,i  #aad? ,,congress  #a/ ,session  ,h4 
,r4 #cceb  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,july #bi1 #bjae ,mr4 
,hultgr5 introduc$ ! foll[+ bill2 :i* 0 
ref]r$ to ! ,committee on ,en]gy &      
,comm]ce1 & 9 addition to ! ,committee  
on ,ways & ,means1 = 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 ! ,pati5t  
,protection & ,af=dable ,c>e ,act & !   
,int]nal ,rev5ue ,code ( #aihf to       
provide great] flexibility ) respect to 
waiv]s grant$ to ,/ates1 & = o!r        
purposes4  #a4 ,%ort title ,?is ,act may
 be cit$ z ! ,/ate ,heal? ,c>e ,options 
,act ( #bjae4  #b4 ,increas+ ,/ate      
flexibility ?r\gh provision ( heal?-flex
 & ex*ange waiv]s  7a7 ,/ate options    
7#a7 ,9 g5]al ,! ,pati5t ,protection &  
,af=dable ,c>e ,act is am5d$ by ins]t+  
aft] section #accb 7#db ,u4,s4,c4       
#ahjeb7 ! foll[+3  #accb;,a4 ,options = 
,/ate flexibility  7a7 ,/ate options    

7#a7 ,9 g5]al ,if a ,/ate provides to ! 
,secret>y a notice 79 ?is section ref]r$
 to z a waiv] notice7 ( int5t to        
implem5t a heal?-flex waiv] 7describ$ 9 
subsection 7b77#a771 an ex*ange waiv]   
7describ$ 9 subsection 7b77#b771 or bo?1
 & su* notice complies ) p>agraph 7#b71 
! waiv] %all be deem$ to be approv$ &   
effective1 except z provid$ 9 p>agraphs 
7#e7 & 7#f74  7#b7 ,cont5ts ( a waiv]   
notice ,a waiv] notice ) respect to a   
,/ate %all include ! foll[+3 7,a7 ,!    
ye>s = :i* ! waiv] %all be effective    
7:i* may be indef9ite74  7,b7 ,an       
assurance t ! ,/ate w comply ) annual   
report+ requirem5ts e/abli%$ by !       
,secret>y relat+ to ! activities ( !    
,/ate "u ! waiv]1 :i* report+           
requirem5ts %all include in=mation on   
af=dability1 access1 & transp>5cy4  7,c7
 ,9 ! case ( a heal?-flex waiv]-- 7i7 ! 
requirem5ts to be waiv$2  7ii7 an       
assurance t !re w be available ?r\gh\t !
 ,/ate "o or m heal? plans t provide !  
cata/rophic level ( cov]age describ$ 9  

subsection 7c77#a77;,b77i7 = :i* an     
enrollee's requir$ contribution 7z def9$
 9 section #ejjj;,a7e77#a77;,b7 ( !     
,int]nal ,rev5ue ,code ( #aihf1 det]m9$ 
on an annual basis7 does n exce$ #f4e   
p]c5t ( ! m$ian h\sehold income 7z def9$
 9 section #cf;,b7d77#b77;,a7 ( su*     
,code7 ( resid5ts ( ! ,/ate = ! mo/     
rec5t taxable ye> = :i* in=mation on su*
 m$ian h\sehold income is available to !
 ,secret>y2 &  7iii7 an assurance t !   
c]tify+ entity 7z def9$ 9 subsection    
7c77#b77 has a process to c]tify heal?  
plans z p]missible heal? plans consi/5t 
) subsection 7c74  7,d7 ,9 ! case ( an  
ex*ange waiv]1 assurances t ! ,/ate--   
7i7 w be responsible = functions t are  
necess>y to c>ry out ! waiv] t w\ld     
o!rwise be p]=m$ by an ,ex*ange2  7ii7 w
 comply ) subsection 7d72  7iii7 has !  
capability to receive f ! ,secret>y     
subsidy eligibility in=mation2 &  7iv7  
has & is apply+ /&>ds = privacy1        
security1 & data encryption = subsidy   
eligibility in=mation t are det]m9$ to  

be satisfactory by ! ,secret>y4  7#c7   
,effectiv5ess ,a waiv] "u ?is section   
%all be effective = ! ye>s describ$ 9 ! 
waiv] notice "u p>agraph 7#b77;,a71     
except t no waiv] "u ?is section %all be
 effective = a ye> unless ! waiv] notice
 = su* waiv] 0 submitt$ be=e ,novemb] #a
 ( ! previ\s ye>4  7#d7 ,modification or
 t]m9ation ,a ,/ate may modify or       
t]m9ate a waiv] = ! ,/ate "u ?is section
 by submitt+ to ! ,secret>y a subsequ5t 
waiv] notice ) respect to su* waiv]4    
7#e7 ,disapproval au?ority ,if !        
,secret>y det]m9es t a waiv] notice     
fails to comply ) p>agraph 7#b7 &       
notifies ! ,/ate ( ! reason = su*       
det]m9ation n lat] ?an #cj days aft] !  
date on :i* ! ,/ate submits ! waiv]     
notice1 su* waiv] notice %all n be      
effective4  7#f7 ,revocation ,if !      
,secret>y det]m9es t a ,/ate is 9       
violation ( an assurance submitt$ "u    
p>agraph 7#b7 & notifies ! ,/ate ( !    
reason = su* det]m9ation1 ! ,secret>y   
may revoke ! waiv]4 ,su* revocation %all

 be effective on ! fir/ day ( ! fir/ ye>
 t beg9s aft] ! #fj-;day p]iod t beg9s  
on ! date on :i* notification ( !       
revocation occurs4  7#g7 ,con/ruction   
,no?+ 9 ?is section %all be con/ru$ z   
requir+ a ,/ate to enact a law 9 ord] to
 c>ry out ! provisions ( ?is section4   
7b7 ,waiv]s  7#a7 ,heal?-flex waiv] ,a  
waiv] "u ?is p>agraph 79 ?is section    
ref]r$ to z a heal?-flex waiv]71 )      
respect to a ,/ate1 is a waiv] ( any ( !
 requirem5ts 9 sections #acja ?r\gh     
#acjc4  7#b7 ,ex*ange waiv] ,a waiv] "u 
?is p>agraph 79 ?is section ref]r$ to z 
an ex*ange waiv]7 p]mits a ,/ate to     
elect to be responsible = c]ta9 ,ex*ange
 functions1 includ+ s]v+ z ! c]tify+    
entity = ! purposes ( subsection 7c74   
7#c7 ,no waiv] ( adult *ild cov]age &   
preexi/+ conditions ,no?+ 9 ?is         
subsection may be con/ru$ to p]mit a    
,/ate to waive ! foll[+3 7,a7           
,prohibition ( preexi/+ condition       
exclusion ,section #bgjd ( ! ,public    
,heal? ,s]vice ,act 7#db ,u4,s4,c4      

#cjj;gg-#c74  7,b7 ,ext5sion ( cov]age =
 adult *ildr5 ,section #bgad ( ! ,public
 ,heal? ,s]vice ,act 7#db ,u4,s4,c4     
#cjj;gg-#ad74  7c7 ,c]tify+ p]missible  
heal? plans  7#a7 ,p]missible heal? plan
 def9$ ,= ! purposes ( ?is section1 !   
t]m p]missible heal? plan means1 )      
respect to a ,/ate1 a heal? plan t is   
(f]$ = sale 9 ! individual or small gr\p
 m>ket 9 ! ,/ate & t is c]tifi$ by a    
c]tify+ entity to meet ! foll[+         
requirem5ts3  7,a7 ,b5efits ,! plan     
provides b5efits = items & s]vices )9   
ea* ( ! foll[+ categories3 7i7          
,ambulatory pati5t s]vices4  7ii7       
,em]g5cy s]vices4  7iii7                
,hospitalization4  7iv7 ,physician      
s]vices4  7,b7 ,levels ( cov]age ,! plan
 provides a level ( cov]age t complies )
 "o ( ! foll[+ levels ( cov]age 7z      
e/abli%$ by ! ,/ate73  7i7 ,cata/rophic4
  7ii7 ,/&>d4  7iii7 ,high4  7,c7       
,transp>5cy ju/ify+ premiums ,! issu] ( 
! plan makes available to ! public      
in=mation ab\t ! demographics ( !       

population enroll$ "u ! plan1 !         
utilization ( heal? c>e items & s]vices 
by su* population "u ! plan1 & o!r      
factors t s]ve z a ju/ification = !     
premium levels 7includ+ any premium     
increases7 "u ! plan4  7,d7 ,in=mation  
requirem5t ,! issu] ( ! plan submits    
in=mation z requir$ "u section          
#cf;,b7g77#c77;,c7 ( ! ,int]nal ,rev5ue 
,code ( #aihf4  7#b7 ,c]tify+ entity    
def9$ ,9 ?is section1 ! t]m c]tify+     
entity means-- 7,a7 9 ! case ( a heal?  
plan t is (f]$ ?r\gh an ,ex*ange        
e/abli%$ by a ,/ate1 su* ,ex*ange2 &    
7,b7 9 ! case ( a heal? plan t is n s   
(f]$1 ! ,/ate 9 :i* su* plan is (f]$4   
7#c7 ,effect ( c]tify+ p]missible heal? 
plans ,) respect to eligibility =       
premium assi/ance tax cr$its & r$uc$    
co/-%>+ = individuals enroll$ 9         
p]missible heal? plans1 see section     
#cf;,b7g7 ( ! ,int]nal ,rev5ue ,code (  
#aihf & section #adjb7;f77#d7 ( !       
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjga71            

respectively4  7d7 ,det]m9+ subsidy     
eligibility  7#a7 ,9 g5]al ,9 ! case ( a
 ,/ate t has 9 effect an ex*ange waiv]1 
! ,/ate %all det]m9e ! eligibility (    
individuals resid+ 9 ! ,/ate = !        
assi/ance describ$ 9 subp>agraphs 7,a7 &
 7,b7 ( p>agraph 7#c74  7#b7 ,disclosure
 ( ,f$]al in=mation ,9 ! case ( a ,/ate 
t has 9 effect an ex*ange waiv]1 !      
,secret>y or ! ,secret>y ( ! ,treasury1 
z appropriate1 %all make subsidy        
eligibility in=mation available to !    
,/ate1 b only ! m9imum am\nt ( in=mation
 necess>y to enable ! ,/ate to det]m9e !
 am\nt ( ! assi/ance describ$ 9         
subp>agraphs 7,a7 & 7,b7 ( p>agraph 7#c7
 = :i* ! individual enroll$ 9 a         
p]missible heal? plan is eligible4  7#c7
 ,subsidy eligibility in=mation def9$ ,9
 ?is subsection1 ! t]m subsidy          
eligibility in=mation means in=mation   
conc]n+ ! eligibility ( an enrollee or a
 prospective enrollee 9 a heal? plan =--
  7,a7 a premium assi/ance cr$it "u     
section #cf;,b7a7 ( ! ,int]nal ,rev5ue  

,code ( #aihf2 &  7,b7 r$uc$ co/-%>+ "u 
section #adjb4  4  7#b7 ,report+        
requirem5ts ,! ,secret>y %all e/abli%   
annual report+ requirem5ts "u           
#accb;,a7a77#b77;,b7 ( ! ,pati5t        
,protection & ,af=dable ,c>e ,act t     
include in=mation on af=dability1       
access1 & transp>5cy4  7#c7 ,con=m+     
am5dm5t ,! table ( cont5ts ( ! ,pati5t  
,protection & ,af=dable ,c>e ,act is    
am5d$ by ins]t+ aft] ! item relat+ to   
section #accb ! foll[+3  ,sec4 #accb;,a4
 ,options = ,/ate flexibility4  4  7b7  
,subsidies = individuals enroll$ 9      
p]missible heal? plans  7#a7 ,premium   
assi/ance tax cr$its ,section #cf;,b ( !
 ,int]nal ,rev5ue ,code ( #aihf is      
am5d$-- 7,a7 by r$esignat+ subsection   
7g7 z subsection 7h72 &  7,b7 by ins]t+ 
aft] subsection 7f7 ! foll[+3  7g7      
,special rules 9 case ( waiv]s "u       
section #accb;,a ( ,,ppaca  7#a7 ,limit+
 eligibility to taxpay]s ) income at or 
bel[ #cjj p]c5t ( ,,fpl ,9 ! case ( a   
section #accb;,a ,/ate1 subsection      

7c77#a77;,a7 %all be appli$ by sub/itut+
 #cjj p]c5t = #djj p]c5t = a taxpay] :o 
obta9s cov]age ?r\gh a plan issu$ "u !  
law ( su* ,/ate = a ye>4  7#b7          
,p]missible heal? plans ,9 ! case ( a   
taxpay] :o obta9s cov]age ) respect to a
 section #accb;,a ,/ate1 = a cov]age    
mon?1 a p]missible heal? plan1 z def9$ 9
 section #accb;,a7c77#a7 ( ! ,pati5t    
,protection & ,af=dable ,c>e ,act1 %all 
be treat$ z a qualifi$ heal? plan )     
respect to su* taxpay]4  7#c7 ,adju/$   
mon?ly premium ,9 ! case ( a ,/ate t has
 9 effect a heal?-flex waiv] describ$ 9 
section #accb;,a7b77#a7 ( su* ,act1     
subsection 7b77#c77;,c7 %all be appli$ z
 if ! adju/$ mon?ly premium calculat$ "u
 su* subsection 7 multipli$ by ! ratio (
 ! full actu>ial value ( ! b5efits      
provid$ "u ! plan be+ (f]$ to ! full    
actu>ial value ( ess5tial heal? b5efits4
  7#d7 ,elim9at+ c]ta9 requirem5ts 9 !  
case ( an ex*ange waiv] ,9 ! case ( a   
,/ate t has 9 effect an ex*ange waiv]   
describ$ 9 section #accb;,a7b77#b7 ( su*

 ,act = a cov]age mon?1 ! foll[+ %all   
apply3  7,a7 ,elim9at+ ex*ange ref]5ces 
,subsections 7b77#b77;,a71              
7c77#b77;,a77i71 7d77#c77;,b71 & 7e77#c7
 %all be appli$ by treat+ ! p]missible  
heal? plan z if x 7 (f]$ ?r\gh an       
,ex*ange4  7,b7 ,applicable second l[e/ 
co/ silv] plan ,subsection 7b77#c77;,b7 
%all be appli$ by sub/itut+-- 7i7       
qualifi$ heal? plan = :i*1 if ! adju/$  
mon?ly premium1 tak+ into acc\nt        
subsection 7g77#c71 7 multipli$ by !    
ratio ( #gj p]c5t to ! level ( cov]age  
express$ z a p]c5t ( ! full actu>ial    
value ( ! b5efits provid$ "u ! plan1 !  
product ( su* multiplication w\ld be !  
second l[e/ su* product = any plan (f]$ 
9 = second l[e/ co/ silv] plan (1 &     
7ii7 is (f]$ 9 su* rat+ area = is (f]$  
?r\gh ! same ,ex*ange ?r\gh :i* !       
qualifi$ heal? plans tak5 into acc\nt "u
 p>agraph 7#b77;,a7 7 (f]$4  7,c7       
,in=mation requirem5t ,9 ! case ( a     
p]missible heal? plan :i* is n (f]$     
?r\gh an ,ex*ange1 su* plan %all provide

 to ! ,secret>y & to ! individual       
enroll$ 9 ! plan ! in=mation describ$ 9 
subsection 7f77#c7 ) respect to su* plan
 & su* individual4  7#e7 ,special rule =
 "p-"t resid5t taxpay]s ) income above  
#cjj p]c5t ( ,,fpl ,9 ! case ( a taxpay]
 :o1 dur+ a taxable ye>1 obta9s cov]age 
) respect to a #accb;,a ,/ate & )       
respect to a ,/ate :i* is n a #accb;,a  
,/ate1 p>agraph 7#a7 %all n apply & !   
premium assi/ance am\nt 7o!rwise det]m9$
 "u subsection 7b77#b77 = su* taxpay] = 
a cov]age mon? %all be #j if--  7,a7 !  
h\sehold income ( ! taxpay] = ! taxable 
ye> equals or exce$s #cjj p]c5t ( an    
am\nt equal to ! pov]ty l9e = a family (
 ! size involv$1 &  7,b7 ! taxpay]      
receives cov]age ) respect to a section 
#accb;,a ,/ate = su* cov]age mon?4  7#f7
 ,section #accb;,a ,/ate def9$ ,=       
purposes ( ?is subsection1 ! t]m section
 #accb;,a ,/ate means a ,/ate has 9     
effect a waiv] "u section #accb;,a ( !  
,pati5t ,protection & ,af=dable ,c>e    
,act4  4  7#b7 ,r$uc$ co/-%>+ ,section  

#adjb7;f7 ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjga7;f77 is am5d$ by add+ at ! end ! 
foll[+3  7#d7 #accb;,a waiv]s ,if a     
,/ate has 9 effect a waiv] "u #accb;,a1 
! foll[+ %all apply ) respect to a      
cov]age mon? ) respect to individuals   
resid+ 9 ! ,/ate on ! fir/ ( ! mon?3    
7,a7 ,elim9at+ r$uc$ co/-%>+ =          
individuals ) income above #cjj p]c5t ( 
,,fpl ,no individual ^: h\sehold income 
exce$s #cjj p]c5t ( ! pov]ty l9e = a    
family ( ! size involv$ may be consid]$ 
an eligible insur$ "u ?is section4  7,b7
 ,p]missible heal? plans ,= ! purposes (
 ?is section1 a p]missible heal? plan1 z
 def9$ 9 section #accb;,a7c77,a71 %all  
be treat$ z a qualifi$ heal? plan4  7,c7
 ,ex*ange waiv] ,if a ,/ate has 9 effect
 an ex*ange waiv] describ$ 9 section    
#accb;,a7b77#b71 subsections 7b77#a71   
7d77#a71 & 7e77#c7 %all apply z if !re 7
 no ref]5ces to an ,ex*ange4  4  7c7    
,accel]ation ( innovation waiv]s        
,section #accb7;a77#a7 ( ! ,pati5t      

,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjeb7 is am5d$1 9 ! matt]   
prec$+ subp>agraph 7,a71 by /rik+       
,janu>y #a1 #bjag & ins]t+ ! date ( !   
enactm5t ( ! ,/ate ,heal? ,c>e ,options 
,act ( #bjae4