,i  #aae? ,,congress  #a/ ,session  ,h4 
,r4 #djid  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,octob] #bc1 #bjag,mr4
 ,higg9s ( ,new ,york 7= himself1 ,mr4  
,l>son ( ,connecticut1 ,mr4 ,c\rtney1   
,mr4 ,scott ( ,virg9ia1 ,mr4 ,o',r\rke1 
& ,mr4 ,polis7 introduc$ ! foll[+ bill2 
:i* 0 ref]r$ to ! ,committee on ,en]gy &
 ,comm]ce1 & 9 addition to ! ,committee 
on ,ways & ,means1 = a p]iod to be      
subsequ5tly det]m9$ by ! ,speak]1 9 ea* 
case = consid]ation ( su* provisions z  
fall )9 ! jurisdiction ( ! committee    
conc]n$  ,a ,,bill  ,to e/abli% a public
 heal? plan4  #a4 ,%ort title ,?is ,act 
may be cit$ z ! ,m$ic>e-,x ,*oice ,act (
 #bjag4  #b4 ,e/abli%m5t & adm9i/ration 
( a public heal? plan ,! ,social        
,security ,act is am5d$ by add+ at ! end
 ! foll[+ new title3  ,,xxii ,m$ic>e    
,ex*ange ,heal? ,plan  #bbja4           
,e/abli%m5t  7a7 ,e/abli%m5t ( plan     
7#a7 ,9 g5]al ,! ,secret>y %all e/abli% 
a coord9at$ & l[-co/ heal? plan1 to be  
kn[n z ! ,m$ic>e ,ex*ange heal? plan    

7ref]r$ to 9 ?is section z ! heal? plan7
 to provide access to quality heal? c>e 
= enrollees4  7#b7 ,timeframe  7,a7     
,individual m>ket availability  7i7 ,9  
g5]al ,9 accordance ) clause 7ii71 !    
,secret>y %all make ! heal? plan        
available 9 ! individual m>ket1 9 c]ta9 
rat+ areas1 = plan ye> #bjbj & ea*      
subsequ5t plan ye>1 & increase !        
availability su* t ! plan is available 9
 ! individual m>ket to all resid5ts (   
all rat+ areas 9 ! ,unit$ ,/ates = plan 
ye> #bjbc & ea* subsequ5t plan ye>4     
7ii7 ,priority areas ,9 det]m9+ 9 :i*   
rat+ areas ! ,secret>y initially w make 
! heal? plan available1 ! ,secret>y %all
 give priority to rat+ areas 9 :i*--    
7,i7 n m ?an #a heal? insurance issu]   
(f]s plans on ! applicable ,/ate or     
,f$]al ,am]ican ,heal? ,b5efit ,ex*ange 
7ref]r$ to 9 ?is title z ! ,ex*ange72 or
  7,,ii7 !re is a %ortage ( heal?       
provid]s or lack ( competition t results
 9 a high co/ ( heal? c>e s]vices1      
includ+ heal? pr(essional %ortage areas 

& rural areas4  7,b7 ,small gr\p m>ket  
,! ,secret>y %all make ! heal? plan     
available 9 ! small gr\p m>ket 9 all    
rat+ areas = plan ye> #bjbd4  7b7       
,e/abli%m5t ( funds  7#a7 ,plan ,res]ve 
,fund  7,a7 ,9 g5]al ,!re is e/abli%$ 9 
! ,treasury ( ! ,unit$ ,/ates a ,plan   
,res]ve ,fund1 to be adm9i/]$ by !      
,secret>y ( ,heal? & ,human ,s]vices1 = 
purposes ( e/abli%+ ! ,m$ic>e ,ex*ange  
heal? plan & adm9i/]+ su* plan1 consi/+ 
( am\nts appropriat$ to su* fund4  7,b7 
,appropriation ,!re is appropriat$      
#a1jjj1jjj1jjj1 out ( monies 9 !        
,treasury n o!rwise obligat$1 to ! ,plan
 ,res]ve ,fund = fiscal ye> #bjah4  7#b7
 ,data & ,te*nology ,fund ,!re is       
e/abli%$ 9 ! ,treasury ( ! ,unit$ ,/ates
 a ,data & ,te*nology ,fund1 to be      
adm9i/]$ by ! ,secret>y ( ,heal? &      
,human ,s]vices1 act+ ?r\gh ! ,*ief     
,actu>y ( ! ,c5t]s = ,m$ic>e  ,m$icaid  
,s]vices1 = purposes ( updat+ te*nology 
& p]=m+ data collection "u section #bbje
 9 ord] to e/abli% appropriate premiums 

= all geographic regions ( ! ,unit$     
,/ates4 ,!re are au?oriz$ to be         
appropriat$ to ! ,data & ,te*nology     
,fund su* sums z may be necess>y =      
fiscal ye> #bjah4  7c7 ,rulemak+ ,!     
,secret>y may promulgate su* regulations
 z may be necess>y to c>ry out ?is      
title4  #bbjb4 ,availability ( plan  7a7
 ,eligibility ,an individual %all be    
eligible to enroll 9 ! heal? plan if su*
 individual1 = ! entire p]iod = :i*     
enrollm5t is s\ght-- 7#a7 is a qualifi$ 
individual )9 ! mean+ ( section #acab ( 
! ,pati5t ,protection & ,af=dable ,c>e  
,act 7#db ,u4,s4,c4 #ahjcb72 &  7#b7 is 
n eligible = b5efits "u ! ,m$ic>e       
program "u title ,,xviii4  7b7 ,ex*anges
 ,9 accordance ) ! timeframe "u section 
#bbja7;a77#b71 ! heal? plan %all be made
 available ?r\gh ! ,am]ican ,heal?      
,b5efit ,ex*anges describ$ 9 sections   
#acaa & #acba ( ! ,pati5t ,protection & 
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjca1 #ahjda71 includ+ ! ,small       
,bus9ess ,heal? ,options ,program       

,ex*ange4  #bbjc4 ,plan requirem5ts  7a7
 ,g5]al requirem5ts ,! heal? plan %all  
comply ) all requirem5ts ( subtitle ,d (
 title ,i ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjba et seq47 & title ,,xxvii ( !     
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #cjj;gg et seq47 applicable to
 qualifi$ heal? plans1 & su* heal? plan 
%all be a qualifi$ heal? plan1 includ+ =
 purposes ( ! ,int]nal ,rev5ue ,code (  
#aihf4  7b7 ,levels ( cov]age ,!        
,secret>y--  7#a7 %all make available a 
silv] level & gold level v]sion ( !     
plan1 9 accordance ) section            
#acja7;a77#a77;,c77ii72 &  7#b7 may make
 available no m ?an #b v]sions ( ! plan 
= ea* ( ! #d levels ( cov]age describ$ 9
 subp>agraphs 7,a7 ?r\gh 7,d7 ( section 
#acjb7;d77#a7 ( ! ,pati5t ,protection & 
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjbb7;d77#a774  #bbjd4 ,adm9i/rative  
contract+  7a7 ,9 g5]al ,! ,secret>y may
 ent] into contracts = ! purpose ( p]=m+
 adm9i/rative functions 7includ+        

functions describ$ 9 subsection 7a77#d7 
( section #ahgd;,a7 ) respect to ! heal?
 plan 9 ! same mann] z ! ,secret>y may  
ent] into contracts "u subsection       
7a77#a7 ( su* section4 ,! ,secret>y %all
 h ! same au?ority ) respect to ! public
 heal? insurance option z ! ,secret>y   
has "u su* subsection 7a77#a7 &         
subsection 7b7 ( section #ahgd;,a )     
respect to title ,,xviii4  7b7 ,transf] 
( insurance risk ,any contract "u       
subsection 7a7 %all n involve ! transf] 
( insurance risk f ! ,secret>y to !     
entity ent]+ into su* contract ) !      
,secret>y1 except 9 ! case ( an         
alt]native paym5t model "u section      
#bbji7;h74  #bbje4 ,data collection     
,subject to all applicable privacy      
requirem5ts1 includ+ ! requirem5ts "u ! 
regulations promulgat$ pursuant to      
section #bfd7;c7 ( ! ,heal? ,insurance  
,portability & ,acc\ntability ,act (    
#aiif 7#db ,u4,s4,c4 #acbj;d-#b note71 !
 ,secret>y may collect data f ,/ate     
insurance commission]s & o!r relevant   

entities to e/abli% rates = premiums & =
 o!r purposes includ+ to improve        
quality1 & r$uce racial1 e?nic1 & o!r   
disp>ities1 ) respect to ! heal? plan4  
#bbjf4 ,premiums2 risk pools2 re9surance
  7a7 ,premium am\nts ,! ,secret>y %all 
e/abli% premiums = ! heal? plan t cov] !
 full actu>ial co/ ( (f]+ su* plan1     
includ+ ! adm9i/rative co/s ( (f]+ su*  
plan4 ,su* premiums %all v>y            
geographically & betwe5 ! small gr\p    
m>ket & ! individual m>ket 9 accordance 
) diff]5ces 9 ! co/ ( provid+ su*       
cov]age4 ,if1 = any plan ye>1 ! am\nt   
collect$ 9 premiums exce$s ! am\nt      
requir$ = heal? c>e b5efits &           
adm9i/rative co/s 9 t plan ye>1 su*     
excess am\nts %all rema9 available to ! 
,secret>y to adm9i/] ! heal? plan &     
f9ance b5efici>y co/s 9 subsequ5t ye>s4 
7b7 ,risk pool ,all enrollees 9 ! heal? 
plan )9 a ,/ate %all be memb]s ( a s+le 
risk pool1 except t ! ,secret>y may     
e/abli% sep>ate risk pools = !          
individual m>ket & small gr\p m>ket if !

 ,/ate has n ex]cis$ its au?ority "u    
section #acab7;c77#c7 ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjcb7;c77#c774  7c7         
,re9surance ,not)/&+ subsection 7b71 !  
,secret>y may e/abli% a me*anism to pool
 ! co/s ( ! highe/-co/ pati5ts on a     
nationwide basis to ! ext5t su* co/s are
 n already pool$ pursuant to section    
#acdc ( ! ,pati5t ,protection &         
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjfc74  #bbjg4 ,reimbursem5t rates    
7a7 ,m$ic>e rates  7#a7 ,9 g5]al ,except
 z provid$ 9 p>agraph 7#b7 & subsections
 7b7 & 7c7 & subject to subsection 7d71 
! ,secret>y %all reimburse heal? c>e    
provid]s furni%+ items & s]vices "u !   
heal? plan at rates det]m9$ = equival5t 
items & s]vices "u ! orig9al ,m$ic>e    
fee-=-s]vice program "u p>ts ,a & ,b (  
title ,,xviii4  7#b7 ,au?ority to       
increase paym5ts rates 9 rural areas ,if
 ! ,secret>y det]m9es appropriate1 !    
,secret>y may increase ! reimbursem5ts  
rates describ$ 9 p>agraph 7#a7 by up to 

#be p]c5t = items & s]vices furni%$ 9   
rural areas 7z def9$ 9 section          
#ahhf7;d77#b77;,d774  7b7 ,prescription 
drugs ,subject to subsection 7d71 paym5t
 rates = prescription drugs %all be at a
 rate negotiat$ by ! ,secret>y4 ,su*    
negotiations may be 9 conjunction )     
negotiations = cov]$ "p ,d drugs "u "p  
,d ( title ,,xviii4  7c7 ,additional    
items & s]vices ,subject to subsection  
7d71 ! ,secret>y %all e/abli%           
reimbursem5t rates = any items & s]vices
 provid$ "u ! heal? plan t are n items &
 s]vices provid$ "u ! orig9al ,m$ic>e   
fee-=-s]vice program "u p>ts ,a & ,b (  
title ,,xviii4  7d7 ,innovative paym5t  
me?ods ,! ,secret>y may utilize         
innovative paym5t me?ods1 includ+       
value-bas$ paym5t arrangem5ts1 9 mak+   
paym5ts = items & s]vices 7includ+      
prescription drugs7 furni%$ "u ! heal?  
plan4  #bbjh4 ,p>ticipat+ provid]s  7a7 
,9 g5]al ,a heal? c>e provid] t is      
enroll$ "u ! ,m$ic>e program "u section 
#ahff7;j7 or is a p>ticipat+ provid] "u 

a ,/ate ,m$icaid plan "u title ,,xix on 
! date ( enactm5t ( ?is ,act %all be a  
p>ticipat+ provid] "u ! heal? plan4  7b7
 ,additional provid]s ,! ,secret>y %all 
e/abli% a process to all[ heal? c>e     
provid]s n describ$ 9 subsection 7a7 to 
become a p>ticipat+ provid] "u ! heal?  
plan4  7c7 ,opt-,out ,! ,secret>y %all  
e/abli% a process by :i* a heal? c>e    
provid] t is a p>ticipat+ provid] "u !  
heal? plan pursuant to subsection 7a7 or
 7b7 may opt-out ( be+ su* a p>ticipat+ 
provid]4  7d7 ,requirem5t ,to p>ticipate
 9 ord] ,to be enroll$ "u ,m$ic>e       
,beg9n+ ,janu>y #a1 #bjai1 a heal? c>e  
provid] may n be enroll$ "u ! ,m$ic>e   
program "u section #ahff7;j7 unless !   
provid] is also a p>ticipat+ provid] "u 
! heal? plan4  #bbji4 ,deliv]y sy/em    
re=m = an enhanc$ heal? plan  7a7 ,9    
g5]al ,= plan ye>s beg9n+ ) plan ye>    
#bjbj1 ! ,secret>y may utilize          
innovative paym5t me*anisms & policies  
to det]m9e paym5ts = items & s]vices "u 
! heal? plan4 ,! paym5t me*anisms &     

policies "u ?is section may include     
pati5t-c5t]$ m$ical home & o!r c>e      
managem5t paym5ts1 acc\ntable c>e       
organizations1 value-bas$ pur*as+1      
bundl+ ( s]vices1 diff]5tial paym5t     
rates1 p]=mance or utilization bas$     
paym5ts1 teleheal?1 remote pati5t       
monitor+1 p>tial capitation1 & direct   
contract+ ) provid]s4  7b7 ,requirem5ts 
= innovative paym5ts ,! ,secret>y %all  
design & implem5t ! paym5t me*anisms &  
policies "u ?is section 9 a mann] t--   
7#a7 seeks to--  7,a7 improve heal?     
outcomes2  7,b7 r$uce heal? disp>ities  
7includ+ racial1 e?nic1 & o!r           
disp>ities72  7,c7 provide effici5t &   
af=dable c>e2  7,d7 address geographic  
v>iation 9 ! provision ( heal? s]vices2 
or  7,e7 prev5t or manage *ronic        
illness2 &  7#b7 promotes c>e t is      
integrat$1 pati5t-c5t]$1 quality1 &     
effici5t4  7c7 ,enc\rag+ ! use (        
high-,value s]vices ,to ! ext5t all[$ by
 ! b5efit /&>ds appli$ to all heal?     
b5efits plans p>ticipat+ 9 ! ,ex*anges  

7z describ$ 9 section #bbjb7;b771 !     
heal? plan may modify co/-%>+ & paym5t  
rates to enc\rage ! use ( s]vices t     
promote heal? & value4  7d7 ,promotion (
 deliv]y sy/em re=m ,! ,secret>y %all   
monitor & evaluate ! progress ( paym5t &
 deliv]y sy/em re=ms "u ?is section &   
%all seek to implem5t su* re=ms subject 
to ! foll[+3  7#a7 ,to ! ext5t t !      
,secret>y f9ds a paym5t & deliv]y sy/em 
re=m successful 9 improv+ quality &     
r$uc+ co/s1 ! ,secret>y %all implem5t   
su* re=m on z l>ge a geographic scale z 
practical & economical4  7#b7 ,!        
,secret>y may delay ! implem5tation (   
su* a re=m 9 geographic areas 9 :i* su* 
implem5tation w\ld place ! public heal? 
insurance option at a competitive       
disadvantage4  7#c7 ,! ,secret>y may    
prioritize implem5tation ( su* a re=m 9 
high-co/ geographic areas or o!rwise 9  
ord] to r$uce total program co/s or to  
promote high-value c>e4  7e7            
,non-,uni=mity p]mitt$ ,no?+ 9 ?is      
section %all prev5t ! ,secret>y f v>y+  

paym5ts bas$ on diff]5t paym5t /ructure 
models 7su* z acc\ntable c>e            
organizations & m$ical homes7 "u ! heal?
 plan = diff]5t geographic areas4  7f7  
,integration ) ,social ,s]vices ,!      
,secret>y %all e/abli% processes &1 :5  
appropriate1 collaborate ) o!r ag5cies  
to integrate m$ical c>e "u ! heal? plan 
) food1 h\s+1 transportation1 & income  
assi/ance if ! ,secret>y det]m9es t su* 
integration is expect$ to-- 7#a7 r$uce  
sp5d+ )\t r$uc+ ! quality ( pati5t c>e2 
or  7#b7 improve ! quality ( pati5t c>e 
)\t increas+ sp5d+4  7g7 ,teleheal? ,!  
,secret>y %all ensure ! integration (   
teleheal? tools t increase pati5t access
 to m$ical c>e1 p>ticul>ly 9 remote or  
und]s]v$ areas1 if ! ,secret>y det]m9es 
t su* integration is expect$ to--  7#a7 
r$uce sp5d+ )\t r$uc+ ! quality ( pati5t
 c>e2 or  7#b7 improve ! quality (      
pati5t c>e )\t increas+ sp5d+4  7h7     
,alt]native paym5t model  7#a7 ,9 g5]al 
,! ,secret>y %all evaluate ! possibility
 ( provid+ inc5tives1 &1 if appropriate1

 apply inc5tives1 = enrollees 9 ! heal? 
plan :o receive s]vices f provid]s :o   
are p>ticipat+ 9 an alt]native paym5t   
model 7z def9$ 9 section                
#ahcc7z77#c77;,c774  7#b7 ,au?ority to  
use apms 9 use "u traditional ,m$ic>e   
,no?+ 9 ?is section %all preclude !     
,secret>y f us+ alt]native paym5t models
 7z s def9$7 "u ?is title t are 9 use "u
 title ,,xviii4  #bbaj4 ,no effect on   
,m$ic>e b5efits or ,m$ic>e ,tru/ ,funds 
,no?+ 9 ?is title %all-- 7#a7 affect !  
b5efits available "u title ,,xviii2 or  
7#b7 impact ! ,f$]al ,hospital          
,insurance ,tru/ ,fund "u section #ahag 
or ! ,f$]al ,supplem5t>y ,m$ical        
,insurance ,tru/ ,fund "u section #ahda 
7includ+ ! ,m$ic>e ,prescription ,drug  
,acc\nt )9 su* ,tru/ ,fund74  4  #c4    
,au?ority to negotiate fair prices =    
,m$ic>e prescription drugs  7a7 ,9 g5]al
 ,section #ahfj;,d-#aa ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#aaa7 is am5d$ by /rik+          
subsection 7i74  7b7 ,effective date ,! 

am5dm5t made by ?is section %all take   
effect on ! date ( ! enactm5t ( ?is     
,act4