,i  #aad? ,,congress  #a/ ,session  ,h4 
,r4 #bgef  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,june #ab1 #bjae ,mr4 
,abraham introduc$ ! foll[+ bill2 :i* 0 
ref]r$ to ! ,committee on ,en]gy &      
,comm]ce1 & 9 addition to ! ,committees 
on ,ways & ,means & ,education & !      
,work=ce1 = a p]iod to be subsequ5tly   
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to re=m ! provision ( heal?   
insurance cov]age by promot+ heal? sav+s
 acc\nts1 ,/ate-bas$ alt]natives to     
cov]age "u ! ,af=dable ,c>e ,act1 &     
price transp>5cy1 9 ord] to promote a m 
m>ket-bas$ heal? c>e sy/em1 & = o!r     
purposes4  #a4 ,%ort title2 table (     
cont5ts  7a7 ,%ort title ,?is ,act may  
be cit$ z ! ,pati5t ,fre$om ,act (      
#bjae4  7b7 ,table ( cont5ts ,! table ( 
cont5ts = ?is ,act is z foll[s3  ,sec4  
#a4 ,%ort title2 table ( cont5ts4 ,sec4 
#b4 ,s5se ( ,congress4 ,title ,i--,heal?
 ,re=m ,sec4 #ajj4 ,def9itions4         

,subtitle ,a--,insurance ,re=ms ,sec4   
#aja4 ,/ate options 9 response to       
,burwell decision4 ,sec4 #ajb4 ,/ate    
alt]native option4 ,sec4 #ajc4          
,computation ( mon?ly ,,hsa deposit     
am\nt = deposit qualify+ resid5ts4 ,sec4
 #ajd4 ,/ate options = improv$ access to
 heal? insurance cov]age 9 ea* ,/ate4   
,sec4 #aje4 ,exp&$ access & pati5t      
protections4 ,sec4 #ajf4 ,sunsett+ c]ta9
 ,,aca provisions2 cont9uation (        
policies ( cov]+ adult *ildr5 & n apply+
 lifetime or annual limits4 ,subtitle   
,b--,m$icaid ,sec4 #aaa4 ,application ( 
heal? sav+s acc\nts 9 relation to       
,m$icaid4 ,subtitle ,c--,provid] ,price 
,transp>5cy ,sec4 #aba4 ,ensur+ access  
to em]g5cy s]vices )\t excessive *>ges =
 out-(-network s]vices4 ,title          
,,ii--,re=m ( ,tax ,provisions ,relat+  
to ,heal? ,c>e ,subtitle ,a--,promotion 
( ,heal? ,sav+s ,acc\nts ,sec4 #bja4    
,repeal ( high d$uctible heal? plan     
requirem5t4 ,sec4 #bjb4 ,treatm5t (     
,,hsa aft] dea? ( acc\nt b5efici>y4     

,sec4 #bjc4 ,pur*ase ( heal? insurance f
 ,,hsa acc\nt4 ,sec4 #bjd4 ,publi%+ (   
ca% price = c>e paid ?r\gh heal? sav+s  
acc\nts4 ,subtitle ,b--,heal? ,c>e ,tax 
cr$its ,sec4 #baa4 ,limit$ application (
 ,,ppaca heal? premium cr$it4 ,sec4     
#bab4 ,new ,,hsa cr$it4  #b4 ,s5se (    
,congress ,x is ! s5se ( ,congress t !re
 is a ne$ = legislation provid+ tempor>y
 transition fund+ = ^? :o lose heal?    
insurance subsidies 9 ! aft]ma? ( a     
,supreme ,c\rt decision 9 favor ( !     
pla9tiffs-appellants 9 ! case ( ,k+ v4  
,burwell4  ,i ,heal? ,re=m  #ajj4       
,def9itions ,9 ?is title3 7#a7          
,pati5t-grant elect+ ,/ate ,! t]m       
pati5t-grant elect+ ,/ate means an      
elect+ ,/ate t specifies "u section     
#ajb7;a77#d77;,b7 t x w c>ry out section
 #ajb7;b7 itself 7& n to h section      
#ajb7;b7 c>ri$ out by means ( ! cr$it "u
 section #cf;,c ( ! ,int]nal ,rev5ue    
,code ( #aihf74  7#b7 ,,*ip ,! t]m ,,*ip
 means ! *ildr5's heal? insurance       
program e/abli%$ "u title ,,xxi ( !     

,social ,security ,act 7#db ,u4,s4,c4   
#acif et seq474  7#c7 ,cr$itable cov]age
 ,! t]m cr$itable cov]age has ! mean+   
giv5 su* t]m 9 section #bgjd7;c77#a7 ( !
 ,public ,heal? ,s]vice ,act 7#db       
,u4,s4,c4 #cjj;gg-#c7;c77#a771 z 9      
effect z ( ! day be=e ! date ( !        
enactm5t ( ?is ,act4  7#d7 ,default     
heal? insurance cov]age ,! t]m default  
heal? insurance cov]age has ! mean+ giv5
 su* t]m 9 section #ajd7;c77#b74  7#e7  
,deposit qualify+ resid5t ,! t]m deposit
 qualify+ resid5t has ! mean+ giv5 su*  
t]m 9 section #ajb7;b77#b74  7#f7       
,elect+ /ate ,! t]m elect+ ,/ate means a
 ,/ate t elects "u section #aja7;a77#c7 
! alt]native option describ$ 9 section  
#ajb4  7#g7 ,heal? insurance cov]age ,! 
t]m heal? insurance cov]age has ! mean+ 
giv5 su* t]m 9 section #bgia7;b77#a7 ( !
 ,public ,heal? ,s]vice ,act 7#db       
,u4,s4,c4 #cjj;gg-#ia7;b77#a774  7#h7   
,heal? sav+s acc\nt2 ,,hsa ,! t]ms heal?
 sav+s acc\nt & ,,hsa mean a heal? sav+s
 acc\nt e/abli%$ "u section #bbc ( !    

,int]nal ,rev5ue ,code ( #aihf4  7#i7   
,heal? sav+s deposit ,! t]m heal? sav+s 
deposit means a deposit made into a     
heal? sav+s acc\nt pursuant to section  
#ajb4  7#aj7 ,m$icaid ,! t]m ,m$icaid   
means ! program "u title ,,xix ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acif et seq474  7#aa7 ,m$ic>e ,! t]m   
,m$ic>e means ! program "u "p ,a or ,b (
 title ,,xviii ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acie et seq474     
7#ab7 ,,ppaca ,! t]m ,,ppaca means !    
,pati5t ,protection & ,af=dable ,c>e    
,act 7,public ,law #aaa-adh71 z 9 effect
 be=e ! date ( ! enactm5t ( ?is ,act1   
unless o!rwise specifi$4  7#ac7         
,qualifi$ heal? plan cov]age ,! t]m     
qualifi$ heal? plan cov]age means1 )    
respect to resid5ts ( a ,/ate1 heal?    
insurance cov]age t meets applicable    
/&>ds "u ,/ate law1 :i* /&>ds ne$ n be !
 same z t previ\sly requir$ ( qualifi$  
heal? plans "u title ,i ( ,,ppaca1 &    
includes a high d$uctible heal? plan 7z 
def9$ 9 section #bbc7;c77#b7 ( !        

,int]nal ,rev5ue ,code ( #aihf7 &       
includes cov]age "u a gr\p heal? plan4  
7#ad7 ,qualifi$ resid5t ,! t]m qualifi$ 
resid5t means1 ) respect to a ,/ate = a 
mon?1 an individual :o is a resid5t ( ! 
,/ate z ( ! fir/ day ( ! mon? & is a    
citiz5 or national ( ! ,unit$ ,/ates or 
o!rwise lawfully resid+ 9 ! ,/ate "u    
color ( law4  7#ae7 ,secret>y ,! t]m    
,secret>y means ! ,secret>y ( ,heal? &  
,human ,s]vices4  7#af7 ,/ate ,! t]m    
,/ate means ! #ej ,/ates & ! ,di/rict ( 
,columbia4  7#ag7 ,un9sur$ ,! t]m       
un9sur$ means1 ) respect to an          
individual1 t ! individual does n h     
cr$itable cov]age4  ,a ,insurance ,re=ms
  #aja4 ,/ate options 9 response to     
,burwell decision  7a7 ,9 g5]al ,ea*    
,/ate may elect1 ?r\gh writt5 notice to 
! ,secret>y aft] ! date ( ! enactm5t (  
?is ,act & 9 accordance ) ?is subtitle1 
"o ( ! foll[+ ?ree options 9 relation to
 ! implem5tation ( title ,i ( ! ,pati5t 
,protection & ,af=dable ,c>e ,act aft] !
 decision ( ! ,supreme ,c\rt 9 ,k+ v4   

,burwell3  7#a7 ,cont9u+ implem5tation (
 ,,ppaca1 includ+ ,f$]al subsidies ?r\gh
 a ,/ate-e/abli%$ ,ex*ange ,"u curr5t   
law1 ! ,/ate e/abli%+ a heal? insurance 
,ex*ange "u title ,i ( ,,ppaca1 :i*     
!reby p]mits ! cont9uation ( ,f$]al     
premium & co/-%>+ subsidies = cov]age   
(f]$ ?r\gh ! ,ex*ange z well z          
cont9uation ( insurance & o!r           
requirem5ts "u su* title4  7#b7         
,rejection ( ,,ppaca1 includ+ elim9ation
 ( ,f$]al subsidies n[ provid$ ?r\gh    
,f$]ally e/abli%$ ,ex*ange ,"u curr5t   
law1 ! ,/ate n e/abli%+ su* an ,ex*ange1
 pot5tially result+1 po/-,burwell1 9 !  
loss ( su* ,f$]al premium & co/-%>+     
subsidies & ! cont9u$ application ( o!r 
requirem5ts "u su* title4  7#c7         
,e/abli%+ new ,/ate & m>ket-bas$        
alt]native1 ) alt]native p] capita      
,f$]al deposit sy/em ,! ,/ate implem5t+ 
! alt]native option describ$ 9 section  
#ajb1 :i* includes-- 7,a7 ! waiv] ( mo/ 
requirem5ts impos$ "u su* title2 &  7,b7
 ! provision ( a new1 ,,hsa- &          

m>ket-bas$ deposit sy/em = individuals  
:o d n o!rwise qualify = ,f$]al or ,/ate
 subsidies = heal? b5efits cov]age4  ,if
 a ,/ate fails to make an election      
describ$ 9 ?is subsection1 ! ,/ate %all 
be deem$ to h made ! election describ$ 9
 p>agraph 7#b74 ,a ,/ate may1 ?r\gh     
writt5 notice to ! ,secret>y1 *ange an  
election previ\sly made "u ?is          
subsection4  7b7 ,relation to curr5t    
,m$icaid ,,aca cov]age option ,no?+ 9   
?is section %all be con/ru$ to *ange !  
option ( a ,/ate ) respect to !         
implem5tation ( ,m$icaid ,,aca cov]age  
"u section                              
#aijb7;a77#aj77;,a77i77,,viii7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acie;a7a77#aj77;,a77i77,,viii771 except
 t a ,/ate t elects n to provide m$ical 
assi/ance to individuals "u su* section 
may make su* individuals deposit        
qualify+ resid5ts "u ?is title4  #ajb4  
,/ate alt]native option  7a7 ,9 g5]al ,9
 ! case ( a ,/ate t elects "u section   
#aja7;a77#c7 ! alt]native option "u ?is 

section1 subject to subsection 7d7 &    
section #aje1 ! foll[+ %all apply3  7#a7
 ,no ,f$]al ,ex*ange ,! ,f$]al ,gov]nm5t
 %all n e/abli% or ma9ta9 an ,ex*ange 9 
! ,/ate "u title ,i ( ,,ppaca4  7#b7    
,elim9ation ( individual & employ] %>$  
responsibility = heal? c>e tax          
requirem5ts = resid5ts & employees 9    
,/ate ,! individual & employ] heal? c>e 
responsibilities "u ! am5dm5ts made by  
title ,i ( ,,ppaca 7includ+ "u sections 
#ejjj;,a & #dihj;,h ( ! ,int]nal ,rev5ue
 ,code ( #aihf7 %all no long] apply     
pursuant to section #ajf ) respect to   
individuals :o are resid5ts ( su* ,/ate 
& ) respect to individuals :o are       
employ$ 9 su* ,/ate1 respectively4  7#c7
 ,modification ( insurance requirem5ts  
,except z specifically provid$ 9 ?is    
title1 ! requirem5ts "u title ,i (      
,,ppaca 7includ+ am5dm5ts made by su*   
title7 relat+ to heal? insurance cov]age
 (f]$ 9 ! ,/ate %all n apply except to !
 ext5t specifi$ by ! ,/ate4  7#d7 ,new  
deposit sy/em ?r\gh fund+ ,h,s,as  7,a7 

,9 g5]al ,deposit qualify+ resid5ts 7z  
def9$ 9 subsection 7b77#b77 :o are      
resid+ 9 ! ,/ate are eligible = a       
deposit to a heal? sav+s acc\nt t may be
 us$ = premiums & co/-%>+ = heal?       
insurance cov]age 9 accordance )        
subsection 7b74  7,b7 ,/ate             
specification ( mann] ( c>ry+ out ,,hsa 
deposit sy/em 7pati5t-grant elect+ /ate7
 ,9 mak+ ! election "u ?is subsection1 a
 ,/ate %all specify :e!r ! ,/ate w c>ry 
out subsection 7b7 or if su* subsection 
%all be c>ri$ out by means ( ! cr$it "u 
section #cf;,c ( ! ,int]nal ,rev5ue     
,code ( #aihf4  7#e7 ,additional am\nts 
= population heal? initiatives = ,/ate  
adm9i/]$ ,,hsa deposit sy/em ,a         
pati5t-grant elect+ ,/ate 7z def9$ 9    
section #ajj7a77 is entitl$ to receive  
additional fund+ "u subsection 7c7 =    
population heal? initiatives4  7b7      
,deposit ?r\gh paym5t into ,,hsa =      
deposit qualify+ resid5ts  7#a7 ,9 g5]al
 ,! subsidies describ$ 9 subsection     
7a77#d7 = an elect+ ,/ate %all be       

furni%$ = ea* deposit qualify+ resid5t  
?r\gh ! deposit ( a contribution into an
 ,,hsa ( ! individual 9 ! am\nt det]m9$ 
"u section #ajc4  7#b7 ,deposit qualify+
 resid5t def9$ ,9 ?is title1 ! t]m      
deposit qualify+ resid5t means1 )       
respect to a ,/ate & a mon?1 an         
individual-- 7,a7 :o is a qualifi$      
resid5t 7z def9$ 9 section #ajj7ad77 ( !
 ,/ate z ( ! fir/ day ( ! mon? 7or su*  
o!r day 9 ! mon? z ! ,secret>y may      
specify72  7,b7 ) respect to :om an     
,,hsa has be5 e/abli%$1 :i* ,,hsa may h 
be5 e/abli%$ by ! ,/ate 9 c>ry+ out ?is 
section2  7,c7 :o is enroll$ 9 qualifi$ 
heal? plan cov]age 7z def9$ 9 section   
#ajj7ac771 :i* enrollm5t may h be5      
effect$ by ! ,/ate 9 c>ry+ out ?is      
section2 &  7,d7 :o is n eligible =     
cov]age "u ,m$ic>e1 is n enroll$ =      
b5efits "u ,m$icaid or ,,*ip1 & is n    
enroll$ = b5efits "u *apt] #ee ( title  
#aj1 ,unit$ ,/ates ,code 7relat+ to     
,,tric>e71 or title #ci ( su* ,code     
7relat+ to vet]ans' b5efits7 or *apt]   

#hi ( title #e ( su* ,code 7relat+ to ! 
,f$]al ,employees ,heal? ,b5efits       
,program74  7#c7 ,paym5t adm9i/ration   
7,a7 ,/ate ,9 ! case ( an elect+ ,/ate t
 elects to c>ry out ?is subsection ?r\gh
 ! ,/ate1 ! ,secret>y %all provide =    
paym5t to ! ,/ate 9 am\nts & 9 a "t &   
mann] suffici5t to p]mit ! ,/ate to make
 timely mon?ly contributions to ,h,s,as 
"u ?is subsection4 ,! ,secret>y may     
provide = paym5t to ! ,/ate us+ ! paym5t
 me?odology describ$ 9 subsection 7d7 ( 
section #aijc ( ! ,social ,security ,act
 = paym5ts "u subsection 7a7 ( su*      
section 7appli$ )\t reg>d to any ,/ate  
mat*+ requirem5t7 & may condition su*   
paym5ts ^u ! provision ( su* in=mation z
 ! ,secret>y may require to ensure !    
prop] paym5ts "u ?is subsection4 ,z a   
condition ( receiv+ paym5t "u ?is       
section1 a ,/ate %all submit su*        
in=mation1 9 su* =m1 & mann]1 z !       
,secret>y %all specify1 includ+         
in=mation necess>y to make !            
computations ( am\nts "u ?is section4   

7,b7 ,f$]al ,9 ! case ( a ,/ate elect+  
to c>ry out ?is subsection o!r ?an ?r\gh
 ! ,/ate1 subsidies describ$ 9          
subsection 7a77#d7 %all be provid$ ?r\gh
 a refundable tax cr$it "u section      
#cf;,c ( ! ,int]nal ,rev5ue ,code (     
#aihf4  7#d7 ,con/ruction ,no?+ 9 ?is   
subsection %all be con/ru$-- 7,a7 to    
prev5t an individual f affirmatively    
elect+ n to h an ,,hsa e/abli%$ on !    
individual's behalf & n to be enroll$ "u
 heal? insurance cov]age2  7,b7 subject 
to subp>agraph 7,a71 to prev5t a ,/ate f
 e/abli%+ an ,,hsa = ea* deposit        
qualify+ resid5t :o does n o!rwise h an 
,,hsa2  7,c7 subject to subp>agraph     
7,a71 to prev5t a ,/ate f e/abli%+ a    
me*anism :]eby individuals :o w\ld be   
deposit qualify+ resid5ts b = p>agraph  
7#b77;,c7 are enroll$ "u heal? insurance
 cov]age2 &  7,d7 to prev5t a ,/ate f   
*ang+ its ,/ate ,m$icaid plan to        
elim9ate cov]age "u section             
#aijb7;a77#aj77;,a77i77,,viii7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   

#acif;a7a77#aj77;,a77i77,,viii771 9 ord]
 t individuals o!rwise cov]$ "u su*     
section may qualify = subsidies "u ?is  
section4  7c7 ,population heal?         
initiative fund+  7#a7 ,9 g5]al ,9 !    
case ( an elect+ ,/ate = a ye>1 ! ,/ate 
is entitl$ to receive paym5t f !        
,secret>y ( ,heal? & ,human ,s]vices    
aft] ! end ( su* ye> 9 an am\nt equal to
 #b p]c5t ( ! actual aggregate am\nt    
deposit$ "u subsection 7b7 into ,h,s,as 
= resid5ts ( ! ,/ate = ! ye>4  7#b7 ,use
 ( funds ,am\nts paid to a ,/ate "u     
p>agraph 7#a7 may only be us$ =         
population heal? initiatives 7z def9$ by
 ! ,secret>y74  7#c7 ,entitlem5t        
,p>agraph 7#a7 con/itutes budget        
au?ority 9 advance ( appropriations     
,acts & repres5ts ! obligation ( !      
,f$]al ,gov]nm5t to provide = ! paym5t  
to ,/ates ( am\nts provid$ "u su*       
p>agraph4  7d7 ,requir+ rules = comput+ 
usual1 cu/om>y1 & reasonable 7,,ucr7    
prices ,z a condition = a ,/ate's       
election ( ! alt]native option "u ?is   

section1 ! ,/ate mu/ provide1 ?r\gh its 
dep>tm5t ( insurance or equival5t ag5cy1
 = e/abli%m5t ( rules to c>ry out       
section #ahfg7;j77#a77;,a77ii7 ( !      
,social ,security ,act1 z add$ by       
section #aba7;a77#b74  #ajc4            
,computation ( mon?ly ,,hsa deposit     
am\nt = deposit qualify+ resid5ts  7a7  
,computation  7#a7 ,9 g5]al ,! ,secret>y
 %all develop a /&>diz$ me?odology to   
det]m9e consi/5t ) ?is section a mon?ly 
,,hsa deposit am\nt = deposit qualify+  
resid5ts 9 ea* ,/ate = mon?s 9 ea* ye>4 
,subject to p>agraphs 7#c7 & 7#d71 su*  
am\nt %all be equal to #a_/ab ( ! av]age
 p] capita annual am\nt comput$ "u      
subsection 7b7 = ! ,/ate = ! ye>1 z     
adju/$ = ! deposit qualify+ resid5t     
involv$--  7,a7 = age & geographic area 
"u subsection 7c72 &  7,b7 = income "u  
subsection 7d74  7#b7 ,no v>iation bas$ 
on h[ deposit am\nt di/ribut$ ,su* am\nt
 %all be ! same = a deposit qualify+    
individual )\t reg>d to :e!r !          
contribution to ! individual's ,,hsa is 

made by a ,/ate "u ?is section or by !  
,f$]al ,gov]nm5t ?r\gh ! op]ation (     
section #cf;,c ( ! ,int]nal ,rev5ue     
,code ( #aihf4  7#c7 ,pati5t-grant      
elect+ ,/ate has flexibility to ma9ta9  
level ( b5efits = curr5t ,,aca          
b5efici>ies ,a pati5t-grant elect+ ,/ate
 may elect to increase ! am\nt ( !      
deposit = all deposit qualify+          
individuals "u ?is section to ! am\nts t
 ! ,secret>y e/imates w\ld h be5 paid ) 
respect to su* individuals "u section   
#cf;,b ( ! ,int]nal ,rev5ue ,code (     
#aihf & section #adjb ( ,,ppaca if ^?   
sections _h rema9$ 9 effect 9 ! ,/ate ) 
respect to su* individuals4 ,su*        
election %all be made = a ye> & %all    
cont9ue f ye> to ye> until ! ,/ate      
elects to t]m9ate su* election4  7#d7   
,special rule = p>tial deposit =        
l[-income individuals ) employ]-sponsor$
 insurance 7,,esi7 ,9 ! case ( an       
individual :o is cov]$ "u a gr\p heal?  
plan & ) respect to su* cov]age !re is a
 contribution by an employ] :i* is      

exclud$ f ! individual's gross income "u
 ! ,int]nal ,rev5ue ,code ( #aihf1 ins(>
 z ! individual is a deposit qualify+   
resid5t1 ! am\nt ( ! deposit ) respect  
to ! individual %all be r$uc$1 9 a mann]
 specifi$ by ! ,secret>y 9 consultation 
) ! ,secret>y ( ! ,treasury & tak+ into 
acc\nt ! income ( ! individual's        
h\sehold1 by an am\nt t is approximately
 equival5t to ! e/imat$ am\nt ( !       
r$uction 9 ! am\nt ( income tax result+ 
f su* exclusion 7& any r$uction 9 taxes 
impos$ by *apt] #ba or *apt] #b ( su*   
,code by reason ( any exclusion ( su*   
contributions f wages & self employm5t  
income74  7b7 ,computation ( unadju/$ p]
 capita  7#a7 ,= ,/ates t cont9ue       
,,ppaca ,m$icaid cov]age  7,a7 ,9 g5]al 
,9 ! case ( a ,/ate t provides m$ical   
assi/ance "u section                    
#aijb7;a77#aj77;,a77i77,,viii7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acif;b7a77#aj77;,a77i77,,viii77 dur+ a 
ye>1 subject to p>agraphs 7#c7 & 7#d71 !
 ,secret>y %all compute an av]age p]    

capita annual am\nt = ! ,/ate = ! ye>   
equal to--  7i7 ! am\nt specifi$ 9      
subp>agraph 7,b71 divid$ by  7ii7 !     
av]age mon?ly numb] ( deposit qualify+  
resid5ts ( ! ,/ate 9 ! ye>4  7,b7 ,am\nt
 bas$ on ,,ppaca project$ ,f$]al        
exp5ditures ,! am\nt specifi$ 9 ?is     
subp>agraph = a ,/ate = a ye> is #ie    
p]c5t ( ! ,secret>y's e/imate ( ! total 
paym5ts t w\ld h be5 made 7assum+ !     
exi/5ce ( a ,/ate e/abli%$ ,ex*ange 9 ! 
,/ate7 "u section #cf;,b ( ! ,int]nal   
,rev5ue ,code ( #aihf & "u section #adjb
 ( ,,ppaca ) respect to all qualifi$    
resid5ts 9 ! ,/ate 9 ! ye> 7or taxable  
ye> end+ ) su* ye>1 if applicable74     
7#b7 ,= ,/ates t d n provide ,,ppaca    
,m$icaid cov]age  7,a7 ,9 g5]al ,9 !    
case ( a ,/ate n describ$ 9 p>agraph    
7#a7 = a ye>1 subject to p>agraphs 7#c7 
& 7#d71 ! ,secret>y %all compute an     
av]age p] capita annual am\nt = ! ,/ate 
= ! ye> equal to--  7i7 ! am\nt specifi$
 9 subp>agraph 7,b7 = ! ,/ate & ye>1    
divid$ by  7ii7 ! av]age mon?ly numb] ( 

deposit qualify+ resid5ts ( ! ,/ate 9 ! 
ye>4  7,b7 ,am\nt bas$ on ,,ppaca &     
,m$icaid project$ ,f$]al exp5ditures ,! 
am\nt specifi$ 9 ?is subp>agraph = a    
,/ate = a ye> is equal to ! sum (-- 7i7 
#ie p]c5t ( ! ,secret>y's e/imate ( !   
total paym5ts t w\ld h be5 made 7assum+ 
! exi/5ce ( a ,/ate-e/abli%$ ,ex*ange 9 
! ,/ate7 "u section #cf;,b ( ! ,int]nal 
,rev5ue ,code ( #aihf & "u section #adjb
 ( ,,ppaca ) respect to all qualifi$    
resid5ts 9 ! ye> 7or taxable ye> end+ ) 
su* ye>1 if applicable72 &  7ii7 !      
,secret>y's e/imate ( ! total paym5ts t 
w\ld h be5 made to ! ,/ate "u title     
,,xix ( ! ,social ,security ,act =      
individuals eligible to be cov]$ "u     
section #aijb7;a77#aj77;,a77i77,,viii7 (
 ! ,social ,security ,act assum+ !      
election ( a ,/ate to provide ,m$icaid  
cov]age "u su* section & assum+ !       
applicable ,f$]al m$ical assi/ance      
p]c5tage 7 #ie p]c5t ) respect to su*   
individuals4  7#c7 ,budget neutral      
adju/m5t 9 paym5ts to take into acc\nt  

election ( high] deposits to ma9ta9     
,,aca subsidy levels ,if a ,/ate makes !
 election describ$ 9 subsection 7a77#c7 
) respect to provid+ high] deposit      
am\nts = c]ta9 individuals describ$ 9   
su* subsection1 !n ! ,secret>y %all     
adju/ ! av]age p] capita annual am\nt "u
 p>agraph 7#a7 or 7#b71 z applicable to 
! ,/ate1 by--  7,a7 r$uc+ ! am\nt       
describ$ 9 p>agraph 7#a77;,b7 7or1 if   
applicable1 p>agraph 7#b77;,b77i77 by an
 am\nt equal to #ie p]c5t ( ! aggregate 
increas$ deposit level attributable to  
subsection 7a77#c72 &  7,b7 n c\nt+ su* 
an individual z a qualify+ resid5t =    
purposes ( p>agraph 7#a77;,a77ii7 7or1  
if applicable1 p>agraph 7#b77;,a77ii774 
7#d7 ,adju/m5t = co/s ( p>tial deposits 
= l[-income ,,esi individuals ,!        
,secret>y %all adju/ ! av]age p] capita 
annual am\nt "u p>agraph 7#a7 or 7#b71 z
 applicable to ! ,/ate1 by--  7,a7 r$uc+
 ! am\nt describ$ 9 p>agraph 7#a77;,b7  
7or1 if applicable1 p>agraph            
7#b77;,b77i77 by an am\nt equal to #ie  

p]c5t ( ! am\nt ( paym5ts "u ?is section
 t are attributable to individuals      
describ$ 9 subsection 7a77#d72 &  7,b7 n
 c\nt+ any individual describ$ 9        
subsection 7a77#d7 z a qualify+ resid5t 
= purposes ( p>agraph 7#a77;,a77ii7 7or1
 if applicable1 p>agraph 7#b77;,a77ii774
  7c7 ,adju/m5t = age1 geographic area1 
& income di/ribution )9 /ate  7#a7 ,9   
g5]al ,! ,secret>y %all apply su*       
adju/m5ts to ! p] capita am\nt comput$  
"u subsection 7b7 z is design$ to take  
into acc\nt1 9 a budget neutral mann] & 
bas$ on ! co/s e/imat$ "u p>agraph 7#b71
 actu>ial diff]5ces 9 heal? c>e co/s    
attributable to individuals 9 diff]5t   
age categories & diff]5t geographic     
locations ( prim>y resid5ces 9 ! ,/ate &
 ! r$uctions bas$ on income "u          
subsection 7d74 ,no su* adju/m5t %all be
 made bas$ on sex4  7#b7 ,data on av]age
 co/s ( s]vices ,n lat] ?an ,decemb] #ae
 be=e ! beg9n+ ( ea* ye>1 ! ,ag5cy =    
,heal?c>e ,rese>* & ,quality %all       
e/imate ! av]age co/ ( heal? c>e = su*  

ye> = individuals "u #fe ye>s ( age &   
may e/imate h[ su* av]age v>ies =       
diff]5t populations ( individuals "u age
 #fe4 ,! adju/m5ts "u p>agraph 7#a7 =   
age categories = a ye> %all be bas$ on  
su* e/imates made4 ,n lat] ?an su* date1
 ! ,secret>y %all prescribe tables =    
purposes ( mak+ adju/m5ts bas$ on age "u
 p>agraph 7#a7 bas$ on su* det]m9ation  
:i* %all apply = taxable ye>s beg9n+ 9 !
 succe$+ cal5d> ye>4  7d7               
,income-,relat$ phase-,out  7#a7 ,9     
g5]al ,! p] capita am\nt z comput$ "u   
subsection 7b7 & adju/$ & appli$ to a   
deposit qualify+ individual "u          
subsection 7c7 %all be multipli$ by a   
phase-out p]c5tage equal to #ajj p]c5t  
r$uc$ by #a p]c5tage po9t = ea* #a1jjj  
7or fraction !re(7 by :i* ! taxpay]'s   
modifi$ adju/$ gross income = ! taxable 
ye> exce$s #ij1jjj 7or1 9 ! case ( a    
jo9t return1 #aej1jjj71 multipli$1 = a  
taxable ye> end+ 9 a ye> beg9n+ aft]    
,decemb] #ca1 #bjae1 by ! co/-(-liv+    
adju/m5t = ! ye> z describ$ 9 section   

#a7;f77#c7 ( ! ,int]nal ,rev5ue ,code ( 
#aihf1 b sub/itut+ #bjae = #aiib 9      
subp>agraph 7,b7 ( su* section4  7#b7   
,z]o p] capita am\nt = m>ri$ fil+       
sep>ately ,! p] capita am\nt "u ?is     
section %all be z]o 9 ! case ( a m>ri$  
c\ple fil+ sep>ately4  #ajd4 ,/ate      
options = improv$ access to heal?       
insurance cov]age 9 ea* ,/ate  7a7 ,/ate
 options ,to improve access  7#a7 ,9    
g5]al ,ea* ,/ate may c>ry out any ( !   
functions describ$ 9 succe$+ subsections
 9 ord] to improve ! access ( resid5ts (
 ! ,/ate to heal? insurance cov]age4    
7#b7 ,repurpos+ ,/ate ,ex*anges ,a ,/ate
 may use or adapt an ,ex*ange t ! ,/ate 
has e/abli%$ "u title ,i ( ,,ppaca to   
c>ry out ! any ( su* functions4  7#c7   
,repurpos+ f$]al ex*ange ,! ,f$]al      
,gov]nm5t %all make available to ,/ates 
curr5t capabilities ( ! ,f$]al ,ex*ange1
 includ+ ! ,f$]al ,data ,s]vices ,hub & 
,ag5t ,brok] ,portal1 to ! ext5t reque/$
 by a ,/ate = activities relat$ to      
enrollm5t ( citiz5s ( ! ,/ate into heal?

 insurance cov]age4  7b7 ,transp>5cy    
portal ,ea* ,/ate may e/abli% & op]ate  
an op5 & transp>5t m>ketplace me*anism  
:]eby qualifi$ resid5ts ( ! ,/ate c     
readily comp>e1 ?r\gh ! use ( !         
,int]net1 ! b5efits & prices betwe5     
diff]5t heal? insurance cov]age options 
made available to !m4  7c7 ,enrollm5t1  
subject to individual opt-,out  7#a7 ,9 
g5]al ,subject to p>agraph 7#b71 a ,/ate
 may provide = ! enrollm5t ( qualifi$   
resid5ts ( ! ,/ate :o are un9sur$ 9     
default heal? insurance cov]age (f]$ "u 
section #aje7;c7 & e/abli%+ an ,,hsa =  
su* resid5ts :o d n h an ,,hsa unless ! 
resid5t has affirmatively elect$ n to be
 s enroll$ & n to h an ,,hsa1           
respectively4 ,any su* enrollm5t "u ?is 
p>agraph %all be coord9at$ ) ! annual   
op5 enrollm5t p]iods provid$ "u section 
#aje7;b74  7#b7 ,simple process =       
individuals to opt-out ,z a condition ( 
a ,/ate provid+ = ! enrollm5t function  
describ$ 9 p>agraph 7#a71 ! ,/ate mu/   
e/abli% an easy-to-use & transp>5t means

 by :i* individuals may elect n to be   
enroll$ 9 default heal? insurance       
cov]age or to h an ,,hsa e/abli%$ on !  
individual's behalf1 or bo?4  7d7 ,risk 
mitigation me*anisms & re9surance &     
risk-,corridor programs  7#a7 ,9 g5]al  
,not)/&+ any o!r provision ( ?is title  
or section #bbc7;c77#b7 ( ! ,int]nal    
,rev5ue ,code ( #aihf1 a ,/ate may      
e/abli%--  7,a7 me*anisms = risk        
mitigation or risk adju/m5t 9 ord] to   
limit volatility 9 ! premiums bas$ on   
heal? exp]i5ce to class-av]age premiums2
 &  7,b7 a re9surance & risk-corridor   
program t involves no ,f$]al funds )    
respect to cov]age bo? 9 ! individual   
m>ket & 9 ! small gr\p m>ket4  7#b7     
,basis = risk adju/m5t ,me*anisms &     
programs "u p>agraph 7#a7 may be bas$ on
 ! heal? /atus score ( ea* individual   
enroll$ 9 heal? insurance cov]age 9 !   
individual m>ket & n solely bas$ on !   
aggregate risk ( ! risk pool ) respect  
to ea* plan ( heal? insurance cov]age4  
#aje4 ,exp&$ access & pati5t protections

  7a7 ,9 g5]al ,z a condition = !       
election ( ! alt]native option "u       
section #ajb 9 a ,/ate1 ! ,/ate mu/ meet
 ! requirem5ts ( ?is section4  7b7      
,annual & o!r op5 enrollm5t p]iods  7#a7
 ,9 g5]al ,! ,/ate %all require1 9      
connection ) ! (f]+ ( heal? insurance   
cov]age 9 ! individual m>ket 9 ! ,/ate1 
t !re are uni=m annual & o!r op5        
enrollm5t p]iods 7su* z ^? = *anges 9   
life ev5ts1 *anges 9 ,/ate resid5cy1 &  
involunt>y *anges 9 eligibility =       
cov]age "u a gr\p heal? plan7 9 ord] to 
p]mit qualifi$ resid5ts to enroll 9     
qualifi$ heal? plan cov]age 9 a mann] t 
promotes cont9uity ( cov]age4 ,su*      
p]iods %all be consi/5t ) ! op5         
enrollm5t p]iods e/abli%$ "u title ,i ( 
,,ppaca1 z 9 effect be=e ! date ( !     
enactm5t ( ?is ,act4  7#b7 ,initial op5 
enrollm5t p]iod ,9 addition1 ! ,/ate    
%all e/abli% an initial op5 enrollm5t   
p]iod dur+ :i* qualifi$ resid5ts may    
enroll 9 qualifi$ heal? plan cov]age )\t
 ! imposition ( any und]writ+ describ$ 9

 subsection 7d77#a77;,b74 ,su* p]iod    
%all be a p]iod ( n less ?an #de days & 
%all provide = enrollm5t to become      
effective on ,janu>y #a ( ! ye> specifi$
 by ! ,/ate 9 :i* su* ,/ate election    
fir/ becomes effective4  7c7 ,(f]+ (    
default heal? insurance cov]age  7#a7 ,9
 g5]al ,! ,/ate %all provide = ! (f]+1  
?r\gh "o or m contracts ) "o or m heal? 
insurance issu]s 9 ! ,/ate1 ( default   
heal? insurance cov]age 7z def9$ 9      
p>agraph 7#b77 to qualifi$ resid5ts ( ! 
,/ate :o are o!rwise un9sur$4 ,su*      
default cov]age %all be made available  
on a cont9u\s basis dur+ a ye>4 ,failure
 ( a qualifi$ resid5t to enroll 9 su*   
default cov]age or o!r cr$itable cov]age
 dur+ a ye> results 9 adv]se consequ5ces
 describ$ 9 subsection 7d77#a77;,b7 to !
 resid5t4  7#b7 ,default heal? insurance
 plan def9$ ,9 ?is title1 ! t]m default 
heal? insurance plan means1 ) respect to
 a ,/ate1 heal? insurance cov]age t--   
7,a7 is a high d$uctible heal? plan 7)9 
! mean+ ( section #bbc7;c77#b7 ( !      

,int]nal ,rev5ue ,code ( #aihf7 )       
prescription drug cov]age limit$ to     
g5]ic drugs = a limit$ numb] ( *ronic   
conditions 7commonly ref]r$ to z ti] ,i 
ph>macy b5efit72  7,b7 meets su*        
requirem5ts z may apply to qualify = !  
paym5t ( plan premiums f a heal? sav+s  
acc\nt "u section #bbc ( su* ,code 7su* 
z age-relat$ premiums & limitation on   
imposition ( preexi/+ condition         
exclusions72  7,c7 has a provid] network
 = cov]$ b5efits t is adequate 7z       
det]m9$ consi/5t ) guidel9es issu$ by ! 
,secret>y7 to ensure access to heal?    
b5efits "u su* plan2  7,d7 provides =   
cov]age ( *ildhood immunizations )\t co/
 %>+ requirem5ts to ! ext5t su*         
immunizations h 9 effect a recomm5dation
 f ! ,advisory ,committee on            
,immunization ,practices ( ! ,c5t]s =   
,disease ,control & ,prev5tion ) respect
 to ! individual involv$2 &  7,e7 meets 
su* o!r requirem5ts z ! ,/ate may       
specify4  7d7 ,consequ5ces respect+     
cont9u\s cov]age  7#a7 ,consequ5ces = n 

ma9ta9+ cont9u\s cov]age  7,a7          
,avoidance ( consequ5ces by ma9ta9+     
cont9u\s cov]age ,all qualifi$ resid5ts 
( a ,/ate are eligible dur+ ! initial   
op5 enrollm5t p]iod provid$ "u          
subsection 7b77#b7 to enroll 9 qualifi$ 
heal? plan cov]age &1 !reaft]1 to ma9ta9
 cont9u\s cov]age 9 ord] to avoid !     
adv]se consequ5ces describ$ 9 ! succe$+ 
provisions ( ?is p>agraph4  7,b7        
,und]writ+ p]mitt$ ,9 ! case ( a        
qualifi$ resid5t ( ! ,/ate :o fails to  
ma9ta9 cont9u\s cr$itable cov]age 7n    
includ+ any breaks 9 cov]age ( less ?an 
#fc days71 ! ,/ate %all--  7i7 p]mit    
heal? insurance issu]s = ! p]iod        
specifi$ 9 subp>agraph 7,c7 to m$ically 
und]write 7?r\gh d5ial ( heal? insurance
 cov]age1 application ( preexi/+        
condition limitations1 diff]5tial       
premiums1 or o!rwise7 ! issuance ( heal?
 insurance cov]age1 o!r ?an ) respect to
 ! issuance ( default heal? insurance   
cov]age "u subsection 7c72 &  7ii7      
require heal? insurance issu]s1 dur+ !  

subsequ5t #b-ye> p]iod 9 ! case (       
issuance ( heal? insurance cov]age o!r  
?an su* default heal? insurance cov]age1
 to impose a mon?ly late enrollm5t      
p5alty 9 ! am\nt specifi$ 9 subp>agraph 
7,d77i7 & to remit ! am\nt ( su* p5alty 
collect$ to ! ,f$]al ,treasury 9        
accordance ) subp>agraph 7,d77ii74  7,c7
 ,p]iod = application ( und]writ+ ,=    
purposes ( subp>agraph 7,b77i71 ! p]iod 
specifi$ 9 ?is subp>agraph is1 ) respect
 to an un9sur$ individual z ( a date1 a 
p]iod 7n to exce$ #ah mon?s7 equival5t  
to numb] ( mon?s 9 ! previ\s #ah-mon?   
p]iod 9 :i* ! individual did n h        
cont9u\s cr$itable cov]age describ$ 9   
subp>agraph 7,b74  7,d7 ,mon?ly late    
enrollm5t p5alty am\nt  7i7 ,9 g5]al ,! 
mon?ly late enrollm5t p5alty am\nt      
specifi$ 9 ?is clause = a mon? is equal 
to ! less] ( #aj p]c5t or ! product (-- 
7,i7 #a p]c5t ( ! mon?ly premium am\nt =
 default heal? insurance cov]age )      
respect to ! individual & mon?2 &       
7,,ii7 ! numb] ( mon?s dur+ ! #b-ye>    

p]iod 7prec$+ ! #ah-mon? p]iod describ$ 
9 subp>agraph 7,b77i77 9 :i* ! resid5t  
fail$ to ma9ta9 ! cont9u\s cov]age      
describ$ 9 p>agraph 7#a77;,d74  7ii7    
,paym5t ( p5alty am\nt to ,f$]al        
,treasury ,! am\nt ( ! mon?ly late      
enrollm5t p5alty collect$ "u ?is        
subp>agraph %all be paid to ! ,treasury 
( ! ,unit$ ,/ates 9 a =m & mann]        
specifi$ by ! ,secret>y ( ! ,treasury4  
7#b7 ,*anges 9 enrollm5t p]mitt$ )\t    
m$ical und]writ+ dur+ annual op5        
enrollm5t p]iods = ^? ma9ta9+ cont9u\s  
cov]age  7,a7 ,dur+ second op5 enrollm5t
 p]iod ,9 ! case ( a qualifi$ resid5t :o
 ma9ta9s cont9u\s cov]age 7n includ+ any
 breaks 9 cov]age ( less ?an #fc days7  
dur+ ! p]iod aft] ! initial op5         
enrollm5t p]iod "u subsection 7b77#b7 & 
?r\gh ! second annual op5 enrollm5t     
p]iod e/abli%$ by ! ,/ate consi/5t )    
subsection 7b77#a71 ! ,/ate %all require
 heal? insurance issu]s to p]mit su*    
resid5ts dur+ su* second annual op5     
enrollm5t p]iod to *ange ! qualifi$     

heal? plan cov]age 9 :i* ! individual is
 enroll$ )\t m$ical und]writ+4  7,b7    
,dur+ ?ird & subsequ5t op5 enrollm5t    
p]iods ,9 ! case ( a qualifi$ resid5t :o
 ma9ta9s cont9u\s cov]age = a p]iod (   
#ah mon?s or long] 7n includ+ any breaks
 9 cov]age ( less ?an #fc days7 z ( !   
initial date ( a ?ird or subsequ5t      
annual op5 enrollm5t p]iod e/abli%$ by !
 ,/ate "u subsection 7b77#a71 ! ,/ate   
%all require heal? insurance issu]s to  
p]mit su* resid5ts dur+ su* an op5      
enrollm5t p]iod to *ange ! qualifi$     
heal? plan cov]age 9 :i* ! individual is
 enroll$ )\t m$ical und]writ+4  #ajf4   
,sunsett+ c]ta9 ,,aca provisions2       
cont9uation ( policies ( cov]+ adult    
*ildr5 & n apply+ lifetime or annual    
limits  7a7 ,9 g5]al ,subject to        
subsections 7b7 & 7c71 title ,i ( !     
,pati5t ,protection & ,af=dable ,c>e    
,act 7includ+ ! am5dm5ts made by su*    
title7 %all n apply 7& ! provisions (   
law am5d$ by su* title are re/or$ z if  
su* title _h n be5 enact$7 9 ! case (   

any ,/ate t does n h 9 effect ! election
 describ$ 9 section #aja7;a77#a74  7b7  
,cont9uation ( policies = ext5sion (    
dep5d5t cov]age = adult *ildr5 &        
prohibition ( lifetime & annual cov]age 
limits ,subsection 7a7 %all n apply )   
respect to ! foll[+3 7#a7 ,section #bgaa
 ( ! ,public ,heal? ,s]vice ,act 7relat+
 to no lifetime or annual limits74  7#b7
 ,section #bgad ( su* ,act 7relat+ to   
ext5sion ( dep5d5t cov]age74  7c7       
,cont9uation ( policies = c]ta9 ,/ates  
op]at+ ,ex*anges ,subsection 7a7 %all n 
apply ) respect to heal? insurance      
cov]age 9 a ,/ate t has 9 effect !      
election describ$ 9 section             
#aja7;a77#a74  ,b ,m$icaid  #aaa4       
,application ( heal? sav+s acc\nts 9    
relation to ,m$icaid  7a7 ,9 g5]al      
,title ,,xix ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #acif et seq47 is am5d$  
by add+ at ! end ! foll[+ new section3  
#aidg4 ,provisions relat+ to heal? sav+s
 acc\nts  7a7 ,disreg>d+ ,,hsa 9 det]m9+
 assets & income = ,m$icaid eligibility 

det]m9ations o!r ?an = long-,t]m c>e    
s]vices ,! assets 9 a heal? sav+s acc\nt
 "u section #bbc ( ! ,int]nal ,rev5ue   
,code ( #aihf1 & any income f su* assets
 9 su* acc\nt1 %all be disreg>d$ =      
purposes ( det]m9+ eligibility & am\nt (
 m$ical assi/ance "u ?is title1 o!r ?an 
= purposes ( det]m9+ eligibility & !    
am\nt ( m$ical assi/ance = long-t]m c>e 
s]vices 7describ$ 9 section             
#aiag7;c77#a77;,c77i774  7b7            
,notifications ( ,treasury ( ,m$icaid   
eligibility ,9 ord] to meet !           
requirem5ts ( ?is subsection 7= purposes
 ( section #aijb7;a77#gh771 a ,/ate %all
 provide su* notice to ! ,secret>y ( !  
,treasury1 9 su* =m & mann] z su*       
,secret>y %all specify1 z may be        
necess>y to id5tify individuals :o are  
eligible =1 & receiv+1 m$ical assi/ance 
"u ?is title 9 a mon? 9 ord] to c>ry out
 section #bbc ( ! ,int]nal ,rev5ue ,code
 ( #aihf4  4  7b7 ,implem5tation (      
notification requirem5t ?r\gh ,/ate plan
 ,section #aijb7;a7 ( ! ,social         

,security ,act 7#db ,u4,s4,c4           
#acif;a7a77 is am5d$ by ins]t+ aft]     
p>agraph 7#gg7 ! foll[+ new p>agraph3   
7#gh7 provide = notice 9 accordance )   
section #aidg7;b7 to ! ,secret>y ( !    
,treasury ( ! id5tity ( individuals :o  
are det]m9$ eligible = 7& receiv+7      
m$ical assi/ance "u ?is title2  4  7c7  
,effective date ,! am5dm5ts made by ?is 
section %all apply to eligibility       
det]m9ations ) respect to m$ical        
assi/ance = p]iods beg9n+ on or aft]    
,janu>y #a1 #bjaf4  ,c ,provid] ,price  
,transp>5cy  #aba4 ,ensur+ access to    
em]g5cy s]vices )\t excessive *>ges =   
out-(-network s]vices  7a7 ,9 g5]al     
,section #ahfg ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acie;dd7 is am5d$--
 7#a7 9 subsection 7d71 by add+ at ! end
 ! foll[+ new p>agraph3  7#e7 ,en=cem5t 
) respect to excessive *>ges ,a         
hospital1 physician1 or o!r entity t    
violates ! requirem5ts ( subsection     
7j77#a7 ) respect to ! furni%+ ( items &
 s]vices is subject to a civil money    

p5alty ( n m ?an #be1jjj = ea* su*      
violation4 ,! provisions ( section      
#aabh;,a 7o!r ?an subsections 7a7 & 7b77
 %all apply to a civil money p5alty "u  
?is p>agraph 9 ! same mann] z su*       
provisions apply ) respect to a p5alty  
or proce$+ "u section #aabh;,a7a74  2 & 
7#b7 by add+ at ! end ! foll[+ new      
subsection3  7j7 ,protections aga9/     
excessive out-(-,network *>ges = em]g5cy
 s]vices  7#a7 ,9 g5]al ,if items or    
s]vices to scre5 or treat an em]g5cy    
m$ical condition are furni%$ "u ?is     
section 9 a p>ticipat+ hospital )       
respect to an individual & ! individual 
has n1 directly or ?r\gh a heal?        
insurance issu]1 gr\p heal? plan1 or o!r
 ?ird p>ty1 negotiat$ a paym5t rate =   
su* items & s]vices1 subject to p>agraph
 7#b71 ! *>ges impos$ = su* items &     
s]vices may n be 9 excess ( ! foll[+3   
7,a7 ,physicians' & o!r pr(essional     
s]vices ,= physicians' s]vices or       
s]vices ( a heal? c>e provid] to :i*    
section #bbc7;e77#i7 ( ! ,int]nal       

,rev5ue ,code ( #aihf applies 7& includ+
 drugs & biologicals furni%$ 9          
conjunction ) & bill$ z "p ( su*        
s]vices71 ! less] (--  7i7 ! ca% price =
 su* s]vices po/$ pursuant to su*       
section2 or  7ii7 #he p]c5t ( ! usual1  
cu/om>y1 & reasonable 7,,ucr7 *>ge = su*
 s]vices1 z det]m9$ "u rules e/abli%$ by
 ! dep>tm5t ( insurance = ! ,/ate 9 :i* 
! s]vices are furni%$4  7,b7 ,hospital  
s]vices ,= inpati5t & outpati5t hospital
 s]vices = :i* paym5t rates are e/abli%$
 "u ?is title 7& includ+ drugs &        
biologicals furni%$ 9 conjunction ) &   
bill$ z "p ( su* s]vices71 ! less] (--  
7i7 ! ca% price = su* s]vices po/$      
pursuant to section #bbc7;e77#i7 ( !    
,int]nal ,rev5ue ,code ( #aihf2 or  7ii7
 #aaj p]c5t ( ! paym5t rate applicable  
to su* s]vices 9 ! case ( an individual 
entitl$ to b5efits "u "p ,a & enroll$ "u
 "p ,b4  7,c7 ,drugs & biologicals ,=   
drugs & o!r ph>maceuticals furni%$ to   
:i* a previ\s subp>agraph does n apply1 
! less] (--  7i7 twice ! acquisition co/

 to ! hospital or o!r provid] = ! dose  
involv$2 or  7ii7 ! acquisition co/ to !
 hospital or o!r provid] plus #bej4  ,! 
doll> am\nt 9 clause 7ii7 %all be       
increas$ f ye> to ye> 7beg9n+ ) ! ye>   
aft] ! fir/ ye> 9 :i* ?is subsection    
applies7 by ! same p]c5tage z ! p]c5tage
 increase 9 ! consum] price index = all 
urban consum]s 7all items2 ,u4,s4 city  
av]age7 = ! ye> involv$ 7z det]m9$ by ! 
,secret>y74 ,any su* doll> am\nt z s    
increas$ t is n a multiple ( #e %all be 
r\nd$ to ! ne>e/ multiple ( #e 7or1 if a
 multiple ( #b4ej1 to ! next highe/     
multiple ( #e74  7,d7 ,o!r items &      
s]vices ,= any o!r items or s]vices1 !  
less] (-- 7i7 ! ca% price = su* items & 
s]vices po/$ pursuant to section        
#bbc7;e77#i7 ( ! ,int]nal ,rev5ue ,code 
( #aihf2 or  7ii7 #aaj p]c5t ( ! paym5t 
basis t w\ld be applicable to paym5t =  
su* items & s]vices "u ?is title 9 !    
case ( an individual entitl$ to b5efits 
"u "p ,a & enroll$ "u "p ,b4  7#b7      
,special rule = items & s]vices furni%$ 

z a bundle ,9 ! case ( items & s]vices =
 :i* !re is a s+le price = a gr\p or    
bundle ( su* items & s]vices1 ! maximum 
*>ge p]mitt$ "u p>agraph 7#a7 may n     
exce$ ! less] (--  7,a7 ! price *>g$ =  
su* bundl$ s]vices2 or  7,b7 ! aggregate
 ( ! maximum *>ges p]mitt$ "u p>agraph  
7#a7 ) respect to items & s]vices       
includ$ 9 su* bundle4  4  7b7 ,ref]5ce  
to price disclosure provision ,=        
requirem5ts relat+ to ! po/+ ( heal? c>e
 prices on ! ,int]net1 see section      
#bbc7;e77#i7 ( ! ,int]nal ,rev5ue ,code 
( #aihf1 z add$ by section #bjd7;a74    
7c7 ,effective date ,! am5dm5ts made by 
?is section %all apply to *>ges impos$ =
 items & s]vices furni%$ on or aft]     
,janu>y #a1 #bjaf4  ,,ii ,re=m ( ,tax   
,provisions ,relat+ to ,heal? ,c>e  ,a  
,promotion ( ,heal? ,sav+s ,acc\nts     
#bja4 ,repeal ( high d$uctible heal?    
plan requirem5t  7a7 ,9 g5]al ,section  
#bbc7;a7 ( ! ,int]nal ,rev5ue ,code (   
#aihf is am5d$ to read z foll[s3  7a7   
,d$uction all[$ ,9 ! case ( an          

individual1 !re %all be all[$ z a       
d$uction = a taxable ye> an am\nt equal 
to ! aggregate am\nt paid 9 ca% dur+ su*
 taxable ye> by or on behalf ( su*      
individual to a heal? sav+s acc\nt ( su*
 individual4  4  7b7 ,con=m+ am5dm5ts   
7#a7 ,section #bbc7;b77#a7 ( su* ,code  
is am5d$ by /rik+ t ! individual is an  
eligible individual4  7#b7 ,section     
#bbc7;b77#b7 ( su* ,code is am5d$ by    
/rik+ "u a high d$uctible heal? plan ea*
 place x appe>s4  7#c7 ,section #bbc7;b7
 ( su* ,code is am5d$ by /rik+ p>agraph 
7#h74  7#d7 ,section #bbc ( su* ,code is
 am5d$ by /rik+ subsection 7c7 &        
r$esignat+ subsections 7d7 ?r\gh 7h7 z  
subsections 7c7 ?r\gh 7g71 respectively4
  7#e7 ,section #bbc7;c77#a77;,a7 ( su* 
,code1 z r$esignat$ by ?is ,act1 is     
am5d$ by /rik+ subsection 7f77#e7 &     
ins]t+ subsection 7e77#e74  7#f7        
,section #bbc7;f77#a7 ( su* ,code1 z    
r$esignat$ by ?is ,act1 is am5d$--  7,a7
 by /rik+ subsections 7b77#b7 &         
7c77#b77;,a7 & ins]t+ subsection        

7b77#b71  7,b7 by /rik+ subp>agraph 7,b7
 !re(-- & all t foll[s ?r\gh ! end (    
subp>agraph 7,b7 & ins]t+ subp>agraph   
7,b7 !re( cal5d> ye> #aiig41 &  7,c7 by 
/rik+ am\nts "u subsections 7b77#b7 &   
7c77#b77;,a7 9 ! second s5t5ce & ins]t+ 
am\nts "u subsection 7b77#b74  7#g7     
,section #bf7;b77#b77,u7 ( su* ,code is 
am5d$ by /rik+ section #bbc7;f77#d7 &   
ins]t+ section #bbc7;e77#d74  7#h7      
,sections #ce7;g77#c71                  
#bbj7;f77#e77;,a71 #hdh7;e77#a77;,b77v71
 #digc7;a77#e71 & #fjea7;a77#ab7 ( su*  
,code are ea* am5d$ by /rik+ section    
#bbc7;d7 ea* place x appe>s & ins]t+    
section #bbc7;c74  7#i7 ,section        
#ajf7;d77#a7 ( su* ,code is am5d$-- 7,a7
 by /rik+ :o is an eligible individual  
7z def9$ 9 section #bbc7;c77#a771 &     
7,b7 by /rik+ section #bbc7;d7 & ins]t+ 
section #bbc7;c74  7#aj7 ,section       
#djh7;d77#i7 ( su* ,code is am5d$--     
7,a7 9 subp>agraph 7,a7 by /rik+ :o is  
an eligible individual 7z def9$ 9       
section #bbc7;c77 &1 &  7,b7 9          

subp>agraph 7,c7 by /rik+ comput$ on !  
basis ( ! type ( cov]age "u ! high      
d$uctible heal? plan cov]+ ! individual 
at ! "t ( ! qualifi$ ,,hsa fund+        
di/ribution4  7#aa7 ,section            
#hgg;,a7g77#f7 ( su* ,code is am5d$ by  
/rik+ #bbc7;f77#d7 & ins]t+             
#bbc7;e77#d74  7#ab7 ,section #digc7;g7 
( su* ,code is am5d$--  7,a7 by /rik+   
section #bbc7;d7 & ins]t+ section       
#bbc7;c71  7,b7 by /rik+ #bbc7;f77#e7 9 
p>agraph 7#a7 & ins]t+ #bbc7;e77#e71    
7,c7 by /rik+ section #bbc7;f77#b7 9    
p>agraph 7#b7 & ins]t+ section          
#bbc7;e77#b71 &  7,d7 by /rik+ section  
#bbc7;f77#c7 9 ! second s5t5ce & ins]t+ 
section #bbc7;e77#c74  7#ac7 ,section   
#dige ( su* ,code is am5d$-- 7,a7 9     
subsection 7c77#f7--  7i7 by /rik+      
section #bbc7;d7 & ins]t+ section       
#bbc7;c71 &  7ii7 by /rik+ section      
#bbc7;e77#b7 & ins]t+ section           
#bbc7;d77#b71 &  7,b7 9 subsection      
7e77#a77;,e71 by /rik+ section #bbc7;d7 
& ins]t+ section #bbc7;c74  7#ad7       

,section #ffic7;a77#b77;,c7 ( su* ,code 
is am5d$ by /rik+ section #bbc7;h7 &    
ins]t+ section #bbc7;g74  7c7 ,effective
 date ,! am5dm5ts made by ?is section   
%all apply to taxable ye>s beg9n+ aft]  
,decemb] #ca1 #bjae4  #bjb4 ,treatm5t ( 
,,hsa aft] dea? ( acc\nt b5efici>y  7a7 
,9 g5]al ,section #bbc7;e77#h7 ( !      
,int]nal ,rev5ue ,code ( #aihf1 z       
r$esignat$ by section #bja7;c77#c7 ( ?is
 ,act1 is am5d$ to read z foll[s3  7#h7 
,treatm5t aft] dea? ( acc\nt b5efici>y  
,if an individual acquires an acc\nt    
b5efici>y's int]e/ 9 a heal? sav+s      
acc\nt by reason ( ! dea? ( ! acc\nt    
b5efici>y1 su* heal? sav+s acc\nt %all  
be treat$ z if ! individual 7 ! acc\nt  
b5efici>y4  4  7b7 ,effective date ,!   
am5dm5t made by ?is section %all apply )
 respect to int]e/s acquir$ aft] ! date 
( ! enactm5t ( ?is ,act4  #bjc4 ,pur*ase
 ( heal? insurance f ,,hsa acc\nt  7a7  
,9 g5]al ,section #bbc7;c77#b7 ( !      
,int]nal ,rev5ue ,code ( #aihf1 z       
r$esignat$ by section #bja7;c77#c71 is  

am5d$--  7#a7 9 subp>agraph 7,c7-- 7,a7 
by /rik+ or at ! end ( clause 7iii71    
7,b7 by /rik+ ! p]iod at ! end ( clause 
7iv7 & ins]t+ 1 &1 &  7,c7 by add+ at ! 
end ! foll[+ new clause3  7v7 9 ! case (
 heal? insurance t meets ! requirem5ts (
 subp>agraph 7,d74  2 &  7#b7 by add+ at
 ! end ! foll[+ new subp>agraphs3  7,d7 
,requirem5ts ,! requirem5ts ( ?is       
subp>agraph are z foll[s3 7i7 ,op5      
enrollm5t )\t preexi/+ condition        
exclusions ,! heal? insurance cov]age or
 gr\p heal? plan mu/ p]mit1 dur+ uni=m  
initial & annual op5 enrollm5t p]iods & 
= special enrollm5t p]iods 7su* z ! loss
 ( cov]age ?r\gh ! loss ( employm5t7    
specifi$ 9 c>ry+ out section #aje7;b7 ( 
! ,pati5t ,fre$om ,act ( #bjae1 any     
individual :o has p]iod ( cont9u\s      
cov]age ( n less ?an #ah mon?s :o is    
o!rwise eligible to enroll "u su*       
cov]age or plan to be s enroll$ )\t !   
imposition ( any preexi/+ condition     
exclusion 7z def9$ = purposes ( title   
,,xxvii ( ! ,public ,heal? ,s]vice      

,act74  7ii7 ,class bas$ premiums =     
basic b5efits  7,i7 ,9 g5]al ,! premium 
= su* cov]age or plan %all be e/abli%$  
bas$ on class-av]age /atus & may v>y by 
age & geographic area1 b may n v>y bas$ 
^u ! heal? /atus ( ! individual1 except 
t 9 ! case ( an individual )\t cont9u\s 
cov]age = a p]iod ( #db mon?s1 su*      
premium may be increas$ above !         
class-av]age 9 ! mann] & = ! "t p]iod   
specifi$ 9 section #aje7;d77#a77;,a77ii7
 ( ! ,pati5t ,fre$om ,act ( #bjae4      
7,,ii7 ,e/abli%m5t ( actu>ial tables ,9 
c>ry+ out subclause 7,i71 ! ,secret>y   
%all ent] into a contract ) a qualifi$  
organization1 su* z ! ,academy (        
,actu>ies1 = ! developm5t ( actu>ial    
tables to calculate class-av]age rates  
bas$ on age & geography4  7,e7 ,cont9u\s
 cov]age ,= purposes ( ?is p>agraph1 an 
individual %all be consid]$ to h        
cont9u\s cov]age z ( a "t if !          
individual has no cont9u\s p]iod 9 :i* !
 individual is un9sur$ 7z def9$ 9       
section #ajj ( ! ,pati5t ,fre$om ,act ( 

#bjae7 = long] ?an #fc days beg9n+ aft] 
! date ( ! enactm5t ( su* ,act4  4  7b7 
,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ,decemb] #ca1 #bjae4  #bjd4 
,publi%+ ( ca% price = c>e paid ?r\gh   
heal? sav+s acc\nts  7a7 ,9 g5]al       
,section #bbc7;e7 ( ! ,int]nal ,rev5ue  
,code ( #aihf1 z r$esignat$ by section  
#bja7;c77#c71 is am5d$ by add+ at ! end 
! foll[+ new p>agraph3  7#i7 ,ca% price 
transp>5cy requir$ = paym5ts to heal?   
c>e provid]s  7,a7 ,9 g5]al ,a paym5t to
 a heal? c>e provid] ) respect to !     
furni%+ ( heal? c>e items & s]vices by  
su* provid] %all n be treat$ z a        
qualifi$ m$ical exp5se unless ! heal?   
c>e provid] provides = cont9u+          
disclosure 7su* z ?r\gh po/+ on a       
publicly accessible website7 ( ! ca%    
price ! heal? c>e provid] *>ges = !     
furni%+ ( su* items & s]vices4  7,b7 ,=m
 ( disclosure ,! disclosure ( prices "u 
?is subsection %all be 9 a =m & mann]   
specifi$ by ! ,secret>y ( ,heal? &      

,human ,s]vices1 9 consultation ) !     
,secret>y1 & %all be design$--  7i7 to  
e/abli% a s+le price = relat$ items &   
s]vices 9 a mann] simil> to ! mann] 9   
:i* pric+ & paym5t = su* items & s]vices
 is provid$ "u ! ,m$ic>e program "u     
title ,,xviii ( ! ,social ,security     
,act1 &  7ii7 to make x easy = consum]s 
to comp>e ! prices = simil> items &     
s]vices furni%$ by diff]5t provid]s4    
7,c7 ,failure to furni% s]vices or *>ge 
9 excess ( /at$ price ,a heal? c>e      
provid] %all be treat$ z n meet+ !      
requirem5t ( subp>agraph 7,a71 9 ! case 
( items & s]vices = :i* ! provid] is    
disclos+ a ca% price1 if ! provid]--    
7i7 refuses to furni% su* items or      
s]vices at ! price li/$1 or  7ii7 *>ges 
m ?an ! price li/$ = ! furni%+ ( ! items
 & s]vices4  4  7b7 ,en=cem5t ,if !     
,secret>y ( ,heal? & ,human ,s]vices    
det]m9es t a heal? c>e provid] has n    
provid$ = cont9u+ disclosure ( ! ca%    
price ( heal? c>e provid] *>ges "u      
section #bbc7;e77#i7 ( ! ,int]nal       

,rev5ue ,code ( #aihf1 ! ,secret>y may  
in/ruct ! ,secret>y ( ! ,treasury t     
paym5ts made to su* provid] %all be n   
treat$1 = purposes ( section #bbc ( !   
,int]nal ,rev5ue ,code ( #aihf1 z an    
am\nt us$ = a qualifi$ m$ical exp5se = a
 p]iod ( n to exce$ #a ye>4  7c7        
,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ,decemb] #ca1 #bjae4  ,b    
,heal? ,c>e ,tax cr$its  #baa4 ,limit$  
application ( ,,ppaca heal? premium     
cr$it  7a7 ,9 g5]al ,section            
#cf;,b7c77#a7 ( ! ,int]nal ,rev5ue ,code
 ( #aihf is am5d$ by add+ at ! end !    
foll[+3  7,e7 ,special rule = resid5ts (
 ,/ates cont9u+ ,,ppaca implem5tation   
,no cr$it %all be all[$ "u ?is section  
to any individual :o is n a qualifi$    
resid5t 7z def9$ 9 section #ajj7ad7 ( ! 
,pati5t ,fre$om ,act ( #bjae7 ( a ,/ate 
t has elect$ ! option "u section        
#aja7;a77#a7 ( su* ,act 9 relation to ! 
implem5tation ( title ,i ( ! ,pati5t    
,protection & ,af=dable ,c>e ,act4  4   

7b7 ,effective date ,! am5dm5t made by  
?is section %all apply to taxable ye>s  
beg9n+ aft] ,decemb] #ca1 #bjae4  #bab4 
,new ,,hsa cr$it  7a7 ,9 g5]al ,subp>t  
,c ( "p ,,iv ( sub*apt] ,a ( *apt] #a ( 
! ,int]nal ,rev5ue ,code ( #aihf is     
am5d$ by add+ at ! end ! foll[+ new     
section3  #cf;,c4 ,,hsa cr$it  7a7 ,9   
g5]al ,9 ! case ( a qualifi$ individual1
 !re %all be all[$ z a cr$it aga9/ ! tax
 impos$ by ?is subtitle = any taxable   
ye>1 an am\nt equal to ! ,,hsa cr$it    
am\nt ( ! individual = ! taxable ye>4   
7b7 ,qualify+ individual ,= purposes (  
?is section1 ! t]m qualify+ individual  
means1 ) respect to any mon?1 any       
individual :o = su* mon? is deposit     
qualify+ resid5t 7z def9$ 9 section     
#ajb7;b77#b7 ( ! ,pati5t ,fre$om ,act ( 
#bjae7 ( a ,/ate describ$ 9 section     
#aja7;a77#c7 ( su* ,act t elects to h   
section #ajb7;b7 ( su* ,act c>ri$ out by
 way ( ! cr$it det]m9$ "u ?is section4  
7c7 ,,hsa cr$it am\nt ,= purposes ( ?is 
section1 ! t]m ,,hsa cr$it am\nt means1 

) respect to any taxable ye>1 ! sum ( ! 
,,hsa deposit am\nts det]m9$ "u section 
#ajc ( ! ,pati5t ,fre$om ,act ( #bjae ) 
respect to ! individual = all mon?s end+
 dur+ ! taxable ye>4  7d7 ,special rules
 ,= purposes ( ?is section-- 7#a7       
,reconciliation ( cr$it & advance cr$it 
7,a7 ,excess advance paym5ts ,if !      
advance paym5ts to an individual = a    
taxable ye> "u subsection 7e7 exce$ !   
cr$it all[$ by ?is section ) respect to 
su* individual = su* taxable ye>1 ! tax 
impos$ by ?is *apt] = ! taxable ye> %all
 be increas$ by ! am\nt ( su* excess4   
7,b7 ,advance paym5t %ortfall ,if !     
cr$it all[$ by ?is section 7det]m9$ )\t 
reg>d to ?is subp>agraph7 ) respect to  
an individual = a taxable ye> exce$s !  
advance paym5ts to su* individual = su* 
taxable ye> "u subsection 7e71 !        
,secret>y %all1 9 lieu ( a cr$it all[$  
aga9/ ! tax impos$ by ?is subtitle1 make
 a paym5t on behalf ( su* individual to 
su* individual's heal? sav+s acc\nt 9 an
 am\nt equal to su* excess4  7#b7 ,m>ri$

 c\ples mu/ file jo9t return ,if !      
taxpay] is m>ri$ 7)9 ! mean+ ( section  
#ggjc7 at ! close ( ! taxable ye>1 !    
cr$it %all be all[$ "u ?is section only 
if ! taxpay] & ! taxpay]'s sp\se file a 
jo9t return = ! taxable ye>4  7e7       
,advance paym5t program  7#a7 ,9 g5]al  
,! ,secret>y ( ! ,treasury1 9           
consultation ) ! ,secret>y ( ,heal? &   
,human ,s]vices1 %all e/abli% a         
program--  7,a7 to make advance         
det]m9ations ) respect to ! eligibility 
( individuals = ! cr$it all[$ "u ?is    
section1 &  7,b7 to make advance paym5ts
 ( ! cr$it all[$ "u ?is section directly
 to ! heal? sav+s acc\nt ( any su*      
individual s eligible4  7#b7 ,program   
requirem5ts ,su* program %all be        
e/abli%$ "u rules simil> to ! rules (   
section #adab ( ! ,pati5t ,protection & 
,af=dable ,c>e ,act1 except t advance   
det]m9ations & advance paym5ts %all be  
made on reque/ ( ! individual ) respect 
to :om ! det]m9ation is to be made &    
tak+ into acc\nt ! enrollm5t process    

7includ+ any opt-out election "u su*    
process7 e/abli%$ "u section            
#ajd7;c77#a7 ( ! ,pati5t ,fre$om ,act ( 
#bjae4  4  7b7 ,cl]ical am5dm5t ,! table
 ( sections = su* subp>t is am5d$ by    
add+ at ! end ! foll[+3  ,sec4 #cf;,c4  
,,hsa cr$it4  4  7c7 ,effective date ,! 
am5dm5ts made by ?is section %all apply 
to taxable ye>s beg9n+ aft] ,decemb]    
#ca1 #bjae4