,i  #aae? ,,congress  #a/ ,session  ,h4 
,r4 #dfie  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,decemb] #bj1         
#bjag,mr4 ,s*rad] 7= himself1 ,mr4 ,re$1
 ,mr4 ,got!im]1 ,mr4 ,lance1 ,mr4 ,b]a1 
,mr4 ,trott1 ,mrs4 ,murphy ( ,florida1  
,mr4 ,?ompson ( ,p5nsylvania1 ,mr4      
,o',hall]an1 ,mr4 ,co/ello (            
,p5nsylvania1 ,mr4 ,suozzi1 ,mr4 ,d5t1  
,mr4 ,panetta1 ,mr4 ,curbelo ( ,florida1
 ,ms4 ,s9ema1 ,mr4 ,fitzpatrick1 ,mr4   
,soto1 ,mr4 ,katko1 ,mr4 ,lip9ski1 ,mr4 
,faso1 ,ms4 ,e/y ( ,connecticut1 ,mr4   
,co/a1 ,mr4 ,nolan1 ,mr4 ,s*neid]1 ,mr4 
,pet]s1 & ,mr4 ,wel*7 introduc$ ! foll[+
 bill2 :i* 0 ref]r$ to ! ,committee on  
,en]gy & ,comm]ce1 & 9 addition to !    
,committee on ,ways & ,means1 = a p]iod 
to be subsequ5tly det]m9$ by ! ,speak]1 
9 ea* case = consid]ation ( su*         
provisions z fall )9 ! jurisdiction ( ! 
committee conc]n$  ,a ,,bill  ,to am5d !
 ,pati5t ,protection & ,af=dable ,c>e   
,act to provide = /abilization 9 !      
individual heal? insurance m>ket1 & =   

o!r purposes4  #a4 ,%ort title ,?is ,act
 may be cit$ z ! ,bip>tisan ,m>ket      
,/abilization & ,innovation ,act (      
#bjag4  #b4 ,fund+ = ,,ppaca ,ex*ange   
plans co/-%>+ r$uctions ,section #adjb (
 ! ,pati5t ,protection & ,af=dable ,c>e 
,act 7#db ,u4,s4,c4 #ahjga7 is am5d$ by 
add+ at ! end ! foll[+ new subsection3  
7g7 ,fund+  7#a7 ,9 g5]al ,out ( any    
funds 9 ! ,treasury n o!rwise           
appropriat$1 !re is appropriat$ su* sums
 z may be necess>y = paym5ts "u ?is     
section1 includ+ ?r\gh advance paym5t "u
 section #adab7;c77#c74 ,funds          
appropriat$ "u ?is p>agraph %all rema9  
available = obligation until exp5d$4    
7#b7 ,reports ,! ,secret>y %all = #bjag 
& ea* subsequ5t ye> submit to !         
,committee on ,en]gy & ,comm]ce1 !      
,committee on ,ways & ,means1 & !       
,committee on ,appropriations ( ! ,h\se 
( ,repres5tatives & ! ,committee on     
,f9ance1 ! ,committee on ,heal?1        
,education1 ,labor1 & ,p5sions1 & !     
,committee on ,appropriations ( ! ,s5ate

 an annual report on--  7,a7 ! am\nt (  
paym5ts made "u ?is section ) respect to
 su* ye>2  7,b7 ! effects ( su* paym5ts 
on ! co/s ( heal? insurance 9 !         
individual m>ket2 &  7,c7 ! project$    
co/s ( heal? insurance 9 ! individual   
m>ket ov] ! subsequ5t ye>4  4  #c4      
,pati5t & ,/ate ,/ability ,fund ,!      
,social ,security ,act 7#db ,u4,s4,c4   
#cja et seq47 is am5d$ by add+ at ! end 
! foll[+ new title3  ,,xxii ,pati5t &   
,/ate ,/ability ,fund  #bbja4           
,e/abli%m5t ( program ,!re is h]eby     
e/abli%$ ! ,pati5t & ,/ate ,/ability    
,fund to be adm9i/]$ by ! ,secret>y (   
,heal? & ,human ,s]vices1 act+ ?r\gh !  
,adm9i/rator ( ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices 79 ?is section ref]r$ 
to z ! ,adm9i/rator71 to provide fund+1 
9 accordance ) ?is title1 to ! #ej      
,/ates & ! ,di/rict ( ,columbia 7ea*    
ref]r$ to 9 ?is section z a ,/ate7 dur+ 
! p]iod1 subject to section #bbjd7;c71  
beg9n+ on ,janu>y #a1 #bjai1 & end+ on  
,decemb] #ca1 #bjbh1 = ! purposes       

describ$ 9 section #bbjb4  #bbjb4 ,use (
 funds  ,a ,/ate may use ! funds        
allocat$ to ! ,/ate "u ?is title = any (
 ! foll[+ purposes3  7#a7 ,help+1 ?r\gh 
! provision ( f9ancial assi/ance1       
high-risk individuals :o d n h access to
 heal? insurance cov]age (f]$ ?r\gh an  
employ] enroll 9 heal? insurance        
cov]age4  7#b7 ,provid+ inc5tives to    
appropriate entities to ent] into       
arrangem5ts ) ! ,/ate to help /abilize  
premiums = heal? insurance cov]age 9 !  
individual m>ket1 z su* m>kets are def9$
 by ! ,/ate4  7#c7 ,r$uc+ ! co/ =       
provid+ heal? insurance cov]age 9 !     
individual m>ket & small gr\p m>ket to  
individuals :o h1 or are project$ to h1 
a high rate ( utilization ( heal?       
s]vices 7z measur$ by co/7 & to         
individuals :o h high co/s ( heal?      
insurance cov]age due to ! l[ d5sity    
population ( ! ,/ate 9 :i* !y reside4   
7#d7 ,promot+ p>ticipation 9 !          
individual m>ket & small gr\p m>ket 9 ! 
,/ate & increas+ heal? insurance options

 available ?r\gh su* m>ket4  7#e7       
,provid+ assi/ance to r$uce out-(-pocket
 co/s1 su* z copaym5ts1 co9surance1     
premiums1 & d$uctibles1 ( individuals   
enroll$ 9 heal? insurance cov]age 9 !   
,/ate4  #bbjc4 ,/ate eligibility &      
approval2 ,default safegu>d  7a7        
,enc\rag+ ,/ate options = allocations   
7#a7 ,9 g5]al ,to be eligible = an      
allocation ( funds "u ?is title = a ye> 
dur+ ! p]iod describ$ 9 section #bbja = 
use = "o or m purposes describ$ 9       
section #bbjb1 a ,/ate %all submit to ! 
,adm9i/rator an application at su* "t 7n
 lat] ?an ,m>* #ca ( ! previ\s ye>7 & 9 
su* =m & mann] z specifi$ by !          
,adm9i/rator & conta9+--  7,a7 a        
description ( h[ ! funds w be us$ = su* 
purposes2  7,b7 a c]tification t ! ,/ate
 w make1 f non-,f$]al funds1 exp5ditures
 = su* purposes 9 an am\nt t is n less  
?an ! ,/ate p]c5tage requir$ = ! ye> "u 
section #bbjd7;e77#a72 &  7,c7 su* o!r  
in=mation z ! ,adm9i/rator may require4 
7#b7 ,adm9i/rator ,det]m9ation ,timel9e 

7,a7 ,9 g5]al ,! ,adm9i/rator %all make 
a det]m9ation z to ! approval or        
disapproval ( an application n lat] ?an 
#ij days aft] ! receipt ( su*           
application4  7,b7 ,exp$it$ ,det]m9ation
 ,! ,adm9i/rator %all make a det]m9ation
 z to ! approval or disapproval ( an    
application n lat] ?an #de days aft] !  
receipt ( su* application if su*        
application--  7i7 is submitt$ 9        
response to an urg5t situation1 )       
respect to areas 9 ! ,/ate t !          
,adm9i/rator det]m9es are at risk =     
excessive premium increases or hav+ no  
heal? plans (f]$ 9 ! applicable heal?   
insurance m>ket = ! curr5t or foll[+    
plan ye>2 or  7ii7 resembles an         
application t is ! same or sub/antially 
simil> to an application t !            
,adm9i/rator has already approv$ = ano!r
 ,/ate4  7#c7 ,p]iod ( approval ,if an  
application ( a ,/ate is approv$ = a    
ye>1 ) respect to a purpose describ$ 9  
section #bbjb1 su* application %all also
 be treat$ z approv$1 ) respect to su*  

purpose1 = ea* ( ! subsequ5t #d ye>s1 b 
9 no case %all an application be approv$
 = a ye> aft] #bjbh4  7#d7 ,treatm5t z a
 ,/ate ,heal? ,c>e ,program ,any program
 receiv+ funds f an allocation = a ,/ate
 "u ?is title1 includ+ pursuant to      
subsection 7b71 %all be consid]$ to be a
 ,/ate heal? c>e program = purposes (   
sections #aabh1 #aabh;,a1 & #aabh;,b4   
7b7 ,default ,f$]al safegu>d  7#a7 ,9   
g5]al ,9 ! case ( a ,/ate t does n h 9  
effect an approv$ application "u ?is    
section = #bjai or a subsequ5t ye>      
beg9n+ dur+ ! p]iod describ$ 9 section  
#bbja1 subject to section #bbjd7;e71 !  
,adm9i/rator1 9 consultation ) ! ,/ate  
insurance commission]1 %all use !       
allocation t w\ld o!rwise be provid$ to 
! ,/ate "u ?is title = su* ye>1 9       
accordance ) p>agraph 7#b71 = su* ,/ate4
  7#b7 ,requir$ use = m>ket /abilization
 paym5ts to issu]s ,subject to section  
#bbjd7;a71 an allocation = a ,/ate made 
pursuant to p>agraph 7#a7 = a ye> %all  
be us$ to c>ry out ! purpose describ$ 9 

section #bbjb7b7 9 su* ,/ate by provid+ 
paym5ts to appropriate entities describ$
 9 su* section ) respect to claims t    
exce$ #ej1jjj 7or1 ) respect to         
allocations made "u ?is title = #bjbj or
 a subsequ5t ye> dur+ ! p]iod specifi$ 9
 section #bbja1 su* doll> am\nt specifi$
 by ! ,adm9i/rator71 b d n exce$        
#cej1jjj 7or1 ) respect to allocations  
made "u ?is title = #bjbj or a subsequ5t
 ye> dur+ su* p]iod1 su* doll> am\nt    
specifi$ by ! ,adm9i/rator71 9 an am\nt 
equal to #ge p]c5t 7or1 ) respect to    
allocations made "u ?is title = #bjbj or
 a subsequ5t ye> dur+ su* p]iod1 su*    
p]c5tage specifi$ by ! ,adm9i/rator7 ( !
 am\nt ( su* claims4  #bbjd4            
,allocations  7a7 ,appropriation ,= !   
purpose ( provid+ allocations = ,/ates  
7includ+ pursuant to section #bbjc7;b77 
"u ?is title !re is appropriat$1 out (  
any money 9 ! ,treasury n o!rwise       
appropriat$1 #aa1ejj1jjj1jjj = ea* (    
#bjai ?r\gh #bjbh4  7b7 ,allocations    
7#a7 ,paym5t ,f am\nts appropriat$ "u   

subsection 7a7 = a ye>1 ! ,adm9i/rator  
%all1 ) respect to a ,/ate & n lat] ?an 
,janu>y #a ( su* ye>1 allocate1 subject 
to subsection 7e71 = su* ,/ate 7includ+ 
pursuant to section #bbjc7;b77 ! am\nt  
det]m9$ = su* ,/ate & ye> "u p>agraph   
7#b74  7#b7 ,allocation am\nt           
det]m9ations  7,a7 ,= #bjai ?r\gh #bjba 
7i7 ,9 g5]al ,= purposes ( p>agraph     
7#a71 ! am\nt det]m9$ "u ?is p>agraph = 
ea* ( #bjai ?r\gh #bjba = a ,/ate is an 
am\nt equal to ! sum (--  7,i7 !        
relative incurr$ claims am\nt describ$ 9
 clause 7ii7 = su* ,/ate & ye>2 &       
7,,ii7 ! relative un9sur$ & issu]       
p>ticipation am\nt describ$ 9 clause    
7iv7 = su* ,/ate & ye>4  7ii7 ,relative 
incurr$ claims am\nt ,= purposes (      
clause 7i71 ! relative incurr$ claims   
am\nt describ$ 9 ?is clause = a ,/ate = 
#bjai1 #bjbj1 & #bjba is ! product (--  
7,i7 #ij p]c5t ( ! am\nt appropriat$ "u 
subsection 7a7 = ! ye>2 &  7,,ii7 !     
relative ,/ate incurr$ claims proportion
 describ$ 9 clause 7iii7 = su* ,/ate &  

ye>4  7iii7 ,relative ,/ate incurr$     
claims proportion ,! relative ,/ate     
incurr$ claims proportion describ$ 9 ?is
 clause = a ,/ate & ye> is ! am\nt equal
 to ! ratio (--  7,i7 ! adju/$ incurr$  
claims by ! ,/ate1 z report$ ?r\gh !    
m$ical loss ratio annual report+ "u     
section #bgah ( ! ,public ,heal? ,s]vice
 ,act = ! ?ird previ\s ye>2 to  7,,ii7 !
 sum ( su* adju/$ incurr$ claims = all  
,/ates1 z s report$1 = su* ?ird previ\s 
ye>4  7iv7 ,relative un9sur$ & issu]    
p>ticipation am\nt ,= purposes ( clause 
7i71 ! relative un9sur$ & issu]         
p>ticipation am\nt describ$ 9 ?is clause
 = a ,/ate = #bjai1 #bjbj1 & #bjba is ! 
product (--  7,i7 #aj p]c5t ( ! am\nt   
appropriat$ "u subsection 7a7 = ! ye>2 &
  7,,ii7 ! relative ,/ate un9sur$ &     
issu] p>ticipation proportion describ$ 9
 clause 7v7 = su* ,/ate & ye>4  7v7     
,relative ,/ate un9sur$ & issu]         
p>ticipation proportion ,! relative     
,/ate un9sur$ & issu] p>ticipation      
proportion describ$ 9 ?is clause = a    

,/ate & ye> is--  7,i7 9 ! case ( a     
,/ate n describ$ 9 clause 7vi7 = su*    
ye>1 #j2 &  7,,ii7 9 ! case ( a ,/ate   
describ$ 9 clause 7vi7 = su* ye>1 !     
am\nt equal to ! ratio (--  7aa7 ! numb]
 ( individuals resid+ 9 su* ,/ate :o = !
 ?ird prec$+ ye> 7 n enroll$ 9 a heal?  
plan or o!rwise did n h heal? insurance 
cov]age 7includ+ ?r\gh a ,f$]al or ,/ate
 heal? program7 & ^: income is bel[ #ajj
 p]c5t ( ! pov]ty l9e applicable to a   
family ( ! size involv$2 to  7bb7 ! sum 
( ! numb] ( su* individuals = all ,/ates
 describ$ 9 clause 7vi7 = ! ?ird prec$+ 
ye>4  7vi7 ,/ates describ$ ,= purposes (
 clause 7v71 a ,/ate is describ$ 9 ?is  
clause1 ) respect to #bjai1 #bjbj1 &    
#bjba1 if ! ,/ate satisfies ei!r ( !    
foll[+ crit]ion3  7,i7 ,! ratio describ$
 9 subclause 7,,ii7 ( clause 7v7 t w\ld 
be det]m9$ = su* ,/ate by sub/itut+     
#bjae = ea* ref]5ce 9 su* subclause to !
 ?ird prec$+ ye> & by sub/itut+ all su* 
,/ates = ! ref]5ce 9 item 7bb7 ( su*    
subclause to all ,/ates describ$ 9      

clause 7vi7 is great] ?an ! ratio       
describ$ 9 su* subclause t w\ld be      
det]m9$ = su* ,/ate by sub/itut+ #bjac =
 ea* ref]5ce 9 su* subclause to ! ?ird  
prec$+ ye> & by sub/itut+ all su* ,/ates
 = ! ref]5ce 9 item 7bb7 ( su* subclause
 to all ,/ates describ$ 9 clause 7vi74  
7,,ii7 ,! ,/ate has few] ?an ?ree heal? 
insurance issu]s (f]+ qualifi$ heal?    
plans ?r\gh ! ,ex*ange = #bjag4  7,b7 ,=
 #bjbb ?r\gh #bjbh ,= purposes (        
p>agraph 7#a71 ! am\nt det]m9$ "u ?is   
p>agraph = a ye> 7beg9n+ ) #bjbb7 dur+ !
 p]iod describ$ 9 section #bbja = a     
,/ate is an am\nt det]m9$ 9 accordance )
 an allocation me?odology specifi$ by ! 
,adm9i/rator :i*--  7i7 takes into      
consid]ation ! adju/$ incurr$ claims (  
su* ,/ate1 ! numb] ( resid5ts ( su*     
,/ate :o = ! previ\s ye> 7 n enroll$ 9 a
 heal? plan or o!rwise did n h heal?    
insurance cov]age 7includ+ ?r\gh a      
,f$]al or ,/ate heal? program7 & ^:     
income is bel[ #ajj p]c5t ( ! pov]ty l9e
 applicable to a family ( ! size        

involv$1 & ! numb] ( heal? insurance    
issu]s p>ticipat+ 9 ! insurance m>ket 9 
su* ,/ate = su* ye>2  7ii7 is e/abli%$  
aft] consultation ) heal? c>e consum]s1 
heal? insurance issu]s1 ,/ate insurance 
commission]s1 & o!r /akehold]s & aft]   
tak+ into consid]ation additional co/ & 
risk factors t may inhibit heal? c>e    
consum] & heal? insurance issu]         
p>ticipation2 &  7iii7 reflects ! goals 
( improv+ ! heal? insurance risk pool1  
promot+ a m competitive heal? insurance 
m>ket1 & increas+ *oice = heal? c>e     
consum]s4  7c7 ,annual di/ribution (    
previ\s ye>'s rema9+ funds ,9 c>ry+ out 
subsection 7b71 ! ,adm9i/rator %all1 )  
respect to a ye> 7beg9n+ ) #bjbb & end+ 
) #bjbh71 n lat] ?an ,m>* #ca ( su*     
ye>--  7#a7 det]m9e ! am\nt ( funds1 if 
any1 f ! am\nts appropriat$ "u          
subsection 7a7 = ! previ\s ye> b n      
allocat$ = su* previ\s ye>2 &  7#b7 if !
 ,adm9i/rator det]m9es t any funds 7 n s
 allocat$ = su* previ\s ye>1 allocate   
su* rema9+ funds1 9 accordance ) !      

allocation me?odology specifi$ pursuant 
to subsection 7b77#b77;,b71 )1 respect  
to a ye> be=e #bjbh1 any rema9+ funds   
be+ made available = allocations to     
,/ates = ! subsequ5t ye>4  7d7          
,availability ,am\nts appropriat$ "u    
subsection 7a7 = a ye> & allocat$ to    
,/ates 9 accordance ) ?is section %all  
rema9 available = exp5diture ?r\gh      
,decemb] #ca1 #bjbh4  7e7 ,conditions = 
& limitations on receipt ( funds ,!     
,secret>y may n make an allocation "u   
?is title = a ,/ate1 ) respect to a     
purpose describ$ 9 section #bbjb 9 !    
case ( an allocation t w\ld be made to a
 ,/ate pursuant to section #bbjc7;a71 if
 ! ,/ate does n agree t ! ,/ate w make  
available non-,f$]al contributions t[>ds
 su* purpose 9 an am\nt equal to--  7#a7
 = #bjbj1 #e p]c5t ( ! am\nt allocat$ "u
 ?is subsection to su* ,/ate = su* ye> &
 purpose2 &  7#b7 = #bjba & ea*         
subsequ5t ye> ?r\gh #bjbh1 #aj p]c5t ( !
 am\nt allocat$ "u ?is subsection to su*
 ,/ate = su* ye> & purpose4  4  #d4     

,modifications to waiv] = ,/ate         
innovation ,section #accb ( ! ,pati5t   
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjeb7 is am5d$-- 7#a7 9     
subsection 7a77#c71 9 ! fir/ s5t5ce1 by 
/rik+ individuals & small employ]s & all
 t foll[s ?r\gh ! ,/ate _h n receiv$ su*
 waiv] & ins]t+ ! ,secret>y det]m9es t  
!re w\ld be a r$uction 9 ! ,f$]al       
deficit dur+ ! waiv] p]iod1 ! ,secret>y 
%all provide = a means by :i* ! am\nt ( 
su* r$uction2 &  7#b7 9 subsection 7d7--
 7,a7 9 p>agraph 7#a71 by /rik+ #ahj    
days & ins]t+ subject to p>agraph 7#c71 
#ij days2 &  7,b7 by add+ at ! end !    
foll[+ new p>agraph3  7#c7 ,exp$it$     
det]m9ation ,) respect to any           
application "u subsection 7a77#a7       
submitt$ on or aft] ! date ( enactm5t ( 
?is p>agraph 7or any su* application    
submitt$ prior to su* date ( enactm5t & 
"u review by ! ,secret>y z ( su* date ( 
enactm5t71 ! ,secret>y %all make a      
det]m9ation on su* application1 us+ !   
crit]ia = approval o!rwise applicable "u

 ?is section1 n lat] ?an #de days aft] !
 receipt ( su* application1 & %all all[ 
! public notice & comm5t at ! ,/ate &   
,f$]al levels describ$ "u subsection    
7a77#d7 to occur concurr5tly if su*     
,/ate application--  7,a7 is submitt$ 9 
response to an urg5t situation1 )       
respect to areas 9 ! ,/ate t ! ,secret>y
 det]m9es are at risk = excessive       
premium increases or hav+ no heal? plans
 (f]$ 9 ! applicable heal? insurance    
m>ket = ! curr5t or foll[+ plan ye>2 or 
7,b7 is = a waiv] t is ! same or        
sub/antially simil> to a waiv] t !      
,secret>y already has approv$ = ano!r   
,/ate4  4  #e4 ,employ] m&ate adju/m5t  
7a7 ,increas+ ! size ( applicable l>ge  
employ]s ,p>agraph 7#b7 ( section       
#dihj;,h7c7 ( ! ,int]nal ,rev5ue ,code (
 #aihf is am5d$ by /rik+ #ej & ins]t+   
#ejj ea* place su* t]m appe>s4  7b7     
,increas+ ! h\rs requir$ ,to qualify z  
full-,"t employees  7#a7 ,9 g5]al       
,subp>agraph 7,a7 ( section             
#dihj;,h7c77#d7 ( ! ,int]nal ,rev5ue    

,code ( #aihf is am5d$ by /rik+ #cj &   
ins]t+ #dj4  7#b7 ,full-,"t equival5ts  
,subp>agraph 7,e7 ( section             
#dihj;,h7c77#b7 ( ! ,int]nal ,rev5ue    
,code ( #aihf is am5d$ by /rik+ #abj &  
ins]t+ #afj4  7c7 ,effective date ,!    
am5dm5ts made by ?is section %all apply 
to mon?s beg9n+ aft] ,decemb] #ca1      
#bjag4  #f4 ,repeal ( m$ical device     
excise tax ,section #daia is am5d$ by   
add+ at ! end ! foll[+ new subsection3  
7d7 ,applicability ,! tax impos$ "u     
subsection 7a7 %all n apply to sales    
aft] ,decemb] #ca1 #bjag4  4  #g4 ,(f]+ 
heal? plans 9 m ?an "o ,/ate  ,n lat]   
?an #a ye> aft] ! date ( enactm5t ( ?is 
,act1 ! ,secret>y ( ,heal? & ,human     
,s]vices1 9 consultation ) ! ,national  
,association ( ,insurance ,commission]s1
 %all issue regulations = !             
implem5tation ( heal? c>e *oice compacts
 e/abli%$ "u section #accc ( ! ,pati5t  
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjec7 to all[ = ! (f]+ (    
heal? plans 9 m ?an "o ,/ate4  #h4 ,s5se

 ( ,congress ,x is ! s5se ( ,congress t 
! provisions ( ?is ,act %\ld n increase 
! deficit1 & any project$ co/s ( su*    
provisions %\ld be (fset ) policies to  
negate any project$ deficit increase4