,,ii  #aac? ,,congress  #a/ ,session    
,s4 #ahfj  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,decemb] #ai1 #bjac,mr4
 ,hell] introduc$ ! foll[+ bill2 :i* 0  
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to re=m ! m$ical   
liability sy/em1 improve access to heal?
 c>e = rural & indig5t pati5ts1 enhance 
access to af=dable prescription drugs1 &
 = o!r purposes4  #a4 ,%ort title2 table
 ( cont5ts  7a7 ,%ort title ,?is ,act   
may be cit$ z ! ,/eps ,t[>d ,access &   
,re=m ,act ( #bjac or ! ,,/> ,act (     
#bjac4  7b7 ,table ( cont5ts ,! table ( 
cont5ts ( ?is ,act is z foll[s3 ,sec4   
#a4 ,%ort title2 table ( cont5ts4,,title
 ,i--,,m$ical ,,liability               
,r,e,f,o,r,m,sec4 #aja4 ,enc\rag+ spe$y 
resolution ( claims4,sec4 #ajb4         
,comp5sat+ pati5t injury4,sec4 #ajc4    
,maximiz+ pati5t recov]y4,sec4 #ajd4    
,additional collat]al s\rce             
b5efits4,sec4 #aje4 ,punitive           
damages4,sec4 #ajf4 ,au?orization (     
paym5t ( future damages to claimants 9  

heal? c>e lawsuits4,sec4 #ajg4 ,effect  
on o!r laws4,sec4 #ajh4 ,/ate           
flexibility & protection ( ,/ates'      
rights4,sec4 #aji4 ,applicability2      
effective date4,sec4 #aaj4 ,s5se (      
,congress4,sec4 #aaa4                   
,def9itions4,,title ,,ii--,,improv+     
,,access ,,= ,,rural ,,& ,,indig5t      
,p,a,t,i,e,n,t,s,sec4 #bja4 ,improv+    
access = rural & indig5t pati5ts4,,title
 ,,iii--,,provid+ ,,= ,,af=dable        
,,prescription ,d,r,u,g,s,sec4 #cja4    
,provid+ = af=dable prescription        
drugs4,,title ,,iv--,exp&+ ,*oices by   
,all[+ ,am]icans to ,buy ,heal? ,c>e    
,cov]age ,across ,/ate ,lines,sec4 #dja4
 ,int]/ate pur*as+ ( heal? insurance4   
,i ,,m$ical ,,liability ,,re=m  #aja4   
,enc\rag+ spe$y resolution ( claims ,!  
"t = ! comm5cem5t ( a heal? c>e lawsuit 
%all be #c ye>s aft] ! date (           
manife/ation ( injury or #a ye> aft] !  
claimant discov]s1 or ?r\gh ! use (     
reasonable dilig5ce %\ld h discov]$1 !  
injury1 :i*ev] occurs fir/4 ,9 no ev5t  

%all ! "t = comm5cem5t ( a heal? c>e    
lawsuit exce$ #c ye>s aft] ! date (     
manife/ation ( injury unless toll$ = any
 ( ! foll[+-- 7#a7 ^u pro( ( fraud2     
7#b7 int5tional concealm5t2 or  7#c7 !  
pres5ce ( a =eign body1 :i* has no      
!rapeutic or diagno/ic purpose or       
effect1 9 ! body ( ! injur$ p]son4      
,actions by a m9or %all be comm5c$ )9 #c
 ye>s f ! date ( ! alleg$ manife/ation (
 injury except t actions by a m9or "u ! 
full age ( #f ye>s %all be comm5c$ )9 #c
 ye>s ( manife/ation ( injury or prior  
to ! m9or's #h? bir?day1 :i*ev] provides
 a long] p]iod4 ,su* "t limitation %all 
be toll$ = m9ors = any p]iod dur+ :i* a 
p>5t or gu>dian & a heal? c>e provid] or
 heal? c>e organization h committ$ fraud
 or collusion 9 ! failure to br+ an     
action on behalf ( ! injur$ m9or4  #ajb4
 ,comp5sat+ pati5t injury  7a7 ,unlimit$
 ,am\nt ( ,damages = ,actual ,economic  
,losses 9 ,heal? ,c>e ,lawsuits ,9 any  
heal? c>e lawsuit1 no?+ 9 ?is title %all
 limit a claimant's recov]y ( ! full    

am\nt ( ! available economic damages1   
not)/&+ ! limitation 9 subsection 7b74  
7b7 ,additional ,noneconomic ,damages ,9
 any heal? c>e lawsuit1 ! am\nt (       
noneconomic damages1 if available1 %all 
n exce$ #bej1jjj1 reg>dless ( ! numb] ( 
p>ties aga9/ :om ! action is br\ght or !
 numb] ( sep>ate claims or actions      
br\ght ) respect to ! same injury4  7c7 
,no ,disc\nt ( ,aw>d = ,noneconomic     
,damages ,= purposes ( apply+ !         
limitation 9 subsection 7b71 future     
noneconomic damages %all n be disc\nt$  
to pres5t value4 ,! jury %all n be in=m$
 ab\t ! maximum aw>d = noneconomic      
damages4 ,an aw>d = noneconomic damages 
9 excess ( #bej1jjj %all be r$uc$ ei!r  
be=e ! entry ( judgm5t1 or by am5dm5t ( 
! judgm5t aft] entry ( judgm5t1 & su*   
r$uction %all be made be=e acc\nt+ = any
 o!r r$uction 9 damages requir$ by law4 
,if sep>ate aw>ds are r5d]$ = pa/ &     
future noneconomic damages & ! comb9$   
aw>ds exce$ #bej1jjj1 ! future          
noneconomic damages %all be r$uc$ fir/4 

7d7 ,fair ,%>e ,rule ,9 any heal? c>e   
lawsuit1 ea* p>ty %all be liable = t    
p>ty's sev]al %>e ( any damages only & n
 = ! %>e ( any o!r p]son4 ,ea* p>ty %all
 be liable only = ! am\nt ( damages     
allocat$ to su* p>ty 9 direct proportion
 to su* p>ty's p]c5tage (               
responsibility4 ,:5ev] a judgm5t (      
liability is r5d]$ z to any p>ty1 a     
sep>ate judgm5t %all be r5d]$ aga9/ ea* 
su* p>ty = ! am\nt allocat$ to su* p>ty4
 ,= purposes ( ?is section1 ! tri] (    
fact %all det]m9e ! proportion (        
responsibility ( ea* p>ty = ! claimant's
 h>m4  #ajc4 ,maximiz+ pati5t recov]y   
7a7 ,c\rt ,sup]vision ( ,%>e ( ,damages 
,actually ,paid to ,claimants ,9 any    
heal? c>e lawsuit1 ! c\rt %all sup]vise 
! arrangem5ts = paym5t ( damages to     
protect aga9/ conflicts ( int]e/ t may h
 ! effect ( r$uc+ ! am\nt ( damages     
aw>d$ t are actually paid to claimants4 
,9 p>ticul>1 9 any heal? c>e lawsuit 9  
:i* ! attorney = a p>ty claims a        
f9ancial /ake 9 ! outcome by virtue ( a 

cont+5t fee1 ! c\rt %all h ! p[] to     
re/rict ! paym5t ( a claimant's damage  
recov]y to su* attorney1 & to r$irect   
su* damages to ! claimant bas$ ^u !     
int]e/s ( ju/ice & pr9ciples ( equity4  
,9 no ev5t %all ! total ( all cont+5t   
fees = repres5t+ all claimants 9 a heal?
 c>e lawsuit exce$ ! foll[+ limits3 7#a7
 #dj p]c5t ( ! fir/ #ej1jjj recov]$ by !
 claimants4  7#b7 #cca_/c p]c5t ( ! next
 #ej1jjj recov]$ by ! claimants4  7#c7  
#be p]c5t ( ! next #ejj1jjj recov]$ by !
 claimants4  7#d7 #ae p]c5t ( any am\nt 
by :i* ! recov]y by ! claimants is 9    
excess ( #fjj1jjj4  7b7 ,applicability  
,! limitations 9 ?is section %all apply 
:e!r ! recov]y is by judgm5t1 settlem5t1
 m$iation1 arbitration1 or any o!r =m ( 
alt]native dispute resolution4 ,9 a     
heal? c>e lawsuit involv+ a m9or or     
incompet5t p]son1 a c\rt reta9s !       
au?ority to au?orize or approve a fee t 
is less ?an ! maximum p]mitt$ "u ?is    
section4 ,! requirem5t = c\rt sup]vision
 9 ! fir/ two s5t5ces ( subsection 7a7  

applies only 9 civil actions4  #ajd4    
,additional collat]al s\rce b5efits ,9  
any heal? c>e lawsuit involv+ injury or 
wrongful dea?1 any p>ty may introduce   
evid5ce ( collat]al s\rce b5efits4 ,if a
 p>ty elects to introduce su* evid5ce1  
any oppos+ p>ty may introduce evid5ce ( 
any am\nt paid or contribut$ or         
reasonably likely to be paid or         
contribut$ 9 ! future by or on behalf ( 
! oppos+ p>ty to secure ! "r to su*     
collat]al s\rce b5efits4 ,no provid] (  
collat]al s\rce b5efits %all recov] any 
am\nt aga9/ ! claimant or receive any   
li5 or cr$it aga9/ ! claimant's recov]y 
or be equitably or legally subrogat$ to 
! "r ( ! claimant 9 a heal? c>e lawsuit 
involv+ injury or wrongful dea?4 ,?is   
section %all apply to any heal? c>e     
lawsuit t is settl$ z well z a heal? c>e
 lawsuit t is resolv$ by a fact f9d]4   
,?is section %all n apply to section    
#ahfb7;b7 7#db ,u4,s4,c4 #aciey7b77 or  
section #aijb7;a77#be7 7#db ,u4,s4,c4   
#acif;a7a77#be77 ( ! ,social ,security  

,act4  #aje4 ,punitive damages  7a7 ,9  
,g5]al ,punitive damages may1 if o!rwise
 p]mitt$ by applicable ,/ate or ,f$]al  
law1 be aw>d$ aga9/ any p]son 9 a heal? 
c>e lawsuit only if x is prov5 by cle> &
 conv9c+ evid5ce t su* p]son act$ )     
malici\s int5t to injure ! claimant1 or 
t su* p]son delib]ately fail$ to avoid  
unnecess>y injury t su* p]son knew !    
claimant 0 sub/antially c]ta9 to suff]4 
,9 any heal? c>e lawsuit :]e no judgm5t 
= comp5satory damages is r5d]$ aga9/ su*
 p]son1 no punitive damages may be aw>d$
 ) respect to ! claim 9 su* lawsuit4 ,no
 dem& = punitive damages %all be includ$
 9 a heal? c>e lawsuit z initially fil$4
 ,a c\rt may all[ a claimant to file an 
am5d$ plead+ = punitive damages only ^u 
a motion by ! claimant & aft] a f9d+ by 
! c\rt1 ^u review ( support+ & oppos+   
affidavits or aft] a he>+1 aft] weigh+ !
 evid5ce1 t ! claimant has e/abli%$ by a
 sub/antial probability t ! claimant w  
prevail on ! claim = punitive damages4  
,at ! reque/ ( any p>ty 9 a heal? c>e   

lawsuit1 ! tri] ( fact %all consid] 9 a 
sep>ate proce$+-- 7#a7 :e!r punitive    
damages are to be aw>d$ & ! am\nt ( su* 
aw>d2 &  7#b7 ! am\nt ( punitive damages
 foll[+ a det]m9ation ( punitive        
liability4  ,if a sep>ate proce$+ is    
reque/$1 evid5ce relevant only to !     
claim = punitive damages1 z det]m9$ by  
applicable ,/ate law1 %all be           
inadmissible 9 any proce$+ to det]m9e   
:e!r comp5satory damages are to be      
aw>d$4  7b7 ,det]m9+ ,am\nt ( ,punitive 
,damages  7#a7 ,factors consid]$ ,9     
det]m9+ ! am\nt ( punitive damages1 if  
aw>d$1 9 a heal? c>e lawsuit1 ! tri] (  
fact %all consid] only ! foll[+-- 7,a7 !
 sev]ity ( ! h>m caus$ by ! conduct (   
su* p>ty2  7,b7 ! duration ( ! conduct  
or any concealm5t ( x by su* p>ty2  7,c7
 ! pr(itability ( ! conduct to su* p>ty2
  7,d7 ! numb] ( products sold or m$ical
 proc$ures r5d]$ = comp5sation1 z ! case
 may be1 by su* p>ty1 ( ! k9d caus+ !   
h>m compla9$ ( by ! claimant2  7,e7 any 
crim9al p5alties impos$ on su* p>ty1 z a

 result ( ! conduct compla9$ ( by !     
claimant2 &  7,f7 ! am\nt ( any civil   
f9es assess$ aga9/ su* p>ty z a result (
 ! conduct compla9$ ( by ! claimant4    
7#b7 ,maximum aw>d ,! am\nt ( punitive  
damages1 if aw>d$1 9 a heal? c>e lawsuit
 may n exce$ #bej1jjj or two times !    
am\nt ( economic damages aw>d$1 :i*ev]  
is great]4 ,! jury %all n be in=m$ ( ?is
 limitation4  7c7 ,no ,punitive ,damages
 = ,products ,t ,comply ,) ,,fda ,/&>ds 
7#a7 ,9 g5]al  7,a7 ,no punitive damages
 may be aw>d$ aga9/ ! manufactur] or    
di/ributor ( a m$ical product1 or a     
suppli] ( any compon5t or raw mat]ial ( 
su* m$ical product1 bas$ on a claim t   
su* product caus$ ! claimant's h>m :]e--
 7i7 7,i7 su* m$ical product 0 subject  
to prem>ket approval1 cle>ance1 or      
lic5sure by ! ,food & ,drug             
,adm9i/ration ) respect to ! safety ( ! 
=mulation or p]=mance ( ! aspect ( su*  
m$ical product :i* caus$ ! claimant's   
h>m or ! adequacy ( ! packag+ or label+ 
( su* m$ical product2 &  7,,ii7 su*     

m$ical product 0 s approv$1 cle>$1 or   
lic5s$2 or  7ii7 su* m$ical product is  
g5]ally recogniz$ among qualifi$ exp]ts 
z safe & effective pursuant to          
conditions e/abli%$ by ! ,food & ,drug  
,adm9i/ration & applicable ,food & ,drug
 ,adm9i/ration regulations1 includ+ )\t 
limitation ^? relat$ to packag+ &       
label+1 unless ! ,food & ,drug          
,adm9i/ration has det]m9$ t su* m$ical  
product 0 n manufactur$ or di/ribut$ 9  
sub/antial compliance ) applicable ,food
 & ,drug ,adm9i/ration /atutes &        
regulations4  7,b7 ,rule ( con/ruction  
,subp>agraph 7,a7 may n be con/ru$ z    
e/abli%+ ! obligation ( ! ,food & ,drug 
,adm9i/ration to demon/rate             
affirmatively t a manufactur]1          
di/ributor1 or suppli] ref]r$ to 9 su*  
subp>agraph meets any ( ! conditions    
describ$ 9 su* subp>agraph4  7#b7       
,liability ( heal? c>e provid]s ,a heal?
 c>e provid] :o prescribes1 or :o       
disp5ses pursuant to a prescription1 a  
m$ical product approv$1 lic5s$1 or cle>$

 by ! ,food & ,drug ,adm9i/ration %all n
 be nam$ z a p>ty to a product liability
 lawsuit involv+ su* product & %all n be
 liable to a claimant 9 a class action  
lawsuit aga9/ ! manufactur]1 di/ributor1
 or sell] ( su* product4 ,no?+ 9 ?is    
p>agraph prev5ts a c\rt f consolidat+   
cases involv+ heal? c>e provid]s & cases
 involv+ products liability claims aga9/
 ! manufactur]1 di/ributor1 or product  
sell] ( su* m$ical product4  7#c7       
,packag+ ,9 a heal? c>e lawsuit = h>m   
:i* is alleg$ to relate to ! adequacy ( 
! packag+ or label+ ( a drug :i* is     
requir$ to h tamp]-resi/ant packag+ "u  
regulations ( ! ,secret>y ( ,heal? &    
,human ,s]vices 7includ+ label+         
regulations relat$ to su* packag+71 !   
manufactur] or product sell] ( ! drug   
%all n be held liable = punitive damages
 unless su* packag+ or label+ is f\nd by
 ! tri] ( fact by cle> & conv9c+ evid5ce
 to be sub/antially out ( compliance )  
su* regulations4  7#d7 ,exception       
,p>agraph 7#a7 %all n apply 9 any heal? 

c>e lawsuit 9 :i*-- 7,a7 a p]son1 be=e  
or aft] prem>ket approval1 cle>ance1 or 
lic5sure ( su* m$ical product1 kn[+ly   
misrepres5t$ to or )held f ! ,food &    
,drug ,adm9i/ration in=mation t is      
requir$ to be submitt$ "u ! ,f$]al      
,food1 ,drug1 & ,cosmetic ,act 7#ba     
,u4,s4,c4 #cja et seq47 or section #cea 
( ! ,public ,heal? ,s]vice ,act 7#db    
,u4,s4,c4 #bfb7 t is mat]ial & is       
causally relat$ to ! h>m :i* ! claimant 
alleg$ly suff]$2 or  7,b7 a p]son made  
an illegal paym5t to an (ficial ( !     
,food & ,drug ,adm9i/ration = ! purpose 
( ei!r secur+ or ma9ta9+ approval1      
cle>ance1 or lic5sure ( su* m$ical      
product4  #ajf4 ,au?orization ( paym5t (
 future damages to claimants 9 heal? c>e
 lawsuits  7a7 ,9 ,g5]al ,9 any heal?   
c>e lawsuit1 if an aw>d ( future        
damages1 )\t r$uction to pres5t value1  
equal+ or exce$+ #ej1jjj is made aga9/ a
 p>ty ) suffici5t insurance or o!r      
assets to fund a p]iodic paym5t ( su* a 
judgm5t1 ! c\rt %all1 at ! reque/ ( any 

p>ty1 ent] a judgm5t ord]+ t ! future   
damages be paid by p]iodic paym5ts4 ,9  
any heal? c>e lawsuit1 ! c\rt may be    
guid$ by ! ,uni=m ,p]iodic ,paym5t (    
,judgm5ts ,act promulgat$ by ! ,national
 ,conf]5ce ( ,commission]s on ,uni=m    
,/ate ,laws4  7b7 ,applicability ,?is   
section applies to all actions :i* h n  
be5 fir/ set = trial or retrial be=e !  
effective date ( ?is ,act4  #ajg4       
,effect on o!r laws  7a7 ,vacc9e ,injury
  7#a7 ,to ! ext5t t title ,,xxi ( !    
,public ,heal? ,s]vice ,act e/abli%es a 
,f$]al rule ( law applicable to a civil 
action br\ght = a vacc9e-relat$ injury  
or dea?-- 7,a7 ?is title does n affect !
 application ( ! rule ( law to su* an   
action2 &  7,b7 any rule ( law prescrib$
 by ?is title 9 conflict ) a rule ( law 
( su* title ,,xxi %all n apply to su*   
action4  7#b7 ,if !re is an aspect ( a  
civil action br\ght = a vacc9e-relat$   
injury or dea? to :i* a ,f$]al rule (   
law "u title ,,xxi ( ! ,public ,heal?   
,s]vice ,act does n apply1 !n ?is title 

or o!rwise applicable law 7z det]m9$ "u 
?is title7 w apply to su* aspect ( su*  
action4  7b7 ,o!r ,f$]al ,law ,except z 
provid$ 9 ?is section1 no?+ 9 ?is title 
%all be deem$ to affect any def5se      
available to a def5dant 9 a heal? c>e   
lawsuit or action "u any o!r provision (
 ,f$]al law4  #ajh4 ,/ate flexibility & 
protection ( ,/ates' rights  7a7 ,heal? 
,c>e ,lawsuits ,! provisions gov]n+     
heal? c>e lawsuits set =? 9 ?is title   
preempt1 subject to subsections 7b7 &   
7c71 ,/ate law to ! ext5t t ,/ate law   
prev5ts ! application ( any provisions (
 law e/abli%$ by or "u ?is title4 ,!    
provisions gov]n+ heal? c>e lawsuits set
 =? 9 ?is title sup]s$e *apt] #aga (    
title #bh1 ,unit$ ,/ates ,code1 to !    
ext5t t su* *apt]-- 7#a7 provides = a   
great] am\nt ( damages or cont+5t fees1 
a long] p]iod 9 :i* a heal? c>e lawsuit 
may be comm5c$1 or a r$uc$ applicability
 or scope ( p]iodic paym5t ( future     
damages1 ?an provid$ 9 ?is title2 or    
7#b7 prohibits ! introduction ( evid5ce 

reg>d+ collat]al s\rce b5efits1 or      
m&ates or p]mits subrogation or a li5 on
 collat]al s\rce b5efits4  7b7          
,protection ( ,/ates' ,rights & ,o!r    
,laws  7#a7 ,any issue t is n gov]n$ by 
any provision ( law e/abli%$ by or "u   
?is title 7includ+ ,/ate /&>ds (        
neglig5ce7 %all be gov]n$ by o!rwise    
applicable ,/ate or ,f$]al law4  7#b7   
,?is title %all n preempt or sup]s$e any
 ,/ate or ,f$]al law t imposes great]   
proc$ural or sub/antive protections =   
heal? c>e provid]s & heal? c>e          
organizations f liability1 loss1 or     
damages ?an ^? provid$ by ?is title or  
create a cause ( action4  7c7 ,/ate     
,flexibility ,no provision ( ?is title  
%all be con/ru$ to preempt-- 7#a7 any   
,/ate law 7:e!r effective be=e1 on1 or  
aft] ! date ( ! enactm5t ( ?is ,act7 t  
specifies a p>ticul> monet>y am\nt (    
comp5satory or punitive damages 7or !   
total am\nt ( damages7 t may be aw>d$ 9 
a heal? c>e lawsuit1 reg>dless ( :e!r   
su* monet>y am\nt is great] or less] ?an

 is provid$ = "u ?is title1 not)/&+     
section #ajd7;a72 or  7#b7 any def5se   
available to a p>ty 9 a heal? c>e       
lawsuit "u any o!r provision ( ,/ate or 
,f$]al law4  #aji4 ,applicability2      
effective date ,?is title %all apply to 
any heal? c>e lawsuit br\ght 9 a ,f$]al 
or ,/ate c\rt1 or subject to an         
alt]native dispute resolution sy/em1 t  
is initiat$ on or aft] ! date ( !       
enactm5t ( ?is ,act1 except t any heal? 
c>e lawsuit aris+ f an injury occurr+   
prior to ! date ( ! enactm5t ( ?is ,act 
%all be gov]n$ by ! applicable /atute ( 
limitations provisions 9 effect at ! "t 
! injury occurr$4  #aaj4 ,s5se (        
,congress ,x is ! s5se ( ,congress t a  
heal? insur] %\ld be liable = damages = 
h>m caus$ :5 x makes a decision z to :at
 c>e is m$ically necess>y & appropriate4
  #aaa4 ,def9itions ,9 ?is title3 7#a7  
,alt]native dispute resolution sy/em2   
,,adr ,! t]m alt]native dispute         
resolution sy/em or ,,adr means a sy/em 
t provides = ! resolution ( heal? c>e   

lawsuits 9 a mann] o!r ?an ?r\gh a civil
 action br\ght 9 a ,/ate or ,f$]al c\rt4
  7#b7 ,claimant ,! t]m claimant means  
any p]son :o br+s a title1 includ+ a    
p]son :o ass]ts or claims a "r to legal 
or equitable contribution1 indemnity1 or
 subrogation1 aris+ out ( a heal? c>e   
liability claim or action1 & any p]son  
on ^: behalf su* a claim is ass]t$ or   
su* an action is br\ght1 :e!r deceas$1  
incompet5t1 or a m9or4  7#c7 ,collat]al 
s\rce b5efits ,! t]m collat]al s\rce    
b5efits means any am\nt paid or         
reasonably likely to be paid 9 ! future 
to or on behalf ( ! claimant1 or any    
s]vice1 product1 or o!r b5efit provid$  
or reasonably likely to be provid$ 9 !  
future to or on behalf ( ! claimant1 z a
 result ( ! injury or wrongful dea?1    
pursuant to-- 7,a7 any ,/ate or ,f$]al  
heal?1 sickness1 income-disability1     
accid5t1 or work]s' comp5sation law2    
7,b7 any heal?1 sickness1               
income-disability1 or accid5t insurance 
t provides heal? b5efits or             

income-disability cov]age2  7,c7 any    
contract or agreem5t ( any gr\p1        
organization1 p>tn]%ip1 or corporation  
to provide1 pay =1 or reimburse ! co/ ( 
m$ical1 hospital1 d5tal1 or             
income-disability b5efits2 &  7,d7 any  
o!r publicly or privately fund$ program4
  7#d7 ,comp5satory damages ,! t]m      
comp5satory damages means objectively   
v]ifiable monet>y losses incurr$ z a    
result ( ! provision (1 use (1 or paym5t
 = 7or failure to provide1 use1 or pay  
=7 heal? c>e s]vices or m$ical products1
 su* z pa/ & future m$ical exp5ses1 loss
 ( pa/ & future e>n+s1 co/ ( obta9+     
dome/ic s]vices1 loss ( employm5t1 &    
loss ( bus9ess or employm5t             
opportunities1 damages = physical &     
emotional pa91 suff]+1 inconv5i5ce1     
physical impairm5t1 m5tal angui%1       
disfigurem5t1 loss ( enjoym5t ( life1   
loss ( society & companion%ip1 loss (   
consortium 7o!r ?an loss ( dome/ic      
s]vice71 h$onic damages1 injury to      
reputation1 & all o!r nonpecuni>y losses

 ( any k9d or nature4 ,! t]m comp5satory
 damages includes economic damages &    
noneconomic damages1 z su* t]ms are     
def9$ 9 ?is section4  7#e7 ,cont+5t fee 
,! t]m cont+5t fee includes all         
comp5sation to any p]son or p]sons :i*  
is payable only if a recov]y is effect$ 
on behalf ( "o or m claimants4  7#f7    
,economic damages ,! t]m economic       
damages means objectively v]ifiable     
monet>y losses incurr$ z a result ( !   
provision (1 use (1 or paym5t = 7or     
failure to provide1 use1 or pay =7 heal?
 c>e s]vices or m$ical products1 su* z  
pa/ & future m$ical exp5ses1 loss ( pa/ 
& future e>n+s1 co/ ( obta9+ dome/ic    
s]vices1 loss ( employm5t1 & loss (     
bus9ess or employm5t opportunities4     
7#g7 ,heal? c>e lawsuit ,! t]m heal? c>e
 lawsuit means any heal? c>e liability  
claim conc]n+ ! provision ( heal? c>e   
goods or s]vices or any m$ical product  
affect+ int]/ate comm]ce1 or any heal?  
c>e liability action conc]n+ ! provision
 ( heal? c>e goods or s]vices or any    

m$ical product affect+ int]/ate comm]ce1
 br\ght 9 a ,/ate or ,f$]al c\rt or     
pursuant to an alt]native dispute       
resolution sy/em1 aga9/ a heal? c>e     
provid]1 a heal? c>e organization1 or ! 
manufactur]1 di/ributor1 suppli]1       
m>ket]1 promot]1 or sell] ( a m$ical    
product1 reg>dless ( ! !ory ( liability 
on :i* ! claim is bas$1 or ! numb] (    
claimants1 pla9tiffs1 def5dants1 or o!r 
p>ties1 or ! numb] ( claims or causes ( 
action1 9 :i* ! claimant alleges a heal?
 c>e liability claim4 ,su* t]m does n   
include a claim or action :i* is bas$ on
 crim9al liability2 :i* seeks civil f9es
 or p5alties paid to ,f$]al1 ,/ate1 or  
local gov]nm5t2 or :i* is gr\nd$ 9      
antitru/4  7#h7 ,heal? c>e liability    
action ,! t]m heal? c>e liability action
 means a civil action br\ght 9 a ,/ate  
or ,f$]al c\rt or pursuant to an        
alt]native dispute resolution sy/em1    
aga9/ a heal? c>e provid]1 a heal? c>e  
organization1 or ! manufactur]1         
di/ributor1 suppli]1 m>ket]1 promot]1 or

 sell] ( a m$ical product1 reg>dless ( !
 !ory ( liability on :i* ! claim is     
bas$1 or ! numb] ( pla9tiffs1 def5dants1
 or o!r p>ties1 or ! numb] ( causes (   
action1 9 :i* ! claimant alleges a heal?
 c>e liability claim4  7#i7 ,heal? c>e  
liability claim ,! t]m heal? c>e        
liability claim means a dem& by any     
p]son1 :e!r or n pursuant to ,,adr1     
aga9/ a heal? c>e provid]1 heal? c>e    
organization1 or ! manufactur]1         
di/ributor1 suppli]1 m>ket]1 promot]1 or
 sell] ( a m$ical product1 includ+1 b n 
limit$ to1 ?ird-p>ty claims1            
cross-claims1 c\nt]-claims1 or          
contribution claims1 :i* are bas$ ^u !  
provision (1 use (1 or paym5t = 7or !   
failure to provide1 use1 or pay =7 heal?
 c>e s]vices or m$ical products1        
reg>dless ( ! !ory ( liability on :i* ! 
claim is bas$1 or ! numb] ( pla9tiffs1  
def5dants1 or o!r p>ties1 or ! numb] (  
causes ( action4  7#aj7 ,heal? c>e      
organization ,! t]m heal? c>e           
organization means any p]son or entity  

:i* is obligat$ to provide or pay =     
heal? b5efits "u any heal? plan1 includ+
 any p]son or entity act+ "u a contract 
or arrangem5t ) a heal? c>e organization
 to provide or adm9i/] any heal? b5efit4
  7#aa7 ,heal? c>e provid] ,! t]m heal? 
c>e provid] means any p]son or entity   
requir$ by ,/ate or ,f$]al laws or      
regulations to be lic5s$1 regi/]$1 or   
c]tifi$ to provide heal? c>e s]vices1 & 
be+ ei!r s lic5s$1 regi/]$1 or c]tifi$1 
or exempt$ f su* requirem5t by o!r      
/atute or regulation4  7#ab7 ,heal? c>e 
goods or s]vices ,! t]m heal? c>e goods 
or s]vices means any goods or s]vices   
provid$ by a heal? c>e organization1    
provid]1 or by any individual work+ "u !
 sup]vision ( a heal? c>e provid]1 t    
relates to ! diagnosis1 prev5tion1 or   
treatm5t ( any human disease or         
impairm5t1 or ! assessm5t or c>e ( !    
heal? ( human be+s4  7#ac7 ,malici\s    
int5t to injure ,! t]m malici\s int5t to
 injure means int5tionally caus+ or     
attempt+ to cause physical injury o!r   

?an provid+ heal? c>e goods or s]vices4 
7#ad7 ,m$ical product ,! t]m m$ical     
product means a drug1 device1 or        
biological product int5d$ = humans1 & ! 
t]ms drug1 device1 & biological product 
h ! mean+s giv5 su* t]ms 9 sections     
#bja7;g77#a7 & #bja7;h7 ( ! ,f$]al      
,food1 ,drug1 & ,cosmetic ,act 7#ba     
,u4,s4,c4 #cba7;g77#a7 & 7h77 & section 
#cea7;a7 ( ! ,public ,heal? ,s]vice ,act
 7#db ,u4,s4,c4 #bfb7;a771 respectively1
 includ+ any compon5t or raw mat]ial us$
 !re91 b exclud+ heal? c>e s]vices4     
7#ae7 ,noneconomic damages ,! t]m       
noneconomic damages means damages =     
physical & emotional pa91 suff]+1       
inconv5i5ce1 physical impairm5t1 m5tal  
angui%1 disfigurem5t1 loss ( enjoym5t ( 
life1 loss ( society & companion%ip1    
loss ( consortium 7o!r ?an loss (       
dome/ic s]vice71 h$onic damages1 injury 
to reputation1 & all o!r nonpecuni>y    
losses ( any k9d or nature4  7#af7      
,punitive damages ,! t]m punitive       
damages means damages aw>d$1 = ! purpose

 ( puni%m5t or det]r5ce1 & n solely =   
comp5satory purposes1 aga9/ a heal? c>e 
provid]1 heal? c>e organization1 or a   
manufactur]1 di/ributor1 or suppli] ( a 
m$ical product4 ,punitive damages are   
nei!r economic nor noneconomic damages4 
7#ag7 ,recov]y ,! t]m recov]y means !   
net sum recov]$ aft] d$uct+ any         
disbursem5ts or co/s incurr$ 9          
connection ) prosecution or settlem5t ( 
! claim1 includ+ all co/s paid or       
advanc$ by any p]son4 ,co/s ( heal? c>e 
incurr$ by ! pla9tiff & ! attorneys'    
(fice ov]head co/s or *>ges = legal     
s]vices are n d$uctible disbursem5ts or 
co/s = su* purpose4  7#ah7 ,/ate ,! t]m 
,/ate means ea* ( ! sev]al ,/ates1 !    
,di/rict ( ,columbia1 ! ,commonweal? (  
,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1   
,am]ican ,samoa1 ! ,nor!rn ,m>iana      
,isl&s1 ! ,tru/ ,t]ritory ( ! ,pacific  
,isl&s1 & any o!r t]ritory or possession
 ( ! ,unit$ ,/ates1 or any political    
subdivision !re(4  ,,ii ,,improv+       
,,access ,,= ,,rural ,,& ,,indig5t      

,,pati5ts  #bja4 ,improv+ access = rural
 & indig5t pati5ts  7a7 ,loan =giv5ess =
 prim>y c>e provid]s  7#a7 ,9 g5]al ,!  
,secret>y ( ,heal? & ,human ,s]vices    
%all c>ry out a program ( ent]+ into    
contracts ) eligible individuals "u     
:i*-- 7,a7 ! individual agrees to s]ve =
 a p]iod ( n less ?an #d ye>s z a prim>y
 c>e provid] 9 a m$ically und]s]v$      
community 7z def9$ 9 section #gii;,b ( !
 ,public ,heal? ,s]vice ,act 7#db       
,u4,s4,c4 #biep772 &  7,b7 9            
consid]ation ( su* s]vice1 ! ,secret>y  
agrees to pay n m ?an #ajj1jjj on !     
pr9cipal & int]e/ on ! individual's     
graduate educational loans4  7#b7       
,eligibility ,to be eligible to ent]    
into a contract "u subsection 7#a71 an  
individual mu/-- 7,a7 h a graduate      
degree 9 m$ic9e1 o/eopa?ic m$ic9e1 or   
ano!r heal? pr(ession f an accr$it$ 7z  
det]m9$ by ! ,secret>y ( ,heal? & ,human
 ,s]vices7 in/itution ( high] education2
 &  7,b7 h practic$ z a prim>y c>e      
provid] = a p]iod 7exclud+ any resid5cy 

or fell[%ip tra9+ p]iod7 ( n less ?an #c
 ye>s 9 a m$ically und]s]v$ community 7z
 def9$ 9 section #gii;,b ( ! ,public    
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#biep774  7#c7 ,in/allm5ts ,paym5ts "u  
?is section may be made 9 in/allm5ts ( n
 m ?an #be1jjj = ea* ye> ( s]vice       
describ$ 9 p>agraph 7#a7 7,a74  7#d7    
,applicability ( c]ta9 provisions ,!    
provisions ( subp>t ,,iii ( "p ,d (     
title ,,iii ( ! ,public ,heal? ,s]vice  
,act %all1 except z inconsi/5t ) ?is    
section1 apply to ! program e/abli%$ "u 
?is section 9 ! same mann] & to ! same  
ext5t z su* provisions apply to !       
,national ,heal? ,s]vice ,corps ,loan   
,repaym5t ,program e/abli%$ 9 su*       
subp>t4  7b7 ,p]mitt+ ,/ate designation 
( critical access hospitals ,section    
#ahbj7;c77#b77;,b77i77,,ii7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acie;i-#d7;c77#b77;,b77i77,,ii77 is    
am5d$ by ins]t+ or on or aft] ! date (  
enactm5t ( ! ,/eps ,t[>d ,access & ,re=m
 ,act ( #bjac aft] ,janu>y #a1 #bjjf14  

7c7 ,pati5t fairness & indig5t c>e      
promotion  7#a7 ,9 ,g5]al ,section #aff 
( ! ,int]nal ,rev5ue ,code ( #aihf      
7relat+ to bad debts7 is am5d$ by       
r$esignat+ subsection 7f7 z subsection  
7g7 & by ins]t+ aft] subsection 7e7 !   
foll[+ new subsection3  7f7 ,unpaid     
,m$ical ,c>e ,provid$ to ,l[-,income    
,individuals  7#a7 ,9 g5]al ,9 ! case ( 
a taxpay] to :om ?is subsection applies1
 ! d$uction "u subsection 7a7 = wor?less
 qualifi$ m$ical c>e debt %all n be less
 ?an #ge p]c5t ( ! taxpay]'s *>ge = su* 
c>e4  7#b7 ,taxpay] to :om subsection   
applies ,?is subsection %all apply to   
any taxpay] :o is engag$ 9 ! trade or   
bus9ess ( provid+ m$ical c>e o!r ?an z  
an employee & :o us$ ! ca% receipts &   
disbursem5ts me?od ( acc\nt+4  7#c7     
,qualifi$ m$ical c>e debt ,= purposes ( 
?is subsection1 ! t]m qualifi$ m$ical   
c>e debt means any debt = m$ical c>e    
provid$ by ! taxpay] to a l[-income     
individual :o is a citiz5 or legal      
resid5t ( ! ,unit$ ,/ates4  7#d7        

,det]m9ation ( *>ge ,! am\nt ( !        
taxpay]'s *>ge :i* may be tak5 into     
acc\nt-- 7,a7 %all n exce$ ! am\nt ( !  
*>ge t w\ld be recogniz$ = purposes (   
title ,,xviii ( ! ,social ,security     
,act1 &  7,b7 %all n include any am\nt =
 :i* ! taxpay] is n entitl$ to          
reimbursem5t f ! l[-income individual4  
7#e7 ,l[-income individual ,= purposes (
 ?is subsection1 ! t]m l[-income        
individual means an individual :o1 at ! 
"t ! m$ical c>e attributable to ! debt  
is provid$1 has an annual h\sehold      
income bel[ #ace p]c5t ( ! pov]ty l9e 7z
 def9$ 9 section #fgc ( ! ,community    
,s]vices ,block ,grant ,act 7#db        
,u4,s4,c4 #iijb77 applicable to ! size (
 ! family involv$1 & is a citiz5 or     
legal resid5t ( ! ,unit$ ,/ates4  7#f7  
,m$ical c>e ,= purposes ( ?is           
subsection1 ! t]m m$ical c>e has ! mean+
 giv5 to su* t]m by section #bac7;d74   
7#g7 ,regulations ,! ,secret>y %all     
prescribe su* regulations z may be      
necess>y or appropriate to c>ry out ?is 

section1 includ+ regulations provid+ =  
me?ods ( e/abli%+ t an individual is a  
l[-income individual = purposes ( ?is   
section4  4  7#b7 ,effective ,date ,!   
am5dm5t made by ?is section %all apply  
to taxable ye>s beg9n+ aft] ! date ( !  
enactm5t ( ?is ,act4  ,,iii ,,provid+   
,,= ,,af=dable ,,prescription ,,drugs   
#cja4 ,provid+ = af=dable prescription  
drugs ,not)/&+ any o!r provision ( law1 
! ,food & ,drug ,adm9i/ration %all n    
take any action to prev5t an individual 
n 9 ! bus9ess ( import+ a prescription  
drug 7)9 ! mean+ ( section #hja7;g7 ( ! 
,f$]al ,food1 ,drug1 & ,cosmetic ,act   
7#ba ,u4,s4,c4 #cha7;g777 f import+ a   
prescription drug f ,canada t complies )
 ! ,f$]al ,food1 ,drug1 & ,cosmetic     
,act4  ,,iv ,exp&+ ,*oices by ,all[+    
,am]icans to ,buy ,heal? ,c>e ,cov]age  
,across ,/ate ,l9es  #dja4 ,int]/ate    
pur*as+ ( heal? insurance  7a7 ,9 ,g5]al
 ,title ,,xxvii ( ! ,public ,heal?      
,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et  
seq47 is am5d$ by add+ at ! end !       

foll[+3  ,d ,coop]ative ,gov]n+ (       
,individual ,heal? ,insurance ,cov]age  
#bgie4 ,def9itions ,9 ?is "p3 7#a7      
,prim>y /ate ,! t]m prim>y ,/ate means1 
) respect to individual heal? insurance 
cov]age (f]$ by a heal? insurance issu]1
 ! ,/ate designat$ by ! issu] z ! ,/ate 
^: cov]$ laws %all gov]n ! heal?        
insurance issu] 9 ! sale ( su* cov]age  
"u ?is "p4 ,an issu]1 ) respect to a    
p>ticul> policy1 may only designate "o  
su* ,/ate z its prim>y ,/ate ) respect  
to all su* cov]age x (f]s4 ,su* an issu]
 may n *ange ! designat$ prim>y ,/ate ) 
respect to individual heal? insurance   
cov]age once ! policy is issu$1 except t
 su* a *ange may be made ^u r5ewal ( !  
policy4 ,) respect to su* designat$     
,/ate1 ! issu] is deem$ to be do+       
bus9ess 9 t ,/ate4  7#b7 ,second>y /ate 
,! t]m second>y ,/ate means1 ) respect  
to individual heal? insurance cov]age   
(f]$ by a heal? insurance issu]1 any    
,/ate t is n ! prim>y ,/ate4 ,9 ! case (
 a heal? insurance issu] t is sell+ a   

policy 91 or to a resid5t (1 a second>y 
,/ate1 ! issu] is deem$ to be do+       
bus9ess 9 t second>y ,/ate4  7#c7 ,heal?
 insurance issu] ,! t]m heal? insurance 
issu] has ! mean+ giv5 su* t]m 9 section
 #bgia7;b77#b71 except t su* an issu]   
mu/ be lic5s$ 9 ! prim>y ,/ate & be     
qualifi$ to sell individual heal?       
insurance cov]age 9 t ,/ate4  7#d7      
,individual heal? insurance cov]age ,!  
t]m individual heal? insurance cov]age  
means heal? insurance cov]age (f]$ 9 !  
individual m>ket1 z def9$ 9 section     
#bgia7;e77#a74  7#e7 ,applicable /ate   
au?ority ,! t]m applicable ,/ate        
au?ority means1 ) respect to a heal?    
insurance issu] 9 a ,/ate1 ! ,/ate      
insurance commission] or (ficial or     
(ficials designat$ by ! ,/ate to en=ce !
 requirem5ts ( ?is title = ! ,/ate )    
respect to ! issu]4  7#f7 ,haz>d\s      
f9ancial condition ,! t]m haz>d\s       
f9ancial condition means t1 bas$ on its 
pres5t or reasonably anticipat$ f9ancial
 condition1 a heal? insurance issu] is  

unlikely to be able-- 7,a7 to meet      
obligations to policyhold]s ) respect to
 kn[n claims & reasonably anticipat$    
claims2 or  7,b7 to pay o!r obligations 
9 ! normal c\rse ( bus9ess4  7#g7 ,cov]$
 laws  7,a7 ,9 g5]al ,! t]m cov]$ laws  
means ! laws1 rules1 regulations1       
agreem5ts1 & ord]s gov]n+ ! insurance   
bus9ess p]ta9+ to-- 7i7 individual heal?
 insurance cov]age issu$ by a heal?     
insurance issu]2  7ii7 ! (f]1 sale1 rat+
 7includ+ m$ical und]writ+71 r5ewal1 &  
issuance ( individual heal? insurance   
cov]age to an individual2  7iii7 !      
provision to an individual 9 relation to
 individual heal? insurance cov]age (   
heal? c>e & insurance relat$ s]vices2   
7iv7 ! provision to an individual 9     
relation to individual heal? insurance  
cov]age ( managem5t1 op]ations1 &       
inve/m5t activities ( a heal? insurance 
issu]2 &  7v7 ! provision to an         
individual 9 relation to individual     
heal? insurance cov]age ( loss control &
 claims adm9i/ration = a heal? insurance

 issu] ) respect to liability = :i* !   
issu] provides insurance4  7,b7         
,exception ,su* t]m does n include any  
law1 rule1 regulation1 agreem5t1 or ord]
 gov]n+ ! use ( c>e or co/ managem5t    
te*niques1 includ+ any requirem5t relat$
 to provid] contract+1 network access or
 adequacy1 heal? c>e data collection1 or
 quality assurance4  7#h7 ,/ate ,! t]m  
,/ate means ! #ej ,/ates & includes !   
,di/rict ( ,columbia1 ,pu]to ,rico1 !   
,virg9 ,isl&s1 ,guam1 ,am]ican ,samoa1 &
 ! ,nor!rn ,m>iana ,isl&s4  7#i7 ,unfair
 claims settlem5t practices ,! t]m      
unfair claims settlem5t practices means 
only ! foll[+ practices3 7,a7 ,kn[+ly   
misrepres5t+ to claimants & insur$      
individuals relevant facts or policy    
provisions relat+ to cov]age at issue4  
7,b7 ,fail+ to ackn[l$ge ) reasonable   
promptness p]t95t communications )      
respect to claims aris+ "u policies4    
7,c7 ,fail+ to adopt & implem5t         
reasonable /&>ds = ! prompt inve/igation
 & settlem5t ( claims aris+ "u policies4

  7,d7 ,fail+ to effectuate prompt1     
fair1 & equitable settlem5t ( claims    
submitt$ 9 :i* liability has become     
reasonably cle>4  7,e7 ,refus+ to pay   
claims )\t conduct+ a reasonable        
inve/igation4  7,f7 ,fail+ to affirm or 
d5y cov]age ( claims )9 a reasonable    
p]iod ( "t aft] hav+ complet$ an        
inve/igation relat$ to ^? claims4  7,g7 
,a patt]n or practice ( compell+ insur$ 
individuals or _! b5efici>ies to        
in/itute suits to recov] am\nts due "u  
its policies by (f]+ sub/antially less  
?an ! am\nts ultimately recov]$ 9 suits 
br\ght by !m4  7,h7 ,a patt]n or        
practice ( attempt+ to settle or settl+ 
claims = less ?an ! am\nt t a reasonable
 p]son w\ld believe ! insur$ individual 
or 8 or h] b5efici>y 0 entitl$ by       
ref]5ce to writt5 or pr9t$ adv]tis+     
mat]ial accompany+ or made "p ( an      
application4  7,i7 ,attempt+ to settle  
or settl+ claims on ! basis ( an        
application t 0 mat]ially alt]$ )\t     
notice to1 or k or cons5t (1 ! insur$4  

7,j7 ,fail+ to provide =ms necess>y to  
pres5t claims )9 #ae cal5d> days ( a    
reque/ ) reasonable explanations reg>d+ 
_! use4  7,k7 ,attempt+ to cancel a     
policy 9 less "t ?an t prescrib$ 9 !    
policy or by ! law ( ! prim>y ,/ate4    
7#aj7 ,fraud & abuse ,! t]m fraud &     
abuse means an act or omission committ$ 
by a p]son :o1 kn[+ly & ) int5t to      
defraud1 commits1 or conceals any       
mat]ial in=mation conc]n+1 "o or m ( !  
foll[+3 7,a7 ,pres5t+1 caus+ to be      
pres5t$ or prep>+ ) k or belief t x w be
 pres5t$ to or by an insur]1 a re9sur]1 
brok] or its ag5t1 false in=mation z "p 
(1 9 support ( or conc]n+ a fact mat]ial
 to "o or m ( ! foll[+3 7i7 ,an         
application = ! issuance or r5ewal ( an 
insurance policy or re9surance contract4
  7ii7 ,! rat+ ( an insurance policy or 
re9surance contract4  7iii7 ,a claim =  
paym5t or b5efit pursuant to an         
insurance policy or re9surance contract4
  7iv7 ,premiums paid on an insurance   
policy or re9surance contract4  7v7     

,paym5ts made 9 accordance ) ! t]ms ( an
 insurance policy or re9surance         
contract4  7vi7 ,a docum5t fil$ ) !     
commission] or ! *ief insurance         
regulatory (ficial ( ano!r jurisdiction4
  7vii7 ,! f9ancial condition ( an      
insur] or re9sur]4  7viii7 ,! =mation1  
acquisition1 m]g]1 reconsolidation1     
dissolution or )drawal f "o or m l9es ( 
insurance or re9surance 9 all or "p ( a 
,/ate by an insur] or re9sur]4  7ix7 ,! 
issuance ( writt5 evid5ce ( insurance4  
7x7 ,! re9/atem5t ( an insurance policy4
  7,b7 ,solicitation or acceptance ( new
 or r5ewal insurance risks on behalf (  
an insur] re9sur] or o!r p]son engag$ 9 
! bus9ess ( insurance by a p]son :o kn[s
 or %\ld "k t ! insur] or o!r p]son     
responsible = ! risk is insolv5t at ! "t
 ( ! transaction4  7,c7 ,transaction ( !
 bus9ess ( insurance 9 violation ( laws 
requir+ a lic5se1 c]tificate ( au?ority 
or o!r legal au?ority = ! transaction ( 
! bus9ess ( insurance4  7,d7 ,attempt to
 commit1 aid+ or abett+ 9 ! commission  

(1 or conspiracy to commit ! acts or    
omissions specifi$ 9 ?is p>agraph4      
#bgif4 ,application ( law  7a7 ,9 ,g5]al
 ,! cov]$ laws ( ! prim>y ,/ate %all    
apply to individual heal? insurance     
cov]age (f]$ by a heal? insurance issu] 
9 ! prim>y ,/ate & 9 any second>y ,/ate1
 b only if ! cov]age & issu] comply ) ! 
conditions ( ?is section ) respect to ! 
(f]+ ( cov]age 9 any second>y ,/ate4    
7b7 ,exemptions ,f ,cov]$ ,laws 9 a     
,second>y ,/ate ,except z provid$ 9 ?is 
section1 a heal? insurance issu] )      
respect to its (f]1 sale1 rat+ 7includ+ 
m$ical und]writ+71 r5ewal1 & issuance ( 
individual heal? insurance cov]age 9 any
 second>y ,/ate is exempt f any cov]$   
laws ( ! second>y ,/ate 7& any rules1   
regulations1 agreem5ts1 or ord]s s\ght  
or issu$ by su* ,/ate "u or relat$ to   
su* cov]$ laws7 to ! ext5t t su* laws   
w\ld-- 7#a7 make unlawful1 or regulate1 
directly or indirectly1 ! op]ation ( !  
heal? insurance issu] op]at+ 9 !        
second>y ,/ate1 except t any second>y   

,/ate may require su* an issu]-- 7,a7 to
 pay1 on a nondiscrim9atory basis1      
applicable premium & o!r taxes 7includ+ 
high risk pool assessm5ts7 :i* are levi$
 on insur]s & surplus l9es insur]s1     
brok]s1 or policyhold]s "u ! laws ( !   
,/ate2  7,b7 to regi/] ) & designate !  
,/ate insurance commission] z its ag5t  
solely = ! purpose ( receiv+ s]vice (   
legal docum5ts or process2  7,c7 to     
submit to an exam9ation ( its f9ancial  
condition by ! ,/ate insurance          
commission] 9 any ,/ate 9 :i* ! issu] is
 do+ bus9ess to det]m9e ! issu]'s       
f9ancial condition1 if-- 7i7 ! ,/ate    
insurance commission] ( ! prim>y ,/ate  
has n done an exam9ation )9 ! p]iod     
recomm5d$ by ! ,national ,association ( 
,insurance ,commission]s2 &  7ii7 any   
su* exam9ation is conduct$ 9 accordance 
) ! exam9]s' h&book ( ! ,national       
,association ( ,insurance ,commission]s 
& is coord9at$ to avoid unju/ifi$       
duplication & unju/ifi$ repetition2     
7,d7 to comply ) a lawful ord] issu$--  

7i7 9 a del9qu5cy proce$+ comm5c$ by !  
,/ate insurance commission] if !re has  
be5 a f9d+ ( f9ancial impairm5t "u      
subp>agraph 7,c72 or  7ii7 9 a volunt>y 
dissolution proce$+2  7,e7 to comply )  
an injunction issu$ by a c\rt ( compet5t
 jurisdiction1 ^u a petition by ! ,/ate 
insurance commission] alleg+ t ! issu]  
is 9 haz>d\s f9ancial condition2  7,f7  
to p>ticipate1 on a nondiscrim9atory    
basis1 9 any insurance insolv5cy gu>anty
 association or simil> association to   
:i* a heal? insurance issu] 9 ! ,/ate is
 requir$ to belong2  7,g7 to comply )   
any ,/ate law reg>d+ fraud & abuse 7z   
def9$ 9 section #bgie7aj771 except t if 
! ,/ate seeks an injunction reg>d+ !    
conduct describ$ 9 ?is subp>agraph1 su* 
injunction mu/ be obta9$ f a c\rt (     
compet5t jurisdiction2  7,h7 to comply )
 any ,/ate law reg>d+ unfair claims     
settlem5t practices 7z def9$ 9 section  
#bgie7i772 or  7,i7 to comply ) !       
applicable requirem5ts = indep5d5t      
review "u section #bgih ) respect to    

cov]age (f]$ 9 ! ,/ate2  7#b7 require   
any individual heal? insurance cov]age  
issu$ by ! issu] to be c\nt]sign$ by an 
insurance ag5t or brok] resid+ 9 t      
,second>y ,/ate2 or  7#c7 o!rwise       
discrim9ate aga9/ ! issu] issu+         
insurance 9 bo? ! prim>y ,/ate & 9 any  
second>y ,/ate4  7c7 ,cle> & ,conspicu\s
 ,disclosure ,a heal? insurance issu]   
%all provide ! foll[+ notice1 9 #ab-po9t
 bold type1 9 any insurance cov]age (f]$
 9 a second>y ,/ate "u ?is "p by su* a  
heal? insurance issu] & at r5ewal ( !   
policy1 ) ! #e blank spaces !re9 be+    
appropriately fill$ ) ! "n ( ! heal?    
insurance issu]1 ! "n ( prim>y ,/ate1 ! 
"n ( ! second>y ,/ate1 ! "n ( ! second>y
 ,/ate1 & ! "n ( ! second>y ,/ate1      
respectively1 = ! cov]age conc]n$3 ,?is 
policy is issu$ by  & is gov]n$ by !    
laws & regulations ( ! ,/ate ( 1 & x has
 met all ! laws ( t ,/ate z det]m9$ by t
 ,/ate's ,dep>tm5t ( ,insurance4 ,?is   
policy may be less exp5sive ?an o!rs    
because x is n subject to all ( !       

insurance laws & regulations ( ! ,/ate (
 1 includ+ cov]age ( "s s]vices or      
b5efits m&at$ by ! law ( ! ,/ate ( 4    
,additionally1 ?is policy is n subject  
to all ( ! consum] protection laws or   
re/rictions on rate *anges ( ! ,/ate ( 4
 ,z ) all insurance products1 be=e      
pur*as+ ?is policy1 y %\ld c>efully     
review ! policy & det]m9e :at heal? c>e 
s]vices ! policy cov]s & :at b5efits x  
provides1 includ+ any exclusions1       
limitations1 or conditions = su* s]vices
 or b5efits4  7d7 ,prohibition on ,c]ta9
 ,reclassifications & ,premium          
,increases  7#a7 ,9 g5]al ,= purposes ( 
?is section1 a heal? insurance issu] t  
provides individual heal? insurance     
cov]age to an individual "u ?is "p 9 a  
prim>y or second>y ,/ate may n ^u       
r5ewal-- 7,a7 move or reclassify !      
individual insur$ "u ! heal? insurance  
cov]age f ! class su* individual is 9 at
 ! "t ( issue ( ! contract bas$ on !    
heal?-/atus relat$ factors ( !          
individual2 or  7,b7 increase ! premiums

 assess$ ! individual = su* cov]age bas$
 on a heal? /atus-relat$ factor or *ange
 ( a heal? /atus-relat$ factor or ! pa/ 
or prospective claim exp]i5ce ( ! insur$
 individual4  7#b7 ,con/ruction ,no?+ 9 
p>agraph 7#a7 %all be con/ru$ to        
prohibit a heal? insurance issu]-- 7,a7 
f t]m9at+ or discont9u+ cov]age or a    
class ( cov]age 9 accordance )          
subsections 7b7 & 7c7 ( section #bgdb2  
7,b7 f rais+ premium rates = all policy 
hold]s )9 a class bas$ on claims        
exp]i5ce2  7,c7 f *ang+ premiums or (f]+
 disc\nt$ premiums to individuals :o    
engage 9 wellness activities at int]vals
 prescrib$ by ! issu]1 if su* premium   
*anges or inc5tives-- 7i7 are disclos$  
to ! consum] 9 ! insurance contract2    
7ii7 are bas$ on specific wellness      
activities t are n applicable to all    
individuals2 &  7iii7 are n obta9able by
 all individuals to :om cov]age is (f]$2
  7,d7 f re9/at+ laps$ cov]age2 or  7,e7
 f retroactively adju/+ ! rates *>g$ an 
insur$ individual if ! initial rates 7  

set bas$ on mat]ial misrepres5tation by 
! individual at ! "t ( issue4  7e7      
,prior ,(f]+ ( ,policy 9 ,prim>y ,/ate  
,a heal? insurance issu] may n (f] =    
sale individual heal? insurance cov]age 
9 a second>y ,/ate unless t cov]age is  
curr5tly (f]$ = sale 9 ! prim>y ,/ate4  
7f7 ,lic5s+ ( ,ag5ts or ,brok]s = ,heal?
 ,insurance ,issu]s ,any ,/ate may      
require t a p]son act+1 or (f]+ to act1 
z an ag5t or brok] = a heal? insurance  
issu] ) respect to ! (f]+ ( individual  
heal? insurance cov]age obta9 a lic5se f
 t ,/ate1 ) commissions or o!r          
comp5sation subject to ! provisions ( ! 
laws ( t ,/ate1 except t a ,/ate may n  
impose any qualification or requirem5t  
:i* discrim9ates aga9/ a nonresid5t ag5t
 or brok]4  7g7 ,docum5ts = ,submission 
to ,/ate ,insurance ,commission] ,ea*   
heal? insurance issu] issu+ individual  
heal? insurance cov]age 9 bo? prim>y &  
second>y ,/ates %all submit-- 7#a7 to ! 
insurance commission] ( ea* ,/ate 9 :i* 
x int5ds to (f] su* cov]age1 be=e x may 

(f] individual heal? insurance cov]age 9
 su* ,/ate-- 7,a7 a copy ( ! plan (     
op]ation or feasibility /udy or any     
simil> /atem5t ( ! policy be+ (f]$ & its
 cov]age 7:i* %all include ! "n ( its   
prim>y ,/ate & its pr9cipal place (     
bus9ess72  7,b7 writt5 notice ( any     
*ange 9 its designation ( its prim>y    
,/ate2 &  7,c7 writt5 notice f ! issu] (
 ! issu]'s compliance ) all ! laws ( !  
prim>y ,/ate2 &  7#b7 to ! insurance    
commission] ( ea* second>y ,/ate 9 :i* x
 (f]s individual heal? insurance        
cov]age1 a copy ( ! issu]'s qu>t]ly     
f9ancial /atem5t submitt$ to ! prim>y   
,/ate1 :i* /atem5t %all be c]tifi$ by an
 indep5d5t public acc\ntant & conta9 a  
/atem5t ( op9ion on loss & loss adju/m5t
 exp5se res]ves made by-- 7,a7 a memb] (
 ! ,am]ican ,academy ( ,actu>ies2 or    
7,b7 a qualifi$ loss res]ve speciali/4  
7h7 ,p[] ( ,c\rts ,to ,enjo9 ,conduct   
,no?+ 9 ?is section %all be con/ru$ to  
affect ! au?ority ( any ,f$]al or ,/ate 
c\rt to enjo9-- 7#a7 ! solicitation or  

sale ( individual heal? insurance       
cov]age by a heal? insurance issu] to   
any p]son or gr\p :o is n eligible = su*
 insurance2 or  7#b7 ! solicitation or  
sale ( individual heal? insurance       
cov]age t violates ! requirem5ts ( ! law
 ( a second>y ,/ate :i* are describ$ 9  
subp>agraphs 7,a7 ?r\gh 7,h7 ( section  
#bgif7;b77#a74  7i7 ,p[] ( ,second>y    
,/ates ,to ,take ,adm9i/rative ,action  
,no?+ 9 ?is section %all be con/ru$ to  
affect ! au?ority ( any ,/ate to enjo9  
conduct 9 violation ( t ,/ate's laws    
describ$ 9 section #bgif7;b77#a74  7j7  
,/ate ,p[]s ,to ,en=ce ,/ate ,laws  7#a7
 ,9 g5]al ,subject to ! provisions (    
subsection 7b77#a77;,g7 7relat+ to      
injunctions7 & p>agraph 7#b71 no?+ 9 ?is
 section %all be con/ru$ to affect !    
au?ority ( any ,/ate to make use ( any (
 its p[]s to en=ce ! laws ( su* ,/ate ) 
respect to :i* a heal? insurance issu]  
is n exempt "u subsection 7b74  7#b7    
,c\rts ( compet5t jurisdiction ,if a    
,/ate seeks an injunction reg>d+ !      

conduct describ$ 9 p>agraphs 7#a7 & 7#b7
 ( subsection 7h71 su* injunction mu/ be
 obta9$ f a ,f$]al or ,/ate c\rt (      
compet5t jurisdiction4  7k7 ,/ates'     
,au?ority ,to ,sue ,no?+ 9 ?is section  
%all affect ! au?ority ( any ,/ate to   
br+ action 9 any ,f$]al or ,/ate c\rt4  
7l7 ,g5]ally ,applicable ,laws ,no?+ 9  
?is section %all be con/ru$ to affect ! 
applicability ( ,/ate laws g5]ally      
applicable to p]sons or corporations4   
7m7 ,gu>ante$ ,availability ( ,cov]age  
to ,,hipaa ,eligible ,individuals ,to ! 
ext5t t a heal? insurance issu] is (f]+ 
cov]age 9 a prim>y ,/ate t does n       
accommodate resid5ts ( second>y ,/ates  
or does n provide a work+ me*anism =    
resid5ts ( a second>y ,/ate1 & ! issu]  
is (f]+ cov]age "u ?is "p 9 su* second>y
 ,/ate :i* has n adopt$ a qualifi$ high 
risk pool z its acceptable alt]native   
me*anism 7z def9$ 9 section             
#bgdd7;c77#b771 ! issu] %all1 ) respect 
to any individual heal? insurance       
cov]age (f]$ 9 a second>y ,/ate "u ?is  

"p1 comply ) ! gu>ante$ availability    
requirem5ts = eligible individuals 9    
section #bgda4  #bgig4 ,prim>y ,/ate mu/
 meet ,f$]al floor be=e issu] may sell  
into second>y ,/ates ,a heal? insurance 
issu] may n (f]1 sell1 or issue         
individual heal? insurance cov]age 9 a  
second>y ,/ate if ! ,/ate insurance     
commission] does n use a risk-bas$      
capital =mula = ! det]m9ation ( capital 
& surplus requirem5ts = all heal?       
insurance issu]s4  #bgih4 ,indep5d5t    
ext]nal appeals proc$ures  7a7 ,"r to   
,ext]nal ,appeal ,a heal? insurance     
issu] may n (f]1 sell1 or issue         
individual heal? insurance cov]age 9 a  
second>y ,/ate "u ! provisions ( ?is    
title unless-- 7#a7 bo? ! second>y ,/ate
 & ! prim>y ,/ate h legislation or      
regulations 9 place e/abli%+ an         
indep5d5t review process = individuals  
:o are cov]$ by individual heal?        
insurance cov]age1 or  7#b7 9 any case 9
 :i* ! requirem5ts ( subp>agraph 7,a7   
are n met ) respect to ! ei!r ( su*     

,/ates1 ! issu] provides an indep5d5t   
review me*anism sub/antially id5tical 7z
 det]m9$ by ! applicable ,/ate au?ority 
( su* ,/ate7 to t prescrib$ 9 ! ,heal?  
,c>ri] ,ext]nal ,review ,model ,act ( ! 
,national ,association ( ,insurance     
,commission]s = all individuals :o      
pur*ase insurance cov]age "u ! t]ms (   
?is "p1 except t1 "u su* me*anism1 !    
review is conduct$ by an indep5d5t      
m$ical review]1 or a panel ( su*        
review]s1 ) respect to :om ! requirem5ts
 ( subsection 7b7 are met4  7b7         
,qualifications ( ,indep5d5t ,m$ical    
,review]s ,9 ! case ( any indep5d5t     
review me*anism ref]r$ to 9 subsection  
7a77#b7-- 7#a7 ,9 g5]al ,9 ref]r+ a     
d5ial ( a claim to an indep5d5t m$ical  
review]1 or to any panel ( su* review]s1
 to conduct indep5d5t m$ical review1 !  
issu] %all ensure t-- 7,a7 ea* indep5d5t
 m$ical review] meets ! qualifications  
describ$ 9 p>agraphs 7#b7 & 7#c72  7,b7 
) respect to ea* review1 ea* review]    
meets ! requirem5ts ( p>agraph 7#d7 & ! 

review]1 or at lea/ #a review] on !     
panel1 meets ! requirem5ts describ$ 9   
p>agraph 7#e72 &  7,c7 comp5sation      
provid$ by ! issu] to ea* review] is    
consi/5t ) p>agraph 7#f74  7#b7         
,lic5sure & exp]tise ,ea* indep5d5t     
m$ical review] %all be a physician      
7allopa?ic or o/eopa?ic7 or heal? c>e   
pr(essional :o-- 7,a7 is appropriately  
cr$5tial$ or lic5s$ 9 #a or m ,/ates to 
deliv] heal? c>e s]vices2 &  7,b7       
typically treats ! condition1 makes !   
diagnosis1 or provides ! type ( treatm5t
 "u review4  7#c7 ,indep5d5ce  7,a7 ,9  
g5]al ,subject to subp>agraph 7,b71 ea* 
indep5d5t m$ical review] 9 a case %all--
 7i7 n be a relat$ p>ty 7z def9$ 9      
p>agraph 7#g772  7ii7 n h a mat]ial     
familial1 f9ancial1 or pr(essional      
relation%ip ) su* a p>ty2 &  7iii7 n    
o!rwise h a conflict ( int]e/ ) su* a   
p>ty 7z det]m9$ "u regulations74  7,b7  
,exception ,no?+ 9 subp>agraph 7,a7 %all
 be con/ru$ to-- 7i7 prohibit an        
individual1 solely on ! basis (         

affiliation ) ! issu]1 f s]v+ z an      
indep5d5t m$ical review] if-- 7,i7 a    
non-affiliat$ individual is n reasonably
 available2  7,,ii7 ! affiliat$         
individual is n involv$ 9 ! provision ( 
items or s]vices 9 ! case "u review2    
7,,iii7 ! fact ( su* an affiliation is  
disclos$ to ! issu] & ! enrollee 7or    
au?oriz$ repres5tative7 & nei!r p>ty    
objects2 &  7,,iv7 ! affiliat$          
individual is n an employee ( ! issu] & 
does n provide s]vices exclusively or   
prim>ily to or on behalf ( ! issu]2     
7ii7 prohibit an individual :o has /aff 
privileges at ! in/itution :]e !        
treatm5t involv$ takes place f s]v+ z an
 indep5d5t m$ical review] m]ely on !    
basis ( su* affiliation if ! affiliation
 is disclos$ to ! issu] & ! enrollee 7or
 au?oriz$ repres5tative71 & nei!r p>ty  
objects2 or  7iii7 prohibit receipt (   
comp5sation by an indep5d5t m$ical      
review] f an entity if ! comp5sation is 
provid$ consi/5t ) p>agraph 7#f74  7#d7 
,practic+ heal? c>e pr(essional 9 same  

field  7,a7 ,9 g5]al ,9 a case involv+  
treatm5t1 or ! provision ( items or     
s]vices-- 7i7 by a physician1 a review] 
%all be a practic+ physician 7allopa?ic 
or o/eopa?ic7 ( ! same or simil>        
specialty1 z a physician :o1 act+ )9 !  
appropriate scope ( practice )9 ! ,/ate 
9 :i* ! s]vice is provid$ or r5d]$1     
typically treats ! condition1 makes !   
diagnosis1 or provides ! type ( treatm5t
 "u review2 or  7ii7 by a non-physician 
heal? c>e pr(essional1 ! review]1 or at 
lea/ #a memb] ( ! review panel1 %all be 
a practic+ non-physician heal? c>e      
pr(essional ( ! same or simil> specialty
 z ! non-physician heal? c>e pr(essional
 :o1 act+ )9 ! appropriate scope (      
practice )9 ! ,/ate 9 :i* ! s]vice is   
provid$ or r5d]$1 typically treats !    
condition1 makes ! diagnosis1 or        
provides ! type ( treatm5t "u review4   
7,b7 ,practic+ def9$ ,= purposes ( ?is  
p>agraph1 ! t]m practic+ means1 )       
respect to an individual :o is a        
physician or o!r heal? c>e pr(essional1 

t ! individual provides heal? c>e       
s]vices to individual pati5ts on av]age 
at lea/ #b days p] week4  7#e7 ,p$iatric
 exp]tise ,9 ! case ( an ext]nal review 
relat+ to a *ild1 a review] %all h      
exp]tise "u p>agraph 7#b7 9 p$iatrics4  
7#f7 ,limitations on review] comp5sation
 ,comp5sation provid$ by ! issu] to an  
indep5d5t m$ical review] 9 connection ) 
a review "u ?is section %all-- 7,a7 n   
exce$ a reasonable level2 &  7,b7 n be  
cont+5t on ! decision r5d]$ by !        
review]4  7#g7 ,relat$ p>ty def9$ ,=    
purposes ( ?is section1 ! t]m relat$    
p>ty means1 ) respect to a d5ial ( a    
claim "u a cov]age relat+ to an         
enrollee1 any ( ! foll[+3 7,a7 ,! issu] 
involv$1 or any fiduci>y1 (fic]1        
director1 or employee ( ! issu]4  7,b7  
,! enrollee 7or au?oriz$ repres5tative74
  7,c7 ,! heal? c>e pr(essional t       
provides ! items or s]vices involv$ 9 ! 
d5ial4  7,d7 ,! in/itution at :i* !     
items or s]vices 7or treatm5t7 involv$ 9
 ! d5ial are provid$4  7,e7 ,!          

manufactur] ( any drug or o!r item t is 
includ$ 9 ! items or s]vices involv$ 9 !
 d5ial4  7,f7 ,any o!r p>ty det]m9$ "u  
any regulations to h a sub/antial int]e/
 9 ! d5ial involv$4  7#h7 ,def9itions ,=
 purposes ( ?is subsection3 7,a7        
,enrollee ,! t]m enrollee means1 )      
respect to heal? insurance cov]age (f]$ 
by a heal? insurance issu]1 an          
individual enroll$ ) ! issu] to receive 
su* cov]age4  7,b7 ,heal? c>e           
pr(essional ,! t]m heal? c>e pr(essional
 means an individual :o is lic5s$1      
accr$it$1 or c]tifi$ "u ,/ate law to    
provide specifi$ heal? c>e s]vices & :o 
is op]at+ )9 ! scope ( su* lic5sure1    
accr$itation1 or c]tification4  #bgii4  
,en=cem5t  7a7 ,9 ,g5]al ,subject to    
subsection 7b71 ) respect to specific   
individual heal? insurance cov]age !    
prim>y ,/ate = su* cov]age has sole     
jurisdiction to en=ce ! prim>y ,/ate's  
cov]$ laws 9 ! prim>y ,/ate & any       
second>y ,/ate4  7b7 ,second>y ,/ate's  
,au?ority ,no?+ 9 subsection 7a7 %all be

 con/ru$ to affect ! au?ority ( a       
second>y ,/ate to en=ce its laws z set  
=? 9 ! exception specifi$ 9 section     
#bgif7;b77#a74  7c7 ,c\rt ,int]pretation
 ,9 review+ action initiat$ by !        
applicable second>y ,/ate au?ority1 !   
c\rt ( compet5t jurisdiction %all apply 
! cov]$ laws ( ! prim>y ,/ate4  7d7     
,notice ( ,compliance ,failure ,9 ! case
 ( individual heal? insurance cov]age   
(f]$ 9 a second>y ,/ate t fails to      
comply ) ! cov]$ laws ( ! prim>y ,/ate1 
! applicable ,/ate au?ority ( ! second>y
 ,/ate may notify ! applicable ,/ate    
au?ority ( ! prim>y ,/ate4  4  7b7      
,effective ,date ,! am5dm5t made by     
subsection 7a7 %all apply to individual 
heal? insurance cov]age (f]$1 issu$1 or 
sold aft] ! date t is "o ye> aft] ! date
 ( ! enactm5t ( ?is ,act4  7c7 ,,gao    
,ongo+ ,/udy & ,reports  7#a7 ,/udy ,!  
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all conduct an ongo+ /udy conc]n+ !    
effect ( ! am5dm5t made by subsection   
7a7 on-- 7,a7 ! numb] ( un9sur$ &       

"u-insur$2  7,b7 ! availability & co/ ( 
heal? insurance policies = individuals )
 preexi/+ m$ical conditions2  7,c7 !    
availability & co/ ( heal? insurance    
policies g5]ally2  7,d7 ! elim9ation or 
r$uction ( diff]5t types ( b5efits "u   
heal? insurance policies (f]$ 9 diff]5t 
,/ates2 &  7,e7 cases ( fraud or abuse  
relat+ to heal? insurance cov]age (f]$  
"u su* am5dm5t & ! resolution ( su*     
cases4  7#b7 ,annual reports ,!         
,comptroll] ,g5]al %all submit to       
,congress an annual report1 aft] ! end (
 ea* ( ! #e ye>s foll[+ ! effective date
 ( ! am5dm5t made by subsection 7a71 on 
! ongo+ /udy conduct$ "u p>agraph 7#a74