tify su* plan z meet+ ! requirem5ts ( ?is "p only if ! applicable au?ority is satisfi$ t ! applicable requirem5ts ( ?is "p are met 7or1 ^u ! date on :i* ! plan is to comm5ce op]ations1 w be met7 ) respect to ! plan4 7c7 ,requirem5ts ,applicable to ,c]tifi$ ,plans ,an association heal? plan ) respect to :i* c]tification "u ?is "p is 9 effect %all meet ! applicable requirem5ts ( ?is "p1 effective on ! date ( c]tification 7or1 if lat]1 on ! date on :i* ! plan is to comm5ce op]ations74 7d7 ,requirem5ts = ,cont9u$ ,c]tification ,! applicable au?ority may provide by regulation = cont9u$ c]tification ( association heal? plans "u ?is "p4 7e7 ,class ,c]tification = ,fully ,insur$ ,plans ,! applicable au?ority %all e/abli% a class c]tification proc$ure = association heal? plans "u :i* all b5efits consi/ ( heal? insurance cov]age4 ,"u su* proc$ure1 ! applicable au?ority %all provide = ! grant+ ( c]tification "u ?is "p to ! plans 9 ea* class ( su* association heal? plans ^u appropriate fil+ "u su* proc$ure 9 connection ) plans 9 su* class & paym5t ( ! prescrib$ fee "u section #hjg7;a74 7f7 ,c]tification ( ,self-,insur$ ,association ,heal? ,plans ,an association heal? plan :i* (f]s "o or m b5efit options :i* d n consi/ ( heal? insurance cov]age may be c]tifi$ "u ?is "p only if su* plan consi/s ( any ( ! foll[+3 7#a7 a plan :i* (f]$ su* cov]age on ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjac1 7#b7 a plan "u :i* ! sponsor does n re/rict memb]%ip to "o or m trades & bus9esses or indu/ries & ^: eligible p>ticipat+ employ]s repres5t a broad cross-section ( trades & bus9esses or indu/ries1 or 7#c7 a plan ^: eligible p>ticipat+ employ]s repres5t "o or m trades or bus9esses1 or "o or m indu/ries1 consi/+ ( any ( ! foll[+3 agriculture2 equipm5t & automobile deal]%ips2 b>b]+ & cosmetology2 c]tifi$ public acc\nt+ practices2 *ild c>e2 con/ruction2 dance1 !atrical & or*e/ra productions2 dis9fect+ & pe/ control2 f9ancial s]vices2 fi%+2 food s]vice e/abli%m5ts2 hospitals2 labor organizations2 logg+2 manufactur+ 7metals72 m9+2 m$ical & d5tal practices2 m$ical laboratories2 pr(essional consult+ s]vices2 sanit>y s]vices2 transportation 7local & freight72 w>eh\s+2 :olesal+_/di/ribut+2 or any o!r trade or bus9ess or indu/ry :i* has be5 indicat$ z hav+ av]age or above-av]age risk or heal? claims exp]i5ce by reason ( ,/ate rate fil+s1 d5ials ( cov]age1 propos$ premium rate levels1 or o!r means demon/rat$ by su* plan 9 accordance ) regulations4 #hjc4 ,requirem5ts relat+ to sponsors & bo>ds ( tru/ees 7a7 ,sponsor ,! requirem5ts ( ?is subsection are met ) respect to an association heal? plan if ! sponsor has met 7or is deem$ "u ?is "p to h met7 ! requirem5ts ( section #hja7;b7 = a cont9u\s p]iod ( n less ?an #c ye>s end+ ) ! date ( ! application = c]tification "u ?is "p4 7b7 ,bo>d ( ,tru/ees ,! requirem5ts ( ?is subsection are met ) respect to an association heal? plan if ! foll[+ requirem5ts are met3 7#a7 ,fiscal control ,! plan is op]at$1 pursuant to a tru/ agreem5t1 by a bo>d ( tru/ees :i* has complete fiscal control ov] ! plan & :i* is responsible = all op]ations ( ! plan4 7#b7 ,rules ( op]ation & f9ancial controls ,! bo>d ( tru/ees has 9 effect rules ( op]ation & f9ancial controls1 bas$ on a #c-ye> plan ( op]ation1 adequate to c>ry out ! t]ms ( ! plan & to meet all requirem5ts ( ?is title applicable to ! plan4 7#c7 ,rules gov]n+ relation%ip to p>ticipat+ employ]s & to contractors 7,a7 ,bo>d memb]%ip 7i7 ,9 g5]al ,except z provid$ 9 clauses 7ii7 & 7iii71 ! memb]s ( ! bo>d ( tru/ees are individuals select$ f individuals :o are ! own]s1 (fic]s1 directors1 or employees ( ! p>ticipat+ employ]s or :o are p>tn]s 9 ! p>ticipat+ employ]s & actively p>ticipate 9 ! bus9ess4 7ii7 ,limitation 7,i7 ,g5]al rule ,except z provid$ 9 subclauses 7,,ii7 & 7,,iii71 no su* memb] is an own]1 (fic]1 director1 or employee (1 or p>tn] 91 a contract adm9i/rator or o!r s]vice provid] to ! plan4 7,,ii7 ,limit$ exception = provid]s ( s]vices solely on behalf ( ! sponsor ,(fic]s or employees ( a sponsor :i* is a s]vice provid] 7o!r ?an a contract adm9i/rator7 to ! plan may be memb]s ( ! bo>d if !y con/itute n m ?an #be p]c5t ( ! memb]%ip ( ! bo>d & !y d n provide s]vices to ! plan o!r ?an on behalf ( ! sponsor4 7,,iii7 ,treatm5t ( provid]s ( m$ical c>e ,9 ! case ( a sponsor :i* is an association ^: memb]%ip consi/s prim>ily ( provid]s ( m$ical c>e1 subclause 7,i7 %all n apply 9 ! case ( any s]vice provid] describ$ 9 subclause 7,i7 :o is a provid] ( m$ical c>e "u ! plan4 7iii7 ,c]ta9 plans exclud$ ,clause 7i7 %all n apply to an association heal? plan :i* is 9 exi/5ce on ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjac4 7,b7 ,sole au?ority ,! bo>d has sole au?ority "u ! plan to approve applications = p>ticipation 9 ! plan & to contract ) a s]vice provid] to adm9i/] ! day-to-day affairs ( ! plan4 7c7 ,treatm5t ( ,fran*ise ,networks ,9 ! case ( a gr\p heal? plan :i* is e/abli%$ & ma9ta9$ by a fran*is] = a fran*ise network consi/+ ( its fran*isees-- 7#a7 ! requirem5ts ( subsection 7a7 & section #hja7;a7 %all be deem$ met if su* requirem5ts w\ld o!rwise be met if ! fran*is] 7 deem$ to be ! sponsor ref]r$ to 9 section #hja7;b71 su* network 7 deem$ to be an association describ$ 9 section #hja7;b71 & ea* fran*isee 7 deem$ to be a memb] 7( ! association & ! sponsor7 ref]r$ to 9 section #hja7;b72 & 7#b7 ! requirem5ts ( section #hjd7;a77#a7 %all be deem$ met4 ,! ,secret>y may by regulation def9e = purposes ( ?is subsection ! t]ms fran*is]1 fran*ise network1 & fran*isee4 #hjd4 ,p>ticipation & cov]age requirem5ts 7a7 ,cov]$ ,employ]s & ,individuals ,! requirem5ts ( ?is subsection are met ) respect to an association heal? plan if1 "u ! t]ms ( ! plan-- 7#a7 ea* p>ticipat+ employ] mu/ be-- 7,a7 a memb] ( ! sponsor1 7,b7 ! sponsor1 or 7,c7 an affiliat$ memb] ( ! sponsor ) respect to :i* ! requirem5ts ( subsection 7b7 are met1 except t1 9 ! case ( a sponsor :i* is a pr(essional association or o!r individual-bas$ association1 if at lea/ "o ( ! (fic]s1 directors1 or employees ( an employ]1 or at lea/ "o ( ! individuals :o are p>tn]s 9 an employ] & :o actively p>ticipates 9 ! bus9ess1 is a memb] or su* an affiliat$ memb] ( ! sponsor1 p>ticipat+ employ]s may also include su* employ]2 & 7#b7 all individuals comm5c+ cov]age "u ! plan aft] c]tification "u ?is "p mu/ be-- 7,a7 active or retir$ own]s 7includ+ self-employ$ individuals71 (fic]s1 directors1 or employees (1 or p>tn]s 91 p>ticipat+ employ]s2 or 7,b7 ! b5efici>ies ( individuals describ$ 9 subp>agraph 7,a74 7b7 ,cov]age ( ,previ\sly ,un9sur$ ,employees ,9 ! case ( an association heal? plan 9 exi/5ce on ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjac1 an affiliat$ memb] ( ! sponsor ( ! plan may be (f]$ cov]age "u ! plan z a p>ticipat+ employ] only if-- 7#a7 ! affiliat$ memb] 0 an affiliat$ memb] on ! date ( c]tification "u ?is "p2 or 7#b7 dur+ ! #ab-mon? p]iod prec$+ ! date ( ! (f]+ ( su* cov]age1 ! affiliat$ memb] has n ma9ta9$ or contribut$ to a gr\p heal? plan ) respect to any ( its employees :o w\ld o!rwise be eligible to p>ticipate 9 su* association heal? plan4 7c7 ,individual ,m>ket ,unaffect$ ,! requirem5ts ( ?is subsection are met ) respect to an association heal? plan if1 "u ! t]ms ( ! plan1 no p>ticipat+ employ] may provide heal? insurance cov]age 9 ! individual m>ket = any employee n cov]$ "u ! plan :i* is simil> to ! cov]age contemporane\sly provid$ to employees ( ! employ] "u ! plan1 if su* exclusion ( ! employee f cov]age "u ! plan is bas$ on a heal? /atus-relat$ factor ) respect to ! employee & su* employee w\ld1 b = su* exclusion on su* basis1 be eligible = cov]age "u ! plan4 7d7 ,prohibition ( ,discrim9ation ,aga9/ ,employ]s & ,employees ,eligible ,to ,p>ticipate ,! requirem5ts ( ?is subsection are met ) respect to an association heal? plan if-- 7#a7 "u ! t]ms ( ! plan1 all employ]s meet+ ! prec$+ requirem5ts ( ?is section are eligible to qualify z p>ticipat+ employ]s = all geographically available cov]age options1 unless1 9 ! case ( any su* employ]1 p>ticipation or contribution requirem5ts ( ! type ref]r$ to 9 section #bgaa ( ! ,public ,heal? ,s]vice ,act are n met2 7#b7 ^u reque/1 any employ] eligible to p>ticipate is furni%$ in=mation reg>d+ all cov]age options available "u ! plan2 & 7#c7 ! applicable requirem5ts ( sections #gja1 #gjb1 & #gjc are met ) respect to ! plan4 #hje4 ,o!r requirem5ts relat+ to plan docum5ts1 contribution rates1 & b5efit options 7a7 ,9 ,g5]al ,! requirem5ts ( ?is section are met ) respect to an association heal? plan if ! foll[+ requirem5ts are met3 7#a7 ,cont5ts ( gov]n+ in/rum5ts ,! in/rum5ts gov]n+ ! plan include a writt5 in/rum5t1 meet+ ! requirem5ts ( an in/rum5t requir$ "u section #djb7;a77#a71 :i*-- 7,a7 provides t ! bo>d ( tru/ees s]ves z ! nam$ fiduci>y requir$ = plans "u section #djb7;a77#a7 & s]ves 9 ! capacity ( a plan adm9i/rator 7ref]r$ to 9 section #c7af77;,a772 7,b7 provides t ! sponsor ( ! plan is to s]ve z plan sponsor 7ref]r$ to 9 section #c7af77;,b772 & 7,c7 incorporates ! requirem5ts ( section #hjf4 7#b7 ,contribution rates mu/ be nondiscrim9atory 7,a7 ,! contribution rates = any p>ticipat+ small employ] d n v>y on ! basis ( any heal? /atus-relat$ factor 9 relation to employees ( su* employ] or _! b5efici>ies & d n v>y on ! basis ( ! type ( bus9ess or indu/ry 9 :i* su* employ] is engag$4 7,b7 ,no?+ 9 ?is title or any o!r provision ( law %all be con/ru$ to preclude an association heal? plan1 or a heal? insurance issu] (f]+ heal? insurance cov]age 9 connection ) an association heal? plan1 f-- 7i7 sett+ contribution rates bas$ on ! claims exp]i5ce ( ! plan2 or 7ii7 v>y+ contribution rates = small employ]s 9 a ,/ate to ! ext5t t su* rates c\ld v>y us+ ! same me?odology employ$ 9 su* ,/ate = regulat+ premium rates 9 ! small gr\p m>ket ) respect to heal? insurance cov]age (f]$ 9 connection ) bona fide associations 7)9 ! mean+ ( section #bgia7;d77#c7 ( ! ,public ,heal? ,s]vice ,act71 subject to ! requirem5ts ( section #gjb7;b7 relat+ to contribution rates4 7#c7 ,floor = numb] ( cov]$ individuals ) respect to c]ta9 plans ,if any b5efit option "u ! plan does n consi/ ( heal? insurance cov]age1 ! plan has z ( ! beg9n+ ( ! plan ye> n few] ?an #a1jjj p>ticipants & b5efici>ies4 7#d7 ,m>ket+ requirem5ts 7,a7 ,9 g5]al ,if a b5efit option :i* consi/s ( heal? insurance cov]age is (f]$ "u ! plan1 ,/ate-lic5s$ insurance ag5ts %all be us$ to di/ribute to small employ]s cov]age :i* does n consi/ ( heal? insurance cov]age 9 a mann] comp>able to ! mann] 9 :i* su* ag5ts are us$ to di/ribute heal? insurance cov]age4 7,b7 ,/ate-lic5s$ insurance ag5ts ,= purposes ( subp>agraph 7,a71 ! t]m ,/ate-lic5s$ insurance ag5ts means "o or m ag5ts :o are lic5s$ 9 a ,/ate & are subject to ! laws ( su* ,/ate relat+ to lic5sure1 qualification1 te/+1 exam9ation1 & cont9u+ education ( p]sons au?oriz$ to (f]1 sell1 or solicit heal? insurance cov]age 9 su* ,/ate4 7#e7 ,regulatory requirem5ts ,su* o!r requirem5ts z ! applicable au?ority det]m9es are necess>y to c>ry out ! purposes ( ?is "p1 :i* %all be prescrib$ by ! applicable au?ority by regulation4 7b7 ,ability ( ,association ,heal? ,plans ,to ,design ,b5efit ,options ,subject to section #ead7;d71 no?+ 9 ?is "p or any provision ( ,/ate law 7z def9$ 9 section #ead7;c77#a77 %all be con/ru$ to preclude an association heal? plan1 or a heal? insurance issu] (f]+ heal? insurance cov]age 9 connection ) an association heal? plan1 f ex]cis+ its sole discretion 9 select+ ! specific items & s]vices consi/+ ( m$ical c>e to be includ$ z b5efits "u su* plan or cov]age1 except 7subject to section #ead7 9 ! case ( 7#a7 any law to ! ext5t t x is n preempt$ "u section #gca7;a77#a7 ) respect to matt]s gov]n$ by section #gaa1 #gab1 or #gac1 or 7#b7 any law ( ! ,/ate ) :i* fil+ & approval ( a policy type (f]$ by ! plan 0 initially obta9$ to ! ext5t t su* law prohibits an exclusion ( a specific disease f su* cov]age4 #hjf4 ,ma9t5ance ( res]ves & provisions = solv5cy = plans provid+ heal? b5efits 9 addition to heal? insurance cov]age 7a7 ,9 ,g5]al ,! requirem5ts ( ?is section are met ) respect to an association heal? plan if-- 7#a7 ! b5efits "u ! plan consi/ solely ( heal? insurance cov]age2 or 7#b7 if ! plan provides any additional b5efit options :i* d n consi/ ( heal? insurance cov]age1 ! plan-- 7,a7 e/abli%es & ma9ta9s res]ves ) respect to su* additional b5efit options1 9 am\nts recomm5d$ by ! qualifi$ actu>y1 consi/+ (-- 7i7 a res]ve suffici5t = une>n$ contributions2 7ii7 a res]ve suffici5t = b5efit liabilities :i* h be5 incurr$1 :i* h n be5 satisfi$1 & = :i* risk ( loss has n yet be5 transf]r$1 & = expect$ adm9i/rative co/s ) respect to su* b5efit liabilities2 7iii7 a res]ve suffici5t = any o!r obligations ( ! plan2 & 7iv7 a res]ve suffici5t = a m>g9 ( error & o!r fluctuations1 tak+ into acc\nt ! specific circum/ances ( ! plan2 & 7,b7 e/abli%es & ma9ta9s aggregate & specific excess_//op loss insurance & solv5cy indemnification1 ) respect to su* additional b5efit options = :i* risk ( loss has n yet be5 transf]r$1 z foll[s3 7i7 ,! plan %all secure aggregate excess_//op loss insurance = ! plan ) an atta*m5t po9t :i* is n great] ?an #abe p]c5t ( expect$ gross annual claims4 ,! applicable au?ority may by regulation provide = upw>d adju/m5ts 9 ! am\nt ( su* p]c5tage 9 specifi$ circum/ances 9 :i* ! plan specifically provides = & ma9ta9s res]ves 9 excess ( ! am\nts requir$ "u subp>agraph 7,a74 7ii7 ,! plan %all secure specific excess_//op loss insurance = ! plan ) an atta*m5t po9t :i* is at lea/ equal to an am\nt recomm5d$ by ! plan's qualifi$ actu>y4 ,! applicable au?ority may by regulation provide = adju/m5ts 9 ! am\nt ( su* insurance 9 specifi$ circum/ances 9 :i* ! plan specifically provides = & ma9ta9s res]ves 9 excess ( ! am\nts requir$ "u subp>agraph 7,a74 7iii7 ,! plan %all secure indemnification insurance = any claims :i* ! plan is unable to satisfy by reason ( a plan t]m9ation4 ,any p]son issu+ to a plan insurance describ$ 9 clause 7i71 7ii71 or 7iii7 ( subp>agraph 7,b7 %all notify ! ,secret>y ( any failure ( premium paym5t m]it+ cancellation ( ! policy prior to und]tak+ su* a cancellation4 ,any regulations prescrib$ by ! applicable au?ority pursuant to clause 7i7 or 7ii7 ( subp>agraph 7,b7 may all[ = su* adju/m5ts 9 ! requir$ levels ( excess_//op loss insurance z ! qualifi$ actu>y may recomm5d1 tak+ into acc\nt ! specific circum/ances ( ! plan4 7b7 ,m9imum ,surplus 9 ,addition to ,claims ,res]ves ,9 ! case ( any association heal? plan describ$ 9 subsection 7a77#b71 ! requirem5ts ( ?is subsection are met if ! plan e/abli%es & ma9ta9s surplus 9 an am\nt at lea/ equal to-- 7#a7 #ejj1jjj1 or 7#b7 su* great] am\nt 7b n great] ?an #b1jjj1jjj7 z may be set =? 9 regulations prescrib$ by ! applicable au?ority1 consid]+ ! level ( aggregate & specific excess_//op loss insurance provid$ ) respect to su* plan & o!r factors relat$ to solv5cy risk1 su* z ! plan's project$ levels ( p>ticipation or claims1 ! nature ( ! plan's liabilities1 & ! types ( assets available to assure t su* liabilities are met4 7c7 ,additional ,requirem5ts ,9 ! case ( any association heal? plan describ$ 9 subsection 7a77#b71 ! applicable au?ority may provide su* additional requirem5ts relat+ to res]ves1 excess_//op loss insurance1 & indemnification insurance z ! applicable au?ority consid]s appropriate4 ,su* requirem5ts may be provid$ by regulation ) respect to any su* plan or any class ( su* plans4 7d7 ,adju/m5ts = ,excess_/,/op ,loss ,insurance ,! applicable au?ority may provide = adju/m5ts to ! levels ( res]ves o!rwise requir$ "u subsections 7a7 & 7b7 ) respect to any plan or class ( plans to take into acc\nt excess_//op loss insurance provid$ ) respect to su* plan or plans4 7e7 ,alt]native ,means ( ,compliance ,! applicable au?ority may p]mit an association heal? plan describ$ 9 subsection 7a77#b7 to sub/itute1 = all or "p ( ! requirem5ts ( ?is section 7except subsection 7a77#b77;,b77iii771 su* security1 gu>antee1 hold-h>mless arrangem5t1 or o!r f9ancial arrangem5t z ! applicable au?ority det]m9es to be adequate to enable ! plan to fully meet all its f9ancial obligations on a timely basis & is o!rwise no less protective ( ! int]e/s ( p>ticipants & b5efici>ies ?an ! requirem5ts = :i* x is sub/itut$4 ,! applicable au?ority may take into acc\nt1 = purposes ( ?is subsection1 evid5ce provid$ by ! plan or sponsor :i* demon/rates an assumption ( liability ) respect to ! plan4 ,su* evid5ce may be 9 ! =m ( a contract ( indemnification1 li51 bond+1 insurance1 lett] ( cr$it1 rec\rse "u applicable t]ms ( ! plan 9 ! =m ( assessm5ts ( p>ticipat+ employ]s1 security1 or o!r f9ancial arrangem5t4 7f7 ,measures ,to ,ensure ,cont9u$ ,paym5t ( ,b5efits by ,c]ta9 ,plans 9 ,di/ress 7#a7 ,paym5ts by c]ta9 plans to association heal? plan fund 7,a7 ,9 g5]al ,9 ! case ( an association heal? plan describ$ 9 subsection 7a77#b71 ! requirem5ts ( ?is subsection are met if ! plan makes paym5ts into ! ,association ,heal? ,plan ,fund "u ?is subp>agraph :5 !y are due4 ,su* paym5ts %all consi/ ( annual paym5ts 9 ! am\nt ( #e1jjj1 &1 9 addition to su* annual paym5ts1 su* supplem5tal paym5ts z ! ,secret>y may det]m9e to be necess>y "u p>agraph 7#b74 ,paym5ts "u ?is p>agraph are payable to ! ,fund at ! "t det]m9$ by ! ,secret>y4 ,initial paym5ts are due 9 advance ( c]tification "u ?is "p4 ,paym5ts %all cont9ue to accrue until a plan's assets are di/ribut$ pursuant to a t]m9ation proc$ure4 7,b7 ,p5alties = failure to make paym5ts ,if any paym5t is n made by a plan :5 x is due1 a late paym5t *>ge ( n m ?an #ajj p]c5t ( ! paym5t :i* 0 n timely paid %all be payable by ! plan to ! ,fund4 7,c7 ,cont9u$ duty ( ! secret>y ,! ,secret>y %all n cease to c>ry out ! provisions ( p>agraph 7#b7 on acc\nt ( ! failure ( a plan to pay any paym5t :5 due4 7#b7 ,paym5ts by secret>y to cont9ue excess_//op loss insurance cov]age & indemnification insurance cov]age = c]ta9 plans ,9 any case 9 :i* ! applicable au?ority det]m9es t !re is1 or t !re is reason to believe t !re w be3 7,a7 a failure to take necess>y corrective actions "u section #hji7;a7 ) respect to an association heal? plan describ$ 9 subsection 7a77#b72 or 7,b7 a t]m9ation ( su* a plan "u section #hji7;b7 or #haj7;b77#h7 7&1 if ! applicable au?ority is n ! ,secret>y1 c]tifies su* det]m9ation to ! ,secret>y71 ! ,secret>y %all det]m9e ! am\nts necess>y to make paym5ts to an insur] 7designat$ by ! ,secret>y7 to ma9ta9 9 =ce excess_//op loss insurance cov]age or indemnification insurance cov]age = su* plan1 if ! ,secret>y det]m9es t !re is a reasonable expectation t1 )\t su* paym5ts1 claims w\ld n be satisfi$ by reason ( t]m9ation ( su* cov]age4 ,! ,secret>y %all1 to ! ext5t provid$ 9 advance 9 appropriation ,acts1 pay su* am\nts s det]m9$ to ! insur] designat$ by ! ,secret>y4 7#c7 ,association heal? plan fund 7,a7 ,9 g5]al ,!re is e/abli%$ on ! books ( ! ,treasury a fund to be kn[n z ! ,association ,heal? ,plan ,fund4 ,! ,fund %all be available = mak+ paym5ts pursuant to p>agraph 7#b74 ,! ,fund %all be cr$it$ ) paym5ts receiv$ pursuant to p>agraph 7#a77;,a71 p5alties receiv$ pursuant to p>agraph 7#a77;,b72 & e>n+s on inve/m5ts ( am\nts ( ! ,fund "u subp>agraph 7,b74 7,b7 ,inve/m5t ,:5ev] ! ,secret>y det]m9es t ! moneys ( ! fund are 9 excess ( curr5t ne$s1 ! ,secret>y may reque/ ! inve/m5t ( su* am\nts z ! ,secret>y det]m9es advisable by ! ,secret>y ( ! ,treasury 9 obligations issu$ or gu>ante$ by ! ,unit$ ,/ates4 7g7 ,excess_/,/op ,loss ,insurance ,= purposes ( ?is section-- 7#a7 ,aggregate excess_//op loss insurance ,! t]m aggregate excess_//op loss insurance means1 9 connection ) an association heal? plan1 a contract-- 7,a7 "u :i* an insur] 7meet+ su* m9imum /&>ds z ! applicable au?ority may prescribe by regulation7 provides = paym5t to ! plan ) respect to aggregate claims "u ! plan 9 excess ( an am\nt or am\nts specifi$ 9 su* contract2 7,b7 :i* is gu>ante$ r5ewable2 & 7,c7 :i* all[s = paym5t ( premiums by any ?ird p>ty on behalf ( ! insur$ plan4 7#b7 ,specific excess_//op loss insurance ,! t]m specific excess_//op loss insurance means1 9 connection ) an association heal? plan1 a contract-- 7,a7 "u :i* an insur] 7meet+ su* m9imum /&>ds z ! applicable au?ority may prescribe by regulation7 provides = paym5t to ! plan ) respect to claims "u ! plan 9 connection ) a cov]$ individual 9 excess ( an am\nt or am\nts specifi$ 9 su* contract 9 connection ) su* cov]$ individual2 7,b7 :i* is gu>ante$ r5ewable2 & 7,c7 :i* all[s = paym5t ( premiums by any ?ird p>ty on behalf ( ! insur$ plan4 7h7 ,indemnification ,insurance ,= purposes ( ?is section1 ! t]m indemnification insurance means1 9 connection ) an association heal? plan1 a contract-- 7#a7 "u :i* an insur] 7meet+ su* m9imum /&>ds z ! applicable au?ority may prescribe by regulation7 provides = paym5t to ! plan ) respect to claims "u ! plan :i* ! plan is unable to satisfy by reason ( a t]m9ation pursuant to section #hji7;b7 7relat+ to m&atory t]m9ation72 7#b7 :i* is gu>ante$ r5ewable & noncancellable = any reason 7except z ! applicable au?ority may prescribe by regulation72 & 7#c7 :i* all[s = paym5t ( premiums by any ?ird p>ty on behalf ( ! insur$ plan4 7i7 ,res]ves ,= purposes ( ?is section1 ! t]m res]ves means1 9 connection ) an association heal? plan1 plan assets :i* meet ! fiduci>y /&>ds "u "p #d & su* additional requirem5ts reg>d+ liquidity z ! applicable au?ority may prescribe by regulation4 7j7 ,solv5cy ,/&>ds ,work+ ,gr\p 7#a7 ,9 g5]al ,)9 #ij days aft] ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjac1 ! applicable au?ority %all e/abli% a ,solv5cy ,/&>ds ,work+ ,gr\p4 ,9 prescrib+ ! initial regulations "u ?is section1 ! applicable au?ority %all take into acc\nt ! recomm5dations ( su* ,work+ ,gr\p4 7#b7 ,memb]%ip ,! ,work+ ,gr\p %all consi/ ( n m ?an #ae memb]s appo9t$ by ! applicable au?ority4 ,! applicable au?ority %all include among p]sons invit$ to memb]%ip on ! ,work+ ,gr\p at lea/ "o ( ea* ( ! foll[+3 7,a7 a repres5tative ( ! ,national ,association ( ,insurance ,commission]s2 7,b7 a repres5tative ( ! ,am]ican ,academy ( ,actu>ies2 7,c7 a repres5tative ( ! ,/ate gov]nm5ts1 or _! int]e/s2 7,d7 a repres5tative ( exi/+ self-insur$ arrangem5ts1 or _! int]e/s2 7,e7 a repres5tative ( associations ( ! type ref]r$ to 9 section #hja7;b77#a71 or _! int]e/s2 & 7,f7 a repres5tative ( multiemploy] plans t are gr\p heal? plans1 or _! int]e/s4 #hjg4 ,requirem5ts = application & relat$ requirem5ts 7a7 ,fil+ ,fee ,"u ! proc$ure prescrib$ pursuant to section #hjb7;a71 an association heal? plan %all pay to ! applicable au?ority at ! "t ( fil+ an application = c]tification "u ?is "p a fil+ fee 9 ! am\nt ( #e1jjj1 :i* %all be available 9 ! case ( ! ,secret>y1 to ! ext5t provid$ 9 appropriation ,acts1 = ! sole purpose ( adm9i/]+ ! c]tification proc$ures applicable ) respect to association heal? plans4 7b7 ,in=mation ,to ,be ,includ$ 9 ,application = ,c]tification ,an application = c]tification "u ?is "p meets ! requirem5ts ( ?is section only if x includes1 9 a mann] & =m :i* %all be prescrib$ by ! applicable au?ority by regulation1 at lea/ ! foll[+ in=mation3 7#a7 ,id5tify+ in=mation ,! names & addresses (-- 7,a7 ! sponsor2 & 7,b7 ! memb]s ( ! bo>d ( tru/ees ( ! plan4 7#b7 ,/ates 9 :i* plan int5ds to d bus9ess ,! ,/ates 9 :i* p>ticipants & b5efici>ies "u ! plan are to be locat$ & ! numb] ( !m expect$ to be locat$ 9 ea* su* ,/ate4 7#c7 ,bond+ requirem5ts ,evid5ce provid$ by ! bo>d ( tru/ees t ! bond+ requirem5ts ( section #dab w be met z ( ! date ( ! application or 7if lat]7 comm5cem5t ( op]ations4 7#d7 ,plan docum5ts ,a copy ( ! docum5ts gov]n+ ! plan 7includ+ any bylaws & tru/ agreem5ts71 ! summ>y plan description1 & o!r mat]ial describ+ ! b5efits t w be provid$ to p>ticipants & b5efici>ies "u ! plan4 7#e7 ,agreem5ts ) s]vice provid]s ,a copy ( any agreem5ts betwe5 ! plan & contract adm9i/rators & o!r s]vice provid]s4 7#f7 ,fund+ report ,9 ! case ( association heal? plans provid+ b5efits options 9 addition to heal? insurance cov]age1 a report sett+ =? in=mation ) respect to su* additional b5efit options det]m9$ z ( a date )9 ! #abj-;day p]iod end+ ) ! date ( ! application1 includ+ ! foll[+3 7,a7 ,res]ves ,a /atem5t1 c]tifi$ by ! bo>d ( tru/ees ( ! plan1 & a /atem5t ( actu>ial op9ion1 sign$ by a qualifi$ actu>y1 t all applicable requirem5ts ( section #hjf are or w be met 9 accordance ) regulations :i* ! applicable au?ority %all prescribe4 7,b7 ,adequacy ( contribution rates ,a /atem5t ( actu>ial op9ion1 sign$ by a qualifi$ actu>y1 :i* sets =? a description ( ! ext5t to :i* contribution rates are adequate to provide = ! paym5t ( all obligations & ! ma9t5ance ( requir$ res]ves "u ! plan = ! #ab-mon? p]iod beg9n+ ) su* date )9 su* #abj-;day p]iod1 tak+ into acc\nt ! expect$ cov]age & exp]i5ce ( ! plan4 ,if ! contribution rates are n fully adequate1 ! /atem5t ( actu>ial op9ion %all indicate ! ext5t to :i* ! rates are inadequate & ! *anges ne$$ to ensure adequacy4 7,c7 ,curr5t & project$ value ( assets & liabilities ,a /atem5t ( actu>ial op9ion sign$ by a qualifi$ actu>y1 :i* sets =? ! curr5t value ( ! assets & liabilities accumulat$ "u ! plan & a projection ( ! assets1 liabilities1 income1 & exp5ses ( ! plan = ! #ab-mon? p]iod ref]r$ to 9 subp>agraph 7,b74 ,! income /atem5t %all id5tify sep>ately ! plan's adm9i/rative exp5ses & claims4 7,d7 ,co/s ( cov]age to be *>g$ & o!r exp5ses ,a /atem5t ( ! co/s ( cov]age to be *>g$1 includ+ an itemization ( am\nts = adm9i/ration1 res]ves1 & o!r exp5ses associat$ ) ! op]ation ( ! plan4 7,e7 ,o!r in=mation ,any o!r in=mation z may be det]m9$ by ! applicable au?ority1 by regulation1 z necess>y to c>ry out ! purposes ( ?is "p4 7c7 ,fil+ ,notice ( ,c]tification ,) ,/ates ,a c]tification grant$ "u ?is "p to an association heal? plan %all n be effective unless writt5 notice ( su* c]tification is fil$ ) ! applicable ,/ate au?ority ( ea* ,/ate 9 :i* at lea/ #be p]c5t ( ! p>ticipants & b5efici>ies "u ! plan are locat$4 ,= purposes ( ?is subsection1 an individual %all be consid]$ to be locat$ 9 ! ,/ate 9 :i* a kn[n address ( su* individual is locat$ or 9 :i* su* individual is employ$4 7d7 ,notice ( ,mat]ial ,*anges ,9 ! case ( any association heal? plan c]tifi$ "u ?is "p1 descriptions ( mat]ial *anges 9 any in=mation :i* 0 requir$ to be submitt$ ) ! application = ! c]tification "u ?is "p %all be fil$ 9 su* =m & mann] z %all be prescrib$ by ! applicable au?ority by regulation4 ,! applicable au?ority may require by regulation prior notice ( mat]ial *anges ) respect to specifi$ matt]s :i* might s]ve z ! basis = susp5sion or revocation ( ! c]tification4 7e7 ,report+ ,requirem5ts = ,c]ta9 ,association ,heal? ,plans ,an association heal? plan c]tifi$ "u ?is "p :i* provides b5efit options 9 addition to heal? insurance cov]age = su* plan ye> %all meet ! requirem5ts ( section #ajc by fil+ an annual report "u su* section :i* %all include in=mation describ$ 9 subsection 7b77#f7 ) respect to ! plan ye> &1 not)/&+ section #ajd7;a77#a77;,a71 %all be fil$ ) ! applicable au?ority n lat] ?an #ij days aft] ! close ( ! plan ye> 7or on su* lat] date z may be prescrib$ by ! applicable au?ority74 ,! applicable au?ority may require by regulation su* int]im reports z x consid]s appropriate4 7f7 ,engagem5t ( ,qualifi$ ,actu>y ,! bo>d ( tru/ees ( ea* association heal? plan :i* provides b5efits options 9 addition to heal? insurance cov]age & :i* is apply+ = c]tification "u ?is "p or is c]tifi$ "u ?is "p %all engage1 on behalf ( all p>ticipants & b5efici>ies1 a qualifi$ actu>y :o %all be responsible = ! prep>ation ( ! mat]ials compris+ in=mation necess>y to be submitt$ by a qualifi$ actu>y "u ?is "p4 ,! qualifi$ actu>y %all utilize su* assumptions & te*niques z are necess>y to enable su* actu>y to =m an op9ion z to :e!r ! cont5ts ( ! matt]s report$ "u ?is "p-- 7#a7 are 9 ! aggregate reasonably relat$ to ! exp]i5ce ( ! plan & to reasonable expectations2 & 7#b7 repres5t su* actu>y's be/ e/imate ( anticipat$ exp]i5ce "u ! plan4 ,! op9ion by ! qualifi$ actu>y %all be made ) respect to1 & %all be made a "p (1 ! annual report4 #hjh4 ,notice requirem5ts = volunt>y t]m9ation ,except z provid$ 9 section #hji7;b71 an association heal? plan :i* is or has be5 c]tifi$ "u ?is "p may t]m9ate 7^u or at any "t aft] cessation ( accruals 9 b5efit liabilities7 only if ! bo>d ( tru/ees1 n less ?an #fj days be=e ! propos$ t]m9ation date-- 7#a7 provides to ! p>ticipants & b5efici>ies a writt5 notice ( int5t to t]m9ate /at+ t su* t]m9ation is int5d$ & ! propos$ t]m9ation date2 7#b7 develops a plan = w9d+ up ! affairs ( ! plan 9 connection ) su* t]m9ation 9 a mann] :i* w result 9 timely paym5t ( all b5efits = :i* ! plan is obligat$2 & 7#c7 submits su* plan 9 writ+ to ! applicable au?ority4 ,actions requir$ "u ?is section %all be tak5 9 su* =m & mann] z may be prescrib$ by ! applicable au?ority by regulation4 #hji4 ,corrective actions & m&atory t]m9ation 7a7 ,actions ,to ,avoid ,depletion ( ,res]ves ,an association heal? plan :i* is c]tifi$ "u ?is "p & :i* provides b5efits o!r ?an heal? insurance cov]age %all cont9ue to meet ! requirem5ts ( section #hjf1 irrespective ( :e!r su* c]tification cont9ues 9 effect4 ,! bo>d ( tru/ees ( su* plan %all det]m9e qu>t]ly :e!r ! requirem5ts ( section #hjf are met4 ,9 any case 9 :i* ! bo>d det]m9es t !re is reason to believe t !re is or w be a failure to meet su* requirem5ts1 or ! applicable au?ority makes su* a det]m9ation & s notifies ! bo>d1 ! bo>d %all imm$iately notify ! qualifi$ actu>y engag$ by ! plan1 & su* actu>y %all1 n lat] ?an ! end ( ! next foll[+ mon?1 make su* recomm5dations to ! bo>d = corrective action z ! actu>y det]m9es necess>y to ensure compliance ) section #hjf4 ,n lat] ?an #cj days aft] receiv+ f ! actu>y recomm5dations = corrective actions1 ! bo>d %all notify ! applicable au?ority 79 su* =m & mann] z ! applicable au?ority may prescribe by regulation7 ( su* recomm5dations ( ! actu>y = corrective action1 toge!r ) a description ( ! actions 7if any7 t ! bo>d has tak5 or plans to take 9 response to su* recomm5dations4 ,! bo>d %all !reaft] report to ! applicable au?ority1 9 su* =m & frequ5cy z ! applicable au?ority may specify to ! bo>d1 reg>d+ corrective action tak5 by ! bo>d until ! requirem5ts ( section #hjf are met4 7b7 ,m&atory ,t]m9ation ,9 any case 9 :i*-- 7#a7 ! applicable au?ority has be5 notifi$ "u subsection 7a7 7or by an issu] ( excess_//op loss insurance or indemnity insurance pursuant to section #hjf7;a77 ( a failure ( an association heal? plan :i* is or has be5 c]tifi$ "u ?is "p & is describ$ 9 section #hjf7;a77#b7 to meet ! requirem5ts ( section #hjf & has n be5 notifi$ by ! bo>d ( tru/ees ( ! plan t corrective action has re/or$ compliance ) su* requirem5ts2 & 7#b7 ! applicable au?ority det]m9es t !re is a reasonable expectation t ! plan w cont9ue to fail to meet ! requirem5ts ( section #hjf1 ! bo>d ( tru/ees ( ! plan %all1 at ! direction ( ! applicable au?ority1 t]m9ate ! plan &1 9 ! c\rse ( ! t]m9ation1 take su* actions z ! applicable au?ority may require1 includ+ satisfy+ any claims ref]r$ to 9 section #hjf7;a77#b77;,b77iii7 & recov]+ = ! plan any liability "u subsection 7a77#b77;,b77iii7 or 7e7 ( section #hjf1 z necess>y to ensure t ! affairs ( ! plan w be1 to ! maximum ext5t possible1 w\nd up 9 a mann] :i* w result 9 timely provision ( all b5efits = :i* ! plan is obligat$4 #haj4 ,tru/ee%ip by ! ,secret>y ( insolv5t association heal? plans provid+ heal? b5efits 9 addition to heal? insurance cov]age 7a7 ,appo9tm5t ( ,secret>y z ,tru/ee = ,insolv5t ,plans ,:5ev] ! ,secret>y det]m9es t an association heal? plan :i* is or has be5 c]tifi$ "u ?is "p & :i* is describ$ 9 section #hjf7;a77#b7 w be unable to provide b5efits :5 due or is o!rwise 9 a f9ancially haz>d\s condition1 z %all be def9$ by ! ,secret>y by regulation1 ! ,secret>y %all1 ^u notice to ! plan1 apply to ! appropriate ,unit$ ,/ates di/rict c\rt = appo9tm5t ( ! ,secret>y z tru/ee to adm9i/] ! plan = ! duration ( ! insolv5cy4 ,! plan may appe> z a p>ty & o!r int]e/$ p]sons may int]v5e 9 ! proce$+s at ! discretion ( ! c\rt4 ,! c\rt %all appo9t su* ,secret>y tru/ee if ! c\rt det]m9es t ! tru/ee%ip is necess>y to protect ! int]e/s ( ! p>ticipants & b5efici>ies or provid]s ( m$ical c>e or to avoid any unreasonable det]ioration ( ! f9ancial condition ( ! plan4 ,! tru/ee%ip ( su* ,secret>y %all cont9ue until ! conditions describ$ 9 ! fir/ s5t5ce ( ?is subsection are rem$i$ or ! plan is t]m9at$4 7b7 ,p[]s z ,tru/ee ,! ,secret>y1 ^u appo9tm5t z tru/ee "u subsection 7a71 %all h ! p[]-- 7#a7 to d any act au?oriz$ by ! plan1 ?is title1 or o!r applicable provisions ( law to be done by ! plan adm9i/rator or any tru/ee ( ! plan2 7#b7 to require ! transf] ( all 7or any "p7 ( ! assets & records ( ! plan to ! ,secret>y z tru/ee2 7#c7 to inve/ any assets ( ! plan :i* ! ,secret>y holds 9 accordance ) ! provisions ( ! plan1 regulations prescrib$ by ! ,secret>y1 & applicable provisions ( law2 7#d7 to require ! sponsor1 ! plan adm9i/rator1 any p>ticipat+ employ]1 & any employee organization repres5t+ plan p>ticipants to furni% any in=mation ) respect to ! plan :i* ! ,secret>y z tru/ee may reasonably ne$ 9 ord] to adm9i/] ! plan2 7#e7 to collect = ! plan any am\nts due ! plan & to recov] reasonable exp5ses ( ! tru/ee%ip2 7#f7 to comm5ce1 prosecute1 or def5d on behalf ( ! plan any suit or proce$+ involv+ ! plan2 7#g7 to issue1 publi%1 or file su* notices1 /atem5ts1 & reports z may be requir$ by ! ,secret>y by regulation or requir$ by any ord] ( ! c\rt2 7#h7 to t]m9ate ! plan 7or provide = its t]m9ation 9 accordance ) section #hji7;b77 & liquidate ! plan assets1 to re/ore ! plan to ! responsibility ( ! sponsor1 or to cont9ue ! tru/ee%ip2 7#i7 to provide = ! enrollm5t ( plan p>ticipants & b5efici>ies "u appropriate cov]age options2 & 7#aj7 to d su* o!r acts z may be necess>y to comply ) ?is title or any ord] ( ! c\rt & to protect ! int]e/s ( plan p>ticipants & b5efici>ies & provid]s ( m$ical c>e4 7c7 ,notice ( ,appo9tm5t ,z soon z practicable aft] ! ,secret>y's appo9tm5t z tru/ee1 ! ,secret>y %all give notice ( su* appo9tm5t to-- 7#a7 ! sponsor & plan adm9i/rator2 7#b7 ea* p>ticipant2 7#c7 ea* p>ticipat+ employ]2 & 7#d7 if applicable1 ea* employee organization :i*1 = purposes ( collective b>ga9+1 repres5ts plan p>ticipants4 7d7 ,additional ,duties ,except to ! ext5t inconsi/5t ) ! provisions ( ?is title1 or z may be o!rwise ord]$ by ! c\rt1 ! ,secret>y1 ^u appo9tm5t z tru/ee "u ?is section1 %all be subject to ! same duties z ^? ( a tru/ee "u section #gjd ( title #aa1 ,unit$ ,/ates ,code1 & %all h ! duties ( a fiduci>y = purposes ( ?is title4 7e7 ,o!r ,proce$+s ,an application by ! ,secret>y "u ?is subsection may be fil$ not)/&+ ! p5d5cy 9 ! same or any o!r c\rt ( any bankruptcy1 mortgage =eclosure1 or equity receiv]%ip proce$+1 or any proce$+ to reorganize1 cons]ve1 or liquidate su* plan or its prop]ty1 or any proce$+ to en=ce a li5 aga9/ prop]ty ( ! plan4 7f7 ,jurisdiction ( ,c\rt 7#a7 ,9 g5]al ,^u ! fil+ ( an application = ! appo9tm5t z tru/ee or ! issuance ( a decree "u ?is section1 ! c\rt to :i* ! application is made %all h exclusive jurisdiction ( ! plan involv$ & its prop]ty :]ev] locat$ ) ! p[]s1 to ! ext5t consi/5t ) ! purposes ( ?is section1 ( a c\rt ( ! ,unit$ ,/ates hav+ jurisdiction ov] cases "u *apt] #aa ( title #aa1 ,unit$ ,/ates ,code4 ,p5d+ an adjudication "u ?is section su* c\rt %all /ay1 & ^u appo9tm5t by x ( ! ,secret>y z tru/ee1 su* c\rt %all cont9ue ! /ay (1 any p5d+ mortgage =eclosure1 equity receiv]%ip1 or o!r proce$+ to reorganize1 cons]ve1 or liquidate ! plan1 ! sponsor1 or prop]ty ( su* plan or sponsor1 & any o!r suit aga9/ any receiv]1 cons]vator1 or tru/ee ( ! plan1 ! sponsor1 or prop]ty ( ! plan or sponsor4 ,p5d+ su* adjudication & ^u ! appo9tm5t by x ( ! ,secret>y z tru/ee1 ! c\rt may /ay any proce$+ to en=ce a li5 aga9/ prop]ty ( ! plan or ! sponsor or any o!r suit aga9/ ! plan or ! sponsor4 7#b7 ,v5ue ,an action "u ?is section may be br\ght 9 ! judicial di/rict :]e ! sponsor or ! plan adm9i/rator resides or does bus9ess or :]e any asset ( ! plan is situat$4 ,a di/rict c\rt 9 :i* su* action is br\ght may issue process ) respect to su* action 9 any o!r judicial di/rict4 7g7 ,p]sonnel ,9 accordance ) regulations :i* %all be prescrib$ by ! ,secret>y1 ! ,secret>y %all appo9t1 reta91 & comp5sate acc\ntants1 actu>ies1 & o!r pr(essional s]vice p]sonnel z may be necess>y 9 connection ) ! ,secret>y's s]vice z tru/ee "u ?is section4 #haa4 ,/ate assessm5t au?ority 7a7 ,9 ,g5]al ,not)/&+ section #ead1 a ,/ate may impose by law a contribution tax on an association heal? plan describ$ 9 section #hjf7;a77#b71 if ! plan comm5c$ op]ations 9 su* ,/ate aft] ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjac4 7b7 ,contribution ,tax ,= purposes ( ?is section1 ! t]m contribution tax impos$ by a ,/ate on an association heal? plan means any tax impos$ by su* ,/ate if-- 7#a7 su* tax is comput$ by apply+ a rate to ! am\nt ( premiums or contributions1 ) respect to individuals cov]$ "u ! plan :o are resid5ts ( su* ,/ate1 :i* are receiv$ by ! plan f p>ticipat+ employ]s locat$ 9 su* ,/ate or f su* individuals2 7#b7 ! rate ( su* tax does n exce$ ! rate ( any tax impos$ by su* ,/ate on premiums or contributions receiv$ by insur]s or heal? ma9t5ance organizations = heal? insurance cov]age (f]$ 9 su* ,/ate 9 connection ) a gr\p heal? plan2 7#c7 su* tax is o!rwise nondiscrim9atory2 & 7#d7 ! am\nt ( any su* tax assess$ on ! plan is r$uc$ by ! am\nt ( any tax or assessm5t o!rwise impos$ by ! ,/ate on premiums1 contributions1 or bo? receiv$ by insur]s or heal? ma9t5ance organizations = heal? insurance cov]age1 aggregate excess_//op loss insurance 7z def9$ 9 section #hjf7;g77#a771 specific excess_//op loss insurance 7z def9$ 9 section #hjf7;g77#b771 o!r insurance relat$ to ! provision ( m$ical c>e "u ! plan1 or any comb9ation !re( provid$ by su* insur]s or heal? ma9t5ance organizations 9 su* ,/ate 9 connection ) su* plan4 #hab4 ,def9itions & rules ( con/ruction 7a7 ,def9itions ,= purposes ( ?is "p-- 7#a7 ,gr\p heal? plan ,! t]m gr\p heal? plan has ! mean+ provid$ 9 section #gcc7;a77#a7 7aft] apply+ subsection 7b7 ( ?is section74 7#b7 ,m$ical c>e ,! t]m m$ical c>e has ! mean+ provid$ 9 section #gcc7;a77#b74 7#c7 ,heal? insurance cov]age ,! t]m heal? insurance cov]age has ! mean+ provid$ 9 section #gcc7;b77#a74 7#d7 ,heal? insurance issu] ,! t]m heal? insurance issu] has ! mean+ provid$ 9 section #gcc7;b77#b74 7#e7 ,applicable au?ority ,! t]m applicable au?ority means ! ,secret>y1 except t1 9 connection ) any ex]cise ( ! ,secret>y's au?ority reg>d+ :i* ! ,secret>y is requir$ "u section #ejf7;d7 to consult ) a ,/ate1 su* t]m means ! ,secret>y1 9 consultation ) su* ,/ate4 7#f7 ,heal? /atus-relat$ factor ,! t]m heal? /atus-relat$ factor has ! mean+ provid$ 9 section #gcc7;d77#b74 7#g7 ,individual m>ket 7,a7 ,9 g5]al ,! t]m individual m>ket means ! m>ket = heal? insurance cov]age (f]$ to individuals o!r ?an 9 connection ) a gr\p heal? plan4 7,b7 ,treatm5t ( v small gr\ps 7i7 ,9 g5]al ,subject to clause 7ii71 su* t]m includes cov]age (f]$ 9 connection ) a gr\p heal? plan t has few] ?an #b p>ticipants z curr5t employees or p>ticipants describ$ 9 section #gcb7;d77#c7 on ! fir/ day ( ! plan ye>4 7ii7 ,/ate exception ,clause 7i7 %all n apply 9 ! case ( heal? insurance cov]age (f]$ 9 a ,/ate if su* ,/ate regulates ! cov]age describ$ 9 su* clause 9 ! same mann] & to ! same ext5t z cov]age 9 ! small gr\p m>ket 7z def9$ 9 section #bgia7;e77#e7 ( ! ,public ,heal? ,s]vice ,act7 is regulat$ by su* ,/ate4 7#h7 ,p>ticipat+ employ] ,! t]m p>ticipat+ employ] means1 9 connection ) an association heal? plan1 any employ]1 if any individual :o is an employee ( su* employ]1 a p>tn] 9 su* employ]1 or a self-employ$ individual :o is su* employ] 7or any dep5d5t1 z def9$ "u ! t]ms ( ! plan1 ( su* individual7 is or 0 cov]$ "u su* plan 9 connection ) ! /atus ( su* individual z su* an employee1 p>tn]1 or self-employ$ individual 9 relation to ! plan4 7#i7 ,applicable /ate au?ority ,! t]m applicable ,/ate au?ority means1 ) respect to a heal? insurance issu] 9 a ,/ate1 ! ,/ate insurance commission] or (ficial or (ficials designat$ by ! ,/ate to en=ce ! requirem5ts ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act = ! ,/ate involv$ ) respect to su* issu]4 7#aj7 ,qualifi$ actu>y ,! t]m qualifi$ actu>y means an individual :o is a memb] ( ! ,am]ican ,academy ( ,actu>ies4 7#aa7 ,affiliat$ memb] ,! t]m affiliat$ memb] means1 9 connection ) a sponsor-- 7,a7 a p]son :o is o!rwise eligible to be a memb] ( ! sponsor b :o elects an affiliat$ /atus ) ! sponsor1 7,b7 9 ! case ( a sponsor ) memb]s :i* consi/ ( associations1 a p]son :o is a memb] ( any su* association & elects an affiliat$ /atus ) ! sponsor1 or 7,c7 9 ! case ( an association heal? plan 9 exi/5ce on ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjac1 a p]son eligible to be a memb] ( ! sponsor or "o ( its memb] associations4 7#ab7 ,l>ge employ] ,! t]m l>ge employ] means1 9 connection ) a gr\p heal? plan ) respect to a plan ye>1 an employ] :o employ$ an av]age ( at lea/ #ea employees on bus9ess days dur+ ! prec$+ cal5d> ye> & :o employs at lea/ #b employees on ! fir/ day ( ! plan ye>4 7#ac7 ,small employ] ,! t]m small employ] means1 9 connection ) a gr\p heal? plan ) respect to a plan ye>1 an employ] :o is n a l>ge employ]4 7b7 ,rules ( ,con/ruction 7#a7 ,employ]s & employees ,= purposes ( det]m9+ :e!r a plan1 fund1 or program is an employee welf>e b5efit plan :i* is an association heal? plan1 & = purposes ( apply+ ?is title 9 connection ) su* plan1 fund1 or program s det]m9$ to be su* an employee welf>e b5efit plan-- 7,a7 9 ! case ( a p>tn]%ip1 ! t]m employ] 7z def9$ 9 section #c7e77 includes ! p>tn]%ip 9 relation to ! p>tn]s1 & ! t]m employee 7z def9$ 9 section #c7f77 includes any p>tn] 9 relation to ! p>tn]%ip2 & 7,b7 9 ! case ( a self-employ$ individual1 ! t]m employ] 7z def9$ 9 section #c7e77 & ! t]m employee 7z def9$ 9 section #c7f77 %all include su* individual4 7#b7 ,plans1 funds1 & programs treat$ z employee welf>e b5efit plans ,9 ! case ( any plan1 fund1 or program :i* 0 e/abli%$ or is ma9ta9$ = ! purpose ( provid+ m$ical c>e 7?r\gh ! pur*ase ( insurance or o!rwise7 = employees 7or _! dep5d5ts7 cov]$ !reund] & :i* demon/rates to ! ,secret>y t all requirem5ts = c]tification "u ?is "p w\ld be met ) respect to su* plan1 fund1 or program if su* plan1 fund1 or program 7 a gr\p heal? plan1 su* plan1 fund1 or program %all be treat$ = purposes ( ?is title z an employee welf>e b5efit plan on & aft] ! date ( su* demon/ration4 4 7b7 ,con=m+ ,am5dm5ts to ,preemption ,rules 7#a7 ,section #ead7;b77#f7 ( su* ,act 7#bi ,u4,s4,c4 #aadd7;b77#f77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,! prec$+ subp>agraphs ( ?is p>agraph d n apply ) respect to any ,/ate law 9 ! case ( an association heal? plan :i* is c]tifi$ "u "p #h4 4 7#b7 ,section #ead ( su* ,act 7#bi ,u4,s4,c4 #aadd7 is am5d$-- 7,a7 9 subsection 7b77#d71 by /rik+ ,subsection 7a7 & ins]t+ ,subsections 7a7 & 7d72 7,b7 9 subsection 7b77#e71 by /rik+ subsection 7a7 9 subp>agraph 7,a7 & ins]t+ subsection 7a7 ( ?is section & subsections 7a77#b77;,b7 & 7b7 ( section #hje1 & by /rik+ subsection 7a7 9 subp>agraph 7,b7 & ins]t+ subsection 7a7 ( ?is section or subsection 7a77#b77;,b7 or 7b7 ( section #hje2 7,c7 by r$esignat+ subsections 7d7 & 7e7 z subsections 7e7 & 7f71 respectively2 & 7,d7 by ins]t+ aft] subsection 7c7 ! foll[+ new subsection3 7d7 7#a7 ,except z provid$ 9 subsection 7b77#d71 ! provisions ( ?is title %all sup]s$e any & all ,/ate laws ins(> z !y may n[ or h]eaft] preclude1 or h ! effect ( preclud+1 a heal? insurance issu] f (f]+ heal? insurance cov]age 9 connection ) an association heal? plan :i* is c]tifi$ "u "p #h4 7#b7 ,except z provid$ 9 p>agraphs 7#d7 & 7#e7 ( subsection 7b7 ( ?is section-- 7,a7 ,9 any case 9 :i* heal? insurance cov]age ( any policy type is (f]$ "u an association heal? plan c]tifi$ "u "p #h to a p>ticipat+ employ] op]at+ 9 su* ,/ate1 ! provisions ( ?is title %all sup]s$e any & all laws ( su* ,/ate ins(> z !y may preclude a heal? insurance issu] f (f]+ heal? insurance cov]age ( ! same policy type to o!r employ]s op]at+ 9 ! ,/ate :i* are eligible = cov]age "u su* association heal? plan1 :e!r or n su* o!r employ]s are p>ticipat+ employ]s 9 su* plan4 7,b7 ,9 any case 9 :i* heal? insurance cov]age ( any policy type is (f]$ 9 a ,/ate "u an association heal? plan c]tifi$ "u "p #h & ! fil+1 ) ! applicable ,/ate au?ority 7z def9$ 9 section #hab7;a77#i771 ( ! policy =m 9 connection ) su* policy type is approv$ by su* ,/ate au?ority1 ! provisions ( ?is title %all sup]s$e any & all laws ( any o!r ,/ate 9 :i* heal? insurance cov]age ( su* type is (f]$1 ins(> z !y may preclude1 ^u ! fil+ 9 ! same =m & mann] ( su* policy =m ) ! applicable ,/ate au?ority 9 su* o!r ,/ate1 ! approval ( ! fil+ 9 su* o!r ,/ate4 7#c7 ,no?+ 9 subsection 7b77#f77;,e7 or ! prec$+ provisions ( ?is subsection %all be con/ru$1 ) respect to heal? insurance issu]s or heal? insurance cov]age1 to sup]s$e or impair ! law ( any ,/ate-- 7,a7 provid+ solv5cy /&>ds or simil> /&>ds reg>d+ ! adequacy ( insur] capital1 surplus1 res]ves1 or contributions1 or 7,b7 relat+ to prompt paym5t ( claims4 7#d7 ,= additional provisions relat+ to association heal? plans1 see subsections 7a77#b77;,b7 & 7b7 ( section #hje4 7#e7 ,= purposes ( ?is subsection1 ! t]m association heal? plan has ! mean+ provid$ 9 section #hja7;a71 & ! t]ms heal? insurance cov]age1 p>ticipat+ employ]1 & heal? insurance issu] h ! mean+s provid$ su* t]ms 9 section #hab1 respectively4 4 7#c7 ,section #ead7;b77#f77;,a7 ( su* ,act 7#bi ,u4,s4,c4 #aadd7;b77#f77;,a77 is am5d$-- 7,a7 9 clause 7i77,,ii71 by /rik+ & at ! end2 7,b7 9 clause 7ii71 by ins]t+ & :i* does n provide m$ical c>e 7)9 ! mean+ ( section #gcc7;a77#b771 aft] arrangem5t1 & by /rik+ title4 & ins]t+ title1 &2 & 7,c7 by add+ at ! end ! foll[+ new clause3 7iii7 subject to subp>agraph 7,e71 9 ! case ( any o!r employee welf>e b5efit plan :i* is a multiple employ] welf>e arrangem5t & :i* provides m$ical c>e 7)9 ! mean+ ( section #gcc7;a77#b771 any law ( any ,/ate :i* regulates insurance may apply4 4 7#d7 ,section #ead7;e7 ( su* ,act 7z r$esignat$ by p>agraph 7#b77;,c77 is am5d$-- 7,a7 by /rik+ ,no?+ & ins]t+ 7#a7 ,except z provid$ 9 p>agraph 7#b71 no?+2 & 7,b7 by add+ at ! end ! foll[+ new p>agraph3 7#b7 ,no?+ 9 any o!r provision ( law enact$ on or aft] ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjac %all be con/ru$ to alt]1 am5d1 modify1 invalidate1 impair1 or sup]s$e any provision ( ?is title1 except by specific cross-ref]5ce to ! affect$ section4 4 7c7 ,plan ,sponsor ,section #c7af77;,b7 ( su* ,act 7#bi ,u4,s4,c4 #ajb7af77;,b77 is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,su* t]m also includes a p]son s]v+ z ! sponsor ( an association heal? plan "u "p #h44 7d7 ,disclosure ( ,solv5cy ,protections ,relat$ to ,self-,insur$ & ,fully ,insur$ ,options ,"u ,association ,heal? ,plans ,section #ajb7;b7 ( su* ,act 7#bi ,u4,s4,c4 #ajb7;b77 is am5d$ by add+ at ! end ! foll[+3 ,an association heal? plan %all include 9 its summ>y plan description1 9 connection ) ea* b5efit option1 a description ( ! =m ( solv5cy or gu>antee fund protection secur$ pursuant to ?is ,act or applicable ,/ate law1 if any44 7e7 ,sav+s ,clause ,section #gca7;c7 ( su* ,act is am5d$ by ins]t+ or "p #h aft] ?is "p4 7f7 ,report to ! ,congress ,reg>d+ ,c]tification ( ,self-,insur$ ,association ,heal? ,plans ,n lat] ?an ,janu>y #a1 #bjaf1 ! ,secret>y ( ,labor %all report to ! ,committee on ,education & ! ,work=ce ( ! ,h\se ( ,repres5tatives & ! ,committee on ,heal?1 ,education1 ,labor1 & ,p5sions ( ! ,s5ate ! effect association heal? plans h _h1 if any1 on r$uc+ ! numb] ( un9sur$ individuals4 7g7 ,cl]ical ,am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by ins]t+ aft] ! item relat+ to section #gcd ! foll[+ new items3 ,"p #h--,rules ,gov]n+ ,association ,heal? ,plans#hja4 ,association heal? plans4#hjb4 ,c]tification ( association heal? plans4#hjc4 ,requirem5ts relat+ to sponsors & bo>ds ( tru/ees4#hjd4 ,p>ticipation & cov]age requirem5ts4#hje4 ,o!r requirem5ts relat+ to plan docum5ts1 contribution rates1 & b5efit options4#hjf4 ,ma9t5ance ( res]ves & provisions = solv5cy = plans provid+ heal? b5efits 9 addition to heal? insurance cov]age4#hjg4 ,requirem5ts = application & relat$ requirem5ts4#hjh4 ,notice requirem5ts = volunt>y t]m9ation4#hji4 ,corrective actions & m&atory t]m9ation4#haj4 ,tru/ee%ip by ! ,secret>y ( insolv5t association heal? plans provid+ heal? b5efits 9 addition to heal? insurance cov]age4#haa4 ,/ate assessm5t au?ority4#hab4 ,def9itions & rules ( con/ruction4 4 #fbb4 ,cl>ification ( treatm5t ( s+le employ] arrangem5ts ,section #c7dj77;,b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajjb7dj77;,b77 is am5d$-- 7#a7 9 clause 7i71 by ins]t+ aft] control gr\p1 ! foll[+3 except t1 9 any case 9 :i* ! b5efit ref]r$ to 9 subp>agraph 7,a7 consi/s ( m$ical c>e 7z def9$ 9 section #hab7;a77#b771 two or m trades or bus9esses1 :e!r or n incorporat$1 %all be deem$ a s+le employ] = any plan ye> ( su* plan1 or any fiscal ye> ( su* o!r arrangem5t1 if su* trades or bus9esses are )9 ! same control gr\p dur+ su* ye> or at any "t dur+ ! prec$+ #a-ye> p]iod12 7#b7 9 clause 7iii71 by /rik+ 7iii7 ! det]m9ation & ins]t+ ! foll[+3 7iii7 7,i7 9 any case 9 :i* ! b5efit ref]r$ to 9 subp>agraph 7,a7 consi/s ( m$ical c>e 7z def9$ 9 section #hab7;a77#b771 ! det]m9ation ( :e!r a trade or bus9ess is "u common control ) ano!r trade or bus9ess %all be det]m9$ "u regulations ( ! ,secret>y apply+ pr9ciples consi/5t & coext5sive ) ! pr9ciples appli$ 9 det]m9+ :e!r employees ( two or m trades or bus9esses are treat$ z employ$ by a s+le employ] "u section #djja7;b71 except t1 = purposes ( ?is p>agraph1 an int]e/ ( great] ?an #be p]c5t may n be requir$ z ! m9imum int]e/ necess>y = common control1 or 7,,ii7 9 any o!r case1 ! det]m9ation 2 7#c7 by r$esignat+ clauses 7iv7 & 7v7 z clauses 7v7 & 7vi71 respectively2 & 7#d7 by ins]t+ aft] clause 7iii7 ! foll[+ new clause3 7iv7 9 any case 9 :i* ! b5efit ref]r$ to 9 subp>agraph 7,a7 consi/s ( m$ical c>e 7z def9$ 9 section #hab7;a77#b771 9 det]m9+1 aft] ! application ( clause 7i71 :e!r b5efits are provid$ to employees ( two or m employ]s1 ! arrangem5t %all be treat$ z hav+ only "o p>ticipat+ employ] if1 aft] ! application ( clause 7i71 ! numb] ( individuals :o are employees & =m] employees ( any "o p>ticipat+ employ] & :o are cov]$ "u ! arrangem5t is great] ?an #ge p]c5t ( ! aggregate numb] ( all individuals :o are employees or =m] employees ( p>ticipat+ employ]s & :o are cov]$ "u ! arrangem5t1 4 #fbc4 ,en=cem5t provisions relat+ to association heal? plans 7a7 ,crim9al ,p5alties = ,c]ta9 ,willful ,misrepres5tations ,section #eja ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aaca7 is am5d$-- 7#a7 by ins]t+ 7a7 aft] ,sec4 #eja42 & 7#b7 by add+ at ! end ! foll[+ new subsection3 7b7 ,any p]son :o willfully falsely repres5ts1 to any employee1 any employee's b5efici>y1 any employ]1 ! ,secret>y1 or any ,/ate1 a plan or o!r arrangem5t e/abli%$ or ma9ta9$ = ! purpose ( (f]+ or provid+ any b5efit describ$ 9 section #c7a7 to employees or _! b5efici>ies z-- 7#a7 be+ an association heal? plan :i* has be5 c]tifi$ "u "p #h2 7#b7 hav+ be5 e/abli%$ or ma9ta9$ "u or pursuant to "o or m collective b>ga9+ agreem5ts :i* are rea*$ pursuant to collective b>ga9+ describ$ 9 section #h7;d7 ( ! ,national ,labor ,relations ,act 7#bi ,u4,s4,c4 #aeh7;d77 or p>agraph f\r? ( section #b ( ! ,railway ,labor ,act 7#de ,u4,s4,c4 #aeb1 p>agraph f\r?7 or :i* are rea*$ pursuant to labor-managem5t negotiations "u simil> provisions ( ,/ate public employee relations laws2 or 7#c7 be+ a plan or arrangem5t describ$ 9 section #c7dj77;,a77i71 %all1 ^u conviction1 be imprison$ n m ?an #e ye>s1 be f9$ "u title #ah1 ,unit$ ,/ates ,code1 or bo?4 4 7b7 ,cease ,activities ,ord]s ,section #ejb ( su* ,act 7#bi ,u4,s4,c4 #aacb7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7n7 ,association ,heal? ,plan ,cease & ,desi/ ,ord]s 7#a7 ,9 g5]al ,subject to p>agraph 7#b71 ^u application by ! ,secret>y %[+ ! op]ation1 promotion1 or m>ket+ ( an association heal? plan 7or simil> arrangem5t provid+ b5efits consi/+ ( m$ical c>e 7z def9$ 9 section #gcc7;a77#b777 t-- 7,a7 is n c]tifi$ "u "p #h1 is subject "u section #ead7;b77#f7 to ! insurance laws ( any ,/ate 9 :i* ! plan or arrangem5t (f]s or provides b5efits1 & is n lic5s$1 regi/]$1 or o!rwise approv$ "u ! insurance laws ( su* ,/ate2 or 7,b7 is an association heal? plan c]tifi$ "u "p #h & is n op]at+ 9 accordance ) ! requirem5ts "u "p #h = su* c]tification1 a di/rict c\rt ( ! ,unit$ ,/ates %all ent] an ord] requir+ t ! plan or arrangem5t cease activities4 7#b7 ,exception ,p>agraph 7#a7 %all n apply 9 ! case ( an association heal? plan or o!r arrangem5t if ! plan or arrangem5t %[s t-- 7,a7 all b5efits "u x ref]r$ to 9 p>agraph 7#a7 consi/ ( heal? insurance cov]age2 & 7,b7 ) respect to ea* ,/ate 9 :i* ! plan or arrangem5t (f]s or provides b5efits1 ! plan or arrangem5t is op]at+ 9 accordance ) applicable ,/ate laws t are n sup]s$$ "u section #ead4 7#c7 ,additional equitable relief ,! c\rt may grant su* additional equitable relief1 includ+ any relief available "u ?is title1 z x deems necess>y to protect ! int]e/s ( ! public & ( p]sons hav+ claims = b5efits aga9/ ! plan4 4 7c7 ,responsibility = ,claims ,proc$ure ,section #ejc ( su* ,act 7#bi ,u4,s4,c4 #aacc7 is am5d$ by ins]t+ 7a7 ,9 g5]al4-- be=e ,9 accordance1 & by add+ at ! end ! foll[+ new subsection3 7b7 ,association ,heal? ,plans ,! t]ms ( ea* association heal? plan :i* is or has be5 c]tifi$ "u "p #h %all require ! bo>d ( tru/ees or ! nam$ fiduci>y 7z applicable7 to ensure t ! requirem5ts ( ?is section are met 9 connection ) claims fil$ "u ! plan4 4 #fbd4 ,coop]ation betwe5 ,f$]al & ,/ate au?orities ,section #ejf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aacf7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7d7 ,consultation ,) ,/ates ,) ,respect to ,association ,heal? ,plans 7#a7 ,agreem5ts ) /ates ,! ,secret>y %all consult ) ! ,/ate recogniz$ "u p>agraph 7#b7 ) respect to an association heal? plan reg>d+ ! ex]cise (-- 7,a7 ! ,secret>y's au?ority "u sections #ejb & #ejd to en=ce ! requirem5ts = c]tification "u "p #h2 & 7,b7 ! ,secret>y's au?ority to c]tify association heal? plans "u "p #h 9 accordance ) regulations ( ! ,secret>y applicable to c]tification "u "p #h4 7#b7 ,recognition ( prim>y domicile /ate ,9 c>ry+ out p>agraph 7#a71 ! ,secret>y %all ensure t only "o ,/ate w be recogniz$1 ) respect to any p>ticul> association heal? plan1 z ! ,/ate ) :i* consultation is requir$4 ,9 c>ry+ out ?is p>agraph-- 7,a7 9 ! case ( a plan :i* provides heal? insurance cov]age 7z def9$ 9 section #hab7;a77#c771 su* ,/ate %all be ! ,/ate ) :i* fil+ & approval ( a policy type (f]$ by ! plan 0 initially obta9$1 & 7,b7 9 any o!r case1 ! ,secret>y %all take into acc\nt ! places ( resid5ce ( ! p>ticipants & b5efici>ies "u ! plan & ! ,/ate 9 :i* ! tru/ is ma9ta9$4 4 #fbe4 ,effective date & transitional & o!r rules 7a7 ,effective ,date ,! am5dm5ts made by ?is *apt] %all take effect #a ye> aft] ! date ( ! enactm5t ( ?is ,act4 ,! ,secret>y ( ,labor %all fir/ issue all regulations necess>y to c>ry out ! am5dm5ts made by ?is *apt] )9 #a ye> aft] ! date ( ! enactm5t ( ?is ,act4 7b7 ,treatm5t ( ,c]ta9 ,exi/+ ,heal? ,b5efits ,programs 7#a7 ,9 g5]al ,9 any case 9 :i*1 z ( ! date ( ! enactm5t ( ?is ,act1 an arrangem5t is ma9ta9$ 9 a ,/ate = ! purpose ( provid+ b5efits consi/+ ( m$ical c>e = ! employees & b5efici>ies ( its p>ticipat+ employ]s1 at lea/ #bjj p>ticipat+ employ]s make contributions to su* arrangem5t1 su* arrangem5t has be5 9 exi/5ce = at lea/ #aj ye>s1 & su* arrangem5t is lic5s$ "u ! laws ( "o or m ,/ates to provide su* b5efits to its p>ticipat+ employ]s1 ^u ! fil+ ) ! applicable au?ority 7z def9$ 9 section #hab7;a77#e7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7z am5d$ by ?is *apt]77 by ! arrangem5t ( an application = c]tification ( ! arrangem5t "u "p #h ( subtitle ,b ( title ,i ( su* ,act-- 7,a7 su* arrangem5t %all be deem$ to be a gr\p heal? plan = purposes ( title ,i ( su* ,act2 7,b7 ! requirem5ts ( sections #hja7;a7 & #hjc7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd %all be deem$ met ) respect to su* arrangem5t2 7,c7 ! requirem5ts ( section #hjc7;b7 ( su* ,act %all be deem$ met1 if ! arrangem5t is op]at$ by a bo>d ( directors :i*-- 7i7 is elect$ by ! p>ticipat+ employ]s1 ) ea* employ] hav+ "o vote2 & 7ii7 has complete fiscal control ov] ! arrangem5t & :i* is responsible = all op]ations ( ! arrangem5t2 7,d7 ! requirem5ts ( section #hjd7;a7 ( su* ,act %all be deem$ met ) respect to su* arrangem5t2 & 7,e7 ! arrangem5t may be c]tifi$ by any applicable au?ority ) respect to its op]ations 9 any ,/ate only if x op]ates 9 su* ,/ate on ! date ( c]tification4 ,! provisions ( ?is subsection %all cease to apply ) respect to any su* arrangem5t at su* "t aft] ! date ( ! enactm5t ( ?is ,act z ! applicable requirem5ts ( ?is subsection are n met ) respect to su* arrangem5t4 7#b7 ,def9itions ,= purposes ( ?is subsection1 ! t]ms gr\p heal? plan1 m$ical c>e1 & p>ticipat+ employ] %all h ! mean+s provid$ 9 section #hab ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 except t ! ref]5ce 9 p>agraph 7#g7 ( su* section to an association heal? plan %all be deem$ a ref]5ce to an arrangem5t ref]r$ to 9 ?is subsection4 #b ,t>get$ ,ef=ts ,to ,exp& ,access #fca4 ,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 ?r\gh at lea/ ! end ( ! plan ye> 9 :i* ! individual turns an age specifi$ 9 ! plan1 b n less ?an #bc 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 ,act 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 ?r\gh at lea/ ! end ( ! plan ye> 9 :i* ! individual turns an age specifi$ 9 ! plan1 b n less ?an #bc 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 ?r\gh at lea/ ! end ( ! plan ye> 9 :i* ! individual turns an age specifi$ 9 ! plan1 b n less ?an #bc 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 ?is section %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 #fcb4 ,all[+ auto-enrollm5t = employ] sponsor$ cov]age 7a7 ,9 g5]al ,no ,/ate %all e/abli% a law t prev5ts an employ] f in/itut+ auto-enrollm5t = cov]age ( a p>ticipant or b5efici>y1 includ+ curr5t employees1 "u a gr\p heal? plan1 or heal? insurance cov]age (f]$ 9 connection ) su* a plan1 s long z ! p>ticipant or b5efici>y has ! option ( decl9+ su* cov]age4 7b7 ,auto-,enrollm5t 7#a7 ,notice requir$ ,employ]s ) auto-enrollm5t "u a gr\p heal? plan or heal? insurance cov]age %all provide annual notification1 )9 a reasonable p]iod be=e ! beg9n+ ( ea* plan ye>1 to ea* employee eligible to p>ticipate 9 ! plan4 ,! notice %all expla9 ! employee contribution to su* plan & ! employee's "r to decl9e cov]age4 7#b7 ,treatm5t ( non-action ,aft] a reasonable p]iod ( "t aft] receipt ( ! notice1 if an employee fails to make an affirmative decl>ation decl9+ cov]age1 !n su* an employee may be enroll$ 9 ! gr\p heal? plan or heal? insurance cov]age (f]$ 9 connection ) su* a plan404 7c7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$ to sup]s$e ,/ate law :i* e/abli%es1 implem5ts1 or cont9ues 9 effect any /&>d or requirem5t relat+ to employ]s 9 connection ) payroll or ! sponsor+ ( employ] sponsor$ heal? insurance cov]age except to ! ext5t t su* /&>d or requirem5t prev5ts an employ] f in/itut+ ! auto-enrollm5t describ$ 9 subsection 7a74 ,,vii ,/opp+ ,m$ic>e1 ,wa/e1 ,fraud1 & ,abuse & ,increas+ ,p5alties = ,abus]s #gja4 ,increas$ civil money p5alties & crim9al f9es = ,m$ic>e fraud & abuse 7a7 ,increas$ ,civil ,money ,p5alties ,section #aabh;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a7 is am5d$-- 7#a7 9 subsection 7a71 9 ! matt] foll[+ p>agraph 7#aj7-- 7,a7 by /rik+ #aj1jjj ea* place x appe>s & ins]t+ #bj1jjj2 7,b7 by /rik+ #ae1jjj & ins]t+ #cj1jjj2 & 7,c7 by /rik+ #ej1jjj ea* place x appe>s & ins]t+ #ajj1jjj2 & 7#b7 9 subsection 7b7-- 7,a7 9 p>agraph 7#a71 9 ! flu% matt] foll[+ subp>agraph 7,b71 by /rik+ #b1jjj & ins]t+ #d1jjj2 7,b7 9 p>agraph 7#b71 by /rik+ #b1jjj & ins]t+ #d1jjj2 & 7,c7 9 p>agraph 7#c77;,a77i71 by /rik+ #e1jjj & ins]t+ #aj1jjj4 7b7 ,increas$ ,crim9al ,f9es ,section #aabh;,b ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;b7 is am5d$-- 7#a7 9 subsection 7a71 9 ! flu% matt] foll[+ p>agraph 7#f7-- 7,a7 by /rik+ #be1jjj & ins]t+ #ajj1jjj2 & 7,b7 by /rik+ #aj1jjj & ins]t+ #bj1jjj2 7#b7 9 subsection 7b7-- 7,a7 9 p>agraph 7#a71 9 ! flu% matt] foll[+ subp>agraph 7,b71 by /rik+ #be1jjj & ins]t+ #ajj1jjj2 & 7,b7 9 p>agraph 7#b71 9 ! flu% matt] foll[+ subp>agraph 7,b71 by /rik+ #be1jjj & ins]t+ #ajj1jjj2 7#c7 9 subsection 7c71 by /rik+ #be1jjj & ins]t+ #ajj1jjj2 7#d7 9 subsection 7d71 9 ! second flu% matt] foll[+ subp>agraph 7,b71 by /rik+ #be1jjj & ins]t+ #ajj1jjj2 & 7#e7 9 subsection 7e71 by /rik+ #b1jjj & ins]t+ #d1jjj4 7c7 ,effective ,date ,! am5dm5ts made by ?is section %all apply to civil money p5alties & f9es impos$ = actions tak5 on or aft] ! date ( enactm5t ( ?is ,act4 #gjb4 ,increas$ s5t5ces = felonies involv+ ,m$ic>e fraud & abuse 7a7 ,false ,/atem5ts & ,repres5tations ,section #aabh;,b7a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;b7a77 is am5d$1 9 clause 7i7 ( ! flu% matt] foll[+ p>agraph 7#f71 by /rik+ n m ?an five ye>s & ins]t+ n m ?an #aj ye>s4 7b7 ,anti-,kickback ,section #aabh;,b7b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;b7b77 is am5d$-- 7#a7 9 p>agraph 7#a71 9 ! flu% matt] foll[+ subp>agraph 7,b71 by /rik+ n m ?an five ye>s & ins]t+ n m ?an #aj ye>s2 & 7#b7 9 p>agraph 7#b71 9 ! flu% matt] foll[+ subp>agraph 7,b71 by /rik+ n m ?an five ye>s & ins]t+ n m ?an #aj ye>s4 7c7 ,false ,/atem5t or ,repres5tation ,) ,respect to ,conditions or ,op]ations ( ,facilities ,section #aabh;,b7c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;b7c77 is am5d$ by /rik+ n m ?an five ye>s & ins]t+ n m ?an #aj ye>s4 7d7 ,excess ,*>ges ,section #aabh;,b7d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;b7d77 is am5d$1 9 ! second flu% matt] foll[+ subp>agraph 7,b71 by /rik+ n m ?an five ye>s & ins]t+ n m ?an #aj ye>s4 7e7 ,effective ,date ,! am5dm5ts made by ?is section %all apply to crim9al p5alties impos$ = actions tak5 on or aft] ! date ( enactm5t ( ?is ,act4 #gjc4 ,o!r ,,dme suppli] anti-fraud & abuse provisions 7a7 ,m&atory p]iodic site inspections = ,,dme suppli]s ,! ,secret>y ( ,heal? & ,human ,s]vices %all require1 z a condition = p>ticipation ( suppli]s ( durable m$ical equipm5t "u "p ,b ( title ,,xviii ( ! ,social ,security ,act-- 7#a7 a site inspection to be conduct$ = ea* su* suppli] t has n previ\sly p>ticipat$ "u su* "p )9 #f mon?s ( ! date ( its initial p>ticipation "u su* "p2 & 7#b7 a site inspection at lea/ e #b ye>s to be conduct$ = ea* su* suppli] t has previ\sly p>ticipat$ "u su* "p4 7b7 ,po/-,paym5t review ,! ,secret>y also %all provide conduct po/-paym5t reviews ( claims = items & s]vices furni%$ "u su* "p by durable m$ical equipm5t suppli]s t beg9 p>ticipation "u su* "p aft] ! date ( ! enactm5t ( ?is ,act4 ,su* reviews %all be conduct$ n less (t5 ?an aft] ! fir/ #f1 #ab1 & #ah mon?s ( su* p>ticipation4 7c7 ,availability ( funds ,funds 9 ! ,heal? ,c>e ,fraud & ,abuse ,control ,acc\nt "u section #ahag7k7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7k77 %all be available = ! conduct ( site inspections & po/-paym5t review requir$ "u ?is section4 7d7 ,treatm5t ( skill$ nurs+ facilities ,9 ?is section1 a skill$ nurs+ facility %all n be treat$ z a suppli] ( durable m$ical equipm5t ) respect to any individual :o is a resid5t ( su* facility4 #gjd4 ,ret5tion ( c]ta9 fraud & abuse provisions ,section #aja %all n apply to ! provisions 7includ+ am5dm5ts made by7 title ,,vi ( ,public ,law #aaa-adh1 o!r ?an subtitles ,d1 ,h1 & ,i ( su* title1 & provisions ( ,public ,law #aaa-aeb ins(> z !y relate to su* provisions4 #gje4 ,ensur+ timely en=cem5t ( ,m$ic>e second>y pay] requirem5ts 9 liability cases ,! ,secret>y ( ,heal? & ,human ,s]vices1 act+ ?r\gh ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices1 %all affirmatively e/abli%1 = initial implem5tation n lat] ?an #ij days aft] ! date ( ! enactm5t ( ?is ,act1 a plan to require applicable plans 7z def9$ 9 subp>agraph 7,f7 ( section #ahfb7;b77#h7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciey7b77#h771 z add$ by section #aaa7;a7 ( ! ,m$ic>e1 ,m$icaid1 & ,,s*ip ,ext5sion ,act ( #bjjg 7,public ,law #aaj-agc771 to meet ! det]m9ation & submission requirem5ts "u subp>agraph 7,a7 ( su* section #ahfb7;b77#h74