,,ii #aacth ,,congress #ast ,session ,s4 #aa ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,february #bf1 #bjac ,mr4 ,corker 7for himself and ,mr4 ,alexander7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to provide a comprehensive deficit reduction plan1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,fiscal ,sustainability ,act of #bjac4 7b7 ,table of contents ,the table of contents for this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,,title ,i--,medicaid ,sec4 #aaja4 ,comprehensive ,medicaid ,waivers4 ,sec4 #aajb4 ,phased-in elimination of allowable provider taxes under ,medicaid4 ,,title ,,ii--,medicare ,subtitle ,a--,medicare ,total ,health program2 ,medicare ,fee-for-,service program reforms2 ,reports ,sec4 #bjjj4 ,short title2 purpose4 ,,part ,i--,medicare ,total ,health program ,sec4 #bjja4 ,establishment of ,medicare ,total ,health program4 ,subpart #b--,medicare ,total ,health program ,sec4 #ahfj;,c-#a4 ,eligibility1 enrollment1 and information4 ,sec4 #ahfj;,c-#b4 ,total ,health plan benefits4 ,sec4 #ahfj;,c-#c4 ,access to a choice of qualified ,total ,health benefits plans4 ,sec4 #ahfj;,c-#d4 ,beneficiary protections for ,total ,health plan enrollees4 ,sec4 #ahfj;,c-#e4 ,total ,health regions2 submission of bids2 ,total ,health plan approval4 ,sec4 #ahfj;,c-#f4 ,requirements for and contracts with ,total ,health sponsors4 ,sec4 #ahfj;,c-#g4 ,total ,health premiums4 ,sec4 #ahfj;,c-#h4 ,premium and cost-sharing support for ,total ,health eligible individuals4 ,sec4 #ahfj;,c-#i4 ,exemption for ,,msa plans4 ,sec4 #ahfj;,c-#aj4 ,special rules for employer-sponsored programs4 ,sec4 #ahfj;,c-#aa4 ,coordination with ,state ,medicaid programs4 ,sec4 #ahfj;,c-#ab4 ,definitions and miscellaneous provisions4 ,sec4 #bjjb4 ,replacement of part ,b premium with ,medicare ,total ,health program plan premium2 other technical and conforming amendments4 ,,part ,,ii--,medicare fee-for-,service reforms ,sec4 #bjaa4 ,medicare protection against high out-of-pocket expenditures for fee-for-service benefits4 ,sec4 #bjab4 ,unified ,medicare deductible4 ,sec4 #bjac4 ,uniform ,medicare coinsurance rate4 ,sec4 #bjad4 ,prohibition on first-dollar coverage under ,medigap policies and development of new standards for ,medigap policies4 ,,part ,,iii--,annual report to ,congress ,sec4 #bjba4 ,annual report to ,congress4 ,subtitle ,b--,elimination of exemption of ,medicare payments to physicians under statutory ,,paygo ,sec4 #baja4 ,elimination of exemption of ,medicare payments to physicians under statutory ,,paygo4 ,subtitle ,c--,adjustments to ,medicare part ,b and ,d premiums for high-,income beneficiaries ,sec4 #bbja4 ,adjustments to ,medicare part ,b and ,d premiums for high-income beneficiaries4 ,subtitle ,d--,increase in the ,medicare eligibility age ,sec4 #bcja4 ,increase in the ,medicare eligibility age4 ,subtitle ,e--,other provisions ,sec4 #bdja4 ,limitation on ,medicare payments for direct graduate medical education 7,,dgme74 ,sec4 #bdjb4 ,reduction in ,medicare indirect graduate medical education 7,,ime7 payments4 ,sec4 #bdjc4 ,acceleration of application of productivity adjustment to ,medicare home health prospective payment amounts4 ,sec4 #bdjd4 ,acceleration of rebasing of ,medicare home health prospective payment amounts4 ,sec4 #bdje4 ,reduction of bad debt treated as an allowable cost4 ,,title ,,iii--,social ,security ,sec4 #caja4 ,adjustments to bend points in determining primary insurance amount4 ,sec4 #cajb4 ,adjustment to calculation of benefit computation years4 ,sec4 #cajc4 ,minimum ,social ,security benefit4 ,sec4 #cajd4 ,increase in benefits starting #bj years after initial eligibility4 ,sec4 #caje4 ,adjustment to normal and early retirement ages4 ,sec4 #cajf4 ,application of actuarial reduction for disabled beneficiaries who attain early retirement age4 ,sec4 #cajg4 ,option to collect up to one-half of old-age insurance benefit at age #fb4 ,sec4 #cajh4 ,coverage of newly hired ,state and local employees4 ,sec4 #caji4 ,inclusion in annual ,social ,security account statement of estimated present value of taxes and benefits for ,social ,security and ,medicare and projected deficit as a percent of lifetime earnings4 ,sec4 #caaj4 ,retirement information campaign4 ,,title ,,iv--,conversion to chained ,,cpi ,sec4 #daja4 ,conversion to ,chained ,,cpi4 ,i ,medicaid #aaja4 ,comprehensive ,medicaid ,waivers ,section #aaae of the ,social ,security ,act 7#db ,u4,s4,c4 #acae7 is amended by adding at the end the following3 7g7 ,comprehensive ,medicaid ,waivers 7#a7 ,authority 7,a7 ,in general ,a ,state may elect to provide medical assistance under title ,,xix1 directly or by contract1 to eligible individuals pursuant to a comprehensive ,medicaid waiver under this subsection in lieu of providing such assistance under a ,state plan approved under title ,,xix or a waiver approved under subsection 7d7 or extended under subsection 7e74 ,a ,state shall make such an election by submitting a waiver application to the ,secretary for certification that the application satisfies the requirements of paragraph 7#b74 7,b7 ,waiver of ,state ,medicaid program requirements ,any requirements applicable under this title or title ,,xix that would prevent a ,state from carrying out a comprehensive ,medicaid waiver in accordance with the ,state's certified application and the requirements of this subsection are deemed waived4 7,c7 ,shared savings bonus ,a ,state conducting a comprehensive ,medicaid waiver under this subsection shall be eligible for a shared savings bonus in accordance with paragraph 7#d74 7,d7 ,option to include ,,chip-eligible individuals ,a ,state may elect to treat individuals eligible for child health assistance under the ,state child health plan under title ,,xxi as eligible individuals under a comprehensive ,medicaid waiver4 ,the waiver application and determination of the aggregate spending cap for the ,state for the waiver period shall take into account the inclusion of such individuals in the comprehensive ,medicaid waiver4 ,any requirements applicable under this title1 title ,,xix1 or title ,,xxi that would prevent a ,state from including such individuals in the comprehensive ,medicaid waiver in accordance with the ,state's certified application and the requirements of this subsection are deemed waived4 7#b7 ,comprehensive ,medicaid waiver application ,an application for a comprehensive ,medicaid waiver under this subsection shall contain the following3 7,a7 ,general description of proposed benefit delivery models1 eligibility criteria1 and benefits ,a brief description1 which may be in outline form1 of the eligibility criteria and medical assistance to be provided that includes the methods for delivery of such assistance1 the criteria for the determination of eligibility for such assistance1 and the amount1 duration1 and scope of such assistance1 including a description of the amount 7if any7 of premiums1 deductibles1 coinsurance1 or other cost-sharing4 7,b7 ,,hedis measures to evaluate performance 7i7 ,in general ,a description of not less than #bj of the standard ,medicaid ,healthcare ,effectiveness ,data and ,information ,set 7,,hedis7 measures established by the ,national ,committee for ,quality ,assurance selected by the ,state to annually evaluate the quality and cost-effectiveness of the medical assistance provided under the waiver1 and for each such measure 7and1 if applicable1 the distinct rates associated with the measure71 the baseline data and the target performance goal applicable for each such measure or rate4 ,the ,state shall select ,,hedis measures that are closely aligned with the health care items and services that are provided to eligible individuals as medical assistance under the waiver4 7ii7 ,evaluation ,the description under this subparagraph shall specify the independent entity that the ,state will use to evaluate the waiver4 ,the ,state shall provide an assurance that the ,state will submit a copy of the annual evaluation to the ,secretary4 7,c7 ,program integrity ,a brief description of the ,state's program to prevent waste1 fraud1 and abuse under the waiver4 7,d7 ,aggregate spending cap ,an assurance that the ,state agrees-- 7i7 to establish categories that accurately account for each of the distinct population groups that will qualify as eligible individuals under the waiver 7such as children1 parents1 pregnant women1 and the blind or disabled7 based on such criteria as are determined appropriate by the ,state 7referred to in this subsection as a population category72 7ii7 to provide the ,secretary with all data relevant to the determination of the aggregate spending cap for the ,state for the waiver period1 as determined by the ,secretary under paragraph 7#c77;,b72 and 7iii7 with respect to each period for which the waiver is approved1 to not receive any ,federal payments from the ,secretary for amounts expended during such period that exceed the aggregate spending cap4 7#c7 ,determination of aggregate spending cap 7,a7 ,establishment of spending template 7i7 ,in general ,the ,secretary1 in coordination with the ,director of the ,office of ,management and ,budget 7referred to in this subsection as the ,director71 shall establish a template for determining1 with respect to each ,state1 the aggregate spending cap for each period for which the ,state conducts a comprehensive ,medicaid waiver under this subsection4 ,the ,secretary shall-- 7,i7 publish a proposed template not later than #fj days after the date of enactment of this subsection2 7,,ii7 provide for a period for public comment on the proposed template2 and 7,,iii7 promulgate a final template not later than #abj days after such date of enactment4 7ii7 ,revisions 7,i7 ,in general ,subject to subclause 7,,ii71 the ,secretary1 in coordination with the ,director1 shall revise the template1 as appropriate1 not less than every #e years pursuant to a process that allows for public comment prior to publication of the revised template4 7,,ii7 ,technical changes ,the ,secretary or the ,director may make any necessary technical or conforming changes to the template at such times and in such manner as is determined appropriate4 7,b7 ,determination of aggregate spending cap for each ,state 7i7 ,in general ,subject to subparagraph 7,c71 the aggregate spending cap applicable to a ,state for a waiver period shall be equal to #ii percent of the amount determined under clause 7ii74 7ii7 ,total amount of projected ,federal payments ,the amount described in this clause is equal to the sum of-- 7,i7 the total amount of ,federal payments that would otherwise be made to the ,state during the waiver period with respect to any disproportionate share payment adjustment made under section #aibc2 and 7,,ii7 the sum of the amounts determined under clause 7iii7 for each population category4 7iii7 ,projected ,federal payments for medical assistance provided to population categories ,for purposes of clause 7ii77,,ii71 the ,secretary and the ,director shall calculate the amount of projected expenditures for the provision of medical assistance to eligible individuals in each population category during the waiver period 7as determined based upon the population categories established and the data provided by the ,state pursuant to paragraph 7#b77;,d71 as well as the annual baseline estimates supplied by the ,director and such other data as is determined appropriate by the ,secretary71 which shall be equal to the product of-- 7,i7 subject to clause 7iv71 the monthly per capita amount of ,federal payments that were made to the ,state under the ,state plan under title ,,xix 7or under a waiver approved under subsection 7d7 or extended under subsection 7e77 for an individual in such population category during the fiscal year prior to the ,state application for the waiver 7referred to in this paragraph as the population category per capita baseline72 7,,ii7 the number of individuals within such population category that are projected to be eligible to receive medical assistance during the waiver period2 and 7,,iii7 the number of months in the waiver period4 7iv7 ,population categories with no baseline data ,for purposes of any determination under clause 7iii77,i7 for a population category that lacks sufficient data to calculate the population category per capita baseline and that consists of individuals for which the ,state would otherwise be required to provide medical assistance to pursuant to section #aijb7;a77#aj77;,a77i77,,viii71 the population category per capita baseline shall be equal to the monthly per capita amount of ,federal payments that would otherwise have been made to the ,state under the ,state plan under title ,,xix 7or under a waiver approved under subsection 7d7 or extended under subsection 7e77 during the preceding fiscal year for an individual who is under #fe years of age1 not pregnant1 not entitled to1 or enrolled for1 benefits under part ,a of title ,,xviii1 or enrolled for benefits under part ,b of title ,,xviii4 7v7 ,budget neutrality ,in no event shall the aggregate spending cap established for a ,state for a waiver period allow for ,federal payments to the ,state during the waiver period that exceed the amount of ,federal payments to the ,state that would have been made during that period if the ,state had not elected to conduct a comprehensive ,medicaid waiver under this subsection during the period4 7,c7 ,adjustment of aggregate spending cap for high unemployment ,for purposes of subparagraph 7,b77i71 if the average monthly unemployment rate 7as defined in paragraph 7#h77;,a77 for a ,state exceeds #aj percent for any consecutive period of at least #f months occurring during the waiver period1 the aggregate spending cap applicable to the ,state for such waiver period shall be equal to #ajj percent of the amount determined under subparagraph 7,b77ii74 7#d7 ,shared savings bonuses 7,a7 ,in general ,the ,secretary shall annually pay each ,state conducting a comprehensive ,medicaid waiver under this subsection an amount equal to #be percent of the waiver savings determined with respect to a ,state and a waiver period under subparagraph 7,c74 7,b7 ,dedicated to health care ,a ,state that receives a payment under this paragraph shall spend not less than #hj percent of the payment on health care services or health-related activities for eligible individuals4 7,c7 ,determination of waiver savings ,the ,secretary and the ,director shall establish a process for determining with respect to a ,state and a waiver period the amount of savings achieved by a ,state for the period4 ,the process shall take into account the difference between the aggregate spending cap applicable to the ,state for the waiver period and the total amount expended by the ,state under the waiver for the period4 7,d7 ,payment2 retrospective adjustment ,the ,secretary shall make annual payments under this paragraph on the basis of claims submitted by the ,state for expenses paid by the ,state for medical assistance provided under the waiver1 and such other investigation as the ,secretary or the ,director may find necessary1 and may reduce or increase the payments as necessary to adjust for prior overpayments or under payments under this paragraph4 7#e7 ,duration 7,a7 ,in general ,a ,state shall conduct a comprehensive ,medicaid waiver under this subsection for a #e-year period4 ,subject to subparagraph 7,b71 a comprehensive ,medicaid waiver may be renewed for additional #c-year periods upon the request of the ,state1 unless within #ij days after receipt of a ,state request for a renewal of a waiver1 the ,secretary and the ,director determine1 based on the ,state evaluations required under paragraph 7#b77;,b71 that the waiver should not be renewed4 7,b7 ,state evaluations and target performance goals ,for purposes of subparagraph 7,a71 the ,secretary and the ,director may not renew a waiver unless each of the measures or rates selected by the ,state pursuant to paragraph 7#b77;,b7 has improved or remained constant during the waiver period4 7#f7 ,limited ,secretarial authority2 administrative and judicial review 7,a7 ,certification of waiver applications 7i7 ,in general ,except as provided under clause 7ii71 the ,secretary and the ,director shall have #ij days from receipt of an application by a ,state for a comprehensive ,medicaid waiver to certify the application as satisfying the requirements of paragraph 7#b74 7ii7 ,inquiries ,the ,secretary and the ,director may submit a single set of inquiries for additional information to the ,state during the initial #ij-;day period described under clause 7i74 ,if a ,state receives a set of inquires1 the ,state shall have up to #fj days to respond4 ,the ,secretary and the ,director shall have an additional #cj-;day period1 starting on the date the ,secretary receives a ,state response to a set of inquiries1 to make a final determination as to whether the ,state's waiver application may be certified as complying with the requirements of paragraph 7#b74 7iii7 ,failure to respond by the ,secretary ,an application by a ,state for a comprehensive ,medicaid waiver shall be deemed certified by the ,secretary if the ,secretary does not submit any inquiries during the initial #ij-;day review period4 7iv7 ,effective date ,a waiver that has been certified by the ,secretary 7or deemed to be certified7 may be effective1 at the discretion of the ,state1 as of the first day of the calendar quarter in which the application for the waiver was submitted by the ,state4 7,b7 ,denial of waiver applications or renewal requests 7i7 ,in general ,if the ,secretary and the ,director determine that an application for a comprehensive ,medicaid waiver1 or a request for extension of an existing comprehensive ,medicaid waiver1 does not satisfy the requirements of paragraph 7#b71 the ,secretary shall notify the ,state of the disapproval by written notification1 not later than #aj days following the issuance of such determination and shall provide a detailed description of the reasons for the denial of the waiver to-- 7,i7 the ,state that submitted the waiver application or extension request2 7,,ii7 the members of ,congress representing such ,state2 and 7,,iii7 the ,committee on ,finance of the ,senate and the ,committee on ,energy and ,commerce of the ,house of ,representatives4 7ii7 ,administrative and judicial review 7,i7 ,administrative review ,within #fj days after the date that a ,state receives notice of the denial of a waiver application or extension request1 the ,state may appeal the determination to the ,departmental ,appeals ,board established in the ,department of ,health and ,human ,services4 ,the ,departmental ,appeals ,board shall make a final determination with respect to an appeal filed under this subparagraph not less than #fj days after the date on which the appeal is filed4 7,,ii7 ,judicial review ,within #fj days after the date of a final decision by the ,board under subclause 7,i7 that is adverse to a ,state1 the ,state may obtain judicial review of the final decision by filing an action in the district court of the ,united ,states for the judicial district in which the principal or headquarters office of the ,state agency responsible for administering the ,state ,medicaid program is located or the ,united ,states ,district ,court for the ,district of ,columbia4 7,c7 ,reports 7i7 ,in general ,not later than #b years after the date on which the ,secretary and the ,director first approve an application for a comprehensive ,medicaid waiver under this subsection and every #c years thereafter1 the ,comptroller ,general of the ,united ,states 7referred to in this subparagraph as the ,comptroller7 shall submit to the ,committee on ,finance of the ,senate and the ,committee on ,energy and ,commerce of the ,house of ,representatives a report on the waivers certified as of the date of such report4 ,each report shall include an evaluation of the quality and cost-effectiveness of the comprehensive ,medicaid waivers in effect during the reporting period in providing medical assistance to eligible individuals1 as well as the financial effort of the waiver on ,state and ,federal budgets4 7ii7 ,reporting of information ,a ,state with a comprehensive ,medicaid waiver under this subsection shall provide the ,comptroller1 in such form and manner as the ,comptroller may require1 with any relevant information regarding the waiver1 including total expenditures by the ,state under the waiver1 the number of individuals provided medical assistance under the waiver1 and such other information as the ,comptroller may require for purposes of preparing the reports required under this subparagraph4 7#g7 ,non-applications ,a comprehensive ,medicaid waiver shall not apply to-- 7,a7 the pediatric vaccine program under section #aibh2 and 7,b7 limitations on total payments to territories under section #aajh4 7#h7 ,outreach and education 7,a7 ,state awareness ,not later than #cj days after the date of enactment of this subsection1 the ,secretary shall conduct an outreach and education campaign to ,states regarding the availability of comprehensive ,medicaid waivers under this subsection4 7,b7 ,public notice and comment ,before submitting an application for a comprehensive ,medicaid waiver1 a ,state shall make the proposed application available to the public through such means as the ,state determines appropriate and allow for a reasonable public comment period of not greater than #cj days4 7,c7 ,public awareness of approved waiver ,a ,state that has been certified for a comprehensive ,medicaid waiver shall conduct an outreach and education campaign to ensure that health care providers and eligible individuals within the ,state are provided with adequate notice regarding the methods and criteria through which the ,state intends to provide medical assistance under the waiver4 7#i7 ,definitions ,in this subsection3 7,a7 ,average monthly unemployment rate ,the term average monthly unemployment rate means the average of the monthly number unemployed in the ,state1 divided by the average of the monthly civilian labor force in the ,state1 seasonally adjusted1 as determined based on the most recent monthly publications of the ,bureau of ,labor ,statistics of the ,department of ,labor4 7,b7 ,eligible individual ,the term eligible individual means1 for each year during the waiver period-- 7i7 any individual who1 for such year1 the ,state would otherwise be required to provide medical assistance to pursuant to-- 7,i7 section #aijb7;a77#aj77;,a77i72 7,,ii7 paragraphs 7#a7 or 7#d7 of section #aijb7;e72 7,,iii7 section #aibe2 or 7,,iv7 section #aica2 and 7ii7 at the option of the ,state1 any individual who1 for such year1 the ,state would otherwise provide child health assistance to under the ,state child health plan under title ,,xxi2 and 7iii7 at the option of the ,state1 any individual who is not described in clause 7i7 or 7ii7 and who satisfies such income1 resources1 health status1 or other criteria as the ,state may establish4 7,c7 ,medical assistance ,the term medical assistance means-- 7i7 health care coverage 7as determined by the ,state72 and 7ii7 rehabilitation and other services to help eligible individuals attain or retain capability for independence or self-care1 such as home and community-based services4 7,d7 ,state ,medicaid program ,the term ,state ,medicaid program means the ,state program for medical assistance provided under a ,state plan under title ,,xix1 including any waiver that has been approved with respect to a ,state plan prior to an application by the ,state for a comprehensive ,medicaid waiver under this subsection4 4 #aajb4 ,phased-in elimination of allowable provider taxes under ,medicaid 7a7 ,in general ,clause 7ii7 of section #aijc7w77#d77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7w77#d77;,c77 is amended to read as follows3 7ii7 ,for purposes of clause 7i71 a determination of the existence of an indirect guarantee shall be made under paragraph 7#c77;i7 of section #dcc4fh7;f7 of title #db1 ,code of ,federal ,regulations1 as in effect on ,november #a1 #bjjf1 except that-- 7,i7 for portions of fiscal years beginning on or after ,january #a1 #bjjh1 and before ,october #a1 #bjaa1 #e4e percent shall be substituted for #f percent each place it appears2 7,,ii7 for fiscal years #bjab and #bjac1 the percentage specified under such paragraph shall apply2 7,,iii7 for fiscal years #bjad through #bjbb1 the percentage determined under clause 7iii7 for the fiscal year shall be substituted for #f percent each place it appears2 and 7,,iv7 for fiscal year #bjbc and each fiscal year thereafter1 #j percent shall be substituted for #f percent each place it appears4 7iii7 ,for purposes of clause 7ii77,,iii71 the percentage determined under this clause shall be equal to the percentage applicable under subclause 7,,ii7 or 7,,iii7 of clause 7ii7 for the preceding fiscal year1 reduced by #j4f percentage points4 4 7b7 ,effective date ,the amendment made by subsection 7a7 shall take effect on ,october #a1 #bjac4 ,,ii ,medicare ,a ,medicare ,total ,health program2 ,medicare ,fee-for-,service program reforms2 ,reports #bjjj4 ,short title2 purpose 7a7 ,short title ,this subtitle may be cited as the ,medicare ,total ,health ,act of #bjac4 7b7 ,purpose ,the purpose of this subtitle is to amend title ,,xviii of the ,social ,security ,act to improve the sustainability of the ,medicare program by establishing a ,total ,health system1 reforming the ,medicare fee-for-service program1 and for other purposes4 ,i ,medicare ,total ,health program #bjja4 ,establishment of ,medicare ,total ,health program 7a7 ,sunset of ,medicare ,advantage plans ,section #ahea7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;a77#a771 in the matter preceding subparagraph 7,a71 is amended by striking ,subject to and inserting ,for plan years beginning prior to ,january #a1 #bjag1 and subject to4 7b7 ,establishment ,part ,c of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba et seq47 is amended-- 7#a7 in the part heading1 by striking ,medicare,choice program and inserting ,medicare ,advantage program2 ,medicare ,total ,health ,program2 7#b7 by inserting before section #ahea the following3 #a ,medicare ,advantage program 2 and 7#c7 by adding at the end the following new subpart3 #b ,medicare ,total ,health program #ahfj;,c-#a4 ,eligibility1 enrollment1 and information 7a7 ,eligibility 7#a7 ,in general ,notwithstanding section #ahea7;a77#a7 and subject to the succeeding provisions of this subpart1 each ,total ,health eligible individual 7as defined in paragraph 7#c77 may elect to receive benefits under this title-- 7,a7 through the original medicare fee-for-service program under parts ,a and ,b1 including the option to elect qualified prescription drug coverage in accordance with section #ahfj;,d-#a2 or 7,b7 through enrollment in a ,total ,health plan under this subpart4 7#b7 ,coverage first effective ,january #a1 #bjag ,coverage under the ,medicare ,total ,health program shall first be effective on ,january #a1 #bjag4 7#c7 ,total health eligible individual ,for purposes of this subpart1 the term ,total ,health eligible individual means an individual who is entitled to benefits under part ,a and enrolled under part ,b who resides in a ,total ,health region4 7#d7 ,types of total health plans that may be available ,a ,total ,health plan may be any of the types of plans of health insurance described in section #ahea7;a77#b77;,a71 including a plan for special needs individuals described in clause 7ii7 of such section4 7b7 ,enrollment process for ,total ,health plans 7#a7 ,establishment of process 7,a7 ,in general ,the ,secretary shall establish a process for the enrollment1 disenrollment1 termination1 and change of enrollment of ,total ,health eligible individuals in ,total ,health plans in a manner similar to 7and coordinated with7 the process established under section #ahfj;,d-#a7;b77#a74 7,b7 ,requirements ,except as otherwise provided in this subsection1 the process established under subparagraph 7,a7 shall include a residency requirement similar to the residency requirement described in section #ahea7;b77#a7 and shall take into account the process for exercising choice described in section #ahea7;c74 7#b7 ,initial enrollment period 7,a7 ,program initiation ,in the case of an individual who is a ,total ,health eligible individual as of ,november #ae1 #bjaf1 there shall be an initial enrollment period beginning on ,october #ae1 #bjaf1 and ending on ,december #g1 #bjaf4 7,b7 ,continuing periods ,in the case of an individual who first becomes a ,total ,health eligible individual after ,november #ae1 #bjaf1 there shall be an initial enrollment period which is the same as the period under section #ahea7;e77#a74 7#c7 ,annual1 coordinated election period 7,a7 ,in general ,as part of the process established under paragraph 7#a71 each individual who is eligible to make an election under this section may change such election during an annual1 coordinated election period4 7,b7 ,annual1 coordinated election period ,for purposes of this section1 the term annual1 coordinated election period means1 with respect to #bjag and succeeding years1 the period beginning on ,october #ae and ending on ,december #g of the year before such year4 7#d7 ,special enrollment periods ,the ,secretary shall establish special enrollment periods that are similar to the special enrollment periods established under section #ahea7;e77#d74 7#e7 ,special rule 7,a7 ,in general ,notwithstanding any other provision of law1 the process established under paragraph 7#a7 shall include1 in the case of a ,total ,health eligible individual who has failed to enroll in either the original medicare fee-for-service program option or a ,total ,health plan prior to the beginning of a plan year 7including a full-benefit dual eligible individual 7as defined in section #aice7;c77#f7771 for the enrollment in a ,total ,health plan with a monthly beneficiary premium under section #ahfj;,c-#g7;a7 7taking into account any adjustment under subparagraph 7,b7 or 7,c7 of section #ahfj;,c-#g7;a77#b7 and without regard to any adjustment under subparagraph 7,d7 or 7,e7 of such section7 that does not exceed the base beneficiary premium computed under section #ahfj;,c-#g7;a77#a74 7,b7 ,selection of plan by the secretary ,in selecting a plan for the enrollment of a ,total ,health eligible individual under subparagraph 7,a71 the ,secretary shall first attempt to identify the ,total ,health plan in which the cost-sharing and health benefits are most similar to the coverage the individual had in the preceding plan year4 ,if there is more than one such plan available1 the ,secretary shall enroll such an individual on a random basis among all such plans in the ,total ,health region4 ,nothing in the previous sentence shall prevent such an individual from declining or changing such enrollment4 7,c7 ,individuals who are not total health eligible individuals ,the ,secretary shall establish procedures under which individuals who are entitled to1 or enrolled for1 coverage under part ,a or enrolled for coverage under part ,b 7but not both71 may continue to receive benefits with deductible and coinsurance amounts comparable to the benefits1 deductible1 and coinsurance amounts they would have received if this subpart had not been enacted4 7c7 ,providing information to beneficiaries 7#a7 ,in general ,the ,secretary shall conduct activities that are designed to broadly disseminate information to ,total ,health eligible individuals 7and prospective ,total ,health eligible individuals7 regarding the coverage provided under this subpart4 ,such activities shall ensure that such information is first made available at least #cj days prior to the initial enrollment period described in subsection 7b77#b77;,a74 7#b7 ,activities ,the activities conducted under paragraph 7#a7 shall be similar to the activities described in paragraph 7#b7 of section #ahfj;,d-#a7;c7 and contain comparative information similar to the information described in paragraph 7#c7 of such section4 #ahfj;,c-#b4 ,total ,health plan benefits 7a7 ,requirements 7#a7 ,qualified total health benefits ,each ,total ,health plan shall provide to individuals enrolled under this subpart1 through providers and other persons that meet the applicable requirements of this title and part ,a of title ,,xi1 a qualified ,total ,health benefits package and qualified prescription drug coverage 7described in section #ahfj;,d-#b7;a774 7#b7 ,definition of qualified total health benefits package ,for purposes of this subpart1 the term qualified ,total ,health benefits package means either of the following3 7,a7 ,standard health benefits coverage with access to negotiated prices ,standard health benefits coverage 7as defined in subsection 7b77 and access to negotiated prices under subsection 7d74 7,b7 ,alternative total health benefits coverage with at least actuarially equivalent benefits and access to negotiated prices ,coverage of health benefits which meets the alternative health benefits coverage requirements under subsection 7c7 and access to negotiated prices under subsection 7d71 but only if the benefit design of such coverage is approved by the ,secretary1 as provided under subsection 7c74 7#c7 ,permitting supplemental health benefits coverage 7,a7 ,in general ,subject to subparagraph 7,b71 a qualified ,total ,health benefits package may include supplemental health benefits coverage consisting of either or both of the following3 7i7 ,certain reductions in cost-sharing 7,i7 ,in general ,a reduction in the annual deductible or a reduction in the coinsurance percentage1 or any combination thereof1 insofar as such a reduction or increase increases the actuarial value of benefits above the actuarial value of a basic ,total ,health benefits package4 7,,ii7 ,construction ,nothing in this clause shall be construed as affecting the application of subsection 7c77#c74 7ii7 ,additional benefits ,coverage of any health care item or service that is not covered under the original medicare fee-for-service program option or that is eligible for coverage under part ,d1 subject to the approval of the ,secretary4 7,b7 ,requirement for at least one basic benefits plan ,a ,total ,health sponsor may not offer a ,total ,health plan that provides supplemental health benefits coverage pursuant to subparagraph 7,a7 in an area unless the sponsor also offers a ,total ,health plan in the area that only provides a basic ,total ,health benefits package4 7#d7 ,basic total health benefits package ,for purposes of this subpart1 the term basic ,total ,health benefits package means either of the following3 7,a7 ,coverage that meets the requirements of paragraph 7#b77;,a74 7,b7 ,coverage that meets the requirements of paragraph 7#b77;,b7 but does not have any supplemental health benefits coverage described in paragraph 7#c77;,a74 7#e7 ,application of secondary payer provisions ,the provisions of section #aheb7;a77#d7 shall apply under this subpart in the same manner as such provisions applied to a ,medicare ,advantage plan4 7#f7 ,construction ,nothing in this subsection shall be construed as changing the computation of incurred costs under subsection 7b77#c74 7b7 ,standard health benefits coverage ,for purposes of this subpart1 the term standard health benefits coverage means coverage of benefits under the original medicare fee-for-service program option 7as defined in section #aheb7;a77#a77;,b771 including the following requirements3 7#a7 ,deductible ,the coverage has an annual deductible that is equal to the amount of the unified deductible for the year under section #ahii;,c4 7#b7 #bj percent coinsurance ,the coverage has coinsurance 7for costs above the annual deductible specified in paragraph 7#a7 and up to the first threshold annual out-of-pocket limit specified in paragraph 7#c77;,b77i77 that is-- 7,a7 equal to #bj percent2 or 7,b7 actuarially equivalent 7using processes and methods established by the ,secretary7 to an average expected payment of #bj percent of such costs4 7#c7 ,protection against high out-of-pocket expenditures 7,a7 ,in general ,the coverage provides benefits1 after the ,total ,health eligible individual has incurred costs 7as described in subparagraph 7,c77 for health benefits in a year equal to-- 7i7 the first threshold annual out-of-pocket limit specified in subparagraph 7,b77i7 for that year but less than the second threshold annual out-of-pocket limit specified in subparagraph 7,b77ii7 for that year1 with coinsurance that is equal to #e percent2 and 7ii7 the second threshold annual out-of-pocket limit specified in subparagraph 7,b77ii7 for that year1 without coinsurance4 7,b7 ,annual out-of-pocket limits specified ,for purposes of this subpart3 7i7 ,first threshold annual out-of-pocket limit specified ,the first threshold annual out-of-pocket limit specified in this clause is equal to the first threshold annual out-of-pocket limit for the year specified in section #ahii;,b7b77#a74 7ii7 ,second threshold annual out-of-pocket limit specified ,the second threshold annual out-of-pocket limit specified in this clause is equal to the second threshold annual out-of-pocket limit for the year specified in section #ahii;,b7b77#b74 7,c7 ,application ,in applying subparagraph 7,a71 incurred costs shall only include costs incurred with respect to health benefits for the annual deductible described in paragraph 7#a7 and for cost-sharing described in paragraph 7#b7 or paragraph 7#c77;,a77i71 or for benefits that would have otherwise been covered under the plan but for the exhaustion of those benefits4 ,incurred costs do not include any costs incurred for health benefits which are not included 7or treated as being included7 under the plan4 7c7 ,alternative total health benefits coverage requirements ,a ,total ,health plan may provide a different benefit design from standard health benefits coverage so long as the ,secretary determines that the following requirements are met and the plan applies for1 and receives1 the approval of the ,secretary for such benefit design3 7#a7 ,assuring at least actuarially equivalent coverage 7,a7 ,assuring equivalent value of total coverage ,the actuarial value of the total coverage is at least equal to the actuarial value of standard health benefits coverage4 7,b7 ,assuring equivalent unsubsidized value of coverage ,the unsubsidized value of the coverage is at least equal to the unsubsidized value of standard health benefits coverage4 ,for purposes of this subparagraph1 the unsubsidized value of coverage is the amount by which the actuarial value of the coverage exceeds the subsidy payments with respect to such coverage4 7,c7 ,assuring standard payment for costs below first threshold annual out-of-pocket limit ,the coverage is designed1 based upon an actuarially representative pattern of utilization1 to provide for the payment1 with respect to costs incurred up to the first threshold annual out-of-pocket limit specified in subsection 7b77#c77;,b77i71 of an amount equal to at least the product of-- 7i7 the amount by which the costs incurred exceed the deductible described in subsection 7b77#a7 for the year2 and 7ii7 #ajj percent minus the coinsurance percentage specified in subsection 7b77#b74 7#b7 ,approval of benefit package ,the benefit package is approved by the ,secretary as containing a comparable range of benefits to standard health benefits coverage and meets such other requirements of this subpart as the ,secretary may specify4 7#c7 ,maximum required deductible ,the deductible under the coverage shall not exceed the deductible amount specified under subsection 7b77#a7 for the year4 7#d7 ,same protection against high out-of-pocket expenditures ,the coverage provides the coverage required under subsection 7b77#c74 7d7 ,access to negotiated prices 7#a7 ,access 7,a7 ,in general ,under a qualified ,total ,health benefits package offered by a ,total ,health sponsor offering a ,total ,health plan1 the sponsor shall provide enrollees with access to negotiated prices used for payment for covered health benefits1 regardless of the fact that no benefits may be payable under the coverage with respect to such benefits because of the application of a deductible or other cost-sharing4 7,b7 ,negotiated prices ,for purposes of this subpart1 negotiated prices shall take into account negotiated price concessions1 such as discounts1 direct or indirect subsidies1 rebates1 and direct or indirect remunerations1 for covered health benefits4 7#b7 ,audits ,to protect against fraud and abuse and to ensure proper disclosures and accounting under this part and in accordance with section #aheg7;d77#b77;,b71 the ,secretary may conduct periodic audits1 directly or through contracts1 of the financial statements and records of ,total ,health sponsors with respect to ,total ,health ,plans4 7#c7 ,application of general exclusion provisions 7,a7 ,in general ,a ,total ,health plan may exclude from a qualified ,total ,health benefits package any health care item or service-- 7i7 for which payment would not be made if section #ahfb7;a7 applied to this subpart2 or 7ii7 which is not prescribed in accordance with the ,total ,health plan or this subpart4 7,b7 ,reconsideration and appeal ,any exclusion under subparagraph 7,a7 is a determination subject to reconsideration and appeal under this subpart4 7e7 ,satisfaction of requirements ,a ,total ,health plan satisfies the requirements of subsection 7a7 in the same way a ,medicare ,advantage plan satisfied the requirements of section #aheb7;a77#b74 #ahfj;,c-#c4 ,access to a choice of qualified ,total ,health benefits plans 7a7 ,assuring access to a choice of plans 7#a7 ,choice of at least two plans in each area ,the ,secretary shall ensure that each ,total ,health eligible individual has available1 consistent with paragraph 7#b71 a choice of enrollment in at least #b ,total ,health plans in the area in which the individual resides4 7#b7 ,requirement for different plan sponsors ,the requirement in paragraph 7#a7 is not satisfied with respect to an area if only one entity offers all of the qualifying plans in the area4 7b7 ,flexibility in risk assumed ,in order to ensure access pursuant to subsection 7a7 in an area the ,secretary may approve limited risk plans under section #ahfj;,c-#e7;g7 for the area4 #ahfj;,c-#d4 ,beneficiary protections for ,total ,health plan enrollees 7a7 ,dissemination of information 7#a7 ,general information ,a ,total ,health sponsor shall disclose1 in a clear1 accurate1 and standardized form to each enrollee with a ,total ,health plan offered by the sponsor under this subpart at the time of enrollment and at least annually thereafter1 the information described in section #aheb7;c77#a7 relating to such plan1 insofar as the ,secretary determines appropriate with respect to benefits provided under this subpart1 and including the information described in section #ahfj;,d-#d relating to qualified prescription drug coverage under the plan4 7#b7 ,disclosure upon request of general coverage1 utilization1 and grievance information ,upon request of a ,total ,health eligible individual who is eligible to enroll in a ,total ,health plan1 the ,total ,health sponsor offering such plan shall provide information similar 7as determined by the ,secretary7 to the information described in section #aheb7;c77#b7 to such individual4 7#c7 ,provision of specific information ,each ,total ,health sponsor offering a ,total ,health plan shall have a mechanism for providing specific information on a timely basis to enrollees upon request4 ,such mechanism shall include access to information through the use of a toll-free telephone number and1 upon request1 the provision of such information in writing4 7#d7 ,claims information 7,a7 ,in general ,a ,total ,health sponsor offering a ,total ,health plan must furnish to each enrollee in a form easily understandable to such enrollees-- 7i7 an explanation of benefits 7in accordance with section #ahjf7;a7 or in a comparable manner72 and 7ii7 when ,total ,health benefits are provided under this subpart1 a notice of the benefits in relation to-- 7,i7 the deductible described in paragraph 7#a7 of section #ahfj;,c-#b7;b7 for the current year2 and 7,,ii7 the annual out-of-pocket limits under paragraph 7#c7 of such section for the current year4 7,b7 ,timing of notices ,notices under subparagraph 7,a77ii7 need not be provided more often than as specified by the ,secretary4 7b7 ,access to health care providers 7#a7 ,assuring provider access 7,a7 ,discounts allowed for network providers ,for health benefits furnished through in-network providers1 a ,total ,health plan may reduce coinsurance or copayments for ,total ,health eligible individuals enrolled in the plan below the level otherwise required4 ,in no case shall such a reduction result in an increase in payments made by the ,secretary under section #ahfj;,c-#h to the ,total ,health sponsor of the plan4 7,b7 ,convenient access for network providers 7i7 ,in general ,the ,total ,health sponsor of the ,total ,health plan shall secure the participation in its network of a sufficient number of health care providers that furnish health care items and services under the plan directly to patients to ensure convenient access 7consistent with rules established by the ,secretary74 7ii7 ,adequate emergency access ,such rules shall include adequate emergency access for enrollees4 7,c7 ,level playing field ,such a sponsor shall permit enrollees to receive benefits through any health care provider participating in the program under this title with any differential in charge paid by such enrollees4 7#b7 ,use of standardized technology 7,a7 ,in general ,the ,total ,health sponsor of a ,total ,health plan shall issue 7and reissue1 as appropriate7 such a card 7or other technology7 that may be used by an enrollee to assure access to health benefits under this subpart4 7,b7 ,standards 7i7 ,in general ,the ,secretary shall provide for the development1 adoption1 or recognition of standards relating to a standardized format for the card or other technology required under subparagraph 7,a74 ,such standards shall be compatible with part ,c of title ,,xi and may be based on standards developed by an appropriate standard setting organization4 7ii7 ,consultation ,in developing the standards under clause 7i71 the ,secretary shall consult with standard setting organizations determined appropriate by the ,secretary4 7iii7 ,implementation ,the ,secretary shall develop1 adopt1 or recognize the standards under clause 7i7 by such date as the ,secretary determines shall be sufficient to ensure that ,total ,health sponsors utilize such standards beginning ,january #a1 #bjag4 7c7 ,cost and utilization management2 quality assurance2 wellness program 7#a7 ,in general ,the ,total ,health sponsor shall have in place1 directly or through appropriate arrangements1 the following3 7,a7 ,a cost-effective health benefits management program1 including incentives to reduce costs when medically appropriate4 7,b7 ,quality assurance measures and systems to reduce errors and improve the use of health benefits4 7,c7 ,a wellness program described in paragraph 7#b74 7,d7 ,a program to control fraud1 abuse1 and waste4 ,nothing in this section shall be construed as impairing a ,total ,health sponsor from utilizing cost management tools 7including differential payments7 under all methods of operation4 7#b7 ,wellness program 7,a7 ,description ,a wellness program described in this paragraph is a program focused on health improvement1 disease prevention1 and management of chronic conditions for ,total ,health eligible individuals enrolled in a plan under this part to optimize health outcomes through improved use of health care items and services and to reduce the risk of adverse events4 7,b7 ,elements ,such program may include elements that promote-- 7i7 enhanced enrollee understanding to promote the appropriate use of health care items and services by enrollees and to reduce the risk of potential adverse events and to improve health outcomes through beneficiary education1 counseling1 and other appropriate means2 7ii7 increased enrollee adherence with recommended regimens through compliance programs and other appropriate means2 and 7iii7 detection of adverse events and patterns of overuse and underuse of health care items and services4 7,c7 ,assessment ,the ,total ,health sponsor shall have in place a process to assess1 at least on a quarterly basis1 the health benefits use of individuals who are not enrolled in the wellness program4 7,d7 ,wellness program enrollment ,the ,total ,health sponsor shall have in place a process to-- 7i7 subject to clause 7ii71 automatically enroll plan enrollees in the wellness program required under this subsection2 and 7ii7 permit plan enrolles to opt-out of enrollment in the wellness program4 7,e7 ,development of program in cooperation with physicians ,such program shall be developed in cooperation with physicians4 7,f7 ,coordination with care management plans ,the ,secretary shall establish guidelines for the coordination of any wellness program under this paragraph with respect to a targeted beneficiary described in section #ahfj;,d-#d7;c77#b77;,a77i7 7applied by substituting ,total ,health eligible individual for part ,d eligible individual7 with any care management plan established with respect to such beneficiary under a chronic care improvement program under section #ahjg4 7,g7 ,considerations in provider fees ,the ,total ,health sponsor of a ,total ,health plan shall take into account1 in establishing fees for entities providing services under such plan1 the resources used1 and time required to1 implement the wellness program under this paragraph4 ,each such sponsor shall disclose to the ,secretary upon request the amount of any such fees4 7d7 ,consumer satisfaction surveys ,in order to provide for comparative information under section #ahfj;,c-#a7;c71 the ,secretary shall conduct consumer satisfaction surveys with respect to ,total ,health sponsors and ,total ,health plans in a manner similar to the manner such surveys were conducted for ,,ma organizations and ,,ma plans under subpart #a4 7e7 ,grievance mechanism ,each ,total ,health sponsor shall provide meaningful procedures for hearing and resolving grievances between the sponsor 7including any entity or individual through which the sponsor provides covered benefits7 and enrollees with ,total ,health plans of the sponsor under this part in accordance with section #aheb7;f74 7f7 ,coverage determinations and reconsiderations ,a ,total ,health sponsor shall meet the requirements of paragraphs 7#a7 through 7#c7 of section #aheb7;g7 with respect to covered benefits under the ,total ,health plan offered by the sponsor under this subpart in the same manner as such requirements applied to an ,,ma organization with respect to covered benefits under an ,,ma plan offered by the organization under subpart #a4 7g7 ,appeals ,a ,total ,health sponsor shall meet the requirements of paragraphs 7#d7 and 7#e7 of section #aheb7;g7 with respect to benefits in a manner similar 7as determined by the ,secretary7 to the manner such requirements applied to an ,,ma organization with respect to benefits under the original medicare fee-for-service program option under an ,,ma plan4 ,in applying this subsection1 only the ,total ,health eligible individual shall be entitled to bring such an appeal4 7h7 ,privacy1 confidentiality1 and accuracy of enrollee records ,the provisions of section #aheb7;h7 shall apply to a ,total ,health sponsor and ,total ,health plan in the same manner as such provisions applied to an ,,ma organization and an ,,ma plan4 7i7 ,treatment of accreditation ,subparagraph 7,a7 of section #aheb7;e77#d7 7relating to treatment of accreditation7 shall apply to a ,total ,health sponsor under this part in the same manner as such subparagraph applied to an ,,ma organization4 7j7 ,requirements with respect to sales and marketing activities ,the following provisions shall apply to a ,total ,health sponsor 7and the agents1 brokers1 and other third parties representing such sponsor7 in the same manner as such provisions applied to a ,medicare ,advantage organization 7and the agents1 brokers1 and other third parties representing such organization73 7#a7 ,the prohibition under section #ahea7;h77#d77;,c7 on conducting activities described in section #ahea7;j77#a74 7#b7 ,the requirement under section #ahea7;h77#d77;,d7 to conduct activities described in paragraph 7#b7 of section #ahea7;j7 in accordance with the limitations established under such section4 7#c7 ,the inclusion of the plan type in the plan name under section #ahea7;h77#f74 7#d7 ,the requirements regarding the appointment of agents and brokers and compliance with ,state information requests under subparagraphs 7,a7 and 7,b71 respectively1 of section #ahea7;h77#g74 #ahfj;,c-#e4 ,total ,health regions2 submission of bids2 ,total ,health plan approval 7a7 ,establishment of total health regions2 service areas 7#a7 ,coverage of entire total health region 7,a7 ,in general ,the service area for a ,total ,health plan shall consist of an entire ,total ,health region established under paragraph 7#b74 7,b7 ,no use of segments of service areas ,in no case may a ,total ,health plan serve only segments of the service area4 7#b7 ,establishment of total health regions 7,a7 ,in general ,the ,secretary shall establish1 and may revise1 ,total ,health regions in accordance with the requirements of this paragraph4 7,b7 ,regions to be larger than a single county ,total ,health regions shall include more than one county4 7,c7 ,regions within msas ,among counties in a metropolitan statistical area1 a ,total ,health region shall include all of the counties located in the same ,state in that metropolitan statistical area4 7,d7 ,regions outside msas ,among counties outside a metropolitan statistical area1 a ,total ,health region shall include all of the counties in the same ,state that the ,secretary determines are accurate reflections of health care market areas1 such as health service areas4 7,e7 ,authority for territories ,the ,secretary shall establish1 and may revise1 ,total ,health regions for areas in ,states that are not within the #ej ,states or the ,district of ,columbia4 7#c7 ,national plan ,nothing in this subsection shall be construed as preventing a ,total ,health plan from being offered in more than one ,total ,health region 7including all ,total ,health regions74 7b7 ,submission of bids1 premiums1 and related information 7#a7 ,in general ,a ,total ,health sponsor shall submit to the ,secretary information described in paragraph 7#b7 with respect to each ,total ,health plan it offers4 ,such information shall be submitted at the same time and in a similar manner to the manner in which information described in paragraph 7#f7 of section #ahed7;a7 was submitted by an ,,ma organization under paragraph 7#a7 of such section4 7#b7 ,information described ,the information described in this paragraph is information on the following3 7,a7 ,benefits package provided ,the qualified ,total ,health benefits package provided under the plan1 including the deductible and other cost-sharing4 7,b7 ,actuarial value ,the actuarial value of the qualified ,total ,health benefits package in the ,total ,health region for a ,total ,health eligible individual with a national average risk profile for the factors described in section #ahfj;,c-#h7;b77#a77;,a7 7as specified by the ,secretary74 7,c7 ,bid ,information on the bid1 including an actuarial certification of-- 7i7 the basis for the actuarial value described in subparagraph 7,b7 assumed in such bid2 7ii7 the portion of such bid attributable to a basic ,total ,health benefits package and1 if applicable1 the portion of such bid attributable to supplemental benefits2 and 7iii7 administrative expenses assumed in the bid4 7,d7 ,service area ,the service area for the plan 7as described in subsection 7a77#a774 7,e7 ,level of risk assumed ,whether the ,total ,health sponsor requires a modification of risk level and1 if so1 the extent of such modification4 ,any such modification shall apply with respect to all ,total ,health plans offered by a ,total ,health sponsor in a ,total ,health region4 7,f7 ,additional information ,such other information as the ,secretary may require to carry out this subpart4 7#c7 ,paperwork reduction for offering of total health plans nationally or in multi-region areas ,the ,secretary shall establish requirements for the submission of information under this subsection in a manner that promotes the offering of such plans in more than one ,total ,health region 7including all regions7 through the filing of consolidated information4 7c7 ,medicare fee-for-,service bid ,for purposes of this subpart1 the bid for benefits under the original medicare fee-for-service program option 7as defined in section #aheb7;a77#a77;,b77 is the dollar amount of the actuarial valuation of the benefits under that option for each ,total ,health region 7as determined and submitted by the ,chief ,actuary of the ,centers for ,medicare ,medicaid ,services using the same processes used to value ,total ,health plans under subsection 7d774 7d7 ,actuarial valuation 7#a7 ,processes ,for purposes of this subpart1 the ,secretary shall establish processes and methods for determining the actuarial valuation of a ,total ,health benefits package1 including-- 7,a7 an actuarial valuation of the benefits under the original medicare fee-for-service program option 7as defined in section #aheb7;a77#a77;,b77 in each service area2 7,b7 actuarial valuations relating to the qualified ,total ,health benefits package under section #ahfj;,c-#b7;a77#a72 7,c7 the use of generally accepted actuarial principles and methodologies2 and 7,d7 applying the same methodology for determinations of actuarial valuations under subparagraphs 7,a7 and 7,b74 7#b7 ,accounting for utilization ,such processes and methods for determining actuarial valuation shall take into account the effect that providing a qualified ,total ,health benefits package 7rather than benefits under the original medicare fee-for-service program option7 has on the utilization of health care items and services4 7#c7 ,responsibilities 7,a7 ,plan responsibilities ,total ,health sponsors are responsible for the preparation and submission of actuarial valuations required under this subpart for the ,total ,health plans offered by the sponsor4 7,b7 ,use of outside actuaries ,under the processes and methods established under paragraph 7#a71 ,total ,health sponsors offering a ,total ,health benefits package may use actuarial opinions certified by independent1 qualified actuaries to establish actuarial values4 7e7 ,review of information and negotiation 7#a7 ,review of information ,the ,secretary shall review the information submitted under subsection 7b7 for the purpose of conducting negotiations under paragraph 7#b74 7#b7 ,negotiation regarding terms and conditions ,subject to subsection 7i71 in exercising the authority under paragraph 7#a71 the ,secretary-- 7,a7 has the authority to negotiate the terms and conditions of the proposed bid submitted and other terms and conditions of a proposed plan2 and 7,b7 has authority similar to the authority of the ,director of the ,office of ,personnel ,management with respect to health benefits plans under chapter #hi of title #e1 ,united ,states ,code4 7#c7 ,rejection of bids ,paragraph 7#e77;,c7 of section #ahed7;a7 shall apply with respect to bids submitted by a ,total ,health sponsor under subsection 7b7 in the same manner as such paragraph applied to bids submitted by an ,,ma organization under such section #ahed7;a74 7f7 ,approval of proposed plans 7#a7 ,in general ,after review and negotiation under subsection 7e71 the ,secretary shall approve or disapprove the ,total ,health plan4 7#b7 ,requirements for approval ,the ,secretary may approve a ,total ,health plan only if the ,secretary determines the following requirements are met3 7,a7 ,compliance with requirements ,the plan and the ,total ,health sponsor offering the plan comply with the requirements under this subpart1 including the provision of a qualified ,total ,health benefits package4 7,b7 ,actuarial determinations ,the plan and ,total ,health sponsor offering the plan meet the requirements under this subpart relating to actuarial determinations1 including such requirements under section #ahfj;,c-#b7;c74 7,c7 ,application of ,,fehbp standard 7i7 ,in general ,the portion of the bid submitted under subsection 7b7 that is attributable to basic health benefits coverage is supported by the actuarial bases provided under such subsection and reasonably and equitably reflects the revenue requirements 7as used for purposes of section #acjb7h77;,c7 of the ,public ,health ,service ,act7 for benefits provided under that plan4 7ii7 ,supplemental coverage ,the portion of the bid submitted under subsection 7b7 that is attributable to supplemental health benefits coverage pursuant to section #ahfj;,c-#b7;a77#c7 is supported by the actuarial bases provided under such subsection and reasonably and equitably reflects the revenue requirements 7as used for purposes of section #acjb7h77;,c7 of the ,public ,health ,service ,act7 for such coverage under the plan4 7,d7 ,plan design ,the design of the plan and covered benefits under the plan are not likely to substantially discourage enrollment by certain ,total ,health eligible individuals in the plan4 7g7 ,application of limited risk plans 7#a7 ,conditions for approval of limited risk plans ,the ,secretary may only approve a limited risk plan 7as defined in paragraph 7#d77;,a77 for a ,total ,health region if the access requirements under section #ahfj;,c-#c7;a7 would not be met for the region but for the approval of such a plan4 7#b7 ,rules ,the following rules shall apply with respect to the approval of a limited risk plan in a ,total ,health region3 7,a7 ,limited exercise of authority ,only the minimum number of such plans may be approved in order to meet the access requirements under section #ahfj;,c-#c7;a74 7,b7 ,maximizing assumption of risk ,the ,secretary shall provide priority in approval for those plans bearing the highest level of risk 7as computed by the ,secretary71 but the ,secretary may take into account the level of the bids submitted by such plans4 7,c7 ,no full underwriting for limited risk plans ,in no case may the ,secretary approve a limited risk plan under which the modification of risk level provides for no 7or a de minimis7 level of financial risk4 7#c7 ,acceptance of all full risk contracts ,there shall be no limit on the number of full risk plans that are approved under subsection 7e74 7#d7 ,risk-plans defined ,for purposes of this subsection3 7,a7 ,limited risk plan ,the term limited risk plan means a ,total ,health plan that provides a basic ,total ,health benefits package and for which the ,total ,health sponsor includes a modification of risk level described in subparagraph 7,e7 of subsection 7b77#b7 in the bid submitted for the plan under such subsection4 7,b7 ,full risk plan ,the term full risk plan means a ,total ,health plan that is not a limited risk plan4 7h7 ,annual report on use of limited risk plans ,the ,secretary shall submit to ,congress an annual report that describes instances in which limited risk plans were approved under this section4 ,the ,secretary shall include in such report such recommendations as may be appropriate to limit the need for the provision of such plans and to maximize the assumption of financial risk under such subsection4 7i7 ,noninterference ,in order to promote competition under this part and in carrying out this part1 the ,secretary-- 7#a7 may not interfere with the negotiations between physicians or other health professionals1 providers1 suppliers1 drug manufacturers1 pharmacies1 and ,total ,health sponsors2 and 7#b7 may not require a particular benefit design or formulary1 or institute a price structure for the reimbursement of covered items and services4 #ahfj;,c-#f4 ,requirements for and contracts with ,total ,health sponsors 7a7 ,general requirements ,each sponsor of a ,total ,health plan shall meet the following requirements3 7#a7 ,licensure ,subject to subsection 7c71 the sponsor is organized and licensed under ,state law as a risk-bearing entity eligible to offer health insurance or health benefits coverage in each ,state in which it offers a ,total ,health plan4 7#b7 ,assumption of financial risk for unsubsidized coverage 7,a7 ,in general ,subject to subparagraph 7,b71 to the extent that the entity is at risk the entity assumes financial risk on a prospective basis for benefits that it offers under a ,total ,health plan4 7,b7 ,reinsurance permitted ,the plan sponsor may obtain insurance or make other arrangements for the cost of coverage provided to any enrollee to the extent that the sponsor is at risk for providing such coverage4 7#c7 ,solvency for unlicensed sponsors ,in the case of a ,total ,health sponsor that is not described in paragraph 7#a7 and for which a waiver has been approved under subsection 7c71 such sponsor shall meet solvency standards established by the ,secretary under subsection 7d74 7b7 ,contract requirements 7#a7 ,in general ,the ,secretary shall not permit the enrollment under section #ahfj;,c-#a in a ,total ,health plan offered by a ,total ,health sponsor under this subpart1 and the sponsor shall not be eligible for payments under section #ahfj;,c-#h1 unless the ,secretary has entered into a contract under this subsection with the sponsor with respect to the offering of such plan4 ,such a contract with a sponsor may cover more than one ,total ,health plan4 ,such contract shall provide that the sponsor agrees to comply with the applicable requirements and standards of this subpart and the terms and conditions of payment as provided for in this subpart4 7#b7 ,incorporation of certain medicare advantage contract requirements ,except as otherwise provided1 the following provisions of section #aheg shall apply to contracts under this section in the same manner as such provisions applied to contracts under section #aheg7;a73 7,a7 ,minimum enrollment ,paragraphs 7#a7 and 7#c7 of section #aheg7;b71 except that-- 7i7 the ,secretary may increase the minimum number of enrollees required under such paragraph 7#a7 as the ,secretary determines appropriate2 and 7ii7 the requirement of such paragraph 7#a7 shall be waived during the first contract year with respect to an organization in a region4 7,b7 ,contract period and effectiveness ,section #aheg7;c71 except that in applying paragraph 7#d77;,b7 of such section any reference to payment amounts under section #ahec is deemed a reference to payment amounts under section #ahfj;,c-#h4 7,c7 ,protections against fraud and beneficiary protections ,section #aheg7;d74 7,d7 ,additional contract terms ,section #aheg7;e72 except that section #aheg7;e77#b7 shall apply as specified to ,total ,health sponsors and payments to a ,total ,health plan under this subpart shall be treated as expenditures made under this subpart4 ,notwithstanding any other provision of law1 information provided to the ,secretary under the application of section #aheg7;e77#a7 to contracts under this section under the preceding sentence-- 7i7 may be used for the purposes of carrying out this subpart1 improving public health through research on the utilization1 safety1 effectiveness1 quality1 and efficiency of health care services 7as the ,secretary determines appropriate72 and 7ii7 shall be made available to ,congressional support agencies 7in accordance with their obligations to support ,congress as set out in their authorizing statutes7 for the purposes of conducting ,congressional oversight1 monitoring1 making recommendations1 and analysis of the program under this title4 7,e7 ,intermediate sanctions ,section #aheg7;g7 7other than paragraph 7#a77;,f7 of such section71 except that in applying such section the reference in section #aheg7;g77#a77;,b7 to section #ahed is deemed a reference to this subpart4 7,f7 ,procedures for termination ,section #aheg7;h74 7c7 ,waiver of certain requirements ,to expand choice 7#a7 ,authorizing waiver 7,a7 ,in general ,in the case of an entity that seeks to offer a ,total ,health plan in a ,state1 the ,secretary shall waive the requirement of subsection 7a77#a7 that the entity be licensed in that ,state if the ,secretary determines1 based on the application and other evidence presented to the ,secretary1 that any of the grounds for approval of the application described in paragraph 7#b7 have been met4 7,b7 ,application of regional plan waiver rule ,in addition to the waiver available under subparagraph 7,a71 the provisions of section #aheh7;d7 shall apply to ,total ,health sponsors under this part in a manner similar to the manner in which such provisions applied to ,,ma organizations4 7#b7 ,grounds for approval 7,a7 ,in general ,the grounds for approval under this paragraph are-- 7i7 subject to subparagraph 7,b71 the grounds for approval described in subparagraphs 7,b71 7,c71 and 7,d7 of section #ahee7;a77#b72 and 7ii7 the application by a ,state of any grounds other than those required under ,federal law4 7,b7 ,special rules ,in applying subparagraph 7,a77i7-- 7i7 the ground of approval described in section #ahee7;a77#b77;,b7 is deemed to have been met if the ,state does not have a licensing process in effect with respect to the ,total ,health sponsor2 and 7ii7 for plan years beginning before ,january #a1 #bjai1 if the ,state does have such a licensing process in effect1 such ground for approval described in such section is deemed to have been met upon submission of an application described in such section4 7#c7 ,application of waiver procedures ,with respect to an application for a waiver 7or a waiver granted7 under paragraph 7#a77;,a7 of this subsection1 the provisions of subparagraphs 7,e71 7,f71 and 7,g7 of section #ahee7;a77#b7 shall apply1 except that clauses 7i7 and 7ii7 of such subparagraph 7,e7 shall not apply in the case of a ,state that does not have a licensing process described in paragraph 7#b77;,b77i7 in effect4 7#d7 ,references to certain provisions ,in applying provisions of section #ahee7;a77#b7 under paragraphs 7#b7 and 7#c7 of this subsection to ,total ,health plans and ,total ,health sponsors-- 7,a7 any reference to a waiver application under section #ahee shall be treated as a reference to a waiver application under paragraph 7#a77;,a7 of this subsection2 and 7,b7 any reference to solvency standards shall be treated as a reference to solvency standards established under subsection 7d7 of this section4 7d7 ,solvency standards for non-,licensed entities 7#a7 ,establishment and publication ,the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners1 shall establish and publish1 by not later than ,january #a1 #bjaf1 financial solvency and capital adequacy standards for entities described in paragraph 7#b74 7#b7 ,compliance with standards ,a ,total ,health sponsor that is not licensed by a ,state under subsection 7a77#a7 and for which a waiver application has been approved under subsection 7c7 shall meet solvency and capital adequacy standards established under paragraph 7#a74 ,the ,secretary shall establish certification procedures for such sponsors with respect to such solvency standards in the manner described in section #ahee7;c77#b74 7e7 ,licensure does not substitute for or constitute certification ,the fact that a ,total ,health sponsor is licensed in accordance with subsection 7a77#a7 or has a waiver application approved under subsection 7c7 does not deem the sponsor to meet other requirements imposed under this subpart for a sponsor4 7f7 ,periodic review and revision of standards 7#a7 ,in general ,subject to paragraph 7#b71 the ,secretary may periodically review the standards established under this section and1 based on such review1 may revise such standards if the ,secretary determines such revision to be appropriate4 7#b7 ,prohibition of midyear implementation of significant new regulatory requirements ,the ,secretary may not implement1 other than at the beginning of a calendar year1 regulations under this section that impose new1 significant regulatory requirements on a ,total ,health sponsor or a ,total ,health plan4 7g7 ,prohibition of state imposition of premium taxes2 relation to state laws ,the provisions of sections #ahed7;g7 and #ahef7;b77#c7 shall apply with respect to ,total ,health sponsors and ,total ,health plans under this part in the same manner as such provisions applied to ,,ma organizations and ,,ma plans4 #ahfj;,c-#g4 ,total ,health premiums 7a7 ,monthly beneficiary premium 7#a7 ,base beneficiary premium ,the base beneficiary premium under this paragraph for a ,total ,health plan for a month is equal to the product of-- 7,a7 #ae percent2 and 7,b7 an amount determined by the ,secretary to be equal to the #djth percentile of the monthly standardized bid amounts 7as defined in subsection 7c71 weighted under subsection 7b71 and adjusted under section #ahfj;,c-#h7;b77#b77 for the service area in which the plan is offered4 7#b7 ,computation of monthly beneficiary premium 7,a7 ,in general ,the monthly beneficiary premium for a ,total ,health plan is the base beneficiary premium computed under paragraph 7#a7 as adjusted under this paragraph4 7,b7 ,adjustment to reflect difference between bid and #djth percentile of the monthly standardized bid amount 7i7 ,above #djth percentile ,if the beneficiary enrolls in a plan with a monthly standardized bid amount that exceeds the #djth percentile 7as determined under paragraph 7#a77;,b771 the base beneficiary premium for the month shall be increased by the amount of such excess4 7ii7 ,below #djth percentile ,if the beneficiary enrolls in a plan with a monthly standardized bid amount that is less than the #djth percentile 7as determined under paragraph 7#a77;,b771 the base beneficiary premium for the month shall be decreased by the amount of such difference4 ,any reduction under the preceding sentence shall not result in a monthly beneficiary premium that is less than #j4 7,c7 ,increase for supplemental benefits ,the base beneficiary premium shall be increased by the portion of the ,total ,health approved bid that is attributable to supplemental benefits4 7,d7 ,increase for late enrollment penalty ,the base beneficiary premium shall be increased by the amount of any late enrollment penalty under subsection 7e74 7,e7 ,increase based on income ,the monthly beneficiary premium shall be increased pursuant to subsection 7f74 7,f7 ,uniform premium ,except as provided in subparagraphs 7,d7 and 7,e71 the monthly beneficiary premium for a ,total ,health plan in a ,total ,health region is the same for all ,total ,health eligible individuals enrolled in the plan4 7b7 ,weighting of bid amounts based on enrollment 7#a7 ,in general ,for purposes of subsection 7a77#a77;,b71 the weight for each plan in the service area shall be equal to the average number of ,total ,health eligible individuals enrolled in such plan in the reference month 7as defined in section #aheh7;f77#d774 7#b7 ,special rule for #bjag ,for purposes of applying this paragraph for #bjag1 the ,secretary shall establish procedures for determining the weighted average under paragraph 7#a7 for #bjaf4 7c7 ,standardized bid amount defined ,for purposes of this subsection1 the term standardized bid amount means the following3 7#a7 ,basic coverage only ,in the case of a ,total ,health plan that provides basic health benefits coverage1 the ,total ,health approved bid 7as defined in subsection 7d774 7#b7 ,plans offering supplemental coverage ,in the case of a ,total ,health plan that provides supplemental health benefits coverage1 only the portion of the ,total ,health approved bid that is attributable to basic health benefits coverage4 7d7 ,total health approved bid defined ,for purposes of this subpart1 the term ,total ,health approved bid means-- 7#a7 with respect to a ,total ,health plan1 the bid amount approved for the plan under section #ahfj;,c-#e2 7#b7 with respect to the original medicare fee-for-service program option1 the bid described in section #ahfj;,c-#e7;c74 7e7 ,late enrollment penalty ,the monthly beneficiary premium established under subsection 7a7 shall be subject to adjustment in the same manner as the part ,b monthly beneficiary premium computed under section #ahci is subject to adjustment under subsection 7b7 of such section1 except that1 in applying the late enrollment penalty under such subsection1 the initial enrollment period of the individual shall be the enrollment period under #ahfj;,c-#a7;b77#b7 instead of the initial enrollment period described in such section #ahci7;b74 7f7 ,increase in base beneficiary premium based on income 7#a7 ,in general ,in the case of an individual whose modified adjusted gross income 7as defined in paragraph 7#b77 exceeds the threshold amount applicable under paragraph 7#b7 of section #ahci7;i7 7including application of paragraph 7#e7 of such section71 the ,secretary shall substitute the applicable percentage determined under paragraph 7#c77;,c7 of section #ahci7;i7 for the individual for the calendar year for the percentage described in subsection 7a77#a77;,a74 7#b7 ,modified adjusted gross income ,for purposes of this subsection1 the term modified adjusted gross income has the meaning given such term in subparagraph 7,a7 of section #ahci7;i77#d71 determined for the taxable year applicable under subparagraphs 7,b7 and 7,c7 of such section4 7#c7 ,determination by commissioner of social security ,the ,commissioner of ,social ,security shall make any determination necessary to carry out the income-related increase in the base beneficiary premium under this subsection4 7#d7 ,procedures to assure correct income-related increase in base beneficiary premium 7,a7 ,disclosure of base beneficiary premium ,not later than ,september #ae of each year beginning with #bjaf1 the ,secretary shall disclose to the ,commissioner of ,social ,security the amount of the base beneficiary premium 7as computed under subsection 7a77#a77 for the purpose of carrying out the income-related increase in the base beneficiary premium under this subsection with respect to the following year4 7,b7 ,additional disclosure ,not later than ,october #ae of each year beginning with #bjaf1 the ,secretary shall disclose to the ,commissioner of ,social ,security the following information for the purpose of carrying out the income-related increase in the base beneficiary premium under this subsection with respect to the following year3 7i7 ,the modified adjusted gross income threshold applicable under paragraph 7#b7 of section #ahci7;i7 7including application of paragraph 7#e7 of such section74 7ii7 ,the applicable percentage determined under paragraph 7#c77;,c7 of section #ahci7;i7 7including application of paragraph 7#e7 of such section74 7iii7 ,any other information the ,commissioner of ,social ,security determines necessary to carry out the income-related increase in the base beneficiary premium under this subsection4 #ahfj;,c-#h4 ,premium and cost-sharing support for ,total ,health eligible individuals 7a7 ,direct subsidy payment ,the ,secretary shall provide for payment to a ,total ,health sponsor that offers a ,total ,health plan a direct subsidy for each ,total ,health eligible individual enrolled in a ,total ,health plan for a month equal to-- 7#a7 the amount of the plan's standardized bid amount 7as defined in section #ahfj;,c-#g7;c771 adjusted under subsection 7b77#a71 reduced by 7#b7 the base beneficiary premium 7as computed under paragraph 7#a7 of section #ahfj;,c-#g7;a7 and as adjusted under paragraph 7#b77;,b7 of such section74 7b7 ,adjustments relating to bids 7#a7 ,health status risk adjustment 7,a7 ,establishment of risk adjustors ,the ,secretary shall establish an appropriate methodology for adjusting the standardized bid amount under subsection 7a77#a7 to take into account variation in costs for health benefits coverage among ,total ,health plans based on the differences in actuarial risk of different enrollees being served4 ,any such risk adjustment shall be designed in a manner so as not to result in a change in the aggregate amounts payable to such plans under subsection 7a7 and through that portion of the monthly beneficiary ,total ,health premiums described in subsection 7a77#b74 7,b7 ,considerations ,in establishing the methodology under subparagraph 7,a71 the ,secretary may take into account the similar methodologies used under section #ahec7;a77#c7 to adjust payments to ,,ma organizations for benefits under the original medicare fee-for-service program option4 7,c7 ,data collection ,in order to carry out this paragraph1 the ,secretary shall require ,total ,health sponsors to submit data regarding claims that can be linked at the individual level to data under this title and such other information as the ,secretary determines necessary4 7,d7 ,publication ,at the time of publication of risk adjustment factors under section #ahfj;,d-#ae7;c77#a77;,d71 the ,secretary shall publish the risk adjusters established under this paragraph for the succeeding year4 7#b7 ,geographic adjustment 7,a7 ,in general ,subject to subparagraph 7,b71 for purposes of section #ahfj;,c-#g7;a77#a77;,b71 the ,secretary shall establish an appropriate methodology for adjusting the amount determined under such section to take into account differences in prices for covered health benefits among ,total ,health regions4 7,b7 ,de minimis rule ,if the ,secretary determines that the price variations described in subparagraph 7,a7 among ,total ,health regions are de minimis1 the ,secretary shall not provide for adjustment under this paragraph4 7,c7 ,budget neutral adjustment ,any adjustment under this paragraph shall be applied in a manner so as to not result in a change in the aggregate payments made under this subpart that would have been made if the ,secretary had not applied such adjustment4 7c7 ,payment methods 7#a7 ,in general ,payments under this section shall be based on such a method as the ,secretary determines4 ,the ,secretary may establish a payment method by which interim payments of amounts under this section are made during a year based on the ,secretary's best estimate of amounts that will be payable after obtaining all of the information4 7#b7 ,requirement for provision of information 7,a7 ,requirement ,payments under this section to a ,total ,health sponsor are conditioned upon the furnishing to the ,secretary1 in a form and manner specified by the ,secretary1 of such information as may be required to carry out this section4 7,b7 ,restriction on use of information ,information disclosed or obtained pursuant to subparagraph 7,a7 may be used by officers1 employees1 and contractors of the ,department of ,health and ,human ,services only for the purposes of1 and to the extent necessary in1 carrying out this section4 7#c7 ,source of payments ,payments under this section shall be made from the ,federal ,hospital ,insurance ,trust ,fund under section #ahag and the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 in such proportion as the ,secretary determines appropriate4 7#d7 ,application of enrollee adjustment ,the provisions of section #ahec7;a77#b7 shall apply to payments to ,total ,health sponsors under this section in the same manner as they applied to payments to ,,ma organizations under section #ahec7;a74 7d7 ,plans at risk for entire amount of benefits ,a ,total ,health sponsor that offers a plan under this subpart shall be at full financial risk for the provision of benefits under such plan4 7e7 ,disclosure of information 7#a7 ,in general ,each contract under this subpart shall provide that-- 7,a7 the ,total ,health sponsor offering a ,total ,health plan shall provide the ,secretary with such information as the ,secretary determines is necessary to carry out this section2 and 7,b7 the ,secretary shall have the right in accordance with section #aheg7;d77#b77;,b7 7as applied under section #ahfj;,c-#f7;b77#b77;,c77 to inspect and audit any books and records of a ,total ,health sponsor that pertain to the information regarding costs provided to the ,secretary under subparagraph 7,a74 7#b7 ,restriction on use of information ,information disclosed or obtained pursuant to the provisions of this section may be used-- 7,a7 by officers1 employees1 and contractors of the ,department of ,health and ,human ,services for the purposes of1 and to the extent necessary in-- 7i7 carrying out this section2 and 7ii7 conducting oversight1 evaluation1 and enforcement under this title2 and 7,b7 by the ,attorney ,general and the ,comptroller ,general of the ,united ,states for the purposes of1 and to the extent necessary in1 carrying out health oversight activities4 #ahfj;,c-#i4 ,exemption for ,,msa plans 7a7 ,in general ,none of the provisions in this subpart shall apply to an ,,msa plan 7as defined in section #ahei7;b77#c77 and an ,,msa plan may not be a ,total ,health plan4 7b7 ,continuing availability ,notwithstanding any other provision of law1 the ,secretary shall establish procedures under which-- 7#a7 ,,msa plans may continue to operate on and after ,january #a1 #bjag2 and 7#b7 individuals who would have been eligible to enroll in those plans prior to such date continue to be eligible to enroll in such a plan4 #ahfj;,c-#aj4 ,special rules for employer-sponsored programs 7a7 ,subsidy payment 7#a7 ,in general ,the ,secretary shall provide in accordance with this subsection for payment to the sponsor of a qualified retiree health benefits plan 7as defined in paragraph 7#b77 of a special subsidy payment equal to the amount specified in paragraph 7#c7 for each qualified covered retiree under the plan 7as defined in paragraph 7#d774 ,this subsection constitutes budget authority in advance of appropriations ,acts and represents the obligation of the ,secretary to provide for the payment of amounts provided under this section4 7#b7 ,qualified retiree health benefits plan defined ,for purposes of this subsection1 the term qualified retiree health benefits plan means employment-based retiree health coverage 7as defined in subsection 7c77#a77 if1 with respect to a ,total ,health eligible individual who is a participant or beneficiary under such coverage1 the following requirements are met3 7,a7 ,attestation of actuarial equivalence to standard coverage ,the sponsor of the plan provides the ,secretary1 annually or at such other time as the ,secretary may require1 with an attestation that the actuarial value of health benefits coverage under the plan 7as determined using the processes and methods described in section #ahfj;,c-#e7;d77 is at least equal to the actuarial value of standard health benefits coverage4 7,b7 ,audits ,the sponsor of the plan1 or an administrator of the plan designated by the sponsor1 shall maintain 7and afford the ,secretary access to7 such records as the ,secretary may require for purposes of audits and other oversight activities necessary to ensure the adequacy of health benefits coverage and the accuracy of payments made under this section4 ,the provisions of section #ahfj;,c-#b7;d77#b7 shall apply to such information under this section 7including such actuarial value and attestation7 in a manner similar to the manner in which they apply to financial records of ,total ,health sponsors4 7,c7 ,provision of disclosure regarding health benefits coverage 7i7 ,in general ,each entity that offers employment-based retiree health coverage shall provide for disclosure1 in a form1 manner1 and time consistent with standards established by the ,secretary1 to the ,secretary and ,total ,health eligible individuals of whether the coverage meets the requirement of subparagraph 7,a7 or whether such coverage is changed so it no longer meets such requirement4 7ii7 ,disclosure of non-qualified coverage ,in the case of such coverage that does not meet such requirement1 the disclosure to ,total ,health eligible individuals under this subparagraph shall include information regarding the fact that because such coverage does not meet such requirement there are limitations on the periods in a year in which the individuals may enroll under a ,total ,health plan4 7iii7 ,waiver of requirement ,in the case of a ,total ,health eligible individual who was enrolled in employment-based retiree health coverage which does not meet the requirement of subparagraph 7,a71 the individual may apply to the ,secretary to have such coverage treated as a qualified retiree health benefits plan if the individual establishes that the individual was not adequately informed that such coverage did not meet such requirement4 7#c7 ,employer and union special subsidy amounts 7,a7 ,in general ,for purposes of this subsection1 the special subsidy payment amount under this paragraph for a qualifying covered retiree for a coverage year enrolled with the sponsor of a qualified retiree health benefits plan is1 for the portion of the retiree's gross covered retiree plan-related health benefits costs 7as defined in subparagraph 7,c77ii77 for such year that exceeds the cost threshold amount specified in subparagraph 7,b7 and does not exceed the cost limit under such subparagraph1 an amount equal to #bh percent of the allowable retiree costs 7as defined in subparagraph 7,c77i77 attributable to such gross covered retiree plan-related health benefits costs4 7,b7 ,cost threshold and cost limit applicable 7i7 ,in general ,subject to clause 7ii7-- 7,i7 the cost threshold under this subparagraph is equal to #bej for plan years that end in #bjag2 and 7,,ii7 the cost limit under this subparagraph is equal to #e1jjj for plan years that end in #bjag4 7ii7 ,indexing ,the cost threshold and cost limit amounts specified in subclauses 7,i7 and 7,,ii7 of clause 7i7 for a plan year that ends after #bjag shall be adjusted in the same manner as the unified deductible and the annual out-of-pocket limits1 respectively1 are annually adjusted under sections #ahii;,b and #ahii;,c4 7,c7 ,definitions ,for purposes of this paragraph3 7i7 ,allowable retiree costs ,the term allowable retiree costs means1 with respect to gross covered health benefits costs under a qualified retiree health benefits plan by a plan sponsor1 the part of such costs that are actually paid 7net of discounts1 chargebacks1 and average percentage rebates7 by the sponsor or by or on behalf of a qualifying covered retiree under the plan4 7ii7 ,gross covered retiree plan-related health benefits costs ,the term gross covered retiree plan-related health benefits costs means1 with respect to a qualifying covered retiree enrolled in a qualified retiree health benefits plan during a coverage year1 the costs incurred under the plan1 not including administrative costs1 but including costs directly related to the furnishing of health benefits items and services during the year4 ,such costs shall be determined whether they are paid by the retiree or under the plan4 7iii7 ,coverage year ,the term coverage year has the meaning given such term in section #ahfj;,d-#ae7;b77#d7 7as applied by substituting covered health benefits for covered part ,d drugs74 7#d7 ,qualifying covered retiree defined ,for purposes of this subsection1 the term qualifying covered retiree means a ,total ,health eligible individual who is not enrolled in a ,total ,health plan but is covered under a qualified retiree health benefits plan4 7#e7 ,payment methods1 including provision of necessary information ,the provisions of section #ahfj;,c-#h7;c7 7including paragraph 7#b7 of such section1 relating to requirement for provision of information7 shall apply to payments under this subsection in a manner similar to the manner in which they apply to payments under section #ahfj;,c-#h4 7#f7 ,construction ,nothing in this subsection shall be construed as-- 7,a7 precluding a ,total ,health eligible individual who is covered under employment-based retiree health coverage from enrolling in a ,total ,health plan2 7,b7 precluding such employment-based retiree health coverage or an employer or other person from paying all or any portion of any premium required for coverage under a ,total ,health plan on behalf of such an individual2 7,c7 preventing such employment-based retiree health coverage from providing coverage-- 7i7 that is better than standard health benefits coverage to retirees who are covered under a qualified retiree health benefits plan2 or 7ii7 that is supplemental to the benefits provided under a ,total ,health plan1 including benefits to retirees who are not covered under a qualified retiree health benefits plan but who are enrolled in such a ,total ,health plan2 or 7,d7 preventing employers from providing for flexibility in benefit design and provider access provisions1 without regard to the requirements for basic health benefits coverage1 so long as the actuarial equivalence requirement of paragraph 7#b77;,a7 is met4 7b7 ,application of ,medicare ,advantage waiver authority ,the provisions of section #aheg7;i7 shall apply with respect to ,total ,health plans in relation to employment-based retiree health coverage in a manner similar to the manner in which they applied to an ,,ma plan in relation to employers1 including authorizing the establishment of separate premium amounts for enrollees in a ,total ,health plan by reason of such coverage and limitations on enrollment to ,total ,health eligible individuals enrolled under such coverage4 7c7 ,definitions ,for purposes of this section3 7#a7 ,employment-based retiree health coverage ,the term employment-based retiree health coverage means health insurance or other coverage of health care costs 7whether provided by voluntary insurance coverage or pursuant to statutory or contractual obligation7 for ,total ,health eligible individuals 7or for such individuals and their spouses and dependents7 under a group health plan based on their status as retired participants in such plan4 7#b7 ,sponsor ,the term sponsor means a plan sponsor1 as defined in section 7#af77;,b7 of the ,employee ,retirement ,income ,security ,act of #aigd1 in relation to a group health plan1 except that1 in the case of a plan maintained jointly by one employer and an employee organization and with respect to which the employer is the primary source of financing1 such term means such employer4 7#c7 ,group health plan ,the term group health plan includes such a plan as defined in section #fjg7a7 of the ,employee ,retirement ,income ,security ,act of #aigd and also includes the following3 7,a7 ,federal and state governmental plans ,such a plan established or maintained for its employees by the ,government of the ,united ,states1 by the government of any ,state or political subdivision thereof1 or by any agency or instrumentality of any of the foregoing1 including a health benefits plan offered under chapter #hi of title #e1 ,united ,states ,code4 7,b7 ,collectively bargained plans ,such a plan established or maintained under or pursuant to one or more collective bargaining agreements4 7,c7 ,church plans ,such a plan established and maintained for its employees 7or their beneficiaries7 by a church or by a convention or association of churches which is exempt from tax under section #eja of the ,internal ,revenue ,code of #aihf4 #ahfj;,c-#aa4 ,coordination with ,state ,medicaid programs 7a7 ,application 7#a7 ,in general ,subject to subsection 7c77#b71 a ,state may apply to the ,secretary for the waiver of any or all requirements described in this subpart for plan years beginning on or after ,january #a1 #bjag1 with respect to a ,total ,health plan offered within the ,state for the purpose of coordinating that plan with its ,state plan under title ,,xix to ensure-- 7,a7 dually eligible individuals have full access to the services to which they are entitled2 7,b7 the development of innovative care coordination and integration models2 and 7,c7 the elimination of financial misalignments that lead to poor quality and cost-shifting4 7#b7 ,requirements ,such application shall-- 7,a7 be filed at such time and in such manner as the ,secretary may require2 7,b7 contain such information as the ,secretary may require1 including-- 7i7 a comprehensive description of the proposal and program to implement a plan meeting the requirements for a waiver under this section2 and 7ii7 an analysis of the proposal demonstrating that the plan will not increase ,federal ,government expenditures2 and 7,c7 provide an assurance that1 if approved1 the ,total ,health sponsor will offer the plan that is the subject of the proposal4 7#c7 ,waiver consideration and transparency 7,a7 ,in general ,an application for a waiver under this section shall be considered by the ,secretary in accordance with the regulations described in subparagraph 7,b74 7,b7 ,regulations ,not later than #ahj days after the date of enactment of this subpart1 the ,secretary shall promulgate regulations relating to waivers under this section that provide-- 7i7 a process for public notice and comment sufficient to ensure a meaningful level of public input2 7ii7 a process for the submission of an application for the waiver2 7iii7 a process for the submission to the ,secretary of periodic reports by the ,state concerning the implementation of the program under the waiver2 and 7iv7 a process for the periodic evaluation by the ,secretary of the program under the waiver4 7,c7 ,report ,the ,secretary shall annually report to ,congress concerning actions taken by the ,secretary with respect to applications for waivers under this section4 7#d7 ,state option to be a total health sponsor ,for purposes of this section1 a ,state may elect to be the sponsor of a ,total ,health plan for residents of the ,state who are eligible for benefits under this title and title ,,xix or to apply on behalf of a ,total ,health sponsor offering a ,total ,health plan in the ,state4 7#e7 ,coordinated waiver process ,the ,secretary shall develop a process for coordinating and consolidating the waiver processes applicable under the provisions of this section to ensure that individuals eligible to enroll in a plan offered under the waiver are initially able to do so during an annual1 coordinated election period4 7b7 ,granting of waivers 7#a7 ,in general ,the ,secretary may grant a request for a waiver under subsection 7a77#a7 only if the ,secretary determines that the proposed ,total ,health plan-- 7,a7 will provide coverage that is at least as comprehensive as the coverage described in section #ahfj;,c-#b7;a77#a7 as certified by ,office of the ,actuary of the ,centers for ,medicare ,medicaid ,services2 7,b7 will provide coverage and cost-sharing protections against excessive out-of-pocket spending that are at least as affordable as the provisions of this subtitle would provide2 and 7,c7 will not increase the ,federal deficit4 7c7 ,scope of waiver 7#a7 ,in general ,subject to paragraph 7#b71 the ,secretary shall determine the scope of a waiver granted with respect to a ,total ,health plan under subsection 7a77#a74 7#b7 ,limitation ,the ,secretary may only waive provisions under this title and titles ,,ii1 ,,xi1 ,,xix1 and ,,xxi under a waiver under this section4 7d7 ,determinations by the secretary 7#a7 ,time for determination ,the ,secretary shall make a determination under subsection 7a77#a7 not later than #ahj days after the receipt of an application from a ,state under such subsection4 7#b7 ,effect of determination 7,a7 ,granting of waivers ,if the ,secretary determines to grant a waiver under subsection 7a77#a71 the ,secretary shall notify the ,total ,health sponsor involved of such determination and the terms and effectiveness of such waiver4 7,b7 ,denial of waiver ,if the ,secretary determines a waiver should not be granted under subsection 7a77#a71 the ,secretary shall notify the ,total ,health sponsor involved1 including the reasons therefor4 7e7 ,term of waiver ,no waiver under this section may extend over a period of longer than #e years unless the ,total ,health sponsor requests continuation of such waiver1 and such request shall be deemed granted unless the ,secretary1 within #ij days after the date of the submission of the request to the ,secretary1 either denies such request in writing or informs the ,state in writing with respect to any additional information that is needed in order to make a final determination with respect to the request4 #ahfj;,c-#ab4 ,definitions and miscellaneous provisions 7a7 ,definitions ,for purposes of this subpart3 7#a7 ,basic health benefits coverage ,the term basic health benefits coverage means coverage of the health care items and services for which payment may be made under the original medicare fee-for-service program option4 7#b7 ,insurance risk ,the term insurance risk means1 with respect to a participating health care provider1 risk of the type commonly assumed only by insurers licensed by a ,state and does not include payment variations designed to reflect performance-based measures of activities within the control of the health care provider4 7#c7 ,,ma plan2 ,medicare ,advantage plan ,the terms ,,ma plan and ,medicare ,advantage plan have the meaning given such terms in section #ahei7;b77#a74 7#d7 ,original medicare fee-for-service program option ,the term original medicare fee-for-service program option means the original medicare fee-for-service program under parts ,a and ,b1 as modified by this subpart4 7#e7 ,standard health benefits coverage ,the term standard health benefits coverage has the meaning given such term in section #ahfj;,c-#b7;b74 7#f7 ,total health eligible individual ,the term ,total ,health eligible individual has the meaning given such term in section #ahfj;,c-#a7;a77#c74 7#g7 ,total health plan ,the term ,total ,health plan means health benefits coverage that is offered-- 7,a7 under a policy1 contract1 or plan that has been approved under section #ahfj;,c-#e7;f72 and 7,b7 by a ,total ,health sponsor pursuant to1 and in accordance with1 a contract between the ,secretary and the sponsor under section #ahfj;,c-#f7;b74 7#h7 ,total health sponsor ,the term ,total ,health sponsor means a nongovernmental entity that is certified under this subpart as meeting the requirements and standards of this subpart for such a sponsor4 7b7 ,application of subpart #a provisions and regulations under this subpart ,for purposes of applying provisions of subpart #a under this subpart 7and regulations implementing such provisions7 with respect to a ,total ,health plan and a ,total ,health sponsor1 unless otherwise provided in this subpart1 and to the extent consistent with this subpart1 such provisions 7and regulations implementing such provisions7 shall be applied as the provisions 7and regulations7 applied for plan years beginning prior to ,january #a1 #bjag1 and as if-- 7#a7 any reference to a ,medicare ,advantage plan or an ,,ma plan included a reference to a ,total ,health plan2 7#b7 any reference to an ,,ma organization or a provider-sponsored organization included a reference to a ,total ,health sponsor2 7#c7 any reference to a contract under section #aheg included a reference to a contract under section #ahfj;,c-#f7;b72 7#d7 any reference to subpart #a included a reference to this subpart2 and 7#e7 any reference to an election period under section #ahea were a reference to an enrollment period under section #ahfj;,c-#a4 4 #bjjb4 ,replacement of part ,b premium with ,medicare ,total ,health program plan premium2 other technical and conforming amendments 7a7 ,replacement of part b premium with ,medicare total health program plan premium ,section #ahci of the ,social ,security ,act 7#db ,u4,s4,c4 #acier7 is amended-- 7#a7 in subsection 7a77#b71 by striking ,the monthly premium and inserting ,subject to subsection 7j712 and 7#b7 by adding at the end the following new subsection3 7j7 ,replacement of part b premium with ,medicare ,total ,health program plan premium 7#a7 ,in general ,notwithstanding the preceding provisions of this section1 except as provided in paragraph 7#b71 on and after ,january #a1 #bjag1 in lieu of the premium otherwise applicable under this section1 the monthly premium of each ,total ,health eligible individual 7as defined in section #ahfj;,c-#a7;a77#c77 shall be the monthly beneficiary premium determined under section #ahfj;,c-#g for the ,total ,health plan or the original medicare fee-for-service program option and the plan year involved4 7#b7 ,individuals enrolled for coverage under part b only ,individuals enrolled under this part only 7and not entitled to1 or enrolled for1 benefits under part ,a7 shall pay the premium that would have been calculated under this section but for the enactment of this subsection4 7#c7 ,crediting of premiums ,premiums paid by each ,total ,health eligible individual enrolled in the original medicare fee-for-service program option 7as defined in section #ahfj;,e-#ac7;a77#d771 shall be deposited in the ,treasury to the credit of the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda4 4 7b7 ,other technical and conforming amendments ,not later than #f months after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall submit to the appropriate committees of ,congress a legislative proposal providing for such technical and conforming amendments in the law as are required by the provisions of this part and part ,,ii4 ,,ii ,medicare fee-for-,service reforms #bjaa4 ,medicare protection against high out-of-pocket expenditures for fee-for-service benefits ,title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 is amended by adding at the end the following new section3 #ahii;,b4 ,protection against high out-of-pocket expenditures 7a7 ,in general ,notwithstanding any other provision of this title1 in the case of an individual entitled to1 or enrolled for1 benefits under part ,a or enrolled in part ,b1 if the amount of the out-of-pocket cost-sharing of such individual for a year 7beginning with #bjae7 equals or exceeds-- 7#a7 the first threshold annual out-of-pocket limit under subsection 7b77#a7 but is less than the second threshold annual out-of-pocket limit under subsection 7b77#b7 for that year1 section #ahii;,d7a7 shall be applied by substituting #e percent for #bj percent2 and 7#b7 the second threshold annual out-of-pocket limit under subsection 7b77#b7 for that year1 there shall not be any additional reduction under section #ahii;,d for the remainder of the year 7and the individual shall not be responsible for additional out-of-pocket cost-sharing incurred during that year74 7b7 ,amount of annual out-of-,pocket limits 7#a7 ,first threshold annual out-of-pocket limit ,the amount of the first threshold annual out-of-pocket limit under this subsection shall be-- 7,a7 for #bjae1 #e1ejj2 or 7,b7 for a subsequent year1 the amount specified in this subsection for the preceding year increased or decreased by the percentage change in the ,chained ,consumer ,price ,index for ,all ,urban ,consumers for the #ab-month period ending with ,june of such preceding year 7as published in its initial form by the ,bureau of ,labor ,statistics of the ,department of ,labor as of the end of such period74 7#b7 ,second threshold annual out-of-pocket limit ,the amount of the second threshold annual out-of-pocket limit under this subsection shall be-- 7,a7 for #bjae1 #g1ejj2 or 7,b7 for a subsequent year1 the amount specified in this subsection for the preceding year increased or decreased by the percentage change in the ,chained ,consumer ,price ,index for ,all ,urban ,consumers for the #ab-month period ending with ,june of such preceding year 7as published in its initial form by the ,bureau of ,labor ,statistics of the ,department of ,labor as of the end of such period74 7#c7 ,rounding ,if any amount determined under subparagraph 7,a7 or 7,b7 is not a multiple of #e1 such amount shall be rounded to the nearest multiple of #e4 7c7 ,out-of-,pocket cost-,sharing defined 7#a7 ,in general ,subject to paragraphs 7#b7 and 7#c71 in this section1 the term out-of-pocket cost-sharing means1 with respect to an individual1 the amount of the expenses incurred by the individual that are attributable to-- 7,a7 deductibles1 coinsurance and copayments applicable under part ,a or ,b2 or 7,b7 for items and services that would have otherwise been covered under part ,a or ,b but for the exhaustion of those benefits4 7#b7 ,certain costs not included 7,a7 ,non-covered items and services ,expenses incurred for items and services which are not included 7or treated as being included7 under part ,a or ,b shall not be considered incurred expenses for purposes of determining out-of-pocket cost-sharing under paragraph 7#a74 7,b7 ,items and services not furnished on an assignment-related basis ,if an item or service is furnished to an individual under this title and is not furnished on an assignment-related basis1 any additional expenses the individual incurs above the amount the individual would have incurred if the item or service was furnished on an assignment-related basis shall not be considered incurred expenses for purposes of determining out-of-pocket cost-sharing under paragraph 7#a74 7#c7 ,source of payment ,for purposes of paragraph 7#a71 the ,secretary shall consider expenses to be incurred by the individual without regard to whether the individual or another person1 including a ,state program or other third-party coverage1 has paid for such expenses4 7d7 ,announcement of annual out-of-,pocket limit and unified deductible ,the ,secretary shall 7beginning in #bjad7 announce 7in a manner intended to provide notice to all interested parties7 the annual out-of-pocket limit under this section and the unified deductible under section #ahii;,c that will be applicable for the succeeding year4 4 #bjab4 ,unified ,medicare deductible 7a7 ,in general ,title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq471 as amended by section #bjaa1 is amended by adding at the end the following new section3 #ahii;,c4 ,unified part ,a and ,b deductible 7a7 ,in general ,notwithstanding any other provision of this title1 subject to subsection 7d71 for a year 7beginning with #bjae71 in the case of an individual entitled to1 or enrolled for1 benefits under part ,a or enrolled in part ,b-- 7#a7 the amount otherwise payable under part ,a and the total amount of expenses incurred by the individual during a year which would 7except for this section7 constitute incurred expenses for which benefits payable under section #ahcc7;a7 are determinable1 shall be reduced by the amount of the unified deductible under subsection 7b72 and 7#b7 the individual shall be responsible for payment of such amount4 7b7 ,amount of unified deductible 7#a7 ,in general ,the amount of the unified deductible under this section shall be-- 7,a7 for #bjae1 #eej2 or 7,b7 for a subsequent year1 the amount specified in this subsection for the preceding year increased or decreased by the percentage change in the ,chained ,consumer ,price ,index for ,all ,urban ,consumers for the #ab-month period ending with ,june of such preceding year 7as published in its initial form by the ,bureau of ,labor ,statistics of the ,department of ,labor as of the end of such period74 7#b7 ,rounding ,if any amount determined under paragraph 7#a7 is not a multiple of #e1 such amount shall be rounded to the nearest multiple of #e4 7c7 ,application to all items and services ,the unified deductible under this section for a year shall be applied as follows3 7#a7 ,with respect to items and services covered under part ,a1 such unified deductible shall be applied on the basis of the amount that is payable for such items and services without regard to any copayments or coinsurance and before the application of any such copayments or coinsurance4 7#b7 ,with respect to items and services covered under part ,b1 such unified deductible shall be applied on the basis of the total amount of the expenses incurred by the individual during a year which would1 except for the application of the unified deductible1 constitute incurred expenses for which items and services are payable under part ,b1 without regard to any copayments or coinsurance and before the application of any such copayments or coinsurance4 7#c7 7,a7 ,except as provided in subparagraph 7,b71 such unified deductible shall be applied with respect to all items and services covered under parts ,a and ,b and in lieu of the deductibles described in sections #ahac7;b7 and #ahcc7;b7 or otherwise4 7,b7 ,the deductible applicable to blood under sections #ahac and #ahcc shall apply to blood instead of such unified deductible4 7d7 ,treatment of individuals not enrolled in both parts ,a and ,b ,the ,secretary shall establish procedures under which an individual who entitled to1 or enrolled for1 benefits under part ,a or enrolled in part ,b 7but not both7 will continue to be subject to a deductible under this title that is comparable to the deductible the individual would have been subject to if this section had not been enacted4 4 7b7 ,clarification regarding application under medicare advantage ,section #aheb7;a77#a77;,b77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;a77#a77;,b77iii77 is amended by adding at the end the following new sentence3 ,for plan years #bjae and #bjaf1 the preceding sentence shall be applied to take into account the application of sections #ahii;,b1 #ahii;,c1 and #ahii;,d44 #bjac4 ,uniform ,medicare coinsurance rate 7a7 ,in general ,title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq471 as amended by sections #bjaa and #bjab1 is amended by adding at the end the following new section3 #ahii;,d4 ,uniform part ,a and ,b coinsurance rate 7a7 ,in general ,notwithstanding any other provision of this title1 in the case of an individual entitled to1 or enrolled for1 benefits under part ,a or enrolled in part ,b1 after the application of the unified deductible under section #ahii;,c and subject to the limit on annual out-of-pocket expenses under section #ahii;,b1 the amount otherwise payable under part ,a and the total amount of expenses incurred by the individual during a year 7beginning in #bjae7 which would 7except for this section7 constitute incurred expenses for which benefits are payable under part ,b1 shall be reduced by a coinsurance of #bj percent of such amount4 7b7 ,application to all items and services ,the uniform coinsurance under this section for a year shall be applied as follows3 7#a7 ,with respect to items and services covered under part ,a1 such uniform coinsurance shall be applied on the basis of the amount that is payable for such items and services4 7#b7 ,with respect to items and services covered under part ,b1 such uniform coinsurance shall be applied on the basis of the total amount of the expenses incurred by the individual during a year which would1 except for the application of the unified deductible1 constitute incurred expenses from which items and services are payable under part ,b4 7#c7 7,a7 ,except as provided in subparagraph 7,b71 such uniform coinsurance shall be applied with respect to all items and services covered under parts ,a and ,b and in lieu of any other copayments or coinsurance under such parts4 7,b7 ,coinsurance for blood under this title shall be determined under the rules that were applicable to blood on ,december #ca1 #bjad1 rather than under this section4 4 7b7 ,conforming amendments 7#a7 ,section #ahac of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;e7 is amended-- 7,a7 in subsection 7a71 by inserting ,subject to sections #ahii;,b1 #ahii;,c1 and #ahii;,d3 before paragraph 7#a72 and 7,b7 in subsection 7b71 by inserting ,subject to sections #ahii;,b1 #ahii;,c1 and #ahii;,d3 before paragraph 7#a74 7#b7 ,section #ahcc of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is amended-- 7,a7 in subsection 7a71 in the matter preceding paragraph 7#a71 by inserting and sections #ahii;,b1 #ahii;,c1 and #ahii;,d after succeeding provisions of this section2 7,b7 in subsection 7b71 in the first sentence1 by striking ,before applying and inserting ,subject to sections #ahii;,b1 #ahii;,c1 and #ahii;,d1 before applying2 7,c7 in subsection 7c77#a71 in the matter preceding subparagraph 7,a71 by inserting subject to sections #ahii;,b1 #ahii;,c1 and #ahii;,d1 after this part12 7,d7 in subsection 7f71 by striking ,in establishing and inserting ,subject to sections #ahii;,b1 #ahii;,c1 and #ahii;,d1 in establishing2 and 7,e7 in subsection 7g77#a71 by inserting and sections #ahii;,b1 #ahii;,c1 and #ahii;,d after paragraphs 7#d7 and 7#e74 7#c7 ,section #aije7p77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7p77#c77 is amended-- 7,a7 in subparagraph 7,b71 by striking section #ahac and inserting sections #ahac and #ahii;,d2 and 7,b7 in subparagraph 7,c71 by striking and section #ahcc7;b7 and inserting 1 #ahcc7;b71 and #ahii;,c4 #bjad4 ,prohibition on first-dollar coverage under ,medigap policies and development of new standards for ,medigap policies ,section #ahhb of the ,social ,security ,act 7#db ,u4,s4,c4 #aciess7 is amended by adding at the end the following new subsections3 7z7 ,prohibition on first-,dollar coverage and development of new standards for medicare supplemental policies 7#a7 ,development ,the ,secretary shall request the ,national ,association of ,insurance ,commissioners to review and revise the standards for benefit packages under subsection 7p77#a71 taking into account the changes in benefits resulting from the enactment of the ,fiscal ,sustainability ,act of #bjac and to otherwise update standards to include the requirements for cost-sharing described in paragraph 7#b74 ,such revisions shall be made consistent with the rules applicable under subsection 7p77#a77;,e7 with the reference to the #aiia ,,naic ,model ,regulation' deemed a reference to the ,,naic ,model ,regulation as published in the ,federal ,register on ,december #d1 #aiih1 and as subsequently updated by the ,national ,association of ,insurance ,commissioners to reflect previous changes in law and the reference to #8date of enactment of this subsection deemed a reference to the date of enactment of the ,fiscal ,sustainability ,act of #bjac4 ,to the extent practicable1 such revision shall provide for the implementation of revised standards for benefit packages as of ,january #a1 #bjae4 7#b7 ,cost-sharing requirements ,the cost-sharing requirements described in this paragraph are that1 notwithstanding any other provision of law1 no medicare supplemental policy may provide for coverage of-- 7,a7 any portion of the unified deductible under section #ahii;,c7b7 for the year2 and 7,b7 more than #ej percent of the cost-sharing 7excluding premiums7 otherwise applicable under parts ,a and ,b after the individual has met the unified deductible under section #ahii;,c7b7 for the year and before the individual has reached the first threshold annual out-of-pocket limit under section #ahii;,b7b77#a7 for the year4 7#c7 ,renewability ,the renewability requirement under subsection 7q77#a7 shall be satisfied with the renewal of the revised package under paragraph 7#a7 that most closely matches the policy in which the individual was enrolled prior to such revision4 7aa7 ,limitation on issuing new medicare supplemental policies after #bjaf 7#a7 ,in general ,notwithstanding any other provision of law1 a medicare supplemental policies may not be issued to an individual after ,december #ca1 #bjaf1 unless the individual was covered under a medicare supplemental policy as of such date4 7#b7 ,renewals and new policies ,nothing in this subsection shall be construed as prohibiting-- 7,a7 the renewal after ,december #ca1 #bjaf1 of a medicare supplemental policy that was issued on or before such date2 or 7,b7 the issuance of a new medicare supplemental policy after such date as long as the individual was covered under any medicare supplemental policy as of such date4 4 ,,iii ,annual report to ,congress #bjba4 ,annual report to ,congress 7a7 ,in general ,not later than ,july #a1 #bjaf1 and annually thereafter1 the ,secretary of ,health and ,human ,services shall submit to the ,committee on ,finance and the ,special ,committee on ,aging of the ,senate and to the ,committee on ,ways and ,means and the ,committee on ,energy and ,commerce of the ,house of ,representatives a report on the provisions of1 and amendments made by1 parts ,i and ,,ii4 7b7 ,contents ,the report submitted under subsection 7a7 shall contain the following information3 7#a7 ,an evaluation of the financial impact of such provisions and amendments4 7#b7 ,an evaluation of changes in access to physicians and other health care providers as a result of such provisions and amendments4 7#c7 ,an evaluation of changes in beneficiary satisfaction under the ,medicare program as a result of such provisions and amendments4 7#d7 ,such other information as the ,secretary determines to be appropriate4 ,b ,elimination of exemption of ,medicare payments to physicians under statutory ,,paygo #baja4 ,elimination of exemption of ,medicare payments to physicians under statutory ,,paygo 7a7 ,in general ,section #g of the ,statutory ,pay-,as-,you-,go ,act of #bjaj 7#b ,u4,s4,c4 #icf7 is amended-- 7#a7 in subsection 7a71 by striking paragraph 7#a72 and 7#b7 by striking subsection 7c74 7b7 ,effective date ,the amendments made by subsection 7a7 shall take effect on the date of the enactment of this ,act4 ,c ,adjustments to ,medicare part ,b and ,d premiums for high-,income beneficiaries #bbja4 ,adjustments to ,medicare part ,b and ,d premiums for high-income beneficiaries 7a7 ,in general ,section #ahci7;i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acier7i77 is amended-- 7#a7 in paragraph 7#b77;,a71 by inserting 7or1 in the case of #bjac or a subsequent year1 #ej1jjj7 after #hj1jjj2 and 7#b7 in paragraph 7#c7-- 7,a7 in subparagraph 7,a77i7-- 7i7 by inserting applicable before table2 and 7ii7 by inserting and year after individual2 and 7,b7 in subparagraph 7,c77i7-- 7i7 by striking 7i7 ,in general4-- and inserting 7i77,i7 ,for #bjjg through #bjab4--;,for each of #bjjg through #bjab32 and 7ii7 by adding at the end the following new subclause3 7,,ii7 ,for #bjac and subsequent years ,for #bjac or a subsequent year3 ,if the modified adjusted gross income is3,the applicable percentage is3 ,more than #ej1jjj but not more than #he1jjjce percent ,more than #he1jjj but not more than #ajg1jjjdj percent ,more than #ajg1jjj but not more than #afj1jjjee percent ,more than #afj1jjj but not more than #bad1jjjgj percent ,more than #bad1jjj but not more than #bej1jjjhe percent ,more than #bej1jjjajj percent4 4 7b7 ,extension of temporary adjustment to income thresholds 7#a7 ,in general ,section #ahci7;i77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acier7i77#f77 is amended-- 7,a7 in the matter preceding subparagraph 7,a71 by striking ,december #ca1 #bjai and inserting ,december #ca1 #bjba2 7,b7 in subparagraph 7,a71 by striking equal to such amount for #bjaj2 and and inserting the following3 8equal to-- 7i7 in the case of each of #bjaa and #bjab1 such amount for #bjaj2 and 7ii7 in the case of each of #bjac through #bjba1 such amount for #bjac2 and 2 and 7,c7 in subparagraph 7,b71 by striking equal to such dollar amounts for #bjaj4 and inserting the following3 8equal to-- 7i7 in the case of each of #bjaa and #bjab1 such dollar amounts for #bjaj2 and 7ii7 in the case of each of #bjac through #bjba1 such dollar amounts for #bjac4 4 7#b7 ,conforming amendment ,section #ahci7;i77#e77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acier7i77#e77;,a77 is amended by inserting for such year after paragraph 7#b7 or 7#c72 ,d ,increase in the ,medicare eligibility age #bcja4 ,increase in the ,medicare eligibility age ,section #bbf of the ,social ,security ,act 7#db ,u4,s4,c4 #dbf7 is amended by adding at the end the following new subsection3 7k7 ,increasing ,medicare qualifying age 7#a7 ,in general ,notwithstanding any other provision of law1 any reference in this section1 title ,,xviii1 or title ,,xix 7insofar as it relates to the eligibility age for ,medicare benefits under title ,,xviii7 to age #fe shall be deemed a reference to the ,medicare qualifying age specified in paragraph 7#b74 7#b7 ,medicare qualifying age specified ,the ,medicare qualifying age specified in this paragraph is determined as follows3 7,a7 ,in the case of an individual who attains #fe years of age before ,january #a1 #bjad1 the ,medicare qualifying age is #fe years of age4 7,b7 ,in the case of an individual who attains #fe years of age in a year after #bjac1 and before #bjbe1 the ,medicare qualifying age is the ,medicare qualifying age specified in this paragraph for the previous year increased by #b months4 7,c7 ,in the case of an individual who attains #fe years of age in a year after #bjbd1 the ,medicare qualifying age is #fg years of age4 4 ,e ,other provisions #bdja4 ,limitation on ,medicare payments for direct graduate medical education 7,,dgme7 ,section #ahhf7;h77#b77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77#b77;,d77 is amended by adding at the end the following new clause3 7v7 ,cap on approved ,,fte resident amount 7,i7 ,in general ,the approved ,,fte resident amount for a hospital for a cost reporting period beginning during fiscal year #bjad or a subsequent fiscal year shall not be more than the applicable amount for the year4 7,,ii7 ,applicable amount ,for purposes of subclause 7,i71 the applicable amount for a year shall be an amount equal to #abj percent of the national average salary paid to residents in #bjaj1 updated through the year involved by the ,chained ,consumer ,price ,index4 7,,iii7 ,chained ,consumer ,price ,index ,in subclause 7,,ii71 the term ,chained ,consumer ,price ,index means the initial ,chained ,consumer ,price ,index for all-urban consumers published by the ,department of ,labor4 4 #bdjb4 ,reduction in ,medicare indirect graduate medical education 7,,ime7 payments 7a7 ,in general ,section #ahhf7;d77#e77;,b77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,b77ii77 is amended-- 7#a7 in subclause 7,,xi71 by striking and at the end2 7#b7 in subclause 7,,xii7-- 7,a7 by inserting and before ,october #a1 #bjac1 after #bjjg12 and 7,b7 by striking the period at the end and inserting 2 and2 and 7#c7 by adding at the end the following new subclause3 7,,xiii7 on or after ,october #a1 #bjac1 c is equal to #j4ed4 4 7b7 ,conforming amendment relating to determination of standardized amount ,section #ahhf7;d77#b77;,c77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#b77;,c77i77 is amended by inserting or of section #bdjb7;a7 of the ,fiscal ,sustainability ,act of #bjac after ,act of #aiig4 #bdjc4 ,acceleration of application of productivity adjustment to ,medicare home health prospective payment amounts ,section #ahie7;b77#c77;,b77vi77,i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;fff7b77#c77;,b77vi77,i77 is amended by striking #bjae and inserting #bjad4 #bdjd4 ,acceleration of rebasing of ,medicare home health prospective payment amounts ,section #ahie7;b77#c77;,a77iii77,,ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;fff7b77#c77;,a77iii77,,ii77 is amended-- 7#a7 in the first sentence-- 7,a7 by striking #d-year and inserting #b-year2 and 7,b7 by striking #bjag and inserting #bjae2 and 7#b7 by striking the second sentence4 #bdje4 ,reduction of bad debt treated as an allowable cost 7a7 ,hospitals ,section #ahfa7v77#a77,t7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7v77#a77,t77 is amended-- 7#a7 in clause 7iv71 by striking and at the end2 7#b7 in clause 7v7-- 7,a7 by striking or a subsequent fiscal year2 and 7,b7 by striking the period at the end and inserting a comma2 and 7#c7 by adding at the end the following3 7vi7 for cost reporting periods beginning during fiscal year #bjad1 by #dh percent of such amount otherwise allowable1 7vii7 for cost reporting periods beginning during fiscal year #bjae1 by #fa percent of such amount otherwise allowable1 7viii7 for cost reporting periods beginning during fiscal year #bjaf1 by #gd percent of such amount otherwise allowable1 7ix7 for cost reporting periods beginning during fiscal year #bjag1 by #hg percent of such amount otherwise allowable1 and 7x7 for cost reporting periods beginning during fiscal year #bjah or a subsequent fiscal year1 by #ajj percent of such amount otherwise allowable4 4 7b7 ,skilled nursing facilities ,section #ahfa7v77#a77,v7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7v77#a77,v77 is amended-- 7#a7 by moving subclauses 7,i7 and 7,,ii7 of clause 7i7 and subclauses 7,i7 through 7,,iv7 of clause 7ii7 two ems to the right2 and 7#b7 in clause 7i7-- 7,a7 in subclause 7,i71 by striking and at the end2 7,b7 in subclause 7,,ii7-- 7i7 by striking or a subsequent fiscal year2 and 7ii7 by striking the period at the end and inserting a semicolon2 and 7,c7 by adding at the end the following3 7,,iii7 for cost reporting periods beginning during fiscal year #bjad1 by #dh percent of such amount otherwise allowable2 7,,iv7 for cost reporting periods beginning during fiscal year #bjae1 by #fa percent of such amount otherwise allowable2 7,v7 for cost reporting periods beginning during fiscal year #bjaf1 by #gd percent of such amount otherwise allowable2 7,,vi7 for cost reporting periods beginning during fiscal year #bjag1 by #hg percent of such amount otherwise allowable2 and 7,,vii7 for cost reporting periods beginning during fiscal year #bjah or a subsequent fiscal year1 by #ajj percent of such amount otherwise allowable4 4 7c7 ,certain other providers ,section #ahfa7v77#a77,w77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7v77#a77,w77i77 is amended-- 7#a7 in subclause 7,,ii71 by striking and at the end2 7#b7 in subclause 7,,iii7-- 7,a7 by striking a subsequent fiscal year and inserting fiscal year #bjae2 and 7,b7 by striking the period at the end and inserting a semicolon2 and 7#c7 by adding at the end the following3 7,,iv7 for cost reporting periods beginning during fiscal year #bjaf1 by #dh percent of such amount otherwise allowable2 7,v7 for cost reporting periods beginning during fiscal year #bjag1 by #fa percent of such amount otherwise allowable2 7,,vi7 for cost reporting periods beginning during fiscal year #bjah1 by #gd percent of such amount otherwise allowable2 7,,vii7 for cost reporting periods beginning during fiscal year #bjai1 by #hg percent of such amount otherwise allowable2 and 7,,viii7 for cost reporting periods beginning during fiscal year #bjbj or a subsequent fiscal year1 by #ajj percent of such amount otherwise allowable4 4 ,,iii ,social ,security #caja4 ,adjustments to bend points in determining primary insurance amount ,section #bae7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #dae7;a77#a77 is amended-- 7#a7 in subparagraph 7,a71 in the matter preceding clause 7i71 by inserting who initially becomes eligible for old-age or disability insurance benefits1 or who dies 7before becoming eligible for such benefits71 in any calendar year after #aigi and before #bjag after individual2 7#b7 in subparagraph 7,b77ii71 in the matter preceding subclause 7,i71 by inserting and before #bjag after after #aigi2 7#c7 in subparagraph 7,c77i71 by inserting or 7,e7 after 7,a72 and 7#d7 by adding at the end the following3 7,e7 7i7 ,the primary insurance amount of an individual who initially becomes eligible for old-age or disability insurance benefits1 or who dies 7before becoming eligible for such benefits71 in any calendar year after #bjaf shall 7except as otherwise provided in this section7 be equal to the sum of-- 7,i7 #ij percent of the individual's average indexed monthly earnings 7determined under subsection 7b77 to the extent that such earnings do not exceed the amount established for purposes of this subclause by clause 7ii71 7,,ii7 #cj percent of the individual's average indexed monthly earnings to the extent that such earnings exceed the amount established for purposes of subclause 7,i7 but do not exceed the amount established for purposes of this subclause by clause 7ii71 7,,iii7 #aj percent of the individual's average indexed monthly earnings to the extent that such earnings exceed the amount established for purposes of subclause 7,,ii7 but do not exceed the amount established for purposes of this subclause by clause 7ii71 and 7,,iv7 #e percent of the individual's average indexed monthly earnings to the extent that such earnings exceed the amount established for purposes of subclause 7,,iii71 rounded1 if not a multiple of #j4aj1 to the next lower multiple of #j4aj1 and thereafter increased as provided in subsection 7i74 7ii7 ,for individuals who initially become eligible for old-age or disability insurance benefits1 or who die 7before becoming eligible for such benefits7 in the calendar year #bjag or later1 the amount established for purposes of subclauses 7,i71 7,,ii71 and 7,,iii7 of subparagraph 7,e77i7 shall be #ahj1 #gcf1 and #a1jhe1 respectively1 as if such amount was applicable with respect to #aigi and was adjusted for years after #aigi in the same manner as provided under subparagraph 7,b77ii71 without regard to the limitation that such adjustment only applies to individuals who initially become eligible for old-age benefits or disability insurance benefits1 or who die 7before becoming eligible for benefits7 before #bjag4 7iii7 7,i7 ,notwithstanding clauses 7i7 and 7ii71 in the case of any individual who becomes eligible for old-age or disability insurance benefits1 or who dies 7before becoming eligible for such benefits7 in any calendar year after #bjaf and before #bjea1 the primary insurance amount of the individual shall be equal to the sum of-- 7aa7 the primary insurance amount determined for the individual under subparagraphs 7,a7 and 7,b7 7without regard to the limitation that such subparagraphs apply only to individuals who initially become eligible for old-age benefits or disability insurance benefits1 or who die 7before becoming eligible for benefits7 before #bjag7 multiplied by the applicable phase-in factor for the calendar year under subclause 7,,ii72 and 7bb7 the primary insurance amount determined for the individual under this subparagraph 7other than under this clause7 multiplied by the applicable phase-in factor for the calendar year under subclause 7,,ii74 7,,ii7 ,for purposes of-- 7aa7 subclause 7,i77aa71 the applicable phase-in factor for calendar year #bjag1 is the quotient of #cc divided by #cd1 and for each year thereafter is the quotient of-- 7,,aa7 the numerator applicable for the preceding year reduced by #a1 divided by 7,,bb7 #cd2 and 7bb7 subclause 7,i77bb71 the applicable phase-in factor for calendar year #bjag is the quotient of #a divided by #cd1 and for each year thereafter is the quotient of-- 7,,aa7 the numerator applicable for the preceding year increased by #a1 divided by 7,,bb7 #cd4 4 #cajb4 ,adjustment to calculation of benefit computation years 7a7 ,in general ,clause 7i7 of section #bae7;b77#b77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #dae7;b77#b77;,a77 is amended to read as follows3 7i7 in the case of an individual who is entitled to old-age insurance benefits 7except as provided in the second sentence of this subparagraph71 or who has died-- 7,i7 before ,january #a1 #bjad1 by #e years2 7,,ii7 after ,december #ca1 #bjac1 and before ,january #a1 #bjae1 by #d years2 7,,iii7 after ,december #ca1 #bjad1 and before ,january #a1 #bjaf1 by #c years2 and 7,,iv7 after ,december #ca1 #bjae1 and before ,january #a1 #bjag1 by #b years2 and 4 7b7 ,effective date ,the amendments made by this section shall apply to benefits payable for months beginning after ,december #ca1 #bjac4 #cajc4 ,minimum ,social ,security benefit 7a7 ,in general ,section #bae of the ,social ,security ,act 7#db ,u4,s4,c4 #dae7 is amended by adding at the end the following3 7j7 ,minimum monthly insurance benefit 7#a7 ,notwithstanding the preceding provisions of this section-- 7,a7 subject to paragraph 7#c71 the primary insurance amount of any individual who is credited with at least #aj years of coverage and who initially becomes eligible for old-age or disability insurance benefits or dies 7before becoming eligible for such benefits7 for a month beginning after ,december #ca1 #bjaf 7in this subsection referred to as a qualified individual71 shall be equal to the greater of-- 7i7 the primary insurance amount determined under this section 7without regard to this subsection71 or 7ii7 the minimum monthly insurance benefit determined under paragraph 7#b71 and 7,b7 any recomputation of the primary insurance amount of a qualified individual shall not result in a primary insurance amount less than the primary insurance amount as in effect immediately prior to such recomputation4 7#b7 ,for purposes of this subsection1 the term minimum monthly insurance benefit means #a_/ab of the applicable percentage of the adjusted minimum benefit level 7as defined in paragraph 7#e774 7#c7 7,a7 ,for purposes of this subsection1 subject to subparagraph 7,b71 the applicable percentage shall be #abe percent reduced by the number of percentage points determined under subparagraph 7,b77ii7 for each year of coverage of the qualified individual less than #cj4 7,b7 7i7 ,in the case of an individual who initially becomes eligible for disability insurance benefits under section #bbc before attaining age #fb1 or who dies before attaining age #fb1 in a month beginning after ,december #ca1 #bjaf1 and who is credited with at least #e years of coverage1 the individual shall be treated as a qualified individual and the applicable percentage shall be #abe reduced by the number of percentage points determined under clause 7ii7 for each year of coverage of the qualified individual less than the number as determined under clause 7iii74 7ii7 ,the number of percentage points under this clause shall be determined by-- 7,i7 dividing the number of the qualifying individual's elapsed years 7as defined in subsection 7b77#b77;,b77iii77 by #dj2 7,,ii7 multiplying the result under subclause 7,i7 by #bj2 and 7,,iii7 dividing #abe by the result under subclause 7,,ii7 and rounding to the nearest one hundredth of #a percentage point4 7iii7 ,the number of years of coverage under this clause shall be determined by multiplying the ratio determined under clause 7ii77,i7 by #cj and rounding to the next lower whole number4 7#d7 ,for purposes of this subsection1 a year of coverage is a calendar year for which an individual is credited with #d quarters of coverage4 7#e7 ,for purposes of this subsection-- 7,a7 for individuals who initially become eligible for old-age or disability insurance benefits or die 7before becoming eligible for such benefits7 in #bjag1 the term adjusted minimum benefit level means the weighted average of the ,federal poverty threshold applicable to a family of #a for #bjji 7as determined by the ,bureau of the ,census71 increased for each year occurring after #bjji and before #bjah1 by the percentage increase 7rounded to the nearest one-tenth of #a percent7 in the ,chained ,consumer ,price ,index for ,all ,urban ,consumers 7as published by the ,bureau of ,labor ,statistics of the ,department of ,labor7 for each such year2 and 7,b7 for individuals who initially become eligible for old-age or disability insurance benefits or die 7before becoming eligible for such benefits7 in a year after #bjag1 the term adjusted minimum benefit level means the amount specified in subparagraph 7,a71 multiplied by the quotient described in subsection 7b77#c77;,a77ii71 except that the reference to the computation base year for which the determination is made in such subsection shall be deemed instead to be a reference to #bjji4 7#f7 ,the provisions of this subsection shall not apply in the case of an individual whose primary insurance amount would otherwise be computed under subsection 7a77#g74 4 7b7 ,conforming amendment ,section #bjb7;a7 of such ,act 7#db ,u4,s4,c4 #djb7;a77 is amended in the last sentence by striking section #bae7;a7 and inserting section #bae4 #cajd4 ,increase in benefits starting #bj years after initial eligibility 7a7 ,in general ,section #bae of the ,social ,security ,act 7#db ,u4,s4,c4 #dae71 as amended by this ,act1 is amended by adding at the end the following new subsection3 7k7 ,increased monthly insurance benefit after #bj years of initial eligibility 7#a7 ,notwithstanding the preceding provisions of this section1 in the case of an individual who is a #bj-year beneficiary1 the primary insurance amount of the individual 7as determined before the application of this subsection7 shall be increased for months beginning with the first month for which the individual attains such status by the amount equal to the applicable percentage of the applicable average primary insurance amount4 7#b7 ,for purposes of this subsection1 the term #bj-year beneficiary means an individual who has been eligible for old-age insurance benefits or disability insurance benefits under this title for at least #bdj months4 7#c7 ,for purposes of paragraph 7#a71 the term applicable average primary insurance amount means1 with respect to a #bj-year beneficiary1 the primary insurance amount determined by the ,commissioner of ,social ,security that would apply to an individual of the same age as the age at which the #bj-year beneficiary first attains such status1 if the individual had earnings for each calendar year in which the individual would have attained ages #bj through the year prior to the age of eligibility1 respectively1 equal to the national average earnings for all such individuals for each such year4 7#d7 ,for purposes of paragraph 7#a71 the applicable percentage is-- 7,a7 for each month occurring during the first #ab-month period for which an individual is a #bj-year beneficiary1 #a percent2 7,b7 for each month occurring during the second #ab-month period for which an individual is such a beneficiary1 #b percent2 7,c7 for each month occurring during the third #ab-month period for which an individual is such a beneficiary1 #c percent2 7,d7 for each month occurring during the fourth #ab-month period for which an individual is such a beneficiary1 #d percent2 and 7,e7 for each month occurring thereafter1 #e percent4 4 7b7 ,effective date ,the amendments made by this section shall apply to benefits payable for months beginning after ,december #ca1 #bjac4 #caje4 ,adjustment to normal and early retirement ages ,section #baf7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #daf7l77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in subparagraph 7,d71 by striking 2 and and inserting a semicolon2 and 7,b7 by striking subparagraph 7,e7 and inserting the following new subparagraphs3 7,e7 with respect to an individual who attains early retirement age after ,december #ca1 #bjba1 and before ,january #a1 #bjbc1 #fg years of age2 7,f7 with respect to an individual who1 during the period after ,december #ca1 #bjbb1 and before ,january #a1 #bjgj-- 7i7 for purposes of paragraph 7#b77;,a77ii71 attains #fb years of age1 such individual's early retirement age plus #fj months2 or 7ii7 attains early retirement age pursuant to paragraph 7#b77;,b71 #fg years plus the number of months determined under the age increase factor for the calendar year in which such individual attains early retirement age2 and 7,g7 with respect to an individual who-- 7i7 for purposes of paragraph 7#b77;,a77iii71 attains #fb years of age after ,december #ca1 #bjfi1 #fi years of age2 or 7ii7 attains early retirement age pursuant to paragraph 7#b77;,b7 after ,december #ca1 #bjfi1 #fi years of age4 2 7#b7 by amending paragraph 7#b7 to read as follows3 7#b7 ,the term early retirement age means-- 7,a7 in the case of an old-age1 wife's1 or husband's insurance benefit-- 7i7 #fb years of age with respect to an individual who attains such age before ,january #a1 #bjbc2 7ii7 with respect to an individual who attains #fb years of age after ,december #ca1 #bjbb1 and before ,january #a1 #bjgj1 #fb years of age plus the number of months determined under the age increase factor for the calendar year in which such individual attains #fb years of age2 and 7iii7 with respect to an individual who attains age #fb after ,december #ca1 #bjfi1 #fd years of age2 or 7,b7 in the case of a widow's or widower's insurance benefit1 #fj years of age4 2 and 7#c7 by adding at the end the following new paragraph3 7#d7 ,the age increase factor shall be equal to #a_/bd of the number of months 7rounded down to a full month7 in the period beginning with ,january #bjbc and ending with ,december of the year in which-- 7,a7 for purposes of paragraph 7#a77;,f77ii71 the individual attains #fj years of age2 or 7,b7 for purposes of paragraph 7#b77;,a77ii71 the individual attains #fb years of age4 4 #cajf4 ,application of actuarial reduction for disabled beneficiaries who attain early retirement age 7a7 ,in general ,section #bjb7k77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #djb7k77#d77 is amended to read as follows3 7#d7 7,a7 ,subject to subparagraph 7,b71 any individual who1 under this section and section #bbc1 is entitled for any month to both an old-age insurance benefit and a disability insurance benefit under this title shall be entitled to only the larger of such benefits for such month1 except that1 if such individual so elects1 he shall instead be entitled to only the smaller of such benefits for such month4 7,b7 ,an individual described in subparagraph 7,a7 who has attained transitional retirement age 7as determined under subparagraph 7,c77 shall only be entitled to the old-age insurance benefit for such month1 as reduced for such month pursuant to subsection 7q77#a74 7,c7 ,for purposes of subparagraph 7,b71 the term transitional retirement age means-- 7i7 with respect to an individual who attains #fb years of age before ,january #a1 #bjad1 #ff years of age2 7ii7 with respect to an individual who attains #fb years of age after ,december #ca1 #bjac1 and before ,january #a1 #bjbe1 #ff years of age reduced by the number of months determined under the transition factor 7as determined under subparagraph 7,d77 for the calendar year in which such individual attains #fb years of age2 and 7iii7 with respect to an individual who attains #fb years of age after ,december #ca1 #bjbd1 #fd years of age4 7,d7 ,for purposes of subparagraph 7,c77ii71 the transition factor shall be equal to two-twelfths of the number of months in the period beginning with ,january #bjad and ending with ,december of the year in which the individual attains #fb years of age4 4 7b7 ,conforming amendments 7#a7 ,period of disability ,clause 7i7 of section #baf7;i77#b77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #daf7;i77#b77;,d77 is amended by striking retirement age 7as defined in subsection 7l77 and inserting transitional retirement age 7as defined in section #baf7k77#d774 7#b7 ,disability insurance benefit payments ,section #bbc7;a77#a7 of the ,social ,security 7#db ,u4,s4,c4 #dbc7;a77#a77 is amended-- 7,a7 in subparagraph 7,b71 by striking retirement age 7as defined in section #baf7l77 and inserting transitional retirement age 7as defined in section #baf7k77#d772 and 7,b7 in the flush matter at the end1 by striking retirement age 7as defined in section #baf7l77 and inserting transitional retirement age 7as defined in section #baf7k77#d774 7c7 ,effective date ,the amendments made by this section shall apply to benefits payable for months beginning after ,december #ca1 #bjac4 #cajg4 ,option to collect up to one-half of old-age insurance benefit at age #fb 7a7 ,in general ,section #bjb of the ,social ,security ,act 7#db ,u4,s4,c4 #djb7 is amended by adding at the end the following3 7z7 ,option to collect up to one-,half of old-,age insurance benefit beginning at age #fb 7#a7 ,not later than ,january #a1 #bjad1 the ,commissioner of ,social ,security shall establish an option1 subject to such regulations as are prescribed by the ,commissioner under paragraph 7#b71 for a fully insured individual 7as defined in section #bad7 to elect to receive a reduced monthly benefit after such individual attains #fb years of age1 consisting of the following3 7,a7 ,subject to paragraph 7#c71 for months beginning with the month in which the individual attains age #fb1 a monthly benefit equal to such percentage as is elected by the individual1 but which shall not be greater than #ej percent1 of the primary insurance amount determined for the individual at age #fb4 7,b7 ,for months beginning with the month in which the individual attains early retirement age1 a monthly benefit equal to the sum of-- 7i7 the monthly benefit payable to the individual under subparagraph 7,a72 and 7ii7 the amount equal to the applicable percentage 7as determined under subparagraph 7,c77 of primary insurance amount determined for the individual under section #bae for such month 7determined without regard to any election under this subsection74 7,c7 ,for purposes of subparagraph 7,b77ii71 the applicable percentage shall be equal to the difference between-- 7i7 #ajj percent2 and 7ii7 the percentage elected by the individual under subparagraph 7,a74 7#b7 ,an individual shall elect the option under this subsection in accordance with regulations prescribed by the ,commissioner of ,social ,security4 7#c7 ,the monthly benefit payable to an individual under paragraph 7#a77;,a7 shall be subject to reduction as provided in subsection 7q74 4 7b7 ,conforming amendment ,section #bjb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #djb7;a77 is amended in the last sentence1 by striking subsection 7q7 and subsection 7w7 and inserting subsections 7q71 7w71 and 7z74 #cajh4 ,coverage of newly hired ,state and local employees 7a7 ,amendments to the ,social ,security ,act 7#a7 ,in general ,paragraph 7#g7 of section #baj7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #daj7;a77#g77 is amended to read as follows3 7#g7 ,excluded ,state or local government employment 7as defined in subsection 7s772 4 7#b7 ,excluded state or local government employment 7,a7 ,in general ,section #baj of such ,act 7#db ,u4,s4,c4 #daj7 is amended by adding at the end the following new subsection3 7s7 ,excluded state or local government employment 7#a7 ,in general ,the term excluded ,state or local government employment means any service performed in the employ of a ,state1 of any political subdivision thereof1 or of any instrumentality of any one or more of the foregoing which is wholly owned thereby1 if-- 7,a7 7i7 such service would be excluded from the term employment for purposes of this title if the preceding provisions of this section as in effect in ,december #bjbj had remained in effect1 and 7ii7 the requirements of paragraph 7#b7 are met with respect to such service1 or 7,b7 the requirements of paragraph 7#c7 are met with respect to such service4 7#b7 ,exception for current employment which continues 7,a7 ,in general ,the requirements of this paragraph are met with respect to service for any employer if-- 7i7 such service is performed by an individual-- 7,i7 who was performing substantial and regular service for remuneration for that employer before ,january #a1 #bjba1 7,,ii7 who is a bona fide employee of that employer on ,december #ca1 #bjbj1 and 7,,iii7 whose employment relationship with that employer was not entered into for purposes of meeting the requirements of this subparagraph1 and 7ii7 the employment relationship with that employer has not been terminated after ,december #ca1 #bjbj4 7,b7 ,treatment of multiple agencies and instrumentalities ,for purposes of subparagraph 7,a71 under regulations 7consistent with regulations established under section #caba7t77#b77;,b7 of the ,internal ,revenue ,code of #aihf7-- 7i7 all agencies and instrumentalities of a ,state 7as defined in section #bah7;b77 or of the ,district of ,columbia shall be treated as a single employer1 and 7ii7 all agencies and instrumentalities of a political subdivision of a ,state 7as so defined7 shall be treated as a single employer and shall not be treated as described in clause 7i74 7#c7 ,exception for certain services 7,a7 ,in general ,the requirements of this paragraph are met with respect to service if such service is performed-- 7i7 by an individual who is employed by a ,state or political subdivision thereof to relieve such individual from unemployment1 7ii7 in a hospital1 home1 or other institution by a patient or inmate thereof as an employee of a ,state or political subdivision thereof or of the ,district of ,columbia1 7iii7 by an individual1 as an employee of a ,state or political subdivision thereof or of the ,district of ,columbia1 serving on a temporary basis in case of fire1 storm1 snow1 earthquake1 flood1 or other similar emergency1 7iv7 by any individual as an employee included under section #ecea7b7 of title #e1 ,united ,states ,code 7relating to certain interns1 student nurses1 and other student employees of hospitals of the ,district of ,columbia ,government71 other than as a medical or dental intern or a medical or dental resident in training1 7v7 by an election official or election worker if the remuneration paid in a calendar year for such service is less than #a1jjj with respect to service performed during #bjba1 and the adjusted amount determined under subparagraph 7,c7 for any subsequent year with respect to service performed during such subsequent year1 except to the extent that service by such election official or election worker is included in employment under an agreement under section #bah1 or 7vi7 by an employee in a position compensated solely on a fee basis which is treated pursuant to section #baa7;c77#b77;,e7 as a trade or business for purposes of inclusion of such fees in net earnings from self-employment4 7,b7 ,definitions ,as used in this paragraph1 the terms ,state and political subdivision have the meanings given those terms in section #bah7;b74 7,c7 ,adjustments to dollar amount for election officials and election workers ,for each year after #bjba1 the ,commissioner of ,social ,security shall adjust the amount referred to in subparagraph 7,a77v7 at the same time and in the same manner as is provided under section #bae7;a77#a77;,b77ii7 with respect to the amounts referred to in section #bae7;a77#a77;,b77i71 except that-- 7i7 for purposes of this subparagraph1 #bjah shall be substituted for the calendar year referred to in section #bae7;a77#a77;,b77ii77,,ii71 and 7ii7 such amount as so adjusted1 if not a multiple of #ajj1 shall be rounded to the next higher multiple of #ajj where such amount is a multiple of #ej and to the nearest multiple of #ajj in any other case4 ,the ,commissioner of ,social ,security shall determine and publish in the ,federal ,register each adjusted amount determined under this subparagraph not later than ,november #a preceding the year for which the adjustment is made4 4 7,b7 ,conforming amendments 7i7 ,subsection 7k7 of section #baj of such ,act 7#db ,u4,s4,c4 #daj7k77 7relating to covered transportation service7 is repealed4 7ii7 ,section #baj7p7 of such ,act 7#db ,u4,s4,c4 #daj7p77 is amended-- 7,i7 in paragraph 7#b71 by striking service is performed and all that follows and inserting service is service described in subsection 7s77#c77;,a742 and 7,,ii7 in paragraph 7#c77;,a71 by inserting under subsection 7a77#g7 as in effect in ,december #bjbj after section4 7iii7 ,section #bah7;c77#f7 of such ,act 7#db ,u4,s4,c4 #dah7;c77#f77 is amended-- 7,i7 by striking subparagraph 7,c72 7,,ii7 by redesignating subparagraphs 7,d7 and 7,e7 as subparagraphs 7,c7 and 7,d71 respectively2 and 7,,iii7 by striking subparagraph 7,f7 and inserting the following3 7,e7 service which is included as employment under section #baj7;a74 4 7b7 ,amendments to the internal revenue code of #aihf 7#a7 ,in general ,paragraph 7#g7 of section #caba7;b7 of the ,internal ,revenue ,code of #aihf 7relating to employment7 is amended to read as follows3 7#g7 excluded ,state or local government employment 7as defined in subsection 7t772 4 7#b7 ,excluded state or local government employment ,section #caba of such ,code is amended by inserting after subsection 7s7 the following new subsection3 7t7 ,excluded state or local government employment 7#a7 ,in general ,for purposes of this chapter1 the term excluded ,state or local government employment means any service performed in the employ of a ,state1 of any political subdivision thereof1 or of any instrumentality of any one or more of the foregoing which is wholly owned thereby1 if-- 7,a7 7i7 such service would be excluded from the term employment for purposes of this chapter if the provisions of subsection 7b77#g7 as in effect in ,december #bjbj had remained in effect1 and 7ii7 the requirements of paragraph 7#b7 are met with respect to such service1 or 7,b7 the requirements of paragraph 7#c7 are met with respect to such service4 7#b7 ,exception for current employment which continues 7,a7 ,in general ,the requirements of this paragraph are met with respect to service for any employer if-- 7i7 such service is performed by an individual-- 7,i7 who was performing substantial and regular service for remuneration for that employer before ,january #a1 #bjba1 7,,ii7 who is a bona fide employee of that employer on ,december #ca1 #bjbj1 and 7,,iii7 whose employment relationship with that employer was not entered into for purposes of meeting the requirements of this subparagraph1 and 7ii7 the employment relationship with that employer has not been terminated after ,december #ca1 #bjbj4 7,b7 ,treatment of multiple agencies and instrumentalities ,for purposes of subparagraph 7,a71 under regulations-- 7i7 all agencies and instrumentalities of a ,state 7as defined in section #bah7;b7 of the ,social ,security ,act7 or of the ,district of ,columbia shall be treated as a single employer1 and 7ii7 all agencies and instrumentalities of a political subdivision of a ,state 7as so defined7 shall be treated as a single employer and shall not be treated as described in clause 7i74 7#c7 ,exception for certain services 7,a7 ,in general ,the requirements of this paragraph are met with respect to service if such service is performed-- 7i7 by an individual who is employed by a ,state or political subdivision thereof to relieve such individual from unemployment1 7ii7 in a hospital1 home1 or other institution by a patient or inmate thereof as an employee of a ,state or political subdivision thereof or of the ,district of ,columbia1 7iii7 by an individual1 as an employee of a ,state or political subdivision thereof or of the ,district of ,columbia1 serving on a temporary basis in case of fire1 storm1 snow1 earthquake1 flood1 or other similar emergency1 7iv7 by any individual as an employee included under section #ecea7b7 of title #e1 ,united ,states ,code 7relating to certain interns1 student nurses1 and other student employees of hospitals of the ,district of ,columbia ,government71 other than as a medical or dental intern or a medical or dental resident in training1 7v7 by an election official or election worker if the remuneration paid in a calendar year for such service is less than #a1jjj with respect to service performed during #bjba1 and the adjusted amount determined under section #baj7s77#c77;,c7 of the ,social ,security ,act for any subsequent year with respect to service performed during such subsequent year1 except to the extent that service by such election official or election worker is included in employment under an agreement under section #bah of the ,social ,security ,act1 or 7vi7 by an employee in a position compensated solely on a fee basis which is treated pursuant to section #adjb7;c77#b77;,e7 as a trade or business for purposes of inclusion of such fees in net earnings from self-employment4 7,b7 ,definitions ,as used in this paragraph1 the terms ,state and political subdivision have the meanings given those terms in section #bah7;b7 of the ,social ,security ,act4 4 7#c7 ,conforming amendments 7,a7 ,subsection 7j7 of such section #caba 7relating to covered transportation service7 is repealed4 7,b7 ,paragraph 7#b7 of section #caba7u7 of such ,code 7relating to application of hospital insurance tax to ,federal1 ,state1 and local employment7 is amended-- 7i7 in subparagraph 7,b71 by striking service is performed in clause 7ii7 and all that follows through the end of such subparagraph and inserting service is service described in subsection 7t77#c77;,a742 and 7ii7 in subparagraph 7,c77i71 by inserting under subsection 7b77#g7 as in effect in ,december #bjbj after chapter4 7c7 ,effective date ,except as otherwise provided in this section1 the amendments made by this section shall apply with respect to service performed after ,december #ca1 #bjbj4 #caji4 ,inclusion in annual ,social ,security account statement of estimated present value of taxes and benefits for ,social ,security and ,medicare and projected deficit as a percent of lifetime earnings 7a7 ,in general ,section #aadc7;a77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;b-#ac7;a77#b77 is amended-- 7#a7 in subparagraph 7,e71 by striking benefits4 and inserting benefits22 and 7#b7 by adding after subparagraph 7,e7 the following new subparagraphs3 7,f7 an estimate1 as determined by the ,commissioner1 in consultation with the ,secretary of ,health and ,human ,services1 on the basis of available records of the ,commissioner and projections based on reasonable assumptions1 of-- 7i7 the present value of potential lifetime aggregate employer1 employee1 and self-employment contributions of the eligible individual for old-age1 survivors1 and disability insurance 7under title ,,ii7 and for hospital insurance 7under part ,a of title ,,xviii72 7ii7 the present value of potential lifetime premiums payable 7under parts ,b and ,d of title ,,xviii72 and 7iii7 the present value of potential lifetime aggregate retirement1 disability1 survivor1 and auxiliary benefits payable on the eligible individual's account under title ,,ii and per capita benefits payable under the ,medicare program of title ,,xviii2 and 7,g7 an estimate1 as determined by the ,commissioner1 in consultation with the ,secretary of ,health and ,human ,services1 on the basis of available records of the ,commissioner and projections based on reasonable assumptions1 of the ratio 7expressed as a percentage7 of-- 7i7 the sum of the projected deficit-financed benefits under the old-age1 survivors1 and disability insurance program with respect to the eligible individual and the projected deficit-financed benefits under part ,a of the ,medicare program under title ,,xviii with respect to the eligible individual1 to 7ii7 projected lifetime earnings of the eligible individual4 4 7b7 ,definitions ,section #aadc7;a7 of such ,act 7#db ,u4,s4,c4 #acbj;b-#ac7;a77 is amended-- 7#a7 by redesignating paragraph 7#c7 as paragraph 7#d72 and 7#b7 by inserting after paragraph 7#b7 the following new paragraph3 7#c7 ,for purposes of paragraph 7#b77;,g7-- 7,a7 ,the term projected deficit-financed benefits means-- 7i7 with respect to an eligible individual in connection with the old-age1 survivors1 and disability insurance program1 the product of-- 7,i7 the benefits described in subparagraph 7,f77ii7 of such individual under such program1 and 7,,ii7 the ratio of future annual deficits1 excluding interest1 of the ,federal ,old-,age and ,survivors ,insurance ,trust ,fund and the ,federal ,disability ,insurance ,trust ,fund over the eligible individual's lifetime to future annual outlays from such ,trust ,funds over such lifetime2 and 7ii7 with respect to an eligible individual in connection with the ,medicare program under title ,,xviii1 the product of-- 7,i7 the benefits for hospital insurance 7under part ,a of title ,,xviii7 described in subparagraph 7,f77ii7 of such individual under such program1 and 7,,ii7 the ratio of future annual deficits of the ,federal ,hospital ,insurance ,trust ,fund over the eligible individual's lifetime to future annual outlays from such ,trust ,fund over such lifetime4 7,b7 ,the term projected lifetime earnings of the eligible individual means the present value of the potential total wages paid to1 and self-employment income derived by1 the eligible individual over the eligible individual's lifetime1 as determined without regard to the contribution and benefit base under section #bcj4 4 7c7 ,effective date ,the amendments made by this section shall apply with respect to annual statements issued after #bjac4 #caaj4 ,retirement information campaign ,the ,commissioner of ,social ,security shall establish a public information campaign to provide information and education regarding the implications on personal financial security of early and other retirement decisions and the need for greater retirement savings4 ,the information campaign should be designed to encourage individuals to delay retirement so as to build enhanced levels of social security benefits and personal retirement savings4 ,to the extent the ,commissioner of ,social ,security determines appropriate1 the information provided through the campaign should utilize behavioral economics approaches1 such as structured choice1 and other scientific approaches4 ,,iv ,conversion to chained ,,cpi #daja4 ,conversion to ,chained ,,cpi 7a7 ,consumer price index adjustments applicable to the ,internal ,revenue ,code provisions 7#a7 ,in general ,paragraph 7#c7 of section #a7;f7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7#c7 ,cost-of-living adjustment 7,a7 ,in general ,for purposes of paragraph 7#b71 the cost-of-living adjustment for any calendar year is-- 7i7 for adjustments first beginning before #bjad1 the product of-- 7,i7 the ,,cpi fraction for calendar years before #bjad1 multiplied by 7,,ii7 the ,chained ,,cpi fraction for calendar years after #bjac1 reduced by #a1 and 7ii7 for adjustments first beginning after #bjac1 the ,chained ,,cpi fraction for years after #bjac4 7,b7 ,,cpi fraction for calendar years before #bjad ,the ,,cpi fraction for calendar years before #bjad is the fraction-- 7i7 the numerator of which is the ,,cpi for the calendar year #bjab2 and 7ii7 the denominator of which is the ,,cpi for the calendar year #aiib4 7,c7 ,chained cpi fraction for calendar years after #bjac ,the ,chained ,,cpi fraction for calendar years after #bjac is the fraction-- 7i7 the numerator of which is the ,chained ,,cpi for the preceding calendar year1 and 7ii7 the denominator of which is the ,chained ,,cpi for the calendar year #bjab4 4 7#b7 ,conforming amendments 7,a7 ,paragraph 7#d7 of section #a7;f7 of such ,code is amended to read as follows3 7#d7 ,cpi and chained cpi for any calendar year ,for purposes of paragraph 7#c7-- 7,a7 ,cpi ,the ,,cpi for any calendar year is the average of the ,consumer ,price ,index as of the close of the #ab-month period ending on ,august #ca of such calendar year4 7,b7 ,chained cpi ,the ,chained ,,cpi for any calendar year is the average of the ,chained ,consumer ,price ,index as of the close of the #ab-month period ending on ,august #ca of such calendar year4 4 7,b7 ,paragraph 7#e7 of section #a7;f7 of such ,code is amended to read as follows3 7#e7 ,consumer price index and chained consumer price index ,for purposes of paragraph 7#d7-- 7,a7 ,consumer price index ,the term ,consumer ,price ,index means the last ,consumer ,price ,index for all urban consumers published by the ,department of ,labor4 ,for purposes of the preceding sentence1 the revision of the ,consumer ,price ,index which is most consistent with the ,consumer ,price ,index for calendar year #aihf shall be used4 7,b7 ,chained consumer price index ,the term ,chained ,consumer ,price ,index means the most recent estimate of the ,chained ,consumer ,price ,index for all urban consumers published by the ,department of ,labor4 4 7,c7 ,subclause 7,,ii7 of section #cf;,b7b77#c77;,a77ii7 of such ,code is amended by striking consumer price index and inserting ,chained ,consumer ,price ,index 7as defined in section #a7;f77#e77;,b774 7,d7 ,subclause 7,,ii7 of section #cf;,b7f77#b77;,b77ii7 of such ,code is amended by striking by substituting calendar year #bjac for calendar year #aiib in subparagraph 7,b7 thereof and inserting by substituting calendar year #bjac for calendar year #bjab in subparagraph 7,c7 thereof4 7,e7 ,clause 7ii7 of section #de,r7d77#c77;,b7 of such ,code is amended by striking determined by substituting calendar year #bjab for calendar year #aiib in subparagraph 7,b7 thereof4 7,f7 ,subparagraph 7,b7 of section #abe7;i77#b7 of such ,code is amended by striking determined by substituting calendar year #bjab for calendar year #aiib in subparagraph 7,b7 thereof4 7,g7 ,subclause 7,,ii7 of section #dihj;,i7b77#c77;,c77v7 of such ,code is amended by striking for #aiib in subparagraph 7,b7 thereof and inserting for #bjab in subparagraph 7,c7 thereof4 7,h7 ,clause 7ii7 of section #ejjj;,a7c77#c77;,d7 of such ,code is amended by striking by substituting calendar year #bjae for calendar year #aiib in subparagraph 7,b7 thereof and inserting by substituting calendar year #bjae for calendar year #bjab in subparagraph 7,c7 thereof4 7#c7 ,effective date ,the amendments made by this subsection shall apply to taxable years beginning after ,december #ca1 #bjac4 7b7 ,modifications to cost-of-,living indexation of ,social ,security benefits 7#a7 ,in general ,section #bae7;i77#a77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #dae7;i77#a77;,d77 is amended to read as follows3 7,d7 the term ,,cpi increase percentage1 with respect to a base quarter or cost-of-living computation quarter in any calendar year1 means the percentage 7rounded to the nearest one-tenth of #a percent7 by which the ,chained ,consumer ,price ,index for ,all ,urban ,consumers 7as published in its initial form by the ,bureau of ,labor ,statistics of the ,department of ,labor7 for such base quarter or cost-of-living computation quarter exceeds such index for the later of-- 7i7 the most recent calendar quarter 7prior to such base quarter or cost-of-living computation quarter7 which was a base quarter under subparagraph 7,a77ii72 or 7ii7 the most recent cost-of-living computation quarter under subparagraph 7,b72 4 7#b7 ,definitions ,section #bae7;i77#a77;,g7 of such ,act 7#db ,u4,s4,c4 #dae7;i77#a77;,g77 is amended to read as follows3 7,g7 the ,chained ,consumer ,price ,index for ,all ,urban ,consumers for a base quarter1 a cost-of-living computation quarter1 or any other calendar quarter shall be the arithmetical mean of such index 7as published in its initial form by the ,bureau of ,labor ,statistics of the ,department of ,labor as of the end of such quarter7 for the #ab-month period ending with such quarter4 4 7#c7 ,conforming changes for pre-#aigg law 7,a7 ,section #bae7;i77#a7 of such ,act1 as in effect in ,december #aigh1 and as applied in certain cases under the provisions of such ,act as in effect after ,december #aigh1 is amended-- 7i7 in subparagraph 7,b71 by striking and after the semicolon2 7ii7 in subparagraph 7,c71 by striking for the #c months in such quarter4 and inserting for the #ab months in the #ab-month period ending with such quarter2 and2 and 7iii7 by adding at the end the following new subparagraph3 7,d7 the term ,consumer ,price ,index means the ,chained ,consumer ,price ,index for ,all ,urban ,consumers 7,c-,,cpi-,u71 as published in its initial form by the ,bureau of ,labor ,statistics of the ,department of ,labor4 4 7,b7 ,section #bae7;i77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #dae7;i77#d77 is amended by inserting and by section #daja7;b7 of the ,fiscal ,sustainability ,act of #bjac after #aihf14 7#d7 ,effective date ,the amendments made by this subsection shall apply with respect to increases described in section #bae7;i7 of the ,social ,security ,act1 and to increases under programs dependent on ,social ,security cost-of-living adjustments1 effective with the month of ,december for years after #bjab4 7c7 ,adjustments of provisions utilizing the consumer price index 7#a7 ,in general ,notwithstanding any other provision of law1 and except as provided in this section1 for purposes of determining the amount of any cost-of-living increase or similar adjustment under a ,federal program or law effective in the month of ,december #bjac and thereafter1 any such increase for the period for which the percentage change is determined shall be deemed to be1 in lieu of the increase otherwise determined under applicable law1 the increase determined under such applicable law by substituting the ,chained ,,cpi for the ,,cpi4 7#b7 ,increases determined from a constant base year 7,a7 ,in general ,in any case in which the amount of a cost-of-living increase effective in the month of ,december #bjab and thereafter is determined under applicable law by reference to a change in the ,,cpi over a period which is determined by reference to a base period which remains constant from year to year1 any such increase for any period shall be deemed to be1 in lieu of the increase otherwise determined under applicable law1 the increase1 expressed as a percentage increase1 equal to the product of-- 7i7 the ,,cpi fraction prior to #bjad2 multiplied by 7ii7 the ,chained ,,cpi fraction after #bjac1 reduced by #a4 7,b7 ,,cpi fraction prior to #bjad ,the ,,cpi fraction prior to #bjad is the fraction-- 7i7 the numerator of which is the ,,cpi for the period1 ending with or during #bjab1 which corresponds to the base period2 and 7ii7 the denominator of which is the ,,cpi for the base period4 7,c7 ,chained ,,cpi fraction after #bjac ,the ,chained ,,cpi fraction after #bjac is the fraction-- 7i7 the numerator of which is the ,chained ,,cpi for the period1 ending with or during the year preceding the year in which the determination takes effect1 which corresponds to the base period2 and 7ii7 the denominator of which is the most recently published estimate of the ,chained ,,cpi for the period1 ending with or during #bjab1 which corresponds to the base period4 7#c7 ,special provisions and exceptions 7,a7 ,programs tied to ,social ,security ,subject to subparagraph 7,b7 and the effective date under subsection 7b77#d71 this section and the amendments made by this section shall apply to any cost-of-living increase or other adjustment which is determined by reference to an adjustment made under section #bae7;i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #dae7;i774 7,b7 ,poverty line ,this subsection shall apply to revisions to the poverty line made pursuant to #db ,u4,s4,c4 #iijb7b71 and any programs for which adjustments or eligibility thresholds are based upon the poverty line as defined in that section4 7#d7 ,cpi and chained cpi ,for purposes of this subsection-- 7,a7 the ,,cpi for any period means the average monthly ,consumer ,price ,index for such period1 or a component thereof1 as determined under the applicable law in connection with any cost-of-living increase or similar adjustment required for such period 7without regard to this subsection72 and 7,b7 the ,chained ,,cpi for any period means1 except as provided in paragraph 7#b77;,c77ii71 the ,chained ,consumer ,price ,index for all urban consumers 7as published in its initial form by the ,bureau of ,labor ,statistics of the ,department of ,labor7 for such period1 or a component thereof1 determined under applicable law in the same manner as the ,,cpi for such period would be determined4 7d7 ,change to #ab-,month period for cost-of-,living indexation for ,federal civil service and military retirement programs 7#a7 ,in general 7,a7 ,federal civil service ,sections #hcdj7;a77#b7 and #hdfb7;a77#b7 of title #e1 ,united ,states ,code1 are each amended by striking #c months comprising such quarter and inserting #ab-month period ending with such quarter4 7,b7 ,military ,section #adja;a7h7 of title #aj1 ,united ,states ,code1 is amended by striking three months comprising that quarter and inserting #ab-month period ending with such quarter4 7#b7 ,effective date ,the amendments made by this subsection shall apply with respect to cost-of-living increases effective with the month of ,december of years after #bjab4