,i  #aad? ,,congress  #a/ ,session  ,h4 
,r4 #cbda  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,july #bh1 #bjae ,mr4 
,mc,dermott introduc$ ! foll[+ bill2 :i*
 0 ref]r$ to ! ,committee on ,en]gy &   
,comm]ce1 & 9 addition to ! ,committees 
on ,ways & ,means1 ,ov]sight & ,gov]nm5t
 ,re=m1 ,arm$ ,s]vices1 & ,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 am5d title ,i ( ! ,pati5t  
,protection & ,af=dable ,c>e ,act to    
au?orize ! e/abli%m5t (1 & provide      
support =1 ,/ate-bas$ univ]sal heal? c>e
 sy/ems t provide compreh5sive heal?    
b5efits to ,/ate resid5ts1 & = o!r      
purposes4  #a4 ,%ort title2 purpose  7a7
 ,%ort title ,?is ,act may be cit$ z !  
,/ate-,bas$ ,univ]sal ,heal? ,c>e ,act (
 #bjae4  7b7 ,purpose ,! purpose ( ?is  
,act is to e/abli% a flexible framework 
"u :i* ea* ,/ate c provide compreh5sive 
univ]sal heal? cov]age to all ( its     

resid5ts4  #b4 ,waiv] = ,/ate univ]sal  
heal? c>e  7a7 ,9 g5]al ,subtitle ,d (  
title ,i ( ! ,pati5t ,protection &      
,af=dable ,c>e ,act 7,public ,law       
#aaa-adh7 is am5d$ by ins]t+ aft]       
section #accb 7#db ,u4,s4,c4 #ahjeb7 !  
foll[+ new section3  #accb;,a4 ,waiv] = 
,/ate univ]sal heal? c>e  7a7           
,application  7#a7 ,9 g5]al ,a ,/ate may
 apply to ! ,secret>y 7z def9$ 9        
subsection 7g77#c77 = ! waiv] ( s mu* ( 
! requirem5ts describ$ 9 p>agraph 7#b7 )
 respect to heal? b5efits cov]age )9 t  
,/ate = plan ye>s beg9n+ on or aft]     
,janu>y #a1 #bjaf1 z is necess>y to     
implem5t a compreh5sive ,/ate univ]sal  
heal? c>e plan 9 ! ,/ate "u ?is section4
 ,su* application %all--  7,a7 be fil$  
at su* "t & 9 su* mann] z ! ,secret>y   
may require2  7,b7 conta9 su* in=mation 
z ! ,secret>y may require1 includ+--    
7i7 a compreh5sive description ( ! ,/ate
 legislation & program to implem5t a    
plan meet+ ! requirem5ts = a waiv] "u   
?is section2 &  7ii7 a #aj-;fiscal-ye>  

budget plan = su* plan t is budget      
neutral = ! ,f$]al ,gov]nm5t2 &  7,c7   
provide an assurance t ! ,/ate has      
enact$ ! law describ$ 9 subsection      
7b77#b74  7#b7 ,requirem5ts ,!          
requirem5ts describ$ 9 ?is p>agraph )   
respect to heal? b5efits cov]age )9 !   
,/ate = plan ye>s beg9n+ on or aft]     
,janu>y #a1 #bjaf1 are z foll[s3  7,a7  
,p>ts ,i1 ,,ii1 & ,,iii ( subtitle ,d4  
7,b7 ,section #adjb4  7,c7 ,sections    
#cf;,b1 #dihj;,h1 & #ejjj;,a ( !        
,int]nal ,rev5ue ,code ( #aihf4  7,d7   
,title ,,xi ( ! ,social ,security ,act4 
7,e7 ,title ,,xviii ( ! ,social         
,security ,act4  7,f7 ,title ,,xix ( !  
,social ,security ,act4  7,g7 ,title    
,,xxi ( ! ,social ,security ,act4  7,h7 
,*apt] #hi ( title #e ( ! ,unit$ ,/ates 
,code4  7,i7 ,*apt] #ee ( title #aj1    
,unit$ ,/ates ,code1 includ+ cov]age "u 
! ,,tric>e program4  7,j7 ,section #ead 
( ! ,employee ,retirem5t ,income        
,security ,act ( #aigd4  7#c7 ,pass     
?r\gh ( fund+ ,) respect to a ,/ate     

waiv] "u p>agraph 7#a71 "u :i* ! ,/ate  
assumes responsibility = heal? cov]age  
"u a specifi$ ,f$]al heal? program1     
includ+ "u ea* ( ! ,f$]al heal? c>e or  
subsidy programs specifi$ 9 subp>agraphs
 7,b71 7,c71 7,e71 7,f71 7,g71 & 7,h7 ( 
p>agraph 7#b71 ! ,secret>y %all n sp5d  
,f$]al heal? funds t w\ld o!rwise h be5 
sp5t = su* program & %all provide = an  
alt]native means by :i* ! aggregate     
am\nt ( su* funds %all be paid to !     
,/ate = purposes ( implem5t+ ! ,/ate    
plan "u ! waiv]4 ,su* am\nt %all be     
det]m9$ annually by ! ,secret>y1 tak+   
into acc\nt ! am\nt t w\ld o!rwise h be5
 sp5t "u su* ,f$]al heal? program )     
respect to resid5ts ( su* ,/ate1 if su* 
waiv] did n apply4 ,su* am\nt %all      
include funds equal to ! am\nt ( premium
 tax cr$its1 co/-%>+ r$uctions1 or      
small-bus9ess cr$its "u sections #cf;,b 
& #de,r ( ! ,int]nal ,rev5ue ,code (    
#aihf or "u section #adjb t w\ld h be5  
available to individuals & bus9esses 9 !
 ,/ate if su* waiv] did n apply4  7#d7  

,waiv] consid]ation & transp>5cy  7,a7  
,9 g5]al ,an application = a waiv] "u   
?is section %all be consid]$ by !       
,secret>y 9 accordance ) ! regulations  
describ$ 9 subp>agraph 7,b74  7,b7      
,regulations ,n lat] ?an #ahj days aft] 
! date ( enactm5t ( ! ,/ate-,bas$       
,univ]sal ,heal? ,c>e ,act ( #bjae1 !   
,secret>y %all promulgate regulations   
relat+ to waiv]s "u ?is section t       
provide-- 7i7 a process = public notice 
& comm5t at ! ,/ate level1 includ+      
public he>+s1 suffici5t to ensure a     
mean+ful level ( public input2  7ii7 a  
process = ! submission ( an application 
t ensures ! disclosure (-- 7,i7 !       
provisions ( law t ! ,/ate involv$ seeks
 to waive2 &  7,,ii7 ! specific plans ( 
! ,/ate to ensure t ! waiv] w be 9      
compliance ) subsection 7b72  7iii7 a   
process = provid+ public notice & comm5t
 aft] ! application is receiv$ by !     
,secret>y1 t is suffici5t to ensure a   
mean+ful level ( public input & t does n
 impose requirem5ts t are 9 addition to1

 or duplicative (1 requirem5ts impos$ "u
 ! ,adm9i/rative ,proc$ure ,act1 or     
requirem5ts t are unreasonable or       
unnecess>ily burd5some ) respect to     
,/ate compliance2  7iv7 a process = !   
submission to ! ,secret>y ( p]iodic     
reports by ! ,/ate conc]n+ !            
implem5tation ( ! program "u ! waiv]2 & 
7v7 a process = ! p]iodic evaluation by 
! ,secret>y ) respect to waiv]s grant$  
"u ?is section4  7,c7 ,report ,!        
,secret>y %all annually report to       
,congress conc]n+ actions tak5 by !     
,secret>y ) respect to applications =   
waiv]s1 & programs conduct$ ?r\gh waiv]s
 grant$1 "u ?is section4  7b7 ,grant+ ( 
waiv]s  7#a7 ,9 g5]al ,! ,secret>y may  
grant a reque/ = a waiv] "u subsection  
7a77#a7 only if ! ,secret>y det]m9es t !
 ,/ate plan--  7,a7 w provide heal?     
b5efits cov]age to ,/ate resid5ts t is  
at lea/ z compreh5sive z ! heal? b5efits
 cov]age t su* resid5ts w\ld h receiv$  
"u ! specifi$ ,f$]al heal? program = :i*
 su* resid5ts w\ld h be5 eligible1 abs5t

 su* waiv]2  7,b7 w provide cov]age &   
co/ %>+ protections aga9/ excessive     
out-(-pocket sp5d+ to ,/ate resid5ts t  
are at lea/ z af=dable z ! cov]age & co/
 %>+ protections "u ! specifi$ ,f$]al   
heal? program = :i* su* resid5ts w\ld h 
be5 eligible1 abs5t su* waiv]2  7,c7 w  
provide cov]age to sub/antially all     
resid5ts ( ! ,/ate1 includ+ sub/antially
 all ^? o!rwise cov]$ "u ! ,f$]al heal? 
c>e or subsidy programs specifi$ 9      
subp>agraphs 7,b71 7,c71 7,e71 7,f71    
7,g71 & 7,h7 ( subsection 7a77#b71      
except individuals :o are eligible =    
b5efits ?r\gh ! ,indian ,heal? ,s]vice  
or = b5efits & s]vices "u title #ch1    
,unit$ ,/ates ,code2  7,d7 w be publicly
 adm9i/]$ by an ag5cy ( ! ,/ate2 &  7,e7
 w n increase ! ,f$]al deficit4         
,subp>agraph 7,d7 %all n be con/ru$ z   
limit+ a ,/ate f contract+ ) "o or m    
private entities to adm9i/] ! plan4     
7#b7 ,requirem5t to enact a law  7,a7 ,9
 g5]al ,a law describ$ 9 ?is p>agraph is
 a ,/ate law t provides = ,/ate actions 

"u a waiv] "u ?is section1 includ+ !    
implem5tation ( ! ,/ate plan "u         
subsection 7a77#a77;,b74  7,b7          
,t]m9ation ( opt out ,a ,/ate may repeal
 a law describ$ 9 subp>agraph 7,a7 &    
t]m9ate ! au?ority provid$ "u ! waiv] ) 
respect to ! ,/ate4  7c7 ,scope ( waiv] 
7#a7 ,9 g5]al ,! ,secret>y %all det]m9e 
! scope ( a waiv] ( a requirem5t        
describ$ 9 subsection 7a77#b7 grant$ to 
a ,/ate "u subsection 7a77#a74  7#b7    
,limitation ,"u ?is section1 ! ,secret>y
 may n waive any ,f$]al law or          
requirem5t t is n li/$ 9 subsection     
7a77#b74  7d7 ,det]m9ations by ,secret>y
  7#a7 ,"t = det]m9ation ,! ,secret>y   
%all make a det]m9ation "u subsection   
7a77#a7 n lat] ?an #ahj days aft] !     
receipt ( an application f a ,/ate "u   
su* subsection4  7#b7 ,effect (         
,det]m9ation  7,a7 ,grant+ ( waiv]s ,if 
! ,secret>y det]m9es to grant a waiv] "u
 subsection 7a77#a71 ! ,secret>y %all   
notify ! ,/ate involv$ ( su* det]m9ation
 & ! t]ms & effectiv5ess ( su* waiv]4   

7,b7 ,d5ial ( waiv] ,if ! ,secret>y     
det]m9es a waiv] %\ld n be grant$ "u    
subsection 7a77#a71 ! ,secret>y %all    
notify ! ,/ate involv$ & ! appropriate  
committees ( ,congress ( su* det]m9ation
 & ! reasons !re=4  7e7 ,t]m ( waiv] ,no
 waiv] "u ?is section may ext5d ov] a   
p]iod ( long] ?an #e ye>s unless ! ,/ate
 reque/s cont9uation ( su* waiv]1 & su* 
reque/ %all be deem$ grant$ unless !    
,secret>y1 )9 #ij days aft] ! date ( its
 submission to ! ,secret>y1 ei!r d5ies  
su* reque/ 9 writ+ or in=ms ! ,/ate 9   
writ+ ) respect to any additional       
in=mation :i* is ne$$ 9 ord] to make a  
f9al det]m9ation ) respect to ! reque/4 
7f7 ,assur+ coord9ation  7#a7 ,9 g5]al  
,n lat] ?an #ahj days aft] ! enactm5t ( 
! ,/ate-,bas$ ,univ]sal ,heal? ,c>e ,act
 ( #bjae1 ! ,secret>y ( ,heal? & ,human 
,s]vices1 ! ,secret>y ( ! ,treasury1 !  
,director ( ! ,(fice ( ,p]sonnel        
,managem5t1 ! ,secret>y ( ,def5se1 & !  
,secret>y ( ,labor %all1 ?r\gh !        
execution ( an int]ag5cy memor&um (     

und]/&+ among su* ,secret>ies & !       
,director--  7,a7 develop a process =   
coord9at+ & consolidat+ ! ,/ate waiv]   
processes applicable "u ! provisions (  
?is section1 & ! exi/+ waiv] processes  
applicable "u--  7i7 titles ,,xi1       
,,xviii1 ,,xix1 & ,,xxi ( ! ,social     
,security ,act2 &  7ii7 any o!r ,f$]al  
law relat+ to ! provision ( heal? c>e   
items or s]vices2 &  7,b7 ensure t-- 7i7
 regulations 7includ+ regulations       
requir$ "u subsection 7a77#d77;,b771    
rul+s1 & int]pretations issu$ by su*    
,secret>ies & ! ,director relat+ to !   
same matt] ov] :i* two or m su*         
,secret>ies or ,director h              
responsibility "u ?is section are       
adm9i/]$ s z to h ! same effect at all  
times2 &  7ii7 coord9ation ( policies   
relat+ to ! grant+1 implem5tation1 &    
cont9uation ( waiv]s ?r\gh su*          
,secret>ies & ,director 9 ord] to h a   
coord9at$ /rategy t avoids duplication (
 ef=t by ! ,/ates or ,secret>ies &      
,director & ensures cl>ity ab\t waiv]   

application /atus & approval4  7#b7     
,s+le application ,! process "u p>agraph
 7#a77;,a7 %all p]mit a ,/ate to submit 
a s+le application = a waiv] "u all ( ! 
provisions ( ?is section & ! provisions 
( law li/$ "u clauses 7i7 & 7ii7 ( su*  
p>agraph4  7#c7 ,submission ( con=m+    
am5dm5ts ,! ,secret>y ( ,heal? & ,human 
,s]vices1 9 coord9ation ) ! o!r         
,secret>ies 7includ+ ! ,director ( !    
,(fice ( ,p]sonnel ,managem5t71 %all    
submit to ,congress su* recomm5dations =
 su* te*nical & con=m+ am5dm5ts to law z
 may be appropriate to assi/ 9 !        
implem5tation ( ?is section4  7g7       
,def9itions ,9 ?is section3 7#a7 ,heal? 
b5efits cov]age ,! t]m heal? b5efits    
cov]age--  7,a7 means-- 7i7 heal?       
insurance cov]age1 z su* t]m is def9$ 9 
section #bgia7;b7 ( ! ,public ,heal?    
,s]vice ,act 7#db ,u4,s4,c4             
#cjj;gg-#ia7;b772 &  7ii7 cov]age "u a  
gr\p heal? plan1 z su* t]m is def9$ 9   
section #bgia7;a7 ( ! ,public ,heal?    
,s]vice ,act 7#db ,u4,s4,c4             

#cjj;gg-#ia7;a772 &  7,b7 includes any  
m$ical cov]age or heal? b5efits provid$ 
"u any specifi$ ,f$]al heal? program    
describ$ 9 subp>agraphs 7,a7 ?r\gh 7,e7 
( p>agraph 7#d74  7#b7 ,resid5t ,)      
respect to a ,/ate1 ! t]m resid5t means 
an individual :o is a citiz5 or national
 ( ! ,unit$ ,/ates or an ali5 lawfully  
resid+ 9 ! ,/ate1 & ^: prim>y resid5ce  
7z def9$ by ! ,/ate7 is locat$ 9 !      
,/ate4  7#c7 ,secret>y ,! t]m ,secret>y 
means-- 7,a7 ! ,secret>y ( ,heal? &     
,human ,s]vices ) respect to waiv]s     
relat+ to ! provisions describ$ 9       
subp>agraphs 7,a71 7,b71 & 7,d7 ?r\gh   
7,g7 ( p>agraph 7#b7 ( subsection 7a72  
7,b7 ! ,secret>y ( ! ,treasury ) respect
 to waiv]s relat+ to ! provisions       
describ$ 9 subp>agraph 7,c7 ( su*       
p>agraph2  7,c7 ! ,director ( ! ,(fice (
 ,p]sonnel ,managem5t ) respect to      
waiv]s relat+ to ! provisions describ$ 9
 subp>agraph 7,h7 ( su* p>agraph2  7,d7 
! ,secret>y ( ,def5se ) respect to      
waiv]s relat+ to ! provisions describ$ 9

 subp>agraph 7,i7 ( su* p>agraph2 &     
7,e7 ! ,secret>y ( ,labor ) respect to  
waiv]s relat+ to ! provisions describ$ 9
 subp>agraph 7,j7 ( su* p>agraph4  7#d7 
,specifi$ ,f$]al heal? program ,! t]m   
specifi$ ,f$]al heal? program means all 
( ! foll[+ programs3 7,a7 ,! ,m$ic>e    
program "u title ,,xviii ( ! ,social    
,security ,act4  7,b7 ,! ,m$icaid       
program "u title ,,xix ( ! ,social      
,security ,act4  7,c7 ,! ,*ildr5's      
,heal? ,insurance ,program "u title     
,,xxi ( ! ,social ,security ,act4  7,d7 
,! ,f$]al ,employees ,heal? ,b5efits    
,plan "u *apt] #hi ( title #e ( ! ,unit$
 ,/ates ,code4  7,e7 ,m$ical cov]age "u 
*apt] #ee ( title #aj1 ,unit$ ,/ates    
,code1 includ+ cov]age "u ! ,,tric>e    
program4  7,f7 ,an ,ex*ange e/abli%$ "u 
?is subtitle4  7,g7 ,subsidies "u       
section #adjb4  7,h7 ,tax cr$its "u     
sections #cf;,b & #de,r ( ! ,int]nal    
,rev5ue ,code ( #aihf4  4  7b7 ,cl]ical 
am5dm5t ,! table ( cont5ts 9 section    
#a7;b7 ( su* ,act is am5d$ by ins]t+    

aft] ! item relat+ to section #accb !   
foll[+ new item3  ,sec4 #accb;,a4 ,waiv]
 = ,/ate univ]sal heal? c>e4  4