,,ii #aad? ,,congress #b;d ,session ,s4 #beai ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,febru>y #i1 #bjaf,mr4 ,mc,cain 7= himself & ,mr4 ,p]due7 introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,f9ance ,a ,,bill ,to provide = inc5tives to enc\rage heal? insurance cov]age1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,emp[]+ ,pati5ts ,fir/ ,act ( #bjae4 7b7 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4,sec4 #b4 ,repeal ( ,,ppaca & heal? c>e-relat$ ,,hc]a provisions4,sec4 #c4 ,no m&ate ( gu>ante$ issue or community rat+4,title ,i--,tax inc5tives = ma9ta9+ heal? insurance coverage,subtitle ,a--,tax cr$it = heal? insurance coverage,sec4 #aja4 ,refundable tax cr$it = heal? insurance cov]age4,sec4 #ajb4 ,election ( tax cr$it in/ead ( alt]native gov]nm5t or gr\p plan b5efits4,subtitle ,b--,heal? sav+s accounts,sec4 #aaa4 ,refundable tax cr$it = heal? sav+s acc\nt contributions4,sec4 #aab4 ,all[+ ,,hsa rollov] to *ild or p>5t ( acc\nt hold]4,sec4 #aac4 ,maximum contribution limit to ,,hsa coord9at$ ) retirem5t sav+s acc\nt limitation4,sec4 #aad4 ,transf] ( requir$ m9imum di/ribution f retirem5t plan to heal? sav+s acc\nt4,sec4 #aae4 ,equival5t bankruptcy protections = heal? sav+s acc\nts z retirem5t funds4,sec4 #aaf4 ,all[ bo? sp\ses to make cat*-up contributions to ! same ,,hsa acc\nt4,sec4 #aag4 ,provisions relat+ to ,m$ic>e4,sec4 #aah4 ,individuals eligible = vet]ans b5efits = a s]vice-connect$ disability4,sec4 #aai4 ,individuals eligible = ,indian ,heal? ,s]vice assi/ance4,sec4 #abj4 ,individuals eligible = ,,tric>e cov]age4,sec4 #aba4 ,,fsa & ,,hra int]action ) ,h,s,as4,sec4 #abb4 ,special rule = c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt4,sec4 #abc4 ,prev5tive c>e prescription drug cl>ification4,sec4 #abd4 ,adm9i/rative error correction be=e due date ( return4,sec4 #abe4 ,memb]s ( heal? c>e %>+ m9i/ries eligible to e/abli% heal? sav+s acc\nts4,sec4 #abf4 ,high d$uctible heal? plans r5am$ ,,hsa qualifi$ plans4,sec4 #abg4 ,treatm5t ( direct prim>y c>e s]vice arrangem5ts4,sec4 #abh4 ,c]ta9 provid] fees to be treat$ z m$ical c>e4,sec4 #abi4 ,cl>ification ( treatm5t ( capitat$ prim>y c>e paym5ts z am\nts paid = m$ical c>e4,subtitle ,c--,o!r provisions,sec4 #aca4 ,limitation on employ]-provid$ heal? c>e cov]age4,sec4 #acb4 ,limitation on abortion fund+4,sec4 #acc4 ,no gov]nm5t discrim9ation aga9/ c]ta9 heal? c>e entities4,sec4 #acd4 ,equal employ] contribution rule to promote *oice4,sec4 #ace4 ,limitations on ,/ate re/rictions on employ] auto-enrollm5t4,sec4 #acf4 ,cr$it = small employ]s adopt+ auto-enrollm5t & def9$ contribution options4,title ,,ii--,heal? ,c>e ,access & ,availability,subtitle ,a--,heal? ,insurance ,pool+ ,me*anisms = ,individuals ,sec4 #bja4 ,f$]al grants = ,/ate insurance exp5ditures4,sec4 #bjb4 ,pool re=m = individual memb]%ip expansion4,subtitle ,b--,small ,bus9ess ,heal? ,fairness,sec4 #baa4 ,%ort title4,sec4 #bab4 ,rules gov]n+ association heal? plans4,sec4 #bac4 ,cl>ification ( treatm5t ( s+le employ] arrangem5ts4,sec4 #bad4 ,en=cem5t provisions relat+ to association heal? plans4,sec4 #bae4 ,coop]ation betwe5 ,f$]al & ,/ate au?orities4,sec4 #baf4 ,effective date & transitional & o!r rules4,subtitle ,c--,heal? ,insurance ,reforms,sec4 #bba4 ,requirem5ts = individual heal? insurance4,title ,,iii--,int]/ate ,m>ket = ,heal? ,insurance,sec4 #cja4 ,coop]ative gov]n+ ( individual heal? insurance cov]age4,title ,,iv--,lawsuit ,abuse ,reforms,sec4 #dja4 ,*ange 9 burd5 ( pro( bas$ on compliance ) cl9ical practice guidel9es4,sec4 #djb4 ,/ate grants to create exp]t panels & adm9i/rative heal? c>e tribunals4,sec4 #djc4 ,paym5t ( damages & recov]y ( co/s 9 heal? c>e lawsuits4,sec4 #djd4 ,def9itions4,sec4 #dje4 ,effect on o!r laws4,sec4 #djf4 ,applicability2 effective date4,title ,v--,wellness & ,prevention,sec4 #eja4 ,provid+ f9ancial inc5tives = treatm5t compliance4,title ,,vi--,transp>5cy & ,insurance ,re=m ,measures,sec4 #fja4 ,receipt & response to reque/s = claim in=mation4,title ,,vii--,quality,sec4 #gja4 ,prohibition on c]ta9 uses ( data obta9$ f comp>ative effectiv5ess rese>* or f pati5t-c5t]$ outcomes rese>*2 acc\nt+ = p]sonaliz$ m$ic9e & diff]5ces 9 pati5t treatm5t response4,sec4 #gjb4 ,e/abli%m5t ( p]=mance-bas$ quality measures4,title ,,viii--,/ate ,transp>5cy ,plan ,portal,sec4 #hja4 ,provid+ in=mation on heal? cov]age options & heal? c>e provid]s4,title ,,ix--,pati5t ,fre$om ( ,*oice ,sec4 #ija4 ,gu>antee+ fre$om ( *oice & contract+ = pati5ts "u ,m$ic>e4,sec4 #ijb4 ,preemption ( ,/ate laws limit+ *>ges = eligible pr(essional s]vices4,sec4 #ijc4 ,heal? c>e provid] lic5sure _c be condition$ on p>ticipation 9 a heal? plan4,sec4 #ijd4 ,bad debt d$uction = doctors to p>tially (fset ! co/ ( provid+ uncomp5sat$ c>e requir$ to be provid$ "u am5dm5ts made by ! ,em]g5cy ,m$ical ,treatm5t & ,labor ,act4,sec4 #ije4 ,"r ( contract ) heal? c>e provid]s4,title ,x--,quality ,heal? ,c>e ,coalition,sec4 #ajja4 ,quality ,heal? ,c>e ,coalition4 #b4 ,repeal ( ,,ppaca & heal? c>e-relat$ ,,hc]a provisions 7a7 ,,ppaca ,effective z ( ! enactm5t ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 su* ,act is repeal$1 & ! provisions ( law am5d$ or repeal$ by su* ,act are re/or$ or reviv$ z if su* ,act _h n be5 enact$4 7b7 ,heal? ,c>e-,relat$ ,provisions 9 ! ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj ,effective z ( ! enactm5t ( ! ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj 7,public ,law #aaa-aeb71 title ,i & subtitle ,b ( title ,,ii ( su* ,act are repeal$1 & ! provisions ( law am5d$ or repeal$ by su* title or subtitle1 respectively1 are re/or$ or reviv$ z if su* title & subtitle _h n be5 enact$4 #c4 ,no m&ate ( gu>ante$ issue or community rat+ ,no?+ 9 ?is ,act %all be con/ru$ to provide a m&ate = gu>ante$ issue or community rat+ 9 ! private insurance m>ket4 ,i ,tax inc5tives = ma9ta9+ heal? insurance cov]age ,a ,tax cr$it = heal? insurance cov]age #aja4 ,refundable tax cr$it = heal? insurance cov]age 7a7 ,9 g5]al ,subp>t ,c ( "p ,,iv ( sub*apt] ,a ( *apt] #a ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #b1 is am5d$ by ins]t+ aft] section #cf;,a ! foll[+ new section3 #cf;,b4 ,heal? insurance cov]age 7a7 ,9 g5]al ,9 ! case ( an individual1 !re %all be all[$ z a cr$it aga9/ ! tax impos$ by subtitle ,a an am\nt equal to ! aggregate mon?ly cr$it am\nts det]m9$ "u subsection 7b7 ) respect to ! taxpay] & ! taxpay]'s qualify+ family memb]s = eligible cov]age mon?s beg9n+ dur+ ! taxable ye>4 7b7 ,mon?ly cr$it am\nts 7#a7 ,9 g5]al ,! mon?ly cr$it am\nt ) respect to any individual = any eligible cov]age mon? is #a_/ab (-- 7,a7 #ijj 9 ! case ( an individual :o has n atta9$ age #ah z ( ! beg9n+ ( su* mon?1 7,b7 #a1bjj 9 ! case ( an individual :o has s atta9$ age #ah b :o has n s atta9$ age #ce1 7,c7 #b1ajj 9 ! case ( an individual :o has s atta9$ age #ce1 b :o has n s atta9$ age #ej1 & 7,d7 #c1jjj 9 ! case ( an individual :o has s atta9$ age #ej4 7#b7 ,inflation adju/m5t ,9 ! case ( any taxable ye> beg9n+ 9 a cal5d> ye> aft] #bjaf1 ea* ( ! doll> am\nts 9 p>agraph 7#a7 %all be increas$ by an am\nt equal to-- 7,a7 su* doll> am\nt1 multipli$ by 7,b7 ! co/-(-liv+ adju/m5t det]m9$ "u section #a7;f77#c7 = ! cal5d> ye> 9 :i* ! taxable ye> beg9s1 det]m9$ by sub/itut+ cal5d> ye> #bjae = cal5d> ye> #aiib 9 subp>agraph 7,b7 !re(4 ,any increase det]m9$ "u ! prec$+ s5t5ce %all be r\nd$ to ! ne>e/ multiple ( #ej4 7c7 ,eligible cov]age mon? ,= purposes ( ?is section1 ! t]m eligible cov]age mon? means1 ) respect to any individual1 any mon? if1 z ( ! fir/ day ( su* mon?1 ! individual-- 7#a7 is cov]$ by qualifi$ heal? insurance1 7#b7 does n h o!r specifi$ cov]age1 & 7#c7 is n imprison$ "u ,f$]al1 ,/ate1 or local au?ority4 7d7 ,qualify+ family memb] ,= purposes ( ?is section1 ! t]m qualify+ family memb] means-- 7#a7 9 ! case ( a jo9t return1 ! taxpay]'s sp\se1 & 7#b7 any dep5d5t ( ! taxpay]4 7e7 ,qualifi$ heal? insurance ,= purposes ( ?is section1 ! t]m qualifi$ heal? insurance means heal? insurance cov]age 7o!r ?an except$ b5efits z def9$ 9 section #ihcb7;c77 :i* con/itutes m$ical c>e4 7f7 ,o!r specifi$ cov]age ,= purposes ( ?is section1 an individual has o!r specifi$ cov]age = any mon? if1 z ( ! fir/ day ( su* mon?-- 7#a7 ,cov]age "u ,m$ic>e1 ,m$icaid1 or ,,s*ip ,su* individual-- 7,a7 is entitl$ to b5efits "u "p ,a ( title ,,xviii ( ! ,social ,security ,act or is enroll$ "u "p ,b ( su* title1 or 7,b7 is enroll$ 9 ! program "u title ,,xix or ,,xxi ( su* ,act 7o!r ?an "u section #aibh ( su* ,act74 7#b7 ,c]ta9 o!r cov]age ,su* individual-- 7,a7 is enroll$ 9 a heal? b5efits plan "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 7,b7 is entitl$ to receive b5efits "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code1 7,c7 is entitl$ to receive b5efits "u *apt] #ag ( title #ch1 ,unit$ ,/ates ,code1 7,d7 is enroll$ 9 a gr\p heal? plan 7)9 ! mean+ ( section #ejjj7;b77#a77 :i* is subsidiz$ by ! employ]1 or 7,e7 is a memb] ( a heal? c>e %>+ m9i/ry4 7#c7 ,heal? c>e %>+ m9i/ry ,= purposes ( ?is subsection1 ! t]m heal? c>e %>+ m9i/ry means an organization-- 7,a7 :i* is describ$ 9 section #eja7;c77#c7 & is exempt f taxation "u section #eja7;a71 7,b7 memb]s ( :i* %>e a common set ( e?ical or religi\s beliefs & %>e m$ical exp5ses among memb]s 9 accordance ) ^? beliefs & )\t reg>d to ! ,/ate 9 :i* a memb] resides or is employ$1 7,c7 memb]s ( :i* reta9 memb]%ip ev5 aft] !y develop a m$ical condition1 7,d7 :i* 7or a pr$ecessor ( :i*7 has be5 9 exi/5ce at all times s9ce ,decemb] #ca1 #aiii1 & m$ical exp5ses ( ! memb]s ( :i* h be5 %>$ cont9u\sly & )\t int]ruption s9ce at lea/ ,decemb] #ca1 #aiii1 & 7,e7 :i* conducts an annual audit :i* is p]=m$ by an indep5d5t c]tifi$ public acc\nt+ firm 9 accordance ) g5]ally accept$ acc\nt+ pr9ciples & :i* is made available to ! public ^u reque/4 7g7 ,special rules 7#a7 ,cr$it 9 excess ( premiums only payable to a heal? sav+s acc\nt 7,a7 ,9 g5]al ,if ! cr$it det]m9$ "u subsection 7a7 7det]m9$ )\t reg>d to clause 7ii77 = any taxable ye> exce$s ! am\nt ( premiums paid by ! taxpay] = cov]age ( ! taxpay] & ! taxpay]'s qualify+ family memb]s "u qualifi$ heal? insurance = eligible cov]age mon?s beg9n+ 9 ! taxable ye>-- 7i7 at ! reque/ ( ! taxpay]1 ! ,secret>y %all pay ! am\nt ( su* excess to "o or m heal? sav+s acc\nts ( ! taxpay] or ( any qualify+ family memb] ( ! taxpay]1 & 7ii7 ! am\nt ( su* excess %all n be treat$ z a cr$it aga9/ ! tax impos$ by subtitle ,a = su* taxable ye>4 7,b7 ,m$ical & heal? sav+s acc\nts ,am\nts di/ribut$ f an ,ar*] ,,msa 7z def9$ 9 section #bbj7;d77 or f a heal? sav+s acc\nt 7z def9$ 9 section #bbc7;d77 %all n be tak5 into acc\nt "u subp>agraph 7,a7 z premiums paid = cov]age4 7,c7 ,insurance :i* cov]s o!r individuals ,= purposes ( ?is p>agraph1 rules simil> to ! rules ( section #bac7;d77#f7 %all apply ) respect to any contract = qualifi$ heal? insurance "u :i* am\nts are payable = cov]age ( an individual o!r ?an ! taxpay] & qualify+ family memb]s4 7,d7 ,contributions treat$ z rollov]s1 etc 7i7 ,9 g5]al ,any am\nt paid by ! ,secret>y to a heal? sav+s acc\nt "u ?is p>agraph %all be treat$ = purposes ( ?is title 9 ! same mann] z a rollov] contribution to su* an acc\nt describ$ 9 section #bbc7;f77#e71 except t ! limitation "u section #bbc7;f77#e77;,b7 %all n apply to su* a contribution & su* contribution %all n be tak5 into acc\nt 9 apply+ su* limitation to any o!r am\nts contribut$4 7ii7 ,coord9ation ) ,h,s,as ,no?+ 9 any provision ( law %all be con/ru$-- 7,i7 to prev5t an individual f e/abli%+ a heal? sav+s acc\nt 7z def9$ 9 section #bbc7;d77 m]ely because su* individual is n an eligible individual 7z def9$ 9 section #bbc7;c771 or 7,,ii7 to prev5t su* an acc\nt f be+ treat$ z a heal? sav+s acc\nt m]ely because all or a sub/antial portion ( ! contributions to su* acc\nt are describ$ 9 ?is p>agraph4 7#b7 ,coord9ation ) advance paym5ts ( cr$it ,) respect to any taxable ye>-- 7,a7 ! am\nt :i* w\ld 7b = ?is subsection7 be all[$ z a cr$it to ! taxpay] "u subsection 7a7 %all be r$uc$ 7b n bel[ z]o7 by ! aggregate am\nt paid on behalf ( su* taxpay] "u section #gebi = mon?s beg9n+ 9 su* taxable ye>1 & 7,b7 ! tax impos$ by section #a = su* taxable ye> %all be increas$ by ! excess 7if any7 (-- 7i7 ! aggregate am\nt paid on behalf ( su* taxpay] "u section #gebi = mon?s beg9n+ 9 su* taxable ye>1 ov] 7ii7 ! am\nt :i* w\ld 7b = ?is subsection7 be all[$ z a cr$it to ! taxpay] "u subsection 7a74 7#c7 ,coord9ation ) o!r provisions ,= purposes ( any d$uction all[$ "u section #afb7l71 #bac1 or #bbd1 & any cr$it all[$ "u section #ce1 any heal? insurance premiums :i* w\ld 7b = ?is p>agraph7 be tak5 into acc\nt %all be r$uc$ 7b n bel[ z]o7 by ! am\nt ( ! cr$it all[$ "u ?is section 7det]m9$ )\t reg>d to p>agraphs 7#a7 & 7#b774 7#d7 ,d5ial ( cr$it to dep5d5ts & nonp]man5t resid5t ali5 individuals ,no cr$it %all be all[$ "u ?is section to any individual :o is-- 7,a7 n a citiz5 or lawful p]man5t resid5t ( ! ,unit$ ,/ates = ! cal5d> ye> 9 :i* ! taxable ye> beg9s1 or 7,b7 a dep5d5t ) respect to ano!r taxpay] = a taxable ye> beg9n+ 9 ! cal5d> ye> 9 :i* su* individual's taxable ye> beg9s4 7#e7 ,regulations ,! ,secret>y may prescribe su* regulations & o!r guidance z may be necess>y or appropriate to c>ry out ?is section1 section #fjej,w1 & section #gebi4 4 7b7 ,advance paym5t ( cr$it 7#a7 ,9 g5]al ,*apt] #gg ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+3 #gebi4 ,advance paym5t ( cr$it = heal? insurance cov]age 7a7 ,g5]al rule ,n lat] ?an ,janu>y #a1 #bjaf1 ! ,secret>y %all e/abli% a program = mak+ paym5ts to-- 7#a7 provid]s ( qualifi$ heal? insurance 7z def9$ 9 section #cf;,b7e771 & 7#b7 z provid$ 9 subsection 7c71 heal? sav+s acc\nts1 on behalf ( taxpay]s eligible = ! cr$it "u section #cf;,b4 7b7 ,am\nt ( paym5ts ,! aggregate paym5ts made "u ?is section ) respect to any taxpay]1 det]m9$ z ( any "t dur+ any cal5d> ye>1 %all n exce$ ! mon?ly cr$it am\nts det]m9$ ) respect to su* taxpay] "u section #cf;,b = mon?s dur+ su* cal5d> ye> :i* h end$ z ( su* "t4 7c7 ,application ( rule t cr$its 9 excess ( premiums only payable to a heal? sav+s acc\nt ,"u rules simil> to ! rules ( section #cf;,b7g77#a71 any am\nt o!rwise payable on behalf ( ! taxpay] "u subsection 7b7 ) respect to any eligible cov]age mon? :i* is 9 excess ( ! am\nt ( premiums paid by ! taxpay] = cov]age ( ! taxpay] & ! taxpay]'s qualify+ family memb]s "u qualifi$ heal? insurance = su* mon? %all be payable only to "o or m heal? sav+s acc\nts ( ! taxpay] or ( any qualify+ family memb] ( ! taxpay]4 7d7 ,c]tification process & pro( ( cov]age ,! ,secret>y %all e/abli% a process "u :i* individuals are c]tifi$ z eligible = paym5t "u ?is section4 ,su* process %all include an initial application by ! taxpay] to det]m9e eligibility & !reaft] cont9u$ eligibility %all be det]m9$1 to ! maximum ext5t feasible1 by ! ,secret>y on ! basis ( in=mation provid$ "u section #fjej,x4 7e7 ,def9itions ,= purposes ( ?is section1 t]ms us$ 9 ?is section :i* are also us$ 9 section #cf;,b %all h ! same mean+ z :5 us$ 9 section #cf;,b4 4 7#b7 ,in=mation report+ 7,a7 ,9 g5]al ,subp>t ,b ( "p ,,iii ( sub*apt] ,a ( *apt] #fa ( su* ,code is am5d$ by add+ at ! end ! foll[+ new section3 #fjej,x4 ,returns relat+ to cr$it = heal? insurance cov]age 7a7 ,requirem5t ( report+ ,e p]son :o provides qualifi$ heal? insurance = any mon? ( any cal5d> ye> ) respect to any individual %all1 at su* "t z ! ,secret>y may prescribe1 make ! return describ$ 9 subsection 7b7 ) respect to ea* su* individual4 ,) respect to any individual ) respect to :om paym5ts "u section #gebi are made by ! ,secret>y1 ! ,secret>y may require t report+ "u subsection 7b7 be made on a mon?ly basis4 7b7 ,=m & mann] ( returns ,a return is describ$ 9 ?is subsection if su* return-- 7#a7 is 9 su* =m z ! ,secret>y may prescribe1 & 7#b7 conta9s1 ) respect to ea* policy ( qualifi$ heal? insurance-- 7,a7 ! "n1 address1 & ,,t9 ( ea* individual cov]$ "u su* policy1 7,b7 ! premiums paid ) respect to su* policy1 & 7,c7 su* o!r in=mation z ! ,secret>y may prescribe4 7c7 ,/atem5ts ,to be furni%$ to individuals ) respect to :om in=mation is requir$ ,e p]son requir$ to make a return "u subsection 7a7 %all furni% to ea* individual ^: "n is requir$ to be set =? 9 su* return a writt5 /atem5t %[+-- 7#a7 ! "n & address ( ! p]son requir$ to make su* return & ! phone numb] ( ! in=mation contact = su* p]son1 & 7#b7 ! in=mation requir$ to be %[n on ! return ) respect to su* individual4 ,! writt5 /atem5t requir$ "u ! prec$+ s5t5ce %all be furni%$ on or be=e ,janu>y #ca ( ! ye> foll[+ ! cal5d> ye> to :i* su* /atem5t relates4 7d7 ,def9itions ,= purposes ( ?is section1 t]ms us$ 9 ?is section :i* are also us$ 9 section #cf;,b %all h ! same mean+ z :5 us$ 9 section #cf;,b4 4 7,b7 ,assessable p5alties 7i7 ,subp>agraph 7,b7 ( section #fgbd7;d77#a7 ( su* ,code1 z am5d$ by section #b1 is am5d$ by /rik+ or at ! end ( clause 7xxii71 by /rik+ & at ! end ( clause 7xxiii7 & ins]t+ or1 & by ins]t+ aft] clause 7xxiii7 ! foll[+ new clause3 7xxiv7 section #fjej,x 7relat+ to returns relat+ to cr$it = heal? insurance cov]age71 & 4 7ii7 ,p>agraph 7#b7 ( section #fgbd7;d7 ( su* ,code1 z am5d$ by section #b1 is am5d$ by /rik+ or at ! end ( subp>agraph 7,,ee71 by /rik+ ! p]iod at ! end ( subp>agraph 7,,ff7 & ins]t+ 1 or1 & by add+ aft] subp>agraph 7,,ff7 ! foll[+ new subp>agraph3 7,,gg7 section #fjej,x 7relat+ to returns relat+ to cr$it = heal? insurance cov]age74 4 7#c7 ,disclosure ( return in=mation = purposes ( advance paym5t ( cr$it z premiums = qualifi$ heal? insurance 7,a7 ,9 g5]al ,subsection 7l7 ( section #fajc ( su* ,code1 z am5d$ by section #b1 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ba7 ,disclosure ( return in=mation relat$ to paym5ts ( ! heal? insurance cov]age cr$it ,! ,secret>y may1 on behalf ( taxpay]s eligible = ! cr$it "u section #cf;,b1 disclose to a provid] ( qualifi$ heal? insurance 7z def9$ 9 section #cf7;e77 or a tru/ee ( a heal? sav+s acc\nt 7& p]sons act+ on behalf ( su* provid] or su* tru/ee71 return in=mation ) respect to any su* taxpay] only to ! ext5t necess>y 7z prescrib$ by regulations issu$ by ! ,secret>y7 to c>ry out sections #cf;,b7g77#a7 7relat+ to cr$it 9 excess ( premiums only payable to a heal? sav+s acc\nt7 & #gebi 7relat+ to advance paym5t ( cr$it = heal? insurance cov]age74 4 7,b7 ,confid5tiality ( in=mation ,p>agraph 7#c7 ( section #fajc7;a7 ( su* ,code1 z am5d$ by section #b1 is am5d$ by /rik+ or 7#bj7 & ins]t+ 7#bj71 or 7#ba74 7,c7 ,unau?oriz$ disclosure ,p>agraph 7#b7 ( section #gbac7;a7 ( su* ,code1 z am5d$ by section #b1 is am5d$ by /rik+ or 7#bj7 & ins]t+ 7#bj71 or 7#ba74 7#d7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ! date ( ! enactm5t ( ?is ,act4 7c7 ,con=m+ am5dm5ts 7#a7 ,p>agraph 7#b7 ( section #acbd7;b7 ( title #ca1 ,unit$ ,/ates ,code1 z am5d$ by section #b1 is am5d$ by ins]t+ #cf;,b1 aft] #cf;,a14 7#b7 ,! table ( sections = subp>t ,c ( "p ,,iv ( sub*apt] ,a ( *apt] #a ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #b1 is am5d$ by ins]t+ aft] ! item relat+ to section #cf;,a ! foll[+ new item3 ,sec4 #cf;,b4 ,heal? insurance cov]age4 4 7#c7 ,! table ( sections = subp>t ,b ( "p ,,iii ( sub*apt] ,a ( *apt] #fa ( su* ,code is am5d$ by add+ at ! end ! foll[+ new item3 ,sec4 #fjej,x4 ,returns relat+ to cr$it = heal? insurance cov]age4 4 7#d7 ,! table ( sections = *apt] #gg ( su* ,code is am5d$ by add+ at ! end ! foll[+ new item3 ,sec4 #gebi4 ,advance paym5t ( cr$it = heal? insurance cov]age4 4 7d7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjae4 #ajb4 ,election ( tax cr$it in/ead ( alt]native gov]nm5t or gr\p plan b5efits 7a7 ,9 g5]al ,not)/&+ any o!r provision ( law1 an individual :o is o!rwise eligible = b5efits "u a heal? program 7z def9$ 9 subsection 7c77 may elect1 9 a =m & mann] specifi$ by ! ,secret>y ( ,heal? & ,human ,s]vices 9 consultation ) ! ,secret>y ( ! ,treasury1 to receive a tax cr$it describ$ 9 section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf 7:i* %all be us$ = ! purpose ( heal? insurance cov]age7 9 lieu ( receiv+ any b5efits "u su* program4 7b7 ,effective date ,an election "u subsection 7a7 may fir/ be made = cal5d> ye> #bjaf & any su* election %all be effective = su* p]iod 7n less ?an "o cal5d> ye>7 z ! ,secret>y ( ,heal? & ,human ,s]vices %all specify1 9 consultation ) ! ,secret>y ( ! ,treasury4 7c7 ,heal? program def9$ ,= purposes ( ?is section1 ! t]m heal? program means any ( ! foll[+3 7#a7 ,m$ic>e ,! ,m$ic>e program "u "p ,a ( title ,,xviii ( ! ,social ,security ,act4 7#b7 ,m$icaid ,! ,m$icaid program "u title ,,xix ( su* ,act 7includ+ su* a program op]at+ "u a ,/atewide waiv] "u section #aaae ( su* ,act74 7#c7 ,,s*ip ,! ,/ate *ildr5's heal? insurance program "u title ,,xxi ( su* ,act4 7#d7 ,,tric>e ,! ,,tric>e program "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code4 7#e7 ,vet]ans b5efits ,cov]age = b5efits "u *apt] #ag ( title #ch1 ,unit$ ,/ates ,code4 7#f7 ,,fehbp ,cov]age "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code4 7#g7 ,subsidiz$ gr\p heal? plans ,cov]age "u a gr\p heal? plan 7)9 ! mean+ ( section #ejjj7;b77#a77 :i* is subsidiz$ by ! employ]4 7d7 ,o!r ,social ,security b5efits n waiv$ ,an election to waive ! b5efits describ$ 9 subsection 7c77#a7 %all n result 9 ! waiv] ( any o!r b5efits "u ! ,social ,security ,act4 ,b ,heal? sav+s acc\nts #aaa4 ,refundable tax cr$it = heal? sav+s acc\nt contributions 7a7 ,9 g5]al ,subp>t ,c ( "p ,,iv ( sub*apt] ,a ( *apt] #a ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$ by ins]t+ aft] section #cf;,b ! foll[+ new section3 #cf;,c4 ,heal? sav+s acc\nt contributions 7a7 ,9 g5]al ,9 ! case ( an individual :o is all[$ a d$uction "u section #bbc7;a7 = any taxable ye>1 !re %all be all[$ z a cr$it aga9/ ! tax impos$ by subtitle ,a = su* taxable ye>1 ! less] (-- 7#a7 ! am\nt s all[$ z a d$uction1 or 7#b7 #a1jjj4 7b7 ,limitation ,! cr$it all[$ "u subsection 7a7 ) respect to any individual = any taxable ye> %all n exce$ ! excess 7if any7 (-- 7#a7 #a1jjj1 ov] 7#b7 ! aggregate cr$its all[$ ) respect to su* individual "u subsection 7a7 = all prior taxable ye>s4 4 7b7 ,con=m+ am5dm5ts 7#a7 ,p>agraph 7#b7 ( section #acbd7;b7 ( title #ca1 ,unit$ ,/ates ,code1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$ by ins]t+ #cf;,c1 aft] #cf;,b14 7#b7 ,! table ( sections = subp>t ,c ( "p ,,iv ( sub*apt] ,a ( *apt] #a ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$ by ins]t+ aft] ! item relat+ to section #cf;,b ! foll[+ new item3 ,sec4 #cf;,c4 ,heal? sav+s acc\nt contributions4 4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aab4 ,all[+ ,,hsa rollov] to *ild or p>5t ( acc\nt hold] 7a7 ,9 g5]al ,section #bbc7;f77#h77;,a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7#a7 by ins]t+ *ild1 p>5t1 or gr&p>5t aft] surviv+ sp\se1 7#b7 by ins]t+ *ild1 p>5t1 or gr&p>5t1 z ! case may be1 aft] ! sp\se1 7#c7 by ins]t+ 1 *ild1 p>5t1 or gr&p>5t aft] sp\se 9 ! head+ !re(1 & 7#d7 by add+ at ! end ! foll[+3 ,9 ! case ( a *ild :o acquires su* b5efici>y's int]e/ & ) respect to :om a d$uction "u section #aea is all[able to ano!r taxpay] = a taxable ye> beg9n+ 9 ! cal5d> ye> 9 :i* su* individual's taxable ye> beg9s1 su* heal? sav+s acc\nt %all be treat$ z a *ild heal? sav+s acc\nt ( ! *ild44 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aac4 ,maximum contribution limit to ,,hsa coord9at$ ) retirem5t sav+s acc\nt limitation 7a7 ,self-,only cov]age ,section #bbc7;b77#b77;,a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #b1bej & ins]t+ ! am\nt 9 effect "u section #bai7;b77#e77;,a74 7b7 ,family cov]age ,section #bbc7;b77#b77;,b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #d1ejj & ins]t+ twice ! am\nt 9 effect "u subp>agraph 7,a74 7c7 ,con=m+ am5dm5ts ,section #bbc7;g77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7#a7 9 ! matt] prec$+ subp>agraph 7,a71 by /rik+ subsections 7b77#b7 & 7c77#b77;,a7 & ins]t+ subsection 7c77#b77;,a71 7#b7 9 subp>agraph 7,b71 by /rik+ by sub/itut+ & all t foll[s ?r\gh ! end ( clause 7ii7 & ins]t+ by sub/itut+ cal5d> ye> #bjjc = cal5d> ye> #aiib 9 subp>agraph 7,b7 !re(41 & 7#c7 9 ! matt] foll[+ subp>agraph 7,b71 by /rik+ subsections 7b77#b7 & 7c77#b77;,a7 & ins]t+ subsection 7c77#b77;,a74 7d7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aad4 ,transf] ( requir$ m9imum di/ribution f retirem5t plan to heal? sav+s acc\nt 7a7 ,transf] f retirem5t plan 7#a7 ,individual retirem5t acc\nts ,section #djh7;d7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#aj7 ,requir$ m9imum di/ribution transf]r$ to heal? sav+s acc\nt 7,a7 ,9 g5]al ,9 ! case ( an individual :o has atta9$ ! age ( #gj & :o elects ! application ( ?is p>agraph = a taxable ye>1 gross income ( ! individual = ! taxable ye> does n include a qualifi$ ,,hsa transf] to ! ext5t su* transf] is o!rwise includible 9 gross income4 7,b7 ,qualifi$ ,,hsa transf] ,= purposes ( ?is p>agraph1 ! t]m qualifi$ ,,hsa transf] means any di/ribution f an individual retirem5t plan-- 7i7 to a heal? sav+s acc\nt ( ! individual 9 a direct tru/ee-to-tru/ee transf]1 & 7ii7 to ! ext5t su* di/ribution does n exce$ ! requir$ m9imum di/ribution det]m9$ "u section #dja7;a77#i7 = ! di/ribution cal5d> ye> end+ dur+ ! taxable ye>4 7,c7 ,application ( section #gb ,not)/&+ section #gb1 9 det]m9+ ! ext5t to :i* an am\nt is treat$ z o!rwise includible 9 gross = purposes ( subp>agraph 7,a71 ! aggregate am\nt di/ribut$ f an individual retirem5t plan %all be treat$ z includible 9 gross income to ! ext5t t su* am\nt does n exce$ ! aggregate am\nt :i* w\ld h be5 s includible if all am\nts f all individual retirem5t plans 7 di/ribut$4 ,prop] adju/m5ts %all be made 9 apply+ section #gb to o!r di/ributions 9 su* taxable ye> & subsequ5t taxable ye>s4 7,d7 ,coord9ation ,an election may n be made "u subp>agraph 7,a7 = a taxable ye> = :i* an election is 9 effect "u p>agraph 7#i74 4 7#b7 ,o!r retirem5t plans ,section #djb ( su* ,code is am5d$ by add+ at ! end ! foll[+ new subsection3 7m7 ,requir$ m9imum di/ribution transf]r$ to heal? sav+s acc\nt 7#a7 ,9 g5]al ,9 ! case ( an individual :o has atta9$ ! age ( #gj & :o elects ! application ( ?is subsection = a taxable ye>1 gross income ( ! individual = ! taxable ye> does n include a qualifi$ ,,hsa transf] to ! ext5t su* transf] is o!rwise includible 9 gross income4 7#b7 ,qualifi$ ,,hsa transf] ,= purposes ( ?is subsection1 ! t]m qualifi$ ,,hsa transf] means any di/ribution f a retirem5t plan-- 7,a7 to a heal? sav+s acc\nt ( ! individual 9 a direct tru/ee-to-tru/ee transf]1 & 7,b7 to ! ext5t su* di/ribution does n exce$ ! requir$ m9imum di/ribution det]m9$ "u section #dja7;a77#i7 = ! di/ribution cal5d> ye> end+ dur+ ! taxable ye>4 7#c7 ,application ( section #gb ,not)/&+ section #gb1 9 det]m9+ ! ext5t to :i* an am\nt is treat$ z o!rwise includible 9 gross = purposes ( p>agraph 7#a71 ! aggregate am\nt di/ribut$ f an individual retirem5t plan %all be treat$ z includible 9 gross income to ! ext5t t su* am\nt does n exce$ ! aggregate am\nt :i* w\ld h be5 s includible if all am\nts f all individual retirem5t plans 7 di/ribut$4 ,prop] adju/m5ts %all be made 9 apply+ section #gb to o!r di/ributions 9 su* taxable ye> & subsequ5t taxable ye>s4 7#d7 ,eligible retirem5t plan ,= purposes ( ?is subsection1 ! t]m eligible retirem5t plan has ! mean+ giv5 su* t]m by subsection 7c77#h77;,b7 7det]m9$ )\t reg>d to clauses 7i7 & 7ii7 !re(74 4 7b7 ,transf] to heal? sav+s acc\nt 7#a7 ,9 g5]al ,section #bbc7;d77#a77;,a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ or at ! end ( clause 7i71 by /rik+ ! p]iod at ! end ( clause 7ii77,,ii7 & ins]t+ 1 or1 & by add+ at ! end ! foll[+ new clause3 7iii7 unless x is a qualifi$ ,,hsa transf] describ$ 9 section #djh7;d77#aj7 or #djb7m74 4 7#b7 ,excise tax inapplicable to qualifi$ ,,hsa transf] ,section #digc7;g77#a7 ( su* ,code is am5d$ by ins]t+ or a qualifi$ ,,hsa transf] describ$ 9 section #djh7;d77#aj7 or #djb7m7 aft] or #bbc7;f77#e74 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to di/ributions made aft] ! date ( ! enactm5t ( ?is ,act4 #aae4 ,equival5t bankruptcy protections = heal? sav+s acc\nts z retirem5t funds 7a7 ,9 g5]al ,section #ebb ( title #aa1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+3 7r7 ,treatm5t ( heal? sav+s acc\nts ,= purposes ( ?is section1 any heal? sav+s acc\nt 7z describ$ 9 section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf7 %all be treat$ 9 ! same mann] z an individual retirem5t acc\nt describ$ 9 section #djh ( su* ,code4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to cases comm5c+ "u title #aa1 ,unit$ ,/ates ,code1 aft] ! date ( enactm5t ( ?is ,act4 #aaf4 ,all[ bo? sp\ses to make cat*-up contributions to ! same ,,hsa acc\nt 7a7 ,9 g5]al ,section #bbc7;b77#c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,special rule :]e bo? sp\ses are eligible individuals ) #a acc\nt ,if-- 7i7 an individual & ! individual's sp\se h bo? atta9$ age #ee be=e ! close ( ! taxable ye>1 & 7ii7 ! sp\se is n an acc\nt b5efici>y ( a heal? sav+s acc\nt z ( ! close ( su* ye>1 ! additional contribution am\nt %all be twice ! am\nt o!rwise det]m9$ "u subp>agraph 7,b74 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aag4 ,provisions relat+ to ,m$ic>e 7a7 ,individuals ov] age #fe only enroll$ 9 ,m$ic>e ,"p ,a ,section #bbc7;b77#g7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+3 ,?is p>agraph %all n apply to any individual dur+ any p]iod = :i* ! individual's only entitlem5t to su* b5efits is an entitlem5t to hospital insurance b5efits "u "p ,a ( title ,,xviii ( su* ,act pursuant to an enrollm5t = su* hospital insurance b5efits "u section #bbf7;a77#a7 ( su* ,act44 7b7 ,m$ic>e b5efici>ies p>ticipat+ 9 ,m$ic>e advantage ,,msa may contribute _! own money to _! ,,msa 7#a7 ,9 g5]al ,section #ach7;b7 ( su* ,code is am5d$ by /rik+ p>agraph 7#b7 & by r$esignat+ p>agraphs 7#c7 & 7#d7 z p>agraphs 7#b7 & 7#c71 respectively4 7#b7 ,con=m+ am5dm5t ,section #ach7;c77#d7 ( su* ,code is am5d$ by /rik+ & p>agraph 7#b74 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aah4 ,individuals eligible = vet]ans b5efits = a s]vice-connect$ disability 7a7 ,9 g5]al ,subp>agraph 7,c7 ( section #bbc7;c77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 7,c7 ,special rule = individuals eligible = c]ta9 vet]ans b5efits ,= purposes ( subp>agraph 7,a77ii71 an individual %all n be treat$ z cov]$ "u a heal? plan describ$ 9 su* subp>agraph m]ely because ! individual receives p]iodic hospital c>e or m$ical s]vices = a s]vice-connect$ disability "u any law adm9i/]$ by ! ,secret>y ( ,vet]ans ,affairs b only if ! individual is n eligible to receive su* c>e or s]vices = any condition o!r ?an a s]vice-connect$ disability4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aai4 ,individuals eligible = ,indian ,heal? ,s]vice assi/ance 7a7 ,9 g5]al ,section #bbc7;c77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,special rule = individuals eligible = assi/ance "u ,indian ,heal? ,s]vice programs ,= purposes ( subp>agraph 7,a77ii71 an individual %all n be treat$ z cov]$ "u a heal? plan describ$ 9 su* subp>agraph m]ely because ! individual receives hospital c>e or m$ical s]vices "u a m$ical c>e program ( ! ,indian ,heal? ,s]vice or ( a tribal organization4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #abj4 ,individuals eligible = ,,tric>e cov]age 7a7 ,9 g5]al ,section #bbc7;c77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,special rule = individuals eligible = assi/ance "u tric>e ,= purposes ( subp>agraph 7,a77ii71 an individual %all n be treat$ z cov]$ "u a heal? plan describ$ 9 su* subp>agraph m]ely because ! individual is eligible to receive hospital c>e1 m$ical s]vices1 or prescription drugs "u ,,tric>e ,extra or ,,tric>e ,/&>d & su* individual is n enroll$ 9 ,,tric>e ,prime4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aba4 ,,fsa & ,,hra int]action ) ,h,s,as 7a7 ,eligible individuals include ,,fsa & ,,hra p>ticipants ,section #bbc7;c77#a77;,b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7#a7 by /rik+ & at ! end ( clause 7ii71 7#b7 by /rik+ ! p]iod at ! end ( clause 7iii7 & ins]t+ 1 &1 & 7#c7 by ins]t+ aft] clause 7iii7 ! foll[+ new clause3 7iv7 = mon?s dur+ a plan ye> 9 :i* a qualifi$ ,,hsa di/ribution 7z def9$ 9 section #ajf7;e77#b77 is made on behalf ( an individual1 cov]age "u a heal? flexible sp5d+ arrangem5t or a heal? reimbursem5t arrangem5t if1 aft] ! qualifi$ ,,hsa di/ribution is made & = ! rema9+ duration ( ! plan ye>1 ! cov]age provid$ "u ! heal? flexible sp5d+ arrangem5t or heal? reimbursem5t arrangem5t is conv]t$ to cov]age :i*-- 7,i7 does n pay or reimburse any m$ical exp5se incurr$ be=e ! m9imum annual d$uctible "u p>agraph 7#b77;,a77i7 7prorat$ = ! p]iod occurr+ aft] ! qualifi$ ,,hsa di/ribution is made7 is satisfi$1 7,,ii7 does n pay or reimburse any m$ical exp5se incurr$ aft] ! qualifi$ ,,hsa di/ribution is made o!r ?an prev5tive c>e z def9$ 9 p>agraph 7#b77;,c71 7,,iii7 pays or reimburses b5efits = cov]age describ$ 9 clause 7ii7 7b n ?r\gh insurance or = long-t]m c>e s]vices71 7,,iv7 pays or reimburses b5efits = p]mitt$ insurance or cov]age describ$ 9 clause 7ii7 7b n = long-t]m c>e s]vices71 7,v7 pays or reimburses only ^? m$ical exp5ses incurr$ aft] an individual's retirem5t 7& no exp5ses incurr$ be=e retirem5t71 or 7,,vi7 is susp5d$1 pursuant to an election made on or be=e ! date ! individual elects ! qualifi$ ,,hsa di/ribution or1 if lat]1 on ! date ( ! individual enrolls 9 a high d$uctible heal? plan1 & :i* does n pay or reimburse1 at any "t1 any m$ical exp5se incurr$ dur+ ! susp5sion p]iod except z def9$ 9 ! prec$+ subclauses ( ?is clause4 4 7b7 ,qualifi$ ,,hsa di/ribution %all n affect flexible sp5d+ arrangem5t ,section #ajf7;e77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 7#a7 ,9 g5]al ,a plan %all n fail to be treat$ z a heal? flexible sp5d+ arrangem5t "u ?is section1 section #aje1 or section #abe1 or z a heal? reimbursem5t arrangem5t "u ?is section or section #aje1 m]ely because su* plan provides = a qualifi$ ,,hsa di/ribution4 4 7c7 ,,fsa balances at ye> end %all n =feit ,section #abe7;d77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,exception = qualifi$ ,,hsa di/ributions ,subp>agraph 7,a7 %all n apply to ! ext5t t !re is an am\nt rema9+ 9 a heal? flexible sp5d+ acc\nt at ! end ( a plan ye> t an individual elects to contribute to a heal? sav+s acc\nt pursuant to a qualifi$ ,,hsa di/ribution 7z def9$ 9 section #ajf7;e77#b774 4 7d7 ,simplification ( limitations on ,,fsa & ,,hra rollov]s ,section #ajf7;e77#b7 ( su* ,code is am5d$ to read z foll[s3 7#b7 ,qualifi$ ,,hsa di/ribution 7,a7 ,9 g5]al ,! t]m qualifi$ ,,hsa di/ribution means a di/ribution f a heal? flexible sp5d+ arrangem5t or heal? reimbursem5t arrangem5t to ! ext5t t su* di/ribution does n exce$ ! less] (-- 7i7 ! balance 9 su* arrangem5t z ( ! date ( su* di/ribution1 or 7ii7 ! am\nt det]m9$ "u subp>agraph 7,b74 ,su* t]m %all n include m ?an #a di/ribution ) respect to any arrangem5t4 7,b7 ,doll> limitations 7i7 ,di/ributions f a heal? flexible sp5d+ arrangem5t ,a qualifi$ ,,hsa di/ribution f a heal? flexible sp5d+ arrangem5t %all n exce$ ! applicable am\nt4 7ii7 ,di/ributions f a heal? reimbursem5t arrangem5t ,a qualifi$ ,,hsa di/ribution f a heal? reimbursem5t arrangem5t %all n exce$-- 7,i7 ! applicable am\nt divid$ by #ab1 multipli$ by 7,,ii7 ! numb] ( mon?s dur+ :i* ! individual is a p>ticipant 9 ! heal? reimbursem5t arrangem5t4 7iii7 ,applicable am\nt ,= purposes ( ?is subp>agraph1 ! applicable am\nt is-- 7,i7 ! doll> am\nt 9 effect "u section #bbc7;b77#b77;,a7 9 ! case ( an eligible individual :o has self-only cov]age "u a high d$uctible heal? plan at ! "t ( su* di/ribution1 & 7,,ii7 twice ! doll> am\nt 9 effect "u subclause 7,i7 9 ! case ( an eligible individual :o has family cov]age "u a high d$uctible heal? plan at ! "t ( su* di/ribution4 4 7e7 ,elim9ation ( additional tax = failure ,to ma9ta9 high d$uctible heal? plan cov]age ,section #ajf7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7#a7 by /rik+ p>agraph 7#c7 & r$esignat+ p>agraphs 7#d7 & 7#e7 z p>agraphs 7#c7 & 7#d71 respectively1 & 7#b7 by /rik+ subp>agraph 7,a7 ( p>agraph 7#c71 z s r$esignat$1 & r$esignat+ subp>agraphs 7,b7 & 7,c7 ( su* p>agraph z subp>agraphs 7,a7 & 7,b7 !re(1 respectively4 7f7 ,limit$ purpose ,f,s,as & ,h,r,as ,section #ajf7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ?is section1 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#e7 ,limit$ purpose ,f,s,as & ,h,r,as ,a plan %all n fail to be a heal? flexible sp5d+ arrangem5t or heal? reimbursem5t arrangem5t "u ?is section or section #aje m]ely because ! plan conv]ts cov]age = individuals :o enroll 9 a high d$uctible heal? plan describ$ 9 section #bbc7;c77#b7 to cov]age describ$ 9 section #bbc7;c77#a77;,b77iv74 ,cov]age = su* individuals may be conv]t$ z ( ! date ( enrollm5t 9 ! high d$uctible heal? plan1 )\t reg>d to ! p]iod ( cov]age "u ! heal? flexible sp5d+ arrangem5t or heal? reimbursem5t arrangem5t1 & )\t requir+ any *ange 9 cov]age to individuals :o d n enroll 9 a high d$uctible heal? plan4 4 7g7 ,disclaim] ( disqualify+ cov]age ,section #bbc7;c77#a77;,b7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ?is section1 is am5d$-- 7#a7 by /rik+ & at ! end ( clause 7iii71 7#b7 by /rik+ ! p]iod at ! end ( clause 7iv7 & ins]t+ 1 &1 & 7#c7 by ins]t+ aft] clause 7iv7 ! foll[+ new clause3 7v7 cov]age 7includ+ prospective cov]age7 "u a heal? plan t is n a high d$uctible heal? plan :i* is disclaim$ 9 writ+1 at ! "t ( ! creation or organization ( ! heal? sav+s acc\nt1 includ+ by execution ( a tru/ describ$ 9 subsection 7d77#a7 ?r\gh a gov]n+ in/rum5t t includes su* a disclaim]1 or by acceptance ( an am5dm5t to su* a tru/ t includes su* a disclaim]4 4 7h7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #abb4 ,special rule = c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt 7a7 ,9 g5]al ,section #bbc7;d77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt treat$ z qualifi$ ,an exp5se %all n fail to be treat$ z a qualifi$ m$ical exp5se solely because su* exp5se 0 incurr$ be=e ! e/abli%m5t ( ! heal? sav+s acc\nt if su* exp5se 0 incurr$-- 7i7 dur+ ei!r-- 7,i7 ! taxable ye> 9 :i* ! heal? sav+s acc\nt 0 e/abli%$1 or 7,,ii7 ! prec$+ taxable ye> 9 ! case ( a heal? sav+s acc\nt e/abli%$ aft] ! taxable ye> 9 :i* su* exp5se 0 incurr$ b be=e ! "t prescrib$ by law = fil+ ! return = su* taxable ye> 7n includ+ ext5sions !re(71 & 7ii7 = m$ical c>e ( an individual dur+ a p]iod t su* individual 0 cov]$ by a high d$uctible heal? plan & met ! requirem5ts ( subsection 7c77#a77;,a77ii7 7aft] application ( subsection 7c77#a77;,b774 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #abc4 ,prev5tive c>e prescription drug cl>ification 7a7 ,cl>ify use ( drugs 9 prev5tive c>e ,section #bbc7;c77#b77;,c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+3 ,= purposes ( ! prec$+ s5t5ce1 ! t]m prev5tative c>e includes prescription & ov]-!-c\nt] drugs & m$ic9es :i* h ! prim>y purpose ( prev5t+ ! onset (1 fur!r det]ioration f1 or complications associat$ ) *ronic conditions1 illnesses1 or diseases44 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjjc4 #abd4 ,adm9i/rative error correction be=e due date ( return 7a7 ,9 g5]al ,section #bbc7;f77#d7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,exception = adm9i/rative errors correct$ be=e due date ( return ,subp>agraph 7,a7 %all n apply if any paym5t or di/ribution is made to correct an adm9i/rative1 cl]ical or payroll contribution error & if-- 7i7 su* di/ribution is receiv$ by ! individual on or be=e ! la/ day prescrib$ by law 7includ+ ext5sions ( "t7 = fil+ su* individual's return = su* taxable ye>1 & 7ii7 su* di/ribution is accompani$ by ! am\nt ( net income attributable to su* contribution4 ,any net income describ$ 9 clause 7ii7 %all be includ$ 9 ! gross income ( ! individual = ! taxable ye> 9 :i* x is receiv$4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all take effect on ! date ( ! enactm5t ( ?is ,act4 #abe4 ,memb]s ( heal? c>e %>+ m9i/ries eligible to e/abli% heal? sav+s acc\nts 7a7 ,9 g5]al ,section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subsection3 7i7 ,application to heal? c>e %>+ m9i/ries ,= purposes ( ?is section1 memb]%ip 9 a heal? c>e %>+ m9i/ry 7z def9$ 9 section #ejjj;,a7d77#b77;,b77ii77 %all be treat$ z cov]age "u a high d$uctible heal? plan4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #abf4 ,high d$uctible heal? plans r5am$ ,,hsa qualifi$ plans 7a7 ,9 g5]al ,section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ?is ,act1 is am5d$ by /rik+ high d$uctible heal? plan ea* place x appe>s & ins]t+ ,,hsa qualifi$ heal? plan4 7b7 ,con=m+ am5dm5ts 7#a7 ,section #ajf7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ?is ,act1 is am5d$ by /rik+ high d$uctible heal? plan ea* place x appe>s & ins]t+ ,,hsa qualifi$ heal? plan4 7#b7 ,! head+ = section #bbc7;c77#b7 ( su* ,code is am5d$ by /rik+ ,high d$uctible heal? plan & ins]t+ ,,hsa qualifi$ heal? plan4 7#c7 ,section #djh7;d77#i7 ( su* ,code is am5d$-- 7,a7 by /rik+ high d$uctible heal? plan ea* place x appe>s 9 subp>agraph 7,c7 & ins]t+ ,,hsa qualifi$ heal? plan1 & 7,b7 by /rik+ ,high d$uctible heal? plan 9 ! head+ ( subp>agraph 7,d7 & ins]t+ ,,hsa qualifi$ heal? plan4 #abg4 ,treatm5t ( direct prim>y c>e s]vice arrangem5ts 7a7 ,9 g5]al ,section #bbc7;c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,treatm5t ( direct prim>y c>e s]vice arrangem5ts ,an arrangem5t "u :i* an individual is provid$ cov]age re/rict$ to prim>y c>e s]vices 9 ex*ange = a fix$ p]iodic fee-- 7,a7 %all n be treat$ z a heal? plan = purposes ( p>agraph 7#a77;,a77ii71 & 7,b7 %all n be treat$ z insurance = purposes ( subsection 7d77#b77;,b74 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #abh4 ,c]ta9 provid] fees to be treat$ z m$ical c>e 7a7 ,9 g5]al ,section #bac7;d7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ab7 ,p]iodic provid] fees ,! t]m m$ical c>e includes p]iodic fees paid to a prim>y c>e physician = ! "r to receive m$ical s]vices on an z-ne$$ basis4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #abi4 ,cl>ification ( treatm5t ( capitat$ prim>y c>e paym5ts z am\nts paid = m$ical c>e 7a7 ,9 g5]al ,section #bac7;d7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ac7 ,treatm5t ( capitat$ prim>y c>e paym5ts ,capitat$ prim>y c>e paym5ts %all be treat$ z am\nts paid = m$ical c>e4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 ,c ,o!r provisions #aca4 ,limitation on employ]-provid$ heal? c>e cov]age 7a7 ,9 g5]al ,section #ajf ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$ by add+ at ! end ! foll[+ new subsection3 7f7 ,limitation on employ]-,provid$ heal? c>e cov]age 7#a7 ,9 g5]al ,! am\nt ( any exclusion "u subsection 7a7 = any taxable ye> ) respect to-- 7,a7 any employ]-provid$ cov]age "u an accid5t or heal? plan :i* con/itutes m$ical c>e1 & 7,b7 any employ] contribution to an ,ar*] ,,msa or a heal? sav+s acc\nt :i* is treat$ by subsection 7b7 or 7d7 z employ]-provid$ cov]age = m$ical exp5ses "u an accid5t or heal? plan1 %all n exce$ #h1jjj p] employee = self-only cov]age & #bj1jjj = family cov]age4 7#b7 ,inflation adju/m5t ,9 ! case ( any taxable ye> beg9n+ 9 a cal5d> ye> aft] #bjaf1 ea* ( ! doll> am\nts 9 p>agraph 7#a7 %all be increas$ by an am\nt equal to-- 7,a7 su* doll> am\nt1 multipli$ by 7,b7 ! co/-(-liv+ adju/m5t det]m9$ "u section #a7;f77#c7 = ! cal5d> ye> 9 :i* ! taxable ye> beg9s1 det]m9$ by sub/itut+ cal5d> ye> #bjae = cal5d> ye> #aiib 9 subp>agraph 7,b7 !re(4 ,any increase det]m9$ "u ! prec$+ s5t5ce %all be r\nd$ to ! ne>e/ multiple ( #ej4 7#c7 ,m$ical c>e ,= purposes ( p>agraph 7#a71 ! t]m m$ical c>e has ! mean+ giv5 to su* t]m 9 section #bac7;d7 det]m9$ )\t reg>d to-- 7,a7 p>agraph 7#a77;,c7 !re(1 & 7,b7 s mu* ( p>agraph 7#a77;,d7 !re( z relates to qualifi$ long-t]m c>e insurance4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjae4 #acb4 ,limitation on abortion fund+ ,no funds au?oriz$ "u1 or cr$its or d$uctions all[$ "u ! ,int]nal ,rev5ue ,code ( #aihf by reason (1 ?is ,act 7or any am5dm5t made by ?is ,act7 may be us$ to pay = any abortion or to cov] any "p ( ! co/s ( any heal? plan t includes cov]age ( abortion1 except 9 ! case :]e a woman suff]s f a physical disord]1 physical injury1 or physical illness t w\ld1 z c]tifi$ by a physician1 place ! woman 9 dang] ( dea? unless an abortion is p]=m$1 includ+ a life-endang]+ physical condition caus$ by or aris+ f ! pregnancy itself1 or unless ! pregnancy is ! result ( an act ( rape or ince/4 #acc4 ,no gov]nm5t discrim9ation aga9/ c]ta9 heal? c>e entities 7a7 ,non-,discrim9ation ,a ,f$]al ag5cy or program1 & any ,/ate or local gov]nm5t t receives ,f$]al f9ancial assi/ance "u ?is ,act or any am5dm5t made by ?is ,act 7ei!r directly or indirectly71 may n subject any individual or in/itutional heal? c>e entity to discrim9ation on ! basis t ! heal? c>e entity does n provide1 pay =1 provide cov]age (1 or ref] = abortions4 7b7 ,heal? c>e entity def9$ ,= purposes ( ?is section1 ! t]m heal? c>e entity includes an individual physician or o!r heal? c>e pr(essional1 a hospital1 a provid]-sponsor$ organization1 a heal? ma9t5ance organization1 a heal? insurance plan1 or any o!r k9d ( heal? c>e facility1 organization1 or plan4 7c7 ,rem$ies 7#a7 ,9 g5]al ,! c\rts ( ! ,unit$ ,/ates %all h jurisdiction to prev5t & r$ress actual or ?reat5$ violations ( ?is section by issu+ any =m ( legal or equitable relief1 includ+-- 7,a7 injunctions prohibit+ conduct t violates ?is section2 & 7,b7 ord]s prev5t+ ! disbursem5t ( all or a portion ( ,f$]al f9ancial assi/ance to a ,/ate or local gov]nm5t1 or to a specific (f5d+ ag5cy or program ( a ,/ate or local gov]nm5t1 until su* "t z ! conduct prohibit$ by ?is section has ceas$4 7#b7 ,comm5cem5t ( action ,an action "u ?is subsection may be in/itut$ by-- 7,a7 any heal? c>e entity t has /&+ to compla9 ( an actual or ?reat5$ violation ( ?is section2 or 7,b7 ! ,attorney ,g5]al ( ! ,unit$ ,/ates4 7d7 ,adm9i/ration ,! ,secret>y ( ,heal? & ,human ,s]vices %all designate ! ,director ( ! ,(fice = ,civil ,rights ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices-- 7#a7 to receive compla9ts alleg+ a violation ( ?is section2 7#b7 subject to p>agraph 7#c71 to pursue ! inve/igation ( su* compla9ts 9 coord9ation ) ! ,attorney ,g5]al2 & 7#c7 9 ! case ( a compla9t relat$ to a ,f$]al ag5cy 7o!r ?an ) respect to ! ,dep>tm5t ( ,heal? & ,human ,s]vices7 or program adm9i/]$ ?r\gh su* o!r ag5cy or any ,/ate or local gov]nm5t receiv+ ,f$]al f9ancial assi/ance ?r\gh su* o!r ag5cy1 to ref] ! compla9t to ! appropriate (fice ( su* o!r ag5cy4 #acd4 ,equal employ] contribution rule to promote *oice 7a7 ,9 g5]al ,section #ejjj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subsection3 7e7 ,heal? c>e contribution election 7#a7 ,9 g5]al ,subsection 7a7 %all n apply 9 ! case ( a gr\p heal? plan ) respect to :i* ! requirem5ts ( p>agraphs 7#b7 & 7#c7 are met4 7#b7 ,contribution election ,! requirem5t ( ?is p>agraph is met ) respect to a gr\p heal? plan if any employee ( an employ] 7:o b = ?is p>agraph w\ld be cov]$ by su* plan7 may elect to h ! employ] or employee organization pay an am\nt :i* is n less ?an ! contribution am\nt to any provid] ( heal? insurance cov]age :i* con/itutes m$ical c>e ( ! individual or individual's sp\se or dep5d5ts 7o!r ?an except$ b5efits z def9$ 9 section #ihcb7;c77 9 lieu ( su* gr\p heal? plan cov]age o!rwise provid$ or contribut$ to by ! employ] ) respect to su* employee4 7#c7 ,pre-exi/+ conditions 7,a7 ,9 g5]al ,! requirem5t ( ?is p>agraph is met ) respect to heal? insurance cov]age provid$ to a p>ticipant or b5efici>y by any heal? insurance issu] if1 "u su* plan ! requirem5ts ( section #ihja are met ) respect to ! p>ticipant or b5efici>y4 7,b7 ,en=cem5t ) respect to individual election ,= purposes ( subp>agraph 7,a71 any heal? insurance cov]age ) respect to ! p>ticipant or b5efici>y %all be treat$ z heal? insurance cov]age "u a gr\p heal? plan to :i* section #ihja applies4 7#d7 ,contribution am\nt ,= purposes ( ?is section1 ! t]m contribution am\nt means1 ) respect to an individual "u a gr\p heal? plan1 ! portion ( ! applicable premium ( su* individual "u su* plan 7z det]m9$ "u section #dihj;,b7f77#d77 :i* is n paid by ! individual4 ,9 ! case t ! employ] (f]s m ?an "o gr\p heal? plan1 ! contribution am\nt %all be ! av]age am\nt ( ! applicable premiums "u su* plans4 7#e7 ,gr\p heal? plan ,= purposes ( ?is subsection1 subsection 7d7 %all n apply4 7#f7 ,application to ,,fehbp ,not)/&+ any o!r provision ( law1 ! ,(fice ( ,p]sonnel ,managem5t %all c>ry out ! heal? b5efits program "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 consi/5t ) ! requirem5ts ( ?is subsection4 4 7b7 ,requirem5t ( equal contributions to all ,,fehbp plans ,section #hijf ( title #e1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+3 7j7 ,not)/&+ subsections 7a7 ?r\gh 7i71 ! ,(fice ( ,p]sonnel ,managem5t %all revise ! am\nt ( ! ,gov]nm5t contribution made "u ?is section 9 a mann] s t-- 7#a7 ! am\nt ( su* contribution does n *ange bas$ on ! heal? b5efits plan 9 :i* ! individual is enroll$2 & 7#b7 ! aggregate am\nt ( su* contributions is e/imat$ to be equal to ! aggregate am\nt ( su* contributions if ?is subsection did n apply4 4 7c7 ,employee ,retirem5t ,income ,security ,act ( #aigd con=m+ am5dm5ts 7#a7 ,exception f ,,hipaa requirem5ts = b5efits provid$ "u heal? c>e contribution election ,section #gcb ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aaia;a7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7e7 ,heal? c>e contribution election 7#a7 ,9 g5]al ,! requirem5ts ( ?is "p %all n apply 9 ! case ( heal? insurance cov]age 7o!r ?an except$ b5efits z def9$ 9 section #ihcb7;c7 ( ! ,int]nal ,rev5ue ,code ( #aihf7-- 7,a7 :i* is provid$ to a p>ticipant or b5efici>y by a heal? insurance issu] "u a gr\p heal? plan1 & 7,b7 ) respect to :i* ! requirem5ts ( p>agraphs 7#b7 & 7#c7 are met4 7#b7 ,contribution election ,! requirem5t ( ?is p>agraph is met ) respect to heal? insurance cov]age provid$ to a p>ticipant or b5efici>y by any heal? insurance issu] "u a gr\p heal? plan if1 "u su* plan-- 7,a7 ! p>ticipant may elect su* cov]age = any p]iod ( cov]age 9 lieu ( heal? insurance cov]age o!rwise provid$ "u su* plan = su* p]iod1 & 7,b7 9 ! case ( su* an election1 ! plan sponsor is requir$ to pay to su* issu] = ! elect$ cov]age = su* p]iod an am\nt :i* is n less ?an ! contribution am\nt = su* heal? insurance cov]age o!rwise provid$ "u su* plan = su* p]iod4 7#c7 ,pre-exi/+ conditions 7,a7 ,9 g5]al ,! requirem5t ( ?is p>agraph is met ) respect to heal? insurance cov]age provid$ to a p>ticipant or b5efici>y by any heal? insurance issu] if1 "u su* plan ! requirem5ts ( section #gja are met ) respect to ! p>ticipant or b5efici>y4 7,b7 ,en=cem5t ) respect to individual election ,= purposes ( subp>agraph 7,a71 any heal? insurance cov]age ) respect to ! p>ticipant or b5efici>y %all be treat$ z heal? insurance cov]age "u a gr\p heal? plan to :i* section #gja applies4 7#d7 ,contribution am\nt 7,a7 ,9 g5]al ,= purposes ( ?is section1 ! t]m contribution am\nt means1 ) respect to any p]iod ( heal? insurance cov]age (f]$ to a p>ticipant or b5efici>y1 ! portion ( ! applicable premium ( su* p>ticipant or b5efici>y "u su* plan :i* is n paid by su* p>ticipant or b5efici>y4 ,9 ! case t ! employ] (f]s m ?an "o gr\p heal? plan1 ! contribution am\nt %all be ! av]age am\nt ( ! applicable premiums "u su* plans4 7,b7 ,applicable premium ,= purposes ( subp>agraph 7,a71 ! t]m applicable premium means1 ) respect to any p]iod ( heal? insurance cov]age ( a p>ticipant or b5efici>y "u a gr\p heal? plan1 ! co/ to ! plan = su* p]iod ( su* cov]age = simil>ly situat$ b5efici>ies 7)\t reg>d to :e!r su* co/ is paid by ! plan sponsor or ! p>ticipant or b5efici>y74 4 7#b7 ,exemption f fiduci>y liability ,section #djd ( su* ,act 7#bi ,u4,s4,c4 #aajd7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7e7 ,! plan sponsor ( a gr\p heal? plan 7z def9$ 9 section #gcc7;a77 %all n be treat$ z brea*+ any ( ! responsibilities1 obligations1 or duties impos$ ^u fiduci>ies by ?is title 9 ! case ( any individual :o is a p>ticipant or b5efici>y "u su* plan solely because ( ! ext5t to :i* ! plan sponsor provides1 9 ! case ( su* individual1 "s or all ( su* b5efits by means ( paym5t ( contribution am\nts pursuant to a contribution election "u section #gcb7;e71 irrespective ( ! am\nt or type ( b5efits t w\ld o!rwise be provid$ to su* individual "u su* plan4 4 7d7 ,exception f ,,hipaa requirem5ts "u ,,irc = b5efits provid$ "u heal? c>e contribution election ,section #ihca ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subsection3 7d7 ,heal? c>e contribution election 7#a7 ,9 g5]al ,! requirem5ts ( ?is *apt] %all n apply 9 ! case ( heal? insurance cov]age 7o!r ?an except$ b5efits z def9$ 9 section #ihcb7;c77-- 7,a7 :i* is provid$ to a p>ticipant or b5efici>y by a heal? insurance issu] "u a gr\p heal? plan1 & 7,b7 ) respect to :i* ! requirem5ts ( p>agraphs 7#b7 & 7#c7 are met4 7#b7 ,contribution election ,! requirem5t ( ?is p>agraph is met ) respect to heal? insurance cov]age provid$ to a p>ticipant or b5efici>y by any heal? insurance issu] "u a gr\p heal? plan if1 "u su* plan-- 7,a7 ! p>ticipant may elect su* cov]age = any p]iod ( cov]age 9 lieu ( heal? insurance cov]age o!rwise provid$ "u su* plan = su* p]iod1 & 7,b7 9 ! case ( su* an election1 ! plan sponsor is requir$ to pay to su* issu] = ! elect$ cov]age = su* p]iod an am\nt :i* is n less ?an ! contribution am\nt = su* heal? insurance cov]age o!rwise provid$ "u su* plan = su* p]iod4 7#c7 ,pre-exi/+ conditions 7,a7 ,9 g5]al ,! requirem5t ( ?is p>agraph is met ) respect to heal? insurance cov]age provid$ to a p>ticipant or b5efici>y by any heal? insurance issu] if1 "u su* plan ! requirem5ts ( section #ihja are met ) respect to ! p>ticipant or b5efici>y4 7,b7 ,en=cem5t ) respect to individual election ,= purposes ( subp>agraph 7,a71 any heal? insurance cov]age ) respect to ! p>ticipant or b5efici>y %all be treat$ z heal? insurance cov]age "u a gr\p heal? plan to :i* section #ihja applies4 7#d7 ,contribution am\nt 7,a7 ,9 g5]al ,= purposes ( ?is subsection1 ! t]m contribution am\nt means1 ) respect to any p]iod ( heal? insurance cov]age (f]$ to a p>ticipant or b5efici>y1 ! portion ( ! applicable premium ( su* p>ticipant or b5efici>y "u su* plan :i* is n paid by su* p>ticipant or b5efici>y4 ,9 ! case t ! employ] (f]s m ?an "o gr\p heal? plan1 ! contribution am\nt %all be ! av]age am\nt ( ! applicable premiums "u su* plans4 7,b7 ,applicable premium ,= purposes ( subp>agraph 7,a71 ! t]m applicable premium means1 ) respect to any p]iod ( heal? insurance cov]age ( a p>ticipant or b5efici>y "u a gr\p heal? plan1 ! co/ to ! plan = su* p]iod ( su* cov]age = simil>ly situat$ b5efici>ies 7)\t reg>d to :e!r su* co/ is paid by ! plan sponsor or ! p>ticipant or b5efici>y74 4 7e7 ,exception f ,,hipaa requirem5ts "u ! ,,phsa = b5efits provid$ "u heal? c>e contribution election ,section #bgba ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ba7 is am5d$-- 7#a7 by r$esignat+ subsection 7e7 z subsection 7f72 & 7#b7 by ins]t+ aft] subsection 7d7 ! foll[+ new subsection3 7e7 ,heal? c>e contribution election 7#a7 ,9 g5]al ,! requirem5ts ( subp>ts #a ?r\gh #c %all n apply 9 ! case ( heal? insurance cov]age 7o!r ?an except$ b5efits z def9$ 9 section #ihcb7;c7 ( ! ,int]nal ,rev5ue ,code ( #aihf7-- 7,a7 :i* is provid$ to a p>ticipant or b5efici>y by a heal? insurance issu] "u a gr\p heal? plan1 & 7,b7 ) respect to :i* ! requirem5ts ( p>agraphs 7#b7 & 7#c7 are met4 7#b7 ,contribution election ,! requirem5t ( ?is p>agraph is met ) respect to heal? insurance cov]age provid$ to a p>ticipant or b5efici>y by any heal? insurance issu] "u a gr\p heal? plan if1 "u su* plan-- 7,a7 ! p>ticipant may elect su* cov]age = any p]iod ( cov]age 9 lieu ( heal? insurance cov]age o!rwise provid$ "u su* plan = su* p]iod1 & 7,b7 9 ! case ( su* an election1 ! plan sponsor is requir$ to pay to su* issu] = ! elect$ cov]age = su* p]iod an am\nt :i* is n less ?an ! contribution am\nt = su* heal? insurance cov]age o!rwise provid$ "u su* plan = su* p]iod4 7#c7 ,pre-exi/+ conditions 7,a7 ,9 g5]al ,! requirem5t ( ?is p>agraph is met ) respect to heal? insurance cov]age provid$ to a p>ticipant or b5efici>y by any heal? insurance issu] if1 "u su* plan ! requirem5ts ( section #bgja are met ) respect to ! p>ticipant or b5efici>y4 7,b7 ,en=cem5t ) respect to individual election ,= purposes ( subp>agraph 7,a71 any heal? insurance cov]age ) respect to ! p>ticipant or b5efici>y %all be treat$ z heal? insurance cov]age "u a gr\p heal? plan to :i* section #bgja applies4 7#d7 ,contribution am\nt 7,a7 ,9 g5]al ,= purposes ( ?is section1 ! t]m contribution am\nt means1 ) respect to any p]iod ( heal? insurance cov]age (f]$ to a p>ticipant or b5efici>y1 ! portion ( ! applicable premium ( su* p>ticipant or b5efici>y "u su* plan :i* is n paid by su* p>ticipant or b5efici>y4 ,9 ! case t ! employ] (f]s m ?an "o gr\p heal? plan1 ! contribution am\nt %all be ! av]age am\nt ( ! applicable premiums "u su* plans4 7,b7 ,applicable premium ,= purposes ( subp>agraph 7,a71 ! t]m applicable premium means1 ) respect to any p]iod ( heal? insurance cov]age ( a p>ticipant or b5efici>y "u a gr\p heal? plan1 ! co/ to ! plan = su* p]iod ( su* cov]age = simil>ly situat$ b5efici>ies 7)\t reg>d to :e!r su* co/ is paid by ! plan sponsor or ! p>ticipant or b5efici>y74 4 #ace4 ,limitations on ,/ate re/rictions on employ] auto-enrollm5t 7a7 ,9 g5]al ,no ,/ate %all e/abli% a law t prev5ts an employ] t is all[$ an exclusion f gross income1 a d$uction1 or a cr$it = ,f$]al income tax purposes = heal? b5efits furni%$ to a p>ticipant or b5efici>y f in/itut+ auto-enrollm5t :i* meets ! requirem5ts ( subsection 7b7 = cov]age ( a p>ticipant or b5efici>y "u a gr\p heal? plan1 or heal? insurance cov]age (f]$ 9 connection ) su* a plan1 s long z ! p>ticipant or b5efici>y has ! option ( decl9+ su* cov]age4 7b7 ,automatic enrollm5t = employ]-,sponsor$ heal? b5efits 7#a7 ,9 g5]al ,! requirem5t ( ?is subsection ) respect to an employ] & an employee is t ! employ] automatically enroll su* employee into ! employm5t-bas$ heal? b5efits plan = individual cov]age "u ! plan option ) ! l[e/ applicable employee premium4 7#b7 ,opt-out ,9 no case may an employ] automatically enroll an employee 9 a plan "u p>agraph 7#a7 if su* employee makes an affirmative election to opt-out ( su* plan or to elect cov]age "u an employm5t-bas$ heal? b5efits plan (f]$ by su* employ]4 ,an employ] %all provide an employee ) a #cj-;day p]iod to make su* an affirmative election be=e ! employ] may automatically enroll ! employee 9 su* a plan4 7#c7 ,notice requirem5ts 7,a7 ,9 g5]al ,ea* employ] describ$ 9 p>agraph 7#a7 :o automatically enrolls an employee into a plan z describ$ 9 su* p>agraph %all provide ! employees1 )9 a reasonable p]iod be=e ! beg9n+ ( ea* plan ye> 7or1 9 ! case ( new employees1 )9 a reasonable p]iod be=e ! end ( ! enrollm5t p]iod = su* a new employee71 writt5 notice ( ! employees' rights & obligations relat+ to ! automatic enrollm5t requirem5t "u su* p>agraph4 ,su* notice mu/ be compreh5sive & und]/ood by ! av]age employee to :om ! automatic enrollm5t requirem5t applies4 7,b7 ,inclusion ( specific in=mation ,! writt5 notice "u subp>agraph 7,a7 mu/ expla9 an employee's "r to opt out ( be+ automatically enroll$ 9 a plan & 9 ! case t m ?an "o level ( b5efits or employee premium level is (f]$ by ! employ] involv$1 ! notice mu/ expla9 :i* level ( b5efits & employee premium level ! employee w be automatically enroll$ 9 ! abs5ce ( an affirmative election by ! employee4 7c7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$ to sup]s$e ,/ate law :i* e/abli%es1 implem5ts1 or cont9ues 9 effect any /&>d or requirem5t relat+ to employ]s 9 connection ) payroll or ! sponsor+ ( employ]-sponsor$ heal? insurance cov]age except to ! ext5t t su* /&>d or requirem5t prev5ts an employ] f in/itut+ ! auto-enrollm5t describ$ 9 subsection 7a74 7d7 ,non-,application to except$ b5efits ,= purposes ( ?is section1 ! t]m gr\p heal? plan does n include except$ b5efits 7z def9$ 9 section #bgha7;c7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ia7;c7774 #acf4 ,cr$it = small employ]s adopt+ auto-enrollm5t & def9$ contribution options 7a7 ,9 g5]al ,subp>t ,d ( "p ,,iv ( sub*apt] ,a ( *apt] #a ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #b1 is am5d$ by add+ at ! end ! foll[+ new section3 #de,r4 ,auto-enrollm5t & def9$ contribution option = heal? b5efits plans ( small employ]s 7a7 ,9 g5]al ,= purposes ( section #ch1 9 ! case ( a small employ]1 ! heal? b5efits plan implem5tation cr$it det]m9$ "u ?is section = ! taxable ye> is an am\nt equal to ! am\nt paid or incurr$ by ! taxpay] dur+ ! taxable ye> = qualifi$ heal? b5efits exp5ses4 7b7 ,limitation ,! cr$it det]m9$ "u subsection 7a7 ) respect to any taxpay] = any taxable ye> %all n exce$ ! excess (-- 7#a7 #a1ejj1 ov] 7#b7 sum ( ! cr$its det]m9$ "u subsection 7a7 ) respect to su* taxpay] = all prec$+ taxable ye>s4 7c7 ,qualifi$ heal? b5efits exp5ses ,= purposes ( ?is section1 ! t]m qualifi$ heal? b5efits exp5ses means1 ) respect to any taxable ye>1 am\nts paid or incurr$ by ! taxpay] dur+ su* taxable ye> =-- 7#a7 e/abli%+ auto-enrollm5t :i* meets ! requirem5ts ( section x ( ! %ort title = cov]age ( a p>ticipant or b5efici>y "u a gr\p heal? plan1 or heal? insurance cov]age (f]$ 9 connection ) su* a plan1 & 7#b7 implem5t+ ! employ] contribution option = heal? insurance cov]age pursuant to section #ejjj7;e77#b74 7d7 ,qualifi$ small employ] ,= purposes ( ?is section1 ! t]m qualifi$ small employ] means any employ] = any taxable ye> if ! numb] ( employees employ$ by su* employ] dur+ su* taxable ye> does n exce$ #ej4 ,all employ]s treat$ z a s+le employ] "u subsection 7a7 or 7b7 ( section #eb %all be treat$ z a s+le employ] = purposes ( ?is section4 7e7 ,no d\ble b5efit ,no d$uction or cr$it %all be all[$ "u any o!r provision ( ?is *apt] ) respect to ! am\nt ( ! cr$it det]m9$ "u ?is section4 7f7 ,t]m9ation ,subsection 7a7 %all n apply to any taxable ye> beg9n+ aft] ! date :i* is #b ye>s aft] ! date ( ! enactm5t ( ?is section4 4 7b7 ,cr$it ,to be "p ( g5]al bus9ess cr$it ,subsection 7b7 ( section #ch ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #b1 is am5d$ by /rik+ plus at ! end ( p>agraph 7#cd71 by /rik+ ! p]iod at ! end ( p>agraph 7#ce7 & ins]t+ 1 plus1 & by add+ at ! end ! foll[+ new p>agraph3 7#cf7 9 ! case ( a small employ] 7z def9$ 9 section #de,r7d771 ! heal? b5efits plan implem5tation cr$it det]m9$ "u section #de,r7a74 4 7c7 ,cl]ical am5dm5t ,! table ( sections = subp>t ,d ( "p ,,iv ( sub*apt] ,a ( *apt] #a ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #b1 is am5d$ by ins]t+ aft] ! item relat+ to section #de,q ! foll[+ new item3 ,sec4 #de,r4 ,auto-enrollm5t & def9$ contribution option = heal? b5efits plans ( small employ]s4 4 7d7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 ,,ii ,heal? ,c>e ,access & ,availability ,a ,heal? ,insurance ,pool+ ,me*anisms = ,individuals #bja4 ,f$]al grants = ,/ate insurance exp5ditures 7a7 ,9 ,g5]al ,subject to ! succe$+ provisions ( ?is section1 ea* ,/ate %all receive f ! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is subtitle ref]r$ to z ! ,secret>y7 a grant = ! ,/ate's provid+ = ! use1 9 connection ) provid+ heal? b5efits cov]age1 ( a qualify+ high-risk pool or a re9surance pool or o!r risk-adju/m5t me*anism us$ = ! purpose ( subsidiz+ ! pur*ase ( private heal? insurance4 7b7 ,fund+ am\nt 7#a7 ,9 g5]al ,!re are h]eby appropriat$1 out ( any funds 9 ! ,treasury n o!rwise appropriat$1 #a1jjj1jjj1jjj = ea* ( fiscal ye>s #bjaf1 #bjag1 & #bjah = grants "u ?is section4 ,su* am\nt %all be divid$ among ! ,/ates z det]m9$ by ! ,secret>y4 7#b7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$ z prev5t+ a ,/ate f us+ fund+ "u section #bgde ( ! ,public ,heal? ,s]vice ,act = purposes ( fund+ re9surance or o!r risk me*anisms4 7c7 ,limitation ,fund+ "u subsection 7a7 may only be us$ = ! foll[+3 7#a7 ,qualify+ high-risk pools 7,a7 ,curr5t pools ,a qualify+ high-risk pool creat$ be=e ! date ( ! enactm5t ( ?is ,act t only cov]s high-risk populations & individuals 7& _! sp\se & dep5d5ts7 receiv+ a heal? c>e tax cr$it "u section #ce ( ! ,int]nal ,rev5ue ,code ( #aihf = a limit$ p]iod ( "t z det]m9$ by ! ,secret>y or "u section #bgda ( ,public ,heal? ,s]vice ,act4 7,b7 ,new pools ,a qualify+ high-risk pool creat$ on or aft] su* date t only cov]s populations & individuals describ$ 9 subp>agraph 7,a7 if ! pool-- 7i7 (f]s at lea/ ! option ( "o or m high-d$uctible plan options1 9 comb9ation ) a contribution into a heal? sav+s acc\nt2 7ii7 (f]s multiple compet+ heal? plan options2 & 7iii7 cov]s only high-risk populations4 7#b7 ,risk insurance pool or o!r risk-adju/m5t me*anisms 7,a7 ,curr5t re9surance ,a re9surance pool1 or o!r risk-adju/m5t me*anism1 creat$ be=e ! date ( ! enactm5t ( ?is ,act t only cov]s populations & individuals describ$ 9 p>agraph 7#a77;,a74 7,b7 ,new pools ,a re9surance pool or o!r risk-adju/m5t me*anism creat$ on or aft] su* date t provides re9surance only cov]s populations & individuals describ$ 9 p>agraph 7#a77;,a7 & only on a prospective basis "u :i* a heal? insurance issu] c$es cov]$ lives to ! pool 9 ex*ange = paym5t ( a re9surance premium4 7#c7 ,transition ,no?+ 9 ?is section %all be con/ru$ z prev5t+ a ,/ate f us+ funds available to transition f an exi/+ high-risk pool to a re9surance pool4 7d7 ,bonus paym5ts ,) respect to any am\nts made available to ! ,/ates "u ?is section1 ! ,secret>y %all set aside a portion ( su* am\nts t %all only be available = ! foll[+ activities by su* ,/ates3 7#a7 ,provid+ gu>ante$ availability ( individual heal? insurance cov]age to c]ta9 individuals ) prior gr\p cov]age "u "p ,b ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act4 7#b7 ,a r$uction 9 premium tr5ds1 actual premiums1 or o!r co/-%>+ requirem5ts4 7#c7 ,an expansion or broad5+ ( ! pool ( high-risk individuals eligible = cov]age4 7#d7 ,/ates t adopt ! ,model ,heal? ,plan = ,un9surable ,individuals ,act ( ! ,national ,association ( ,insurance ,commission]s 7if & :5 updat$ by su* ,association74 ,! ,secret>y may reque/ su* ,association to update su* ,model ,heal? ,plan z ne$$ by #bjae4 7e7 ,requirem5ts = receipt ( bonus paym5ts ,! requirem5ts ( ?is subsection1 = ! availability ( bonus paym5ts to a ,/ate "u subsection 7d71 are z foll[s1 9 ! case ( an individual :o is cov]$ "u a high-risk pool or o!r pool or me*anism describ$ 9 subsection 7b7 op]at+ 9 ! ,/ate = :i* funds "u ?is section may be appli$3 7#a7 ,limitation on annual premiums = ea* individual bas$ on adju/$ gross family income ,! premiums impos$ = cov]age ( ea* individual "u heal? insurance cov]age (f]$ ?r\gh su* pool or me*anism may n exce$ 7on an annual basis7 ! foll[+3 7,a7 ,if ! adju/$ gross income 7z def9$ 9 section #fb ( ! ,int]nal ,rev5ue ,code ( #aihf7 ( all individuals 9 ! individual's family does n exce$ ! pov]ty l9e 7z def9$ 9 section #fgc7b7 ( ! ,community ,s]vices ,block ,grant ,act 7#db ,u4,s4,c4 #iijb7b771 includ+ any revision requir$ by su* section7 applicable to a family ( ! size involv$1 #b p]c5t ( su* income4 7,b7 ,if su* adju/$ gross income = all individuals 9 ! individual's family exce$s su* applicable pov]ty l9e1 ! sum (-- 7i7 #b p]c5t ( su* applicable pov]ty l9e2 & 7ii7 #aj p]c5t ( ! am\nt ( su* income t exce$s su* applicable pov]ty l9e4 7#b7 ,limitation on annual out-(-pocket co/s = ea* individual ,!re %all be a limit on ! annual out-(-pocket exp5ditures 7includ+ annual premiums7 = ea* individual = cov]age "u su* pool or me*anism equal to twice ! maximum all[able premiums = su* individual p]mitt$ "u p>agraph 7#a74 7f7 ,adm9i/ration ,! ,secret>y %all provide = ! adm9i/ration ( ?is section & may e/abli% su* t]ms & conditions1 includ+ ! requirem5t ( an application1 z may be appropriate to c>ry out ?is section4 7g7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$ z requir+ a ,/ate to op]ate a re9surance pool 7or o!r risk-adju/m5t me*anism7 "u ?is section or z prev5t+ a ,/ate f op]at+ su* a pool or me*anism ?r\gh "o or m private entities4 7h7 ,def9itions ,9 ?is section3 7#a7 ,qualify+ high-risk pool ,! t]m qualify+ high-risk pool means any qualifi$ high-risk pool 7z def9$ 9 subsection 7g77#a77;,a7 ( section #bgde ( ! ,public ,heal? ,s]vice ,act7 t meets ! conditions to receive a grant "u section 7b77#a7 ( su* section4 7#b7 ,re9surance pool or o!r risk-,adju/m5t me*anism def9$ ,! t]m re9surance pool or o!r risk-adju/m5t me*anism means any ,/ate-bas$ risk spread+ me*anism to subsidize ! pur*ase ( private heal? insurance = ! high-risk population4 7#c7 ,high-,risk population ,! t]m high-risk population means-- 7,a7 individuals :o1 by reason ( ! exi/5ce or hi/ory ( a m$ical condition1 are able to acquire heal? cov]age only at rates :i* are at lea/ #aej p]c5t ( ! /&>d risk rates = su* cov]age 79 a non-community-rat$ non-gu>ante$ issue ,/ate71 & 7,b7 individuals :o are provid$ heal? cov]age by a high-risk pool4 7#d7 ,/ate def9$ ,! t]m ,/ate includes ! ,di/rict ( ,columbia1 ,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1 ,am]ican ,samoa1 & ! ,nor!rn ,m>iana ,isl&s4 7i7 ,ext5d+ fund+ ,section #bgde7;d77#b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#de7;d77#b77 is am5d$-- 7#a7 9 ! head+1 by ins]t+ & #bjaf ?r\gh #bjah aft] #bjaj2 & 7#b7 by ins]t+ & = ea* ( fiscal ye>s #bjaf ?r\gh #bjah aft] = ea* ( fiscal ye>s #bjjg ?r\gh #bjaj4 7j7 ,sunset ,funds made available "u ?is section %all n be us$ = ! purpose ( subsidiz+ ! pur*ase ( private heal? insurance on or aft] ,octob] #a1 #bjah4 #bjb4 ,pool re=m = individual memb]%ip expansion ,! ,public ,heal? ,s]vice ,act1 z am5d$ by section #b1 is fur!r am5d$ by ins]t+ aft] title ,,xxx ! foll[+ new title3 ,,xxxi ,pool ,re=m = ,individual ,memb]%ip ,expansion #cajj4 ,purpose ,! purpose ( ?is title is to provide1 ?r\gh ! e/abli%m5t ( indep5d5t heal? pools 7ref]r$ to 9 ?is title z ,,ihp71 = ! re=m (1 & expansion ( enrollm5t 91 heal? insurance cov]age = individuals & small employ]s4 #caja4 ,def9ition ( indep5d5t heal? pool 7a7 ,9 ,g5]al ,= purposes ( ?is title1 ! t]ms individual heal? pool & ,,ihp mean a legal nonpr(it entity t meets ! foll[+ requirem5ts3 7#a7 ,organization ,! ,,ihp-- 7,a7 has be5 =m$ & ma9ta9$ 9 good fai? = a purpose t includes ! =mation ( a risk pool 9 ord] to (f] heal? insurance cov]age to its memb]s2 7,b7 does n condition memb]%ip 9 ! ,,ihp on any heal? /atus-relat$ factor relat+ to an individual 7includ+ an employee ( an employ] or a dep5d5t ( an employee72 7,c7 does n make heal? insurance cov]age (f]$ ?r\gh ! ,,ihp available o!r ?an 9 connection ) a memb] ( ! ,,ihp2 7,d7 is n a heal? insurance issu]2 & 7,e7 does n receive any consid]ation directly or indirectly f any heal? insurance issu] 9 connection ) ! enrollm5t ( any individuals1 or employees ( employ]s1 9 any heal? insurance cov]age1 except 9 conjunction ) s]vices (f]$ ?r\gh ! ,,ihp4 7#b7 ,(f]+ heal? b5efits cov]age 7,a7 ,diff]5t gr\ps ,! ,,ihp1 9 conjunction ) ^? heal? insurance issu]s t (f] heal? b5efits cov]age ?r\gh ! ,,ihp1 makes available heal? b5efits cov]age 9 ! mann] describ$ 9 subsection 7b7 to all memb]s ( ! ,,ihp & ! dep5d5ts ( su* memb]s 7&1 9 ! case ( small employ]s1 employees & _! dep5d5ts7 9 ! mann] describ$ 9 subsection 7c77#b7 at rates t are e/abli%$ by ! heal? insurance issu] on a policy or product specific basis & t may v>y = individuals cov]$ ?r\gh an ,,ihp4 7,b7 ,nondiscrim9ation 9 cov]age (f]$ 7i7 ,9 g5]al ,subject to clause 7ii71 ! ,,ihp may n (f] heal? b5efits cov]age to a memb] ( an ,,ihp unless ! same cov]age is (f]$ to all su* memb]s ( ! ,,ihp4 7ii7 ,con/ruction ,no?+ 9 ?is title %all be con/ru$ z requir+ or p]mitt+ a heal? insurance issu] to provide cov]age outside ! s]vice area ( ! issu]1 z approv$ "u ,/ate law1 or prev5t+ a heal? insurance issu] f und]writ+ or f exclud+ or limit+ ! cov]age on any individual1 subject to ! requirem5t ( section #bgda 7relat+ to gu>ante$ availability ( individual heal? insurance cov]age to c]ta9 individuals ) prior gr\p cov]age74 7,c7 ,no assumption ( insurance risk by ,,ihp ,! ,,ihp provides heal? b5efits cov]age only ?r\gh contracts ) heal? insurance issu]s & does n assume insurance risk ) respect to su* cov]age4 7#c7 ,geographic areas ,no?+ 9 ?is title %all be con/ru$ z prev5t+ ! e/abli%m5t & op]ation ( m ?an "o ,,ihp 9 a geographic area or z limit+ ! numb] ( ,i,h,ps t may op]ate 9 any area4 7#d7 ,provision ( adm9i/rative s]vices to pur*as]s ,! ,,ihp may provide adm9i/rative s]vices = memb]s4 ,su* s]vices may include acc\nt+1 bill+1 & enrollm5t in=mation4 7b7 ,heal? b5efits cov]age requirem5ts 7#a7 ,compliance ) consum] protection requirem5ts ,except z provid$ 9 section #cajb1 any heal? b5efits cov]age (f]$ ?r\gh an ,,ihp-- 7,a7 %all be issu$ by a heal? insurance issu] t meets all applicable ,/ate /&>ds relat+ to consum] protection2 7,b7 %all be approv$ or o!rwise p]mitt$ to be (f]$ "u ,/ate law2 & 7,c7 may n impose any exclusion ( a specific disease f su* cov]age4 7#b7 ,wellness bonuses = heal? promotion ,no?+ 9 ?is title %all be con/ru$ z preclud+ a heal? insurance issu] (f]+ heal? b5efits cov]age ?r\gh an ,,ihp f e/abli%+ premium disc\nts or rebates = memb]s or f modify+ o!rwise applicable copaym5ts or d$uctibles 9 return = adh]5ce to programs ( heal? promotion & disease prev5tion s long z su* programs are agre$ to 9 advance by ! ,,ihp & comply ) all o!r provisions ( ?is title & d n discrim9ate among simil>ly situat$ memb]s4 7c7 ,memb]s2 heal? insurance issu]s 7#a7 ,memb]s 7,a7 ,9 g5]al ,"u rules e/abli%$ to c>ry out ?is title1 ) respect to an individual or small employ] :o is a memb] ( an ,,ihp1 ! individual may enroll = heal? b5efits cov]age 7includ+ cov]age = dep5d5ts ( su* individual7 or employ] may enroll employees = heal? b5efits cov]age 7includ+ cov]age = dep5d5ts ( su* employees7 (f]$ by a heal? insurance issu] ?r\gh ! ,,ihp4 7,b7 ,rules = enrollm5t ,no?+ 9 ?is p>agraph %all preclude an ,,ihp f e/abli%+ rules ( enrollm5t & re5rollm5t ( memb]s4 ,su* rules %all be appli$ consi/5tly to all memb]s )9 ! ,,ihp & %all n be bas$ 9 any mann] on heal? /atus-relat$ factors4 7#b7 ,heal? insurance issu]s ,! contract betwe5 an ,,ihp & a heal? insurance issu] %all provide1 ) respect to a memb] enroll$ ) heal? b5efits cov]age (f]$ by ! issu] ?r\gh ! ,,ihp1 = ! paym5t to ! issu] ( ! premiums 7if any7 collect$ by ! ,,ihp = heal? insurance cov]age (f]$ by ! issu]4 #cajb4 ,application ( c]ta9 laws & requirem5ts 7a7 ,preemption ( ,/ate laws re/rict+ =mation ( ,i,h,ps ,any ,/ate law or regulation relat+ to ! composition or organization ( an ,,ihp is preempt$ to ! ext5t ! law or regulation is inconsi/5t ) ! provisions ( ?is title4 7b7 ,preemption ( ,/ate requirem5ts relat+ to heal? b5efit cov]age 7#a7 ,b5efit requirem5ts 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 ,/ate laws are sup]s$$1 & %all n apply to heal? b5efits cov]age made available ?r\gh an ,,ihp1 ins(> z su* laws impose b5efit requirem5ts = su* cov]age1 includ+ requirem5ts relat+ to cov]age ( specific provid]s1 specific s]vices or conditions1 or ! am\nt1 duration1 or scope ( b5efits4 7,b7 ,exception = ,f$]ally impos$ requirem5ts & = requirem5ts prohibit+ disease-specific exclusions ,subp>agraph 7,a7 %all n apply to a requirem5t to ! ext5t ! requirem5t-- 7i7 implem5ts title ,,xxvii or o!r ,f$]al law2 or 7ii7 prohibits imposition ( an exclusion ( a specific disease f heal? b5efits cov]age4 7#b7 ,o!r requirem5ts prev5t+ (f]+ ( cov]age ?r\gh an ,,ihp ,/ate laws are sup]s$$1 & %all n apply to heal? b5efits cov]age made available ?r\gh an ,,ihp1 ins(> z su* laws impose any o!r requirem5ts 7includ+ limitations on comp5sation arrangem5ts7 t1 directly or indirectly1 preclude 7or h ! effect ( preclud+7 ! (f]+ ( su* cov]age ?r\gh an ,,ihp1 if ! ,,ihp meets ! requirem5ts ( ?is title4 7c7 ,preemption ( ,/ate premium rat+ requirem5ts ,/ate laws are sup]s$$1 & %all n apply to ! premiums impos$ = heal? b5efits cov]age made available ?r\gh an ,,ihp1 ins(> z su* laws impose re/rictions on ! v>iation ( premiums among su* cov]age (f]$ to memb]s ( ! ,,ihp4 #cajc4 ,def9itions ,= purposes ( ?is title3 7#a7 ,dep5d5t ,! t]m dep5d5t1 z appli$ to heal? insurance cov]age (f]$ by a heal? insurance issu] lic5s$ 7or o!rwise regulat$7 9 a ,/ate1 %all h ! mean+ appli$ to su* t]m ) respect to su* cov]age "u ! laws ( ! ,/ate relat+ to su* cov]age & su* an issu]4 ,su* t]m may include ! sp\se & *ildr5 ( ! individual involv$4 7#b7 ,heal? b5efits cov]age ,! t]m heal? b5efits cov]age has ! mean+ giv5 ! t]m heal? insurance cov]age 9 section #bgia7;b77#a71 & does n include except$ b5efits 7z def9$ 9 section #bgia7;c774 7#c7 ,heal? insurance issu] ,! t]m heal? insurance issu] has ! mean+ giv5 su* t]m 9 section #bgia7;b77#b74 7#d7 ,heal? /atus-relat$ factor ,! t]m heal? /atus-relat$ factor has ! mean+ giv5 su* t]m 9 section #bgia7;d77#i74 7#e7 ,memb] ,! t]m memb] means1 ) respect to an ,,ihp1 an individual or small employ] :o is a memb] ( ! legal entity describ$ 9 section #caja7;a77#a7 to :i* ! ,,ihp is (f]+ cov]age4 7#f7 ,small employ] ,! t]m small employ] has ! mean+ giv5 su* t]m 9 section #gab7;c77#a77;,b7 ( ! ,employee ,retirem5t & ,income ,security ,act ( #aigd4 4 ,b ,small ,bus9ess ,heal? ,fairness #baa4 ,%ort title ,?is subtitle may be cit$ z ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjae4 #bab4 ,rules gov]n+ association heal? plans 7a7 ,9 ,g5]al ,subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by add+ aft] "p #g ! foll[+ new "p3 #h ,,rules ,,gov]n+ ,,association ,,heal? ,,plans #hja4 ,association heal? plans 7a7 ,9 ,g5]al ,= purposes ( ?is "p1 ! t]m association heal? plan means a gr\p heal? plan ^: sponsor is 7or is deem$ "u ?is "p to be7 describ$ 9 subsection 7b74 7b7 ,sponsor%ip ,! sponsor ( a gr\p heal? plan is describ$ 9 ?is subsection if su* sponsor-- 7#a7 is organiz$ & ma9ta9$ 9 good fai?1 ) a con/itution & bylaws specifically /at+ its purpose & provid+ = p]iodic meet+s on at lea/ an annual basis1 z a bona fide trade association1 a bona fide indu/ry association 7includ+ a rural electric coop]ative association or a rural telephone coop]ative association71 a bona fide pr(essional association1 or a bona fide *amb] ( comm]ce 7or simil> bona fide bus9ess association1 includ+ a corporation or simil> organization t op]ates on a coop]ative basis 7)9 ! mean+ ( section #acha ( ! ,int]nal ,rev5ue ,code ( #aihf771 = sub/antial purposes o!r ?an t ( obta9+ or provid+ m$ical c>e2 7#b7 is e/abli%$ z a p]man5t entity :i* receives ! active support ( its memb]s & requires = memb]%ip paym5t on a p]iodic basis ( dues or paym5ts necess>y to ma9ta9 eligibility = memb]%ip 9 ! sponsor2 & 7#c7 does n condition memb]%ip1 su* dues or paym5ts1 or cov]age "u ! plan on ! basis ( heal? /atus-relat$ factors ) respect to ! employees ( its memb]s 7or affiliat$ memb]s71 or ! dep5d5ts ( su* employees1 & does n condition su* dues or paym5ts on ! basis ( gr\p heal? plan p>ticipation4 ,any sponsor consi/+ ( an association ( entities :i* meet ! requirem5ts ( p>agraphs 7#a71 7#b71 & 7#c7 %all be deem$ to be a sponsor describ$ 9 ?is subsection4 #hjb4 ,c]tification ( association heal? plans 7a7 ,9 ,g5]al ,! applicable au?ority %all prescribe by regulation a proc$ure "u :i*1 subject to subsection 7b71 ! applicable au?ority %all c]tify association heal? plans :i* apply = c]tification z meet+ ! requirem5ts ( ?is "p4 7b7 ,/&>ds ,"u ! proc$ure prescrib$ pursuant to subsection 7a71 9 ! case ( an association heal? plan t provides at lea/ "o b5efit option :i* does n consi/ ( heal? insurance cov]age1 ! applicable au?ority %all c]tify su* plan z meet+ ! requirem5ts ( ?is "p only if ! applicable au?ority is satisfi$ t ! applicable requirem5ts ( ?is "p are met 7or1 ^u ! date on :i* ! plan is to comm5ce op]ations1 w be met7 ) respect to ! plan4 7c7 ,requirem5ts ,applicable to ,c]tifi$ ,plans ,an association heal? plan ) respect to :i* c]tification "u ?is "p is 9 effect %all meet ! applicable requirem5ts ( ?is "p1 effective on ! date ( c]tification 7or1 if lat]1 on ! date on :i* ! plan is to comm5ce op]ations74 7d7 ,requirem5ts = ,cont9u$ ,c]tification ,! applicable au?ority may provide by regulation = cont9u$ c]tification ( association heal? plans "u ?is "p4 7e7 ,class ,c]tification = ,fully ,insur$ ,plans ,! applicable au?ority %all e/abli% a class c]tification proc$ure = association heal? plans "u :i* all b5efits consi/ ( heal? insurance cov]age4 ,"u su* proc$ure1 ! applicable au?ority %all provide = ! grant+ ( c]tification "u ?is "p to ! plans 9 ea* class ( su* association heal? plans ^u appropriate fil+ "u su* proc$ure 9 connection ) plans 9 su* class & paym5t ( ! prescrib$ fee "u section #hjg7;a74 7f7 ,c]tification ( ,self-,insur$ ,association ,heal? ,plans ,an association heal? plan :i* (f]s "o or m b5efit options :i* d n consi/ ( heal? insurance cov]age may be c]tifi$ "u ?is "p only if su* plan consi/s (-- 7#a7 a plan :i* (f]$ su* cov]age on ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjae2 7#b7 a plan "u :i* ! sponsor does n re/rict memb]%ip to "o or m trades & bus9esses or indu/ries & ^: eligible p>ticipat+ employ]s repres5t a broad cross-section ( trades & bus9esses or indu/ries2 or 7#c7 a plan ^: eligible p>ticipat+ employ]s repres5t "o or m trades or bus9esses1 or "o or m indu/ries1 consi/+ ( any ( ! foll[+3 agriculture2 equipm5t & automobile deal]%ips2 b>b]+ & cosmetology2 c]tifi$ public acc\nt+ practices2 *ild c>e2 con/ruction2 dance1 !atrical & or*e/ra productions2 dis9fect+ & pe/ control2 f9ancial s]vices2 fi%+2 food s]vice e/abli%m5ts2 hospitals2 labor organizations2 logg+2 manufactur+ 7metals72 m9+2 m$ical & d5tal practices2 m$ical laboratories2 pr(essional consult+ s]vices2 sanit>y s]vices2 transportation 7local & freight72 w>eh\s+2 :olesal+_/di/ribut+2 or any o!r trade or bus9ess or indu/ry :i* has be5 indicat$ z hav+ av]age or above-av]age risk or heal? claims exp]i5ce by reason ( ,/ate rate fil+s1 d5ials ( cov]age1 propos$ premium rate levels1 or o!r means demon/rat$ by su* plan 9 accordance ) regulations4 #hjc4 ,requirem5ts relat+ to sponsors & bo>ds ( tru/ees 7a7 ,sponsor ,! requirem5ts ( ?is subsection are met ) respect to an association heal? plan if ! sponsor has met 7or is deem$ "u ?is "p to h met7 ! requirem5ts ( section #hja7;b7 = a cont9u\s p]iod ( n less ?an #c ye>s end+ ) ! date ( ! application = c]tification "u ?is "p4 7b7 ,bo>d ( ,tru/ees ,! requirem5ts ( ?is subsection are met ) respect to an association heal? plan if ! foll[+ requirem5ts are met3 7#a7 ,fiscal control ,! plan is op]at$1 pursuant to a tru/ agreem5t1 by a bo>d ( tru/ees :i* has complete fiscal control ov] ! plan & :i* is responsible = all op]ations ( ! plan4 7#b7 ,rules ( op]ation & f9ancial controls ,! bo>d ( tru/ees has 9 effect rules ( op]ation & f9ancial controls1 bas$ on a #c-ye> plan ( op]ation1 adequate to c>ry out ! t]ms ( ! plan & to meet all requirem5ts ( ?is title applicable to ! plan4 7#c7 ,rules gov]n+ relation%ip to p>ticipat+ employ]s & to contractors 7,a7 ,bo>d memb]%ip 7i7 ,9 g5]al ,except z provid$ 9 clauses 7ii7 & 7iii71 ! memb]s ( ! bo>d ( tru/ees are individuals select$ f individuals :o are ! own]s1 (fic]s1 directors1 or employees ( ! p>ticipat+ employ]s or :o are p>tn]s 9 ! p>ticipat+ employ]s & actively p>ticipate 9 ! bus9ess4 7ii7 ,limitation 7,i7 ,g5]al rule ,except z provid$ 9 subclauses 7,,ii7 & 7,,iii71 no su* memb] is an own]1 (fic]1 director1 or employee (1 or p>tn] 91 a contract adm9i/rator or o!r s]vice provid] to ! plan4 7,,ii7 ,limit$ exception = provid]s ( s]vices solely on behalf ( ! sponsor ,(fic]s or employees ( a sponsor :i* is a s]vice provid] 7o!r ?an a contract adm9i/rator7 to ! plan may be memb]s ( ! bo>d if !y con/itute n m ?an #be p]c5t ( ! memb]%ip ( ! bo>d & !y d n provide s]vices to ! plan o!r ?an on behalf ( ! sponsor4 7,,iii7 ,treatm5t ( provid]s ( m$ical c>e ,9 ! case ( a sponsor :i* is an association ^: memb]%ip consi/s prim>ily ( provid]s ( m$ical c>e1 subclause 7,i7 %all n apply 9 ! case ( any s]vice provid] describ$ 9 subclause 7,i7 :o is a provid] ( m$ical c>e "u ! plan4 7iii7 ,c]ta9 plans exclud$ ,clause 7i7 %all n apply to an association heal? plan :i* is 9 exi/5ce on ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjae4 7,b7 ,sole au?ority ,! bo>d has sole au?ority "u ! plan to approve applications = p>ticipation 9 ! plan & to contract ) a s]vice provid] to adm9i/] ! day-to-day affairs ( ! plan4 7c7 ,treatm5t ( ,fran*ise ,networks ,9 ! case ( a gr\p heal? plan :i* is e/abli%$ & ma9ta9$ by a fran*is] = a fran*ise network consi/+ ( its fran*isees-- 7#a7 ! requirem5ts ( subsection 7a7 & section #hja7;a7 %all be deem$ met if su* requirem5ts w\ld o!rwise be met if ! fran*is] 7 deem$ to be ! sponsor ref]r$ to 9 section #hja7;b71 su* network 7 deem$ to be an association describ$ 9 section #hja7;b71 & ea* fran*isee 7 deem$ to be a memb] 7( ! association & ! sponsor7 ref]r$ to 9 section #hja7;b72 & 7#b7 ! requirem5ts ( section #hjd7;a77#a7 %all be deem$ met4 ,! ,secret>y may by regulation def9e = purposes ( ?is subsection ! t]ms fran*is]1 fran*ise network1 & fran*isee4 #hjd4 ,p>ticipation & cov]age requirem5ts 7a7 ,cov]$ ,employ]s & ,individuals ,! requirem5ts ( ?is subsection are met ) respect to an association heal? plan if1 "u ! t]ms ( ! plan-- 7#a7 ea* p>ticipat+ employ] mu/ be-- 7,a7 a memb] ( ! sponsor2 7,b7 ! sponsor2 or 7,c7 an affiliat$ memb] ( ! sponsor ) respect to :i* ! requirem5ts ( subsection 7b7 are met1 except t1 9 ! case ( a sponsor :i* is a pr(essional association or o!r individual-bas$ association1 if at lea/ "o ( ! (fic]s1 directors1 or employees ( an employ]1 or at lea/ "o ( ! individuals :o are p>tn]s 9 an employ] & :o actively p>ticipates 9 ! bus9ess1 is a memb] or su* an affiliat$ memb] ( ! sponsor1 p>ticipat+ employ]s may also include su* employ]2 & 7#b7 all individuals comm5c+ cov]age "u ! plan aft] c]tification "u ?is "p mu/ be-- 7,a7 active or retir$ own]s 7includ+ self-employ$ individuals71 (fic]s1 directors1 or employees (1 or p>tn]s 91 p>ticipat+ employ]s2 or 7,b7 ! b5efici>ies ( individuals describ$ 9 subp>agraph 7,a74 7b7 ,cov]age ( ,previ\sly ,un9sur$ ,employees ,9 ! case ( an association heal? plan 9 exi/5ce on ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjae1 an affiliat$ memb] ( ! sponsor ( ! plan may be (f]$ cov]age "u ! plan z a p>ticipat+ employ] only if-- 7#a7 ! affiliat$ memb] 0 an affiliat$ memb] on ! date ( c]tification "u ?is "p2 or 7#b7 dur+ ! #ab-mon? p]iod prec$+ ! date ( ! (f]+ ( su* cov]age1 ! affiliat$ memb] has n ma9ta9$ or contribut$ to a gr\p heal? plan ) respect to any ( its employees :o w\ld o!rwise be eligible to p>ticipate 9 su* association heal? plan4 7c7 ,individual ,m>ket ,unaffect$ ,! requirem5ts ( ?is subsection are met ) respect to an association heal? plan if1 "u ! t]ms ( ! plan1 no p>ticipat+ employ] may provide heal? insurance cov]age 9 ! individual m>ket = any employee n cov]$ "u ! plan :i* is simil> to ! cov]age contemporane\sly provid$ to employees ( ! employ] "u ! plan1 if su* exclusion ( ! employee f cov]age "u ! plan is bas$ on a heal? /atus-relat$ factor ) respect to ! employee & su* employee w\ld1 b = su* exclusion on su* basis1 be eligible = cov]age "u ! plan4 7d7 ,prohibition ( ,discrim9ation ,aga9/ ,employ]s & ,employees ,eligible ,to ,p>ticipate ,! requirem5ts ( ?is subsection are met ) respect to an association heal? plan if-- 7#a7 "u ! t]ms ( ! plan1 all employ]s meet+ ! prec$+ requirem5ts ( ?is section are eligible to qualify z p>ticipat+ employ]s = all geographically available cov]age options1 unless1 9 ! case ( any su* employ]1 p>ticipation or contribution requirem5ts ( ! type ref]r$ to 9 section #bgaa ( ! ,public ,heal? ,s]vice ,act are n met2 7#b7 ^u reque/1 any employ] eligible to p>ticipate is furni%$ in=mation reg>d+ all cov]age options available "u ! plan2 & 7#c7 ! applicable requirem5ts ( sections #gja1 #gjb1 & #gjc are met ) respect to ! plan4 #hje4 ,o!r requirem5ts relat+ to plan docum5ts1 contribution rates1 & b5efit options 7a7 ,9 ,g5]al ,! requirem5ts ( ?is section are met ) respect to an association heal? plan if ! foll[+ requirem5ts are met3 7#a7 ,cont5ts ( gov]n+ in/rum5ts ,! in/rum5ts gov]n+ ! plan include a writt5 in/rum5t1 meet+ ! requirem5ts ( an in/rum5t requir$ "u section #djb7;a77#a71 :i*-- 7,a7 provides t ! bo>d ( tru/ees s]ves z ! nam$ fiduci>y requir$ = plans "u section #djb7;a77#a7 & s]ves 9 ! capacity ( a plan adm9i/rator 7ref]r$ to 9 section #c7af77;,a772 7,b7 provides t ! sponsor ( ! plan is to s]ve z plan sponsor 7ref]r$ to 9 section #c7af77;,b772 & 7,c7 incorporates ! requirem5ts ( section #hjf4 7#b7 ,contribution rates mu/ be nondiscrim9atory 7,a7 ,! contribution rates = any p>ticipat+ small employ] d n v>y on ! basis ( any heal? /atus-relat$ factor 9 relation to employees ( su* employ] or _! b5efici>ies & d n v>y on ! basis ( ! type ( bus9ess or indu/ry 9 :i* su* employ] is engag$4 7,b7 ,no?+ 9 ?is title or any o!r provision ( law %all be con/ru$ to preclude an association heal? plan1 or a heal? insurance issu] (f]+ heal? insurance cov]age 9 connection ) an association heal? plan1 f-- 7i7 sett+ contribution rates bas$ on ! claims exp]i5ce ( ! plan2 or 7ii7 v>y+ contribution rates = small employ]s 9 a ,/ate to ! ext5t t su* rates c\ld v>y us+ ! same me?odology employ$ 9 su* ,/ate = regulat+ premium rates 9 ! small gr\p m>ket ) respect to heal? insurance cov]age (f]$ 9 connection ) bona fide associations 7)9 ! mean+ ( section #bgia7;d77#c7 ( ! ,public ,heal? ,s]vice ,act71 subject to ! requirem5ts ( section #gjb7;b7 relat+ to contribution rates4 7#c7 ,floor = numb] ( cov]$ individuals ) respect to c]ta9 plans ,if any b5efit option "u ! plan does n consi/ ( heal? insurance cov]age1 ! plan has z ( ! beg9n+ ( ! plan ye> n few] ?an #a1jjj p>ticipants & b5efici>ies4 7#d7 ,m>ket+ requirem5ts 7,a7 ,9 g5]al ,if a b5efit option :i* consi/s ( heal? insurance cov]age is (f]$ "u ! plan1 ,/ate-lic5s$ insurance ag5ts %all be us$ to di/ribute to small employ]s cov]age :i* does n consi/ ( heal? insurance cov]age 9 a mann] comp>able to ! mann] 9 :i* su* ag5ts are us$ to di/ribute heal? insurance cov]age4 7,b7 ,/ate-lic5s$ insurance ag5ts ,= purposes ( subp>agraph 7,a71 ! t]m ,/ate-lic5s$ insurance ag5ts means "o or m ag5ts :o are lic5s$ 9 a ,/ate & are subject to ! laws ( su* ,/ate relat+ to lic5sure1 qualification1 te/+1 exam9ation1 & cont9u+ education ( p]sons au?oriz$ to (f]1 sell1 or solicit heal? insurance cov]age 9 su* ,/ate4 7#e7 ,regulatory requirem5ts ,su* o!r requirem5ts z ! applicable au?ority det]m9es are necess>y to c>ry out ! purposes ( ?is "p1 :i* %all be prescrib$ by ! applicable au?ority by regulation4 7b7 ,ability ( ,association ,heal? ,plans ,to ,design ,b5efit ,options ,subject to section #ead7;d71 no?+ 9 ?is "p or any provision ( ,/ate law 7z def9$ 9 section #ead7;c77#a77 %all be con/ru$ to preclude an association heal? plan1 or a heal? insurance issu] (f]+ heal? insurance cov]age 9 connection ) an association heal? plan1 f ex]cis+ its sole discretion 9 select+ ! specific items & s]vices consi/+ ( m$ical c>e to be includ$ z b5efits "u su* plan or cov]age1 except 7subject to section #ead7 9 ! case ( 7#a7 any law to ! ext5t t x is n preempt$ "u section #gca7;a77#a7 ) respect to matt]s gov]n$ by section #gaa1 #gab1 or #gac1 or 7#b7 any law ( ! ,/ate ) :i* fil+ & approval ( a policy type (f]$ by ! plan 0 initially obta9$ to ! ext5t t su* law prohibits an exclusion ( a specific disease f su* cov]age4 #hjf4 ,ma9t5ance ( res]ves & provisions = solv5cy = plans provid+ heal? b5efits 9 addition to heal? insurance cov]age 7a7 ,9 ,g5]al ,! requirem5ts ( ?is section are met ) respect to an association heal? plan if-- 7#a7 ! b5efits "u ! plan consi/ solely ( heal? insurance cov]age2 or 7#b7 if ! plan provides any additional b5efit options :i* d n consi/ ( heal? insurance cov]age1 ! plan-- 7,a7 e/abli%es & ma9ta9s res]ves ) respect to su* additional b5efit options1 9 am\nts recomm5d$ by ! qualifi$ heal? actu>y1 consi/+ (-- 7i7 a res]ve suffici5t = une>n$ contributions2 7ii7 a res]ve suffici5t = b5efit liabilities :i* h be5 incurr$1 :i* h n be5 satisfi$1 & = :i* risk ( loss has n yet be5 transf]r$1 & = expect$ adm9i/rative co/s ) respect to su* b5efit liabilities2 7iii7 a res]ve suffici5t = any o!r obligations ( ! plan2 & 7iv7 a res]ve suffici5t = a m>g9 ( error & o!r fluctuations1 tak+ into acc\nt ! specific circum/ances ( ! plan2 & 7,b7 e/abli%es & ma9ta9s aggregate & specific excess_//op loss insurance & solv5cy indemnification1 ) respect to su* additional b5efit options = :i* risk ( loss has n yet be5 transf]r$1 z foll[s3 7i7 ,! plan %all secure aggregate excess_//op loss insurance = ! plan ) an atta*m5t po9t :i* is n great] ?an #abe p]c5t ( expect$ gross annual claims4 ,! applicable au?ority may by regulation provide = upw>d adju/m5ts 9 ! am\nt ( su* p]c5tage 9 specifi$ circum/ances 9 :i* ! plan specifically provides = & ma9ta9s res]ves 9 excess ( ! am\nts requir$ "u subp>agraph 7,a74 7ii7 ,! plan %all secure specific excess_//op loss insurance = ! plan ) an atta*m5t po9t :i* is at lea/ equal to an am\nt recomm5d$ by ! plan's qualifi$ heal? actu>y4 ,! applicable au?ority may by regulation provide = adju/m5ts 9 ! am\nt ( su* insurance 9 specifi$ circum/ances 9 :i* ! plan specifically provides = & ma9ta9s res]ves 9 excess ( ! am\nts requir$ "u subp>agraph 7,a74 7iii7 ,! plan %all secure indemnification insurance = any claims :i* ! plan is unable to satisfy by reason ( a plan t]m9ation4 ,any p]son issu+ to a plan insurance describ$ 9 clause 7i71 7ii71 or 7iii7 ( subp>agraph 7,b7 %all notify ! ,secret>y ( any failure ( premium paym5t m]it+ cancellation ( ! policy prior to und]tak+ su* a cancellation4 ,any regulations prescrib$ by ! applicable au?ority pursuant to clause 7i7 or 7ii7 ( subp>agraph 7,b7 may all[ = su* adju/m5ts 9 ! requir$ levels ( excess_//op loss insurance z ! qualifi$ heal? actu>y may recomm5d1 tak+ into acc\nt ! specific circum/ances ( ! plan4 7b7 ,m9imum ,surplus 9 ,addition to ,claims ,res]ves ,9 ! case ( any association heal? plan describ$ 9 subsection 7a77#b71 ! requirem5ts ( ?is subsection are met if ! plan e/abli%es & ma9ta9s surplus 9 an am\nt at lea/ equal to-- 7#a7 #ejj1jjj2 or 7#b7 su* great] am\nt 7b n great] ?an #b1jjj1jjj7 z may be set =? 9 regulations prescrib$ by ! applicable au?ority1 consid]+ ! level ( aggregate & specific excess_//op loss insurance provid$ ) respect to su* plan & o!r factors relat$ to solv5cy risk1 su* z ! plan's project$ levels ( p>ticipation or claims1 ! nature ( ! plan's liabilities1 & ! types ( assets available to assure t su* liabilities are met4 7c7 ,additional ,requirem5ts ,9 ! case ( any association heal? plan describ$ 9 subsection 7a77#b71 ! applicable au?ority may provide su* additional requirem5ts relat+ to res]ves1 excess_//op loss insurance1 & indemnification insurance z ! applicable au?ority consid]s appropriate4 ,su* requirem5ts may be provid$ by regulation ) respect to any su* plan or any class ( su* plans4 7d7 ,adju/m5ts = ,excess_/,/op ,loss ,insurance ,! applicable au?ority may provide = adju/m5ts to ! levels ( res]ves o!rwise requir$ "u subsections 7a7 & 7b7 ) respect to any plan or class ( plans to take into acc\nt excess_//op loss insurance provid$ ) respect to su* plan or plans4 7e7 ,alt]native ,means ( ,compliance ,! applicable au?ority may p]mit an association heal? plan describ$ 9 subsection 7a77#b7 to sub/itute1 = all or "p ( ! requirem5ts ( ?is section 7except subsection 7a77#b77;,b77iii771 su* security1 gu>antee1 hold-h>mless arrangem5t1 or o!r f9ancial arrangem5t z ! applicable au?ority det]m9es to be adequate to enable ! plan to fully meet all its f9ancial obligations on a timely basis & is o!rwise no less protective ( ! int]e/s ( p>ticipants & b5efici>ies ?an ! requirem5ts = :i* x is sub/itut$4 ,! applicable au?ority may take into acc\nt1 = purposes ( ?is subsection1 evid5ce provid$ by ! plan or sponsor :i* demon/rates an assumption ( liability ) respect to ! plan4 ,su* evid5ce may be 9 ! =m ( a contract ( indemnification1 li51 bond+1 insurance1 lett] ( cr$it1 rec\rse "u applicable t]ms ( ! plan 9 ! =m ( assessm5ts ( p>ticipat+ employ]s1 security1 or o!r f9ancial arrangem5t4 7f7 ,measures ,to ,ensure ,cont9u$ ,paym5t ( ,b5efits by ,c]ta9 ,plans 9 ,di/ress 7#a7 ,paym5ts by c]ta9 plans to association heal? plan fund 7,a7 ,9 g5]al ,9 ! case ( an association heal? plan describ$ 9 subsection 7a77#b71 ! requirem5ts ( ?is subsection are met if ! plan makes paym5ts into ! ,association ,heal? ,plan ,fund "u ?is subp>agraph :5 !y are due4 ,su* paym5ts %all consi/ ( annual paym5ts 9 ! am\nt ( #e1jjj1 &1 9 addition to su* annual paym5ts1 su* supplem5tal paym5ts z ! ,secret>y may det]m9e to be necess>y "u p>agraph 7#b74 ,paym5ts "u ?is p>agraph are payable to ! ,fund at ! "t det]m9$ by ! ,secret>y4 ,initial paym5ts are due 9 advance ( c]tification "u ?is "p4 ,paym5ts %all cont9ue to accrue until a plan's assets are di/ribut$ pursuant to a t]m9ation proc$ure4 7,b7 ,p5alties = failure to make paym5ts ,if any paym5t is n made by a plan :5 x is due1 a late paym5t *>ge ( n m ?an #ajj p]c5t ( ! paym5t :i* 0 n timely paid %all be payable by ! plan to ! ,fund4 7,c7 ,cont9u$ duty ( ! secret>y ,! ,secret>y %all n cease to c>ry out ! provisions ( p>agraph 7#b7 on acc\nt ( ! failure ( a plan to pay any paym5t :5 due4 7#b7 ,paym5ts by secret>y to cont9ue excess_//op loss insurance cov]age & indemnification insurance cov]age = c]ta9 plans ,9 any case 9 :i* ! applicable au?ority det]m9es t !re is1 or t !re is reason to believe t !re w be3 7,a7 a failure to take necess>y corrective actions "u section #hji7;a7 ) respect to an association heal? plan describ$ 9 subsection 7a77#b72 or 7,b7 a t]m9ation ( su* a plan "u section #hji7;b7 or #haj7;b77#h7 7&1 if ! applicable au?ority is n ! ,secret>y1 c]tifies su* det]m9ation to ! ,secret>y71 ! ,secret>y %all det]m9e ! am\nts necess>y to make paym5ts to an insur] 7designat$ by ! ,secret>y7 to ma9ta9 9 =ce excess_//op loss insurance cov]age or indemnification insurance cov]age = su* plan1 if ! ,secret>y det]m9es t !re is a reasonable expectation t1 )\t su* paym5ts1 claims w\ld n be satisfi$ by reason ( t]m9ation ( su* cov]age4 ,! ,secret>y %all1 to ! ext5t provid$ 9 advance 9 appropriation ,acts1 pay su* am\nts s det]m9$ to ! insur] designat$ by ! ,secret>y4 7#c7 ,association heal? plan fund 7,a7 ,9 g5]al ,!re is e/abli%$ 9 ! ,treasury a fund to be kn[n z ! ,association ,heal? ,plan ,fund4 ,! ,fund %all be available = mak+ paym5ts pursuant to p>agraph 7#b74 ,! ,fund %all be cr$it$ ) paym5ts receiv$ pursuant to p>agraph 7#a77;,a71 p5alties receiv$ pursuant to p>agraph 7#a77;,b71 & e>n+s on inve/m5ts ( am\nts ( ! ,fund "u subp>agraph 7,b74 7,b7 ,inve/m5t ,:5ev] ! ,secret>y det]m9es t ! moneys ( ! fund are 9 excess ( curr5t ne$s1 ! ,secret>y may reque/ ! inve/m5t ( su* am\nts z ! ,secret>y det]m9es advisable by ! ,secret>y ( ! ,treasury 9 obligations issu$ or gu>ante$ by ! ,unit$ ,/ates4 7g7 ,excess_/,/op ,loss ,insurance ,= purposes ( ?is section3 7#a7 ,aggregate excess_//op loss insurance ,! t]m aggregate excess_//op loss insurance means1 9 connection ) an association heal? plan1 a contract-- 7,a7 "u :i* an insur] 7meet+ su* m9imum /&>ds z ! applicable au?ority may prescribe by regulation7 provides = paym5t to ! plan ) respect to aggregate claims "u ! plan 9 excess ( an am\nt or am\nts specifi$ 9 su* contract2 7,b7 :i* is gu>ante$ r5ewable2 & 7,c7 :i* all[s = paym5t ( premiums by any ?ird p>ty on behalf ( ! insur$ plan4 7#b7 ,specific excess_//op loss insurance ,! t]m specific excess_//op loss insurance means1 9 connection ) an association heal? plan1 a contract-- 7,a7 "u :i* an insur] 7meet+ su* m9imum /&>ds z ! applicable au?ority may prescribe by regulation7 provides = paym5t to ! plan ) respect to claims "u ! plan 9 connection ) a cov]$ individual 9 excess ( an am\nt or am\nts specifi$ 9 su* contract 9 connection ) su* cov]$ individual2 7,b7 :i* is gu>ante$ r5ewable2 & 7,c7 :i* all[s = paym5t ( premiums by any ?ird p>ty on behalf ( ! insur$ plan4 7h7 ,indemnification ,insurance ,= purposes ( ?is section1 ! t]m indemnification insurance means1 9 connection ) an association heal? plan1 a contract-- 7#a7 "u :i* an insur] 7meet+ su* m9imum /&>ds z ! applicable au?ority may prescribe by regulation7 provides = paym5t to ! plan ) respect to claims "u ! plan :i* ! plan is unable to satisfy by reason ( a t]m9ation pursuant to section #hji7;b7 7relat+ to m&atory t]m9ation72 7#b7 :i* is gu>ante$ r5ewable & noncancellable = any reason 7except z ! applicable au?ority may prescribe by regulation72 & 7#c7 :i* all[s = paym5t ( premiums by any ?ird p>ty on behalf ( ! insur$ plan4 7i7 ,res]ves ,= purposes ( ?is section1 ! t]m res]ves means1 9 connection ) an association heal? plan1 plan assets :i* meet ! fiduci>y /&>ds "u "p #d & su* additional requirem5ts reg>d+ liquidity z ! applicable au?ority may prescribe by regulation4 7j7 ,solv5cy ,/&>ds ,work+ ,gr\p 7#a7 ,9 g5]al ,)9 #ij days aft] ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjae1 ! applicable au?ority %all e/abli% a ,solv5cy ,/&>ds ,work+ ,gr\p4 ,9 prescrib+ ! initial regulations "u ?is section1 ! applicable au?ority %all take into acc\nt ! recomm5dations ( su* ,work+ ,gr\p4 7#b7 ,memb]%ip ,! ,work+ ,gr\p %all consi/ ( n m ?an #ae memb]s appo9t$ by ! applicable au?ority4 ,! applicable au?ority %all include among p]sons invit$ to memb]%ip on ! ,work+ ,gr\p at lea/ "o ( ea* ( ! foll[+3 7,a7 ,a repres5tative ( ! ,national ,association ( ,insurance ,commission]s4 7,b7 ,a repres5tative ( ! ,am]ican ,academy ( ,actu>ies4 7,c7 ,a repres5tative ( ! ,/ate gov]nm5ts1 or _! int]e/s4 7,d7 ,a repres5tative ( exi/+ self-insur$ arrangem5ts1 or _! int]e/s4 7,e7 ,a repres5tative ( associations ( ! type ref]r$ to 9 section #hja7;b77#a71 or _! int]e/s4 7,f7 ,a repres5tative ( multiemploy] plans t are gr\p heal? plans1 or _! int]e/s4 #hjg4 ,requirem5ts = application & relat$ requirem5ts 7a7 ,fil+ ,fee ,"u ! proc$ure prescrib$ pursuant to section #hjb7;a71 an association heal? plan %all pay to ! applicable au?ority at ! "t ( fil+ an application = c]tification "u ?is "p a fil+ fee 9 ! am\nt ( #e1jjj1 :i* %all be available 9 ! case ( ! ,secret>y1 to ! ext5t provid$ 9 appropriation ,acts1 = ! sole purpose ( adm9i/]+ ! c]tification proc$ures applicable ) respect to association heal? plans4 7b7 ,in=mation ,to ,be ,includ$ 9 ,application = ,c]tification ,an application = c]tification "u ?is "p meets ! requirem5ts ( ?is section only if x includes1 9 a mann] & =m :i* %all be prescrib$ by ! applicable au?ority by regulation1 at lea/ ! foll[+ in=mation3 7#a7 ,id5tify+ in=mation ,! names & addresses (-- 7,a7 ! sponsor2 & 7,b7 ! memb]s ( ! bo>d ( tru/ees ( ! plan4 7#b7 ,/ates 9 :i* plan int5ds to d bus9ess ,! ,/ates 9 :i* p>ticipants & b5efici>ies "u ! plan are to be locat$ & ! numb] ( !m expect$ to be locat$ 9 ea* su* ,/ate4 7#c7 ,bond+ requirem5ts ,evid5ce provid$ by ! bo>d ( tru/ees t ! bond+ requirem5ts ( section #dab w be met z ( ! date ( ! application or 7if lat]7 comm5cem5t ( op]ations4 7#d7 ,plan docum5ts ,a copy ( ! docum5ts gov]n+ ! plan 7includ+ any bylaws & tru/ agreem5ts71 ! summ>y plan description1 & o!r mat]ial describ+ ! b5efits t w be provid$ to p>ticipants & b5efici>ies "u ! plan4 7#e7 ,agreem5ts ) s]vice provid]s ,a copy ( any agreem5ts betwe5 ! plan & contract adm9i/rators & o!r s]vice provid]s4 7#f7 ,fund+ report ,9 ! case ( association heal? plans provid+ b5efits options 9 addition to heal? insurance cov]age1 a report sett+ =? in=mation ) respect to su* additional b5efit options det]m9$ z ( a date )9 ! #abj-;day p]iod end+ ) ! date ( ! application1 includ+ ! foll[+3 7,a7 ,res]ves ,a /atem5t1 c]tifi$ by ! bo>d ( tru/ees ( ! plan1 & a /atem5t ( actu>ial op9ion1 sign$ by a qualifi$ heal? actu>y1 t all applicable requirem5ts ( section #hjf are or w be met 9 accordance ) regulations :i* ! applicable au?ority %all prescribe4 7,b7 ,adequacy ( contribution rates ,a /atem5t ( actu>ial op9ion1 sign$ by a qualifi$ heal? actu>y1 :i* sets =? a description ( ! ext5t to :i* contribution rates are adequate to provide = ! paym5t ( all obligations & ! ma9t5ance ( requir$ res]ves "u ! plan = ! #ab-mon? p]iod beg9n+ ) su* date )9 su* #abj-;day p]iod1 tak+ into acc\nt ! expect$ cov]age & exp]i5ce ( ! plan4 ,if ! contribution rates are n fully adequate1 ! /atem5t ( actu>ial op9ion %all indicate ! ext5t to :i* ! rates are inadequate & ! *anges ne$$ to ensure adequacy4 7,c7 ,curr5t & project$ value ( assets & liabilities ,a /atem5t ( actu>ial op9ion sign$ by a qualifi$ heal? actu>y1 :i* sets =? ! curr5t value ( ! assets & liabilities accumulat$ "u ! plan & a projection ( ! assets1 liabilities1 income1 & exp5ses ( ! plan = ! #ab-mon? p]iod ref]r$ to 9 subp>agraph 7,b74 ,! income /atem5t %all id5tify sep>ately ! plan's adm9i/rative exp5ses & claims4 7,d7 ,co/s ( cov]age to be *>g$ & o!r exp5ses ,a /atem5t ( ! co/s ( cov]age to be *>g$1 includ+ an itemization ( am\nts = adm9i/ration1 res]ves1 & o!r exp5ses associat$ ) ! op]ation ( ! plan4 7,e7 ,o!r in=mation ,any o!r in=mation z may be det]m9$ by ! applicable au?ority1 by regulation1 z necess>y to c>ry out ! purposes ( ?is "p4 7c7 ,fil+ ,notice ( ,c]tification ,) ,/ates ,a c]tification grant$ "u ?is "p to an association heal? plan %all n be effective unless writt5 notice ( su* c]tification is fil$ ) ! applicable ,/ate au?ority ( ea* ,/ate 9 :i* at lea/ #be p]c5t ( ! p>ticipants & b5efici>ies "u ! plan are locat$4 ,= purposes ( ?is subsection1 an individual %all be consid]$ to be locat$ 9 ! ,/ate 9 :i* a kn[n address ( su* individual is locat$ or 9 :i* su* individual is employ$4 7d7 ,notice ( ,mat]ial ,*anges ,9 ! case ( any association heal? plan c]tifi$ "u ?is "p1 descriptions ( mat]ial *anges 9 any in=mation :i* 0 requir$ to be submitt$ ) ! application = ! c]tification "u ?is "p %all be fil$ 9 su* =m & mann] z %all be prescrib$ by ! applicable au?ority by regulation4 ,! applicable au?ority may require by regulation prior notice ( mat]ial *anges ) respect to specifi$ matt]s :i* might s]ve z ! basis = susp5sion or revocation ( ! c]tification4 7e7 ,report+ ,requirem5ts = ,c]ta9 ,association ,heal? ,plans ,an association heal? plan c]tifi$ "u ?is "p :i* provides b5efit options 9 addition to heal? insurance cov]age = su* plan ye> %all meet ! requirem5ts ( section #ajc by fil+ an annual report "u su* section :i* %all include in=mation describ$ 9 subsection 7b77#f7 ) respect to ! plan ye> &1 not)/&+ section #ajd7;a77#a77;,a71 %all be fil$ ) ! applicable au?ority n lat] ?an #ij days aft] ! close ( ! plan ye> 7or on su* lat] date z may be prescrib$ by ! applicable au?ority74 ,! applicable au?ority may require by regulation su* int]im reports z x consid]s appropriate4 7f7 ,engagem5t ( ,qualifi$ ,heal? ,actu>y ,! bo>d ( tru/ees ( ea* association heal? plan :i* provides b5efits options 9 addition to heal? insurance cov]age & :i* is apply+ = c]tification "u ?is "p or is c]tifi$ "u ?is "p %all engage1 on behalf ( all p>ticipants & b5efici>ies1 a qualifi$ heal? actu>y :o %all be responsible = ! prep>ation ( ! mat]ials compris+ in=mation necess>y to be submitt$ by a qualifi$ heal? actu>y "u ?is "p4 ,! qualifi$ heal? actu>y %all utilize su* assumptions & te*niques z are necess>y to enable su* actu>y to =m an op9ion z to :e!r ! cont5ts ( ! matt]s report$ "u ?is "p-- 7#a7 are 9 ! aggregate reasonably relat$ to ! exp]i5ce ( ! plan & to reasonable expectations2 & 7#b7 repres5t su* actu>y's be/ e/imate ( anticipat$ exp]i5ce "u ! plan4 ,! op9ion by ! qualifi$ heal? actu>y %all be made ) respect to1 & %all be made a "p (1 ! annual report4 #hjh4 ,notice requirem5ts = volunt>y t]m9ation ,except z provid$ 9 section #hji7;b71 an association heal? plan :i* is or has be5 c]tifi$ "u ?is "p may t]m9ate 7^u or at any "t aft] cessation ( accruals 9 b5efit liabilities7 only if ! bo>d ( tru/ees1 n less ?an #fj days be=e ! propos$ t]m9ation date-- 7#a7 provides to ! p>ticipants & b5efici>ies a writt5 notice ( int5t to t]m9ate /at+ t su* t]m9ation is int5d$ & ! propos$ t]m9ation date2 7#b7 develops a plan = w9d+ up ! affairs ( ! plan 9 connection ) su* t]m9ation 9 a mann] :i* w result 9 timely paym5t ( all b5efits = :i* ! plan is obligat$2 & 7#c7 submits su* plan 9 writ+ to ! applicable au?ority4 ,actions requir$ "u ?is section %all be tak5 9 su* =m & mann] z may be prescrib$ by ! applicable au?ority by regulation4 #hji4 ,corrective actions & m&atory t]m9ation 7a7 ,actions ,to ,avoid ,depletion ( ,res]ves ,an association heal? plan :i* is c]tifi$ "u ?is "p & :i* provides b5efits o!r ?an heal? insurance cov]age %all cont9ue to meet ! requirem5ts ( section #hjf1 irrespective ( :e!r su* c]tification cont9ues 9 effect4 ,! bo>d ( tru/ees ( su* plan %all det]m9e qu>t]ly :e!r ! requirem5ts ( section #hjf are met4 ,9 any case 9 :i* ! bo>d det]m9es t !re is reason to believe t !re is or w be a failure to meet su* requirem5ts1 or ! applicable au?ority makes su* a det]m9ation & s notifies ! bo>d1 ! bo>d %all imm$iately notify ! qualifi$ heal? actu>y engag$ by ! plan1 & su* actu>y %all1 n lat] ?an ! end ( ! foll[+ mon?1 make su* recomm5dations to ! bo>d = corrective action z ! actu>y det]m9es necess>y to ensure compliance ) section #hjf4 ,n lat] ?an #cj days aft] receiv+ f ! actu>y recomm5dations = corrective actions1 ! bo>d %all notify ! applicable au?ority 79 su* =m & mann] z ! applicable au?ority may prescribe by regulation7 ( su* recomm5dations ( ! actu>y = corrective action1 toge!r ) a description ( ! actions 7if any7 t ! bo>d has tak5 or plans to take 9 response to su* recomm5dations4 ,! bo>d %all !reaft] report to ! applicable au?ority1 9 su* =m & frequ5cy z ! applicable au?ority may specify to ! bo>d1 reg>d+ corrective action tak5 by ! bo>d until ! requirem5ts ( section #hjf are met4 7b7 ,m&atory ,t]m9ation ,9 any case 9 :i*-- 7#a7 ! applicable au?ority has be5 notifi$ "u subsection 7a7 7or by an issu] ( excess_//op loss insurance or indemnity insurance pursuant to section #hjf7;a77 ( a failure ( an association heal? plan :i* is or has be5 c]tifi$ "u ?is "p & is describ$ 9 section #hjf7;a77#b7 to meet ! requirem5ts ( section #hjf & has n be5 notifi$ by ! bo>d ( tru/ees ( ! plan t corrective action has re/or$ compliance ) su* requirem5ts2 & 7#b7 ! applicable au?ority det]m9es t !re is a reasonable expectation t ! plan w cont9ue to fail to meet ! requirem5ts ( section #hjf1 ! bo>d ( tru/ees ( ! plan %all1 at ! direction ( ! applicable au?ority1 t]m9ate ! plan &1 9 ! c\rse ( ! t]m9ation1 take su* actions z ! applicable au?ority may require1 includ+ satisfy+ any claims ref]r$ to 9 section #hjf7;a77#b77;,b77iii7 & recov]+ = ! plan any liability "u subsection 7a77#b77;,b77iii7 or 7e7 ( section #hjf1 z necess>y to ensure t ! affairs ( ! plan w be1 to ! maximum ext5t possible1 w\nd up 9 a mann] :i* w result 9 timely provision ( all b5efits = :i* ! plan is obligat$4 #haj4 ,tru/ee%ip by ! ,secret>y ( insolv5t association heal? plans provid+ heal? b5efits 9 addition to heal? insurance cov]age 7a7 ,appo9tm5t ( ,secret>y z ,tru/ee = ,insolv5t ,plans ,:5ev] ! ,secret>y det]m9es t an association heal? plan :i* is or has be5 c]tifi$ "u ?is "p & :i* is describ$ 9 section #hjf7;a77#b7 w be unable to provide b5efits :5 due or is o!rwise 9 a f9ancially haz>d\s condition1 z %all be def9$ by ! ,secret>y by regulation1 ! ,secret>y %all1 ^u notice to ! plan1 apply to ! appropriate ,unit$ ,/ates di/rict c\rt = appo9tm5t ( ! ,secret>y z tru/ee to adm9i/] ! plan = ! duration ( ! insolv5cy4 ,! plan may appe> z a p>ty & o!r int]e/$ p]sons may int]v5e 9 ! proce$+s at ! discretion ( ! c\rt4 ,! c\rt %all appo9t su* ,secret>y tru/ee if ! c\rt det]m9es t ! tru/ee%ip is necess>y to protect ! int]e/s ( ! p>ticipants & b5efici>ies or provid]s ( m$ical c>e or to avoid any unreasonable det]ioration ( ! f9ancial condition ( ! plan4 ,! tru/ee%ip ( su* ,secret>y %all cont9ue until ! conditions describ$ 9 ! fir/ s5t5ce ( ?is subsection are rem$i$ or ! plan is t]m9at$4 7b7 ,p[]s z ,tru/ee ,! ,secret>y1 ^u appo9tm5t z tru/ee "u subsection 7a71 %all h ! p[]-- 7#a7 to d any act au?oriz$ by ! plan1 ?is title1 or o!r applicable provisions ( law to be done by ! plan adm9i/rator or any tru/ee ( ! plan2 7#b7 to require ! transf] ( all 7or any "p7 ( ! assets & records ( ! plan to ! ,secret>y z tru/ee2 7#c7 to inve/ any assets ( ! plan :i* ! ,secret>y holds 9 accordance ) ! provisions ( ! plan1 regulations prescrib$ by ! ,secret>y1 & applicable provisions ( law2 7#d7 to require ! sponsor1 ! plan adm9i/rator1 any p>ticipat+ employ]1 & any employee organization repres5t+ plan p>ticipants to furni% any in=mation ) respect to ! plan :i* ! ,secret>y z tru/ee may reasonably ne$ 9 ord] to adm9i/] ! plan2 7#e7 to collect = ! plan any am\nts due ! plan & to recov] reasonable exp5ses ( ! tru/ee%ip2 7#f7 to comm5ce1 prosecute1 or def5d on behalf ( ! plan any suit or proce$+ involv+ ! plan2 7#g7 to issue1 publi%1 or file su* notices1 /atem5ts1 & reports z may be requir$ by ! ,secret>y by regulation or requir$ by any ord] ( ! c\rt2 7#h7 to t]m9ate ! plan 7or provide = its t]m9ation 9 accordance ) section #hji7;b77 & liquidate ! plan assets1 to re/ore ! plan to ! responsibility ( ! sponsor1 or to cont9ue ! tru/ee%ip2 7#i7 to provide = ! enrollm5t ( plan p>ticipants & b5efici>ies "u appropriate cov]age options2 & 7#aj7 to d su* o!r acts z may be necess>y to comply ) ?is title or any ord] ( ! c\rt & to protect ! int]e/s ( plan p>ticipants & b5efici>ies & provid]s ( m$ical c>e4 7c7 ,notice ( ,appo9tm5t ,z soon z practicable aft] ! ,secret>y's appo9tm5t z tru/ee1 ! ,secret>y %all give notice ( su* appo9tm5t to-- 7#a7 ! sponsor & plan adm9i/rator2 7#b7 ea* p>ticipant2 7#c7 ea* p>ticipat+ employ]2 & 7#d7 if applicable1 ea* employee organization :i*1 = purposes ( collective b>ga9+1 repres5ts plan p>ticipants4 7d7 ,additional ,duties ,except to ! ext5t inconsi/5t ) ! provisions ( ?is title1 or z may be o!rwise ord]$ by ! c\rt1 ! ,secret>y1 ^u appo9tm5t z tru/ee "u ?is section1 %all be subject to ! same duties z ^? ( a tru/ee "u section #gjd ( title #aa1 ,unit$ ,/ates ,code1 & %all h ! duties ( a fiduci>y = purposes ( ?is title4 7e7 ,o!r ,proce$+s ,an application by ! ,secret>y "u ?is subsection may be fil$ not)/&+ ! p5d5cy 9 ! same or any o!r c\rt ( any bankruptcy1 mortgage =eclosure1 or equity receiv]%ip proce$+1 or any proce$+ to reorganize1 cons]ve1 or liquidate su* plan or its prop]ty1 or any proce$+ to en=ce a li5 aga9/ prop]ty ( ! plan4 7f7 ,jurisdiction ( ,c\rt 7#a7 ,9 g5]al ,^u ! fil+ ( an application = ! appo9tm5t z tru/ee or ! issuance ( a decree "u ?is section1 ! c\rt to :i* ! application is made %all h exclusive jurisdiction ( ! plan involv$ & its prop]ty :]ev] locat$ ) ! p[]s1 to ! ext5t consi/5t ) ! purposes ( ?is section1 ( a c\rt ( ! ,unit$ ,/ates hav+ jurisdiction ov] cases "u *apt] #aa ( title #aa1 ,unit$ ,/ates ,code4 ,p5d+ an adjudication "u ?is section su* c\rt %all /ay1 & ^u appo9tm5t by x ( ! ,secret>y z tru/ee1 su* c\rt %all cont9ue ! /ay (1 any p5d+ mortgage =eclosure1 equity receiv]%ip1 or o!r proce$+ to reorganize1 cons]ve1 or liquidate ! plan1 ! sponsor1 or prop]ty ( su* plan or sponsor1 & any o!r suit aga9/ any receiv]1 cons]vator1 or tru/ee ( ! plan1 ! sponsor1 or prop]ty ( ! plan or sponsor4 ,p5d+ su* adjudication & ^u ! appo9tm5t by x ( ! ,secret>y z tru/ee1 ! c\rt may /ay any proce$+ to en=ce a li5 aga9/ prop]ty ( ! plan or ! sponsor or any o!r suit aga9/ ! plan or ! sponsor4 7#b7 ,v5ue ,an action "u ?is section may be br\ght 9 ! judicial di/rict :]e ! sponsor or ! plan adm9i/rator resides or does bus9ess or :]e any asset ( ! plan is situat$4 ,a di/rict c\rt 9 :i* su* action is br\ght may issue process ) respect to su* action 9 any o!r judicial di/rict4 7g7 ,p]sonnel ,9 accordance ) regulations :i* %all be prescrib$ by ! ,secret>y1 ! ,secret>y %all appo9t1 reta91 & comp5sate acc\ntants1 actu>ies1 & o!r pr(essional s]vice p]sonnel z may be necess>y 9 connection ) ! ,secret>y's s]vice z tru/ee "u ?is section4 #haa4 ,/ate assessm5t au?ority 7a7 ,9 ,g5]al ,not)/&+ section #ead1 a ,/ate may impose by law a contribution tax on an association heal? plan describ$ 9 section #hjf7;a77#b71 if ! plan comm5c$ op]ations 9 su* ,/ate aft] ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjae4 7b7 ,contribution ,tax ,= purposes ( ?is section1 ! t]m contribution tax impos$ by a ,/ate on an association heal? plan means any tax impos$ by su* ,/ate if-- 7#a7 su* tax is comput$ by apply+ a rate to ! am\nt ( premiums or contributions1 ) respect to individuals cov]$ "u ! plan :o are resid5ts ( su* ,/ate1 :i* are receiv$ by ! plan f p>ticipat+ employ]s locat$ 9 su* ,/ate or f su* individuals2 7#b7 ! rate ( su* tax does n exce$ ! rate ( any tax impos$ by su* ,/ate on premiums or contributions receiv$ by insur]s or heal? ma9t5ance organizations = heal? insurance cov]age (f]$ 9 su* ,/ate 9 connection ) a gr\p heal? plan2 7#c7 su* tax is o!rwise nondiscrim9atory2 & 7#d7 ! am\nt ( any su* tax assess$ on ! plan is r$uc$ by ! am\nt ( any tax or assessm5t o!rwise impos$ by ! ,/ate on premiums1 contributions1 or bo? receiv$ by insur]s or heal? ma9t5ance organizations = heal? insurance cov]age1 aggregate excess_//op loss insurance 7z def9$ 9 section #hjf7;g77#a771 specific excess_//op loss insurance 7z def9$ 9 section #hjf7;g77#b771 o!r insurance relat$ to ! provision ( m$ical c>e "u ! plan1 or any comb9ation !re( provid$ by su* insur]s or heal? ma9t5ance organizations 9 su* ,/ate 9 connection ) su* plan4 #hab4 ,def9itions & rules ( con/ruction 7a7 ,def9itions ,= purposes ( ?is "p-- 7#a7 ,gr\p heal? plan ,! t]m gr\p heal? plan has ! mean+ provid$ 9 section #gcc7;a77#a7 7aft] apply+ subsection 7b7 ( ?is section74 7#b7 ,m$ical c>e ,! t]m m$ical c>e has ! mean+ provid$ 9 section #gcc7;a77#b74 7#c7 ,heal? insurance cov]age ,! t]m heal? insurance cov]age has ! mean+ provid$ 9 section #gcc7;b77#a74 7#d7 ,heal? insurance issu] ,! t]m heal? insurance issu] has ! mean+ provid$ 9 section #gcc7;b77#b74 7#e7 ,applicable au?ority ,! t]m applicable au?ority means ! ,secret>y1 except t1 9 connection ) any ex]cise ( ! ,secret>y's au?ority reg>d+ :i* ! ,secret>y is requir$ "u section #ejf7;d7 to consult ) a ,/ate1 su* t]m means ! ,secret>y1 9 consultation ) su* ,/ate4 7#f7 ,heal? /atus-relat$ factor ,! t]m heal? /atus-relat$ factor has ! mean+ provid$ 9 section #gcc7;d77#b74 7#g7 ,individual m>ket 7,a7 ,9 g5]al ,! t]m individual m>ket means ! m>ket = heal? insurance cov]age (f]$ to individuals o!r ?an 9 connection ) a gr\p heal? plan4 7,b7 ,treatm5t ( v small gr\ps 7i7 ,9 g5]al ,subject to clause 7ii71 su* t]m includes cov]age (f]$ 9 connection ) a gr\p heal? plan t has few] ?an #b p>ticipants z curr5t employees or p>ticipants describ$ 9 section #gcb7;d77#c7 on ! fir/ day ( ! plan ye>4 7ii7 ,/ate exception ,clause 7i7 %all n apply 9 ! case ( heal? insurance cov]age (f]$ 9 a ,/ate if su* ,/ate regulates ! cov]age describ$ 9 su* clause 9 ! same mann] & to ! same ext5t z cov]age 9 ! small gr\p m>ket 7z def9$ 9 section #bgia7;e77#e7 ( ! ,public ,heal? ,s]vice ,act7 is regulat$ by su* ,/ate4 7#h7 ,p>ticipat+ employ] ,! t]m p>ticipat+ employ] means1 9 connection ) an association heal? plan1 any employ]1 if any individual :o is an employee ( su* employ]1 a p>tn] 9 su* employ]1 or a self-employ$ individual :o is su* employ] 7or any dep5d5t1 z def9$ "u ! t]ms ( ! plan1 ( su* individual7 is or 0 cov]$ "u su* plan 9 connection ) ! /atus ( su* individual z su* an employee1 p>tn]1 or self-employ$ individual 9 relation to ! plan4 7#i7 ,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 ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act = ! ,/ate involv$ ) respect to su* issu]4 7#aj7 ,qualifi$ heal? actu>y ,! t]m qualifi$ heal? actu>y means an individual :o is a memb] ( ! ,am]ican ,academy ( ,actu>ies ) exp]tise 9 heal? c>e4 7#aa7 ,affiliat$ memb] ,! t]m affiliat$ memb] means1 9 connection ) a sponsor-- 7,a7 a p]son :o is o!rwise eligible to be a memb] ( ! sponsor b :o elects an affiliat$ /atus ) ! sponsor1 7,b7 9 ! case ( a sponsor ) memb]s :i* consi/ ( associations1 a p]son :o is a memb] ( any su* association & elects an affiliat$ /atus ) ! sponsor1 or 7,c7 9 ! case ( an association heal? plan 9 exi/5ce on ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjae1 a p]son eligible to be a memb] ( ! sponsor or "o ( its memb] associations4 7#ab7 ,l>ge employ] ,! t]m l>ge employ] means1 9 connection ) a gr\p heal? plan ) respect to a plan ye>1 an employ] :o employ$ an av]age ( at lea/ #ea employees on bus9ess days dur+ ! prec$+ cal5d> ye> & :o employs at lea/ #b employees on ! fir/ day ( ! plan ye>4 7#ac7 ,small employ] ,! t]m small employ] means1 9 connection ) a gr\p heal? plan ) respect to a plan ye>1 an employ] :o is n a l>ge employ]4 7b7 ,rules ( ,con/ruction 7#a7 ,employ]s & employees ,= purposes ( det]m9+ :e!r a plan1 fund1 or program is an employee welf>e b5efit plan :i* is an association heal? plan1 & = purposes ( apply+ ?is title 9 connection ) su* plan1 fund1 or program s det]m9$ to be su* an employee welf>e b5efit plan-- 7,a7 9 ! case ( a p>tn]%ip1 ! t]m employ] 7z def9$ 9 section #c7e77 includes ! p>tn]%ip 9 relation to ! p>tn]s1 & ! t]m employee 7z def9$ 9 section #c7f77 includes any p>tn] 9 relation to ! p>tn]%ip2 & 7,b7 9 ! case ( a self-employ$ individual1 ! t]m employ] 7z def9$ 9 section #c7e77 & ! t]m employee 7z def9$ 9 section #c7f77 %all include su* individual4 7#b7 ,plans1 funds1 & programs treat$ z employee welf>e b5efit plans ,9 ! case ( any plan1 fund1 or program :i* 0 e/abli%$ or is ma9ta9$ = ! purpose ( provid+ m$ical c>e 7?r\gh ! pur*ase ( insurance or o!rwise7 = employees 7or _! dep5d5ts7 cov]$ !reund] & :i* demon/rates to ! ,secret>y t all requirem5ts = c]tification "u ?is "p w\ld be met ) respect to su* plan1 fund1 or program if su* plan1 fund1 or program 7 a gr\p heal? plan1 su* plan1 fund1 or program %all be treat$ = purposes ( ?is title z an employee welf>e b5efit plan on & aft] ! date ( su* demon/ration4 7#c7 ,exception = c]ta9 b5efits ,! requirem5ts ( ?is "p %all n apply to a gr\p heal? plan 9 relation to its provision ( except$ b5efits1 z def9$ 9 section #gjf7;c74 4 7b7 ,con=m+ ,am5dm5ts to ,preemption ,rules 7#a7 ,section #ead7;b77#f7 ( su* ,act 7#bi ,u4,s4,c4 #aadd7;b77#f77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,! prec$+ subp>agraphs ( ?is p>agraph d n apply ) respect to any ,/ate law 9 ! case ( an association heal? plan :i* is c]tifi$ "u "p #h4 4 7#b7 ,section #ead ( su* ,act 7#bi ,u4,s4,c4 #aadd7 is am5d$-- 7,a7 9 subsection 7b77#d71 by /rik+ ,subsection 7a7 & ins]t+ ,subsections 7a7 & 7d72 7,b7 9 subsection 7b77#e71 by /rik+ subsection 7a7 9 subp>agraph 7,a7 & ins]t+ subsection 7a7 ( ?is section & subsections 7a77#b77;,b7 & 7b7 ( section #hje1 & by /rik+ subsection 7a7 9 subp>agraph 7,b7 & ins]t+ subsection 7a7 ( ?is section or subsection 7a77#b77;,b7 or 7b7 ( section #hje2 7,c7 by r$esignat+ subsection 7d7 z subsection 7e72 & 7,d7 by ins]t+ aft] subsection 7c7 ! foll[+ new subsection3 7d7 7#a7 ,except z provid$ 9 subsection 7b77#d71 ! provisions ( ?is title %all sup]s$e any & all ,/ate laws ins(> z !y may n[ or h]eaft] preclude1 or h ! effect ( preclud+1 a heal? insurance issu] f (f]+ heal? insurance cov]age 9 connection ) an association heal? plan :i* is c]tifi$ "u "p #h4 7#b7 ,except z provid$ 9 p>agraphs 7#d7 & 7#e7 ( subsection 7b7 ( ?is section-- 7,a7 ,9 any case 9 :i* heal? insurance cov]age ( any policy type is (f]$ "u an association heal? plan c]tifi$ "u "p #h to a p>ticipat+ employ] op]at+ 9 su* ,/ate1 ! provisions ( ?is title %all sup]s$e any & all laws ( su* ,/ate ins(> z !y may preclude a heal? insurance issu] f (f]+ heal? insurance cov]age ( ! same policy type to o!r employ]s op]at+ 9 ! ,/ate :i* are eligible = cov]age "u su* association heal? plan1 :e!r or n su* o!r employ]s are p>ticipat+ employ]s 9 su* plan4 7,b7 ,9 any case 9 :i* heal? insurance cov]age ( any policy type is (f]$ 9 a ,/ate "u an association heal? plan c]tifi$ "u "p #h & ! fil+1 ) ! applicable ,/ate au?ority 7z def9$ 9 section #hab7;a77#i771 ( ! policy =m 9 connection ) su* policy type is approv$ by su* ,/ate au?ority1 ! provisions ( ?is title %all sup]s$e any & all laws ( any o!r ,/ate 9 :i* heal? insurance cov]age ( su* type is (f]$1 ins(> z !y may preclude1 ^u ! fil+ 9 ! same =m & mann] ( su* policy =m ) ! applicable ,/ate au?ority 9 su* o!r ,/ate1 ! approval ( ! fil+ 9 su* o!r ,/ate4 7#c7 ,no?+ 9 subsection 7b77#f77;,e7 or ! prec$+ provisions ( ?is subsection %all be con/ru$1 ) respect to heal? insurance issu]s or heal? insurance cov]age1 to sup]s$e or impair ! law ( any ,/ate-- 7,a7 provid+ solv5cy /&>ds or simil> /&>ds reg>d+ ! adequacy ( insur] capital1 surplus1 res]ves1 or contributions1 or 7,b7 relat+ to prompt paym5t ( claims4 7#d7 ,= additional provisions relat+ to association heal? plans1 see subsections 7a77#b77;,b7 & 7b7 ( section #hje4 7#e7 ,= purposes ( ?is subsection1 ! t]m association heal? plan has ! mean+ provid$ 9 section #hja7;a71 & ! t]ms heal? insurance cov]age1 p>ticipat+ employ]1 & heal? insurance issu] h ! mean+s provid$ su* t]ms 9 section #hab1 respectively4 4 7#c7 ,section #ead7;b77#f77;,a7 ( su* ,act 7#bi ,u4,s4,c4 #aadd7;b77#f77;,a77 is am5d$-- 7,a7 9 clause 7i77,,ii71 by /rik+ & at ! end2 7,b7 9 clause 7ii7-- 7i7 by ins]t+ & :i* does n provide m$ical c>e 7)9 ! mean+ ( section #gcc7;a77#b771 aft] arrangem5t12 & 7ii7 by /rik+ title4 & ins]t+ title1 &2 & 7,c7 by add+ at ! end ! foll[+ new clause3 7iii7 subject to subp>agraph 7,e71 9 ! case ( any o!r employee welf>e b5efit plan :i* is a multiple employ] welf>e arrangem5t & :i* provides m$ical c>e 7)9 ! mean+ ( section #gcc7;a77#b771 any law ( any ,/ate :i* regulates insurance may apply4 4 7#d7 ,section #ead7;e7 ( su* ,act 7z r$esignat$ by p>agraph 7#b77;,c77 is am5d$-- 7,a7 by /rik+ ,no?+ & ins]t+ 7#a7 ,except z provid$ 9 p>agraph 7#b71 no?+2 & 7,b7 by add+ at ! end ! foll[+ new p>agraph3 7#b7 ,no?+ 9 any o!r provision ( law enact$ on or aft] ! date ( ! enactm5t ( ! ,small ,bus9ess ,heal? ,fairness ,act ( #bjae %all be con/ru$ to alt]1 am5d1 modify1 invalidate1 impair1 or sup]s$e any provision ( ?is title1 except by specific cross-ref]5ce to ! affect$ section4 4 7c7 ,plan ,sponsor ,section #c7af77;,b7 ( su* ,act 7#bi ,u4,s4,c4 #ajb7af77;,b77 is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,su* t]m also includes a p]son s]v+ z ! sponsor ( an association heal? plan "u "p #h44 7d7 ,disclosure ( ,solv5cy ,protections ,relat$ to ,self-,insur$ & ,fully ,insur$ ,options ,"u ,association ,heal? ,plans ,section #ajb7;b7 ( su* ,act 7#bi ,u4,s4,c4 #ajbb7;b77 is am5d$ by add+ at ! end ! foll[+3 ,an association heal? plan %all include 9 its summ>y plan description1 9 connection ) ea* b5efit option1 a description ( ! =m ( solv5cy or gu>antee fund protection secur$ pursuant to ?is ,act or applicable ,/ate law1 if any44 7e7 ,sav+s ,clause ,section #gca7;c7 ( su* ,act is am5d$ by ins]t+ or "p #h aft] ?is "p4 7f7 ,report to ! ,congress ,reg>d+ ,c]tification ( ,self-,insur$ ,association ,heal? ,plans ,n lat] ?an ,janu>y #a1 #bjah1 ! ,secret>y ( ,labor %all report to ! ,committee on ,education & ! ,work=ce ( ! ,h\se ( ,repres5tatives & ! ,committee on ,heal?1 ,education1 ,labor1 & ,p5sions ( ! ,s5ate ! effect association heal? plans h _h1 if any1 on r$uc+ ! numb] ( un9sur$ individuals4 7g7 ,cl]ical ,am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by ins]t+ aft] ! item relat+ to section #gcd ! foll[+ new items3 ,"p #h--,rules ,gov]n+ ,association ,heal? ,plans#hja4 ,association heal? plans4#hjb4 ,c]tification ( association heal? plans4#hjc4 ,requirem5ts relat+ to sponsors & bo>ds ( tru/ees4#hjd4 ,p>ticipation & cov]age requirem5ts4#hje4 ,o!r requirem5ts relat+ to plan docum5ts1 contribution rates1 & b5efit options4#hjf4 ,ma9t5ance ( res]ves & provisions = solv5cy = plans provid+ heal? b5efits 9 addition to heal? insurance cov]age4#hjg4 ,requirem5ts = application & relat$ requirem5ts4#hjh4 ,notice requirem5ts = volunt>y t]m9ation4#hji4 ,corrective actions & m&atory t]m9ation4#haj4 ,tru/ee%ip by ! ,secret>y ( insolv5t association heal? plans provid+ heal? b5efits 9 addition to heal? insurance cov]age4#haa4 ,/ate assessm5t au?ority4#hab4 ,def9itions & rules ( con/ruction4 4 #bac4 ,cl>ification ( treatm5t ( s+le employ] arrangem5ts ,section #c7dj77;,b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajjb7dj77;,b77 is am5d$-- 7#a7 9 clause 7i71 by ins]t+ aft] control gr\p1 ! foll[+3 except t1 9 any case 9 :i* ! b5efit ref]r$ to 9 subp>agraph 7,a7 consi/s ( m$ical c>e 7z def9$ 9 section #hab7;a77#b771 #b or m trades or bus9esses1 :e!r or n incorporat$1 %all be deem$ a s+le employ] = any plan ye> ( su* plan1 or any fiscal ye> ( su* o!r arrangem5t1 if su* trades or bus9esses are )9 ! same control gr\p dur+ su* ye> or at any "t dur+ ! prec$+ #a-ye> p]iod12 7#b7 9 clause 7iii71 by /rik+ 7iii7 ! det]m9ation & ins]t+ ! foll[+3 7iii7 7,i7 9 any case 9 :i* ! b5efit ref]r$ to 9 subp>agraph 7,a7 consi/s ( m$ical c>e 7z def9$ 9 section #hab7;a77#b771 ! det]m9ation ( :e!r a trade or bus9ess is "u common control ) ano!r trade or bus9ess %all be det]m9$ "u regulations ( ! ,secret>y apply+ pr9ciples consi/5t & coext5sive ) ! pr9ciples appli$ 9 det]m9+ :e!r employees ( #b or m trades or bus9esses are treat$ z employ$ by a s+le employ] "u section #djja7;b71 except t1 = purposes ( ?is p>agraph1 an int]e/ ( great] ?an #be p]c5t may n be requir$ z ! m9imum int]e/ necess>y = common control1 or 7,,ii7 9 any o!r case1 ! det]m9ation 2 7#c7 by r$esignat+ clauses 7iv7 & 7v7 z clauses 7v7 & 7vi71 respectively2 & 7#d7 by ins]t+ aft] clause 7iii7 ! foll[+ new clause3 7iv7 9 any case 9 :i* ! b5efit ref]r$ to 9 subp>agraph 7,a7 consi/s ( m$ical c>e 7z def9$ 9 section #hab7;a77#b771 9 det]m9+1 aft] ! application ( clause 7i71 :e!r b5efits are provid$ to employees ( #b or m employ]s1 ! arrangem5t %all be treat$ z hav+ only "o p>ticipat+ employ] if1 aft] ! application ( clause 7i71 ! numb] ( individuals :o are employees & =m] employees ( any "o p>ticipat+ employ] & :o are cov]$ "u ! arrangem5t is great] ?an #ge p]c5t ( ! aggregate numb] ( all individuals :o are employees or =m] employees ( p>ticipat+ employ]s & :o are cov]$ "u ! arrangem5t1 4 #bad4 ,en=cem5t provisions relat+ to association heal? plans 7a7 ,crim9al ,p5alties = ,c]ta9 ,willful ,misrepres5tations ,section #eja ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aaca7 is am5d$-- 7#a7 by ins]t+ 7a7 aft] ,sec4 #eja42 & 7#b7 by add+ at ! end ! foll[+ new subsection3 7b7 ,any p]son :o willfully falsely repres5ts1 to any employee1 any employee's b5efici>y1 any employ]1 ! ,secret>y1 or any ,/ate1 a plan or o!r arrangem5t e/abli%$ or ma9ta9$ = ! purpose ( (f]+ or provid+ any b5efit describ$ 9 section #c7a7 to employees or _! b5efici>ies z-- 7#a7 be+ an association heal? plan :i* has be5 c]tifi$ "u "p #h2 7#b7 hav+ be5 e/abli%$ or ma9ta9$ "u or pursuant to "o or m collective b>ga9+ agreem5ts :i* are rea*$ pursuant to collective b>ga9+ describ$ 9 section #h7;d7 ( ! ,national ,labor ,relations ,act 7#bi ,u4,s4,c4 #aeh7;d77 or p>agraph ,f\r? ( section #b ( ! ,railway ,labor ,act 7#de ,u4,s4,c4 #aeb1 p>agraph ,f\r?7 or :i* are rea*$ pursuant to labor-managem5t negotiations "u simil> provisions ( ,/ate public employee relations laws2 or 7#c7 be+ a plan or arrangem5t describ$ 9 section #c7dj77;,a77i71 %all1 ^u conviction1 be imprison$ n m ?an #e ye>s1 be f9$ "u title #ah1 ,unit$ ,/ates ,code1 or bo?4 4 7b7 ,cease ,activities ,ord]s ,section #ejb ( su* ,act 7#bi ,u4,s4,c4 #aacb7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7n7 ,association ,heal? ,plan ,cease & ,desi/ ,ord]s 7#a7 ,9 g5]al ,subject to p>agraph 7#b71 ^u application by ! ,secret>y %[+ ! op]ation1 promotion1 or m>ket+ ( an association heal? plan 7or simil> arrangem5t provid+ b5efits consi/+ ( m$ical c>e 7z def9$ 9 section #gcc7;a77#b777 t-- 7,a7 is n c]tifi$ "u "p #h1 is subject "u section #ead7;b77#f7 to ! insurance laws ( any ,/ate 9 :i* ! plan or arrangem5t (f]s or provides b5efits1 & is n lic5s$1 regi/]$1 or o!rwise approv$ "u ! insurance laws ( su* ,/ate2 or 7,b7 is an association heal? plan c]tifi$ "u "p #h & is n op]at+ 9 accordance ) ! requirem5ts "u "p #h = su* c]tification1 a di/rict c\rt ( ! ,unit$ ,/ates %all ent] an ord] requir+ t ! plan or arrangem5t cease activities4 7#b7 ,exception ,p>agraph 7#a7 %all n apply 9 ! case ( an association heal? plan or o!r arrangem5t if ! plan or arrangem5t %[s t-- 7,a7 all b5efits "u x ref]r$ to 9 p>agraph 7#a7 consi/ ( heal? insurance cov]age2 & 7,b7 ) respect to ea* ,/ate 9 :i* ! plan or arrangem5t (f]s or provides b5efits1 ! plan or arrangem5t is op]at+ 9 accordance ) applicable ,/ate laws t are n sup]s$$ "u section #ead4 7#c7 ,additional equitable relief ,! c\rt may grant su* additional equitable relief1 includ+ any relief available "u ?is title1 z x deems necess>y to protect ! int]e/s ( ! public & ( p]sons hav+ claims = b5efits aga9/ ! plan4 4 7c7 ,responsibility = ,claims ,proc$ure ,section #ejc ( su* ,act 7#bi ,u4,s4,c4 #aacc7 is am5d$-- 7#a7 by ins]t+ 7a7 ,9 g5]al4-- be=e ,9 accordance2 & 7#b7 by add+ at ! end ! foll[+ new subsection3 7b7 ,association ,heal? ,plans ,! t]ms ( ea* association heal? plan :i* is or has be5 c]tifi$ "u "p #h %all require ! bo>d ( tru/ees or ! nam$ fiduci>y 7z applicable7 to ensure t ! requirem5ts ( ?is section are met 9 connection ) claims fil$ "u ! plan4 4 #bae4 ,coop]ation betwe5 ,f$]al & ,/ate au?orities ,section #ejf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aacf7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7d7 ,consultation ,) ,/ates ,) ,respect to ,association ,heal? ,plans 7#a7 ,agreem5ts ) /ates ,! ,secret>y %all consult ) ! ,/ate recogniz$ "u p>agraph 7#b7 ) respect to an association heal? plan reg>d+ ! ex]cise (-- 7,a7 ! ,secret>y's au?ority "u sections #ejb & #ejd to en=ce ! requirem5ts = c]tification "u "p #h2 & 7,b7 ! ,secret>y's au?ority to c]tify association heal? plans "u "p #h 9 accordance ) regulations ( ! ,secret>y applicable to c]tification "u "p #h4 7#b7 ,recognition ( prim>y domicile /ate ,9 c>ry+ out p>agraph 7#a71 ! ,secret>y %all ensure t only "o ,/ate w be recogniz$1 ) respect to any p>ticul> association heal? plan1 z ! ,/ate ) :i* consultation is requir$4 ,9 c>ry+ out ?is p>agraph-- 7,a7 9 ! case ( a plan :i* provides heal? insurance cov]age 7z def9$ 9 section #hab7;a77#c771 su* ,/ate %all be ! ,/ate ) :i* fil+ & approval ( a policy type (f]$ by ! plan 0 initially obta9$2 & 7,b7 9 any o!r case1 ! ,secret>y %all take into acc\nt ! places ( resid5ce ( ! p>ticipants & b5efici>ies "u ! plan & ! ,/ate 9 :i* ! tru/ is ma9ta9$4 4 #baf4 ,effective date & transitional & o!r rules 7a7 ,effective ,date ,! am5dm5ts made by ?is subtitle %all take effect #a ye> aft] ! date ( ! enactm5t ( ?is ,act4 ,! ,secret>y ( ,labor %all fir/ issue all regulations necess>y to c>ry out ! am5dm5ts made by ?is subtitle )9 #a ye> aft] ! date ( ! enactm5t ( ?is ,act4 7b7 ,treatm5t ( ,c]ta9 ,exi/+ ,heal? ,b5efits ,programs 7#a7 ,9 g5]al ,9 any case 9 :i*1 z ( ! date ( ! enactm5t ( ?is ,act1 an arrangem5t is ma9ta9$ 9 a ,/ate = ! purpose ( provid+ b5efits consi/+ ( m$ical c>e = ! employees & b5efici>ies ( its p>ticipat+ employ]s1 at lea/ #bjj p>ticipat+ employ]s make contributions to su* arrangem5t1 su* arrangem5t has be5 9 exi/5ce = at lea/ #aj ye>s1 & su* arrangem5t is lic5s$ "u ! laws ( "o or m ,/ates to provide su* b5efits to its p>ticipat+ employ]s1 ^u ! fil+ ) ! applicable au?ority 7z def9$ 9 section #hab7;a77#e7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7z am5d$ by ?is subtitle77 by ! arrangem5t ( an application = c]tification ( ! arrangem5t "u "p #h ( subtitle ,b ( title ,i ( su* ,act-- 7,a7 su* arrangem5t %all be deem$ to be a gr\p heal? plan = purposes ( title ,i ( su* ,act2 7,b7 ! requirem5ts ( sections #hja7;a7 & #hjc7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd %all be deem$ met ) respect to su* arrangem5t2 7,c7 ! requirem5ts ( section #hjc7;b7 ( su* ,act %all be deem$ met1 if ! arrangem5t is op]at$ by a bo>d ( directors :i*-- 7i7 is elect$ by ! p>ticipat+ employ]s1 ) ea* employ] hav+ "o vote2 & 7ii7 has complete fiscal control ov] ! arrangem5t & :i* is responsible = all op]ations ( ! arrangem5t2 7,d7 ! requirem5ts ( section #hjd7;a7 ( su* ,act %all be deem$ met ) respect to su* arrangem5t2 & 7,e7 ! arrangem5t may be c]tifi$ by any applicable au?ority ) respect to its op]ations 9 any ,/ate only if x op]ates 9 su* ,/ate on ! date ( c]tification4 ,! provisions ( ?is subsection %all cease to apply ) respect to any su* arrangem5t at su* "t aft] ! date ( ! enactm5t ( ?is ,act z ! applicable requirem5ts ( ?is subsection are n met ) respect to su* arrangem5t4 7#b7 ,def9itions ,= purposes ( ?is subsection1 ! t]ms gr\p heal? plan1 m$ical c>e1 & p>ticipat+ employ] %all h ! mean+s provid$ 9 section #hab ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 except t ! ref]5ce 9 p>agraph 7#g7 ( su* section to an association heal? plan %all be deem$ a ref]5ce to an arrangem5t ref]r$ to 9 ?is subsection4 ,c ,heal? ,insurance ,re=ms #bba4 ,requirem5ts = individual heal? insurance 7a7 ,9 g5]al ,section #bgda ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#da71 z re/or$ & reviv$ by section #b ( ?is ,act1 is am5d$-- 7#a7 9 subsection 7a7-- 7,a7 9 ! head+1 by /rik+ to c]ta9 individuals ) prior gr\p cov]age2 7,b7 9 p>agraph 7#a71 by /rik+ & section #bgdd2 7,c7 9 p>agraph 7#a77;,b71 by ins]t+ unless su* exclusion complies ) p>agraph 7#b7 be=e ! p]iod2 & 7,d7 by /rik+ p>agraph 7#b7 & ins]t+ ! foll[+ new p>agraphs3 7#b7 ,limitation on preexi/+ condition exclusion p]iod 7,a7 ,limitation ,a heal? insurance issu] (f]+ heal? insurance cov]age 9 ! individual m>ket may n1 ) respect to an enrollee 9 su* cov]age1 impose any preexi/+ condition exclusion if su* enrollee has at lea/ #ah mon?s ( cont9u\s cr$itable cov]age 7z def9$ 9 section #bgja7;c77#a77 imm$iately prec$+ ! enrollm5t date4 7,b7 ,imposition ( exclusion ,not)/&+ p>agraph 7#a77;,b71 a heal? insurance issu] (f]+ heal? insurance cov]age 9 ! individual m>ket may1 ) respect to an enrollee 9 su* cov]age :o is n describ$ 9 subp>agraph 7,a71 impose a preexi/+ condition exclusion only if-- 7i7 su* exclusion relates to a condition 7:e!r physical or m5tal71 reg>dless ( ! cause ( ! condition1 = :i* m$ical advice1 diagnosis1 c>e1 or treatm5t 0 recomm5d$ or receiv$ )9 ! #f-mon? p]iod end+ on ! enrollm5t date2 7ii7 su* exclusion ext5ds = a p]iod ( n m ?an #ah mon?s aft] ! enrollm5t date2 & 7iii7 ! p]iod ( any su* preexi/+ condition exclusion is r$uc$ by ! aggregate ( ! p]iods ( cr$itable cov]age 7if any1 z def9$ 9 section #bgja7;c77#a77 applicable to ! enrollee z ( ! enrollm5t date4 7,c7 ,premium sur*>ge ,not)/&+ p>agraph 7#f71 ) respect to an enrollee describ$ 9 subp>agraph 7,b71 a heal? insurance issu] may *>ge a premium = ! cov]age involv$ t does n exce$ #aej p]c5t ( ! applicable /&>d rate1 = n to exce$ #b ye>s 7or #c ye>s if ! heal? insurance issu] does n impose any preexi/+ condition exclusion ) respect to su* enrollee71 r$uc$ by ! aggregate ( ! p]iods ( cr$itable cov]age 7if any1 z def9$ 9 section #bgja7;c77#a77 applicable to ! enrollee z ( ! enrollm5t date4 ,= purposes ( ?is subsection1 ! t]m applicable /&>d rate means ! /&>d premium rate t ! issu] *>ges = ! cov]age involv$ ) respect to an individual describ$ 9 subp>agraph 7,a7 ) ! same rat+ *>act]i/ics or rat+ factors z ! enrollee describ$ 9 subp>agraph 7,b71 provid$ t any v>iations 9 /&>d premium rates are bas$ on ! uni=m application ( rat+ *>act]i/ics or rat+ factors t are p]mitt$ by ,/ate law & are n o!rwise prohibit$ by p>agraph 7#f74 7#c7 ,exceptions ,not)/&+ p>agraph 7#b71 & subject to subp>agraph 7,d71 a heal? insurance issu] (f]+ heal? insurance cov]age 9 ! individual m>ket1 may n impose any ( ! foll[+ preexi/+ condition exclusion3 7,a7 ,exclusion n applicable to c]ta9 newborns ,9 ! case ( an individual :o1 z ( ! la/ day ( ! #cj-;day p]iod beg9n+ ) ! date ( bir?1 is a dep5d5t ( an enrollee 9 su* cov]age4 7,b7 ,exclusion n applicable to c]ta9 adopt$ *ildr5 ,9 ! case ( a *ild :o is adopt$ or plac$ = adoption be=e atta9+ #ah ye>s ( age & :o1 z ( ! la/ day ( ! #cj-;day p]iod beg9n+ on ! date ( ! adoption or placem5t = adoption1 is a dep5d5t ( an enrollee 9 su* cov]age4 ,! previ\s s5t5ce %all n apply to cov]age be=e ! date ( su* adoption or placem5t = adoption4 7,c7 ,exclusion n applicable to pregnancy ,relat+ to pregnancy z a preexi/+ condition4 7,d7 ,loss if break 9 cov]age ,subp>agraphs 7,a7 & 7,b7 %all no long] apply to an individual aft] ! end ( ! fir/ #fc-;day p]iod dur+ all ( :i* ! individual 0 n cov]$ "u any cr$itable cov]age4 7#d7 ,op5 enrollm5t p]iods ,a heal? insurance issu] (f]+ heal? insurance cov]age 9 ! individual m>ket may limit ! applicability ( ! provisions ( p>agraph 7#a7 to s*$ul$ op5 enrollm5t p]iods1 provid$ t-- 7,a7 any su* op5 enrollm5t p]iod %all n be less ?an #cj days2 7,b7 any p]iod betwe5 s*$ul$ op5 enrollm5t p]iods %all n exce$ #bd mon?s2 & 7,c7 su* limitation %all n apply to any individual :o qualifies = a special enrollm5t p]iod "u p>agraph 7#e74 7#e7 ,special enrollm5t p]iods 7,a7 ,9 g5]al ,subject to subp>agraphs 7,b7 & 7,c71 a heal? insurance issu] (f]+ heal? insurance cov]age 9 ! individual m>ket %all p]mit an individual :o is an eligible individual or a dep5d5t to enroll 9 cov]age dur+ a special enrollm5t p]iod if ! individual exp]i5ces any ( ! foll[+ qualify+ ev5ts3 7i7 ,= dep5d5t b5efici>ies ,! individual becomes1 by reason ( m>riage1 bir?1 adoption or placem5t = adoption1 a dep5d5t ( an individual enroll$ 9 a plan (f]$ by ! heal? insurance issu] & su* individual o!rwise qualifies1 "u ! t]ms ( ! plan1 z eligible = cov]age z a dep5d5t ( su* enrollee4 7ii7 ,loss ( gr\p cov]age ,! individual loses cov]age "u a gr\p heal? plan z a result (-- 7,i7 loss ( eligibility = ! cov]age 7includ+ z a result ( legal sep>ation1 divorce1 dea?1 atta9+ an age at :i* eligibility t]m9ates1 t]m9ation ( employm5t1 or r$uction 9 ! numb] ( h\rs ( employm5t72 or 7,,ii7 t]m9ation ( ! cov]age by ! plan sponsor4 7iii7 ,loss ( individual cov]age ,! individual loses individual m>ket cov]age z a result (-- 7,i7 discont9uation ( a plan z a result ( a heal? insurance issu] ceas+ to (f] cov]age 9 ! individual m>ket 9 accordance ) section #bgdb7;c77#b72 7,,ii7 expiration ( ,,cobra1 or o!r1 cont9uation cov]age2 7,,iii7 ceas+ to qualify1 "u ! t]ms ( ! cov]age1 z a dep5d5t 7includ+ z a result ( legal sep>ation1 divorce1 dea?1 or atta9+ an age at :i* eligibility t]m9ates72 or 7,,iv7 p]man5tly mov+ outside ! ,/ate 9 :i* ! cov]age 0 issu$1 or 9 ! case ( a network plan1 outside ! plan's s]vice area4 7iv7 ,loss ( eligibility = a gov]nm5t cov]age program ,! individual loses cov]age by ceas+ to be eligible = cov]age "u any ( ! foll[+3 7,i7 ,"p ,a or "p ,b ( title ,,xviii ( ! ,social ,security ,act4 7,,ii7 ,title ,,xix ( ! ,social ,security ,act1 o!r ?an cov]age consi/+ solely ( b5efits "u section #aibh ( su* title4 7,,iii7 ,title ,,xxi ( ! ,social ,security ,act4 7,,iv7 ,*apt] #ee ( title #aj4 7,v7 ,*apt] #hi ( title #e4 7,,vi7 ,a ,/ate heal? b5efits risk pool4 7,b7 ,loss ( cov]age def9$ ,= purposes ( ?is p>agraph1 loss ( cov]age %all n include any ( ! foll[+3 7i7 ,volunt>y t]m9ation ( cov]age by an individual1 except if su* t]m9ation is ! result ( circum/ances describ$ 9 clause 7iii77,,iv74 7ii7 ,t]m9ation ( cov]age by ! issu] or ! plan sponsor ( ! cov]age = any reason describ$ 9 p>agraph 7#a7 or 7#b7 ( section #bgdb7;b74 7iii7 ,loss ( any cov]age t consi/s solely ( cov]age ( except$ b5efits 7z def9$ 9 section #bgia74 7,c7 ,special enrollm5t p]iod ,any special enrollm5t p]iod %all n be less ?an #fj days & %all beg9 on ! date ( ! qualify+ ev5t4 7#f7 ,/&>d premium rates ,) respect to ! premium rate *>g$ by a heal? insurance issu] = heal? insurance cov]age (f]$ 9 ! individual m>ket1 su* rate1 ) respect to ! p>ticul> plan or cov]age involv$1 %all n v>y bas$ on any ( ! foll[+ heal? /atus-relat$ factors 9 relation to an eligible individual or dep5d5t3 7,a7 ,heal? /atus4 7,b7 ,m$ical condition 7includ+ physical & m5tal illnesses74 7,c7 ,claims exp]i5ce4 7,d7 ,receipt ( heal? c>e4 7,e7 ,m$ical hi/ory4 7,f7 ,g5etic in=mation4 7,g7 ,evid5ce ( insurability 7includ+ conditions aris+ out ( acts ( dome/ic viol5ce74 7,h7 ,disability4 2 7#b7 by am5d+ subsection 7b7 to read z foll[s3 7b7 ,def9itions ,= purposes ( ?is section3 7#a7 ,eligible individual ,! t]m eligible individual means an individual :o is eligible "u applicable ,/ate law to pur*ase individual heal? insurance cov]age 9 ! ,/ate4 7#b7 ,dep5d5t ,! t]m dep5d5t means an individual :o1 "u ! t]ms ( ! cov]age & applicable ,/ate law1 qualifies to enroll 9 su* cov]age z a dep5d5t ( an individual describ$ 9 p>agraph 7#a74 2 7#c7 by /rik+ subsection 7c72 & 7#d7 by r$esignat+ subsection 7d7 & ! fir/ subsection 7e7 z subsections 7c7 & 7d71 respectively4 7b7 ,con=m+ am5dm5t ,section #bgdd ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#dd71 z re/or$ & reviv$ by section #b ( ?is ,act1 is repeal$4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply ) respect to heal? insurance cov]age (f]$ = plan ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 ,,iii ,int]/ate ,m>ket = ,heal? ,insurance #cja4 ,coop]ative gov]n+ ( individual heal? insurance cov]age 7a7 ,9 ,g5]al ,title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq471 z re/or$ by section #b1 is am5d$ by add+ at ! end ! foll[+ new "p3 ,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#a71 b does n include except$ b5efits describ$ 9 section #bgia7;c74 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 only ! #ej ,/ates & ! ,di/rict ( ,columbia4 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$4 7,j7 ,fail+ to provide =ms necess>y to pres5t claims )9 #ae cal5d> days ( a reque/s ) reasonable explanations reg>d+ _! use4 7,k7 ,attempt+ to cancel a policy 9 less "t ?an t prescrib$ 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]1 re9sur]1 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 #bgii ) 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 ,limitation on individual pur*ase 9 second>y ,/ate ,effective beg9n+ #b ye>s aft] ! date ( enactm5t ( ?is "p1 an individual 9 a ,/ate may n buy individual heal? insurance cov]age 9 a second>y ,/ate if ! premium = individual heal? insurance 9 ! prim>y ,/ate 7) respect to ! individual7 exce$s ! national av]age premium by #aj p]c5t or m4 #bgii4 ,indep5d5t ext]nal appeals proc$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]age2 or 7#b7 9 any case 9 :i* ! requirem5ts ( p>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#b73 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 "o 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$itation1 or c]tification4 #bgii;,a4 ,en=cem5t 7a7 ,9 ,g5]al ,subject to subsection 7b71 ) respect to specific individual heal? insurance cov]age ! prim>y ,/ate = su* cov]age has sole jurisdiction to en=ce ! prim>y ,/ate's cov]$ 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$2 7,b7 ! availability & co/ ( heal? insurance policies = individuals ) pre-exi/+ m$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 7d7 ,sev]ability ,if any provision ( ! section or ! application ( su* provision to any p]son or circum/ance is held to be uncon/itutional1 ! rema9d] ( ?is section & ! application ( ! provisions ( su* to any o!r p]son or circum/ance %all n be affect$4 ,,iv ,lawsuit ,abuse ,re=ms #dja4 ,*ange 9 burd5 ( pro( bas$ on compliance ) cl9ical practice guidel9es 7a7 ,selection & issuance ( cl9ical practices guidel9es 7#a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is section ref]r$ to z ! ,secret>y7 %all provide = ! selection & issuance ( cl9ical practice guidel9es = treatm5t ( m$ical conditions 7ea* 9 ?is subsection ref]r$ to z a guidel9e7 9 accordance ) p>agraphs 7#b7 & 7#c74 7#b7 ,developm5t process ,n lat] ?an #ij days aft] ! date ( enactm5t ( ?is title1 ! ,secret>y %all ent] into a contract ) a qualifi$ physician cons5sus-build+ organization 7su* z ! ,physician ,consortium = ,p]=mance ,improvem5t71 9 conc]t & agreem5t ) physician specialty organizations1 to develop guidel9es4 ,! contract %all require t ! organization submit guidel9es to ! ag5cy n lat] ?an #ah mon?s aft] ! date ( ! enactm5t ( ?is title4 7#c7 ,issuance 7,a7 ,9 g5]al ,n lat] ?an #b ye>s aft] ! date ( ! enactm5t ( ?is title1 ! ,secret>y %all1 aft] notice & opportunity = public comm5t1 make a rule t provides = ! issuance ( ! guidel9es submitt$ "u p>agraph 7#b74 7,b7 ,limitation ,! ,secret>y may n make a rule t includes guidel9es o!r ?an ^? submitt$ "u p>agraph 7#b74 7,c7 ,dissem9ation ,! ,secret>y %all po/ su* guidel9es on ! public ,int]net ,web site ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 7#d7 ,ma9t5ance ,n lat] ?an #d ye>s aft] ! date ( enactm5t ( ?is title1 & e #b ye>s !reaft]1 ! ,secret>y %all review ! guidel9es & %all1 z necess>y1 ent] into contracts simil> to ! contract describ$ 9 p>agraph 7#b71 & issue guidel9es 9 a mann] simil> to ! issuance ( guidel9es "u p>agraph 7#c74 7b7 ,use 7#a7 ,use by def5dant to *ange ! burd5 ( pro( ,if a def5dant 9 a heal? c>e lawsuit relat+ to treatm5t ( an individual e/abli%es by a prepond]ance ( ! evid5ce t ! treatm5t 0 provid$ 9 a mann] consi/5t ) an applicable guidel9e issu$ "u subsection 7a71 ! def5dant may n be held liable unless ! pla9tiff e/abli%es ! liability ( ! def5dant by cle> & conv9c+ evid5ce4 7#b7 ,limitation on introduction z evid5ce aga9/ a def5dant ,guidel9es issu$ "u subsection 7a7 may n be introduc$ z evid5ce ( neglig5ce or deviation 9 ! /&>d ( c>e 9 any heal? c>e lawsuit unless !y h previ\sly be5 introduc$ by ! def5dant4 7#c7 ,no presumption ( neglig5ce aga9/ a def5dant ,!re %all be no presumption ( neglig5ce ) respect to treatm5t if a heal? c>e provid] provides ! treatm5t 9 a mann] inconsi/5t ) su* guidel9es4 7c7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$ z prev5t+ a ,/ate f-- 7#a7 replac+ _! curr5t m$ical malpractice rules ) rules t rely1 z a def5se1 ^u a heal? c>e provid]'s compliance ) a guidel9e issu$ "u subsection 7a72 or 7#b7 apply+ additional guidel9es or limitations on liability t are 9 addition to1 b n 9 lieu (1 ! guidel9es issu$ "u subsection 7a74 #djb4 ,/ate grants to create exp]t panels & adm9i/rative heal? c>e tribunals ,"p ,p ( title ,,iii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bhj;g et seq47 is am5d$ by add+ at ! end ! foll[+3 #cii,u4 ,/ate grants to create adm9i/rative heal? c>e tribunals 7a7 ,9 g5]al ,! ,secret>y may aw>d grants to ,/ates = ! developm5t1 implem5tation1 & evaluation ( adm9i/rative heal? c>e tribunals t comply ) ?is section1 = ! resolution ( disputes conc]n+ injuries alleg$ly caus$ by heal? c>e provid]s4 7b7 ,conditions = demon/ration grants ,to be eligible to receive a grant "u ?is section1 a ,/ate %all submit to ! ,secret>y an application at su* "t1 9 su* mann]1 & conta9+ su* in=mation z may be requir$ by ! ,secret>y4 ,a grant %all be aw>d$ "u ?is section on su* t]ms & conditions z ! ,secret>y det]m9es appropriate4 7c7 ,repres5tation by c\nsel ,a ,/ate t receives a grant "u ?is section may n preclude any p>ty to a dispute be=e an adm9i/rative heal? c>e tribunal op]at$ "u su* grant f obta9+ legal repres5tation dur+ any review by ! exp]t panel "u subsection 7d71 ! adm9i/rative heal? c>e tribunal "u subsection 7e71 or a ,/ate c\rt "u subsection 7f74 7d7 ,exp]t panel review & e>ly (f] guidel9es 7#a7 ,9 g5]al ,if1 9 any heal? c>e liability action aga9/ a heal? c>e provid]1 ! heal? c>e provid] alleges1 9 any response to ! claimant's fil+1 t ! heal? c>e provid] adh]$ to an applicable practice guidel9e 9 ! provision ( heal? c>e items or s]vices to ! claimant1 !n fur!r proce$+s on ! heal? c>e liability action %all be susp5d$ prior to discov]y proce$+s1 until ! completion ( a review ( ! action by an indep5d5t exp]t panel 9 accordance ) ?is subsection4 7#b7 ,composition 7,a7 ,9 g5]al ,! memb]s ( ea* exp]t panel "u ?is subsection %all be appo9t$ by ! head ( ! ,/ate ag5cy responsible = heal?4 ,ea* exp]t panel %all be compos$ ( no few] ?an #c memb]s & n m ?an #e memb]s4 ,at lea/ "o-half ( su* memb]s %all be m$ical exp]ts 7ei!r physicians or heal? c>e pr(essionals74 7,b7 ,lic5sure & exp]tise ,ea* physician or heal? c>e pr(essional appo9t$ to an exp]t panel "u subp>agraph 7,a7 %all-- 7i7 be appropriately cr$5tial$ or lic5s$ 9 "o or m ,/ates to deliv] heal? c>e s]vices2 & 7ii7 typically treat ! condition1 make ! diagnosis1 or provide ! type ( treatm5t t is "u review4 7,c7 ,indep5d5ce 7i7 ,9 g5]al ,subject to clause 7ii71 ea* individual appo9t$ to an exp]t panel "u ?is p>agraph %all-- 7,i7 n h a mat]ial familial1 f9ancial1 or pr(essional relation%ip ) a p>ty involv$ 9 ! dispute review$ by ! panel2 & 7,,ii7 n o!rwise h a conflict ( int]e/ ) su* a p>ty4 7ii7 ,exception ,no?+ 9 clause 7i7 %all be con/ru$ to prohibit an individual :o has /aff privileges at an in/itution :]e ! treatm5t involv$ 9 ! dispute 0 provid$ f s]v+ z a memb] ( an exp]t panel m]ely on ! basis ( su* affiliation1 if ! affiliation is disclos$ to ! p>ties & nei!r p>ty objects4 7,d7 ,practic+ heal? c>e pr(essional 9 same field 7i7 ,9 g5]al ,9 a dispute be=e an exp]t panel t involves treatm5t1 or ! provision ( items or s]vices-- 7,i7 by a physician1 ! m$ical exp]ts on ! exp]t panel %all be practic+ physicians 7allopa?ic or o/eopa?ic7 ( ! same or simil> specialty z a physician :o typically treats ! condition1 makes ! diagnosis1 or provides ! type ( treatm5t "u review2 or 7,,ii7 by a heal? c>e pr(essional o!r ?an a physician1 at lea/ #b m$ical exp]ts on ! exp]t panel %all be practic+ physicians 7allopa?ic or o/eopa?ic7 ( ! same or simil> specialty z ! heal? c>e pr(essional :o typically treats ! condition1 makes ! diagnosis1 or provides ! type ( treatm5t "u review1 &1 if det]m9$ appropriate by ! ,/ate ag5cy1 an additional m$ical exp]t %all be a practic+ heal? c>e pr(essional 7o!r ?an su* a physician7 ( su* a same or simil> specialty4 7ii7 ,practic+ def9$ ,9 ?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 a week4 7,e7 ,p$iatric exp]tise ,9 ! case ( dispute relat+ to a *ild1 at lea/ #a m$ical exp]t on ! exp]t panel %all h exp]tise describ$ 9 subp>agraph 7,d77i7 9 p$iatrics4 7,f7 ,no civil liability = memb]s ,no civil action %all be br\ght 9 any c\rt aga9/ any memb] ( an exp]t panel = any act done1 failure to act1 or /atem5t or op9ion made1 )9 ! scope ( ! individual's duties z a memb] ( ! exp]t panel4 7#c7 ,det]m9ation 7,a7 ,9 g5]al ,aft] a review "u p>agraph 7#a71 an exp]t panel %all make a det]m9ation z to ! liability ( ! p>ties involv$ & comp5sation4 7,b7 ,consid]ations 9 mak+ det]m9ations ,9 mak+ a det]m9ation "u ?is subsection z to ! liability ( p>ties involv$ & comp5sation1 ! foll[+ %all apply3 7i7 ,treatm5t ( cl9ical practice guidel9es ,an exp]t panel %all ackn[l$ge ! ability ( physicians to dep>t f ! recomm5dations 9 cl9ical practice guidel9es1 :5 appropriate1 9 ! c>e ( individual pati5ts4 7ii7 ,limitation ,an exp]t panel %all n make a f9d+ ( neglig5ce f ! m]e fact t a treatm5t or proc$ure 0 unsuccessful or fail$ to br+ ! be/ result4 7#d7 ,e>ly (f] ,if ! p>ties to a dispute be=e an exp]t panel "u ?is subsection accept ! det]m9ation ( ! exp]t panel conc]n+ liability & comp5sation1 su* comp5sation %all be paid to ! claimant & ! claimant %all agree to =go any fur!r action aga9/ ! heal? c>e provid]s involv$4 7#e7 ,failure to accept ,if any p>ty decides n to accept ! exp]t panel's det]m9ation1 ! matt] %all be ref]r$ to an adm9i/rative heal? c>e tribunal creat$ pursuant to ?is section4 7e7 ,adm9i/rative heal? c>e tribunals 7#a7 ,9 g5]al ,^u ! failure ( any p>ty to accept ! det]m9ation ( an exp]t panel "u subsection 7d71 ! p>ties %all h ! "r to reque/ a he>+ conc]n+ ! liability or comp5sation involv$ by an adm9i/rative heal? c>e tribunal e/abli%$ by ! ,/ate involv$4 7#b7 ,requirem5ts ,9 e/abli%+ an adm9i/rative heal? c>e tribunal "u ?is section1 a ,/ate %all-- 7,a7 ensure t su* tribunals are presid$ ov] by special judges ) heal? c>e exp]tise2 7,b7 provide au?ority to su* judges to make b9d+ rul+s1 r5d]$ 9 writt5 decisions1 on /&>ds ( c>e1 causation1 comp5sation1 & relat$ issues ) reliance on indep5d5t exp]t witnesses commission$ by ! tribunal2 7,c7 e/abli% gross neglig5ce z ! legal /&>d = ! tribunal2 & 7,d7 all[ ! admission into evid5ce ( ! recomm5dation made by ! exp]t panel "u subsection 7d74 7f7 ,review by ,/ate c\rt aft] exhau/ion ( adm9i/rative rem$ies 7#a7 ,"r to file ,if any p>ty to a dispute be=e a heal? c>e tribunal "u subsection 7e7 is n satisfi$ ) ! det]m9ations ( ! tribunal1 ! p>ty %all h ! "r to file _! claim 9 a ,/ate c\rt ( compet5t jurisdiction4 7#b7 ,=feit ( aw>ds ,any p>ty fil+ an action 9 a ,/ate c\rt 9 accordance ) p>agraph 7#a7 %all =feit any comp5sation aw>d made "u subsection 7e74 7#c7 ,admissibility ,! det]m9ations ( ! exp]t panel & ! adm9i/rative heal? c>e tribunal pursuant to subsections 7d7 & 7e7 ) respect to a ,/ate c\rt proce$+ "u p>agraph 7#a7 %all be admissible into evid5ce 9 any su* ,/ate c\rt proce$+4 7#d7 ,treatm5t ( c]ta9 exp]t panel & adm9i/rative heal? c>e tribunal f9d+s 7,a7 ,"w product ,no f9d+ by an exp]t panel "u subsection 7d7 or adm9i/rative heal? c>e tribunal "u subsection 7e7 t ! def5dant applicable eligible pr(essional brea*$ ! /&>d ( c>e z set =? "u ! prescrib$ practice guidel9es %all con/itute neglig5ce p] se or conclusive evid5ce ( liability4 7,b7 ,f9d+ relat+ to cl9ical practice guidel9es ,if an adm9i/rative heal? c>e tribunal did n make a f9d+ "u subsection 7e7 t !re 0 an applicable cl9ical practice guidel9e t ! def5dant adh]$ to1 ) respect to ! ,/ate c\rt proce$+ "u p>agraph 7#a7 ! ,/ate c\rt may issue summ>y judgm5t 9 favor ( ! def5dant heal? c>e pr(essional unless ! claimant is able to %[ o!rwise by cle> & conv9c+ evid5ce4 ,if an adm9i/rative heal? c>e tribunal made a f9d+ "u subsection 7e7 t !re 0 an applicable cl9ical practice guidel9e t ! def5dant adh]$ to1 ) respect to a ,/ate c\rt proce$+ "u p>agraph 7#a7 ! ,/ate c\rt %all issue summ>y judgm5t 9 favor ( ! applicable heal? c>e pr(essional unless ! claimant is able to %[ o!rwise by cle> & conv9c+ evid5ce4 7,c7 ,f9d+ relat+ to /&>d ( c>e ,any f9d+ ( an exp]t panel or adm9i/rative heal? c>e tribunal "u subsection 7d7 or 7e71 respectively1 t ! def5dant did n brea* ! /&>d ( c>e z set =? "u ! prescrib$ cl9ical practice guidel9es or t ! def5dant's failure to con=m to ! requir$ /&>d 0 nei!r ! cause 9 fact nor ! proximate cause ( ! pla9tiff's injury or t ! pla9tiff did n incur any damages z a result %all be giv5 def]5ce by ! ,/ate c\rt involv$ & %all entitle ! def5dant to summ>y judgm5t unless ! pla9tiff is able to %[ by cle> & conv9c+ evid5ce t ! exp]t panel or heal? c>e tribunal1 respectively1 0 9 error & t !re is a g5u9e issue z to a mat]ial fact 9 ! case4 7g7 ,def9ition ,9 ?is section1 ! 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 7h7 ,au?orization ( appropriations ,!re are au?oriz$ to be appropriat$ = any fiscal ye> su* sums z may be necess>y = purposes ( mak+ grants to ,/ates "u ?is section4 4 #djc4 ,paym5t ( damages & recov]y ( co/s 9 heal? c>e lawsuits 7a7 ,au?orization ( paym5t ( future damages to claimants 9 heal? c>e lawsuits ,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 paym5ts1 9 accordance ) ! ,uni=m ,p]iodic ,paym5t ( ,judgm5ts ,act promulgat$ by ! ,national ,conf]5ce ( ,commission]s on ,uni=m ,/ate ,laws4 7b7 ,recov]y ( co/s2 paym5t ( aw>d ,9 any heal? c>e lawsuit1 ! c\rt may 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 7c7 ,applicability ,?is section applies to all actions :i* h n be5 fir/ set = trial or retrial be=e ! effective date ( ?is title4 7d7 ,/atute ( limitations 7#a7 ,9 g5]al ,except 9 ! case ( a ,/ate law t provides = a %ort] p]iod ( "t1 ! "t = ! comm5cem5t ( a heal? c>e lawsuit %all be no m ?an #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 ! p]son ( ! injur$ p]son4 7#b7 ,cases involv+ m9ors ,except 9 ! case ( a ,/ate law t provides = a %ort] p]iod ( "t1 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 7e7 ,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 7f7 ,apologies ,9 any heal? c>e lawsuit1 if a claimant receives any expression ( regret = any act p]ta9+ to conduct giv+ rise to ! heal? c>e lawsuit1 su* expression ( regret1 not)/&+ any applicable rule ( evid5ce may n be admitt$ into evid5ce 9 ! heal? c>e lawsuit4 #djd4 ,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$]al c\rt4 7#b7 ,claimant ,! t]m claimant means any p]son :o br+s a heal? c>e lawsuit1 includ+ a p]son :o ass]ts or claims a "r to legal or equitable contribution1 indemnity1 or subrogation1 aris+ out ( a heal? c>e liability claim or action1 & any p]son on ^: behalf su* a claim is ass]t$ or su* an action is br\ght1 :e!r deceas$1 incompet5t1 or a m9or4 7#c7 ,f$]al tax b5efit ,a claimant %all be treat$ z receiv+ a ,f$]al tax b5efit ) respect to paym5t = items or s]vices if-- 7,a7 su* paym5t is comp5sation by insurance-- 7i7 :i* con/itutes m$ical c>e1 & 7ii7 ) respect to ! paym5t ( premiums = :i* ! claimant1 or ! employ] ( ! claimant1 0 all[$ an exclusion f gross income1 a d$uction1 or a cr$it = ,f$]al income tax purposes1 7,b7 a d$uction 0 all[$ ) respect to su* paym5t = ,f$]al income tax purposes1 or 7,c7 su* paym5t 0 f an ,ar*] ,,msa 7z def9$ 9 section #bbj7;d7 ( ! ,int]nal ,rev5ue ,code ( #aihf71 a heal? sav+s acc\nt 7z def9$ 9 section #bbc7;d7 ( su* ,code71 a flexible sp5d+ arrangem5t 7z def9$ 9 section #ajf7;c77#b7 ( su* ,code71 or a heal? reimbursem5t arrangem5t :i* is treat$ z employ]-provid$ cov]age "u an accid5t or heal? plan = purposes ( section #ajf ( su* ,code4 7#d7 ,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 br\ght 9 a ,f$]al c\rt or 9 a ,/ate c\rt or pursuant to an alt]native dispute resolution sy/em1 if su* claim conc]ns items or s]vices = :i* cov]age is provid$ "u title ,,xviii1 ,,xix1 or ,,xxi ( ! ,social ,security ,act or = :i* ! claimant receives a ,f$]al tax b5efit1 aga9/ a heal? c>e provid]1 a heal? c>e organization1 or ! manufactur]1 di/ributor1 suppli]1 m>ket]1 promot]1 or sell] ( a m$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$]al ,gov]nm5t2 or :i* is gr\nd$ 9 antitru/4 7#e7 ,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$1 or ! numb] ( pla9tiffs1 def5dants1 or o!r p>ties1 or ! numb] ( causes ( action1 9 :i* ! claimant alleges a heal? c>e liability claim4 7#f7 ,heal? c>e liability claim ,! t]m heal? c>e liability claim means a dem& by any p]son1 :e!r or n pursuant to ,,adr1 aga9/ a heal? c>e provid]1 heal? c>e organization1 or ! manufactur]1 di/ributor1 suppli]1 m>ket]1 promot]1 or sell] ( a m$ical product1 includ+ ?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$1 or ! numb] ( pla9tiffs1 def5dants1 or o!r p>ties1 or ! numb] ( causes ( action4 7#g7 ,heal? c>e organization ,! t]m heal? c>e organization means any p]son or entity :i* is obligat$ 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#h7 ,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#i7 ,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#aj7 ,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#aa7 ,m$ical treatm5t ,! t]m m$ical treatm5t means ! provision ( any goods or s]vices by a heal? c>e provid] 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#ab7 ,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$uctible disbursem5ts or co/s = su* purpose4 7#ac7 ,/ate ,! t]m ,/ate means ea* ( ! sev]al ,/ates1 ! ,di/rict ( ,columbia1 ! ,commonweal? ( ,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1 ,am]ican ,samoa1 ! ,nor!rn ,m>iana ,isl&s1 ! ,tru/ ,t]ritory ( ! ,pacific ,isl&s1 & any o!r t]ritory or possession ( ! ,unit$ ,/ates1 or any political subdivision !re(4 #dje4 ,effect on o!r laws 7a7 ,vacc9e ,injury 7#a7 ,non-applicability ( ?is title ,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 ,applicability ( ?is title ,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$]al law4 #djf4 ,applicability2 effective date ,?is title %all apply to any heal? c>e lawsuit br\ght 9 a ,f$]al or ,/ate c\rt1 or subject to an alt]native dispute resolution sy/em1 t is initiat$ on or aft] ! date ( ! enactm5t ( ?is title1 except t any heal? c>e lawsuit aris+ f an injury occurr+ prior to ! date ( ! enactm5t ( ?is title %all be gov]n$ by ! applicable /atute ( limitations provisions 9 effect at ! "t ! injury occurr$4 ,v ,wellness & ,prev5tion #eja4 ,provid+ f9ancial inc5tives = treatm5t compliance 7a7 ,limitation on exception = wellness programs "u ,,hipaa discrim9ation rules 7#a7 ,employee ,retirem5t ,income ,security ,act ( #aigd am5dm5t ,section #gjb7;b77#b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahb7;b77#b77 is am5d$ by add+ aft] subp>agraph 7,b7 ! foll[+3 ,9 apply+ subp>agraph 7,b71 a gr\p heal? plan 7or a heal? insurance issu] ) respect to heal? insurance cov]age7 may v>y premiums & co/-%>+ by up to #ej p]c5t ( ! value ( ! b5efits "u ! plan 7or cov]age7 bas$ on p>ticipation 7or lack ( p>ticipation7 9 a /&>ds-bas$ wellness program4 4 7#b7 ,,phsa am5dm5t ,section #bgjb7;b77#b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#a7;b77#b77 is am5d$ by add+ aft] subp>agraph 7,b7 ! foll[+3 ,9 apply+ subp>agraph 7,b71 a gr\p heal? plan 7or a heal? insurance issu] ) respect to heal? insurance cov]age7 may v>y premiums & co/-%>+ by up to #ej p]c5t ( ! value ( ! b5efits "u ! plan 7or cov]age7 bas$ on p>ticipation 7or lack ( p>ticipation7 9 a /&>ds-bas$ wellness program4 4 7#c7 ,,irc am5dm5t ,section #ihjb7;b77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ aft] subp>agraph 7,b7 ! foll[+3 ,9 apply+ subp>agraph 7,b71 a gr\p heal? plan may v>y premiums & co/-%>+ by up to #ej p]c5t ( ! value ( ! b5efits "u ! plan bas$ on p>ticipation 7or lack ( p>ticipation7 9 a /&>ds-bas$ wellness program4 4 7b7 ,effective date ,! am5dm5ts made by subsection 7a7 %all apply to plan ye>s beg9n+ m ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act4 ,,vi ,transp>5cy & ,insurance ,re=m ,measures #fja4 ,receipt & response to reque/s = claim in=mation 7a7 ,9 g5]al ,title ,,xxvii ( ! ,public ,heal? ,s]vice ,act is am5d$ by ins]t+ aft] section #bgac ! foll[+ new section3 #bgad4 ,receipt & response to reque/s = claim in=mation 7a7 ,requirem5t 7#a7 ,9 g5]al ,9 ! case ( heal? insurance cov]age (f]$ 9 connection ) a gr\p heal? plan1 n lat] ?an #cj days aft] ! date on :i* a heal? insurance issu] receives a writt5 reque/ = a writt5 report ( claim in=mation f ! plan1 plan sponsor1 or plan adm9i/rator1 ! heal? insurance issu] %all provide ! reque/+ p>ty ! report1 subject to ! succe$+ provisions ( ?is section4 7#b7 ,exception ,! heal? insurance issu] is n obligat$ to provide a report "u ?is subsection reg>d+ a p>ticul> employ] or gr\p heal? plan m ?an twice 9 any #ab-mon? p]iod & is n obligat$ to provide su* a report 9 ! case ( an employ] ) few] ?an #ej employees4 7#c7 ,deadl9e ,a plan1 plan sponsor1 or plan adm9i/rator mu/ reque/ a report "u ?is subsection be=e or on ! second anniv]s>y ( ! date ( t]m9ation ( cov]age "u a gr\p heal? plan issu$ by ! heal? insurance issu]4 7b7 ,=m ( report2 in=mation ,to be includ$ 7#a7 ,9 g5]al ,a heal? insurance issu] %all provide ! report ( claim in=mation "u subsection 7a7-- 7,a7 9 a writt5 report2 7,b7 ?r\gh an electronic file transmitt$ by secure electronic mail or a file transf] protocol site2 or 7,c7 by mak+ ! requir$ in=mation available ?r\gh a secure ,int]net ,web site or ,web portal accessible by ! reque/+ plan1 plan sponsor1 or plan adm9i/rator4 7#b7 ,in=mation to be includ$ ,a report ( claim in=mation provid$ "u subsection 7a7 %all conta9 all in=mation available to ! heal? insurance issu] t is responsive to ! reque/ made "u su* subsection1 includ+1 subject to subsection 7c71 protect$ heal? in=mation1 = ! #c-ye> p]iod prec$+ ! date ( ! report or ! p]iod specifi$ by subp>agraphs 7,d71 7,e71 & 7,f7 ( p>agraph 7#c71 if applicable1 or = ! entire p]iod ( cov]age1 :i*ev] p]iod is %ort]4 7#c7 ,requir$ in=mation ,subject to subsection 7c71 a report provid$ "u subsection 7a7 %all include ! foll[+3 7,a7 ,aggregate paid claims exp]i5ce by mon?1 includ+ claims exp]i5ce = m$ical1 d5tal1 & ph>macy b5efits1 z applicable4 7,b7 ,total premium paid by mon?4 7,c7 ,total numb] ( cov]$ employees on a mon?ly basis by cov]age ti]1 includ+ :e!r cov]age 0 =-- 7i7 an employee only2 7ii7 an employee ) dep5d5ts only2 7iii7 an employee ) a sp\se only2 or 7iv7 an employee ) a sp\se & dep5d5ts4 7,d7 ,! total doll> am\nt ( claims p5d+ z ( ! date ( ! report4 7,e7 ,a sep>ate description & individual claims report = any individual ^: total paid claims exce$ #ae1jjj dur+ ! #ab-mon? p]iod prec$+ ! date ( ! report1 includ+ ! foll[+ in=mation relat$ to ! claims = t individual-- 7i7 a unique id5tify+ numb]1 *>act]i/ic1 or code = ! individual2 7ii7 ! am\nts paid2 7iii7 dates ( s]vice2 & 7iv7 applicable proc$ure codes & diagnosis codes4 7,f7 ,= claims t are n "p ( ! in=mation describ$ 9 a previ\s subp>agraph1 a /atem5t describ+ prec]tification reque/s = hospital /ays ( #e days or long] t 7 made dur+ ! #cj-;day p]iod prec$+ ! date ( ! report4 7c7 ,limitations on disclosure 7#a7 ,9 g5]al ,a heal? insurance issu] may n disclose protect$ heal? in=mation 9 a report ( claim in=mation provid$ "u ?is section if ! heal? insurance issu] is prohibit$ f disclos+ t in=mation "u ano!r ,/ate or ,f$]al law t imposes m /r+5t privacy re/rictions ?an ^? impos$ "u ,f$]al law "u ! ,,hipaa privacy regulations4 ,to )hold in=mation 9 accordance ) ?is subsection1 ! heal? insurance issu] %all-- 7,a7 notify ! plan1 plan sponsor1 or plan adm9i/rator reque/+ ! report t in=mation is be+ )held2 & 7,b7 provide to ! plan1 plan sponsor1 or plan adm9i/rator a li/ ( categories ( claim in=mation t ! heal? insurance issu] has det]m9$ are subject to ! m /r+5t privacy re/rictions "u ano!r ,/ate or ,f$]al law4 7#b7 ,protection ,a plan sponsor is entitl$ to receive protect$ heal? in=mation "u subp>agraphs 7,e7 & 7,f7 ( subsection 7b77#c7 & subsection 7d7 only aft] an appropriately au?oriz$ repres5tative ( ! plan sponsor makes to ! heal? insurance issu] a c]tification sub/antially simil> to ! foll[+ c]tification3 ,i h]eby c]tify t ! plan docum5ts comply ) ! requirem5ts ( section #afd4ejd7;f77#b7 ( title #de1 ,code ( ,f$]al ,regulations1 & t ! plan sponsor w safegu>d & limit ! use & disclosure ( protect$ heal? in=mation t ! plan sponsor may receive f ! gr\p heal? plan to p]=m ! plan adm9i/ration functions44 7#c7 ,results ,a plan sponsor t does n provide ! c]tification requir$ by p>agraph 7#b7 is n entitl$ to receive ! protect$ heal? in=mation describ$ by subp>agraphs 7,e7 & 7,f7 ( subsection 7b77#c7 & subsection 7d71 b is entitl$ to receive a report ( claim in=mation t includes ! in=mation describ$ 9 subp>agraphs 7,a7 ?r\gh 7,d7 ( subsection 7b77#c74 7#d7 ,in=mation ,9 ! case ( a reque/ made "u subsection 7a7 aft] ! date ( t]m9ation ( cov]age1 ! report %all conta9 all in=mation available to ! heal? insurance issu] z ( ! date ( ! report t is responsive to ! reque/1 includ+ protect$ heal? in=mation1 & includ+ ! in=mation describ$ 9 subsection 7b77#c71 = ! p]iod describ$ 9 subsection 7b77#b7 prec$+ ! date ( t]m9ation ( cov]age or = ! entire policy p]iod1 :i*ev] p]iod is %ort]4 ,not)/&+ ?is subsection1 ! report may n include ! protect$ heal? in=mation describ$ 9 subp>agraphs 7,e7 & 7,f7 ( subsection 7b77#c7 unless a c]tification has be5 provid$ 9 accordance ) p>agraph 7#b74 7d7 ,reque/ = additional in=mation 7#a7 ,review ,on receipt ( ! report requir$ by subsection 7a71 ! plan1 plan sponsor1 or plan adm9i/rator may review ! report &1 n lat] ?an #aj days aft] ! date on :i* ! report is receiv$1 may make a writt5 reque/ to ! heal? insurance issu] = additional in=mation 9 accordance ) ?is subsection = specifi$ individuals4 7#b7 ,reque/ ,) respect to a reque/ = additional in=mation conc]n+ specifi$ individuals = :om claims in=mation has be5 provid$ "u subsection 7b77#c77;,e71 ! heal? insurance issu] %all provide additional in=mation on ! prognosis or recov]y if available &1 = individuals 9 active case managem5t1 ! mo/ rec5t case managem5t in=mation1 includ+ any future expect$ co/s & treatm5t plan1 t relate to ! claims = t individual4 7#c7 ,response ,! heal? insurance issu] mu/ respond to ! reque/ = additional in=mation "u ?is subsection n lat] ?an #ae days aft] ! date ( su* reque/ unless ! reque/+ plan1 plan sponsor1 or plan adm9i/rator agrees to a reque/ = additional "t4 7#d7 ,limitation ,! heal? insurance issu] is n requir$ to produce ! report describ$ by ?is subsection unless a c]tification has be5 provid$ 9 accordance ) subsection 7c77#b74 7#e7 ,compliance ) section does n create liability ,a heal? insurance issu] t releases in=mation1 includ+ protect$ heal? in=mation1 9 accordance ) ?is subsection has n violat$ a /&>d ( c>e & is n liable = civil damages result+ f1 & is n subject to crim9al prosecution =1 releas+ t in=mation4 7e7 ,limitation on preemption ,no?+ 9 ?is section is meant to limit ,/ates f enact+ additional laws 9 addition to ! provisions ( ?is section1 b n 9 lieu ( su* provisions4 7f7 ,def9itions ,9 ?is section3 7#a7 ,! t]ms employ]1 plan adm9i/rator1 & plan sponsor h ! mean+s giv5 su* t]ms 9 section #c ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd4 7#b7 ,! t]m ,,hipaa privacy regulations has ! mean+ giv5 su* t]m 9 section #aahj7;b77#c7 ( ! ,social ,security ,act4 7#c7 ,! t]m protect$ heal? in=mation has ! mean+ giv5 su* t]m "u ! ,,hipaa privacy regulations4 4 7b7 ,effective date ,! am5dm5t made by subsection 7a7 %all take effect on ! date ( ! enactm5t ( ?is ,act4 ,,vii ,quality #gja4 ,prohibition on c]ta9 uses ( data obta9$ f comp>ative effectiv5ess rese>* or f pati5t-c5t]$ outcomes rese>*2 acc\nt+ = p]sonaliz$ m$ic9e & diff]5ces 9 pati5t treatm5t response 7a7 ,9 g5]al ,not)/&+ any o!r provision ( law1 ! ,secret>y ( ,heal? & ,human ,s]vices-- 7#a7 %all n use data obta9$ f ! conduct ( comp>ative effectiv5ess rese>* or pati5t-c5t]$ outcomes rese>*1 includ+ su* rese>* t is conduct$ or support$ us+ funds appropriat$ "u ! ,am]ican ,recov]y & ,re9ve/m5t ,act ( #bjji 7,public ,law #aaa-e71 to d5y cov]age ( an item or s]vice "u a ,f$]al heal? c>e program 7z def9$ 9 section #aabh;,b7f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;b7f7772 & 7#b7 %all ensure t comp>ative effectiv5ess rese>* & pati5t-c5t]$ outcomes rese>* conduct$ or support$ by ! ,f$]al ,gov]nm5t acc\nts = factors contribut+ to diff]5ces 9 ! treatm5t response & treatm5t pref]5ces ( pati5ts1 includ+ pati5t-report$ outcomes1 g5omics & p]sonaliz$ m$ic9e1 ! unique ne$s ( heal? disp>ity populations1 & indirect pati5t b5efits4 7b7 ,consultation & approval requir$ ,no?+ ! ,f$]al ,coord9at+ ,c\ncil = ,comp>ative ,effectiv5ess ,rese>* f9ds c be releas$ 9 f9al =m until aft] consultation ) & approv$ by relevant physician specialty organizations4 7c7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ z affect+ ! au?ority ( ! ,commission] ( ,food & ,drugs "u ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cja et seq47 or ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bja et seq474 #gjb4 ,e/abli%m5t ( p]=mance-bas$ quality measures ,n lat] ?an ,janu>y #a1 #bjag1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit to ,congress a proposal = a =maliz$ process = ! developm5t ( p]=mance-bas$ quality measures t c\ld be appli$ to physicians' s]vices "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq474 ,su* proposal %all be 9 conc]t & agreem5t ) ! ,physician ,consortium = ,p]=mance ,improvem5t & %all only utilize measures agre$ ^u by ea* physician specialty organization4 ,,viii ,/ate ,transp>5cy ,plan ,portal #hja4 ,provid+ in=mation on heal? cov]age options & heal? c>e provid]s 7a7 ,/ate-,bas$ portal ,a ,/ate 7by itself or jo9tly ) o!r ,/ates7 may contract ) a private entity to e/abli% a ,heal? ,plan & ,provid] ,portal ,web site 7ref]r$ to 9 ?is section z a plan portal7 = ! purposes ( provid+ /&>diz$ in=mation-- 7#a7 on heal? insurance plans t h be5 c]tifi$ to be available = pur*ase 9 t ,/ate2 & 7#b7 on price & quality in=mation on heal? c>e provid]s 7includ+ physicians1 hospitals1 & o!r heal? c>e in/itutions74 7b7 ,prohibitions 7#a7 ,direct ,enrollm5t ,a plan portal may n directly enroll individuals 9 heal? insurance plans or "u a ,/ate ,m$icaid plan "u title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 or a ,/ate *ild heal? plan "u ! ,/ate ,*ildr5's ,heal? ,insurance ,program e/abli%$ "u title ,,xxi ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acig;aa et seq474 7#b7 ,conflicts ( int]e/ 7,a7 ,companies ,a heal? insurance issu] (f]+ a heal? insurance plan ?r\gh a plan portal may n-- 7i7 be ! private entity develop+ & ma9ta9+ a plan portal "u ?is section2 or 7ii7 h an own]%ip int]e/ 9 su* private entity or 9 ! plan portal4 7,b7 ,individuals ,an individual employ$ by a heal? insurance issu] (f]+ a heal? insurance plan ?r\gh a plan portal may n s]ve z a director or (fic] =-- 7i7 ! private entity develop+ & ma9ta9+ a plan portal "u ?is section2 or 7ii7 ! plan portal4 7c7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$ to prohibit heal? insurance brok]s & ag5ts f-- 7#a7 utiliz+ ! plan portal = any purpose2 or 7#b7 m>ket+ or (f]+ heal? insurance products4 7d7 ,/ate def9$ ,9 ?is section1 ! t]m ,/ate has ! mean+ giv5 su* t]m = purposes ( title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq474 7e7 ,heal? insurance plans ,= purposes ( ?is section1 ! t]m heal? insurance plan does n include cov]age ( except$ b5efits1 z def9$ 9 section #bgia7;c7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ia7;c774 ,,ix ,pati5t ,fre$om ( ,*oice #ija4 ,gu>antee+ fre$om ( *oice & contract+ = pati5ts "u ,m$ic>e 7a7 ,9 g5]al ,section #ahjb ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;a7 is am5d$ to read z foll[s3 #ahjb4 ,fre$om ( *oice & contract+ by pati5t gu>ante$ 7a7 ,basic fre$om ( *oice ,any individual entitl$ to insurance b5efits "u ?is title may obta9 heal? s]vices f any in/itution1 ag5cy1 or p]son qualifi$ to p>ticipate "u ?is title if su* in/itution1 ag5cy1 or p]son und]takes to provide t individual su* s]vices4 7b7 ,fre$om ,to contract by ,m$ic>e b5efici>ies 7#a7 ,9 g5]al ,subject to ! provisions ( ?is subsection1 no?+ 9 ?is title %all prohibit a ,m$ic>e b5efici>y f ent]+ into a contract ) an eligible pr(essional 7:e!r or n ! pr(essional is a p>ticipat+ or non-p>ticipat+ physician or practition]7 = any item or s]vice cov]$ "u ?is title4 7#b7 ,submission ( claims ,any ,m$ic>e b5efici>y t ent]s into a contract "u ?is section ) an eligible pr(essional %all be p]mitt$ to submit a claim = paym5t "u ?is title = s]vices furni%$ by su* pr(essional1 & su* paym5t %all be made 9 ! am\nt t w\ld o!rwise apply to su* pr(essional "u ?is title except t :]e su* pr(essional is consid]$ to be non-p>ticipat+1 paym5t %all be paid z if ! pr(essional 7 p>ticipat+4 ,paym5t made "u ?is title = any item or s]vice provid$ "u ! contract %all n r5d] ! pr(essional a p>ticipat+ or non-p>ticipat+ physician or practition]1 & z su*1 requirem5ts ( ?is title t may o!rwise apply to a p>ticipat+ or non-p>ticipat+ physician or practition] w\ld n apply ) respect to any items or s]vices furni%$ "u ! contract4 7#c7 ,b5efici>y protections 7,a7 ,9 g5]al ,p>agraph 7#a7 %all n apply to any contract unless-- 7i7 ! contract is 9 writ+1 is sign$ by ! ,m$ic>e b5efici>y & ! eligible pr(essional1 & e/abli%es all t]ms ( ! contract 7includ+ specific paym5t = items & s]vices cov]$ by ! contract7 be=e any item or s]vice is provid$ pursuant to ! contract1 & ! b5efici>y %all be held h>mless = any subsequ5t paym5t *>g$ = an item or s]vice 9 excess ( ! am\nt e/abli%$ "u ! contract dur+ ! p]iod ! contract is 9 effect2 7ii7 ! contract conta9s ! items describ$ 9 subp>agraph 7,b72 & 7iii7 ! contract is n ent]$ into at a "t :5 ! ,m$ic>e b5efici>y is fac+ an em]g5cy m$ical condition or urg5t heal? c>e situation4 7,b7 ,items requir$ to be includ$ 9 contract ,any contract to provide items & s]vices to :i* p>agraph 7#a7 applies %all cle>ly indicate to ! ,m$ic>e b5efici>y t by sign+ su* contract ! b5efici>y-- 7i7 agrees to be responsible = paym5t to su* eligible pr(essional = su* items or s]vices "u ! t]ms ( & am\nts e/abli%$ "u ! contract2 7ii7 agrees to be responsible = submitt+ claims "u ?is title to ! ,secret>y1 & to any o!r supplem5tal insurance plan t may provide supplem5tal insurance1 = su* items or s]vices furni%$ "u ! contract if su* items or s]vices are cov]$ by ?is title1 unless o!rwise provid$ 9 ! contract "u subp>agraph 7,c77i72 & 7iii7 ackn[l$ges t no limits or o!r paym5t inc5tives t may o!rwise apply "u ?is title 7su* z ! limits "u subsection 7g7 ( section #ahdh or inc5tives "u subsections 7a77#e71 7m71 7q71 & 7p7 ( su* section7 %all apply to am\nts t may be *>g$1 or paid to a b5efici>y =1 su* items or s]vices4 ,su* contract %all also cle>ly indicate :e!r ! eligible pr(essional is exclud$ f p>ticipation "u ! ,m$ic>e program "u section #aabh4 7,c7 ,b5efici>y elections "u ! contract ,any ,m$ic>e b5efici>y t ent]s into a contract "u ?is section may elect to negotiate1 z a t]m ( ! contract1 a provision "u :i*-- 7i7 ! eligible pr(essional %all file claims on behalf ( ! b5efici>y ) ! ,secret>y & any supplem5tal insurance plan = items or s]vices furni%$ "u ! contract if su* items or s]vices are cov]$ "u ?is title or "u ! plan2 & 7ii7 ! b5efici>y assigns paym5t to ! eligible pr(essional = any claims fil$ by1 or on behalf (1 ! b5efici>y ) ! ,secret>y & any supplem5tal insurance plan = items or s]vices furni%$ "u ! contract4 7,d7 ,exclusion ( dual eligible individuals ,p>agraph 7#a7 %all n apply to any contract if a b5efici>y :o is eligible = m$ical assi/ance "u title ,,xix is a p>ty to ! contract4 7#d7 ,limitation on actual *>ge & claim submission requirem5t n applicable ,section #ahdh7;g7 %all n apply ) respect to any item or s]vice provid$ to a ,m$ic>e b5efici>y "u a contract describ$ 9 p>agraph 7#a74 7#e7 ,con/ruction ,no?+ 9 ?is section %all be con/ru$-- 7,a7 to prohibit any eligible pr(essional f ma9ta9+ an election & act+ z a p>ticipat+ or non-p>ticipat+ physician or practition] ) respect to any pati5t n cov]$ "u a contract e/abli%$ "u ?is section2 & 7,b7 z *ang+ ! items & s]vices = :i* an eligible pr(essional may bill "u ?is title4 7#f7 ,def9itions ,9 ?is subsection3 7,a7 ,m$ic>e b5efici>y ,! t]m ,m$ic>e b5efici>y means an individual :o is entitl$ to b5efits "u "p ,a or enroll$ "u "p ,b4 7,b7 ,eligible pr(essional ,! t]m eligible pr(essional has ! mean+ giv5 su* t]m 9 section #ahdh7k77#c77;,b74 7,c7 ,em]g5cy m$ical condition ,! t]m em]g5cy m$ical condition means a m$ical condition manife/+ itself by acute symptoms ( suffici5t sev]ity 7includ+ sev]e pa97 su* t a prud5t layp]son1 ) an av]age k ( heal? & m$ic9e1 c\ld reasonably expect ! abs5ce ( imm$iate m$ical att5tion to result 9-- 7i7 s]i\s jeop>dy to ! heal? ( ! individual or1 9 ! case ( a pregnant woman1 ! heal? ( ! woman or h] unborn *ild2 7ii7 s]i\s impairm5t to bodily functions2 or 7iii7 s]i\s dysfunction ( any bodily organ or "p4 7,d7 ,urg5t heal? c>e situation ,! t]m urg5t heal? c>e situation means s]vices furni%$ to an individual :o requires s]vices to be furni%$ )9 #ab h\rs 9 ord] to avoid ! likely onset ( an em]g5cy m$ical condition4 4 #ijb4 ,preemption ( ,/ate laws limit+ *>ges = eligible pr(essional s]vices 7a7 ,9 g5]al ,no ,/ate may impose a limit on ! am\nt ( *>ges = s]vices1 furni%$ by an eligible pr(essional 7z def9$ 9 subsection 7k77#c77;,b7 ( section #ahdh ( ! ,social ,security ,act1 #db ,u4,s4,c4 #aciew-#d71 = :i* paym5t is made "u su* section1 & any su* limit is h]eby preempt$4 7b7 ,/ate ,9 ?is section1 ! t]m ,/ate includes ! ,di/rict ( ,columbia1 ,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1 & ,am]ican ,samoa4 #ijc4 ,heal? c>e provid] lic5sure _c be condition$ on p>ticipation 9 a heal? plan 7a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices & any ,/ate 7z a condition ( receiv+ ,f$]al f9ancial p>ticipation "u title ,,xix ( ! ,social ,security ,act7 may n require any heal? c>e provid] to p>ticipate 9 any heal? plan z a condition ( lic5sure ( ! provid] 9 any ,/ate4 7b7 ,def9itions ,9 ?is section3 7#a7 ,heal? plan ,! t]m heal? plan has ! mean+ giv5 su* t]m 9 section #aaga7e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d7#e774 7#b7 ,heal? c>e provid] ,! t]m heal? c>e provid] means any p]son or entity t is requir$ by ,/ate or ,f$]al laws or regulations to be lic5s$1 regi/]$1 or c]tifi$ to provide heal? c>e s]vices & is s lic5s$1 regi/]$1 or c]tifi$1 or exempt$ f su* requirem5t by o!r /atute or regulation4 7#c7 ,/ate ,! t]m ,/ate has ! mean+ giv5 su* t]m = purposes ( title ,,xix ( ! ,social ,security ,act4 #ijd4 ,bad debt d$uction = doctors to p>tially (fset ! co/ ( provid+ uncomp5sat$ c>e requir$ to be provid$ "u am5dm5ts made by ! ,em]g5cy ,m$ical ,treatm5t & ,labor ,act 7a7 ,9 g5]al ,section #aff ( ! ,int]nal ,rev5ue ,code ( #aihf 7relat+ to bad debts7 is am5d$ by r$esignat+ subsection 7f7 z subsection 7g7 & by ins]t+ aft] subsection 7e7 ! foll[+ new subsection3 7f7 ,bad debt treatm5t = doctors ,to p>tially (fset co/ ( provid+ uncomp5sat$ c>e requir$ ,to be provid$ 7#a7 ,am\nt ( d$uction 7,a7 ,9 g5]al ,= purposes ( subsection 7a71 ! basis = det]m9+ ! am\nt ( any d$uction = an eligible ,,emtala debt %all be treat$ z be+ equal to ! ,m$ic>e paym5t am\nt4 7,b7 ,m$ic>e paym5t am\nt ,= purposes ( subp>agraph 7,a71 ! ,m$ic>e paym5t am\nt ) respect to an eligible ,,emtala debt is ! fee s*$ule am\nt e/abli%$ "u section #ahdh ( ! ,social ,security ,act = ! physicians' s]vice 7to :i* su* debt relates7 z if ! s]vice 7 provid$ to an individual enroll$ "u "p ,b ( title ,,xviii ( su* ,act4 7#b7 ,eligible ,,emtala debt ,= purposes ( ?is section1 ! t]m eligible ,,emtala debt means any debt if-- 7,a7 su* debt arose z a result ( physicians' s]vices-- 7i7 :i* 7 p]=m$ 9 an ,,emtala hospital by a bo>d-c]tifi$ physician 7:e!r z "p ( m$ical scre5+ or necess>y /abiliz+ treatm5t & :e!r z an em]g5cy dep>tm5t physician1 z an on-call physician1 or o!rwise71 & 7ii7 :i* 7 requir$ to be provid$ "u section #ahfg ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;dd71 & 7,b7 su* debt is ow$-- 7i7 to su* physician1 or 7ii7 to an entity if-- 7,i7 su* entity is a corporation & ! sole %>ehold] ( su* corporation is su* physician1 or 7,,ii7 su* entity is a p>tn]%ip & any d$uction "u ?is subsection ) respect to su* debt is allocat$ to su* physician or to an entity describ$ 9 subclause 7,i74 7#c7 ,bo>d-c]tifi$ physician ,= purposes ( ?is subsection1 ! t]m bo>d-c]tifi$ physician means any physician 7z def9$ 9 section #ahfa7r7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7r777 :o is c]tifi$ by ! ,am]ican ,bo>d ( ,em]g5cy ,m$ic9e or o!r appropriate m$ical specialty bo>d = ! specialty 9 :i* ! physician practices1 or :o meets comp>able requirem5ts1 z id5tifi$ by ! ,secret>y ( ! ,treasury 9 consultation ) ,secret>y ( ,heal? & ,human ,s]vices4 7#d7 ,o!r def9itions ,= purposes ( ?is subsection-- 7,a7 ,,emtala hospital ,! t]m ,,emtala hospital means any hospital hav+ a hospital em]g5cy dep>tm5t :i* is requir$ to comply ) section #ahfg ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;dd7 7relat+ to exam9ation & treatm5t = em]g5cy m$ical conditions & wom5 9 labor74 7,b7 ,physicians' s]vices ,! t]m physicians' s]vices has ! mean+ giv5 su* t]m 9 section #ahfa7q7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7q774 4 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply to debts aris+ f s]vices p]=m$ 9 taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #ije4 ,"r ( contract ) heal? c>e provid]s 7a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices %all n preclude an enrollee1 p>ticipant1 or b5efici>y 9 a heal? b5efits plan f ent]+ into any contract or arrangem5t = heal? c>e ) any heal? c>e provid]4 7b7 ,heal? b5efits plan def9$ 7#a7 ,9 g5]al ,9 ?is section1 subject to p>agraph 7#b71 ! t]m heal? b5efits plan means any ( ! foll[+3 7,a7 ,a gr\p heal? plan 7z def9$ 9 section #bgia ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;g-#a774 7,b7 ,heal? insurance cov]age 7z def9$ 9 section #bgia ( su* ,act 7#db ,u4,s4,c4 #cjj;g-#a774 7,c7 ,a heal? b5efits plan "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code4 7#b7 ,exclusion ( ,m$icaid & ,tric>e ,su* t]m does n include a heal? plan p>ticipat+ 9-- 7,a7 ! ,m$icaid program "u title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq472 or 7,b7 ! ,,tric>e program "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code4 7c7 ,heal? c>e provid] def9$ ,9 ?is section1 ! t]m heal? c>e provid] means-- 7#a7 a physician1 z def9$ 9 p>agraphs 7#a71 7#b71 7#c71 & 7#d7 ( section #ahfa7r7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7r772 & 7#b7 a heal? c>e practition] describ$ 9 section #ahdb7;b77#ah77;,c7 ( su* ,act 7#db ,u4,s4,c4 #acieu7b77#ah77;,c774 ,x ,quality ,heal? ,c>e ,coalition #ajja4 ,quality ,heal? ,c>e ,coalition 7a7 ,application ( ! ,f$]al antitru/ laws to heal? c>e pr(essionals negotiat+ ) heal? plans 7#a7 ,9 g5]al ,any heal? c>e pr(essionals :o are engag$ 9 negotiations ) a heal? plan reg>d+ ! t]ms ( any contract "u :i* ! pr(essionals provide heal? c>e items or s]vices = :i* b5efits are provid$ "u su* plan %all1 9 connection ) su* negotiations1 be exempt f ! ,f$]al antitru/ laws4 7#b7 ,limitation 7,a7 ,no new "r = collective cessation ( s]vice ,! exemption provid$ 9 p>agraph 7#a7 %all n conf] any new "r to p>ticipate 9 any collective cessation ( s]vice to pati5ts n already p]mitt$ by exi/+ law4 7,b7 ,no *ange 9 ,national ,labor ,relations ,act ,?is section applies only to heal? c>e pr(essionals exclud$ f ! ,national ,labor ,relations ,act4 ,no?+ 9 ?is section %all be con/ru$ z *ang+ or am5d+ any provision ( ! ,national ,labor ,relations ,act1 or z affect+ ! /atus ( any gr\p ( p]sons "u t ,act4 7#c7 ,no application to ,f$]al programs ,no?+ 9 ?is section %all apply to negotiations betwe5 heal? c>e pr(essionals & heal? plans p]ta9+ to b5efits provid$ "u any ( ! foll[+3 7,a7 ,! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq474 7,b7 ,! ,m$icaid program "u title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq474 7,c7 ,! ,/ate ,*ildr5's ,heal? ,insurance ,program "u title ,,xxi ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acig;aa et seq474 7,d7 ,*apt] #ee ( title #aj1 ,unit$ ,/ates ,code 7relat+ to m$ical & d5tal c>e = memb]s ( ! uni=m$ s]vices74 7,e7 ,*apt] #ag ( title #ch1 ,unit$ ,/ates ,code 7relat+ to ,vet]ans' m$ical c>e74 7,f7 ,*apt] #hi ( title #e1 ,unit$ ,/ates ,code 7relat+ to ! ,f$]al ,employees ,heal? ,b5efits program74 7,g7 ,! ,indian ,heal? ,c>e ,improvem5t ,act 7#be ,u4,s4,c4 #afja et seq474 7b7 ,def9itions ,9 ?is section1 ! foll[+ def9itions %all apply3 7#a7 ,antitru/ laws ,! t]m antitru/ laws-- 7,a7 has ! mean+ giv5 x 9 subsection 7a7 ( ! fir/ section ( ! ,clayton ,act 7#ae ,u4,s4,c4 #ab7;a771 except t su* t]m includes section #e ( ! ,f$]al ,trade ,commission ,act 7#ae ,u4,s4,c4 #de7 to ! ext5t su* section applies to unfair me?ods ( competition2 & 7,b7 includes any ,/ate law simil> to ! laws ref]r$ to 9 subp>agraph 7,a74 7#b7 ,gr\p heal? plan ,! t]m gr\p heal? plan means an employee welf>e b5efit plan to ! ext5t t ! plan provides m$ical c>e 7includ+ items & s]vices paid = z m$ical c>e7 to employees or _! dep5d5ts 7z def9$ "u ! t]ms ( ! plan7 directly or ?r\gh insurance1 reimbursem5t1 or o!rwise4 7#c7 ,gr\p heal? plan1 heal? insurance issu] ,! t]ms gr\p heal? plan & heal? insurance issu] include a ?ird-p>ty adm9i/rator or o!r p]son act+ = or on behalf ( su* plan or issu]4 7#d7 ,heal? c>e s]vices ,! t]m heal? c>e s]vices means any s]vices = :i* paym5t may be made "u a heal? plan1 includ+ s]vices relat$ to ! deliv]y or adm9i/ration ( su* s]vices4 7#e7 ,heal? c>e pr(essional ,! t]m heal? c>e pr(essional means any individual or entity t provides heal? c>e items or s]vices1 treatm5t1 assi/ance ) activities ( daily liv+1 or m$ications to pati5ts & :o1 to ! ext5t requir$ by ,/ate or ,f$]al law1 possesses specializ$ tra9+ t conf]s exp]tise 9 ! provision ( su* items or s]vices1 treatm5t1 assi/ance1 or m$ications4 7#f7 ,heal? insurance cov]age ,! t]m heal? insurance cov]age means b5efits consi/+ ( m$ical c>e 7provid$ directly1 ?r\gh insurance or reimbursem5t1 or o!rwise & includ+ items & s]vices paid = z m$ical c>e7 "u any hospital or m$ical s]vice policy or c]tificate1 hospital or m$ical s]vice plan contract1 or heal? ma9t5ance organization contract (f]$ by a heal? insurance issu]4 7#g7 ,heal? insurance issu] ,! t]m heal? insurance issu] means an insurance company1 insurance s]vice1 or insurance organization 7includ+ a heal? ma9t5ance organization7 t is lic5s$ to engage 9 ! bus9ess ( insurance 9 a ,/ate & t is subject to ,/ate law regulat+ insurance4 ,su* t]m does n include a gr\p heal? plan4 7#h7 ,heal? ma9t5ance organization ,! t]m heal? ma9t5ance organization means-- 7,a7 a f$]ally qualifi$ heal? ma9t5ance organization 7z def9$ 9 section #acja7;a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;e7a7772 7,b7 an organization recogniz$ "u ,/ate law z a heal? ma9t5ance organization2 or 7,c7 a simil> organization regulat$ "u ,/ate law = solv5cy 9 ! same mann] & to ! same ext5t z su* a heal? ma9t5ance organization4 7#i7 ,heal? plan ,! t]m heal? plan means a gr\p heal? plan or a heal? insurance issu] t is (f]+ heal? insurance cov]age4 7#aj7 ,m$ical c>e ,! t]m m$ical c>e means am\nts paid =-- 7,a7 ! diagnosis1 cure1 mitigation1 treatm5t1 or prev5tion ( disease1 or am\nts paid = ! purpose ( affect+ any /ructure or function ( ! body2 & 7,b7 transportation prim>ily = & ess5tial to receiv+ items & s]vices ref]r$ to 9 subp>agraph 7,a74 7#aa7 ,p]son ,! t]m p]son includes a ,/ate or unit ( local gov]nm5t4 7#ab7 ,/ate ,! t]m ,/ate includes ! sev]al ,/ates1 ! ,di/rict ( ,columbia1 ,pu]to ,rico1 ! ,virg9 ,isl&s ( ! ,unit$ ,/ates1 ,guam1 ,am]ican ,samoa1 & ! ,commonweal? ( ! ,nor!rn ,m>iana ,isl&s4 7c7 ,effective date ,?is section %all take effect on ! date ( ! enactm5t ( ?is ,act & %all n apply ) respect to conduct occurr+ be=e su* date4