,,ii ,calendar ,no4 #abj #aaeth ,,congress #ast ,session ,h4 ,r4 #afbh ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,june #g1 #bjag,received2 read the first time ,june #h1 #bjag,read twice and placed on the calendar ,,an ,,act ,to provide for reconciliation pursuant to title ,,ii of the concurrent resolution on the budget for fiscal year #bjag4 #a4 ,short title ,this ,act may be cited as the ,american ,health ,care ,act of #bjag4 #b4 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title4 ,sec4 #b4 ,table of contents4 ,title ,i--,energy and ,commerce ,subtitle ,a--,patient ,access to ,public ,health ,programs ,sec4 #aja4 ,the ,prevention and ,public ,health ,fund4 ,sec4 #ajb4 ,community health center program4 ,sec4 #ajc4 ,federal payments to ,states4 ,subtitle ,b--,medicaid ,program ,enhancement ,sec4 #aaa4 ,repeal of ,medicaid provisions4 ,sec4 #aab4 ,repeal of ,medicaid expansion4 ,sec4 #aac4 ,elimination of ,,dsh cuts4 ,sec4 #aad4 ,reducing ,state ,medicaid costs4 ,sec4 #aae4 ,safety net funding for non-expansion ,states4 ,sec4 #aaf4 ,providing incentives for increased frequency of eligibility redeterminations4 ,sec4 #aag4 ,permitting ,states to apply a work requirement for nondisabled1 nonelderly1 nonpregnant adults under ,medicaid4 ,subtitle ,c--,per ,capita ,allotment for ,medical ,assistance ,sec4 #aba4 ,per capita allotment for medical assistance4 ,subtitle ,d--,patient ,relief and ,health ,insurance ,market ,stability ,sec4 #aca4 ,repeal of cost-sharing subsidy4 ,sec4 #acb4 ,patient and ,state ,stability ,fund4 ,sec4 #acc4 ,continuous health insurance coverage incentive4 ,sec4 #acd4 ,increasing coverage options4 ,sec4 #ace4 ,change in permissible age variation in health insurance premium rates4 ,subtitle ,e--,implementation ,funding ,sec4 #ada4 ,american ,health ,care ,implementation ,fund4 ,title ,,ii--,committee on ,ways and ,means ,subtitle ,a--,repeal and ,replace of ,health-,related ,tax ,policy ,sec4 #bja4 ,recapture excess advance payments of premium tax credits4 ,sec4 #bjb4 ,additional modifications to premium tax credit4 ,sec4 #bjc4 ,small business tax credit4 ,sec4 #bjd4 ,individual mandate4 ,sec4 #bje4 ,employer mandate4 ,sec4 #bjf4 ,repeal of the tax on employee health insurance premiums and health plan benefits4 ,sec4 #bjg4 ,repeal of tax on over-the-counter medications4 ,sec4 #bjh4 ,repeal of increase of tax on health savings accounts4 ,sec4 #bji4 ,repeal of limitations on contributions to flexible spending accounts4 ,sec4 #baj4 ,repeal of medical device excise tax4 ,sec4 #baa4 ,repeal of elimination of deduction for expenses allocable to medicare part ,d subsidy4 ,sec4 #bab4 ,reduction of income threshold for determining medical care deduction4 ,sec4 #bac4 ,repeal of ,medicare tax increase4 ,sec4 #bad4 ,refundable tax credit for health insurance coverage4 ,sec4 #bae4 ,maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation4 ,sec4 #baf4 ,allow both spouses to make catch-up contributions to the same health savings account4 ,sec4 #bag4 ,special rule for certain medical expenses incurred before establishment of health savings account4 ,subtitle ,b--,repeal of certain consumer taxes ,sec4 #bba4 ,repeal of tax on prescription medications4 ,sec4 #bbb4 ,repeal of health insurance tax4 ,subtitle ,c--,repeal of ,tanning ,tax ,sec4 #bca4 ,repeal of tanning tax4 ,subtitle ,d--,remuneration from ,certain ,insurers ,sec4 #bda4 ,remuneration from certain insurers4 ,subtitle ,e--,repeal of ,net ,investment ,income ,tax ,sec4 #bea4 ,repeal of net investment income tax4 ,i ,energy and ,commerce ,a ,patient ,access to ,public ,health ,programs #aja4 ,the ,prevention and ,public ,health ,fund 7a7 ,in general ,subsection 7b7 of section #djjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #cjju-#aa71 as amended by section #ejji of the #bast ,century ,cures ,act1 is amended-- 7#a7 in paragraph 7#b71 by adding and at the end2 7#b7 in paragraph 7#c7-- 7,a7 by striking each of fiscal years #bjah and #bjai and inserting fiscal year #bjah2 and 7,b7 by striking the semicolon at the end and inserting a period2 and 7#c7 by striking paragraphs 7#d7 through 7#h74 7b7 ,rescission of unobligated funds ,of the funds made available by such section #djjb1 the unobligated balance at the end of fiscal year #bjah is rescinded4 #ajb4 ,community health center program ,effective as if included in the enactment of the ,medicare ,access and ,,chip ,reauthorization ,act of #bjae 7,public ,law #aad-aj1 #abi ,stat4 #hg71 paragraph 7#a7 of section #bba7;a7 of such ,act is amended by inserting 1 and an additional #dbb1jjj1jjj for fiscal year #bjag after #bjag4 #ajc4 ,federal payments to ,states 7a7 ,in general ,notwithstanding section #ejd7;a71 #aijb7;a77#bc71 #aijc7;a71 #bjjb1 #bjje7;a77#d71 #bajb7;a77#g71 or #baje7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #gjd7;a71 #acif;a7a77#bc71 #acif;b7a71 #acig;a1 #acig;d7a77#d71 #acig;bb7a77#g71 #acig;ee7a77#a771 or the terms of any ,medicaid waiver in effect on the date of enactment of this ,act that is approved under section #aaae or #aiae of the ,social ,security ,act 7#db ,u4,s4,c4 #acae1 #acifn71 for the #a-year period beginning on the date of the enactment of this ,act1 no ,federal funds provided from a program referred to in this subsection that is considered direct spending for any year may be made available to a ,state for payments to a prohibited entity1 whether made directly to the prohibited entity or through a managed care organization under contract with the ,state4 7b7 ,definitions ,in this section3 7#a7 ,prohibited entity ,the term prohibited entity means an entity1 including its affiliates1 subsidiaries1 successors1 and clinics-- 7,a7 that1 as of the date of enactment of this ,act-- 7i7 is an organization described in section #eja7;c77#c7 of the ,internal ,revenue ,code of #aihf and exempt from tax under section #eja7;a7 of such ,code2 7ii7 is an essential community provider described in section #aef4bce of title #de1 ,code of ,federal ,regulations 7as in effect on the date of enactment of this ,act71 that is primarily engaged in family planning services1 reproductive health1 and related medical care2 and 7iii7 provides for abortions1 other than an abortion-- 7,i7 if the pregnancy is the result of an act of rape or incest2 or 7,,ii7 in the case where a woman suffers from a physical disorder1 physical injury1 or physical illness that would1 as certified by a physician1 place the woman in danger of death unless an abortion is performed1 including a life-endangering physical condition caused by or arising from the pregnancy itself2 and 7,b7 for which the total amount of ,federal and ,state expenditures under the ,medicaid program under title ,,xix of the ,social ,security ,act in fiscal year #bjad made directly to the entity and to any affiliates1 subsidiaries1 successors1 or clinics of the entity1 or made to the entity and to any affiliates1 subsidiaries1 successors1 or clinics of the entity as part of a nationwide health care provider network1 exceeded #cej1jjj1jjj4 7#b7 ,direct spending ,the term direct spending has the meaning given that term under section #bej7;c7 of the ,balanced ,budget and ,emergency ,deficit ,control ,act of #aihe 7#b ,u4,s4,c4 #ijj7;c774 ,b ,medicaid ,program ,enhancement #aaa4 ,repeal of ,medicaid provisions ,the ,social ,security ,act is amended-- 7#a7 in section #aijb 7#db ,u4,s4,c4 #acif;a7-- 7,a7 in subsection 7a77#dg77;,b71 by inserting and provided that any such election shall cease to be effective on ,january #a1 #bjbj1 and no such election shall be made after that date before the semicolon at the end2 and 7,b7 in subsection 7l77#b77;,c71 by inserting and ending ,december #ca1 #bjai1 after ,january #a1 #bjad12 7#b7 in section #aiae7k77#b7 7#db ,u4,s4,c4 #acifn7k77#b771 by striking during the period described in paragraph 7#a7 and inserting on or after the date referred to in paragraph 7#a7 and before ,january #a1 #bjbj2 and 7#c7 in section #aibj7;e7 7#db ,u4,s4,c4 #acifr-#a7;e771 by striking under clause 7i77,,viii71 clause 7i77,,ix71 or clause 7ii77,,xx7 of subsection 7a77#aj77;,a7 and inserting under clause 7i77,,viii7 or clause 7ii77,,xx7 of section #aijb7;a77#aj77;,a7 before ,january #a1 #bjbj1 section #aijb7;a77#aj77;,a77i77,,ix714 #aab4 ,repeal of ,medicaid expansion 7a7 ,in general ,title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 is amended-- 7#a7 in section #aijb 7#db ,u4,s4,c4 #acif;a7-- 7,a7 in subsection 7a77#aj77;,a7-- 7i7 in clause 7i77,,viii71 by inserting and ending ,december #ca1 #bjai1 after #bjad12 7ii7 in clause 7ii77,,xx71 by inserting and ending ,december #ca1 #bjag1 after #bjad12 and 7iii7 in clause 7ii71 by adding at the end the following new subclause3 7,,xxiii7 beginning ,january #a1 #bjbj-- 7aa7 who are expansion enrollees 7as defined in subsection 7nn77#a772 or 7bb7 who are grandfathered expansion enrollees 7as defined in subsection 7nn77#b772 2 and 7,b7 by adding at the end the following new subsection3 7nn7 ,expansion enrollees ,in this title3 7#a7 ,in general ,the term expansion enrollee means an individual-- 7,a7 who is under #fe years of age2 7,b7 who is not pregnant2 7,c7 who is not entitled to1 or enrolled for1 benefits under part ,a of title ,,xviii1 or enrolled for benefits under part ,b of title ,,xviii2 7,d7 who is not described in any of subclauses 7,i7 through 7,,vii7 of subsection 7a77#aj77;,a77i72 and 7,e7 whose income 7as determined under subsection 7e77#ad77 does not exceed #acc percent of the poverty line 7as defined in section #baaj7;c77#e77 applicable to a family of the size involved4 7#b7 ,grandfathered expansion enrollees ,the term grandfathered expansion enrollee means an expansion enrollee who-- 7,a7 was enrolled under the ,state plan under this title 7or under a waiver of such plan7 as of ,december #ca1 #bjai2 and 7,b7 does not have a break in eligibility for medical assistance under such ,state plan 7or waiver7 for more than one month after such date4 7#c7 ,application of related provisions ,any reference in subsection 7a77#aj77;,g71 7k71 or 7gg7 of this section or in section #aijc1 #aije7;a71 #aibj7;e71 or #aicg7;a77#a77;,b7 to individuals described in subclause 7,,viii7 of subsection 7a77#aj77;,a77i7 shall be deemed to include a reference to expansion enrollees 7including grandfathered expansion enrollees74 2 and 7#b7 in section #aije 7#db ,u4,s4,c4 #acif;d7-- 7,a7 in subsection 7y77#a71 in the matter preceding subparagraph 7,a7-- 7i7 by inserting and that has elected to cover newly eligible individuals before ,march #a1 #bjag after that is one of the #ej ,states or the ,district of ,columbia2 and 7ii7 by inserting after subclause 7,,viii7 of section #aijb7;a77#aj77;,a77i7 the following3 who1 for periods after ,december #ca1 #bjai1 are grandfathered expansion enrollees 7as defined in section #aijb7nn77#b772 and 7,b7 in subsection 7z77#b7-- 7i7 in subparagraph 7,a71 by inserting after section #aicg the following3 and1 for periods after ,december #ca1 #bjai1 who are grandfathered expansion enrollees 7as defined in section #aijb7nn77#b772 and 7ii7 in subparagraph 7,b77ii7-- 7,i7 in subclause 7,,iii71 by adding and at the end2 and 7,,ii7 by striking subclauses 7,,iv71 7,v71 and 7,,vi7 and inserting the following new subclause3 7,,iv7 #bjag and each subsequent year is #hj percent4 4 7b7 ,sunset of essential health benefits requirement ,section #aicg7;b77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#g7;b77#e77 is amended by adding at the end the following3 ,this paragraph shall not apply after ,december #ca1 #bjai44 #aac4 ,elimination of ,,dsh cuts ,section #aibc7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#d7;f77 is amended-- 7#a7 in paragraph 7#g7-- 7,a7 in subparagraph 7,a7-- 7i7 in clause 7i7-- 7,i7 in the matter preceding subclause 7,i71 by striking #bjbe and inserting #bjai2 and 7ii7 in clause 7ii7-- 7,i7 in subclause 7,i71 by adding and at the end2 7,,ii7 in subclause 7,,ii71 by striking the semicolon at the end and inserting a period2 and 7,,iii7 by striking subclauses 7,,iii7 through 7,,viii72 and 7,b7 by adding at the end the following new subparagraph3 7,c7 ,exemption from ,reduction for non-expansion ,states 7i7 ,in general ,in the case of a ,state that is a non-expansion ,state for a fiscal year1 subparagraph 7,a77i7 shall not apply to the ,,dsh allotment for such ,state and fiscal year4 7ii7 ,no change in reduction for expansion ,states ,in the case of a ,state that is an expansion ,state for a fiscal year1 the ,,dsh allotment for such ,state and fiscal year shall be determined as if clause 7i7 did not apply4 7iii7 ,non-expansion and expansion ,state defined 7,i7 ,the term expansion ,state means with respect to a fiscal year1 a ,state that1 as of ,july #a of the preceding fiscal year1 provides for eligibility under clause 7i77,,viii7 or 7ii77,,xx7 of section #aijb7;a77#aj77;,a7 for medical assistance under this title 7or a waiver of the ,state plan approved under section #aaae74 7,,ii7 ,the term non-expansion ,state means1 with respect to a fiscal year1 a ,state that is not an expansion ,state4 2 and 7#b7 in paragraph 7#h71 by striking fiscal year #bjbe and inserting fiscal year #bjai4 #aad4 ,reducing ,state ,medicaid costs 7a7 ,letting ,states disenroll high dollar lottery winners 7#a7 ,in general ,section #aijb of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7 is amended-- 7,a7 in subsection 7a77#ag71 by striking 7e77#ad71 7e77#ad7 and inserting 7e77#ad71 7e77#ae72 and 7,b7 in subsection 7e7-- 7i7 in paragraph 7#ad7 7relating to modified adjusted gross income71 by adding at the end the following new subparagraph3 7,j7 ,treatment of certain lottery winnings and income received as a lump sum 7i7 ,in general ,in the case of an individual who is the recipient of qualified lottery winnings 7pursuant to lotteries occurring on or after ,january #a1 #bjbj7 or qualified lump sum income 7received on or after such date7 and whose eligibility for medical assistance is determined based on the application of modified adjusted gross income under subparagraph 7,a71 a ,state shall1 in determining such eligibility1 include such winnings or income 7as applicable7 as income received-- 7,i7 in the month in which such winnings or income 7as applicable7 is received if the amount of such winnings or income is less than #hj1jjj2 7,,ii7 over a period of #b months if the amount of such winnings or income 7as applicable7 is greater than or equal to #hj1jjj but less than #ij1jjj2 7,,iii7 over a period of #c months if the amount of such winnings or income 7as applicable7 is greater than or equal to #ij1jjj but less than #ajj1jjj2 and 7,,iv7 over a period of #c months plus #a additional month for each increment of #aj1jjj of such winnings or income 7as applicable7 received1 not to exceed a period of #abj months 7for winnings or income of #a1bfj1jjj or more71 if the amount of such winnings or income is greater than or equal to #ajj1jjj4 7ii7 ,counting in equal installments ,for purposes of subclauses 7,,ii71 7,,iii71 and 7,,iv7 of clause 7i71 winnings or income to which such subclause applies shall be counted in equal monthly installments over the period of months specified under such subclause4 7iii7 ,hardship exemption ,an individual whose income1 by application of clause 7i71 exceeds the applicable eligibility threshold established by the ,state1 may continue to be eligible for medical assistance to the extent that the ,state determines1 under procedures established by the ,state under the ,state plan 7or in the case of a waiver of the plan under section #aaae1 incorporated in such waiver71 or as otherwise established by such ,state in accordance with such standards as may be specified by the ,secretary1 that the denial of eligibility of the individual would cause an undue medical or financial hardship as determined on the basis of criteria established by the ,secretary4 7iv7 ,notifications and assistance required in case of loss of eligibility ,a ,state shall1 with respect to an individual who loses eligibility for medical assistance under the ,state plan 7or a waiver of such plan7 by reason of clause 7i71 before the date on which the individual loses such eligibility1 inform the individual of the date on which the individual would no longer be considered ineligible by reason of such clause to receive medical assistance under the ,state plan or under any waiver of such plan and the date on which the individual would be eligible to reapply to receive such medical assistance4 7v7 ,qualified lottery winnings defined ,in this subparagraph1 the term qualified lottery winnings means winnings from a sweepstakes1 lottery1 or pool described in paragraph 7#c7 of section #ddjb of the ,internal ,revenue ,code of #aihf or a lottery operated by a multistate or multijurisdictional lottery association1 including amounts awarded as a lump sum payment4 7vi7 ,qualified lump sum income defined ,in this subparagraph1 the term qualified lump sum income means income that is received as a lump sum from one of the following sources3 7,i7 ,monetary winnings from gambling 7as defined by the ,secretary and including monetary winnings from gambling activities described in section #aiee7;b77#d7 of title #ah1 ,united ,states ,code74 7,,ii7 ,income received as liquid assets from the estate 7as defined in section #aiag7;b77#d77 of a deceased individual4 2 and 7ii7 by striking 7#ad7 ,exclusion and inserting 7#ae7 ,exclusion4 7#b7 ,rules of construction 7,a7 ,interception of lottery winnings allowed ,nothing in the amendment made by paragraph 7#a77;,b77i7 shall be construed as preventing a ,state from intercepting the ,state lottery winnings awarded to an individual in the ,state to recover amounts paid by the ,state under the ,state ,medicaid plan under title ,,xix of the ,social ,security ,act for medical assistance furnished to the individual4 7,b7 ,applicability limited to eligibility of recipient of lottery winnings or lump sum income ,nothing in the amendment made by paragraph 7#a77;,b77i7 shall be construed1 with respect to a determination of household income for purposes of a determination of eligibility for medical assistance under the ,state plan under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 7or a waiver of such plan7 made by applying modified adjusted gross income under subparagraph 7,a7 of section #aijb7;e77#ad7 of such ,act 7#db ,u4,s4,c4 #acif;a7e77#ad771 as limiting the eligibility for such medical assistance of any individual that is a member of the household other than the individual 7or the individual's spouse7 who received qualified lottery winnings or qualified lump-sum income 7as defined in subparagraph 7,j7 of such section #aijb7;e77#ad71 as added by paragraph 7#a77;,b77i7 of this subsection74 7b7 ,repeal of retroactive eligibility 7#a7 ,in general 7,a7 ,state plan requirements ,section #aijb7;a77#cd7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#cd77 is amended by striking in or after the third month before the month in which he made application and inserting in or after the month in which the individual made application4 7,b7 ,definition of medical assistance ,section #aije7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a77 is amended by striking in or after the third month before the month in which the recipient makes application for assistance and inserting in or after the month in which the recipient makes application for assistance4 7#b7 ,effective date ,the amendments made by paragraph 7#a7 shall apply to medical assistance with respect to individuals whose eligibility for such assistance is based on an application for such assistance made 7or deemed to be made7 on or after ,october #a1 #bjag4 7c7 ,updating allowable home equity limits in ,medicaid 7#a7 ,in general ,section #aiag7;f77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifp7f77#a77 is amended-- 7,a7 in subparagraph 7,a71 by striking subparagraphs 7,b7 and 7,c7 and inserting subparagraph 7,b72 7,b7 by striking subparagraph 7,b72 7,c7 by redesignating subparagraph 7,c7 as subparagraph 7,b72 and 7,d7 in subparagraph 7,b71 as so redesignated1 by striking dollar amounts specified in this paragraph and inserting dollar amount specified in subparagraph 7,a74 7#b7 ,effective date 7,a7 ,in general ,the amendments made by paragraph 7#a7 shall apply with respect to eligibility determinations made after the date that is #ahj days after the date of the enactment of this section4 7,b7 ,exception for ,state legislation ,in the case of a ,state plan under title ,,xix of the ,social ,security ,act that the ,secretary of ,health and ,human ,services determines requires ,state legislation in order for the respective plan to meet any requirement imposed by amendments made by this subsection1 the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the ,state legislature that begins after the date of the enactment of this ,act4 ,for purposes of the previous sentence1 in the case of a ,state that has a #b-year legislative session1 each year of the session shall be considered to be a separate regular session of the ,state legislature4 #aae4 ,safety net funding for non-expansion ,states ,title ,,xix of the ,social ,security ,act is amended by inserting after section #aibc 7#db ,u4,s4,c4 #acifr-#d7 the following new section3 #aibc;,a4 ,adjustment in payment for services of safety net providers in non-expansion ,states 7a7 ,in general ,subject to the limitations of this section1 for each year during the period beginning with fiscal year #bjah and ending with fiscal year #bjbb1 each ,state that is one of the #ej ,states or the ,district of ,columbia and that1 as of ,july #a of the preceding fiscal year1 did not provide for eligibility under clause 7i77,,viii7 or 7ii77,,xx7 of section #aijb7;a77#aj77;,a7 for medical assistance under this title 7or a waiver of the ,state plan approved under section #aaae7 7each such ,state or ,district referred to in this section for the fiscal year as a non-expansion ,state7 may adjust the payment amounts otherwise provided under the ,state plan under this title 7or a waiver of such plan7 to health care providers that provide health care services to individuals enrolled under this title 7in this section referred to as eligible providers7 so long as the payment adjustment to such an eligible provider does not exceed the provider's costs in furnishing health care services 7as determined by the ,secretary and net of payments under this title1 other than under this section1 and by uninsured patients7 to individuals who either are eligible for medical assistance under the ,state plan 7or under a waiver of such plan7 or have no health insurance or health plan coverage for such services4 7b7 ,increase in applicable ,,fmap ,notwithstanding section #aije7;b71 the ,federal medical assistance percentage applicable with respect to expenditures attributable to a payment adjustment under subsection 7a7 for which payment is permitted under subsection 7c7 shall be equal to-- 7#a7 #ajj percent for calendar quarters in fiscal years #bjah1 #bjai1 #bjbj1 and #bjba2 and 7#b7 #ie percent for calendar quarters in fiscal year #bjbb4 7c7 ,annual allotment limitation ,payment under section #aijc7;a7 shall not be made to a ,state with respect to any payment adjustment made under this section for all calendar quarters in a fiscal year in excess of the #b1jjj1jjj1jjj multiplied by the ratio of-- 7#a7 the population of the ,state with income below #ach percent of the poverty line in #bjae 7as determined based the table entitled ,health ,insurance ,coverage ,status and ,type by ,ratio of ,income to ,poverty ,level in the ,past #ab ,months by ,age for the universe of the civilian noninstitutionalized population for whom poverty status is determined based on the #bjae ,american ,community ,survey #a-,year ,estimates1 as published by the ,bureau of the ,census71 to 7#b7 the sum of the populations under paragraph 7#a7 for all non-expansion ,states4 7d7 ,disqualification in case of ,state coverage expansion ,if a ,state is a non-expansion for a fiscal year and provides eligibility for medical assistance described in subsection 7a7 during the fiscal year1 the ,state shall no longer be treated as a non-expansion ,state under this section for any subsequent fiscal years4 4 #aaf4 ,providing incentives for increased frequency of eligibility redeterminations 7a7 ,in general ,section #aijb7;e77#ad7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7e77#ad77 7relating to modified adjusted gross income71 as amended by section #aad7;a77#a71 is further amended by adding at the end the following3 7,k7 ,frequency of eligibility redeterminations ,beginning on ,october #a1 #bjag1 and notwithstanding subparagraph 7,h71 in the case of an individual whose eligibility for medical assistance under the ,state plan under this title 7or a waiver of such plan7 is determined based on the application of modified adjusted gross income under subparagraph 7,a7 and who is so eligible on the basis of clause 7i77,,viii7 or clause 7ii77,,xx7 of subsection 7a77#aj77;,a71 a ,state shall redetermine such individual's eligibility for such medical assistance no less frequently than once every #f months4 4 7b7 ,increased administrative matching percentage ,for each calendar quarter during the period beginning on ,october #a1 #bjag1 and ending on ,december #ca1 #bjai1 the ,federal matching percentage otherwise applicable under section #aijc7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7a77 with respect to ,state expenditures during such quarter that are attributable to meeting the requirement of section #aijb7;e77#ad7 7relating to determinations of eligibility using modified adjusted gross income7 of such ,act shall be increased by #e percentage points with respect to ,state expenditures attributable to activities carried out by the ,state 7and approved by the ,secretary7 to increase the frequency of eligibility redeterminations required by subparagraph 7,k7 of such section 7relating to eligibility redeterminations made on a #f-month basis7 7as added by subsection 7a774 #aag4 ,permitting ,states to apply a work requirement for nondisabled1 nonelderly1 nonpregnant adults under ,medicaid 7a7 ,in general ,section #aijb of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a71 as previously amended1 is further amended by adding at the end the following new subsection3 7oo7 ,work requirement option for nondisabled1 nonelderly1 nonpregnant adults 7#a7 ,in general ,beginning ,october #a1 #bjag1 subject to paragraph 7#c71 a ,state may elect to condition medical assistance to a nondisabled1 nonelderly1 nonpregnant individual under this title upon such an individual's satisfaction of a work requirement 7as defined in paragraph 7#b774 7#b7 ,work requirement defined ,in this section1 the term work requirement means1 with respect to an individual1 the individual's participation in work activities 7as defined in section #djg7;d77 for such period of time as determined by the ,state1 and as directed and administered by the ,state4 7#c7 ,required exceptions ,states administering a work requirement under this subsection may not apply such requirement to-- 7,a7 a woman during pregnancy through the end of the month in which the #fj-;day period 7beginning on the last day of her pregnancy7 ends2 7,b7 an individual who is under #ai years of age2 7,c7 an individual who is the only parent or caretaker relative in the family of a child who has not attained #f years of age or who is the only parent or caretaker of a child with disabilities2 or 7,d7 an individual who is married or a head of household and has not attained #bj years of age and who-- 7i7 maintains satisfactory attendance at secondary school or the equivalent2 or 7ii7 participates in education directly related to employment4 4 7b7 ,increase in matching rate for implementation ,section #aijc of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7 is amended by adding at the end the following3 7aa7 ,the ,federal matching percentage otherwise applicable under subsection 7a7 with respect to ,state administrative expenditures during a calendar quarter for which the ,state receives payment under such subsection shall1 in addition to any other increase to such ,federal matching percentage1 be increased for such calendar quarter by #e percentage points with respect to ,state expenditures attributable to activities carried out by the ,state 7and approved by the ,secretary7 to implement subsection 7oo7 of section #aijb4 4 ,c ,per ,capita ,allotment for ,medical ,assistance #aba4 ,per capita allotment for medical assistance ,title ,,xix of the ,social ,security ,act is amended-- 7#a7 in section #aijc 7#db ,u4,s4,c4 #acif;b7-- 7,a7 in subsection 7a71 in the matter before paragraph 7#a71 by inserting and section #aijc;,a7a7 after except as otherwise provided in this section2 and 7,b7 in subsection 7d77#a71 by striking to which and inserting to which1 subject to section #aijc;,a7a712 and 7#b7 by inserting after such section #aijc the following new section3 #aijc;,a4 ,per capita-based cap on payments for medical assistance 7a7 ,application of per capita cap on payments for medical assistance expenditures 7#a7 ,in general ,if a ,state has excess aggregate medical assistance expenditures 7as defined in paragraph 7#b77 for a fiscal year 7beginning with fiscal year #bjbj71 the amount of payment to the ,state under section #aijc7;a77#a7 for each quarter in the following fiscal year shall be reduced by of the excess aggregate medical assistance payments 7as defined in paragraph 7#c77 for that previous fiscal year4 ,in this section1 the term ,state means only the #ej ,states and the ,district of ,columbia4 7#b7 ,excess aggregate medical assistance expenditures ,in this subsection1 the term excess aggregate medical assistance expenditures means1 for a ,state for a fiscal year1 the amount 7if any7 by which-- 7,a7 the amount of the adjusted total medical assistance expenditures 7as defined in subsection 7b77#a77 for the ,state and fiscal year2 exceeds 7,b7 the amount of the target total medical assistance expenditures 7as defined in subsection 7c77 for the ,state and fiscal year4 7#c7 ,excess aggregate medical assistance payments ,in this subsection1 the term excess aggregate medical assistance payments means1 for a ,state for a fiscal year1 the product of-- 7,a7 the excess aggregate medical assistance expenditures 7as defined in paragraph 7#b77 for the ,state for the fiscal year2 and 7,b7 the ,federal average medical assistance matching percentage 7as defined in paragraph 7#d77 for the ,state for the fiscal year4 7#d7 ,federal average medical assistance matching percentage ,in this subsection1 the term ,federal average medical assistance matching percentage means1 for a ,state for a fiscal year1 the ratio 7expressed as a percentage7 of-- 7,a7 the amount of the ,federal payments that would be made to the ,state under section #aijc7;a77#a7 for medical assistance expenditures for calendar quarters in the fiscal year if paragraph 7#a7 did not apply2 to 7,b7 the amount of the medical assistance expenditures for the ,state and fiscal year4 7b7 ,adjusted total medical assistance expenditures ,subject to subsection 7g71 the following shall apply3 7#a7 ,in general ,in this section1 the term adjusted total medical assistance expenditures means1 for a ,state-- 7,a7 for fiscal year #bjaf1 the product of-- 7i7 the amount of the medical assistance expenditures 7as defined in paragraph 7#b77 for the ,state and fiscal year1 reduced by the amount of any excluded expenditures 7as defined in paragraph 7#c77 for the ,state and fiscal year otherwise included in such medical assistance expenditures2 and 7ii7 the #aijc;,a ,,fy#af population percentage 7as defined in paragraph 7#d77 for the ,state2 or 7,b7 for fiscal year #bjai or a subsequent fiscal year1 the amount of the medical assistance expenditures 7as defined in paragraph 7#b77 for the ,state and fiscal year that is attributable to #aijc;,a enrollees1 reduced by the amount of any excluded expenditures 7as defined in paragraph 7#c77 for the ,state and fiscal year otherwise included in such medical assistance expenditures and includes non-,,dsh supplemental payments 7as defined in subsection 7d77#d77;,a77ii77 and payments described in subsection 7d77#d77;,a77iii7 but shall not be construed as including any expenditures attributable to the program under section #aibh4 ,in applying subparagraph 7,b71 non-,,dsh supplemental payments 7as defined in subsection 7d77#d77;,a77ii77 and payments described in subsection 7d77#d77;,a77iii7 shall be treated as fully attributable to #aijc;,a enrollees4 7#b7 ,medical assistance expenditures ,in this section1 the term medical assistance expenditures means1 for a ,state and fiscal year1 the medical assistance payments as reported by medical service category on the ,form ,,cms-#fd quarterly expense report 7or successor to such a report form1 and including enrollment data and subsequent adjustments to any such report1 in this section referred to collectively as a ,,cms-#fd report7 for which payment is 7or may otherwise be7 made pursuant to section #aijc7;a77#a74 7#c7 ,excluded expenditures ,in this section1 the term excluded expenditures means1 for a ,state and fiscal year1 expenditures under the ,state plan 7or under a waiver of such plan7 that are attributable to any of the following3 7,a7 ,,dsh ,payment adjustments made for disproportionate share hospitals under section #aibc4 7,b7 ,medicare cost-sharing ,payments made for medicare cost-sharing 7as defined in section #aije7p77#c774 7,c7 ,safety net provider payment adjustments in non-expansion ,states ,payment adjustments under subsection 7a7 of section #aibc;,a for which payment is permitted under subsection 7c7 of such section4 7#d7 #aijc;,a ,,fy #af population percentage ,in this subsection1 the term #aijc;,a ,,fy#af population percentage means1 for a ,state1 the ,secretary's calculation of the percentage of the actual medical assistance expenditures1 as reported by the ,state on the ,,cms-#fd reports for calendar quarters in fiscal year #bjaf1 that are attributable to #aijc;,a enrollees 7as defined in subsection 7e77#a774 7c7 ,target total medical assistance expenditures 7#a7 ,calculation ,in this section1 the term target total medical assistance expenditures means1 for a ,state for a fiscal year and subject to paragraph 7#d71 the sum of the products1 for each of the #aijc;,a enrollee categories 7as defined in subsection 7e77#b771 of-- 7,a7 the target per capita medical assistance expenditures 7as defined in paragraph 7#b77 for the enrollee category1 ,state1 and fiscal year2 and 7,b7 the number of #aijc;,a enrollees for such enrollee category1 ,state1 and fiscal year1 as determined under subsection 7e77#d74 7#b7 ,target per capita medical assistance expenditures ,in this subsection1 the term #8target per capita medical assistance expenditures' means1 for a #aijc;,a enrollee category and ,state-- 7,a7 for fiscal year #bjbj1 an amount equal to-- 7i7 the provisional ,,fy#ai target per capita amount for such enrollee category 7as calculated under subsection 7d77#e77 for the ,state2 increased by 7ii7 the applicable annual inflation factor 7as defined in paragraph 7#c77 for fiscal year #bjbj2 and 7,b7 for each succeeding fiscal year1 an amount equal to-- 7i7 the target per capita medical assistance expenditures 7under subparagraph 7,a7 or this subparagraph7 for the #aijc;,a enrollee category and ,state for the preceding fiscal year1 increased by 7ii7 the applicable annual inflation factor for that succeeding fiscal year4 7#c7 ,applicable annual inflation factor ,in paragraph 7#b71 the term applicable annual inflation factor means1 for a fiscal year-- 7,a7 for each of the #aijc;,a enrollee categories described in subparagraphs 7,c71 7,d71 and 7,e7 of subsection 7e77#b71 the percentage increase in the medical care component of the consumer price index for all urban consumers 7,u4,s4 city average7 from ,september of the previous fiscal year to ,september of the fiscal year involved2 and 7,b7 for each of the #aijc;,a enrollee categories described in subparagraphs 7,a7 and 7,b7 of subsection 7e77#b71 the percentage increase described in subparagraph 7,a7 plus #a percentage point4 7#d7 ,decrease in target expenditures for required expenditures by certain political subdivisions 7,a7 ,in general ,in the case of a ,state that had a ,,dsh allotment under section #aibc7;f7 for fiscal year #bjaf that was more than #f times the national average of such allotments for all the ,states for such fiscal year and that requires political subdivisions within the ,state to contribute funds towards medical assistance or other expenditures under the ,state plan under this title 7or under a waiver of such plan7 for a fiscal year 7beginning with fiscal year #bjbj71 the target total medical assistance expenditures for such ,state and fiscal year shall be decreased by the amount that political subdivisions in the ,state are required to contribute under the plan 7or waiver7 without reimbursement from the ,state for such fiscal year1 other than contributions described in subparagraph 7,b74 7,b7 ,exceptions ,the contributions described in this subparagraph are the following3 7i7 ,contributions required by a ,state from a political subdivision that1 as of the first day of the calendar year in which the fiscal year involved begins-- 7,i7 has a population of more than #e1jjj1jjj1 as estimated by the ,bureau of the ,census2 and 7,,ii7 imposes a local income tax upon its residents4 7ii7 ,contributions required by a ,state from a political subdivision for administrative expenses if the ,state required such contributions from such subdivision without reimbursement from the ,state as of ,january #a1 #bjag4 7d7 ,calculation of ,,fy#ai provisional target amount for each #aijc;,a enrollee category ,subject to subsection 7g71 the following shall apply3 7#a7 ,calculation of base amounts for fiscal year #bjaf ,for each ,state the ,secretary shall calculate 7and provide notice to the ,state not later than ,april #a1 #bjah1 of7 the following3 7,a7 ,the amount of the adjusted total medical assistance expenditures 7as defined in subsection 7b77#a77 for the ,state for fiscal year #bjaf4 7,b7 ,the number of #aijc;,a enrollees for the ,state in fiscal year #bjaf 7as determined under subsection 7e77#d774 7,c7 ,the average per capita medical assistance expenditures for the ,state for fiscal year #bjaf equal to-- 7i7 the amount calculated under subparagraph 7,a72 divided by 7ii7 the number calculated under subparagraph 7,b74 7#b7 ,fiscal year #bjai average per capita amount based on inflating the fiscal year #bjaf amount to fiscal year #bjai by ,,cpi-medical ,the ,secretary shall calculate a fiscal year #bjai average per capita amount for each ,state equal to-- 7,a7 the average per capita medical assistance expenditures for the ,state for fiscal year #bjaf 7calculated under paragraph 7#a77;,c772 increased by 7,b7 the percentage increase in the medical care component of the consumer price index for all urban consumers 7,u4,s4 city average7 from ,september1 #bjaf to ,september1 #bjai4 7#c7 ,aggregate and average expenditures per capita for fiscal year #bjai ,the ,secretary shall calculate for each ,state the following3 7,a7 ,the amount of the adjusted total medical assistance expenditures 7as defined in subsection 7b77#a77 for the ,state for fiscal year #bjai4 7,b7 ,the number of #aijc;,a enrollees for the ,state in fiscal year #bjai 7as determined under subsection 7e77#d774 7#d7 ,per capita expenditures for fiscal year #bjai for each #aijc;,a enrollee category ,the ,secretary shall calculate 7and provide notice to each ,state not later than ,january #a1 #bjbj1 of7 the following3 7,a7 7i7 ,for each #aijc;,a enrollee category1 the amount of the adjusted total medical assistance expenditures 7as defined in subsection 7b77#a77 for the ,state for fiscal year #bjai for individuals in the enrollee category1 calculated by excluding from medical assistance expenditures those expenditures attributable to expenditures described in clause 7iii7 or non-,,dsh supplemental expenditures 7as defined in clause 7ii774 7ii7 ,in this paragraph1 the term non-,,dsh supplemental expenditure means a payment to a provider under the ,state plan 7or under a waiver of the plan7 that-- 7,i7 is not made under section #aibc2 7,,ii7 is not made with respect to a specific item or service for an individual2 7,,iii7 is in addition to any payments made to the provider under the plan 7or waiver7 for any such item or service2 and 7,,iv7 complies with the limits for additional payments to providers under the plan 7or waiver7 imposed pursuant to section #aijb7;a77#cj77;,a71 including the regulations specifying upper payment limits under the ,state plan in part #ddg of title #db1 ,code of ,federal ,regulations 7or any successor regulations74 7iii7 ,an expenditure described in this clause is an expenditure that meets the criteria specified in subclauses 7,i71 7,,ii71 and 7,,iii7 of clause 7ii7 and is authorized under section #aaae for the purposes of funding a delivery system reform pool1 uncompensated care pool1 a designated state health program1 or any other similar expenditure 7as defined by the ,secretary74 7,b7 ,for each #aijc;,a enrollee category1 the number of #aijc;,a enrollees for the ,state in fiscal year #bjai in the enrollee category 7as determined under subsection 7e77#d774 7,c7 ,for fiscal year #bjaf1 the ,state's non-,,dsh supplemental and pool payment percentage is equal to the ratio 7expressed as a percentage7 of-- 7i7 the total amount of non-,,dsh supplemental expenditures 7as defined in subparagraph 7,a77ii77 and payments described in subparagraph 7,a77iii7 for the ,state for fiscal year #bjaf2 to 7ii7 the amount described in subsection 7b77#a77;,a7 for the ,state for fiscal year #bjaf4 7,d7 ,for each #aijc;,a enrollee category an average medical assistance expenditures per capita for the ,state for fiscal year #bjai for the enrollee category equal to-- 7i7 the amount calculated under subparagraph 7,a7 for the ,state1 increased by the non-,,dsh supplemental and pool payment percentage for the ,state 7as calculated under subparagraph 7,c772 divided by 7ii7 the number calculated under subparagraph 7,b7 for the ,state for the enrollee category4 7#e7 ,provisional ,,fy#ai per capita target amount for each #aijc;,a enrollee category ,subject to subsection 7f77#b71 the ,secretary shall calculate for each ,state a provisional ,,fy#ai per capita target amount for each #aijc;,a enrollee category equal to the average medical assistance expenditures per capita for the ,state for fiscal year #bjai 7as calculated under paragraph 7#d77;,d77 for such enrollee category multiplied by the ratio of-- 7,a7 the product of-- 7i7 the fiscal year #bjai average per capita amount for the ,state1 as calculated under paragraph 7#b72 and 7ii7 the number of #aijc;,a enrollees for the ,state in fiscal year #bjai1 as calculated under paragraph 7#c77;,b72 to 7,b7 the amount of the adjusted total medical assistance expenditures for the ,state for fiscal year #bjai1 as calculated under paragraph 7#c77;,a74 7e7 #aijc;,a enrollee2 #aijc;,a enrollee category ,subject to subsection 7g71 for purposes of this section1 the following shall apply3 7#a7 #aijc;,a enrollee ,the term #aijc;,a enrollee means1 with respect to a ,state and a month and subject to subsection 7i77#a77;,b71 any ,medicaid enrollee 7as defined in paragraph 7#c77 for the month1 other than such an enrollee who for such month is in any of the following categories of excluded individuals3 7,a7 ,,chip ,an individual who is provided1 under this title in the manner described in section #baja7;a77#b71 child health assistance under title ,,xxi4 7,b7 ,,ihs ,an individual who receives any medical assistance under this title for services for which payment is made under the third sentence of section #aije7;b74 7,c7 ,breast and cervical cancer services eligible individual ,an individual who is entitled to medical assistance under this title only pursuant to section #aijb7;a77#aj77;,a77ii77,,xviii74 7,d7 ,partial-benefit enrollees ,an individual who-- 7i7 is an alien who is entitled to medical assistance under this title only pursuant to section #aijc7v77#b72 7ii7 is entitled to medical assistance under this title only pursuant to subclause 7,,xii7 or 7,,xxi7 of section #aijb7;a77#aj77;,a77ii7 7or pursuant to a waiver that provides only comparable benefits72 7iii7 is a dual eligible individual 7as defined in section #aiae7;h77#b77;,b77 and is entitled to medical assistance under this title 7or under a waiver7 only for some or all of medicare cost-sharing 7as defined in section #aije7p77#c772 or 7iv7 is entitled to medical assistance under this title and for whom the ,state is providing a payment or subsidy to an employer for coverage of the individual under a group health plan pursuant to section #aijf or section #aijf;,a 7or pursuant to a waiver that provides only comparable benefits74 7#b7 #aijc;,a enrollee category ,the term #aijc;,a enrollee category means each of the following3 7,a7 ,elderly ,a category of #aijc;,a enrollees who are #fe years of age or older4 7,b7 ,blind and disabled ,a category of #aijc;,a enrollees 7not described in the previous subparagraph7 who are eligible for medical assistance under this title on the basis of being blind or disabled4 7,c7 ,children ,a category of #aijc;,a enrollees 7not described in a previous subparagraph7 who are children under #ai years of age4 7,d7 ,expansion enrollees ,a category of #aijc;,a enrollees 7not described in a previous subparagraph7 for whom the amounts expended for medical assistance are subject to an increase or change in the ,federal medical assistance percentage under subsection 7y7 or 7z77#b71 respectively1 of section #aije4 7,e7 ,other nonelderly1 nondisabled1 non-expansion adults ,a category of #aijc;,a enrollees who are not described in any previous subparagraph4 7#c7 ,medicaid enrollee ,the term ,medicaid enrollee means1 with respect to a ,state for a month1 an individual who is eligible for medical assistance for items or services under this title and enrolled under the ,state plan 7or a waiver of such plan7 under this title for the month4 7#d7 ,determination of number of #aijc;,a enrollees ,the number of #aijc;,a enrollees for a ,state and fiscal year1 and1 if applicable1 for a #aijc;,a enrollee category1 is the average monthly number of ,medicaid enrollees for such ,state and fiscal year 7and1 if applicable1 in such category7 that are reported through the ,,cms-#fd report under 7and subject to audit under7 subsection 7h74 7f7 ,special payment rules 7#a7 ,application in case of research and demonstration projects and other waivers ,in the case of a ,state with a waiver of the ,state plan approved under section #aaae1 section #aiae1 or another provision of this title1 this section shall apply to medical assistance expenditures and medical assistance payments under the waiver1 in the same manner as if such expenditures and payments had been made under a ,state plan under this title and the limitations on expenditures under this section shall supersede any other payment limitations or provisions 7including limitations based on a per capita limitation7 otherwise applicable under such a waiver4 7#b7 ,treatment of ,states expanding coverage after fiscal year #bjaf ,in the case of a ,state that did not provide for medical assistance for the #aijc;,a enrollee category described in subsection 7e77#b77;,d7 during fiscal year #bjaf but which provides for such assistance for such category in a subsequent year1 the provisional ,,fy#ai per capita target amount for such enrollee category under subsection 7d77#e7 shall be equal to the provisional ,,fy#ai per capita target amount for the #aijc;,a enrollee category described in subsection 7e77#b77;,e74 7#c7 ,in case of ,state failure to report necessary data ,if a ,state for any quarter in a fiscal year 7beginning with fiscal year #bjai7 fails to satisfactorily submit data on expenditures and enrollees in accordance with subsection 7h77#a71 for such fiscal year and any succeeding fiscal year for which such data are not satisfactorily submitted-- 7,a7 the ,secretary shall calculate and apply subsections 7a7 through 7e7 with respect to the ,state as if all #aijc;,a enrollee categories for which such expenditure and enrollee data were not satisfactorily submitted were a single #aijc;,a enrollee category2 and 7,b7 the growth factor otherwise applied under subsection 7c77#b77;,b7 shall be decreased by #a percentage point4 7g7 ,recalculation of certain amounts for data errors ,the amounts and percentage calculated under paragraphs 7#a7 and 7#d77;,c7 of subsection 7d7 for a ,state for fiscal year #bjaf1 and the amounts of the adjusted total medical assistance expenditures calculated under subsection 7b7 and the number of ,medicaid enrollees and #aijc;,a enrollees determined under subsection 7e77#d7 for a ,state for fiscal year #bjaf1 fiscal year #bjai1 and any subsequent fiscal year1 may be adjusted by the ,secretary based upon an appeal 7filed by the ,state in such a form1 manner1 and time1 and containing such information relating to data errors that support such appeal1 as the ,secretary specifies7 that the ,secretary determines to be valid1 except that any adjustment by the ,secretary under this subsection for a ,state may not result in an increase of the target total medical assistance expenditures exceeding #b percent4 7h7 ,required reporting and auditing of ,,cms-#fd data2 transitional increase in ,federal matching percentage for certain administrative expenses 7#a7 ,reporting ,in addition to the data required on form ,group ,,viii on the ,,cms-#fd report form as of ,january #a1 #bjag1 in each ,,cms-#fd report required to be submitted 7for each quarter beginning on or after ,october #a1 #bjah71 the ,state shall include data on medical assistance expenditures within such categories of services and categories of enrollees 7including each #aijc;,a enrollee category and each category of excluded individuals under subsection 7e77#a77 and the numbers of enrollees within each of such enrollee categories1 as the ,secretary determines are necessary 7including timely guidance published as soon as possible after the date of the enactment of this section7 in order to implement this section and to enable ,states to comply with the requirement of this paragraph on a timely basis4 7#b7 ,auditing ,the ,secretary shall conduct for each ,state an audit of the number of individuals and expenditures reported through the ,,cms-#fd report for fiscal year #bjaf1 fiscal year #bjai1 and each subsequent fiscal year1 which audit may be conducted on a representative sample 7as determined by the ,secretary74 7#c7 ,temporary increase in federal matching percentage to support improved data reporting systems for fiscal years #bjah and #bjai ,for amounts expended during calendar quarters beginning on or after ,october #a1 #bjag1 and before ,october #a1 #bjai-- 7,a7 the ,federal matching percentage applied under section #aijc7;a77#c77;,a77i7 shall be increased by #aj percentage points to #ajj percent2 7,b7 the ,federal matching percentage applied under section #aijc7;a77#c77;,b7 shall be increased by #be percentage points to #ajj percent2 and 7,c7 the ,federal matching percentage applied under section #aijc7;a77#g7 shall be increased by #aj percentage points to #fj percent but only with respect to amounts expended that are attributable to a ,state's additional administrative expenditures to implement the data requirements of paragraph 7#a74 7i7 ,flexible block grant option for ,states 7#a7 ,in general ,in the case of a ,state that elects the option of applying this subsection for a #aj-;fiscal-year period 7beginning no earlier than fiscal year #bjbj and1 at the ,state option1 for any succeeding #aj-;fiscal-year period7 and that has a plan approved by the ,secretary under paragraph 7#b7 to carry out the option for such period-- 7,a7 the ,state shall receive1 instead of amounts otherwise payable to the ,state under this title for medical assistance for block grant individuals within the applicable block grant category 7as defined in paragraph 7#f77 for the ,state during the period in which the election is in effect1 the amount specified in paragraph 7#d72 7,b7 the previous provisions of this section shall be applied as if-- 7i7 block grant individuals within the applicable block grant category for the ,state and period were not section #aijc;,a enrollees for each #aj-;fiscal year period for which the ,state elects to apply this subsection2 and 7ii7 if such option is not extended at the end of a #aj-;fiscal-year-period1 the per capita limitations under such previous provisions shall again apply after such period and such limitations shall be applied as if the election under this subsection had never taken place2 7,c7 the payment under this subsection may only be used consistent with the ,state plan under paragraph 7#b7 for block grant health care assistance 7as defined in paragraph 7#g772 and 7,d7 with respect to block grant individuals within the applicable block grant category for the ,state for which block grant health care assistance is made available under this subsection1 such assistance shall be instead of medical assistance otherwise provided to the individual under this title4 7#b7 ,state plan for administering block grant option 7,a7 ,in general ,no payment shall be made under this subsection to a ,state pursuant to an election for a #aj-;fiscal-year period under paragraph 7#a7 unless the ,state has a plan1 approved under subparagraph 7,b71 for such period that specifies-- 7i7 the applicable block grant category with respect to which the ,state will apply the option under this subsection for such period2 7ii7 the conditions for eligibility of block grant individuals within such applicable block grant category for block grant health care assistance under the option1 which shall be instead of other conditions for eligibility under this title1 except that in the case of a ,state that has elected the applicable block grant category described in-- 7,i7 subparagraph 7,a7 of paragraph 7#f71 the plan must provide for eligibility for pregnant women and children required to be provided medical assistance under subsections 7a77#aj77;,a77i7 and 7e77#d7 of section #aijb2 or 7,,ii7 subparagraph 7,b7 of paragraph 7#f71 the plan must provide for eligibility for pregnant women required to be provided medical assistance under subsection 7a77#aj77;,a77i72 and 7iii7 the types of items and services1 the amount1 duration1 and scope of such services1 the cost-sharing with respect to such services1 and the method for delivery of block grant health care assistance under this subsection1 which shall be instead of the such types1 amount1 duration1 and scope1 cost-sharing1 and methods of delivery for medical assistance otherwise required under this title1 except that the plan must provide for assistance for-- 7,i7 hospital care2 7,,ii7 surgical care and treatment2 7,,iii7 medical care and treatment2 7,,iv7 obstetrical and prenatal care and treatment2 7,v7 prescribed drugs1 medicines1 and prosthetic devices2 7,,vi7 other medical supplies and services2 and 7,,vii7 health care for children under #ah years of age4 7,b7 ,review and approval ,a plan described in subparagraph 7,a7 shall be deemed approved by the ,secretary unless the ,secretary determines1 within #cj days after the date of the ,secretary's receipt of the plan1 that the plan is incomplete or actuarially unsound and1 with respect to such plan and its implementation under this subsection1 the requirements of paragraphs 7#a71 7#aj77;,b71 7#ag71 and 7#bc7 of section #aijb7;a7 shall not apply4 7#c7 ,amount of block grant funds 7,a7 ,for initial fiscal year ,the block grant amount under this paragraph for a ,state for the initial fiscal year in the first #aj-;fiscal-year period is equal to the sum of the products 7for each applicable block grant category for such ,state and period7 of-- 7i7 the target per capita medical assistance expenditures for such ,state for such fiscal year 7under subsection 7c77#b772 7ii7 the number of #aijc;,a enrollees for such category and ,state for fiscal year #bjai1 as determined under subsection 7e77#d72 and 7iii7 the ,federal average medical assistance matching percentage 7as defined in subsection 7a77#d77 for the ,state for fiscal year #bjai4 7,b7 ,for any subsequent fiscal year ,the block grant amount under this paragraph for a ,state for each succeeding fiscal year 7in any #aj-;fiscal-year period7 is equal to the block grant amount under subparagraph 7,a7 7or this subparagraph7 for the ,state for the previous fiscal year increased by the annual increase in the consumer price index for all urban consumers 7all items2 ,u4,s4 city average7 for the fiscal year involved4 7,c7 ,availability of rollover funds ,the block grant amount under this paragraph for a ,state for a fiscal year shall remain available to the ,state for expenditures under this subsection for the succeeding fiscal year but only if an election is in effect under this subsection for the ,state in such succeeding fiscal year4 7#d7 ,federal payment and ,state responsibility ,the ,secretary shall pay to each ,state with an election in effect under this subsection for a fiscal year1 from its block grant amount under paragraph 7#c7 available for such fiscal year1 an amount for each quarter of such fiscal year equal to the enhanced ,,fmap described in the first sentence of section #baje7;b7 of the total amount expended under the ,state plan under this subsection during such quarter1 and the ,state is responsible for the balance of funds to carry out such plan4 7#e7 ,block grant individual defined ,in this subsection1 the term block grant individual means1 with respect to a ,state for a #aj-;fiscal-year period1 an individual who is not disabled 7as defined for purposes of the ,state plan7 and who is within an applicable block grant category for the ,state and such period4 7#f7 ,applicable block grant category defined ,in this subsection1 the term applicable block grant category means with respect to a ,state for a #aj-;fiscal-year period1 either of the following as specified by the ,state for such period in its plan under paragraph 7#b77;,a77i73 7,a7 #b enrollee categories ,both of the following #aijc;,a enrollee categories3 7i7 ,children ,the #aijc;,a enrollee category specified in subparagraph 7,c7 of subsection 7e77#b74 7ii7 ,other nonelderly1 nondisabled1 non-expansion adults ,the #aijc;,a enrollee category specified in subparagraph 7,e7 of such subsection4 7,b7 ,other nonelderly1 nondisabled1 non-expansion adults ,only the #aijc;,a enrollee category specified in subparagraph 7,e7 of subsection 7e77#b74 7#g7 ,block grant health care assistance ,in this subsection1 the term block grant health care assistance means assistance for health-care-related items and medical services for block grant individuals within the applicable block grant category for the ,state and #aj-;fiscal-year period involved who are low-income individuals 7as defined by the ,state74 7#h7 ,auditing ,as a condition of receiving funds under this subsection1 a ,state shall contract with an independent entity to conduct audits of its expenditures made with respect to activities funded under this subsection for each fiscal year for which the ,state elects to apply this subsection to ensure that such funds are used consistent with this subsection and shall make such audits available to the ,secretary upon the request of the ,secretary4 4 ,d ,patient ,relief and ,health ,insurance ,market ,stability #aca4 ,repeal of cost-sharing subsidy 7a7 ,in general ,section #adjb of the ,patient ,protection and ,affordable ,care ,act is repealed4 7b7 ,effective date ,the repeal made by subsection 7a7 shall apply to cost-sharing reductions 7and payments to issuers for such reductions7 for plan years beginning after ,december #ca1 #bjai4 #acb4 ,patient and ,state ,stability ,fund ,the ,social ,security ,act 7#db ,u4,s4,c4 #cja et seq47 is amended by adding at the end the following new title3 ,,xxii ,patient and ,state ,stability ,fund #bbja4 ,establishment of program ,there is hereby established the ,patient and ,state ,stability ,fund to be administered by the ,secretary of ,health and ,human ,services1 acting through the ,administrator of the ,centers for ,medicare ,medicaid ,services 7in this section referred to as the ,administrator71 to provide funding1 in accordance with this title1 to the #ej ,states and the ,district of ,columbia 7each referred to in this section as a ,state7 during the period1 subject to section #bbjd7;c71 beginning on ,january #a1 #bjah1 and ending on ,december #ca1 #bjbf1 for the purposes described in section #bbjb4 #bbjb4 ,use of funds 7a7 ,in ,general ,subject to subsections 7b7 and 7c71 a ,state may use the funds allocated to the ,state under this title for any of the following purposes3 7#a7 ,helping1 through the provision of financial assistance1 high-risk individuals who do not have access to health insurance coverage offered through an employer enroll in health insurance coverage in the individual market in the ,state1 as such market is defined by the ,state 7whether through the establishment of a new mechanism or maintenance of an existing mechanism for such purpose74 7#b7 ,providing incentives to appropriate entities to enter into arrangements with the ,state to help stabilize premiums for health insurance coverage in the individual market1 as such markets are defined by the ,state4 7#c7 ,reducing the cost for providing health insurance coverage in the individual market and small group market1 as such markets are defined by the ,state1 to individuals who have1 or are projected to have1 a high rate of utilization of health services 7as measured by cost7 and to individuals who have high costs of health insurance coverage due to the low density population of the ,state in which they reside4 7#d7 ,promoting participation in the individual market and small group market in the ,state and increasing health insurance options available through such market4 7#e7 ,promoting access to preventive services2 dental care services 7whether preventive or medically necessary72 vision care services 7whether preventive or medically necessary72 or any combination of such services4 7#f7 ,maternity coverage and newborn care4 7#g7 ,prevention1 treatment1 or recovery support services for individuals with mental or substance use disorders1 focused on either or both of the following3 7,a7 ,direct inpatient or outpatient clinical care for treatment of addiction and mental illness4 7,b7 ,early identification and intervention for children and young adults with serious mental illness4 7#h7 ,providing payments1 directly or indirectly1 to health care providers for the provision of such health care services as are specified by the ,administrator4 7#i7 ,providing assistance to reduce out-of-pocket costs1 such as copayments1 coinsurance1 premiums1 and deductibles1 of individuals enrolled in health insurance coverage in the ,state4 7b7 ,required use of increase in allotment ,a ,state shall use the additional allocation provided to the ,state from the funds appropriated under the second sentence of section #bbjd7;a7 for each year only for the purposes described in paragraphs 7#f7 and 7#g7 of subsection 7a74 7c7 ,required use of additional increase to certain waiver ,states to provide financial hardship assistance ,a ,state shall use the additional allocation provided to the ,state from the funds appropriated under the last sentence of section #bbjd7;a7 only in accordance with such last sentence4 #bbjc4 ,state eligibility and approval2 ,default safeguard 7a7 ,encouraging ,state options for allocations 7#a7 ,in general ,to be eligible for an allocation of funds under this title for a year during the period described in section #bbja for use for one or more purposes described in section #bbjb1 a ,state shall submit to the ,administrator an application at such time 7but1 in the case of allocations for #bjah1 not later than #de days after the date of the enactment of this title and1 in the case of allocations for a subsequent year1 not later than ,march #ca of the previous year7 and in such form and manner as specified by the ,administrator and containing-- 7,a7 a description of how the funds will be used for such purposes2 7,b7 a certification that the ,state will make1 from non-,federal funds1 expenditures for such purposes in an amount that is not less than the ,state percentage required for the year under section #bbjd7;e77#a72 and 7,c7 such other information as the ,administrator may require4 7#b7 ,automatic approval ,an application so submitted is approved unless the ,administrator notifies the ,state submitting the application1 not later than #fj days after the date of the submission of such application1 that the application has been denied for not being in compliance with any requirement of this title and of the reason for such denial4 7#c7 ,one-time application ,if an application of a ,state is approved for a year1 with respect to a purpose described in section #bbjb1 such application shall be treated as approved1 with respect to such purpose1 for each subsequent year through #bjbf4 7#d7 ,treatment as a ,state ,health ,care ,program ,any program receiving funds from an allocation for a ,state under this title1 including pursuant to subsection 7b71 shall be considered to be a ,state health care program for purposes of sections #aabh1 #aabh;,a1 and #aabh;,b4 7b7 ,default ,federal safeguard 7#a7 ,in general 7,a7 #bjah ,for allocations made under this title for #bjah1 in the case of a ,state that does not submit an application under subsection 7a7 by the #de-;day submission date applicable to such year under subsection 7a77#a7 and in the case of a ,state that does submit such an application by such date that is not approved1 subject to section #bbjd7;e71 the ,administrator1 in consultation with the ,state insurance commissioner1 shall use the allocation that would otherwise be provided to the ,state under this title for such year1 in accordance with paragraph 7#b71 for such ,state4 7,b7 #bjai through #bjbf ,in the case of a ,state that does not have in effect an approved application under this section for #bjai or a subsequent year beginning during the period described in section #bbja1 subject to section #bbjd7;e71 the ,administrator1 in consultation with the ,state insurance commissioner1 shall use the allocation that would otherwise be provided to the ,state under this title for such year1 in accordance with paragraph 7#b71 for such ,state4 7#b7 ,required use for market stabilization payments to issuers ,subject to section #bbjd7;a71 an allocation for a ,state made pursuant to paragraph 7#a7 for a year shall be used to carry out the purpose described in section #bbjb7b7 in such ,state by providing payments to appropriate entities described in such section with respect to claims that exceed #ej1jjj 7or1 with respect to allocations made under this title for #bjbj or a subsequent year during the period specified in section #bbja1 such dollar amount specified by the ,administrator71 but do not exceed #cej1jjj 7or1 with respect to allocations made under this title for #bjbj or a subsequent year during such period1 such dollar amount specified by the ,administrator71 in an amount equal to #ge percent 7or1 with respect to allocations made under this title for #bjbj or a subsequent year during such period1 such percentage specified by the ,administrator7 of the amount of such claims4 #bbjd4 ,allocations 7a7 ,appropriation ,for the purpose of providing allocations for ,states 7including pursuant to section #bbjc7;b77 under this title there is appropriated1 out of any money in the ,treasury not otherwise appropriated-- 7#a7 for #bjah1 #ae1jjj1jjj1jjj2 7#b7 for #bjai1 #ae1jjj1jjj1jjj2 7#c7 for #bjbj1 #aj1jjj1jjj1jjj2 7#d7 for #bjba1 #aj1jjj1jjj1jjj2 7#e7 for #bjbb1 #aj1jjj1jjj1jjj2 7#f7 for #bjbc1 #aj1jjj1jjj1jjj2 7#g7 for #bjbd1 #aj1jjj1jjj1jjj2 7#h7 for #bjbe1 #aj1jjj1jjj1jjj2 and 7#i7 for #bjbf1 #aj1jjj1jjj1jjj4 ,the amount otherwise appropriated under the previous sentence for #bjbj shall be increased by #ae1jjj1jjj1jjj1 to be used and available under subsection 7d7 only for the purposes described in paragraphs 7#f7 and 7#g7 of section #bbjb7;a74 ,the amount otherwise appropriated under this subsection shall be increased by #h1jjj1jjj1jjj for the period beginning with #bjah and ending with #bjbc1 to be allocated to ,states with a waiver in effect under section #bgja7;b7 of the ,public ,health ,service ,act with respect to the purpose described in paragraph 7#a77;,c7 of such section1 in accordance with an allocation methodology specified by the ,secretary that takes into account the relative allocation of other amounts appropriated under this subsection among such ,states1 and to be used by 7and made available under subsection 7d71 for any year during such period that such waiver is in effect1 to7 such ,states for the purpose of providing assistance to reduce premiums or other out-of-pocket costs of individuals who are subject to an increase in the monthly premium rate for health insurance coverage as a result of such waiver4 7b7 ,allocations 7#a7 ,payment 7,a7 ,in general ,from amounts appropriated under subsection 7a7 for a year1 the ,administrator shall1 with respect to a ,state and not later than the date specified under subparagraph 7,b7 for such year1 allocate1 subject to subsection 7e71 for such ,state 7including pursuant to section #bbjc7;b77 the amount determined for such ,state and year under paragraph 7#b74 7,b7 ,specified date ,for purposes of subparagraph 7,a71 the date specified in this subparagraph is-- 7i7 for #bjah1 the date that is #de days after the date of the enactment of this title2 and 7ii7 for #bjai and subsequent years1 ,january #a of the respective year4 7#b7 ,allocation amount determinations 7,a7 ,for #bjah and #bjai 7i7 ,in general ,for purposes of paragraph 7#a71 the amount determined under this paragraph for #bjah and #bjai for a ,state is an amount equal to the sum of-- 7,i7 the relative incurred claims amount described in clause 7ii7 for such ,state and year2 and 7,,ii7 the relative uninsured and issuer participation amount described in clause 7iv7 for such ,state and year4 7ii7 ,relative incurred claims amount ,for purposes of clause 7i71 the relative incurred claims amount described in this clause for a ,state for #bjah and #bjai is the product of-- 7,i7 #he percent of the amount appropriated under subsection 7a7 for the year2 and 7,,ii7 the relative ,state incurred claims proportion described in clause 7iii7 for such ,state and year4 7iii7 ,relative ,state incurred claims proportion ,the relative ,state incurred claims proportion described in this clause for a ,state and year is the amount equal to the ratio of-- 7,i7 the adjusted incurred claims by the ,state1 as reported through the medical loss ratio annual reporting under section #bgah of the ,public ,health ,service ,act for the third previous year2 to 7,,ii7 the sum of such adjusted incurred claims for all ,states1 as so reported1 for such third previous year4 7iv7 ,relative uninsured and issuer participation amount ,for purposes of clause 7i71 the relative uninsured and issuer participation amount described in this clause for a ,state for #bjah and #bjai is the product of-- 7,i7 #ae percent of the amount appropriated under subsection 7a7 for the year2 and 7,,ii7 the relative ,state uninsured and issuer participation proportion described in clause 7v7 for such ,state and year4 7v7 ,relative ,state uninsured and issuer participation proportion ,the relative ,state uninsured and issuer participation proportion described in this clause for a ,state and year is-- 7,i7 in the case of a ,state not described in clause 7vi7 for such year1 #j2 and 7,,ii7 in the case of a ,state described in clause 7vi7 for such year1 the amount equal to the ratio of-- 7aa7 the number of individuals residing in such ,state who for the third preceding year were not enrolled in a health plan or otherwise did not have health insurance coverage 7including through a ,federal or ,state health program7 and whose income is below #ajj percent of the poverty line applicable to a family of the size involved2 to 7bb7 the sum of the number of such individuals for all ,states described in clause 7vi7 for the third preceding year4 7vi7 ,states described ,for purposes of clause 7v71 a ,state is described in this clause1 with respect to #bjah and #bjai1 if the ,state satisfies either of the following criterion3 7,i7 ,the ratio described in subclause 7,,ii7 of clause 7v7 that would be determined for such ,state by substituting #bjae for each reference in such subclause to the third preceding year and by substituting all such ,states for the reference in item 7bb7 of such subclause to all ,states described in clause 7vi7 is greater than the ratio described in such subclause that would be determined for such ,state by substituting #bjac for each reference in such subclause to the third preceding year and by substituting all such ,states for the reference in item 7bb7 of such subclause to all ,states described in clause 7vi74 7,,ii7 ,the ,state has fewer than three health insurance issuers offering qualified health plans through the ,exchange for #bjag4 7,b7 ,for #bjbj through #bjbf ,for purposes of paragraph 7#a71 the amount determined under this paragraph for a year 7beginning with #bjbj7 during the period described in section #bbja for a ,state is an amount determined in accordance with an allocation methodology specified by the ,administrator which-- 7i7 takes into consideration the adjusted incurred claims of such ,state1 the number of residents of such ,state who for the previous year were not enrolled in a health plan or otherwise did not have health insurance coverage 7including through a ,federal or ,state health program7 and whose income is below #ajj percent of the poverty line applicable to a family of the size involved1 and the number of health insurance issuers participating in the insurance market in such ,state for such year2 7ii7 is established after consultation with health care consumers1 health insurance issuers1 ,state insurance commissioners1 and other stakeholders and after taking into consideration additional cost and risk factors that may inhibit health care consumer and health insurance issuer participation2 and 7iii7 reflects the goals of improving the health insurance risk pool1 promoting a more competitive health insurance market1 and increasing choice for health care consumers4 7c7 ,annual distribution of previous year's remaining funds ,in carrying out subsection 7b71 the ,administrator shall1 with respect to a year 7beginning with #bjbj and ending with #bjbg71 not later than ,march #ca of such year-- 7#a7 determine the amount of funds1 if any1 from the amounts appropriated under subsection 7a7 for the previous year but not allocated for such previous year2 and 7#b7 if the ,administrator determines that any funds were not so allocated for such previous year1 allocate such remaining funds1 in accordance with the allocation methodology specified pursuant to subsection 7b77#b77;,b7-- 7,a7 to ,states that have submitted an application approved under section #bbjc7;a7 for such previous year for any purpose for which such an application was approved2 and 7,b7 for ,states for which allocations were made pursuant to section #bbjc7;b7 for such previous year1 to be used by the ,administrator for such ,states1 to carry out the ,federal ,invisible ,risk ,sharing ,program in such ,states under section #bbje2 with1 respect to a year before #bjbg1 any remaining funds being made available for allocations to ,states for the subsequent year4 7d7 ,availability ,amounts appropriated under subsection 7a7 for a year and allocated to ,states in accordance with this section shall remain available for expenditure through ,december #ca1 #bjbg4 7e7 ,conditions for and limitations on receipt of funds ,the ,secretary may not make an allocation under this title for a ,state1 with respect to a purpose described in section #bbjb-- 7#a7 in the case of an allocation that would be made to a ,state pursuant to section #bbjc7;a71 if the ,state does not agree that the ,state will make available non-,federal contributions towards such purpose in an amount equal to-- 7,a7 for #bjbj1 #g percent of the amount allocated under this subsection to such ,state for such year and purpose2 7,b7 for #bjba1 #ad percent of the amount allocated under this subsection to such ,state for such year and purpose2 7,c7 for #bjbb1 #ba percent of the amount allocated under this subsection to such ,state for such year and purpose2 7,d7 for #bjbc1 #bh percent of the amount allocated under this subsection to such ,state for such year and purpose2 7,e7 for #bjbd1 #ce percent of the amount allocated under this subsection to such ,state for such year and purpose2 7,f7 for #bjbe1 #db percent of the amount allocated under this subsection to such ,state for such year and purpose2 and 7,g7 for #bjbf1 #ej percent of the amount allocated under this subsection to such ,state for such year and purpose2 7#b7 in the case of an allocation that would be made for a ,state pursuant to section #bbjc7;b71 if the ,state does not agree that the ,state will make available non-,federal contributions towards such purpose in an amount equal to-- 7,a7 for #bjbj1 #aj percent of the amount allocated under this subsection to such ,state for such year and purpose2 7,b7 for #bjba1 #bj percent of the amount allocated under this subsection to such ,state for such year and purpose2 and 7,c7 for #bjbb1 #cj percent of the amount allocated under this subsection to such ,state for such year and purpose2 7,d7 for #bjbc1 #dj percent of the amount allocated under this subsection to such ,state for such year and purpose2 7,e7 for #bjbd1 #ej percent of the amount allocated under this subsection to such ,state for such year and purpose2 7,f7 for #bjbe1 #ej percent of the amount allocated under this subsection to such ,state for such year and purpose2 and 7,g7 for #bjbf1 #ej percent of the amount allocated under this subsection to such ,state for such year and purpose2 or 7#c7 if such an allocation for such purpose would not be permitted under subsection 7c77#g7 of section #baje if such allocation were payment made under such section4 #bbje4 ,federal ,invisible ,risk ,sharing ,program 7a7 ,in general ,there is established within the ,patient and ,state ,stability ,fund a ,federal ,invisible ,risk ,sharing ,program 7in this section referred to as the ,program71 to be administered by the ,secretary of ,health and ,human ,services1 acting through the ,administrator of the ,centers for ,medicare ,medicaid ,services 7in this section referred to as the ,administrator71 to provide payments to health insurance issuers with respect to claims for eligible individuals for the purpose of lowering premiums for health insurance coverage offered in the individual market4 7b7 ,funding 7#a7 ,appropriation ,for the purpose of providing funding for the ,program there is appropriated1 out of any money in the ,treasury not otherwise appropriated1 #ae1jjj1jjj1jjj for the period beginning on ,january #a1 #bjah1 and ending on ,december #ca1 #bjbf4 7#b7 ,use of unallocated funds ,funds provided under section #bbjd7;c77#b77;,b7 to carry out this section are in addition to the amount appropriated under paragraph 7#a74 7c7 ,operation of program 7#a7 ,in general ,the ,administrator shall establish1 after consultation with health care consumers1 health insurance issuers1 ,state insurance commissioners1 and other stakeholders and after taking into consideration high cost health conditions and other health trends that generate high cost1 parameters for the operation of the ,program consistent with this section and consistent with the same limitation on payment with respect to health insurance coverage that applies to payment with respect health benefits coverage under section #baje7;c77#g74 7#b7 ,deadline for initial operation ,not later than #fj days after the date of the enactment of this title1 the ,administrator shall establish sufficient parameters to specify how the ,program will operate for plan year #bjah4 7#c7 ,state operation of program ,the ,administrator shall establish a process for a ,state to operate the ,program in such ,state beginning with plan year #bjbj4 7d7 ,details of program ,the parameters for the ,program shall include the following3 7#a7 ,eligible individuals ,a definition for eligible individuals4 7#b7 ,health status statements ,the development and use of health status statements with respect to such individuals4 7#c7 ,standards for qualification 7,a7 ,automatic qualification ,the identification of health conditions that automatically qualify individuals as eligible individuals at the time of application for health insurance coverage4 7,b7 ,voluntary qualification ,a process under which health insurance issuers may voluntarily qualify individuals1 who do not automatically qualify under subparagraph 7,a71 as eligible individuals at the time of application for such coverage4 7#d7 ,percentage of insurance premiums to be applied ,the percentage of the premiums paid1 to health insurance issuers for health insurance coverage by eligible individuals1 that shall be collected and deposited to the credit 7and available for the use7 of the ,program4 7#e7 ,attachment dollar amount and payment proportion ,the dollar amount of claims for eligible individuals after which the ,program will provide payments to health insurance issuers and the proportion of such claims above such dollar amount that the ,program will pay4 4 #acc4 ,continuous health insurance coverage incentive ,subpart ,i of part ,a of title ,,xxvii of the ,public ,health ,service ,act is amended-- 7#a7 in section #bgja7;a77#a77;,b71 by striking such rate and inserting subject to section #bgaj;,a1 such rate2 7#b7 by redesignating the second section #bgji as section #bgaj2 and 7#c7 by adding at the end the following new section3 #bgaj;,a4 ,encouraging continuous health insurance coverage 7a7 ,penalty applied 7#a7 ,in general ,subject to the succeeding provisions of this section1 a health insurance issuer offering health insurance coverage in the individual market shall1 in the case of an individual who is an applicable policyholder of such coverage with respect to an enforcement period applicable to enrollments for a plan year beginning with plan year #bjai 7or1 in the case of enrollments during a special enrollment period1 beginning with plan year #bjah71 increase the monthly premium rate otherwise applicable to such individual for such coverage during each month of such period1 by an amount determined under paragraph 7#b74 7#b7 ,amount of penalty ,the amount determined under this paragraph for an applicable policyholder enrolling in health insurance coverage described in paragraph 7#a7 for a plan year1 with respect to each month during the enforcement period applicable to enrollments for such plan year1 is the amount that is equal to #cj percent of the monthly premium rate otherwise applicable to such applicable policyholder for such coverage during such month4 7b7 ,definitions ,for purposes of this section3 7#a7 ,applicable policyholder ,the term applicable policyholder means1 with respect to months of an enforcement period and health insurance coverage1 an individual who-- 7,a7 is a policyholder of such coverage for such months2 7,b7 cannot demonstrate that 7through presentation of certifications described in section #bgjd7;e7 or in such other manner as may be specified in regulations1 such as a return or statement made under section #fjee7;d7 or #cf;,b of the ,internal ,revenue ,code of #aihf71 during the look-back period that is with respect to such enforcement period1 there was not a period of at least #fc continuous days during which the individual did not have creditable coverage 7as defined in paragraph 7#a7 of section #bgjd7;c7 and credited in accordance with paragraphs 7#b7 and 7#c7 of such section72 and 7,c7 in the case of an individual who had been enrolled under dependent coverage under a group health plan or health insurance coverage by reason of section #bgad and such dependent coverage of such individual ceased because of the age of such individual1 is not enrolling during the first open enrollment period following the date on which such coverage so ceased4 7#b7 ,look-back period ,the term look-back period means1 with respect to an enforcement period applicable to an enrollment of an individual for a plan year beginning with plan year #bjai 7or1 in the case of an enrollment of an individual during a special enrollment period1 beginning with plan year #bjah7 in health insurance coverage described in subsection 7a77#a71 the #ab-month period ending on the date the individual enrolls in such coverage for such plan year4 7#c7 ,enforcement period ,the term enforcement period means-- 7,a7 with respect to enrollments during a special enrollment period for plan year #bjah1 the period beginning with the first month that is during such plan year and that begins subsequent to such date of enrollment1 and ending with the last month of such plan year2 and 7,b7 with respect to enrollments for plan year #bjai or a subsequent plan year1 the #ab-month period beginning on the first day of the respective plan year4 4 #acd4 ,increasing coverage options ,section #acjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7 is amended-- 7#a7 in subsection 7a77#c71 by inserting and with respect to a plan year before plan year #bjbj after subsection 7e72 and 7#b7 in subsection 7d71 by adding at the end the following3 7#e7 ,sunset ,the provisions of this subsection shall not apply after ,december #ca1 #bjai1 and after such date any reference to this subsection or level of coverage or plan described in this subsection and any requirement under law applying such a level of coverage or plan shall have no force or effect 7and such a requirement shall be applied as if this section had been repealed74 4 #ace4 ,change in permissible age variation in health insurance premium rates ,section #bgja7;a77#a77;,a77iii7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg7a77#a77;,a77iii771 as inserted by section #abja7d7 of the ,patient ,protection and ,affordable ,care ,act1 is amended by inserting after 7consistent with section #bgjg7;c77 the following3 or1 for plan years beginning on or after ,january #a1 #bjah1 as the ,secretary may implement through interim final regulation1 #e to #a for adults 7consistent with section #bgjg7;c77 or such other ratio for adults 7consistent with section #bgjg7;c77 as the ,state involved may provide 7or1 in the case of a ,state with a waiver under subsection 7b7 in effect for such a plan year1 the ratio applied for such plan year in accordance with such waiver74 #acf4 ,permitting ,states to waive certain ,,aca requirements to encourage fair health insurance premiums 7a7 ,in general ,section #bgja of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg7 is amended by adding at the end the following new subsection3 7b7 ,permissible ,state waiver to encourage fair health insurance premiums 7#a7 ,in general ,a ,state may submit an application to the ,secretary for one or more of the following purposes3 7,a7 ,in the case of plan years beginning on or after ,january #a1 #bjah1 to apply1 subject to paragraph 7#e71 under subsection 7a77#a77;,a77iii71 instead of the ratio specified in such subsection1 a higher ratio specified by the ,state 7consistent with section #bgjg7;c774 7,b7 ,in the case of plan years beginning on or after ,january #a1 #bjbj1 for health insurance coverage offered in the individual or small group market in such ,state1 to apply1 subject to paragraph 7#e71 instead of the essential health benefits specified under subsection 7b7 of section #acjb of the ,patient ,protection and ,affordable ,care ,act1 essential health benefits as specified by the ,state4 7,c7 ,in the case of a ,state that has in place a program that carries out the purpose described in paragraph 7#a7 or 7#b7 of section #bbjb7;a7 of the ,social ,security ,act or participates in the program established under section #bbje of such ,act1 for health insurance offered in the individual market in such ,state1 with respect to an individual who is an applicable policyholder of such coverage with respect to an enforcement period 7as defined in section #bgaj;,a7b77 applicable to enrollments for a plan year beginning with plan year #bjai 7or1 in the case of enrollments during a special enrollment period1 beginning with plan year #bjah71 to-- 7i7 subject to paragraph 7#e71 not apply any increase to the monthly premium rate that would otherwise apply under section #bgaj;,a to such individual for such coverage2 and 7ii7 instead1 subject to paragraph 7#e7-- 7,i7 apply subsection 7a77#a7 as if health status were included as a factor described in subparagraph 7,a7 of such subsection2 and 7,,ii7 not apply section #bgje7;b74 7#b7 ,default approval ,an application submitted under paragraph 7#a7 is approved unless the ,secretary notifies the ,state submitting the application1 not later than #fj days after the date of the submission of such application1 that the application has been denied for not being in compliance with any requirement of paragraph 7#c7 and of the reason for such denial4 7#c7 ,requirements ,the requirements of this paragraph1 with respect to an application submitted under paragraph 7#a71 are the following3 7,a7 ,the application is submitted at such time1 and in such manner1 as the ,secretary may require4 7,b7 ,the application specifies how the approval of such application will provide for one or more of the following3 7i7 ,reducing average premiums for health insurance coverage in the ,state4 7ii7 ,increasing enrollment in health insurance coverage in the ,state4 7iii7 ,stabilizing the market for health insurance coverage in the ,state4 7iv7 ,stabilizing premiums for individuals with pre-existing conditions4 7v7 ,increasing the choice of health plans in the ,state4 7,c7 ,the application specifies the period for which the waiver is to be effective1 consistent with paragraph 7#d74 7,d7 ,in the case of an application for purposes of paragraph 7#a77;,a71 the application specifies the higher ratio to be applied pursuant to such paragraph4 7,e7 ,in the case of an application for purposes of paragraph 7#a77;,b71 the application specifies the essential health benefits to be applied pursuant to such paragraph4 7,f7 ,in the case of an application for purposes of paragraph 7#a77;,c71 the application demonstrates that the ,state has in place a program that carries out the purpose described in paragraph 7#a7 or 7#b7 of section #bbjb7;a7 of the ,social ,security ,act or participates in the program established under section #bbje of such ,act4 7#d7 ,term of waiver 7,a7 ,in general ,no waiver for a ,state under this subsection may extend over a period of longer than #aj years unless the ,state requests continuation of such waiver1 and such request shall be deemed granted unless the ,secretary1 within #ij days after the date of its submission to the ,secretary1 either denies such request in writing or informs the ,state in writing with respect to any additional information which is needed in order to make a final determination with respect to the request4 7,b7 ,special rule ,a waiver applied for by a ,state under paragraph 7#a77;,c7 may only be effective for a period during which the ,state-- 7i7 has in place a program that carries out the purpose described in paragraph 7#a7 or 7#b7 of section #bbjb7;a7 of the ,social ,security ,act2 or 7ii7 participates in the program established under section #bbje of such ,act4 7#e7 ,non-application rules 7,a7 ,specified non-application provisions ,in no case may a waiver for purposes of paragraph 7#a7 apply with respect to any of the following provisions3 7i7 ,section #acja of the ,patient ,protection and ,affordable ,care ,act1 to the extent that such section applies to qualified health plans offered through the ,,co-,,op program under section #acbb of such ,act or multi-,state plans under section #accd of such ,act4 7ii7 ,sections #acab7;d77#c77;,d71 #acca1 #accb1 #accc1 and #accd of such ,act4 7,b7 ,hold harmless ,any standard or requirement adopted by a ,state pursuant to the terms of a waiver approved under this subsection shall be deemed to comply with section #abeb of the ,patient ,protection and ,affordable ,care ,act and subsection 7a7 of section #acbd of such ,act1 insofar as such standard or requirement relates to a ,federal or ,state law described in subsection 7b77#b7 of such section 7relating to rating74 4 7b7 ,application to essential health benefits ,section #acjb7;a77#a7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;a77#a77 is amended by inserting 7or1 in the case of health insurance coverage offered in the individual or small group market in a ,state for which there is an applicable waiver in effect under section #bgja7;b7 of the ,public ,health ,service ,act for a plan year1 the essential health benefits applicable under such waiver7 after subsection 7b74 #acg4 ,constructions 7a7 ,no gender rating ,nothing in this ,act shall be construed as permitting health insurance issuers to discriminate in rates for health insurance coverage by gender4 7b7 ,no limiting access to coverage for individuals with preexisting conditions ,nothing in this ,act shall be construed as permitting health insurance issuers to limit access to health coverage for individuals with preexisting conditions4 ,e ,implementation ,funding #ada4 ,american ,health ,care ,implementation ,fund 7a7 ,in general ,there is hereby established an ,american ,health ,care ,implementation ,fund 7referred to in this section as the ,fund7 within the ,department of ,health and ,human ,services to carry out sections #aba1 #acb1 #bjb1 and #bad 7including the amendments made by such sections74 7b7 ,funding ,there is appropriated to the ,fund1 out of any funds in the ,treasury not otherwise appropriated1 #a1jjj1jjj1jjj for ,federal administrative expenses to carry out the sections described in subsection 7a7 7including the amendments made by such sections74 ,,ii ,committee on ,ways and ,means ,a ,repeal and ,replace of ,health-,related ,tax ,policy #bja4 ,recapture excess advance payments of premium tax credits ,subparagraph 7,b7 of section #cf;,b7f77#b7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new clause3 7iii7 ,nonapplicability of limitation ,this subparagraph shall not apply to taxable years beginning after ,december #ca1 #bjag1 and before ,january #a1 #bjbj4 4 #bjb4 ,additional modifications to premium tax credit 7a7 ,modification of definition of qualified health plan 7#a7 ,in general ,section #cf;,b7c77#c77;,a7 of the ,internal ,revenue ,code of #aihf is amended-- 7,a7 by inserting 7determined without regard to subparagraphs 7,a71 7,c77ii71 and 7,c77iv7 of paragraph 7#a7 thereof and without regard to whether the plan is offered on an ,exchange7 after #acja7;a7 of the ,patient ,protection and ,affordable ,care ,act1 and 7,b7 by striking shall not include and all that follows and inserting shall not include any health plan that-- 7i7 is a grandfathered health plan or a grandmothered health plan1 or 7ii7 includes coverage for abortions 7other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest74 4 7#b7 ,definition of grandmothered health plan ,section #cf;,b7c77#c7 of such ,code is amended by adding at the end the following new subparagraph3 7,c7 ,grandmothered health plan 7i7 ,in general ,the term grandmothered health plan means health insurance coverage which is offered in the individual health insurance market as of ,october #a1 #bjac1 and is permitted to be offered in such market after ,january #a1 #bjad1 as a result of ,,cciio guidance4 7ii7 ,,cciio guidance defined ,the term ,,cciio guidance means the letter issued by the ,centers for ,medicare ,medicaid ,services on ,november #ad1 #bjac1 to the ,state ,insurance ,commissioners outlining a transitional policy for non-grandfathered coverage in the individual health insurance market1 as subsequently extended and modified 7including by a communication entitled ,insurance ,standards ,bulletin ,series--,,information--,extension of ,transitional ,policy through ,calendar ,year #bjag issued on ,february #bi1 #bjaf1 by the ,director of the ,center for ,consumer ,information ,insurance ,oversight of such ,centers74 7iii7 ,individual health insurance market ,the term individual health insurance market means the market for health insurance coverage 7as defined in section #ihcb7;b77 offered to individuals other than in connection with a group health plan 7within the meaning of section #ejjj7;b77#a774 4 7#c7 ,conforming amendment related to abortion coverage ,section #cf;,b7c77#c7 of such ,code1 as amended by paragraph 7#b71 is amended by adding at the end the following new subparagraph3 7,d7 ,certain rules related to abortion 7i7 ,option to purchase separate coverage or plan ,nothing in subparagraph 7,a7 shall be construed as prohibiting any individual from purchasing separate coverage for abortions described in such subparagraph1 or a health plan that includes such abortions1 so long as no credit is allowed under this section with respect to the premiums for such coverage or plan4 7ii7 ,option to offer coverage or plan ,nothing in subparagraph 7,a7 shall restrict any health insurance issuer offering a health plan from offering separate coverage for abortions described in such subparagraph1 or a plan that includes such abortions1 so long as premiums for such separate coverage or plan are not paid for with any amount attributable to the credit allowed under this section 7or the amount of any advance payment of the credit under section #adab of the ,patient ,protection and ,affordable ,care ,act74 7iii7 ,other treatments ,the treatment of any infection1 injury1 disease1 or disorder that has been caused by or exacerbated by the performance of an abortion shall not be treated as an abortion for purposes of subparagraph 7,a74 4 7#d7 ,conforming amendments related to off-,exchange coverage 7,a7 ,advance payment not applicable ,section #adab of the ,patient ,protection and ,affordable ,care ,act is amended by adding at the end the following new subsection3 7f7 ,exclusion of off-,exchange coverage ,advance payments under this section1 and advance determinations under section #adaa1 with respect to any credit allowed under section #cf;,b shall not be made with respect to any health plan which is not enrolled in through an ,exchange4 4 7,b7 ,reporting ,section #fjee7;b7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new paragraph3 7#c7 ,information relating to off-,exchange premium credit eligible coverage ,if minimum essential coverage provided to an individual under subsection 7a7 consists of a qualified health plan 7as defined in section #cf;,b7c77#c77 which is not enrolled in through an ,exchange established under title ,i of the ,patient ,protection and ,affordable ,care ,act1 a return described in this subsection shall include-- 7,a7 a statement that such plan is a qualified health plan 7as defined in section #cf;,b7c77#c771 7,b7 the premiums paid with respect to such coverage1 7,c7 the months during which such coverage is provided to the individual1 7,d7 the adjusted monthly premium for the applicable second lowest cost silver plan 7as defined in section #cf;,b7b77#c77 for each such month with respect to such individual1 and 7,e7 such other information as the ,secretary may prescribe4 4 7,c7 ,other conforming amendments 7i7 ,section #cf;,b7b77#b77;,a7 of such ,code is amended by striking and which were enrolled and all that follows and inserting 1 or4 7ii7 ,section #cf;,b7b77#c77;,b77i7 of such ,code is amended by striking the same ,exchange and all that follows and inserting the ,exchange through which such taxpayer is permitted to obtain coverage1 and4 7iii7 ,section #cf;,b7c77#b77;,a77i7 of such ,code is amended by striking that was enrolled in through an ,exchange established by the ,state under section #acaa of the ,patient ,protection and ,affordable ,care ,act4 7b7 ,modification of applicable percentage ,section #cf;,b7b77#c77;,a7 of such ,code is amended to read as follows3 7,a7 ,applicable percentage 7i7 ,in general ,the applicable percentage for any taxable year shall be the percentage such that the applicable percentage for any taxpayer whose household income is within an income tier specified in the following table shall increase1 on a sliding scale in a linear manner1 from the initial percentage to the final percentage specified in such table for such income tier with respect to a taxpayer of the age involved3 ,in the case of household income 7expressed as a percent of the poverty line7 within the following income tier3,up to ,age #bi;,age #cj-ci;,age #dj-di;,age #ej-ei,over ,age #ei ,initial ,final ,initial ,final ,initial ,final ,initial ,final ,initial ,final ,up to #accbbbbbbbbbb #acc-aejcdcdcdcdcd #aej-bjjdd4cde4cdf4cdg4cdh4c #bjj-bejd4cd4ce4ce4if4ch4jeg4cih4caj #bej-cjjd4cd4ce4ie4ih4jeh4ceiaj4eajaa4e #cjj-djjd4cd4ce4ie4ih4ceh4ceaj4eaj4eaa4e aa4e 7ii7 ,age determinations 7,i7 ,in general ,for purposes of clause 7i71 the age of the taxpayer taken into account under clause 7i7 with respect to any taxable year is the age attained by such taxpayer before the close of such taxable year4 7,,ii7 ,joint returns ,in the case of a joint return1 the age of the older spouse shall be taken into account under clause 7i74 7iii7 ,indexing ,in the case of any taxable year beginning in calendar year #bjai1 the initial and final percentages contained in clause 7i7 shall be adjusted to reflect-- 7,i7 the excess 7if any7 of the rate of premium growth for the period beginning with calendar year #bjac and ending with calendar year #bjah1 over the rate of income growth for such period1 and 7,,ii7 in addition to any adjustment under subclause 7,i71 the excess 7if any7 of the rate of premium growth for calendar year #bjah1 over the rate of growth in the consumer price index for calendar year #bjah4 7iv7 ,failsafe ,clause 7iii77,,ii7 shall apply only if the aggregate amount of premium tax credits under this section and cost-sharing reductions under section #adjb of the ,patient ,protection and ,affordable ,care ,act for calendar year #bjah exceeds an amount equal to #j4ejd percent of the gross domestic product for such calendar year4 4 7c7 ,effective date 7#a7 ,in general ,except as otherwise provided in this subsection1 the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjag4 7#b7 ,advance payment not applicable to off-,exchange coverage ,the amendment made by subsection 7a77#d77;,a7 shall take effect on ,january #a1 #bjah4 7#c7 ,reporting ,the amendment made by subsection 7a77#d77;,b7 shall apply to coverage provided for months beginning after ,december #ca1 #bjag4 7#d7 ,modification of applicable percentage ,the amendment made by subsection 7b7 shall apply to taxable years beginning after ,december #ca1 #bjah4 #bjc4 ,small business tax credit 7a7 ,in general ,section #de,r of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7j7 ,shall not apply ,this section shall not apply with respect to amounts paid or incurred in taxable years beginning after ,december #ca1 #bjai4 4 7b7 ,disallowance of small employer health insurance expense credit for plan which includes coverage for abortion ,subsection 7h7 of section #de,r of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 by striking ,any term and inserting the following3 7#a7 ,in general ,any term 2 and 7#b7 by adding at the end the following new paragraph3 7#b7 ,exclusion of health plans including coverage for abortion 7,a7 ,in general ,the term qualified health plan does not include any health plan that includes coverage for abortions 7other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest74 7,b7 ,certain rules related to abortion 7i7 ,option to purchase separate coverage or plan ,nothing in subparagraph 7,a7 shall be construed as prohibiting any employer from purchasing for its employees separate coverage for abortions described in such subparagraph1 or a health plan that includes such abortions1 so long as no credit is allowed under this section with respect to the employer contributions for such coverage or plan4 7ii7 ,option to offer coverage or plan ,nothing in subparagraph 7,a7 shall restrict any health insurance issuer offering a health plan from offering separate coverage for abortions described in such subparagraph1 or a plan that includes such abortions1 so long as such separate coverage or plan is not paid for with any employer contribution eligible for the credit allowed under this section4 7iii7 ,other treatments ,the treatment of any infection1 injury1 disease1 or disorder that has been caused by or exacerbated by the performance of an abortion shall not be treated as an abortion for purposes of subparagraph 7,a74 4 7c7 ,effective dates 7#a7 ,in general ,the amendment made by subsection 7a7 shall apply to taxable years beginning after ,december #ca1 #bjai4 7#b7 ,disallowance of small employer health insurance expense credit for plan which includes coverage for abortion ,the amendments made by subsection 7b7 shall apply to taxable years beginning after ,december #ca1 #bjag4 #bjd4 ,individual mandate 7a7 ,in general ,section #ejjj;,a7c7 of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 in paragraph 7#b77;,b77iii71 by striking #b4e percent and inserting ,zero percent1 and 7#b7 in paragraph 7#c7-- 7,a7 by striking #fie in subparagraph 7,a7 and inserting #j1 and 7,b7 by striking subparagraph 7,d74 7b7 ,effective date ,the amendments made by this section shall apply to months beginning after ,december #ca1 #bjae4 #bje4 ,employer mandate 7a7 ,in general 7#a7 ,paragraph 7#a7 of section #dihj;,h7c7 of the ,internal ,revenue ,code of #aihf is amended by inserting 7#j in the case of months beginning after ,december #ca1 #bjae7 after #b1jjj4 7#b7 ,paragraph 7#a7 of section #dihj;,h7b7 of the ,internal ,revenue ,code of #aihf is amended by inserting 7#j in the case of months beginning after ,december #ca1 #bjae7 after #c1jjj4 7b7 ,effective date ,the amendments made by this section shall apply to months beginning after ,december #ca1 #bjae4 #bjf4 ,repeal of the tax on employee health insurance premiums and health plan benefits ,section #dihj;,i of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7h7 ,shall not apply ,no tax shall be imposed under this section with respect to any taxable period beginning after ,december #ca1 #bjai1 and before ,january #a1 #bjbf4 4 #bjg4 ,repeal of tax on over-the-counter medications 7a7 ,h,s,as ,subparagraph 7,a7 of section #bbc7;d77#b7 of the ,internal ,revenue ,code of #aihf is amended by striking ,such term and all that follows through the period4 7b7 ,archer ,m,s,as ,subparagraph 7,a7 of section #bbj7;d77#b7 of the ,internal ,revenue ,code of #aihf is amended by striking ,such term and all that follows through the period4 7c7 ,health flexible spending arrangements and health reimbursement arrangements ,section #ajf of the ,internal ,revenue ,code of #aihf is amended by striking subsection 7f7 and by redesignating subsection 7g7 as subsection 7f74 7d7 ,effective dates 7#a7 ,distributions from savings accounts ,the amendments made by subsections 7a7 and 7b7 shall apply to amounts paid with respect to taxable years beginning after ,december #ca1 #bjaf4 7#b7 ,reimbursements ,the amendment made by subsection 7c7 shall apply to expenses incurred with respect to taxable years beginning after ,december #ca1 #bjaf4 #bjh4 ,repeal of increase of tax on health savings accounts 7a7 ,h,s,as ,section #bbc7;f77#d77;,a7 of the ,internal ,revenue ,code of #aihf is amended by striking #bj percent and inserting #aj percent4 7b7 ,archer ,m,s,as ,section #bbj7;f77#d77;,a7 of the ,internal ,revenue ,code of #aihf is amended by striking #bj percent and inserting #ae percent4 7c7 ,effective date ,the amendments made by this section shall apply to distributions made after ,december #ca1 #bjaf4 #bji4 ,repeal of limitations on contributions to flexible spending accounts 7a7 ,in general ,section #abe of the ,internal ,revenue ,code of #aihf is amended by striking subsection 7i74 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjaf4 #baj4 ,repeal of medical device excise tax ,section #daia of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7d7 ,applicability ,the tax imposed under subsection 7a7 shall not apply to sales after ,december #ca1 #bjaf4 4 #baa4 ,repeal of elimination of deduction for expenses allocable to medicare part ,d subsidy 7a7 ,in general ,section #aci;,a of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new sentence3 ,this section shall not be taken into account for purposes of determining whether any deduction is allowable with respect to any cost taken into account in determining such payment44 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjaf4 #bab4 ,reduction of income threshold for determining medical care deduction 7a7 ,in general ,subsection 7a7 of section #bac of the ,internal ,revenue ,code of #aihf is amended by striking #aj percent and inserting #e4h percent4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjaf4 #bac4 ,repeal of ,medicare tax increase 7a7 ,in general ,subsection 7b7 of section #caja of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7b7 ,hospital insurance ,in addition to the tax imposed by the preceding subsection1 there is hereby imposed on the income of every individual a tax equal to #a4de percent of the wages 7as defined in section #caba7;a77 received by such individual with respect to employment 7as defined in section #caba7;b774 4 7b7 ,,seca ,subsection 7b7 of section #adja of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7b7 ,hospital insurance ,in addition to the tax imposed by the preceding subsection1 there shall be imposed for each taxable year1 on the self-employment income of every individual1 a tax equal to #b4i percent of the amount of the self-employment income for such taxable year4 4 7c7 ,effective date ,the amendments made by this section shall apply with respect to remuneration received after1 and taxable years beginning after1 ,december #ca1 #bjbb4 #bad4 ,refundable tax credit for health insurance coverage 7a7 ,in general ,section #cf;,b of the ,internal ,revenue ,code of #aihf is amended to read as follows3 #cf;,b4 ,refundable credit for coverage under a qualified health plan 7a7 ,allowance of premium tax credit ,in the case of an individual1 there shall be allowed as a credit against the tax imposed by this subtitle for the taxable year the sum of the monthly credit amounts with respect to such taxpayer for calendar months during such taxable year which are eligible coverage months appropriately taken into account under subsection 7b77#b7 with respect to the taxpayer or any qualifying family member of the taxpayer4 7b7 ,monthly credit amounts 7#a7 ,in general ,the monthly credit amount with respect to any taxpayer for any calendar month is the lesser of-- 7,a7 the sum of the monthly limitation amounts determined under subsection 7c7 with respect to the taxpayer and the taxpayer's qualifying family members for such month1 or 7,b7 the amount paid for a qualified health plan for the taxpayer and the taxpayer's qualifying family members for such month4 7#b7 ,eligible coverage month requirement ,no amount shall be taken into account under subparagraph 7,a7 or 7,b7 of paragraph 7#a7 with respect to any individual for any month unless such month is an eligible coverage month with respect to such individual4 7c7 ,monthly limitation amounts 7#a7 ,in general ,the monthly limitation amount with respect to any individual for any eligible coverage month during any taxable year is #a_/ab of-- 7,a7 #b1jjj in the case of an individual who has not attained age #cj as of the beginning of such taxable year1 7,b7 #b1ejj in the case of an individual who has attained age #cj but who has not attained age #dj as of such time1 7,c7 #c1jjj in the case of an individual who has attained age #dj but who has not attained age #ej as of such time1 7,d7 #c1ejj in the case of an individual who has attained age #ej but who has not attained age #fj as of such time1 and 7,e7 #d1jjj in the case of an individual who has attained age #fj as of such time4 7#b7 ,limitation based on modified adjusted gross income ,the credit allowed under subsection 7a7 with respect to any taxpayer for any taxable year shall be reduced 7but not below zero7 by #aj percent of the excess 7if any7 of-- 7,a7 the taxpayer's modified adjusted gross income 7as defined in section #cf;,b7d77#b77;,b71 as in effect for taxable years beginning before ,january #a1 #bjbj7 for such taxable year1 over 7,b7 #ge1jjj 7twice such amount in the case of a joint return74 7#c7 ,other limitations 7,a7 ,aggregate dollar limitation ,the sum of the monthly limitation amounts taken into account under this section with respect to any taxpayer for any taxable year shall not exceed #ad1jjj4 7,b7 ,maximum number of individuals taken into account ,with respect to any taxpayer for any month1 monthly limitation amounts shall be taken into account under this section only with respect to the #e oldest individuals with respect to whom monthly limitation amounts could 7without regard to this subparagraph7 otherwise be so taken into account4 7d7 ,eligible coverage month ,for purposes of this section1 the term eligible coverage month means1 with respect to any individual1 any month if1 as of the first day of such month1 the individual meets the following requirements3 7#a7 ,the individual is covered by a health insurance coverage which is certified by the ,state in which such insurance is offered as coverage that meets the requirements for qualified health plans under subsection 7f74 7#b7 ,the individual is not eligible for-- 7,a7 coverage under a group health plan 7within the meaning of section #ejjj7;b77#a77 other than coverage under a plan substantially all of the coverage of which is of excepted benefits described in section #ihcb7;c71 or 7,b7 coverage described in section #ejjj;,a7f77#a77;,a74 7#c7 ,the individual is either-- 7,a7 a citizen or national of the ,united ,states1 or 7,b7 a qualified alien 7within the meaning of section #dca of the ,personal ,responsibility and ,work ,opportunity ,reconciliation ,act of #aiif 7#h ,u4,s4,c4 #afda774 7#d7 ,the individual is not incarcerated1 other than incarceration pending the disposition of charges4 7e7 ,qualifying family member ,for purposes of this section1 the term qualifying family member means-- 7#a7 in the case of a joint return1 the taxpayer's spouse1 7#b7 any dependent of the taxpayer1 and 7#c7 with respect to any eligible coverage month1 any child 7as defined in section #aeb7;f77#a77 of the taxpayer who as of the end of the taxable year has not attained age #bg if such child is covered for such month under a qualified health plan which also covers the taxpayer 7in the case of a joint return1 either spouse74 7f7 ,qualified health plan ,for purposes of this section1 the term qualified health plan means any health insurance coverage 7as defined in section #ihcb7;b77 if-- 7#a7 such coverage is offered in the individual health insurance market within a ,state 7within the meaning of section #ejjj;,a7f77#a77;,c771 7#b7 substantially all of such coverage is not of excepted benefits described in section #ihcb7;c71 7#c7 such coverage does not consist of short-term limited duration insurance 7within the meaning of section #bgia7;b77#e7 of the ,public ,health ,service ,act71 7#d7 such coverage is not a grandfathered health plan 7as defined in section #abea of the ,patient ,protection and ,affordable ,care ,act7 or a grandmothered health plan 7as defined in section #cf;,b7c77#c77;,c7 as in effect for taxable years beginning before ,january #a1 #bjbj71 and 7#e7 such coverage does not include coverage for abortions 7other than any abortion necessary to save the life of the mother or any abortion with respect to a pregnancy that is the result of an act of rape or incest74 7g7 ,special rules 7#a7 ,married couples must file joint return 7,a7 ,in general ,except as provided in subparagraph 7,b71 if the taxpayer is married 7within the meaning of section #ggjc7 at the close of the taxable year1 no credit shall be allowed under this section to such taxpayer unless such taxpayer and the taxpayer's spouse file a joint return for such taxable year4 7,b7 ,exception for certain taxpayers ,subparagraph 7,a7 shall not apply to any married taxpayer who-- 7i7 is living apart from the taxpayer's spouse at the time the taxpayer files the tax return1 7ii7 is unable to file a joint return because such taxpayer is a victim of domestic abuse or spousal abandonment1 7iii7 certifies on the tax return that such taxpayer meets the requirements of clauses 7i7 and 7ii71 and 7iv7 has not met the requirements of clauses 7i71 7ii71 and 7iii7 for each of the #c preceding taxable years4 7#b7 ,denial of credit to dependents 7,a7 ,in general ,no credit shall be allowed under this section to any individual who is a dependent with respect to another taxpayer for a taxable year beginning in the calendar year in which such individual's taxable year begins4 7,b7 ,coordination with rule for older children ,in the case of any individual who is a qualifying family member described in subsection 7e77#c7 with respect to another taxpayer for any month1 in determining the amount of any credit allowable to such individual under this section for any taxable year of such individual which includes such month1 the monthly limitation amount with respect to such individual for such month shall be zero and no amount paid for any qualified health plan with respect to such individual for such month shall be taken into account4 7#c7 ,coordination with medical expense deduction ,amounts described in subsection 7b77#a77;,b7 with respect to any month shall not be taken into account in determining the deduction allowed under section #bac except to the extent that such amounts exceed the amount described in subsection 7b77#a77;,a7 with respect to such month4 7#d7 ,coordination with advance payments of credit ,with respect to any taxable year-- 7,a7 the amount which would 7but for this subsection7 be allowed as a credit to the taxpayer under subsection 7a7 shall be reduced 7but not below zero7 by the aggregate amount paid on behalf of such taxpayer under section #adab of the ,patient ,protection and ,affordable ,care ,act for months beginning in such taxable year1 and 7,b7 the tax imposed by section #a for such taxable year shall be increased by the excess 7if any7 of-- 7i7 the aggregate amount paid on behalf of such taxpayer under such section #adab for months beginning in such taxable year1 over 7ii7 the amount which would 7but for this subsection7 be allowed as a credit to the taxpayer under subsection 7a74 7#e7 ,special rules for qualified small employer health reimbursement arrangements 7,a7 ,in general ,if the taxpayer or any qualifying family member of the taxpayer is provided a qualified small employer health reimbursement arrangement for an eligible coverage month1 the sum determined under subsection 7b77#a77;,a7 with respect to the taxpayer shall be reduced 7but not below zero7 by #a_/ab of the permitted benefit 7as defined in section #ihca7;d77#c77;,c77 under such arrangement for each such month such arrangement is provided to such taxpayer4 7,b7 ,qualified small employer health reimbursement arrangement ,for purposes of this paragraph1 the term qualified small employer health reimbursement arrangement has the meaning given such term by section #ihca7;d77#b74 7,c7 ,coverage for less than entire year ,in the case of an employee who is provided a qualified small employer health reimbursement arrangement for less than an entire year1 subparagraph 7,a7 shall be applied by substituting the number of months during the year for which such arrangement was provided for #ab4 7#f7 ,certain rules related to nonqualified health plans ,the rules of section #cf;,b7c77#c77;,d71 as in effect for taxable years beginning before ,january #a1 #bjbj1 shall apply with respect to subsection 7f77#e74 7#g7 ,inflation adjustment 7,a7 ,in general ,in the case of any taxable year beginning in a calendar year after #bjbj1 each dollar amount in subsection 7c77#a71 the #ge1jjj amount in subsection 7c77#b77;,b71 and the dollar amount in subsection 7c77#c77;,a71 shall be increased by an amount equal to-- 7i7 such dollar amount1 multiplied by 7ii7 the cost-of-living adjustment determined under section #a7;f77#c7 for the calendar year in which the taxable year begins1 determined-- 7,i7 by substituting calendar year #bjai for calendar year #aiib in subparagraph 7,b7 thereof1 and 7,,ii7 by substituting for the ,,cpi referred to section #a7;f77#c77;,a7 the amount that such ,,cpi would have been if the annual percentage increase in ,,cpi with respect to each year after #bjai had been one percentage point greater4 7,b7 ,terms related to ,,cpi 7i7 ,annual percentage increase ,for purposes of subparagraph 7,a77ii77,,ii71 the term annual percentage increase means the percentage 7if any7 by which ,,cpi for any year exceeds ,,cpi for the prior year4 7ii7 ,other terms ,terms used in this paragraph which are also used in section #a7;f77#c7 shall have the same meanings as when used in such section4 7,c7 ,rounding ,any increase determined under subparagraph 7,a7 shall be rounded to the nearest multiple of #ej4 7#h7 ,rules related to ,state certification of qualified health plans ,a certification shall not be taken into account under subsection 7d77#a7 unless such certification is made available to the public and meets such other requirements as the ,secretary may provide4 7#i7 ,regulations ,the ,secretary may prescribe such regulations and other guidance as may be necessary or appropriate to carry out this section and section #adab of the ,patient ,protection and ,affordable ,care ,act4 4 7b7 ,advance payment of credit ,section #adab7;f7 of the ,patient ,protection and ,affordable ,care ,act1 as added by section #bjb1 is amended to read as follows3 7f7 ,application to certain plans ,the ,secretary and the ,secretary of the ,treasury shall prescribe such regulations as each respective ,secretary may deem necessary in order to establish and operate the advance payment program established under this section for individuals covered under qualified health plans 7whether enrolled in through an ,exchange or otherwise7 in such a manner that protects taxpayer information 7including names1 taxpayer identification numbers1 and other confidential information71 provides robust verification of all information necessary to establish eligibility of taxpayer for advance payments under this section1 ensures proper and timely payments to appropriate health providers1 and protects program integrity to the maximum extent feasible4 4 7c7 ,increased penalty on erroneous claims of credit ,section #ffgf7;a7 of the ,internal ,revenue ,code of #aihf is amended by inserting 7#be percent in the case of a claim for refund or credit relating to the health insurance coverage credit under section #cf;,b74 7d7 ,reporting by employers ,section #fjea7;a7 of such ,code is amended by striking and at the end of paragraph 7#ad71 by striking the period at the end of paragraph 7#ae7 and inserting 1 and1 and by inserting after paragraph 7#ae7 the following new paragraph3 7#af7 each month with respect to which the employee is eligible for coverage described in section #cf;,b7d77#b7 in connection with employment with the employer4 4 7e7 ,coordination with other tax benefits 7#a7 ,credit for health insurance costs of eligible individuals ,section #ce7;g7 of such ,code is amended by adding at the end the following new paragraph3 7#ad7 ,coordination with health insurance coverage credit 7,a7 ,in general ,an eligible coverage month to which the election under paragraph 7#aa7 applies shall not be treated as an eligible coverage month 7as defined in section #cf;,b7d77 for purposes of section #cf;,b with respect to the taxpayer or any of the taxpayer's qualifying family members 7as defined in section #cf;,b7e774 7,b7 ,coordination with advance payments of health insurance coverage credit ,in the case of a taxpayer who makes the election under paragraph 7#aa7 with respect to any eligible coverage month in a taxable year or on behalf of whom any advance payment is made under section #gebg with respect to any month in such taxable year-- 7i7 the tax imposed by this chapter for the taxable year shall be increased by the excess1 if any1 of-- 7,i7 the sum of any advance payments made on behalf of the taxpayer under section #gebg and section #adab of the ,patient ,protection and ,affordable ,care ,act1 over 7,,ii7 the sum of the credits allowed under this section 7determined without regard to paragraph 7#a77 and section #cf;,b 7determined without regard to subsection 7g77#d77;,a7 thereof7 for such taxable year1 and 7ii7 section #cf;,b7g77#d77;,b7 shall not apply with respect to such taxpayer for such taxable year4 4 7#b7 ,trade or business deduction ,section #afb7l7 of such ,code is amended by adding at the end the following new paragraph3 7#f7 ,coordination with health insurance coverage credit ,the deduction otherwise allowable to a taxpayer under paragraph 7#a7 for any taxable year shall be reduced 7but not below zero7 by the amount of the credit allowable to such taxpayer under section #cf;,b 7determined without regard to subsection 7g77#d77;,a7 thereof7 for such taxable year4 4 7f7 ,effective date ,the amendments made by this section shall apply to months beginning after ,december #ca1 #bjai1 in taxable years ending after such date4 #bae4 ,maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation 7a7 ,self-,only coverage ,section #bbc7;b77#b77;,a7 of the ,internal ,revenue ,code of #aihf is amended by striking #b1bej and inserting the amount in effect under subsection 7c77#b77;,a77ii77,i74 7b7 ,family coverage ,section #bbc7;b77#b77;,b7 of such ,code is amended by striking #d1ejj and inserting the amount in effect under subsection 7c77#b77;,a77ii77,,ii74 7c7 ,conforming amendments ,section #bbc7;g77#a7 of such ,code is amended-- 7#a7 by striking subsections 7b77#b7 and both places it appears and inserting subsection1 and 7#b7 in subparagraph 7,b71 by striking determined by and all that follows through calendar year #bjjc4 and inserting determined by substituting calendar year #bjjc for calendar year #aiib in subparagraph 7,b7 thereof44 7d7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjag4 #baf4 ,allow both spouses to make catch-up contributions to the same health savings account 7a7 ,in general ,section #bbc7;b77#e7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7#e7 ,special rule for married individuals with family coverage 7,a7 ,in general ,in the case of individuals who are married to each other1 if both spouses are eligible individuals and either spouse has family coverage under a high deductible health plan as of the first day of any month-- 7i7 the limitation under paragraph 7#a7 shall be applied by not taking into account any other high deductible health plan coverage of either spouse 7and if such spouses both have family coverage under separate high deductible health plans1 only one such coverage shall be taken into account71 7ii7 such limitation 7after application of clause 7i77 shall be reduced by the aggregate amount paid to ,archer ,m,s,as of such spouses for the taxable year1 and 7iii7 such limitation 7after application of clauses 7i7 and 7ii77 shall be divided equally between such spouses unless they agree on a different division4 7,b7 ,treatment of additional contribution amounts ,if both spouses referred to in subparagraph 7,a7 have attained age #ee before the close of the taxable year1 the limitation referred to in subparagraph 7,a77iii7 which is subject to division between the spouses shall include the additional contribution amounts determined under paragraph 7#c7 for both spouses4 ,in any other case1 any additional contribution amount determined under paragraph 7#c7 shall not be taken into account under subparagraph 7,a77iii7 and shall not be subject to division between the spouses4 4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjag4 #bag4 ,special rule for certain medical expenses incurred before establishment of health savings account 7a7 ,in general ,section #bbc7;d77#b7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subparagraph3 7,d7 ,treatment of certain medical expenses incurred before establishment of account ,if a health savings account is established during the #fj-;day period beginning on the date that coverage of the account beneficiary under a high deductible health plan begins1 then1 solely for purposes of determining whether an amount paid is used for a qualified medical expense1 such account shall be treated as having been established on the date that such coverage begins4 4 7b7 ,effective date ,the amendment made by this section shall apply with respect to coverage beginning after ,december #ca1 #bjag4 ,b ,repeal of certain consumer taxes #bba4 ,repeal of tax on prescription medications ,subsection 7j7 of section #ijjh of the ,patient ,protection and ,affordable ,care ,act is amended to read as follows3 7j7 ,repeal ,this section shall apply to calendar years beginning after ,december #ca1 #bjaj1 and ending before ,january #a1 #bjag4 4 #bbb4 ,repeal of health insurance tax ,subsection 7j7 of section #ijaj of the ,patient ,protection and ,affordable ,care ,act is amended to read as follows3 7j7 ,repeal ,this section shall apply to calendar years beginning after ,december #ca1 #bjac1 and ending before ,january #a1 #bjag4 4 ,c ,repeal of ,tanning ,tax #bca4 ,repeal of tanning tax 7a7 ,in general ,the ,internal ,revenue ,code of #aihf is amended by striking chapter #di4 7b7 ,effective date ,the amendment made by this section shall apply to services performed after ,june #cj1 #bjag4 ,d ,remuneration from ,certain ,insurers #bda4 ,remuneration from certain insurers ,paragraph 7#f7 of section #afb7m7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subparagraph3 7,i7 ,termination ,this paragraph shall not apply to taxable years beginning after ,december #ca1 #bjaf4 4 ,e ,repeal of ,net ,investment ,income ,tax #bea4 ,repeal of net investment income tax 7a7 ,in general ,subtitle ,a of the ,internal ,revenue ,code of #aihf is amended by striking chapter #b;,a4 7b7 ,effective date ,the amendment made by this section shall apply to taxable years beginning after ,december #ca1 #bjaf4 ,passed the ,house of ,representatives ,may #d1 #bjag4,karen ,l4 ,haas1,clerk ,june #h1 #bjag,read twice and placed on the calendar