,,ii #aadth ,,congress #b;d ,session ,s4 #bihe ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,may #be1 #bjaf,mr4 ,cassidy introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to eliminate the individual and employer health coverage mandates under the ,patient ,protection and ,affordable ,care ,act1 to expand beyond that ,act the choices in obtaining and financing affordable health insurance coverage1 and for other purposes4 #a4 ,short title2 purposes2 table of contents 7a7 ,short title ,this ,act may be cited as the ,world's ,greatest ,healthcare ,plan ,act of #bjaf4 7b7 ,purposes ,the purposes of this ,act are as follows3 7#a7 ,elimination of individual and employer mandates under ,,aca ,to eliminate mandates on individuals and employers1 and other tax requirements1 imposed under ,patient ,protection and ,affordable ,care ,act4 7#b7 ,providing ,states with alternative1 affordable coverage options ,to provide greater flexibility in providing ,states with options in making affordable health insurance coverage available by eliminating certain mandates under ,,ppaca1 while retaining essential consumer protections1 by promoting health savings accounts to pay for such coverage and long-term care coverage1 while permitting ,states to continue coverage as provided under ,,ppaca4 7c7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 purposes2 table of contents4 ,sec4 #b4 ,definitions4 ,,title ,i--,revisions of ,,ppaca ,subtitle ,a--,elimination of ,individual and ,employer ,mandates ,sec4 #aja4 ,repeal of individual health insurance mandate4 ,sec4 #ajb4 ,repeal of employer health insurance mandate4 ,sec4 #ajc4 ,clarifying employer's ability to reimburse employee premiums for purchase of individual health insurance coverage4 ,subtitle ,b--,limitation on ,application of ,,ppaca ,plan ,requirements ,sec4 #aba4 ,limiting application of requirements to consumer protections4 ,sec4 #abb4 ,offering of basic health insurance2 protection of assets from liability or attachment or seizure4 ,subtitle ,c--,universal ,health ,insurance ,tax ,benefit ,sec4 #aca4 ,universal health insurance tax benefit4 ,sec4 #acb4 ,application of portion of unused tax credits by ,states for indigent health care4 ,sec4 #acc4 ,medicaid option of enrollment under private plan and contribution to an ,,hsa4 ,,title ,,ii--,improving ,health ,savings ,accounts to ,promote ,accountability ,sec4 #bja4 ,transition to non-deductible ,h,s,as4 ,sec4 #bjb4 ,elimination of medical expense deduction4 ,sec4 #bjc4 ,treatment of ,,hsa after death of account beneficiary4 ,sec4 #bjd4 ,treatment of direct primary care4 ,,title ,,iii--,state flexibility in regulation of health insurance coverage ,sec4 #cja4 ,state flexibility in regulation of health insurance coverage4 ,,title ,,iv--,medicaid ,payment ,reform ,sec4 #dja4 ,medicaid payment reform4 ,,title ,v--,increasing ,price ,transparency and ,freedom of ,practice ,sec4 #eja4 ,ensuring access to emergency services without excessive charges for out-of-network services4 ,sec4 #ejb4 ,publishing of cash price for care paid through health savings accounts4 ,sec4 #ejc4 ,liberating the local practice of health care4 #b4 ,definitions ,except as otherwise provided1 in this ,act3 7#a7 ,basic health insurance ,the term basic health insurance has the meaning given such term in section #abb7;a74 7#b7 ,default health insurance coverage ,the term default health insurance coverage has the meaning given such term in section #aba7;b77#d77;,b74 7#c7 ,exchange ,the term ,exchange means an ,exchange established under title ,i of ,,ppaca4 7#d7 ,health insurance coverage2 group health plan1 etc ,the terms defined in section #bgia of the ,public ,health ,service ,act1 including health insurance coverage1 group health planindividual market1 shall apply4 7#e7 ,limited benefit insurance ,the term limited benefit insurance has the meaning given such term in section #abb7;b74 7#f7 ,,ppaca ,the term ,,ppaca means the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh74 7#g7 ,secretary ,the term ,secretary means the ,secretary of ,health and ,human ,services4 7#h7 ,state ,the term ,state includes the ,district of ,columbia1 ,puerto ,rico1 the ,united ,states ,virgin ,islands1 ,american ,samoa1 ,guam1 and the ,northern ,mariana ,islands4 ,i ,revisions of ,,ppaca ,a ,elimination of ,individual and ,employer ,mandates #aja4 ,repeal of individual health insurance mandate ,section #ejjj;,a of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7h7 ,termination ,this section shall not apply with respect to any month beginning more than #cj days after the date of the enactment of the ,world's ,greatest ,healthcare ,plan ,act of #bjaf4 4 #ajb4 ,repeal of employer health insurance mandate 7a7 ,in general ,chapter #dc of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 by striking section #dihj;,h2 and 7#b7 by striking the item relating to section #dihj;,h from the table of sections for such chapter4 7b7 ,repeal of related reporting requirements ,subpart ,d of part ,,iii of subchapter ,a of chapter #fa of such ,code is amended by striking section #fjef and by striking the item relating to section #fjef in the table of sections for such subpart4 7c7 ,conforming amendments 7#a7 ,section #fgbd7;d77#a77;,b7 of such ,code is amended-- 7,a7 by inserting or at the end of clause 7xxiii72 7,b7 by striking 1 or at the end of clause 7xxiv7 and inserting a period2 and 7,c7 by striking clause 7xxv74 7#b7 ,section #fgbd7;d77#b7 of such ,code is amended by inserting or at the end of subparagraph 7,,gg71 by striking subparagraph 7,,hh71 and by redesignating subparagraph 7,,ii7 as subparagraph 7,,hh74 7#c7 ,section #aeac of the ,patient ,protection and ,affordable ,care ,act is amended by striking subsection 7c74 7d7 ,effective dates 7#a7 ,in general ,except as otherwise provided in this subsection1 the amendments made by this section shall apply to months and other periods beginning more than #cj days after the date of the enactment of this ,act4 7#b7 ,repeal of study and report ,the amendment made by subsection 7c77#c7 shall take effect on the date of the enactment of this ,act4 #ajc4 ,clarifying employer's ability to reimburse employee premiums for purchase of individual health insurance coverage ,an employer health care arrangement1 such as a health or medical reimbursement arrangement or other employment plans1 under which an employer reimburses an employee for the premiums for the purchase of individual health insurance coverage does not constitute a group health plan for any purposes1 including for purposes of applying any of the following3 7#a7 ,the ,public ,health ,service ,act 7including sections #bgaa and #bgad of such ,act 7#db ,u4,s4,c4 #cjj;gg-#aa1 #cjj;gg-#ad774 7#b7 ,the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh74 7#c7 ,the ,internal ,revenue ,code of #aihf4 7#d7 ,the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #ajja et seq474 7#e7 ,the ,,hipaa privacy regulations 7as defined in section #aahj7;b77#c7 of the ,social ,security ,act1 #db ,u4,s4,c4 #acbj;d-#i7;b77#c774 7#f7 ,the ,health ,insurance ,portability and ,accountability ,act of #aiif 7,public ,law #ajd-aia74 7#g7 ,,cobra continuation coverage under title ,,xxii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;bb-#a et seq471 section #dihj;,b of the ,internal ,revenue ,code of #aihf1 or part #f of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aafa et seq474 ,b ,limitation on ,application of ,,ppaca ,plan ,requirements #aba4 ,limiting application of requirements to consumer protections 7a7 ,removal of ,,ppaca plan requirements1 other than certain consumer protections 7#a7 ,in general ,notwithstanding any other provision of law1 with respect to group health plans and health insurance coverage whether or not offered through an ,exchange1 except as provided in paragraphs 7#b7 and 7#c71 the provisions of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 as in effect before the date of the enactment of ,,ppaca shall apply instead of the provisions of such title as in effect after such date4 7#b7 ,,ppaca consumer protections continuing to be applied ,the following sections of the ,public ,health ,service ,act1 that were added or amended by subtitles ,a and ,c of title ,i of ,,ppaca1 shall continue to apply to group health plans and to health insurance coverage offered in the individual and group market3 7,a7 ,no lifetime or annual limits ,section #bgaa 7relating to no lifetime or annual limits71 except in the case of limited benefit insurance 7as defined in section #abb7;b774 7,b7 ,dependent coverage through age #bf ,section #bgad 7relating to extension of dependent coverage74 7,c7 ,modified guaranteed availability ,section #bgjb 7relating to guaranteed availability of coverage71 subject to paragraph 7#c7 and subsection 7c74 7,d7 ,guaranteed renewability ,section #bgjc 7relating to guaranteed renewability of coverage74 7,e7 ,prohibiting pre-existing condition exclusions ,section #bgjd 7relating to prohibition on preexisting conditions74 7,f7 ,prohibiting discrimination based on health status ,section #bgje 7relating to prohibiting discrimination against individual participants and beneficiaries based on health status71 subject to subsection 7c74 7,g7 ,non-discrimination in health care ,section #bgjf 7relating to non-discrimination in health care74 7#c7 ,application of a late enrollment penalty for those without continuous coverage 7,a7 ,in general ,in the case of an individual who seeks to enroll in health insurance coverage and who1 as of the effective date of such enrollment1 does not have a continuous period of at least #ab-months of creditable coverage1 there shall be imposed a late enrollment penalty in the form of an increase in the monthly premiums for coverage of under the plan of #bj percent of the monthly premium otherwise determined for each consecutive full #ab-month period 7ending before such effective date7 in which the individual was not enrolled in creditable coverage4 ,such increase shall apply during a period1 to be specified under regulations of the ,secretary but in no case longer than #c times the length of the most recent period in which the individual did not have continuous coverage4 7,b7 ,state waiver ,a ,state may apply to the ,secretary for a waiver of the provisions of subparagraph 7,a7 and the application of alternative provisions providing incentives for ,state residents to enroll in creditable coverage and maintain continuous creditable coverage4 ,the ,secretary shall approve such waiver if the ,secretary determines that the alternative provisions provide similar or greater incentives for such enrollment than the incentives otherwise applicable4 7#d7 ,coordinating implementation of pre-,,ppaca ,,phsa provisions with ,,ppaca consumer protections 7,a7 ,in general ,in applying this subsection1 the provisions described in paragraph 7#b7 shall be treated as if they were included in title ,,xxvii of the ,public ,health ,service ,act1 as in effect on the day before the date of enactment of ,,ppaca1 and1 with respect to group health plans and health insurance coverage offered in connection with such plans1 in part #g of subtitle ,b of title ,i of the ,employee ,retirement and ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aha et seq471 and1 with respect to group health plans1 in chapter #ajj of the ,internal ,revenue ,code of #aihf as follows3 7i7 ,lifetime limits2 dependent coverage ,the provisions described in paragraphs 7#b77;,a7 and 7#b77;,b7 shall be treated as included-- 7,i7 with respect to group health plans 7and health insurance coverage offered with respect to such plans71 under subpart #b of part ,a of title ,,xxvii of the ,public ,health ,service ,act and subpart ,b of part #g of subtitle ,b of title ,i of the ,employee ,retirement and ,income ,security ,act of #aigd2 7,,ii7 with respect to group health plans1 under subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf2 and 7,,iii7 with respect to individual health insurance coverage1 under subpart #b of part ,b of title ,,xxvii of the ,public ,health ,service ,act4 7ii7 ,remaining provisions ,the provision described in paragraph 7#b7 7other than in subparagraph 7,a7 or 7,b7 of such paragraph7 shall be treated as included-- 7,i7 with respect to group health plans 7and health insurance coverage offered with respect to such plans71 under subpart #a of part ,a of title ,,xxvii of the ,public ,health ,service ,act and subpart ,a of part #g of subtitle ,b of title ,i of the ,employee ,retirement and ,income ,security ,act of #aigd2 7,,ii7 also with respect to group health plans1 under subchapter ,a of chapter #ajj of the ,internal ,revenue ,code of #aihf2 and 7,,iii7 with respect to individual health insurance coverage1 under subpart #a of part ,b of title ,,xxvii of the ,public ,health ,service ,act4 7,b7 ,conflicting provisions ,in the case described in paragraph 7#a7 where there is a conflict between a provision described in paragraph 7#b7 and a provision of law described in paragraph 7#a71 the provision described in paragraph 7#b7 shall control and the ,secretary1 in consultation with the ,secretary of the ,treasury and the ,secretary of ,labor1 shall establish such rules as may be necessary to carry out this subparagraph4 7#e7 ,conforming amendments 7,a7 ,,erisa ,section #gae of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe;d7 is amended-- 7i7 in subsection 7a71 by striking subsection 7b7 and inserting subsections 7b7 and 7c72 and 7ii7 by adding at the end the following new subsection3 7c7 ,additional exception ,pursuant to section #aba of the ,world's ,greatest ,healthcare ,plan ,act of #bjaf1 the provisions of part ,a of title ,,xxvii of the ,public ,health ,service ,act referred to in subsection 7a71 other than those provisions specified in section #aba7;a77#b7 of the ,world's ,greatest ,healthcare ,plan ,act of #bjaf1 shall not apply to plans and coverage described in subsection 7a71 whether or not the plans or coverage are offered through an ,exchange established under the ,patient ,protection and ,affordable ,care ,act4 4 7,b7 ,,irc ,section #ihae of the ,internal ,revenue ,code of #aihf is amended-- 7i7 in subsection 7a71 by striking subsection 7b7 and inserting subsections 7b7 and 7c72 and 7ii7 by adding at the end the following new subsection3 7c7 ,additional exception ,pursuant to section #aba of the ,world's ,greatest ,healthcare ,plan ,act of #bjaf1 the provisions of part ,a of title ,,xxvii of the ,public ,health ,service ,act referred to in subsection 7a71 other than those provisions specified in section #aba7;a77#b7 of the ,world's ,greatest ,healthcare ,plan ,act of #bjaf1 shall not apply to plans described in subsection 7a74 4 7b7 ,state flexibility in ensuring orderly health insurance market outside of an ,exchange 7#a7 ,in general ,with respect to health insurance coverage offered in a ,state1 the ,state may1 in consultation with the ,secretary1 take such steps1 such as limiting the availability of general open enrollment periods1 imposing delays in the effectiveness for coverage1 permitting differentials in premiums based on age and other factors1 as the ,state determines necessary in order to ensure an orderly market for health insurance coverage in the ,state that is not offered through an ,exchange4 ,such steps may include the establishment of such initial open enrollment period during which qualified residents may enroll in health insurance coverage without the imposition of any underwriting as the ,state determines to be appropriate in ensuring initial access to such coverage4 7#b7 ,flexibility in imposing additional requirements ,nothing in this section shall be construed as preventing a ,state from continuing to apply1 to health insurance coverage issued in the ,state1 requirements under the provisions of title ,,xxvii of the ,public ,health ,service ,act 7as amended by subtitles ,a and ,c of title ,i of ,,ppaca7 that are not continued under subsection 7a74 7#c7 ,state flexibility with respect to ,exchanges ,a ,state may waive such provisions of part #b of subtitle ,d of title ,i of ,,ppaca1 in relation to the establishment of an ,exchange in such ,state1 as the ,state determines appropriate in order for the ,state to implement and administer a market-based system for the availability of health insurance coverage throughout the ,state4 7#d7 ,state default enrollment option 7,a7 ,enrollment1 subject to individual opt-,out ,subject to subparagraph 7,d71 a ,state may elect to provide for the enrollment of residents of the ,state who are uninsured in default health insurance coverage 7as defined in subparagraph 7,b77 and establishing a ,roth ,,hsa for such residents who do not have a ,roth ,,hsa unless the resident has affirmatively elected not to be so enrolled and not to have such an account4 respectively4 ,if a ,state makes such an election1 the ,state shall permit eligible residents to enroll in such coverage on a continuous basis4 7,b7 ,default health insurance coverage defined ,in this paragraph1 the term default health insurance coverage means1 with respect to a ,state1 health insurance coverage that-- 7i7 is a high deductible health plan 7within the meaning of section #bbc7;c77#b7 of the ,internal ,revenue ,code of #aihf7 with prescription drug coverage limited to generic drugs for a limited number of chronic conditions 7commonly referred to as tier ,i pharmacy benefit72 7ii7 meets such requirements as may apply to qualify for the payment of plan premiums from a health savings account under section #bbc of such ,code 7such as age-related premiums and limitation on imposition of preexisting condition exclusions72 7iii7 has a provider network for covered benefits that is adequate 7as determined consistent with guidelines issued by the ,secretary7 to ensure access to health benefits under such plan2 7iv7 provides for coverage of childhood immunizations without cost sharing requirements to the extent such immunizations have in effect a recommendation from the ,advisory ,committee on ,immunization ,practices of the ,centers for ,disease ,control and ,prevention with respect to the individual involved2 and 7v7 meets such other requirements as the ,state may specify4 7,c7 ,roth ,,hsa ,in this paragraph1 the term ,roth ,,hsa shall have the meaning given such term by section #ecj;,a7c7 of the ,internal ,revenue ,code of #aihf4 7,d7 ,simple process for individuals to opt-out ,as a condition of a ,state providing for the enrollment function described in subparagraph 7,a71 the ,state shall establish an easy-to-use and transparent means by which individuals may elect not to be enrolled in default health insurance coverage or to have a ,roth ,,hsa established on the individual's behalf1 or both4 7c7 ,inapplicability of required essential health benefits 7#a7 ,in general ,notwithstanding any other provision of law1 no health benefits plan shall be required by reason of ,federal law to comply with the requirements of sections #acja7;a77#a77;,b7 and #acjb of ,,ppaca 7#db ,u4,s4,c4 #ahjba7;a77#a77;,b71 #ahjbb74 7#b7 ,state flexibility ,nothing in this subsection shall be construed as preventing a ,state from applying1 at its option with respect to health insurance coverage offered through an ,exchange or otherwise in the ,state1 the requirements referred to in paragraph 7#a74 7d7 ,effective date2 transition 7#a7 ,in general ,subsections 7a71 7b71 and 7c7 shall apply to plan years beginning after the date of the enactment of this ,act4 7#b7 ,sunsetting required contribution for ,,aca reinsurance program ,no contribution shall be required under section #acda of ,,ppaca 7#db ,u4,s4,c4 #ahjfa7 from any group health plan or health insurance issuer for portions of plans years occurring in months beginning more than #cj days after the date of the enactment of this ,act4 7e7 ,secretarial guidance ,the ,secretary of ,health and ,human ,services1 in coordination with the ,secretary of ,labor and the ,secretary of the ,treasury1 shall provide such guidance as may be necessary for the coordinated implementation of this section on a timely basis4 7f7 ,transferring health plan records upon changing plans 7#a7 ,in general ,in the case of an individual who is covered under health insurance coverage or as a beneficiary or participant in a group health plan 7as such terms are defined in section #bgia of the ,public ,health ,service ,act71 if such coverage is ended and the individual obtains other health insurance coverage1 group health plan coverage1 or other creditable coverage 7as defined for purposes of title ,,xxvii of such ,act71 the issuer of the prior coverage or administrator of the prior plan shall forward information respecting such prior coverage to the issuer of the new coverage or administrator of the new plan or coverage1 as the case may be1 subject to such rules as the ,secretary establishes regarding the right of the beneficiary or participant to object to such forwarding of information4 7#b7 ,treatment as plan requirement under ,,phsa1 ,,erisa1 ,,irc ,the requirement of paragraph 7#a7 shall apply as if it were included in part ,a of title ,,xxvii of the ,public ,health ,service ,act1 including for purposes of applying section #gae of the ,employee ,retirement ,income ,security ,act of #aigf 7#bi ,u4,s4,c4 #aahe;d7 and section #ihae of the ,internal ,revenue ,code of #aihf4 7g7 ,application of risk adjustment 7#a7 ,in general ,any issuer that offers health insurance coverage in the individual market in any of the #ej ,states or the ,district of ,columbia shall participate in a risk adjustment mechanism under this subsection with respect to any health insurance coverage it so offers in such market1 whether or not such coverage is offered through an ,exchange4 7#b7 ,form and design of risk adjustment mechanism ,the ,secretary shall1 in consultation with the ,national ,association of ,insurance ,commissioners and other interested parties1 develop a mechanism to permit the adjustment of risk among health insurance coverage offered in the individual market throughout the #ej ,states and the ,district of ,columbia4 ,such mechanism shall be designed to effect the same type of risk adjustment among such coverage that is applicable to risk adjustment of payments among ,medicare ,advantage organizations under part ,c of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba et seq474 7#c7 ,transition for new coverage ,the mechanism developed under paragraph 7#b7 shall provide for transitional protection1 over a #c-year period1 in the case of health insurance coverage that has not been previously marketed4 7#d7 ,development of further risk adjustment mechanism ,the ,secretary shall request the ,national ,association of ,insurance ,commissioners to develop a permanent model for adjustment of risk among health insurance issuers with respect to health insurance coverage offered in the individual market1 with the intention that such a model would substitute for the mechanism developed under paragraph 7#b74 7#e7 ,treatment as plan requirement under ,,phsa1 ,,erisa1 ,,irc ,the requirement of paragraph 7#a7 shall apply as if it were included in part ,a of title ,,xxvii of the ,public ,health ,service ,act1 including for purposes of applying section #gae of the ,employee ,retirement ,income ,security ,act of #aigf 7#bi ,u4,s4,c4 #aahe;d7 and section #ihae of the ,internal ,revenue ,code of #aihf4 #abb4 ,offering of basic health insurance2 protection of assets from liability or attachment or seizure 7a7 ,requirement for ,exchanges 7#a7 ,in general ,no tax credit shall be allowable under section #cf;,b or #cf;,c of the ,internal ,revenue ,code of #aihf for residents of a ,state unless any ,exchange established in the ,state provides for the offering of basic health insurance in all areas of the ,state4 7#b7 ,basic health insurance defined ,in this subsection1 the term basic health insurance means1 with respect to a ,state1 such health insurance coverage as the ,state may specify and includes limited benefit insurance 7as defined in subsection 7b774 7b7 ,limited benefit insurance defined 7#a7 ,in general ,in this section1 the term limited benefit insurance means individual health insurance coverage that1 with respect to a plan year1 imposes 7consistent with paragraph 7#b77 an annual limit on the amounts that may be payable under the coverage with respect to expenses incurred for items and services furnished in that plan year4 7#b7 ,specification of annual limit2 variation in limit for individual and family coverage ,the ,secretary shall specify1 from year to year1 the annual limit 7or range of annual limits7 that may be applied under paragraph 7#a74 ,such a limit may distinguish between coverage that is only provided for an individual and coverage that is provided also for family members of the individual4 7c7 ,protection of certain assets in case of individuals covered under limited benefit insurance 7#a7 ,in general ,notwithstanding any other provision of law1 if an individual is covered under limited benefit insurance for a plan year and benefits under such insurance have reached the annual limit under such insurance for items and services furnished in the plan year1 the individual is not liable for debt incurred and arising from the provision of subsequently furnished items and services during the plan year1 regardless of whether benefits are otherwise covered for such items and services under such policy1 insofar as the liability attributable to such items and services exceeds-- 7,a7 the bankruptcy valuation of the individual's property at the time the debt is incurred2 reduced by 7,b7 such annual limit of benefits under the limited benefit insurance for the plan year4 ,property in the amount so protected from liability shall be exempt and immune from attachment or seizure with respect to any judgment related to such debt4 7#b7 ,bankruptcy valuation defined ,in this subsection1 the term bankruptcy valuation means1 with respect to property of an individual as of a date1 the value of the property as of such date as determined as if the individual were a debtor in a bankruptcy case that could have been filed under title #aa of the ,united ,states ,code and the property could not be exempt under section #ebb of such title4 7#c7 ,no requirement for providers to furnish subsequent services without ensuring payment ,except as may be explicitly provided in other law 7such as under section #ahfg of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;dd71 popularly known as ,,emtala71 a health care provider is not required to furnish any items or services to an individual who has exhausted benefits under limited benefit insurance for a plan year without the individual 7or another person on the individual's behalf7 providing for such advance or guarantee of payment for such items and services as may be arranged between the health care provider and the individual4 ,c ,universal ,health ,insurance ,tax ,benefit #aca4 ,universal health insurance tax benefit 7a7 ,in general ,subpart ,c of part ,,iv of subchapter ,a of chapter #a of the ,internal ,revenue ,code of #aihf is amended by inserting after section #cf;,b the following new section3 #cf;,c4 ,universal health insurance tax credit 7a7 ,in general ,in the case of a taxpayer who is a qualified resident1 there shall be allowed as a credit against the tax imposed by this subtitle for any taxable year an amount equal to the universal health credit amount of the taxpayer for the taxable year4 7b7 ,universal health credit amount ,for purposes of this section-- 7#a7 ,in general ,the term universal health credit amount means the sum of the amounts determined under paragraph 7#b7 with respect to all months of the taxpayer for the taxable year4 7#b7 ,monthly credit amount 7,a7 ,in general ,subject to paragraph 7#c71 the amount determined under this paragraph with respect to any month shall be an amount equal to the sum of-- 7i7 #a_/ab of #b1ejj in the case of any month the first day of which the taxpayer is a qualified resident and is covered by creditable coverage 7twice such amount in the case of a joint return if both spouses are so covered by creditable coverage and are qualified residents71 plus 7ii7 #a_/ab of an amount equal to #a1ejj multiplied by the number of qualifying children 7within the meaning of section #aeb7;c77 who are qualified residents and-- 7,i7 for whom the taxpayer is allowed a deduction under section #aea for the taxable year in which such month ends1 and 7,,ii7 who are covered by creditable coverage on the first day of such month4 7,b7 ,carryforward of monthly credit amount in case credit amount exceeds ,,hsa contributions and premium payments ,in the case of any month for which the credit amount determined with respect to the taxpayer under subparagraph 7,a7 exceeds the limitation amount determined with respect to the taxpayer for such month under paragraph 7#c71 such excess may be carried forward to any subsequent month during the taxable year for purposes of determining the credit amount for such month under this paragraph4 7#c7 ,monthly limitation 7,a7 ,in general ,the amount determined under paragraph 7#b7 for any month of the taxpayer shall not exceed the sum of-- 7i7 the amounts contributed to a health savings account of the taxpayer for such month1 plus 7ii7 the premiums paid by the taxpayer for creditable coverage4 7,b7 ,carryforward of monthly limitation in case ,,hsa contributions and premium payments exceed monthly credit amount ,in the case of any month for which the amount determined with respect to the taxpayer under subparagraph 7,a7 exceeds the credit amount determined with respect to the taxpayer for such month under paragraph 7#b71 such excess may be carried forward to any subsequent month during the taxable year for purposes of determining the limitation under subparagraph 7,a74 7#d7 ,adjustment for limited benefit insurance ,in the case of a taxpayer whose only health insurance coverage for a month is limited benefit insurance 7as defined in section #abb7;b7 of the ,world's ,greatest ,healthcare ,plan ,act of #bjaf71 the amount determined under paragraph 7#b7 shall be decreased by such proportion as the ,secretary1 in consultation with the ,secretary of ,health and ,human ,services1 determines appropriate1 taking into account the ratio of the actuarial value of such limited benefit insurance to the average actuarial value of health insurance coverage that is not limited benefit insurance4 7#e7 ,adjustment for geographic area and age of covered individual ,the amount determined under paragraph 7#b7 shall be adjusted1 in a manner specified by the ,secretary1 in consultation with and based on data collected by the ,secretary of ,health and ,human ,services1 to take into account the age and area of residence of a taxpayer or other covered individual based on the ratio of the average cost of typical individual health insurance coverage for an individual of such age and residing in such area to the national average cost of such typical health insurance coverage4 ,such adjustment shall be made in a manner so that the application of this paragraph is estimated not to change the aggregate amount of the credits allowable under this section for taxable years ending in a year4 7c7 ,coordination with employer-,provided health insurance tax subsidy 7#a7 ,credit limited by employer-provided health insurance tax subsidy ,the credit allowed under this section for any taxable year shall not exceed an amount equal to the excess 7if any7 of-- 7,a7 the maximum credit which would be allowed for all months of the taxpayer during the taxable year 7determined under subsection 7b77#b7 and without regard to this subsection1 the limitation under subsection 7b77#c71 and any reduction under subsection 7d77#a771 over 7,b7 the taxpayer's employer-provided health insurance tax subsidy for the taxable year4 7#b7 ,recapture of excess employer-provided health insurance tax subsidy ,in the case of a taxpayer for whom the amount described in subparagraph 7,b7 of paragraph 7#a7 exceeds the amount described in subparagraph 7,a7 of such paragraph for any taxable year1 the credit allowed under this section shall be treated as zero and the tax imposed by this chapter for the taxable year shall be increased by the amount of such excess4 7#c7 ,employer-provided health insurance tax subsidy ,for purposes of this subsection-- 7,a7 ,in general ,the term employer-provided health insurance tax subsidy means1 with respect to any taxpayer for a taxable year1 the sum of-- 7i7 the ,federal income tax subsidy of the taxpayer for the taxable year1 plus 7ii7 the ,federal payroll tax subsidy of the taxpayer for the taxable year4 7,b7 ,federal income tax subsidy ,the term ,federal income tax subsidy means1 with respect to any taxpayer for the taxable year1 the excess 7if any7 of-- 7i7 the amount of tax that would have been imposed by this chapter for the taxable year had such tax been determined without regard to this section and by including amounts otherwise excluded from gross income which were paid by or on behalf of the taxpayer for employer-provided insurance that constitutes medical care1 over 7ii7 the amount of tax imposed by this chapter for the taxable year 7determined without regard to this section74 7,c7 ,federal payroll tax subsidy ,the term ,federal payroll tax subsidy means1 with respect to any taxpayer for the taxable year1 the excess 7if any7 of-- 7i7 the sum of-- 7,i7 the amount of tax that would have been imposed by chapter #ba with respect to any wages of the taxpayer paid during the taxable year had such tax been determined by including amounts otherwise excluded from wages which were paid by or on behalf of the taxpayer during the taxable year for employer-provided insurance that constitutes medical care1 plus 7,,ii7 the amount of tax that would have been imposed by chapter #b on any self-employment income of the taxpayer for such taxable year had self-employment income been determined without regard to any deduction from gross income for amounts paid for insurance which constitutes medical care for the taxpayer1 the taxpayer's spouse1 and any qualifying children 7within the meaning of section #aeb7 for whom the taxpayer is allowed a deduction under section #aea for the taxable year1 over 7ii7 the amount of tax imposed with respect to the taxpayer during such taxable year under chapter #ba and for such taxable year under chapter #b4 7#d7 ,no credit or recapture for insurance provided by employer electing exclusion regime ,in the case of an individual who for any month is covered by insurance that constitutes medical care and that is provided by an employer with respect to which an election is in effect for such month under section #aca7;b7 of the ,world's ,greatest ,healthcare ,plan ,act of #bjaf-- 7,a7 the monthly credit amount determined under subsection 7b77#b7 for such month with respect to such individual shall be zero1 and 7,b7 such month shall not be taken into account for purposes of determining any recapture under paragraph 7#b7 with respect to such individual4 7d7 ,reconciliation of credit and advance credit 7#a7 ,in general ,the amount of the credit allowed under this section for any taxable year 7after the application of subsections 7b7 and 7c77 shall be reduced 7but not below zero7 by the amount of any advance payment of such credit under subsection 7e77#a74 7#b7 ,excess advance payments 7,a7 ,in general ,if the advance payments to a taxpayer under subsection 7e77#a7 for a taxable year exceed the credit allowed by this section 7determined without regard to paragraph 7#a771 the tax imposed by this chapter for the taxable year shall be increased by the amount of such excess4 7,b7 ,limitation on increase ,in the case of a taxpayer whose household income is less than #djj percent of the poverty line for the size of the family involved for the taxable year1 the amount of the increase under subparagraph 7,a7 shall not exceed the applicable dollar amount determined in accordance with the following table 7one-half of such amount in the case of a taxpayer whose tax is determined under section #a7;c7 for the taxable year73 ,if the household income 7expressed as a percent of poverty line7 is3,the applicable dollar amount is3,less than #bjjfjj;,at least #bjj but less than #cjja1ejj;,at least #cjj but less than #djjb1ejj 7e7 ,special rules ,for purpose of this section-- 7#a7 ,advance payment program 7,a7 ,in general ,the ,secretary of the ,treasury1 in consultation with the ,secretary of ,health and ,human ,services1 shall establish a program-- 7i7 to make advance determinations with respect to the eligibility of individuals for the credit allowed under this section1 and 7ii7 to make advance payments of the credit allowed under this section1 at the election of any such individual so eligible1 directly to the health savings account of any such individual1 or1 as a subsidy to the cost of health insurance coverage provided to any such individual1 to the health insurance issuer providing such coverage or the person that administers the plan benefits with respect to such coverage4 7,b7 ,program requirements ,such program shall be established under rules similar to the rules of section #adab of the ,patient ,protection and ,affordable ,care ,act1 as in effect on the day before the date of the enactment of this section1 except that advance determinations and advance payments shall be made on request of the individual with respect to whom the determination is to be made4 7#b7 ,information requirements 7,a7 ,in general ,each person providing insurance coverage which constitutes medical care1 and each trustee of a health savings account1 shall provide the following information to the ,secretary and to the taxpayer with respect to such coverage or such account3 7i7 ,the total premium for the coverage without regard to the credit under this section4 7ii7 ,the aggregate amount of any advance payment of such credit made with respect to such coverage or to such account4 7iii7 ,the name1 address1 age1 and ,,tin of the primary insured or account holder 7as the case may be7 and the name1 age1 and ,,tin of each other individual obtaining coverage under such policy of insurance4 7iv7 ,any information provided to such person necessary to determine eligibility for1 and the amount of1 such credit4 7v7 ,information necessary to determine whether a taxpayer has received excess advance payments4 7,b7 ,exception ,subparagraph 7,a7 shall not apply to any coverage with respect to which reporting under section #fjea is required4 7#c7 ,indexing 7,a7 ,in general ,in the case of any calendar year beginning after #bjaf1 each of the dollar amounts in subsection 7b77#b7 and in the table contained under subsection 7d77#b77;,b7 shall be equal to such dollar amount multiplied by the ratio of-- 7i7 the current dollar gross domestic product 7as determined based on the third estimate of the ,bureau of ,economic ,analysis of the ,department of ,commerce for the second quarter of the previous year71 to 7ii7 the current dollar gross domestic product 7as so determined7 for the second quarter of #bjae4 7,b7 ,rounding ,if any dollar amount adjusted under subparagraph 7,a7 is not a multiple of #ej1 such amount shall be rounded to the next lowest multiple of #ej4 7f7 ,definitions ,for purposes of this section-- 7#a7 ,creditable coverage ,the term creditable coverage has the meaning given such term for purposes of title ,,xxvii of the ,public ,health ,service ,act4 7#b7 ,qualified resident ,the term qualified resident means an individual who is a citizen or national of the ,united ,states or otherwise lawfully residing in the ,united ,states under color of law4 4 7b7 ,election by employer ,to make excise tax applicable and ,to be governed solely by exclusion regime 7#a7 ,in general ,if an eligible employer makes the election under this subsection 7at such time and in such form and manner as the ,secretary shall prescribe7 the tax imposed by section #dihj;,i of the ,internal ,revenue ,code of #aihf shall apply to any excess benefit with respect to employer-sponsored health coverage provided by such employer and the credit and recapture under section #cf;,c of such ,code shall not apply with respect to individuals covered by such coverage4 ,such election1 once made1 may be revoked only with the consent of the ,secretary4 7#b7 ,eligible employer ,for purposes of this subsection1 the term eligible employer means an employer in existence before the date of the enactment of this ,act4 7#c7 ,controlled groups ,for purposes of this subsection1 all persons treated as a single employer under subsection 7a7 or 7b7 of section #eb of the ,internal ,revenue ,code of #aihf or subsection 7m7 or 7o7 of section #dad of such ,code shall be treated as a single eligible employer4 7#d7 ,regulations ,the ,secretary of the ,treasury shall prescribe such regulations as may be necessary to prevent the avoidance of the purposes of this subsection4 7c7 ,excise tax on high cost employer-,sponsored health insurance only ,to apply to employers making election ,section #dihj;,i7d77#a77;,b7 of such ,code 7relating to exceptions7 is amended by striking or at the end of clauses 7i7 and 7ii71 by striking the period at the end of clause 7iii7 and inserting 1 or1 and by adding at the end the following new clause3 7iv7 any group health plan made available by an employer which does not have in effect an election under section #aca7;b7 of the ,world's ,greatest ,healthcare ,plan ,act of #bjaf4 4 7d7 ,disqualification from ,exchange plan subsidies for individual once they elect tax benefits ,section #cf;,b7c77#a7 of such ,code is amended by adding at the end the following new subparagraph3 7,e7 ,denial of credit for those electing universal credit ,in the case of an individual who is allowed a credit under section #cf;,c for any taxable year1 no credit shall be allowed under this section to such individual for such taxable year or any subsequent taxable year4 4 7e7 ,guidance ,the ,secretary of the ,treasury shall issue such guidance as is necessary-- 7#a7 to assist employees and employers in adjusting ,federal income tax withholding to take into account the universal health insurance tax credit under section #cf;,c of the ,internal ,revenue ,code of #aihf 7and any advance payment thereof71 and 7#b7 to require employers to report to each employee with respect to periods not longer than quarterly the employer-provided health insurance tax subsidy 7as defined in section #cf;,c7c77#c7 of such ,code7 with respect to such employee for such period4 7f7 ,clerical amendment ,the table of sections for subpart ,c of part ,,iv of subchapter ,a of chapter #a of the ,internal ,revenue ,code of #aihf is amended by inserting after the item relating to section #cf;,b the following new item3 ,sec4 #cf;,c4 ,universal health insurance tax credit4 4 7g7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjae4 #acb4 ,application of portion of unused tax credits by ,states for indigent health care 7a7 ,computation of unused credits ,the ,secretary1 in consultation with the ,secretary of the ,treasury1 shall calculate for each ,state for each year1 beginning with #bjag1 using the most recent data available -- 7#a7 the maximum aggregate amount of credits under section #cf;,c of the ,internal ,revenue ,code of #aihf that would have been allowed for the year for qualified residents of the ,state for taxable years ending in the year if all eligible qualified residents had qualified for such credits2 7#b7 the aggregate amount of credits under such section that were allowed for taxable years ending in that year by qualified residents of such ,state2 and 7#c7 #be percent of the amount by which-- 7,a7 the amount determined under paragraph 7#a7 with respect to qualified residents of the ,state for such year2 exceeds 7,b7 the amount determined under paragraph 7#b7 for such ,state for that year4 7b7 ,appropriation ,for the purpose of making grants to ,states under this section1 there is hereby appropriated to the ,secretary1 out of any funds in the ,treasury not otherwise appropriated1 for each year 7beginning with #bjag7 an amount equivalent to the amount determined under subsection 7a77#c7 for all ,states for the year in which such fiscal year ends1 subject to adjustment under subsection 7d77#b74 7c7 ,grants to ,states for indigent assistance 7#a7 ,application ,a ,state may file with the ,secretary 7in a form and manner specified by the ,secretary7 an application to provide assistance in furnishing health services to indigent individuals residing in the ,state4 ,such application shall demonstrate the manner in which such assistance is furnished in an equitable manner to individuals residing in all parts of the ,state4 7#b7 ,amount of funds ,from the funds appropriated under subsection 7b7 for a year1 the amount of funds paid to any ,state in any year under this section with an application filed in accordance with paragraph 7#a7 is equal to an amount specified in the application1 but not to exceed the amount computed under subsection 7a77#c7 for the ,state and the year4 7#c7 ,use of funds ,funds paid to a ,state under this subsection may be used only to assist in the furnishing of health services to uninsured individuals residing in the ,state or for purposes of increasing the payment adjustments made under sections #ahhf7;d77#e77;,f7 and #aibc of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,f71 #acifr-#d7 to hospitals that serve a disproportionate share of such individuals in the ,state4 7d7 ,initial estimate2 final calculation and reconciliation 7#a7 ,use of estimates ,the calculations under subsection 7a7 for a year shall initially be estimated before the beginning of the year4 ,payments under this section to a ,state for a year shall be made1 subject to reconciliation under paragraph 7#b71 based on the amount so estimated4 7#b7 ,reconciliation based on final calculation ,the calculations under subsection 7a7 for a year shall also be made after the end of the year4 ,insofar as the amount calculated under this paragraph for subsection 7a77#c7 for a ,state for a year exceeds 7or is less than7 by a material amount from the amount for subsection 7a77#c7 estimated and applied for the ,state and year under paragraph 7#a71 the amount calculated under subsection 7a77#c7 for the ,state for the #bnd year beginning after such year1 shall be reduced or increased1 respectively by the amount of such excess or deficit4 #acc4 ,medicaid option of enrollment under private plan and contribution to an ,,hsa 7a7 ,in general ,notwithstanding any other provision of law1 a ,state plan under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 may make available to an individual1 who is entitled to medical assistance for a full range of acute care items and services under such title and at the individual's option1 instead of the medical assistance otherwise provided1 medical assistance consisting of coverage under a health plan that qualifies for a tax credit under section #cf;,c of the ,internal ,revenue ,code of #aihf1 but only if1 for each year the individual receives medical assistance in the form of such coverage1 the ,state also deposits into a health savings account for the individual an amount equal to the amount 7if any7 by which the amount of the tax credit for the individual under such section exceeds the cost of coverage of the individual under the plan4 7b7 ,,ffp treatment ,the payments by a ,state described in subsection 7a7 for coverage under a health plan and for deposit into a health savings account shall be treated as medical assistance for purposes of section #aijc of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7 and section #aijc;,a of such ,act 7as added by section #dja7 and subject to ,federal financial participation1 including the application of ,state matching payments1 in the same manner as other medical assistance furnished under title ,,xix of such ,act1 except that such amount shall be reduced by the amount of any health insurance credits provided under section #cf;,c of the ,internal ,revenue ,code of #aihf with respect to such coverage or deposit4 ,,ii ,improving ,health ,savings ,accounts to ,promote ,accountability #bja4 ,transition to non-deductible ,h,s,as 7a7 ,non-,deductible ,h,s,as ,subchapter ,f of chapter #a of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new part3 ,,ix ,health savings accounts ,sec4 #ecj;,a4 ,roth ,h,s,as4 #ecj;,a4 ,roth ,h,s,as 7a7 ,in general ,with the exception of the taxes imposed by section #eaa 7relating to imposition of tax on unrelated business income of charitable organizations71 a ,roth ,,hsa shall be exempt from taxation under this subtitle4 ,no deduction shall be allowed for any contribution to a ,roth ,,hsa4 7b7 ,dollar limitation 7#a7 ,in general ,the aggregate amount of contributions for any taxable year to all ,roth ,h,s,as maintained for the benefit of an individual shall not exceed the sum of the monthly limitations for any month during such taxable year that the individual is an eligible individual4 7#b7 ,monthly limitation ,the monthly limitation for any month is #a_/ab of-- 7,a7 in the case of an eligible individual who has self-only creditable coverage as of the first day of such month1 #e1jjj1 and 7,b7 in the case of an eligible individual who has family creditable coverage as of the first day of such month1 the amount in effect under subparagraph 7,a7 for the taxable year multiplied by the number of individuals 7including the eligible individual7 covered under such family creditable coverage as of such day4 7#c7 ,additional contributions for individuals #ee or older ,in the case of an individual who has attained age #ee before the close of the taxable year1 the applicable limitation under subparagraphs 7,a7 and 7,b7 of paragraph 7#b7 shall be increased by #a1jjj4 7#d7 ,coordination with other contributions ,the limitation which would 7but for this paragraph7 apply under this subsection to an individual for any taxable year shall be reduced 7but not below zero7 by the sum of-- 7,a7 the aggregate amount paid for such taxable year to ,archer ,m,s,as of such individual1 7,b7 the aggregate amount contributed to ,roth ,h,s,as of such individual which is excludable from the taxpayer's gross income for such taxable year under section #ajf7;d7 7and such amount shall not be allowed as a deduction under subsection 7a771 and 7,c7 the aggregate amount contributed to ,roth ,h,s,as of such individual for such taxable year under section #djh7;d77#i7 7and such amount shall not be allowed as a deduction under subsection 7a774 ,subparagraph 7,a7 shall not apply with respect to any individual to whom paragraph 7#e7 applies4 7#e7 ,special rule for married individuals ,in the case of individuals who are married to each other1 if either spouse has family coverage-- 7,a7 both spouses shall be treated as having only such family coverage 7and if such spouses each have family coverage under different plans1 as having the family coverage with the lowest annual deductible71 and 7,b7 the limitation under paragraph 7#a7 7after the application of subparagraph 7,a7 and without regard to any additional contribution amount under paragraph 7#c77-- 7i7 shall be reduced by the aggregate amount paid to ,archer ,m,s,as of such spouses for the taxable year1 and 7ii7 after such reduction1 shall be divided equally between them unless they agree on a different division4 7#f7 ,denial of deduction to dependents ,no contribution may be made to a ,roth ,,hsa under this section by any individual with respect to whom a deduction under section #aea is allowable to another taxpayer for a taxable year beginning in the calendar year in which such individual's taxable year begins4 7#g7 ,medicare eligible individuals ,the limitation under this subsection for any month with respect to an individual shall be zero for the first month such individual is entitled to benefits under title ,,xviii of the ,social ,security ,act and for each month thereafter4 7#h7 ,increase in limit for individuals becoming eligible individuals after the beginning of the year 7,a7 ,in general ,for purposes of computing the limitation under paragraph 7#a7 for any taxable year1 an individual who is an eligible individual during the last month of such taxable year shall be treated-- 7i7 as having been an eligible individual during each of the months in such taxable year1 and 7ii7 as having been enrolled1 during each of the months such individual is treated as an eligible individual solely by reason of clause 7i71 in the same high deductible health plan in which the individual was enrolled for the last month of such taxable year4 7,b7 ,failure to maintain creditable coverage 7i7 ,in general ,if1 at any time during the testing period1 the individual is not an eligible individual1 then-- 7,i7 the gross income of the individual for the taxable year in which occurs the first month in the testing period for which such individual is not an eligible individual shall be increased by the aggregate amount of all contributions to the ,roth ,,hsa of the individual which could not have been made but for subparagraph 7,a71 and 7,,ii7 the tax imposed by this chapter for any taxable year on the individual shall be increased by #aj percent of the amount of such increase4 7ii7 ,exception for disability or death ,clause 7i7 shall not apply if the individual ceased to be an eligible individual by reason of the death of the individual or the individual becoming disabled 7within the meaning of section #gb7m77#g774 7iii7 ,testing period ,the term testing period means the period beginning with the last month of the taxable year referred to in subparagraph 7,a7 and ending on the last day of the #abth month following such month4 7c7 ,roth ,,hsa ,for purposes of this section-- 7#a7 ,in general ,the term ,roth ,,hsa means a trust created or organized in the ,united ,states as a ,roth ,,hsa exclusively for the purpose of paying the qualified medical expenses of the account beneficiary1 but only if the written governing instrument creating the trust meets the following requirements3 7,a7 ,except in the case of a rollover contribution described in subsection 7f77#e7 or section #bbj7;f77#e71 no contribution will be accepted-- 7i7 unless it is in cash1 or 7ii7 to the extent such contribution1 when added to previous contributions to the trust for the calendar year1 exceeds the sum of-- 7,i7 the dollar amount in effect under subsection 7b77#b77;,b71 and 7,,ii7 the dollar amount in effect under subsection 7b77#c74 7,b7 ,the trustee is a bank 7as defined in section #djh7n771 an insurance company 7as defined in section #haf71 or another person who demonstrates to the satisfaction of the ,secretary that the manner in which such person will administer the trust will be consistent with the requirements of this section4 7,c7 ,no part of the trust assets will be invested in life insurance contracts4 7,d7 ,the assets of the trust will not be commingled with other property except in a common trust fund or common investment fund4 7,e7 ,the interest of an individual in the balance in his account is nonforfeitable4 7#b7 ,qualified medical expenses ,for purposes of this section-- 7,a7 ,in general ,the term qualified medical expenses means1 with respect to an account beneficiary1 amounts paid by such beneficiary for medical care 7as defined in section #bac7;d7 as in effect on the day before the date of the enactment of the ,world's ,greatest ,healthcare ,plan ,act of #bjaf7 for such individual1 the spouse of such individual1 and any dependent 7as defined in section #aeb1 determined without regard to subsections 7b77#a71 7b77#b71 and 7d77#a77;,b7 thereof7 of such individual1 but only to the extent such amounts are not compensated for by insurance or otherwise4 7,b7 ,limitation on health insurance purchased from account ,such term shall not include any payment for health benefits coverage that is not creditable coverage 7as defined in section #cf;,c74 7,c7 ,exceptions ,subparagraph 7,b7 shall not apply to any expense for coverage under-- 7i7 a health plan during any period of continuation coverage required under any ,federal law1 7ii7 a qualified long-term care insurance contract 7as defined in section #ggjb;,b7b771 7iii7 a health plan during a period in which the individual is receiving unemployment compensation under any ,federal or ,state law1 or 7iv7 in the case of an account beneficiary who has attained the age specified in section #ahaa of the ,social ,security ,act1 any health insurance other than a medicare supplemental policy 7as defined in section #ahhb of the ,social ,security ,act74 7#c7 ,account beneficiary ,the term account beneficiary means the individual on whose behalf the ,roth ,,hsa was established4 7#d7 ,certain rules to apply ,rules similar to the following rules shall apply for purposes of this section3 7,a7 ,section #bai7;f77#c7 7relating to time when contributions deemed made74 7,b7 ,except as provided in section #ajf7;d71 section #bai7;f77#e7 7relating to employer payments74 7,c7 ,section #djh7;g7 7relating to community property laws74 7,d7 ,section #djh7;h7 7relating to custodial accounts74 7d7 ,eligible individual2 creditable coverage ,for purposes of this section-- 7#a7 ,eligible individual ,the term eligible individual means1 with respect to any month1 any individual who is covered under creditable coverage as of the #ast day of such month4 7#b7 ,creditable coverage ,the term creditable coverage shall have the meaning given such term in section #cf;,c7f77#a74 7e7 ,tax treatment of distributions 7#a7 ,amounts used for qualified medical expenses ,any amount paid or distributed out of a ,roth ,,hsa which is used exclusively to pay qualified medical expenses of any account beneficiary shall not be includible in gross income4 7#b7 ,inclusion of amounts not used for qualified medical expenses ,any amount paid or distributed out of a ,roth ,,hsa which is not used exclusively to pay the qualified medical expenses of the account beneficiary shall be included in the gross income of such beneficiary4 7#c7 ,excess contributions returned before due date of return 7,a7 ,in general ,if any excess contribution is contributed for a taxable year to any ,roth ,,hsa of an individual1 paragraph 7#b7 shall not apply to distributions from the ,roth ,h,s,as of such individual 7to the extent such distributions do not exceed the aggregate excess contributions to all such accounts of such individual for such year7 if-- 7i7 such distribution is received by the individual on or before the last day prescribed by law 7including extensions of time7 for filing such individual's return for such taxable year1 and 7ii7 such distribution is accompanied by the amount of net income attributable to such excess contribution4 ,any net income described in clause 7ii7 shall be included in the gross income of the individual for the taxable year in which it is received4 7,b7 ,excess contribution ,for purposes of subparagraph 7,a71 the term excess contribution means any contribution 7other than a rollover contribution described in paragraph 7#e7 or section #bbj7;f77#e77 which exceeds the contribution limitation with respect to the individual for the taxable year4 7#d7 ,additional tax on distributions not used for qualified medical expenses 7,a7 ,in general ,the tax imposed by this chapter on the account beneficiary for any taxable year in which there is a payment or distribution from a ,roth ,,hsa of such beneficiary which is includible in gross income under paragraph 7#b7 shall be increased by #aj percent of the amount which is so includible4 7,b7 ,exception for disability or death ,subparagraph 7,a7 shall not apply if the payment or distribution is made after the account beneficiary becomes disabled within the meaning of section #gb7m77#g7 or dies4 7,c7 ,exception for distributions after medicare eligibility ,subparagraph 7,a7 shall not apply to any payment or distribution after the date on which the account beneficiary attains the age specified in section #ahaa of the ,social ,security ,act4 7#e7 ,rollover contribution ,an amount is described in this paragraph as a rollover contribution if it meets the requirements of subparagraphs 7,a7 and 7,b74 7,a7 ,in general ,paragraph 7#b7 shall not apply to any amount paid or distributed from a health savings account 7as defined in section #bbc7 or a ,roth ,,hsa to the account beneficiary to the extent the amount received is paid into a ,roth ,,hsa for the benefit of such beneficiary not later than the #fjth day after the day on which the beneficiary receives the payment or distribution4 7,b7 ,limitation ,this paragraph shall not apply to any amount described in subparagraph 7,a7 received by an individual from a health savings account or a ,roth ,,hsa if1 at any time during the #a-year period ending on the day of such receipt1 such individual received any other amount described in subparagraph 7,a7 from a health savings account or ,roth ,,hsa which was not includible in the individual's gross income because of the application of this paragraph4 7#f7 ,transfer of account incident to divorce ,the transfer of an individual's interest in a ,roth ,,hsa to an individual's spouse or former spouse under a divorce or separation instrument described in subparagraph 7,a7 of section #ga7;b77#b7 shall not be considered a taxable transfer made by such individual notwithstanding any other provision of this subtitle1 and such interest shall1 after such transfer1 be treated as a ,roth ,,hsa with respect to which such spouse is the account beneficiary4 7#g7 ,treatment after death of account beneficiary ,if an individual acquires an account beneficiary's interest in a health savings account by reason of the death of the account beneficiary1 such health savings account shall be treated as if the individual were the account beneficiary4 7f7 ,cost-of-,living adjustment 7#a7 ,in general ,in the case of any calendar year beginning after #bjaf1 the #e1jjj dollar amount in subsection 7b77#b7 shall be increased by an amount equal to-- 7,a7 such dollar amount1 multiplied by 7,b7 the cost-of-living adjustment determined under section #a7;f77#c7 for the calendar year1 determined-- 7i7 by substituting calendar year #bjae for calendar year #aiib in subparagraph 7,b7 thereof1 and 7ii7 by substituting ,,cpi medical care component for ,,cpi4 7#b7 ,,cpi medical care component ,for purposes of this paragraph1 the term ,,cpi medical care component means the medical care component for the ,consumer ,price ,index for ,all ,urban ,consumers published by the ,department of ,labor4 7#c7 ,rounding ,if the amount of any increase under the preceding sentence is not a multiple of #ej1 such increase shall be rounded to the next lowest multiple of #ej4 7g7 ,reports ,the ,secretary may require-- 7#a7 the trustee of a ,roth ,,hsa to make such reports regarding such account to the ,secretary and to the account beneficiary with respect to contributions1 distributions1 the return of excess contributions1 and such other matters as the ,secretary determines appropriate1 and 7#b7 any person who provides an individual with creditable coverage to make such reports to the ,secretary and to the account beneficiary with respect to such plan as the ,secretary determines appropriate4 ,the reports required by this subsection shall be filed at such time and in such manner and furnished to such individuals at such time and in such manner as may be required by the ,secretary4 4 7b7 ,limit on contributions to deductible health savings accounts ,section #bbc of such ,code is amended by adding at the end the following new subsection3 7i7 ,limited contributions after #bjaf 7#a7 ,in general ,no contribution may be accepted by a health savings account after ,december #ca1 #bjaf4 7#b7 ,exceptions ,paragraph 7#a7 shall not apply-- 7,a7 in the case of a rollover contribution described in subsection 7f77#e7 or section #bbj7;f77#e71 or 7,b7 in the case of a month for which an individual is covered by insurance that constitutes medical care and that is provided by an employer with respect to which an election is in effect for such month under section #aca7;b7 of the ,world's ,greatest ,healthcare ,plan ,act of #bjaf4 4 7c7 ,clerical amendment ,the table of parts for subchapter ,f of chapter #a of such ,code is amended by adding a the end the following new item3 ,part ,,ix4 ,roth health savings accounts4 7d7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjaf4 #bjb4 ,elimination of medical expense deduction ,section #bac of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7g7 ,termination ,except in the case of long-term care premiums 7as defined in subsection 7d77#aj771 subsection 7a7 shall not apply to any amounts paid during any taxable year beginning after ,december #ca1 #bjae4 4 #bjc4 ,treatment of ,,hsa after death of account beneficiary 7a7 ,in general ,section #bbc7;f77#h7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7#h7 ,treatment after death of account beneficiary ,if an individual acquires an account beneficiary's interest in a health savings account by reason of the death of the account beneficiary1 such health savings account shall be treated as if the individual were the account beneficiary4 4 7b7 ,effective date ,the amendment made by this section shall apply with respect to interests acquired after the date of the enactment of this ,act4 #bjd4 ,treatment of direct primary care 7a7 ,h,s,as 7#a7 ,roth ,,hsa ,section #ecj;,a7c77#b77;,a7 of the ,internal ,revenue ,code of #aihf1 as added by this ,act1 is amended by adding at the end the following3 ,such term shall include the payment of a monthly or other prepaid amount for the furnishing 7or access to the furnishing7 by a physician or group of physicians of physician professional services 7and ancillary services744 7#b7 ,,hsa ,section #bbc7;d77#b77;,a7 of such ,code is amended by adding at the end the following3 ,such term shall include the payment of a monthly or other prepaid amount for the furnishing 7or access to the furnishing7 by a physician or group of physicians of physician professional services 7and ancillary services744 7b7 ,not treated as health insurance coverage 7#a7 ,in general ,for purposes of title ,,xxvii of the ,public ,health ,service ,act1 subtitle ,b of title ,i of the ,employee ,retirement and ,income ,security ,act of #aigd1 ,,ppaca1 and this ,act1 the offering of direct primary care shall not be treated as the offering of health insurance coverage and shall not be subject to regulations as such coverage under such ,acts4 7#b7 ,direct primary care defined ,in this subsection1 the term direct primary care means the furnishing 7or access to the furnishing7 by a physician or group of physicians of physician professional services 7and ancillary services7 in return for payment of a monthly or other prepaid amount4 ,,iii ,state flexibility in regulation of health insurance coverage #cja4 ,state flexibility in regulation of health insurance coverage 7a7 ,in general ,states are given the flexibility under section #abb7;b7 to revise their regulations of the health insurance marketplace1 without regard to many of the requirements imposed under ,,ppaca1 in order to promote freedom of choice of affordable health insurance coverage options offered outside of an ,exchange4 7b7 ,construction ,nothing in the ,employee ,retirement and ,income ,security ,act of #aigd or of any amendments made by the ,health ,insurance ,portability and ,accountability ,act of #aiif shall be interpreted as preventing an employer from offering1 or making an employer contribution towards1 individual health insurance coverage for employees and dependent family members4 ,,iv ,medicaid ,payment ,reform #dja4 ,medicaid payment reform 7a7 ,in general ,title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 is amended by inserting after section #aijc the following section3 #aijc;,a4 ,reformed payment to ,states 7a7 ,reformed payment system 7#a7 ,in general ,for quarters beginning on or after the implementation date 7as defined in subsection 7k77#a771 in lieu of amounts otherwise payable to a ,state under this title 7including any payments attributable to section #aibc71 except as otherwise provided in this section1 the amount payable to such ,state shall be equal to the sum of the following3 7,a7 ,adjusted aggregate beneficiary-based amount ,the aggregate beneficiary-based amount specified in subsection 7b7 for the quarter and the ,state1 adjusted under subsection 7e74 7,b7 ,chronic care quality bonus ,the amount 7if any7 of the chronic care quality bonus payment specified in subsection 7f7 for the quarter for the ,state4 7#b7 ,requirement of ,state share 7,a7 ,in general ,a ,state shall make1 from non-,federal funds1 expenditures in an amount equal to its ,state share 7as determined under subparagraph 7,b77 for a quarter for items1 services1 and other costs for which1 but for paragraph 7#a71 ,federal funds would have been payable under this title4 7,b7 ,state share ,the ,state share for a ,state for a quarter in a fiscal year is equal to the product of-- 7i7 the aggregate beneficiary-based amount specified in subsection 7b7 for the quarter and the ,state2 and 7ii7 the ratio of-- 7,i7 the ,state percentage described in subparagraph 7,d77ii7 for such ,state and fiscal year2 to 7,,ii7 the ,federal percentage described in subparagraph 7,d77i7 for such ,state and fiscal year4 7,c7 ,nonpayment for failure to pay state share 7i7 ,in general ,if a ,state fails to expend the amount required under subparagraph 7,a7 for a quarter in a fiscal year1 the amount payable to the ,state under paragraph 7#a7 shall be reduced by the product of the amount by which the ,state payment is less than the ,state share and the ratio of-- 7,i7 the ,federal percentage described in subparagraph 7,d77i7 for such ,state and fiscal year2 to 7,,ii7 the ,state percentage described in subparagraph 7,d77ii7 for such ,state and fiscal year4 7ii7 ,grace period ,a ,state shall not be considered to have failed to provide payment of its required ,state share for a quarter under subparagraph 7,a7 if the aggregate ,state payment towards the ,state's required ,state share for the #d-quarter period beginning with such quarter exceeds the required ,state share amount for such #d-quarter period4 7,d7 ,federal and ,state percentages ,in this paragraph1 with respect to a ,state and a fiscal year3 7i7 ,federal percentage ,the ,federal percentage described in this clause is #ge percent or1 if higher1 the ,federal medical assistance percentage for such ,state for such fiscal year4 7ii7 ,state percentage ,the ,state percentage described in this clause is #ajj percent minus the ,federal percentage described in clause 7i74 7,e7 ,rules for crediting toward ,state share 7i7 ,general limitation to matchable expenditures ,a payment for expenditures shall not be counted toward the ,state share under subparagraph 7,a7 unless ,federal payments may be used for such expenditures consistent with paragraph 7#c77;,b74 7ii7 ,further limitations on allowable expenditures ,a payment for expenditures shall not be counted towards the ,state share under subparagraph 7,a7 if the expenditure is for any of the following3 7,i7 ,abortion ,expenditures for an abortion4 7,,ii7 ,intergovernmental transfers ,an expenditure that is attributable to an intergovernmental transfer4 7,,iii7 ,certified public expenditures ,an expenditure that is attributable to certified public expenditures4 7iii7 ,crediting fraud and abuse recoveries ,amounts recovered by a ,state through the operation of its ,medicaid fraud and abuse control unit described in section #aijc7q7 shall be fully counted toward the ,state share under subparagraph 7,a74 7,f7 ,construction ,nothing in the paragraph shall be construed as preventing a ,state from expending1 from non-,federal funds1 an amount under this title in excess of the amount of the ,state share4 7,g7 ,determination based upon submitted claims ,in applying this paragraph with respect to expenditures of a ,state for a quarter1 the determination of the expenditures for such ,state for such quarter shall be made after the end of the period 7which1 as of the date of the enactment of this section1 is #b years7 for which the ,secretary accepts claims for payment under this title with respect to such quarter4 7#c7 ,use of ,federal payments 7,a7 ,application of ,medicaid limitations ,a ,state may only use ,federal payments received under subsection 7a7 for expenditures for which ,federal funds would have been payable under this title but for this section4 7,b7 ,limitation for certain eligibles 7i7 ,application of #ajj percent federal poverty line limit on eligibility ,subject to clause 7iii71 a ,state may not use such ,federal payments to provide medical assistance for an individual who has an income 7as determined under clause 7ii77 that exceeds #ajj percent of the poverty line 7as defined in section #baaj7;c77#e77 applicable to a family of the size involved4 7ii7 ,determination of income using modified adjusted gross income without any #e percent increase ,in determining income for purposes of clause 7i7 under section #aijb7;e77#ad7 7relating to modified adjusted gross income71 the following rules shall apply3 7,i7 ,application of spend down ,the ,state shall take into account the costs incurred for medical care or for any other type of remedial care recognized under ,state law in the same manner and to the same extent that such ,state takes such costs into account for purposes of section #aijb7;a77#ag74 7,,ii7 ,disregard of #e percent increase ,subparagraph 7,i7 of section #aijb7;e77#ad7 7relating to a #e percent reduction7 shall not apply4 7iii7 ,exception ,clause 7i7 shall not apply to an individual who is-- 7,i7 a woman described in clause 7i7 of section #aijc7v77#d77;,a72 7,,ii7 a child who is an individual described in clause 7i7 of section #aije7;a72 7,,iii7 enrolled in a ,state plan under this title as of the date of the enactment of this section for the period of continuous enrollment2 or 7,,iv7 described in section #aijb7;e77#ad77;,d7 7relating to modified adjusted gross income74 7iv7 ,clarification related to community spouse ,nothing in this subparagraph shall supersede the application of section #aibd 7related to community spouse income and assets74 7#d7 ,exceptions for pass-through payments 7,a7 ,in general ,paragraph 7#a7 shall not apply1 and amounts shall continue to be payable under this title 7and not under this subsection71 in the case of the following payments 7and related administrative costs and expenditures73 7i7 ,payments to territories ,payments to a ,state other than the #ej ,states and the ,district of ,columbia4 7ii7 ,medicare cost sharing ,payments attributable to ,medicare cost sharing under section #aije7p74 7iii7 ,pediatric vaccines ,payments attributable to section #aibh4 7iv7 ,emergency services for certain individuals ,payments for treatment of emergency medical conditions attributable to the application of section #aijc7v77#b74 7v7 ,indian health care facilities ,payments for medical assistance described in the third sentence of section #aije7;b74 7vi7 ,employer-sponsored insurance 7,,esi7 ,payments for medical assistance attributable to payments to employers for employer-sponsored health benefits coverage4 7vii7 ,other populations with limited benefit coverage ,other payments that are determined by the ,secretary to be related to a specified population for which the medical assistance under this title is limited and does not include any inpatient1 nursing facility1 or long-term care services4 7,b7 ,certain expenses ,paragraph 7#a7 shall not apply1 and amounts shall continue to be payable under this title 7and not under this subsection71 in the case of the following3 7i7 ,administration of medicare prescription drug benefit ,expenditures described in section #aice7;b7 7relating to administration of the ,medicare prescription drug benefit74 7ii7 ,payments for ,,hit bonuses ,payments under section #aijc7;a77#c77;,f7 7relating to payments to encourage the adoption and use of certified ,,ehr technology74 7iii7 ,payments for design1 development1 and installation of ,,mmis and eligibility systems ,payments under subparagraphs 7,a77i7 and 7,h77i7 of section #aijc7;a77#c7 for expenditures for design1 development1 and installation of the ,medicaid management information systems and mechanized verification and information retrieval systems 7related to eligibility74 7#e7 ,payment of amounts 7,a7 ,in general ,except as the ,secretary may otherwise provide1 amounts shall be payable to a ,state under this subsection in the same manner as amounts are payable under subsection 7d7 of section #aijc to a ,state under subsection 7a7 of such section4 7,b7 ,information and forms 7i7 ,submission ,as a condition of receiving payment under this subsection1 a ,state shall submit such information1 in such form1 and manner1 as the ,secretary shall specify1 including information necessary to make the computations under subsections 7c77#b77;,c7 and 7e74 7ii7 ,uniform reporting ,the ,secretary shall develop such forms as may be needed to assure a system of uniform reporting of such information across ,states4 7,c7 ,required reporting of information on medical loss ratios for managed care ,the information required to be reported under subparagraph 7,b77i7 shall include information on the medical loss ratio with respect to coverage provided under each ,medicaid managed care plan with a contract with the ,state under section #aijc7m7 or #aicb4 7b7 ,aggregate beneficiary-,based amount 7#a7 ,in general ,the aggregate beneficiary-based amount specified in this subsection for a ,state for a quarter is equal to the sum of the products1 for each of the categories of ,medicaid beneficiaries specified in paragraph 7#b71 of the following3 7,a7 ,beneficiary-based quarterly amount ,the beneficiary-based quarterly amount for such category computed under subsection 7c7 for such ,state for such quarter4 7,b7 ,number of individuals in category ,subject to subsection 7d71 the average number of ,medicaid beneficiaries enrolled in such category in the ,state in such quarter4 7#b7 ,categories ,the categories specified in this paragraph are the following3 7,a7 ,elderly ,a category of ,medicaid beneficiaries who are #fe years of age or older4 7,b7 ,blind or disabled ,a category of ,medicaid beneficiaries not described in subparagraph 7,a7 who are described in section #aicg7;a77#b77;,b77ii74 7,c7 ,children ,a category of ,medicaid beneficiaries not described in subparagraph 7,b7 who are under #ba years of age4 7,d7 ,other adults ,a category of any ,medicaid beneficiaries who are not described in a previous subparagraph of this paragraph4 7c7 ,computation of per beneficiary1 per category quarterly amount 7#a7 ,in general ,for a ,state1 for each category of beneficiary for a quarter-- 7,a7 ,first reform year ,for quarters in the first reform year 7as defined in subsection 7k77#b771 the beneficiary-based quarterly amount is equal to #a_/d of the base average per beneficiary ,federal payments for such ,state for such category determined under paragraph 7#b71 increased by a factor that reflects the sum of the following3 7i7 ,historical medical care component of ,,cpi through previous reform year ,the percentage increase in the historical medical care component of the ,consumer ,price ,index for all urban consumers 7,u4,s4 city average7 from the midpoint of the base fiscal year 7as defined in paragraph 7#f77 to the midpoint of the fiscal year preceding the first reform year4 7ii7 ,projected medical care component of ,,cpi for the first reform year ,the percentage increase in the projected medical care component of the ,consumer ,price ,index for all urban consumers 7,u4,s4 city average7 from the midpoint of the previous fiscal year referred to in clause 7i7 to the midpoint of the first reform year4 7,b7 ,second and third reform years ,the beneficiary-based quarterly amount for a ,state for a category for quarters in the second reform year or the third reform year is equal to the beneficiary-based quarterly amount under this paragraph for such ,state and category for the previous reform year increased by the per beneficiary percentage increase 7as defined in subparagraph 7,e77 for such category and reform year4 7,c7 ,fourth through tenth reform years ,the beneficiary-based quarterly amount for a ,state for a category for quarters in a reform year beginning with the fourth reform year and ending with the tenth reform year is-- 7i7 in the case of a ,state that is a high per beneficiary ,state or a low per beneficiary ,state 7as defined in paragraph 7#d77;,b77iii77 for the category1 the amount determined under clause 7i7 or 7ii7 of paragraph 7#d77;,b7 for such ,state1 category1 and reform year2 or 7ii7 in the case of any other ,state1 the beneficiary-based quarterly amount under this paragraph for such ,state and category for the previous reform year increased by the per beneficiary percentage increase for such category and reform year4 7,d7 ,eleventh reform year and subsequent reform years ,the beneficiary-based quarterly amount for a ,state for a category for quarters in a reform year beginning with the eleventh reform year is equal to the beneficiary-based quarterly amount under this paragraph for such ,state and category for the previous reform year increased by the per beneficiary percentage increase for such category and reform year4 7,e7 ,annual percentage increase beginning with second reform year ,for purposes of this subsection1 the term per beneficiary percentage increase means1 for a reform year1 the sum of-- 7i7 the projected percentage change_/increase1 if any1 in nominal gross domestic product from the midpoint of the previous reform year to the midpoint of the reform year for which the percentage increase is being applied2 and 7ii7 one percentage point4 7#b7 ,base per beneficiary1 per category amount for each ,state 7,a7 ,average per category 7i7 ,in general ,the ,secretary shall determine1 consistent with this paragraph and paragraph 7#c71 a base per beneficiary1 per category amount for each of the #ej ,states and the ,district of ,columbia equal to the average amount1 per ,medicaid beneficiary1 of ,federal payments under this title1 including payments attributable to disproportionate share hospital payments under section #aibc1 for each of the categories of beneficiaries under subsection 7b77#b7 for the base fiscal year for each of the #ej ,states and the ,district of ,columbia4 7ii7 ,best available data ,the determination under clause 7i7 shall initially be estimated by the ,secretary1 based upon the best available data at the time the determination is made4 7iii7 ,updates ,the determination under clause 7i7 shall be updated by the ,secretary on an annual basis based upon improved data4 ,the ,secretary shall adjust the amounts under subsection 7a77#a77;,a7 to reflect changes in the amounts so determined based on such updates4 7,b7 ,exclusion of pass-through payments ,in computing base per beneficiary1 per category amounts under subparagraph 7,a77i7 the ,secretary shall exclude payments described in subsection 7a77#d74 7,c7 ,standardization 7i7 ,in general ,in computing each such amount1 the ,secretary shall standardize the amount in order to remove the variation attributable to the following3 7,i7 ,risk factors ,such risk factors as age1 health and disability status 7including high cost medical conditions71 gender1 institutional status1 and such other factors as the ,secretary determines to be appropriate1 so as to ensure actuarial equivalence4 7,,ii7 ,geographic ,variations in costs on a county-by-county basis4 7ii7 ,method of standardization 7,i7 ,consultation in development of risk standardization ,in developing the methodology for risk standardization for purposes of clause 7i77,i71 the ,secretary shall consult with the ,medicaid and ,,chip ,payment and ,access ,commission1 the ,medicare ,payment ,advisory ,commission1 and the ,national ,association of ,medicaid ,directors4 7,,ii7 ,method for risk standardization ,in carrying out clause 7i77,i71 the ,secretary may apply the hierarchal condition category methodology under section #ahec7;a77#a77;,c74 ,if the ,secretary uses such methodology1 the ,secretary shall adjust the application of such methodology to take into account the differences in services provided under this title compared to title ,,xviii1 such as the coverage of long-term care1 pregnancy1 and pediatric services4 7,,iii7 ,method for geographic standardization ,the ,secretary shall apply the standardization under clause 7i77,,ii7 in a manner similar to that applied under section #ahec7;c77#d77;,a77iii74 7iii7 ,application on a national1 budget neutral basis ,the standardization under clause 7i7 shall be designed and implemented on a uniform national basis and shall be budget neutral so as to not result in any aggregate change in payments under subsection 7a74 7iv7 ,response to new risk ,subject to clause 7iii71 the ,secretary may adjust the standardization under clause 7i7 to respond promptly to new instances of communicable diseases and other public health hazards4 7v7 ,reference to application of risk adjustment ,for rules related to the application of risk adjustment to amounts under subsection 7a77#a77;,a71 see subsection 7e74 7,d7 ,adjustment for temporary ,,fmap increases ,in computing each base per beneficiary1 per category amounts under subparagraph 7,a77i7 the ,secretary shall disregard portions of payments that are attributable to a temporary increase in the ,federal matching rates1 including those attributable to the following3 7i7 ,,ppaca disaster ,,fmap ,section #aije7;aa74 7ii7 ,,arra ,section #ejja of the ,american ,recovery and ,reinvestment ,act of #bjji 7#db ,u4,s4,c4 #acif;d note74 7iii7 ,extraordinary employer pension contribution ,section #fad of the ,children's ,health ,insurance ,program ,reauthorization ,act of #bjji 7#db ,u4,s4,c4 #acif;d note74 7#c7 ,allocation of nonmedical assistance payments ,the ,secretary shall establish rules for the allocation of payments under this title 7other than those payments described in paragraph 7#a7 or 7#e7 of section #aijc7;a7 and including such payments attributable to section #aibc7-- 7,a7 among different categories of beneficiaries2 and 7,b7 between payments included under subsection 7a77#a7 and payments described in subsection 7a77#d74 7#d7 ,transition to a corridor around the national average 7,a7 ,determination of national average base per beneficiary1 per category amount ,subject to subparagraph 7,c71 the ,secretary shall determine a national average base per beneficiary1 per category amount equal to the average of the base per beneficiary1 per category amounts for each of the #ej ,states and the ,district of ,columbia determined under paragraph 7#b71 weighted by the average number of beneficiaries in each such category and ,state as determined by the ,secretary consistent with subsection 7d7 for the base fiscal year4 7,b7 ,transition adjustment 7i7 ,high per beneficiary states ,in the case of a high per beneficiary ,state 7as defined in clause 7iii77,i77 for a category1 the beneficiary-based quarterly amount for such ,state and category for a quarter in a reform year 7beginning with the fourth reform year and ending with the tenth reform year7 is equal to the sum of-- 7,i7 the product of the ,state-specific factor for such reform year 7as defined in clause 7iv77 and the beneficiary-based quarterly amount that would otherwise be determined under paragraph 7#a7 for such ,state and category if the ,state were a ,state described in clause 7ii7 of paragraph 7#a77;,c71 instead of a ,state described in clause 7i7 of such paragraph2 and 7,,ii7 the product of #a minus the ,state-specific factor for such reform year and the beneficiary-based quarterly amount that would otherwise be determined under paragraph 7#a7 for a ,state and category if the base per beneficiary1 per category amount determined under paragraph 7#b7 for the ,state and category were equal to #aaj percent of the national average base per beneficiary1 per category amount determined under subparagraph 7,a7 for such category4 7ii7 ,low per beneficiary states ,in the case of a low per beneficiary ,state 7as defined in clause 7iii77,,ii77 for a category1 the beneficiary-based quarterly amount for such ,state and category for a quarter in a reform year 7beginning with the fourth reform year and ending with the tenth reform year7 is equal to the sum of-- 7,i7 the product of the ,state-specific factor for such reform year and the beneficiary-based quarterly amount that would otherwise be determined under paragraph 7#a7 for such ,state and category if the ,state were a ,state described in clause 7ii7 of paragraph 7#a77;,c71 instead of a ,state described in clause 7i7 of such paragraph2 and 7,,ii7 the product of #a minus the ,state-specific factor for such reform year and the beneficiary-based quarterly amount that would otherwise be determined under paragraph 7#a7 for a ,state and category if the base per beneficiary1 per category amount determined under paragraph 7#b7 for the ,state and category were equal to #ij percent of the national average base per beneficiary1 per category amount determined under subparagraph 7,a7 for such category4 7iii7 ,high and low per beneficiary ,states defined ,in this subparagraph3 7,i7 ,high per beneficiary ,state ,the term high per beneficiary ,state means1 with respect to a category1 a ,state for which the base per beneficiary1 per category amount determined under paragraph 7#b7 for such category is greater than #aaj percent of the national average base per beneficiary1 per category amount determined under subparagraph 7,a7 for such category4 7,,ii7 ,low per beneficiary ,state ,the term low per beneficiary ,state means1 with respect to a category1 a ,state for which the base per beneficiary1 per category amount determined under paragraph 7#b7 for such category is less than #ij percent of the national average base per beneficiary1 per category amount determined under subparagraph 7,a7 for such category4 7iv7 ,state-specific factor ,in this subparagraph1 the term ,state-specific factor means-- 7,i7 for the fourth reform year1 #g_/h2 and 7,,ii7 for a subsequent reform year1 the ,state-specific factor under this clause for the previous reform year minus #a_/h4 7,c7 ,no additional expenditures 7i7 ,determination of increase in ,federal expenditures ,for each category for each reform year 7beginning with the fourth reform year and ending with the tenth reform year71 the ,secretary shall determine whether the application of this paragraph-- 7,i7 to the category for the reform year will result in an aggregate increase in the aggregate ,federal expenditures under subsection 7a72 and 7,,ii7 to all the categories for the reform year will result in a net aggregate increase in the aggregate ,federal expenditures under subsection 7a74 7ii7 ,adjustment ,if the ,secretary determines under clause 7i77,,ii7 that the application of this paragraph to all the categories for a reform year will result in a net aggregate increase in the aggregate ,federal expenditures under subsection 7a71 the ,secretary shall reduce the national average base per beneficiary1 per category amount computed under subparagraph 7,a7 for each of the categories determined under clause 7i77,i7 for which there will be an aggregate increase in the aggregate ,federal expenditures under subsection 7a7 by such uniform percentage as will ensure that there is no net aggregate ,federal expenditure increase described in clause 7i77,,ii7 for the reform year4 7#e7 ,reports on per beneficiary rates2 appeals 7,a7 ,report to states ,not later than #h months after the date of the enactment of this section1 the ,secretary shall submit to each ,state the ,secretary's initial determination of-- 7i7 the base per beneficiary1 per category amounts under paragraph 7#b7 for such ,state2 and 7ii7 the national average base per beneficiary1 per category amounts under paragraph 7#d77;,a74 7,b7 ,opportunity to appeal ,not later than #c months after the date a ,state receives notice of the ,secretary's initial determination of such base per beneficiary1 per category amounts for such ,state under subparagraph 7,a77i71 the ,state may file with the ,secretary1 in a form and manner specified by the ,secretary1 an appeal of such determination4 7,c7 ,determination on appeal ,not later than #c months after receiving such an appeal1 the ,secretary shall make a final determination on such amounts for such ,state4 ,if no such appeal is received for a ,state1 the ,secretary's initial determination under subparagraph 7,a77i7 shall become final4 7#f7 ,base fiscal year defined ,in this section1 the term base fiscal year means the latest fiscal year1 ending before the date of the enactment of this section1 for which the ,secretary determines that adequate data are available to make the computations required under this subsection4 7d7 ,not counting individuals ,to account for excluded payments ,under rules specified by the ,secretary1 individuals shall not be counted as ,medicaid beneficiaries for purposes of subsection 7b77#a77;,b7 and subsection 7c77#b77;,a7 in proportion to the extent that such individuals are receiving medical assistance for which payments described under subsection 7a77#d77;,a7 are made4 7e7 ,risk ,adjustment 7#a7 ,in general ,the amount under subsection 7a77#a77;,a7 shall be adjusted under this subsection in an appropriate manner1 specified by the ,secretary and consistent with paragraph 7#b71 to take into account-- 7,a7 the factors described in subsection 7c77#b77;,c77i77,i7 within a category of beneficiaries2 and 7,b7 variations in costs on a county-by-county basis for medical assistance and administrative expenses4 7#b7 ,method of adjustment 7,a7 ,in general ,the adjustments under paragraph 7#a7 shall be made in a manner similar to the manner in which similar adjustments are made under subsection 7c77#b77;,c7 and consistent with the requirements of clause 7iii7 of such subsection and subparagraph 7,b74 7,b7 ,biannual update of risk adjustment methodology ,in applying clause 7i77,i7 of subsection 7c77#b77;,c7 for purposes of subparagraph 7,a71 the ,secretary shall1 in consultation with the entities described in clause 7ii77,i7 of such subsection1 update the risk adjustment methodology applied as appropriate not less often than every #b years4 7f7 ,chronic care quality bonus payments 7#a7 ,determination of bonus payments ,if the ,secretary determines that1 based on the reports under paragraph 7#e71 with respect to categories of chronic disease for which chronic care performance targets had been established under paragraph 7#c7 for each category of ,medicaid beneficiaries specified under subsection 7b77#b7 such targets have been met by a ,state for a reform year1 the ,secretary shall make an additional payment to such ,state in the amount specified in paragraph 7#f7 for each quarter in the succeeding reform year4 ,such payments shall be made in a manner specified by the ,secretary and may only be used consistent with subsection 7a77#c74 7#b7 ,identification of categories of chronic disease ,the ,secretary shall determine the categories of chronic disease for which bonus payments may be available under this subsection for each category of ,medicaid beneficiaries4 7#c7 ,adoption of quality measurement system and identification of performance targets 7,a7 ,system and data ,with respect to the categories of chronic disease under paragraph 7#b71 the ,secretary shall adopt a quality measurement system that uses data described in paragraph 7#d7 and is similar to the ,five-,star ,quality ,rating ,system used to indicate the performance of ,medicare ,advantage plans under part ,c of title ,,xviii4 7,b7 ,targets ,using such system and data1 the ,secretary shall establish for each reform year the chronic care performance targets for purposes of the payments under paragraph 7#a74 ,such performance targets shall be established in consultation with ,states1 associations representing individuals with chronic illnesses1 entities providing treatment to such individuals for such chronic illnesses1 and other stakeholders1 including the ,national ,association of ,medicaid ,directors and the ,national ,governors ,association4 7#d7 ,data to be used ,the data to be used under paragraph 7#c7 shall include-- 7,a7 data collected through methods such as-- 7i7 the ,healthcare ,effectiveness ,data and ,information ,set 7also known as ,,hedis7 7or an appropriate successor performance measurement tool72 7ii7 the ,consumer ,assessment of ,healthcare ,providers and ,systems 7also known as ,,cahps7 7or an appropriate successor performance measurement tool72 and 7iii7 the ,health ,outcomes ,survey 7also known as ,,hos7 7or an appropriate successor performance measurement tool72 and 7,b7 other data collected by the ,state4 7#e7 ,reports 7,a7 ,in general ,each ,state shall collect1 analyze1 and report to the ,secretary1 at a frequency and in a manner to be established by the ,secretary1 data described in paragraph 7#d7 that permit the ,secretary to monitor the ,state's performance relative to the chronic care performance targets established under paragraph 7#c74 7,b7 ,review and verification ,the ,secretary may review the data collected by the ,state under subparagraph 7,a7 to verify the ,state's analysis of such data with respect to the performance targets under paragraph 7#c74 7#f7 ,amount of bonus payments 7,a7 ,in general ,subject to subparagraphs 7,b7 and 7,c71 with respect to each category of ,medicaid beneficiaries1 in the case of a ,state that the ,secretary determines1 based on the chronic care performance targets set under paragraph 7#c7 for a reform year for such category1 performs-- 7i7 in the top five ,states in such category1 subject to subparagraph 7,c77ii71 the amount of the bonus for each quarter in the succeeding reform year shall be #aj percent of the payment amount otherwise paid to the ,state under subsection 7a7 for individuals enrolled under the plan within such category2 7ii7 in the next five ,states in such category1 subject to subparagraph 7,c77ii71 the amount of the bonus for each such quarter shall be #e percent of the payment amount otherwise paid to the ,state under subsection 7a7 for individuals enrolled under the plan within such category2 7iii7 in the next five ,states in such category1 subject to clauses 7i7 and 7iii7 of subparagraph 7,c71 the amount of the bonus for each such quarter shall be #c percent of the payment amount otherwise paid to the ,state under subsection 7a7 for individuals enrolled under the plan within such category2 7iv7 in the next five ,states in such category1 subject to clauses 7i7 and 7iii7 of subparagraph 7,c71 the amount of the bonus for each such quarter shall be #b percent of the payment amount otherwise paid to the ,state under subsection 7a7 for individuals enrolled under the plan within such category2 and 7v7 in the next five ,states in such category1 subject to clauses 7i7 and 7iii7 of subparagraph 7,c71 the amount of the bonus for each such quarter shall be #a percent of the payment amount otherwise paid to the ,state under subsection 7a7 for individuals enrolled under the plan within such category4 7,b7 ,aggregate annual limit for each category of ,medicaid beneficiaries 7i7 ,in general ,in no case may the aggregate amount of bonuses under this subsection for quarters in a reform year for a category of ,medicaid beneficiaries exceed the limit specified in clause 7ii7 for the reform year4 7ii7 ,limit ,the limit specified in this clause-- 7,i7 for the second reform year is equal to #bej1jjj1jjj2 or 7,,ii7 for a subsequent reform year is equal to the limit specified in this clause for the previous reform year increased by the per beneficiary percentage increase determined under paragraph 7#a77;,e7 of subsection 7c74 7,c7 ,limitation and proration of bonuses based on application of aggregate limit 7i7 ,no bonus for third or subsequent tiers unless aggregate limit not reached on first two tiers ,no bonus shall be payable under clause 7iii71 7iv71 or 7v7 of subparagraph 7,a7 for a category of ,medicaid beneficiaries for a quarter in a reform year unless the aggregate amount of bonuses under clauses 7i7 and 7ii7 of such subparagraph for such category and reform year is less than the limit specified in subparagraph 7,b77ii7 for the reform year4 7ii7 ,proration for first two tiers ,if the aggregate amount of bonuses under clauses 7i7 and 7ii7 of subparagraph 7,a7 for a category of ,medicaid beneficiaries for quarters in a reform year exceeds the limit specified in subparagraph 7,b77ii7 for the reform year1 the amount of each such bonus shall be prorated in a manner so the aggregate amount of such bonuses is equal to such limit4 7iii7 ,proration for next three tiers ,if the aggregate amount of bonuses under clauses 7i7 and 7ii7 of subparagraph 7,a7 for a category of ,medicaid beneficiaries for quarters in a reform year is less than the limit specified in subparagraph 7,b77ii7 for the reform year1 but the aggregate amount of bonuses under clauses 7i7 through 7v7 of subparagraph 7,a7 for the category and such quarters in the reform year exceeds the limit specified in subparagraph 7,b77ii7 for the reform year1 the amount of each bonus in clauses 7iii71 7iv71 and 7v7 of subparagraph 7,a7 shall be prorated in a manner so the aggregate amount of all the bonuses under subparagraph 7,a7 is equal to such limit4 7g7 ,state option for receiving ,medicare payments for full-,benefit dual eligible individuals 7#a7 ,in general ,under this subsection a ,state may elect for quarters beginning on or after the implementation date in a reform year to receive payment from the ,secretary under paragraph 7#c74 ,as a condition of receiving such payment1 the ,state shall agree to provide to full-benefit dual eligible individuals eligible for medical assistance under the ,state plan-- 7,a7 the medical assistance to which such eligible individuals would otherwise be entitled under this title2 and 7,b7 any items and services which such eligible individuals would otherwise receive under title ,,xviii4 7#b7 ,provider payment requirement 7,a7 ,in general ,a ,state electing the option under this subsection shall provide payment to health care providers for the items and services described under paragraph 7#a77;,b7 at a rate that is not less than the rate at which payments would be made to such providers for such items and services under title ,,xviii4 7,b7 ,flexibility in payment methods ,nothing in subparagraph 7,a7 shall be construed as preventing a ,state from using alternative payment methodologies 7such as bundled payments or the use of accountable care organizations 7as such term is used in section #ahii77 for purposes of making payments to health care providers for items and services provided to dual eligible individuals in the ,state under the option under this subsection4 7#c7 ,payments to ,states in lieu of ,medicare payments ,with respect to a full-benefit dual eligible individual1 in the case of a ,state that elects the option under paragraph 7#a7 for quarters in a reform year-- 7,a7 the ,secretary shall not make any payment under title ,,xviii for items and services furnished to such individual for such quarters2 and 7,b7 the ,secretary shall pay to the ,state1 in addition to the amounts paid to such ,state under subsection 7a71 the amount that the ,secretary would1 but for this subsection1 otherwise pay under title ,,xviii for items and services furnished to such an individual in such ,state for such quarters4 7#d7 ,full-benefit dual eligible individual defined ,in this subsection1 the term full-benefit dual eligible individual means an individual who meets the requirements of section #aice7;c77#f77;,a77ii74 7h7 ,audits ,the ,secretary shall conduct such audits on the number and classification of ,medicaid beneficiaries under such subsections and expenditures under this section as may be necessary to ensure appropriate payments under this section4 7i7 ,treatment of waivers 7#a7 ,no impact on current waivers ,in the case of a waiver of requirements of this title pursuant to section #aaae or other law that is in effect as of the date of the enactment of this section1 nothing in this section shall be construed to affect such waiver for the period of the waiver as approved as of such date4 7#b7 ,application of budget neutrality to subsequent waivers and renewals taking section into account ,in the case of a waiver of requirements of this title pursuant to section #aaae or other law that is approved or renewed after the date of the enactment of this section1 to the extent that such approval or renewal is conditioned upon a demonstration of budget neutrality1 budget neutrality shall be determined taking into account the application of this section4 7j7 ,report to ,congress ,not later than ,january #a of the second reform year1 the ,secretary shall submit to ,congress a report on the implementation of this section4 7k7 ,definitions ,in this section3 7#a7 ,implementation date ,the term implementation date means-- 7,a7 ,july #a1 #bjag1 if this section is enacted on or before ,july #a1 #bjaf2 or 7,b7 ,july #a1 #bjah1 if this section is enacted after ,july #a1 #bjaf4 7#b7 ,reform years 7,a7 ,the term reform year means a fiscal year beginning with the first reform year4 7,b7 ,the term first reform year means the fiscal year in which the implementation date occurs4 7,c7 ,the terms second1 third1 and successive similar terms mean1 with respect to a reform year1 the second1 third1 or successive reform year1 respectively1 succeeding the first reform year4 4 7b7 ,conforming amendments 7#a7 ,continued application of clawback provisions 7,a7 ,continued application ,subsections 7a7 and 7c77#a77;,c7 of section #aice of such ,act 7#db ,u4,s4,c4 #acifu-#e7 are each amended by inserting or #aijc;,a7a7 after #aijc7;a74 7,b7 ,technical amendment ,section #aice7;d77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#e7;d77#a77 is amended by inserting except as provided in section #aijc;,a7g7 after any other provision of this title4 7#b7 ,payment rules under section #aijc 7,a7 ,section #aijc7;a7 of such ,act 7#db ,u4,s4,c4 #acif;b7a77 is amended1 in the matter before paragraph 7#a71 by inserting and section #aijc;,a after except as otherwise provided in this section4 7,b7 ,section #aijc7;d7 of such ,act 7#db ,u4,s4,c4 #acif;b7d77 is amended-- 7i7 in paragraph 7#a71 by inserting and under section #aijc;,a after subsections 7a7 and 7b72 7ii7 in paragraph 7#b7-- 7,i7 in subparagraph 7,a71 by inserting or section #aijc;,a after was made under this section2 and 7,,ii7 in subparagraph 7,b71 by inserting or section #aijc;,a after under subsection 7a72 7iii7 in paragraph 7#d7-- 7,i7 by striking under this subsection and inserting 1 with respect to this section or section #aijc;,a1 under this subsection2 and 7,,ii7 by striking under this section and inserting under the respective section2 and 7iv7 in paragraph 7#e71 by inserting or section #aijc;,a after overpayment under this section4 7#c7 ,conforming waiver authority ,section #aaae7;a77#b77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae7;a77#b77;,a77 is amended by striking or #aijc and inserting #aijc1 or #aijc;,a4 7#d7 ,report on additional conforming amendments needed ,not later than #f months after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report that includes a description of any additional technical and conforming amendments to law that are required to properly carry out this ,act4 ,v ,increasing ,price ,transparency and ,freedom of ,practice #eja4 ,ensuring access to emergency services without excessive charges for out-of-network services 7a7 ,in general ,section #ahfg of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;dd7 is amended-- 7#a7 in subsection 7d71 by adding at the end the following new paragraph3 7#e7 ,enforcement with respect to excessive charges ,a hospital1 physician1 or other entity that violates the requirements of subsection 7j77#a7 with respect to the furnishing of items and services is subject to a civil money penalty of not more than #be1jjj for each such violation4 ,the provisions of section #aabh;,a 7other than subsections 7a7 and 7b77 shall apply to a civil money penalty under this paragraph in the same manner as such provisions apply with respect to a penalty or proceeding under section #aabh;,a7a74 2 and 7#b7 by adding at the end the following new subsection3 7j7 ,protections against excessive out-of-,network charges for emergency services 7#a7 ,in general ,if items or services to screen or treat an emergency medical condition are furnished under this section in a participating hospital with respect to an individual and the individual has not1 directly or through a health insurance issuer1 group health plan1 or other third party1 negotiated a payment rate for such items and services1 subject to paragraph 7#b71 the charges imposed for such items and services may not be in excess of the following3 7,a7 ,physicians' and other professional services ,for physicians' services or services of a health care provider to which section #bbc7;f77#i7 of the ,internal ,revenue ,code of #aihf applies 7and including drugs and biologicals furnished in conjunction with and billed as part of such services71 the lesser of-- 7i7 the cash price for such services posted pursuant to such section2 or 7ii7 #he percent of the usual1 customary1 and reasonable 7,,ucr7 charge for such services1 as determined under rules established by the department of insurance for the ,state in which the services are furnished4 7,b7 ,hospital services ,for inpatient and outpatient hospital services for which payment rates are established under this title 7and including drugs and biologicals furnished in conjunction with and billed as part of such services71 the lesser of-- 7i7 the cash price for such services posted pursuant to section #bbc7;f77#i7 of the ,internal ,revenue ,code of #aihf2 or 7ii7 #aaj percent of the payment rate applicable to such services in the case of an individual entitled to benefits under part ,a and enrolled under part ,b4 7,c7 ,drugs and biologicals ,for drugs and other pharmaceuticals furnished to which a previous subparagraph does not apply1 the lesser of-- 7i7 twice the acquisition cost to the hospital or other provider for the dose involved2 or 7ii7 the acquisition cost to the hospital or other provider plus #bej4 ,the dollar amount in clause 7ii7 shall be increased from year to year 7beginning with the year after the first year in which this subsection applies7 by the same percentage as the percentage increase in the consumer price index for all urban consumers 7all items2 ,u4,s4 city average7 for the year involved 7as determined by the ,secretary74 ,any such dollar amount as so increased that is not a multiple of #e shall be rounded to the nearest multiple of #e 7or1 if a multiple of #b4ej1 to the next highest multiple of #e74 7,d7 ,other items and services ,for any other items or services1 the lesser of-- 7i7 the cash price for such items and services posted pursuant to section #bbc7;f77#i7 of the ,internal ,revenue ,code of #aihf2 or 7ii7 #aaj percent of the payment basis that would be applicable to payment for such items and services under this title in the case of an individual entitled to benefits under part ,a and enrolled under part ,b4 7#b7 ,special rule for items and services furnished as a bundle ,in the case of items and services for which there is a single price for a group or bundle of such items and services1 the maximum charge permitted under paragraph 7#a7 may not exceed the lesser of-- 7,a7 the price charged for such bundled services2 or 7,b7 the aggregate of the maximum charges permitted under paragraph 7#a7 with respect to items and services included in such bundle4 4 7b7 ,effective date ,the amendments made by this section shall apply to charges imposed for items and services furnished on or after ,january #a1 #bjag4 #ejb4 ,publishing of cash price for care paid through health savings accounts 7a7 ,health ,savings ,accounts ,section #bbc7;f7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#i7 ,cash price transparency required for payments to health care providers 7,a7 ,in general ,a payment to a health care provider with respect to the furnishing of health care items and services by such provider shall not be treated as a qualified medical expense unless health care provider provides for continuing disclosure 7such as through posting on a publicly accessible website7 of the cash price the health care provider charges for the furnishing of such items and services4 7,b7 ,form of disclosure ,the disclosure of prices under this subsection shall be in a form and manner specified by the ,secretary of ,health and ,human ,services1 in consultation with the ,secretary1 and shall be designed-- 7i7 to establish a single price for related items and services in a manner similar to the manner in which pricing and payment for such items and services is provided under the ,medicare program under title ,,xviii of the ,social ,security ,act1 and 7ii7 to make it easy for consumers to compare the prices for similar items and services furnished by different providers4 7,c7 ,failure to furnish services or charge in excess of stated price ,a health care provider shall be treated as not meeting the requirement of subparagraph 7,a71 in the case of items and services for which the provider is disclosing a cash price1 if the provider-- 7i7 refuses to furnish such items or services at the price listed1 or 7ii7 charges more than the price listed for the furnishing of the items and services4 4 7b7 ,roth ,,hsa ,section #ecj;,a7c77#d7 of such ,code1 as added by this ,act1 is amended by adding at the end the following new subparagraph3 7,e7 ,section #bbc7;f77#i7 7relating to cash price transparency required for payments to health care providers74 4 7c7 ,enforcement ,if the ,secretary determines that a health care provider has not provided for continuing disclosure of the cash price of health care provider charges under section #bbc7;f77#i7 of the ,internal ,revenue ,code of #aihf1 the ,secretary may instruct the ,secretary of the ,treasury that payments made to such provider shall be not treated1 for purposes of section #bbc of the ,internal ,revenue ,code of #aihf1 as an amount used for a qualified medical expense for a period of not to exceed #a year4 7d7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjaf4 #ejc4 ,liberating the local practice of health care 7a7 ,waiving national restrictions on physician-,owned facilities ,section #ahgg of the ,social ,security ,act 7#db ,u4,s4,c4 #acienn7 is amended by adding at the end the following new subsection3 7j7 ,waiver authority ,a physician or other entity may apply to the ,secretary to waive any provision of this section and the ,secretary may waive such provision with respect to such physician or entity if the ,secretary determines that such waiver would-- 7#a7 increase competition within the health care market2 7#b7 reduce the costs of health care2 and 7#c7 increase the quality of health care4 4 7b7 ,removing certain ,state and local licensure or certification restrictions 7#a7 ,application for waiver of restrictions ,an individual who is required to be licensed or certified by a ,state as a condition of furnishing items or services as a health care professional 7as defined by the ,secretary of ,health and ,human ,services7 may submit to the ,secretary an application to waive any condition of such licensure or certification4 7#b7 ,standard ,the ,secretary may grant a waiver submitted under paragraph 7#a7 if the ,secretary determines such waiver would-- 7,a7 increase competition within the health care market2 7,b7 reduce the costs of health care2 and 7,c7 increase the quality of health care4 7#c7 ,preemption ,in the case of a health care professional granted a waiver under paragraph 7#b71 any requirement with respect to which such waiver is granted is preempted to the extent specified in such waiver4