,i #aae? ,,congress #b;d ,session ,h4 ,r4 #gcci ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,decemb] #ai1 #bjah,ms4 ,de,lauro 7= h]self & ,ms4 ,s*ak[sky7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,ways & ,means1 & 9 addition to ! ,committees on ,en]gy & ,comm]ce1 ,education & ! ,work=ce1 ,natural ,res\rces1 & ! ,judici>y1 = 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 ! ,social ,security ,act to e/abli% a ,m$ic>e = ,am]ica heal? program to provide = compreh5sive heal? cov]age = all ,am]icans4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,m$ic>e = ,am]ica ,act ( #bjah4 7b7 ,table ( cont5ts ,! table ( cont5ts ( ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4 ,title ,i--,transition+ to & ,e/abli%+ ,m$ic>e = ,am]ica ,subtitle ,a--,transitional public heal? option ,sec4 #aja4 ,e/abli%m5t4 ,sec4 #ajb4 ,eligibility4 ,sec4 #ajc4 ,b5efits4 ,sec4 #ajd4 ,premiums4 ,sec4 #aje4 ,provid]s & reimbursem5t rates4 ,sec4 #ajf4 ,acc\nt2 fund+4 ,subtitle ,b--,m$ic>e = ,am]ica ,sec4 #aaa4 ,e/abli%m5t & adm9i/ration ( ,m$ic>e = ,am]ica4 ,sec4 #aab4 ,modifications to & coord9ation ) exi/+ ,f$]al heal? programs4 ,subtitle ,c--,t>get$ ,re=ms ,sec4 #aba4 ,limitation on removal ( ,m$ic>e ,advantage provid]s by ,,ma organizations4 ,sec4 #abb4 ,network adequacy4 ,sec4 #abc4 ,elim9at+ ! #bd-mon? wait+ p]iod = ,m$ic>e cov]age = individuals ) disabilities4 ,sec4 #abd4 ,employ] heal? plan options4 ,sec4 #abe4 ,prohibition on /ep !rapy & prior au?orization "u gr\p heal? plans4 ,sec4 #abf4 ,m$ic>e outpati5t obs]vation s]vices4 ,sec4 #abg4 ,abortion cov]age4 ,title ,,ii--,tax ,provisions ,sec4 #bja4 ,sunset ( ,public ,law #aae-ig4 ,sec4 #bjb4 ,surtax4 ,sec4 #bjc4 ,basis ( prop]ty acquir$ f a dec$5t4 ,sec4 #bjd4 ,m$ic>e payroll tax4 ,sec4 #bje4 ,net inve/m5t income tax4 ,sec4 #bjf4 ,t]m9ation ( heal? sav+s acc\nts4 ,sec4 #bjg4 ,t]m9ation ( flexible sp5d+ arrangem5ts4 ,sec4 #bjh4 ,increase 9 excise tax on small cig>s & cig>ettes & o!r tobacco products4 ,sec4 #bji4 ,excise tax on alcohol4 ,sec4 #baj4 ,tax on sug>$ dr9ks4 ,title ,,iii--,drug-,relat$ ,provisions ,sec4 #cja4 ,e/abli%m5t ( ! prescription drug & m$ical device review bo>d4 ,sec4 #cjb4 ,memb]%ip2 /aff4 ,sec4 #cjc4 ,report+ requirem5ts4 ,sec4 #cjd4 ,prohibition aga9/ excessive price4 ,sec4 #cje4 ,en=cem5t provisions4 ,sec4 #cjf4 ,au?ority4 ,sec4 #cjg4 ,regulations4 ,sec4 #cjh4 ,report to ,f$]al ag5cies4 ,sec4 #cji4 ,def9itions4 ,sec4 #caj4 ,moratorium on direct-to-consum] drug adv]tis+4 ,sec4 #caa4 ,report+ on ju/ification = drug price increases4 ,i ,transition+ to & ,e/abli%+ ,m$ic>e = ,am]ica ,a ,transitional public heal? option #aja4 ,e/abli%m5t ,! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is subtitle ref]r$ to z ! ,secret>y7 %all e/abli% a public heal? plan option t is (f]$ 9 ! individual m>ket ?r\gh ! ,f$]al & ,/ate ,ex*anges "u title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act to eligible individuals = plan ye>s #bjbj & #bjba 9 accordance ) ?is subtitle4 #ajb4 ,eligibility 7a7 ,9 g5]al ,subject to subsection 7b71 an individual is eligible to enroll 9 su* public heal? plan option if ! individual is o!rwise eligible to pur*ase individual heal? insurance cov]age ?r\gh an ,ex*ange & ! individual resides 9 a rat+ area 9 :i* ! ,secret>y makes ! public heal? plan option available4 7b7 ,priority ,9 det]m9+ 9 :i* rat+ areas ! ,secret>y initially w make ! public heal? plan option available1 ! ,secret>y %all give priority to rat+ areas 9 :i*-- 7#a7 n m ?an #a heal? insurance issu] (f]s plans on ! applicable ,/ate or ,f$]al ,am]ican ,heal? ,b5efit ,ex*ange2 or 7#b7 !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 #ajc4 ,b5efits 7a7 ,9 g5]al ,! public heal? plan option %all be a qualifi$ heal? plan )9 ! mean+ ( section #acja7;a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjba7;a77 t-- 7#a7 meets all requirem5ts applicable to qualifi$ heal? plans "u subtitle ,d ( title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7o!r ?an ! requirem5t "u section #acja7;a77#a77;,c77ii7 ( su* ,act 7#db ,u4,s4,c4 #ahjba7;a77#a77;,c77ii777 & title ,,xxvii ( ! ,public ,heal? ,s]vice ,act2 7#b7 provides cov]age ( ! ess5tial heal? b5efits describ$ 9 section #acjb7;b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjbb7;b772 7#c7 provides silv] & gold-level cov]age describ$ 9 section #acjb7;d77#a77;,c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjbb7;d77#a77;,c772 & 7#d7 provides cov]age ( abortions & all o!r reproductive heal? s]vices4 7b7 ,preemption ,not)/&+ section #acjc7;a77#a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjbc7;a77#a77-- 7#a7 a ,/ate may n prohibit ! public heal? plan option f (f]+ ! cov]age describ$ 9 subsection 7a77#d72 & 7#b7 no ,/ate law t w\ld prohibit su* a plan f (f]+ su* cov]age %all apply to su* plan4 #ajd4 ,premiums ,! ,secret>y %all e/abli% premium rates = ! public heal? plan option t-- 7#a7 are adju/$ bas$ on ! applicable rat+ area2 7#b7 are at a level suffici5t to fully f9ance-- 7,a7 ! co/s ( heal? b5efits provid$ by su* plans2 & 7,b7 adm9i/rative co/s relat$ to op]at+ ! plans2 & 7#c7 comply ) ! requirem5ts "u section #bgja ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg74 #aje4 ,provid]s & reimbursem5t rates 7a7 ,9 g5]al ,! ,secret>y %all e/abli% a rate s*$ule = reimburs+ types ( heal? c>e provid]s furni%+ items & s]vices "u ! public heal? insurance plan option at rates bas$ on rates appli$ = su* items & s]vices "u title ,,xviii ( ! ,social ,security ,act1 z ( ! date ( ! enactm5t ( ?is ,act1 t are necess>y to ma9ta9 network adequacy4 ,! ,secret>y %all e/abli% a rate s*$ule = items & s]vices n curr5tly cov]$ "u title ,,xviii ( ! ,social ,security ,act at a level to ensure adequate access to provid]s4 7b7 ,p>ticipat+ provid]s 7#a7 ,9 g5]al ,a heal? c>e provid] t is a p>ticipat+ provid] ( s]vices or suppli] "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act or "u ! ,m$icaid program "u title ,,xix ( su* ,act on ! date ( enactm5t ( ?is title %all be a p>ticipat+ provid] = public heal? insurance plan option4 7#b7 ,additional provid]s ,! ,secret>y %all e/abli% a process to all[ heal? c>e provid]s n describ$ 9 p>agraph 7#a7 to become p>ticipat+ provid]s = ! public heal? insurance plan option4 7c7 ,prescription drugs ,! ,secret>y %all apply ! provisions ( section #ahfj;,d-#aa7;i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aaa7;i77 to prescription drugs "u ! public heal? plan option 9 ! same mann] z su* provisions apply ) respect to applicable cov]$ "p ,d drugs "u su* section4 #ajf4 ,acc\nt2 fund+ 7a7 ,e/abli%m5t ,!re is e/abli%$ 9 ! ,treasury ( ! ,unit$ ,/ates an acc\nt = ! receipts & disbursem5ts attributable to ! op]ation ( ! public heal? plan option4 7b7 ,appropriation ,!re is appropriat$ to ! acc\nt e/abli%$ "u subsection 7a71 out ( any funds 9 ! ,treasury n o!rwise obligat$1 su* sums z may be necess>y to be us$ by ! ,secret>y = purposes ( c>ry+ out ?is "p4 7c7 ,prohibition ( ,/ate imposition ( taxes ,section #ahed7;g7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bd7;g77 %all apply to receipts & disbursem5ts describ$ 9 subsection 7a7 9 ! same mann] z su* section applies to paym5ts or premiums describ$ 9 su* section4 7d7 ,cl>ification ,any provision ( law re/rict+ ! use ( ,f$]al funds ) respect to any reproductive heal? s]vice %all n apply to funds appropriat$ "u subsection 7b7 or ) respect to ! acc\nt "u subsection 7a74 ,b ,m$ic>e = ,am]ica #aaa4 ,e/abli%m5t & adm9i/ration ( ,m$ic>e = ,am]ica ,! ,social ,security ,act is am5d$ by add+ at ! end ! foll[+ new title3 ,,xxii ,m$ic>e = ,am]ica ,a ,compreh5sive ,heal? ,cov]age #bbja4 ,e/abli%m5t ,! ,secret>y %all e/abli% a public heal? insurance program1 to be kn[n z ,m$ic>e = ,am]ica1 :i* %all = cal5d> ye> #bjbb & ea* subsequ5t cal5d> ye> provide compreh5sive heal? b5efits 9 accordance ) ?is "p to individuals enroll$ = cov]age "u ?is title4 #bbjb4 ,eligibility2 ,automatic enrollm5t 7a7 ,eligible individuals ,= purposes ( ?is title1 e individual :o is a resid5t ( ! ,unit$ ,/ates is entitl$ to b5efits = heal? c>e s]vices "u ?is title4 ,! ,secret>y %all promulgate a rule t provides crit]ia = det]m9+ resid5cy = eligibility purposes "u ?is title4 7b7 ,enrollm5ts ,subject to subsection 7c73 7#a7 ,9 g5]al ,beg9n+ 9 #bjbb1 ! ,secret>y %all provide a me*anism = ! enrollm5t ( individuals entitl$ to b5efits "u ?is title &1 9 conjunction ) su* enrollm5t1 ! issuance ( a ,m$ic>e c>d :i* may be us$ = purposes ( id5tification & process+ ( claims = b5efits "u ?is title4 ,z a condition ( p>ticipation 9 ! program1 p>ticipat+ provid]s %all facilitate enrollm5t z specifi$ by ! ,secret>y4 7#b7 ,automatic enrollm5ts ,! me*anism provid$ "u p>agraph 7#a7 %all1 subject to p>agraph 7#d71 provide1 = plan ye>s beg9n+ ) plan ye> #bjbb1 = ! foll[+ automatic enrollm5ts "u ,m$ic>e = ,am]ica3 7,a7 ,enrollm5t at bir? ,= plan ye>s 7beg9n+ ) plan ye> #bjbb71 a process1 e/abli%$ by ! ,secret>y 9 consultation ) ! ,commission] ( ,social ,security1 = ! automatic enrollm5t ( eligible individuals born dur+ su* plan ye>4 7,b7 ,curr5t ,m$ic>e b5efici>ies 7i7 ,curr5t ,m$ic>e b5efici>ies ,= plan ye>s 7beg9n+ ) plan ye> #bjbb71 a process e/abli%$ by ! ,secret>y = ! automatic enrollm5t ( all individuals :o are enroll$ = b5efits "u "p ,a or ,b ( title ,,xviii 7o!r ?an individuals :o are enroll$ = su* b5efits & receiv+ b5efits "u title ,,xix74 7ii7 ,cont9u+ population ,= plan ye>s 7beg9n+ ) plan ye> #bjbb71 a process e/abli%$ by ! ,secret>y = ! automatic enrollm5t ( eligible individuals :o atta9 ! age ( #fe dur+ su* plan ye>4 7iii7 ,duals ,= plan ye>s 7beg9n+ ) plan ye> #bjbd71 a process e/abli%$ by ! ,secret>y = ! automatic enrollm5t ( eligible individuals :o are enroll$ = b5efits "u "p ,a or ,b ( title ,,xviii & receiv+ b5efits "u title ,,xix4 7,c7 ,o!r individuals )\t qualifi$ heal? cov]age ,= plan ye>s 7beg9n+ ) plan ye> #bjbb71 a process e/abli%$ by ! ,secret>y = ! automatic enrollm5t ( eligible individuals :o are n enroll$ 9 o!r qualifi$ heal? cov]age 7z def9$ 9 p>agraph 7#d77;,b77 = su* plan ye>4 7#c7 ,o!r enrollm5ts ,! me*anism provid$ "u p>agraph 7#a7 %all provide = ! foll[+3 7,a7 ,9 g5]al ,enrollm5t p]iods & processes = ea* plan ye> 7beg9n+ ) plan ye> #bjbb7 = enrollm5t "u ,m$ic>e = ,am]ica ( any eligible individual n o!rwise describ$ 9 p>agraph 7#b74 7,b7 ,small employ]s ,= plan ye>s 7beg9n+ ) plan ye> #bjbb71 a process & me?odology "u :i* a small employ]1 z def9$ 9 section #abd7;d77#c7 ( ! ,m$ic>e = ,am]ica ,act1 may provide = ! enrollm5t ( ! employees ( su* employ] "u ,m$ic>e = ,am]ica4 ,= purposes ( ! previ\s s5t5ce1 ! t]m small employ] means any employ] = any cal5d> ye> if ! annual payroll ( su* employ] = ! prec$+ cal5d> ye> does n exce$ #b1jjj1jjj or has few] ?an #ajj employees4 7,c7 ,l>ge employ]s ,= plan ye>s 7beg9n+ ) plan ye> #bjbf71 ! ,secret>y %all provide = a process & me?odology "u :i* a l>ge employ] may provide = ! enrollm5t ( ! employees ( su* employ] "u ,m$ic>e = ,am]ica4 ,= purposes ( ! prec$+ s5t5ce1 ! t]m l>ge employ] means an employ] ) at lea/ #ajj employees4 7#d7 ,opt out = individuals enroll$ "u qualifi$ heal? cov]age 7,a7 ,9 g5]al ,! me*anism provid$ "u p>agraph 7#a7 %all provide1 ) respect to a plan ye>1 = a process t enables individuals :o are enroll$ 9 qualifi$ heal? cov]age = su* plan ye> to opt out ( cov]age "u ,m$ic>e = ,am]ica = su* ye>4 7,b7 ,qualifi$ heal? cov]age def9$ ,= purposes ( ?is section1 ! t]m qualifi$ heal? cov]age means cov]age "u any ( ! foll[+3 7i7 ,= plan ye>s #bjbb & #bjbc3 7,i7 ,qualifi$ employ] cov]age1 z def9$ 9 section #abd ( ! ,m$ic>e = ,am]ica ,act4 7,,ii7 ,m$ical cov]age "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code1 includ+ cov]age "u ! ,,tric>e program4 7,,iii7 ,a heal? c>e program "u *apt] #ag or #ah ( title #ch1 ,unit$ ,/ates ,code1 z det]m9$ by ! ,secret>y ( ,vet]ans ,affairs1 9 coord9ation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y4 7,,iv7 ,! heal? b5efit program "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code4 7,v7 ,m$ical b5efits & s]vices provid$ by or ?r\gh ! ,indian ,heal? ,s]vice4 7,,vi7 ,! ,m$icaid program "u title ,,xix ( ! ,social ,security ,act4 7,,vii7 ,! ,,*ip program "u title ,,xxi ( ! ,social ,security ,act4 7ii7 ,= plan ye>s #bjbd & #bjbe3 7,i7 ,cov]age describ$ 9 subclause 7,i71 7,,ii71 7,,iii71 7,,iv71 or 7,v7 ( clause 7i74 7,,ii7 ,cov]age describ$ 9 subclause 7,,vi7 ( clause 7i71 b only ) respect to cov]age t is n = individuals describ$ 9 subclause 7,,viii7 ( section #aijb7;a77#aj77;,a77i7 or :o are also enroll$ = b5efits "u title ,,xviii4 7iii7 ,= ea* subsequ5t plan ye>1 cov]age describ$ 9 subclause 7,i71 7,,ii71 7,,iii71 7,,iv71 or 7,v7 ( clause 7i74 7c7 ,waiv] ,! ,secret>y %all e/abli% a process "u :i* ! ,secret>y may grant waiv]s to ,/ates = additional "t be=e populations describ$ 9 a previ\s subsection ( ?is section ( su* ,/ate are automatically enroll$ "u ,m$ic>e = ,am]ica4 #bbjc4 ,b5efits 7a7 ,9 g5]al ,m$ic>e = ,am]ica %all1 9 accordance ) ?is section1 provide cov]age = all ! b5efits1 z det]m9$ to be m$ically necess>y & reasonable1 z cov]$ & def9$ "u p>ts ,a & ,b ( title ,,xviii & title ,,xix z ( ! date ( ! enactm5t ( ?is title1 includ+ ! foll[+3 7#a7 ,ambulatory pati5t s]vices4 7#b7 ,em]g5cy c>e & urg5t c>e s]vices4 7#c7 ,hospitalization4 7#d7 ,mat]nity & newborn c>e4 7#e7 ,behavioral heal?1 m5tal heal? & sub/ance use disord] s]vices1 includ+ ! foll[+3 7,a7 ,home-bas$ s]vices4 7,b7 ,acute s]vices = m5tal heal? crises1 includ+ crisis /abilization s]vices su* z mobile crisis s]vices1 includ+ em]g5cy mobile psy*iatric s]vices4 7,c7 #bc-;h\r obs]vation4 7,d7 ,outpati5t s]vices provid$ by hospitals1 free/&+ cl9ics1 & behavioral heal? provid]s 9 indep5d5t practice4 7,e7 ,smok+ & tobacco cessation4 7,f7 ,case managem5t4 7,g7 ,pe] support s]vices4 7,h7 ,c\nsel+4 7,i7 ,o!r int5sive outpati5t community-bas$ s]vices1 su* z ,ass]tive ,community ,treatm5t & support$ employm5t1 provid$ ?r\gh ! ,,ltss b5efit4 7,j7 ,o!r int5sive community-bas$ s]vices provid$ ?r\gh ! ,e>ly & ,p]iodic ,scre5+1 ,diagno/ic1 & ,treatm5t 7,,epsdt7 b5efit 7z def9$ 9 subp>t ,b ( "p #dda ( title #db ( ! ,code ( ,f$]al ,regulations74 7,k7 ,m$ication assi/$ treatm5t & ma9t5ance s]vices4 7,l7 ,inpati5t detoxification4 7,m7 ,ambulatory detoxification4 7,n7 ,psy*ological te/+4 7,o7 ,home heal? ag5cy s]vices4 7#f7 ,prescription drugs4 7#g7 ,rehabilitative & habilitative s]vices & devices1 includ+ ! foll[+3 7,a7 ,physical !rapy4 7,b7 ,spee* !rapy4 7,c7 ,occupational !rapy4 7#h7 ,laboratory s]vices4 7#i7 ,prev5tive & wellness s]vices & *ronic disease managem5t4 7#aj7 ,p$iatric s]vices1 includ+ oral & vision c>e & all s]vices t w\ld o!rwise be cov]$ "u ,e>ly & ,p]iodic ,scre5+1 ,diagno/ic1 & ,treatm5t "u ! ,m$icaid program "u title ,,xix4 7#aa7 ,d5tal4 7#ab7 ,he>+ heal? s]vices includ+ aids & exams4 7#ac7 ,home & community-bas$ long-t]m supports & s]vices4 7#ad7 ,*iropractic s]vices4 7#ae7 ,durable m$ical equipm5t1 includ+ ! foll[+3 7,a7 ,:eel*airs & accessories4 7,b7 ,walk+ aides su* z walk]s1 canes1 & crut*es4 7,c7 ,ba?room equipm5t su* z commodes & safety equipm5t4 7,d7 ,inhalation !rapy equipm5t su* z nebuliz]s4 7,e7 ,hospital b$s & accessories4 7,f7 ,o!r devices su* z cont9u\s positive airway pressure 7,,cpap7 ma*9es1 apnea monitors1 & v5tilators4 7,g7 ,insul9 pumps & glucomet]s4 7,h7 ,brea/ pumps4 7,i7 ,lymph$ema compression treatm5t items4 7,j7 ,wigs4 7,k7 ,augm5tative & alt]native communication devices1 includ+ dual-use devices4 7#af7 ,family plann+1 includ+ ! foll[+3 7,a7 ,reproductive heal? exams4 7,b7 ,pati5t c\nsel+ & education relat$ to family plann+4 7,c7 ,abortion4 7,d7 ,scre5+1 te/+1 treatm5t1 & pre- & po/-te/ c\nsel+ = sexually transmitt$ diseases & ,,hiv4 7,e7 ,contraceptives includ+ pill1 pat*1 m$ication1 condom1 implant1 or o!r devices us$ to prev5t pregnancy4 7,f7 ,/]ilization = b5efici>ies ov] ! age ( #ba4 7,g7 ,inf]tility treatm5t4 7#ag7 ,g5d]-confirm+ m$ical proc$ures & treatm5t4 7#ah7 ,diet>y & nutrition c\nsel+4 7#ai7 ,m$ically necess>y food & vitam9s = dige/ive & inh]it$ metabolic disord]s4 7#bj7 ,nurs+ facilities4 7#ba7 ,or?otic & pro/hetics devices4 7#bb7 ,oxyg54 7#bc7 ,acupuncture4 7#bd7 ,teleheal?4 7#be7 ,s]vices o!rwise includ$ "u ! mat]nal1 infant1 & e>ly *ildhood home visit+ program "u section #eaa ( ! ,social ,security ,act1 z ( ! date ( ! enactm5t ( ?is title4 7#bf7 ,any additional b5efit or s]vice n includ$ 9 ?is section t is cov]$ by any ,/ate plan 7or waiv] ( su* ,/ate plan7 "u title ,,xix on ! date ( ! enactm5t ( ?is title4 7b7 ,updates ,b5efits cov]$ "u ,m$ic>e = ,am]ica %all be updat$ 9 accordance ) ! ,national ,cov]age ,det]m9ation process t _h1 z ( ! date be=e ! date ( ! enactm5t ( ?is title1 appli$ ) respect to b5efits cov]$ "u title ,,xviii4 7c7 ,prohibition aga9/ duplicat+ cov]age 7#a7 ,9 g5]al ,x is unlawful = a private heal? insur] 7o!r ?an an insur] ) respect to a ,m$ic>e ,advantage = ,am]ica plan "u "p ,c ( ?is title or qualifi$ employ]-bas$ cov]age7 to sell heal? insurance cov]age t duplicates ! b5efits provid$ "u ,m$ic>e = ,am]ica "u ?is "p4 7#b7 ,con/ruction ,no?+ 9 p>agraph 7#a7 %all be con/ru$ z prohibit+ ! sale ( heal? insurance cov]age = any additional b5efits n cov]$ by ?is "p1 ins(> z ! cov]age satisfies ! conditions ( p>agraph 7#c74 7#c7 ,application ( protections ,= purposes ( p>agraph 7#b71 heal? insurance cov]age = any additional b5efits mu/ satisfy ! foll[+ conditions3 7,a7 ,! provisions ( section #bgah ( ! ,public ,heal? ,s]vice ,act1 relat+ to a m$ical loss ratio4 7,b7 ,! provisions ( section #bgjb ( ! ,public ,heal? ,s]vice ,act1 relat+ to gu>ante$ issue4 7,c7 ,! provisions ( section #bgja ( ! ,public ,heal? ,s]vice ,act1 relat+ to community rat+4 7,d7 ,! provisions ( section #bgjd ( ! ,public ,heal? ,s]vice ,act1 relat+ to ! ban on pre-exi/+ conditions exclusions4 7d7 ,/ates may provide additional b5efits ,individual ,/ates may provide additional b5efits = ! resid5ts ( su* ,/ates at ! exp5se ( ! ,/ate4 7e7 ,prohibition aga9/ /ep !rapy & prior au?orization ,items & s]vices cov]$ "u ,m$ic>e = ,am]ica %all be cov]$ )\t any ne$ = any prior au?orization det]m9ation & )\t any limitation appli$ ?r\gh ! use ( /ep !rapy protocols4 #bbjd4 ,premiums 7a7 ,9 g5]al 7#a7 ,subject to p>agraph 7#b71 ea* individual enroll$ = b5efits "u ?is title = a ye> %all pay mon?ly community-rat$ premiums = su* ye> 9 an am\nt det]m9$ by ! ,secret>y 9 accordance ) subsection 7b74 7#b7 ,gr&fa!r$ ,m$ic>e b5efici>ies ,9 ! case ( an individual enroll$ "u "p ,b ( title ,,xviii z ( ! date ( ! enactm5t ( ?is "p1 ! premium appli$ "u ?is section = su* individual = b5efits "u ?is title %all be ! less] (-- 7,a7 ! premium o!rwise applicable to su* individual "u su* title ,,xviii if ?is title _h n be5 enact$2 or 7,b7 ! premium t w\ld be appli$ to su* individual "u ?is title )\t ! application ( ?is p>agraph4 7b7 ,premium contribution bas$ on income ,! am\nt ( a mon?ly premium1 ) respect to a plan ye> 7beg9n+ ) #bjbb71 "u ?is section %all be e/abli%$ by ! ,secret>y 9 accordance ) ! foll[+3 7#a7 ,su* premium %all be det]m9$ su* t ! collective premiums = ! plan ye> are ) respect to ! co/s ( heal? b5efits provid$ "u ?is title = su* ye> & relat$ adm9i/rative co/s4 7#b7 ,premiums %all v>y by family composition only4 7#c7 ,f$]al subsidies %all be provid$ to ensure t ! premium %all be-- 7,a7 z]o 9 ! case ( an individual ^: annual h\sehold income is bel[ #bjj p]c5t ( ! pov]ty l9e2 7,b7 det]m9$ by a l9e> slid+ scale1 9 ! case ( an individual ^: h\sehold income is at lea/ #bjj p]c5t ( ! pov]ty l9e1 b n m ?an #fjj p]c5t ( ! pov]ty l9e1 ) ! premiums rang+ betwe5 ! am\nt det]m9$ = individuals describ$ 9 clause 7i7 & = individuals describ$ 9 clause 7iii72 & 7,c7 no individual or h\sehold w pay m ?an #i4fi p]c5t ( mon?ly income t[>d su* mon?ly premium4 7#d7 ,= an individual ^: employ] w be mak+ a firm-wide contribution "u ?is title 9 lieu ( (f]+ employ] sponsor$ insurance 7z specifi$ 9 section #abd7;b77#a77;,b7 ( ! ,m$ic>e = ,am]ica ,act71 su* individual %all pay a premium 9 accordance ) ?is subsection4 7#e7 ,= an individual :o has opt$ out ( _! employ] sponsor$ insurance 9 ord] to enroll 9 ,m$ic>e = ,am]ica z specifi$ 9 section #abd7;c7 ( su* ,act1 ! individual %all pay ! premium describ$ 9 ?is subsection4 7c7 ,deposits ,am\nts paid "u ?is section = cov]age "u ?is title %all be deposit$ 9 ! ,treasury to ! cr$it ( ! ,tru/ ,fund e/abli%$ "u section #bbjf4 7d7 ,appeals = c]ta9 ,m$ic>e gr&fa!r$ population ,9 calculat+ premiums = purposes ( subsection 7a77#b73 7#a7 ,any individual t 0 subject to a late enrollm5t p5alty "u "p ,b ( title ,,xviii %all h ! "r to appeal ! assessm5t ( ! p5alty = good fai? enrollm5t mi/akes4 7#b7 ,9 any case 9 :i* ! ,secret>y f9ds t an individual's enrollm5t or non5rollm5t 9 ! insurance program e/abli%$ by ?is "p or "p ,a ( title ,,xviii pursuant to section #ahah is un9t5tional1 inadv]t5t1 or errone\s1 :e!r ! result ( ! error1 misrepres5tation1 or inaction ( an (fic]1 employee1 or ag5t ( ! ,f$]al ,gov]nm5t or its in/rum5talities1 an employ]1 a repres5tative ( a gr\p heal? plan1 a ,/ate1 or = any o!r good fai? reason on ! "p ( su* individual1 ! ,secret>y %all take su* action 7includ+ ! designation = su* individual ( a special initial or subsequ5t enrollm5t p]iod1 includ+ retroactive enrollm5t1 ) a cov]age p]iod det]m9$ on ! basis !re( & ) appropriate adju/m5ts ( premiums7 z may be necess>y to correct or elim9ate ! effects ( su* error1 misrepres5tation1 or inaction4 ,! failure ( an individual to enroll 9 ! insurance program e/abli%$ by ?is "p or "p ,a pursuant to section #ahah due to enrollm5t "u a gr\p heal? plan2 cov]age pursuant to title ,,xxii ( ! ,public ,heal? ,s]vice ,act1 section #dihj;,b ( ! ,int]nal ,rev5ue ,code ( #aihf1 title ,,vi ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or title ,,xix2 or enrollm5t "u a qualifi$ heal? plan (f]$ ?r\gh an ,ex*ange e/abli%$ "u title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act %all "u ?is subsection abs5t exceptional circum/ances1 z det]m9$ by ! ,secret>y4 7#c7 ,! ,secret>y1 9 consultation ) ! ,commission] ( ,social ,security1 %all develop & publi% a =mal application = reque/+ an action ( ! ,secret>y "u p>agraph 7#a7 to correct or elim9ate ! effects ( an error1 misrepres5tation1 or inaction describ$ 9 su* p>agraph & det]m9e & publi% specific timel9es = timely resolution ( su* a reque/4 7#d7 ,! ,secret>y %all also require t all su* det]m9ations ) respect to su* reque/s %all be rea*$ )9 #ae bus9ess days ( ! submission ( su* application4 ,all det]m9ations %all be 9 writ+ ?r\gh a /&>d decision notice :i* %all include an explanation ( ! reasons = ! det]m9ation4 7#e7 ,! ,commission] ( ,social ,security %all ent] into contracts ) indep5d5t review organizations 9 accordance ) ?is subsection = ! purpose ( review+ & det]m9+ individual appeals ( det]m9ations "u p>agraph 7#c7 ) respect to an application submitt$ pursuant to p>agraph 7#b7 relat+ to enrollm5t "u "p ,a or "p ,b4 7#f7 ,an individual :o receives an adv]se det]m9ation "u p>agraph 7#c7 ) respect to an application submitt$ pursuant to p>agraph 7#b7 may appeal to an indep5d5t review organization designat$ by ! ,commission4 ,any su* appeal mu/ be s5t to ! indep5d5t review organization )9 #ij days ( ! date ! individual receiv$ ! det]m9ation to be eligible = review4 ,! indep5d5t review organization %all review & rea* a det]m9ation ( ! review 9 writ+ )9 #de days ( ! receipt ( any su* appeal4 7#g7 ,! ,secret>y ( ! ,treasury may n ent] into a contract "u p>agraph 7#e7 ) an indep5d5t review organization-- 7,a7 unless ! organization has /aff t has ! appropriate k (1 & exp]i5ce )1 ! eligibility & coord9ation ( b5efits rules & regulations "u ?is title2 & 7,b7 to ! ext5t ! organization is a fiscal int]m$i>y "u section #ahaf1 a c>ri] "u section #ahdb1 or a ,m$ic>e adm9i/rative contractor "u section #ahgd;,a4 7#h7 ,! ,secret>y ( ,heal? & ,human ,s]vices %all provide = access by indep5d5t review organizations conduct+ appeal det]m9ations "u ?is subsection1 to ! database ( ! ,coord9ation ( ,b5efits ,contractor ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices z necess>y 9 ord] to conduct ! duties ( su* organizations to det]m9e appeals pursuant to ?is subsection4 #bbje4 ,paym5t ( b5efits2 co/-%>+2 out-(-pocket limits 7a7 ,paym5t ( b5efits2 co/-,%>+ ,!re %all be paid1 9 ! case ( ea* individual :o is enroll$ "u ,m$ic>e = ,am]ica & incurs exp5ses = items & s]vices ) respect to :i* b5efits are payable "u ?is "p1 aft] application ( subsection 7b7 & subject to subsection 7c71 #hj p]c5t ( ! reimbursem5t rates e/abli%$ pursuant to section #bbjf = su* items & s]vices1 except t ) respect to ,,usptf recomm5d$ prev5tive & *ronic disease s]vices1 & g5]ic drugs1 ! am\nts paid "u ?is section %all be equal to #ajj p]c5t ( ! reimbursem5t rates e/abli%$ pursuant to section #bbjf = su* items & s]vices4 7b7 ,d$uctible 7#a7 ,9 g5]al ,!re %all be a d$uctible appli$ "u ?is "p = ea* plan ye> t %all be det]m9$ on a l9e> slid+ scale = h\sehold income t is at lea/ #bjj p]c5t ( ! pov]ty l9e1 b n m ?an #fjj p]c5t ( ! pov]ty l9e1 & %all n exce$1 subject to p>agraphs 7#b7 & 7#c7-- 7,a7 #cej = an individual2 or 7,b7 #ejj total = all memb]s ( a h\sehold4 7#b7 ,index+ ,9 ! case ( plan ye>s beg9n+ aft] #bjba1 ! doll> am\nts describ$ 9 p>agraph 7#a7 %all be increas$ by ! p]c5tage increase ov] ! previ\s ye> 9 ! m$ical c>e exp5diture category ( ! ,consum] ,price ,index = ,all ,urban ,consum]s 7,unit$ ,/ates city av]age71 publi%$ by ! ,bureau ( ,labor ,/ati/ics4 7#c7 ,exception ,!re %all be no d$uctible appli$ "u ?is "p = mon?s 9 a plan ye> = individuals & h\seholds ) annual income bel[ #bjj p]c5t ( ! f$]al pov]ty l9e4 7c7 ,maximum out-(-,pocket limit 7#a7 ,9 g5]al ,! cov]age "u ,m$ic>e %all provide b5efits1 aft] ! eligible individual has incurr$ out-(-pocket exp5ses = items & s]vices ) respect to :i* b5efits are payable "u ?is "p 9 a ye> equal to ! annual out-(-pocket ?re%old specifi$ 9 p>agraph 7#b71 ) co/-%>+ t is equal to #j4 7#b7 ,annual out-(-pocket ?re%old 7,a7 ,9 g5]al ,= purposes ( p>agraph 7#a71 subject to subp>agraphs 7,b7 & 7,c71 ! annual out-(-pocket ?re%old specifi$ 9 ?is p>agraph is a ?re%old t %all be det]m9$ on a l9e> slid+ scale = h\sehold income t is at lea/ #bjj p]c5t ( ! pov]ty l9e1 b n m ?an #fjj p]c5t ( ! pov]ty l9e1 & t %all n exce$-- 7i7 ) respect to an individual1 #c1ejj2 or 7ii7 ) respect to a h\sehold1 #e1jjj4 7,b7 ,index+ ,9 ! case ( plan ye>s beg9n+ aft] #bjba1 ! ?re%old describ$ 9 subp>agraph 7,a7 7z 9 effect = ! prec$+ plan ye> aft] application ( ?is subp>agraph7 %all be increas$ by ! p]c5tage increase ov] ! previ\s ye> 9 ! m$ical c>e exp5diture category ( ! ,consum] ,price ,index = ,all ,urban ,consum]s 7,unit$ ,/ates city av]age71 publi%$ by ! ,bureau ( ,labor ,/ati/ics4 7,c7 ,exception ,= purposes ( p>agraph 7#a71 ! annual out-(-pocket ?re%old = individuals & h\seholds ) annual income bel[ #bjj p]c5t ( ! f$]al pov]ty l9e is #j4 7d7 ,no balance bill+ ,no provid] may impose a *>ge to an enroll$ individual = cov]$ s]vices = :i* b5efits are provid$ "u ?is "p 9 an am\nt high] ?an ! reimbursem5t rate = su* s]vices "u section #bbjf & may n impose a *>ge to su* individual = su* s]vice o!r ?an ) respect to ! d$uctible or o!r co/-%>+ describ$ 9 ?is section4 #bbjf4 ,provid]s network & reimbursem5t rates 7a7 ,9 g5]al ,! ,secret>y %all e/abli% a rate s*$ule = reimburs+ types ( heal? c>e provid]s furni%+ items & s]vices "u ,m$ic>e = ,am]ica at rates t are consi/5t ) subsection 7b7 & are necess>y to ma9ta9 network adequacy4 7b7 ,rates 7#a7 ,9 g5]al ,except z provid$ 9 p>agraphs 7#b7 & 7#c71 ! ,secret>y %all provide = rates to be provid$ to heal? c>e provid]s & suppli]s furni%+ items & s]vices "u ,m$ic>e = ,am]ica bas$ on rates t w\ld be appli$ 7includ+ z comput$1 updat$1 & adju/$7 "u title ,,xviii = su* type ( heal? c>e provid]s & suppli]s & item & s]vice if su* title rema9$ 9 effect &1 9 ! case ( a type ( provid] & suppli] or item or s]vice cov]$ "u ,m$ic>e = ,am]ica b n o!rwise cov]$ "u title ,,xviii1 %all provide = rates t ensure adequate access to c>e4 7#b7 ,exceptions ,= purposes ( ?is section1 9 apply+ p>agraph 7#a7 ! ,secret>y %all ensure t rates to hospitals = inpati5t s]vices or outpati5t s]vices furni%$ "u ,m$ic>e = ,am]ica are at lea/ #aaj p]c5t ( su* rates on av]age or 9 ! aggregate = furni%+ su* inpati5t or outpati5t s]vices o!rwise appli$ "u title ,,xviii1 except t = hospitals s]v+ und]s]v$ areas z specifi$ by ! ,secret>y1 su* rates are increas$ z necess>y to ensure adequate access to c>e4 7#c7 ,application ,9 apply+ rates "u title ,,xviii = purposes ( ?is "p1 ! foll[+ %all apply3 7,a7 ,! ,secret>y %all provide = site-neutral paym5ts = items & s]vices furni%$ 9 an outpati5t hospital & physician (fice1 ! rate ( paym5t = su* s]vice %all be ! same4 7,b7 ,! ,secret>y %all increase ! av]age relative value ( prim>y c>e & o!r m5tal & behavioral heal? & cognitive s]vices by n less ?an #bj p]c5t 9 ord] to ensure adequate access to inpati5t & outpati5t c>e4 7,c7 ,z a condition ( p>ticipation 9 ! program1 p>ticipat+ provid]s %all accept ,m$ic>e = ,am]ica rates paid by employ]-sponsor$ insurance plans & ,m$ic>e ,advantage plans4 7c7 ,p>ticipat+ provid]s 7#a7 ,9 g5]al ,a heal? c>e provid] t is a p>ticipat+ provid] ( s]vices or suppli] "u ! ,m$ic>e program "u title ,,xviii on ! date ( enactm5t ( ?is title %all rema9 a p>ticipat+ provid] = ,m$ic>e = ,am]ica4 7#b7 ,additional provid]s ,! ,secret>y %all e/abli% a process to all[ heal? c>e provid]s n describ$ 9 p>agraph 7#a7 to become p>ticipat+ provid]s = ,m$ic>e = ,am]ica4 7d7 ,prescription drugs 7#a7 ,9 g5]al ,any paym5t rate "u ?is "p = a prescription drug %all be at a rate negotiat$ by ! ,secret>y bas$ on value assessm5ts by "o or m indep5d5t nonpr(it organizations c]tifi$ by ! ,national ,academy ( ,m$ic9e & ,med,p,a,c4 ,if ! ,secret>y is unable to rea* a negotiat$ agreem5t on su* a reimbursem5t rate1 ! ,secret>y %all apply prices paid by ! ,dep>tm5t ( ,vet]ans ,affairs = su* drugs or ! av]age price ( su* drugs 9 nations :i* are memb]s ( ! ,organization = ,economic ,coop]ation & ,developm5t1 :i*ev] is l[]4 7#b7 ,failure to negotiate ,if a drug manufactur] refuses to negotiate ) ! ,secret>y1 !n ,m$ic>e = ,am]ica w n cov] any ( ! manufactur]'s products4 ,!re %all be an exceptions process = drugs t are o!rwise unavailable = p ) *ronic conditions4 ,individuals %all cont9ue to h access to drugs dur+ ! appeals process4 ,! ,secret>y %all modify su* rates 9 ord] to accommodate paym5ts = drugs t are n o!rwise cov]$ "u ! orig9al ,m$ic>e fee-=-s]vice program "u title ,,xviii4 7#c7 ,value or co/-effectiv5ess assessm5ts ,! use ( ,quality-,adju/$ ,life ,ye>s1 ,disability-,adju/$ ,life ,ye>s1 or o!r simil> me*anisms is prohibit$ = use 9 value or co/-effectiv5ess assessm5ts = purposes ( ?is subsection4 #bbjg4 ,tru/ ,fund2 fund+ 7a7 ,tru/ ,fund ,!re %all be e/abli%$ a unifi$ ,m$ic>e ,tru/ ,fund 9 :i* funds provid$ "u ?is title are deposit$ & f :i* exp5ditures "u ?is title are made4 ,! ,tru/ ,fund %all consi/ ( su* gifts & beque/s z may be made & su* am\nts z may be deposit$ 91 or appropriat$ to1 su* ,tru/ ,fund z provid$ 9 ?is ,act4 7b7 ,fund+ 7#a7 ,taxes ,!re are h]eby appropriat$ to ! ,tru/ ,fund = ea* fiscal ye> beg9n+ ) fiscal ye> #bjbb1 out ( any moneys 9 ! ,treasury n o!rwise appropriat$1 am\nts equival5t to #ajj p]c5t ( ! net increase 9 rev5ues to ! ,treasury :i* is attributable to ! am5dm5ts made by title ,,ii ( ! ,m$ic>e = ,am]ica ,act & premiums collect$ "u ?is title4 ,! am\nts appropriat$ by ! prec$+ s5t5ce %all be transf]r$ f "t to "t 7b n less frequ5tly ?an mon?ly7 f ! g5]al fund 9 ! ,treasury to ! ,tru/ ,fund1 su* am\nts to be det]m9$ on ! basis ( e/imates by ! ,secret>y ( ! ,treasury ( ! taxes paid to or deposit$ into ! ,treasury2 & prop] adju/m5ts %all be made 9 am\nts subsequ5tly transf]r$ to ! ext5t prior e/imates 7 9 excess ( or 7 less ?an ! am\nts t %\ld h be5 s transf]r$4 7#b7 ,curr5t program receipts ,not)/&+ any o!r provision ( law1 !re are h]eby appropriat$ to ! ,tru/ ,fund = ea* fiscal ye>1 beg9n+ ) fiscal ye> #bjbb1 ! am\nts t w\ld o!rwise h be5 appropriat$ to c>ry out ! foll[+ programs3 7,a7 ,! ,m$ic>e program "u title ,,xviii4 7,b7 ,! ,m$icaid program "u title ,,xix1 beg9n+ z ( #bjbf4 7#c7 ,additional appropriations ,additional sums are au?oriz$ to be appropriat$ annually z ne$$ to ma9ta9 maximum quality1 effici5cy1 & access "u ?is "p4 7#d7 ,m$icaid ma9t5ance ( ef=t paym5ts ,!re %all be transf]r$ to ! ,tru/ ,fund ! ma9t5ance ( ef=t paym5ts made "u section #bbji4 7c7 ,re/rictions %all n apply ,any o!r provision ( law 9 effect on ! date ( enactm5t ( ?is title re/rict+ ! use ( ,f$]al funds = any reproductive heal? s]vice1 includ+ abortion1 %all n apply to monies 9 ! ,tru/ ,fund4 7d7 ,incorporation ( provisions ,! provisions ( subsections 7b7 ?r\gh 7i7 ( section #ahag %all apply to ! ,tru/ ,fund "u ?is section 9 ! same mann] z su* provisions appli$ to ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u su* section #ahag1 except t1 = purposes ( apply+ su* subsections to ?is section1 ! ,bo>d ( ,tru/ees ( ! ,tru/ ,fund %all mean ! ,secret>y4 7e7 ,transf] ( funds ,any am\nts rema9+ 9 ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u section #ahag or ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda aft] ! paym5t ( claims = items & s]vices furni%$ "u title ,,xviii h be5 complet$1 %all be transf]r$ into ! ,tru/ ,fund "u ?is section4 #bbjh4 ,adm9i/rative provisions 7a7 ,c5t] = ,m$ic>e ,beg9n+ #bjbb1 ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices %all be r5am$ ! ,c5t] = ,m$ic>e & all ref]5ces 9 law & regulation to su* ,c5t]s %all be deem$ a ref]5ce to su* ,c5t]4 ,all p[]s1 duties1 & responsibilities ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices %all be transf]r$ to ! ,c5t] = ,m$ic>e4 7b7 ,au?ority ,! ,secret>y %all h ! au?ority to issue int]im f9al rules ) respect to any provision 9 ?is "p4 7c7 ,adm9i/rative law judges 7#a7 ,9 g5]al ,! ,c5t] = ,m$ic>e is n au?oriz$ to appo9t adm9i/rative law judges1 9 accordance ) pages #aadbj ?r\gh #dii ( title #gj ( ! ,f$]al ,regi/] 7,m>* #h1 #bjje74 7#b7 ,tim+ ,"u ?is title1 adm9i/rative law judges mu/ issue a decision )9 #ij days ( receipt ( a he>+ reque/1 z specifi$ 9 subsections 7a7 & 7c7 ( section #dje4ajaf ( title #b1 ,code ( ,f$]al ,regulations4 7d7 ,cov]age det]m9ations appeals 7#a7 ,individuals may appeal a cov]age det]m9ation "u ?is title be=e ! individual obta9s ! s]vice or item t is ! subject ( ! appeal4 7#b7 ,! ,secret>y %all elim9ate ! r$et]m9ation by a ,m$ic>e adm9i/rative contractor f ! appeals process "u ! ,m$ic>e program = b5efici>ies4 7e7 ,private "r ( action 7#a7 ,9 g5]al ,an applicant or recipi5t aggriev$ by any law1 regulation1 policy or practice 9 violation ( a provision ( ?is title may br+ a civil action seek+ any rem$y available 9 law or equity to rem$y t violation4 ,9 addition to any cause ( action t may be available 9 a ,/ate c\rt1 ! di/rict c\rts ( ! ,unit$ ,/ates %all h concurr5t jurisdiction 9 ! matt]s "u ! provisions ( ?is title4 7#b7 ,reasonable attorney fees ,9 any action or proce$+ to en=ce ?is title1 ! c\rt may aw>d reasonable attorneys' fees & litigation co/s 7includ+ exp]t fees7 reasonably incurr$ aga9/ ! def5dant or def5dants4 7#c7 ,appeal ,any civil action br\ght "u ?is section %all be subject to appeal z provid$ 9 sections #abia & #abib ( title #bh ( ! ,unit$ ,/ates ,code4 #bbji4 ,ma9t5ance ( ef=t requirem5t 7a7 ,9 g5]al ,a ,/ate is n eligible = paym5t "u any program specifi$ 9 subsection 7d7 = a cal5d> qu>t] 9 a plan ye> beg9n+ aft] #bjbf unless ! ,/ate makes to ! ,secret>y = transf] to ! unifi$ ,m$ic>e ,tru/ ,fund "u section #bbjg ! ma9t5ance ( ef=t paym5t applicable to su* ,/ate & plan ye> "u subsection 7b74 ,! ,secret>y %all ext5d su* a waiv] 7includ+ ! availability ( ,f$]al f9ancial p>ticipation "u su* waiv]7 = su* p]iod z may be requir$ = a ,/ate to meet ! requirem5t ( ! previ\s s5t5ce4 7b7 ,ma9t5ance ( ef=t paym5ts ,= purposes ( ?is section1 a ma9t5ance ( ef=t paym5t ) respect to a ,/ate & plan ye> is-- 7#a7 = plan ye> #bjbg & a ,/ate1 a paym5t 9 an am\nt equal to ! total am\nt ( exp5ditures ( ! ,/ate = m$ical assi/ance "u title ,,xix & *ild heal? assi/ance "u title ,,xxi includ+ adm9i/rative co/s = ! plan ye> be=e ! date ( ! enactm5t ( ?is title2 7#b7 = plan ye> #bjbh & ea* subsequ5t plan ye> be=e plan ye> #bjcb-- 7,a7 9 ! case ( a ,/ate t is a ,,ppaca expansion ,/ate1 ! paym5t am\nt appli$ "u ?is subsection = ! previ\s plan ye>1 increas$ by gr[? 9 ,,gdp p] capita plus #j4d p]c5t2 & 7,b7 9 ! case ( a ,/ate t is n a ,,ppaca expansion ,/ate1 ! paym5t am\nt appli$ "u ?is subsection = ! previ\s plan ye>1 increas$ by gr[? 9 ,,gdp p] capita plus #j4g p]c5t2 & 7#c7 beg9n+ 9 #bjcb1 = ea* subsequ5t plan ye>1 ) respect to any ,/ate1 ! paym5t am\nt appli$ "u ?is subsection = ! previ\s ye>1 increas$ by gr[? 9 ,,gdp p] capita plus #j4g p]c5t4 7c7 ,programs specifi$ ,= purposes ( ?is section1 ! programs specifi$ 9 ?is subsection are ea* ( ! foll[+3 7#a7 ,block grants = community m5tal heal? s]vices "u subp>t ,i ( "p ,b ( title ,,xix ( ! ,public ,heal? ,s]vice ,act4 7#b7 ,block grants & programs = social s]vices & eld] ju/ice "u title ,,xx ( ! ,social ,security ,act4 7#c7 ,mat]nal & *ild heal? s]vices block grants "u title ,v ( ! ,social ,security ,act4 7#d7 ,block grants = prev5tion & treatm5t ( sub/ance abuse "u subp>t ,,ii ( "p ,b ( title ,,xix ( ! ,public ,heal? ,s]vice ,act4 7#e7 ,/ate ,t>get$ ,response to ,opioid ,crisis ,grant ,community ,s]vices ,block ,grant4 7#f7 ,grants "u section #ccj ( ! ,public ,heal? ,s]vice ,act4 7#g7 ,ryan ,:ite ,,hiv_/,,aids ,program grants "u title ,,xxvi ( ! ,public ,heal? ,s]vice ,act4 #bbaj4 ,application ( title ,,xviii provisions ,except z specifi$ o!rwise 9 ?is title1 9 implem5t+ ,m$ic>e = ,am]ica1 ! ,secret>y %all to ! greate/ ext5t practicable apply ! foll[+ provisions ( title ,,xviii to ! program "u ?is title1 b5efits cov]$ "u ?is title1 individuals entitl$ to b5efits "u ?is title1 & provid]s ( s]vices & suppli]s p>ticipat+ "u ! program "u ?is title 9 a simil> mann] z su* provisions appli$ to ! program "u title ,,xviii1 b5efits cov]$ "u su* title1 individuals entitl$ to b5efits or enroll$ "u su* title1 & provid]s ( s]vices & suppli]s p>ticipat+ "u ! program "u su* title3 7#a7 ,section #ahja4 7#b7 ,section #ahje4 7#c7 ,section #ahjf4 7#d7 ,section #ahjg4 7#e7 ,section #ahji4 7#f7 ,section #ahab4 7#g7 ,section #ahad4 7#h7 ,section #ahae4 7#i7 ,section #ahaf4 7#aj7 ,section #ahah4 7#aa7 ,section #ahah;,a4 7#ab7 ,section #ahai4 7#ac7 ,section #ahbj4 7#ad7 ,section #ahcb4 7#ae7 ,section #ahcd4 7#af7 ,section #ahcd;,a4 7#ag7 ,section #ahce4 7#ah7 ,section #ahdc4 7#ai7 ,section #ahdf4 7#bj7 ,section #ahdg4 7#ba7 ,section #ahea4 7#bb7 ,section #aheb4 7#bc7 ,section #ahee4 7#bd7 ,section #ahef4 7#be7 ,section #aheg4 7#bf7 ,section #aheh4 7#bg7 ,section #ahfa4 7#bh7 ,section #ahfc4 7#bi7 ,section #ahfd4 7#cj7 ,section #ahff;,b4 7#ca7 ,section #ahff;,c4 7#cb7 ,section #ahff;,e4 7#cc7 ,section #ahfg4 7#cd7 ,section #ahfh4 7#ce7 ,section #ahfi4 7#cf7 ,section #ahga4 7#cg7 ,section #ahgd;,a4 7#ch7 ,section #ahhj4 7#ci7 ,section #ahha4 7#dj7 ,section #ahha;,a4 7#da7 ,section #ahia4 7#db7 ,section #ahid4 7#dc7 ,section #ahie4 7#dd7 ,section #ahif4 ,b ,long-t]m s]vices & supports #bbba4 ,long-t]m s]vices & supports b5efit ,all individuals enroll$ "u ,m$ic>e = ,am]ica "u ?is title %all h cov]age = long-t]m s]vices & supports b5efits4 #bbbb4 ,eligibility 7a7 ,eligible individuals ,an individual :o is eligible = long-t]m c>e b5efits "u ?is "p is an individual :o satisfies ea* ( ! foll[+3 7#a7 ,! individual is eligible = ,m$ic>e = ,am]ica4 7#b7 ,! individual is det]m9$ to h a condition1 z c]tifi$ by a lic5s$ heal? c>e practition]1 t results 9 sub/antially r$uc$ functional capacity 9 "o or m ( ! foll[+ areas3 7,a7 ,communication4 7,b7 ,social int]action4 7,c7 ,le>n+4 7,d7 ,mobility4 7,e7 ,self-c>e4 7,f7 ,self-managem5t4 7,g7 ,impairm5ts t affect ! p]son's capacity = social or economic p>ticipation4 7b7 ,cl>ification ,"u ?is "p1 9 ! case ( an individual describ$ 9 subsection 7a7 :o1 due to ! nature ( ! condition ( ! individual1 exp]i5ce p]iods 9 :i* _! functional capacity *anges or improves1 su* individual %all cont9ue to h access to b5efits "u ?is "p z ne$$4 ,if su* an individual's functional capacity improves to a po9t 9 :i* ! individual no long] requires long t]m supports & s]vices1 or requires few] s]vices1 ! individual %all be able to imm$iately & seamlessly resume receiv+ all ne$$ s]vices if & :5 _! functional ne$s recur4 ,eligibility = s]vices %all be ma9ta9$ if1 )\t ! s]vices1 ! individual w\ld h r$uc$ functional capacity4 ,! pres5ce ( supports & s]vices or o!r mitigat+ measures %all n be tak5 into acc\nt :5 look+ at functional impairm5t4 7c7 ,b5efits 7#a7 ,def9ition ,= purposes ( ?is title1 ! t]m long-t]m s]vices & supports b5efit means ! daily liv+ supports ne$$ by eligible individuals & includes all long-t]m s]vices & supports cov]$1 z ( ! date ( ! enactm5t ( ?is title1 "u any ,/ate plan "u title ,,xix1 includ+-- 7,a7 home & community-bas$ s]vices2 & 7,b7 any additional s]vices & supports develop$ to help p ) disabilities live1 "w1 & p>ticipate 9 _! communities1 includ+-- 7i7 home heal? aides & homemak]s2 7ii7 direct support pr(essionals & p]sonal att5dant c>e s]vices2 7iii7 hospice2 7iv7 nurs+ c>e2 7v7 m$ical social s]vices2 7vi7 case managem5t1 fiscal int]m$i>y1 & support brok]age s]vices2 7vii7 %ort-t]m inpati5t c>e1 includ+ respite c>e & c>e = pa9 control2 7viii7 behavioral heal? long-t]m s]vices & supports1 includ+ ass]tive community treatm5t1 pe] support s]vices1 int5sive case managem5t1 support$ employm5t1 & support$ h\s+ wrap>\nd2 & 7ix7 all additional s]vices cov]able 9 ,m$icaid "u /ate plan s]vices1 sections #aaae1 #aiae7;c71 #aiae7k71 #aiae7;i71 & #aiae7;j71 = p ) disabilities4 7#b7 ,self-direct$ model ,all eligible individuals %all be default$ into a self-direct$ c>e option 7z def9$ by ! ,secret>y74 7#c7 ,community fir/ ,! b5efit "u ?is "p %all be provid$ ) a community-fir/ presumption & eligible individuals %\ld be initially provid$ home & community-bas$ s]vices1 z def9$ = purposes ( section #aiae7;i74 ,be=e an eligible individual is admitt$ into a long t]m c>e in/itution1 ! ,/ate m5tal heal? or developm5tal disability au?ority or ,/ate ag5cy t adm9i/]s ! ,/ate plan "u title ,,xix %all conduct a m&atory assessm5t to det]m9e :e!r _! ne$s c\ld be met ?r\gh home & community-bas$ s]vices & if s1 ! s]vices w\ld h to be arrang$ = by ! ,/ate & ! cov]age w\ld n be provid$ = ! individual ) respect to su* an admission4 ,?is assessm5t %all be conduct$ at lea/ annually or ^u a *ange 9 condition = all individual already admitt$ to an in/itution4 7d7 ,coord9ation ) o!r ,f$]al b5efits 7#a7 ,rule ( con/ruction ,no?+ 9 ?is "p %all be con/ru$ z prohibit+ b5efits paid "u ?is "p f be+ us$ to comp5sate a c>egiv] :o provides community liv+ assi/ance s]vices & supports to a dep5d5t relative n less ?an #hj h\rs a mon? = provid+ community liv+ assi/ance s]vices & supports to an eligible individual "u ?is "p4 7#b7 ,dep5d5t relative def9$ ,! t]m dep5d5t relative means-- 7,a7 a *ild1 gr&*ild1 niece1 or nephew 7( su* c>egiv] or su* c>egiv]'s sp\se or dome/ic p>tn]72 7,b7 a *ild to :i* ! c>egiv] or ! c>egiv]'s sp\se or dome/ic p>tn] is /&+ 9 loco p>5tis2 7,c7 a p>5t1 gr&p>5t1 sibl+1 aunt1 or uncle 7( su* c>egiv] or 8 or h] sp\se or dome/ic p>tn]72 or 7,d7 su* c>egiv]'s sp\se or dome/ic p>tn]1 if su* *ild1 gr&*ild1 niece1 nephew1 p>5t1 gr&p>5t1 sibl+1 aunt1 uncle1 sp\se1 or dome/ic p>tn] is an eligible individual4 7#c7 ,supplem5t n supplant ,b5efits receiv$ "u ?is "p by a c>egiv] %all supplem5t1 b n supplant1 o!r b5efits = :i* ! individual is eligible "u any o!r ,f$]ally fund$ program t provides b5efits or assi/ance4 7#d7 ,disreg>d ,b5efits paid to a c>egiv] "u ?is "p %all be disreg>d$ = purposes ( det]m9+ or cont9u+ ! eligibility ( ! individual or ! sp\se ( ! individual = receipt ( b5efits "u any o!r ,f$]al1 ,/ate1 or locally fund$ assi/ance program1 includ+ b5efits paid "u titles ,,ii or ,,xvi "u ! laws adm9i/]$ by ! ,secret>y ( ,vet]ans ,affairs1 "u l[-income h\s+ assi/ance programs1 "u ! supplem5tal nutrition assi/ance program e/abli%$ "u ! ,food & ,nutrition ,act ( #bjjh1 or "u programs adm9i/]$ by ,/ate vocational rehabilitation ag5cies4 ,c ,m$ic>e ,advantage = ,am]ica #bbca4 ,all private plans 7a7 ,9 g5]al ,= plan ye>s beg9n+ ) plan ye> #bjbf1 a heal? insurance issu] may (f] heal? insurance cov]age 9 ! individual m>ket only if su* issu] has ent]$ into a contract ) ! ,secret>y "u subsection 7b7 to (f] su* cov]age4 7b7 ,agreem5ts ,! ,secret>y %all ent] into an agreem5t ) an ,,ma = ,am]ica sponsor to (f] ,,ma = ,am]ica plans "u ?is "p = ! cov]age ( individuals enroll$ "u ,m$ic>e = ,am]ica :o elect to receive b5efits "u "p ,a ?r\gh su* a plan4 7c7 ,,ma = ,am]ica plan2 ,,ma = ,am]ica sponsor ,= purposes ( ?is "p-- 7#a7 ,,ma = ,am]ica plan ,an ,,ma = ,am]ica plan is a ,m$ic>e ,advantage plan "u "p ,c ( title ,,xviii1 except su* plan %all provide cov]age = individuals enroll$ "u ,m$ic>e = ,am]ica "u "p ,a ( ?is title1 ) respect to at lea/ ! b5efits cov]$ "u su* "p ,a4 7#b7 ,,ma = ,am]ica sponsor ,an ,,ma = ,am]ica sponsor is a sponsor ( an ,,ma = ,am]ica plan4 #bbcb4 ,application ( ,m$ic>e ,advantage provisions ,= purposes ( apply+ ?is "p1 except z o!rwise specifi$ "u ?is "p1 ! provisions ( "p ,c ( title ,,xviii1 z 9 effect z ( ! date ( ! enactm5t ( ?is title %all apply ) respect to an ,,ma = ,am]ica sponsor1 ,,ma = ,am]ica plan1 individuals eligible = cov]age "u ?is "p1 individuals enroll$ "u su* plan1 & b5efits cov]$ "u "p ,a 9 a simil> mann] & to a simil> ext5t z su* provisions appli$ to an ,,ma organization1 ,,ma plan1 individuals eligible = "u "p ,c ( su* title1 individuals enroll$ "u an ,,ma plan1 & b5efits cov]$ "u fee-=-s]vice ,m$ic>e z ( su* date4 #bbcc4 ,increas$ premium = ,m$ic>e ,advantage = ,am]ica plans ,no?+ 9 ?is "p %all preclude an individual f *oos+ a ,m$ic>e ,advantage = ,am]ica plan :i* requires ! individual to pay an additional am\nt because ( supplem5tal b5efits or because x is a m exp5sive plan4 ,9 su* case ! individual enroll$ "u su* plan w\ld be responsible = ! increas$ mon?ly premium4 #bbcd4 ,ref]5ces ,beg9n+ 9 #bjbb1 all ref]5ces 9 law & regulation to ,m$ic>e ,advantage %all be deem$ a ref]5ce to ,m$ic>e ,advantage = ,am]ica4 4 #aab4 ,modifications to & coord9ation ) exi/+ ,f$]al heal? programs 7a7 ,m$ic>e1 ,m$icaid1 & ,/ate ,*ildr5's ,heal? ,insurance ,program 7,,s*ip7 7#a7 ,9 g5]al ,not)/&+ any o!r provision ( law1 subject to p>agraphs 7#b7 & 7#c7 & section #bbjb7;c7 ( ! ,social ,security ,act1 z add$ by section #aaa-- 7,a7 no b5efits %all be available "u title ,,xviii ( ! ,social ,security ,act = any item or s]vice furni%$-- 7i7 beg9n+ on or aft] ,janu>y #a1 #bjbb 7except 9 ! case ( an individual enroll$ "u su* title & title ,,xix ( su* ,act72 & 7ii7 beg9n+ on or aft] ,janu>y #a1 #bjbd1 ) respect to all individuals1 includ+ individuals enroll$ "u su* title & title ,,xix ( su* ,act2 7,b7 no individual is entitl$ to m$ical assi/ance "u a ,/ate plan approv$ "u title ,,xix ( su* ,act-- 7i7 = any item or s]vice furni%$ on or aft] ,janu>y #a1 #bjbd1 9 ! case ( an individual enroll$ "u su* title & title ,,xviii ( ! ,social ,security ,act or an individual describ$ 9 subclause 7,,viii7 ( section #aijb7;a77#aj77;,a77i72 & 7ii7 = any item or s]vice furni%$ on or aft] ,janu>y #a1 #bjbf2 7,c7 no individual is entitl$ to m$ical assi/ance "u a ,/ate *ild heal? plan "u title ,,xxi ( su* ,act = any item or s]vice furni%$ on or aft] ,janu>y #a1 #bjbd2 & 7,d7 no paym5t %all be made to a ,/ate "u section #aijc7;a7 or #baje7;a7 ( su* ,act ) respect to m$ical assi/ance or *ild heal? assi/ance-- 7i7 = any item or s]vice furni%$ on or aft] ,janu>y #a1 #bjbd1 9 ! case ( an individual enroll$ "u su* title & title ,,xviii ( ! ,social ,security ,act or an individual describ$ 9 subclause 7,,viii7 ( section #aijb7;a77#aj77;,a77i72 & 7ii7 = any item or s]vice furni%$ on or aft] ,janu>y #a1 #bjbf4 7#b7 ,transition ,9 ! case ( inpati5t hospital s]vices & ext5d$ c>e s]vices dur+ a cont9u\s p]iod ( /ay :i* began be=e ,janu>y #a1 #bjbd = ,m$ic>e & #bjbf = ,m$icaid or ,,*ip1 & :i* _h n end$ z ( su* date1 = :i* b5efits are provid$ "u title ,,xviii ( ! ,social ,security ,act1 "u a ,/ate plan "u title ,,xix ( su* ,act1 or "u a ,/ate *ild heal? plan "u title ,,xxi su* ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all provide = cont9uation ( b5efits "u su* title or plan until ! end ( ! p]iod ( /ay4 7b7 ,o!r ,f$]al heal? programs 7#a7 ,f$]al employees heal? b5efits program ,no?+ 9 ?is ,act1 or ! am5dm5ts made by ?is ,act1 %all affect b5efits made available "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code4 7#b7 ,,tric>e ,no?+ 9 ?is ,act1 or ! am5dm5ts made by ?is ,act1 %all affect b5efits made available "u sections #ajgi & #ajhf ( title #aj1 ,unit$ ,/ates ,code4 7#c7 ,treatm5t ( b5efits = vet]ans & native ,am]icans 7,a7 ,9 g5]al ,no?+ 9 ?is ,act1 or ! am5dm5ts made by ?is ,act1 %all affect ! eligibility ( vet]ans = ! m$ical b5efits & s]vices provid$ "u title #ch1 ,unit$ ,/ates ,code1 or ( ,indians = ! m$ical b5efits & s]vices provid$ by or ?r\gh ! ,indian ,heal? ,s]vice4 7,b7 ,reevaluation ,no reevaluation ( ! ,indian ,heal? ,s]vice %all be und]tak5 )\t consultation ) tribal lead]s & /akehold]s4 7c7 ,sunset ( provisions relat$ to ! ,/ate ,ex*anges ,effective ,janu>y #a1 #bjbb1 ! ,f$]al & ,/ate ,ex*anges e/abli%$ pursuant to title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh7 %all t]m9ate1 & any o!r provision ( law t relies ^u p>ticipation 9 or enrollm5t ?r\gh su* an ,ex*ange1 includ+ su* provisions ( ! ,int]nal ,rev5ue ,code ( #aihf1 %all cease to h =ce or effect4 7d7 ,sev]ability ,e provision 9 ?is ,act & e application ( ! provisions 9 ?is ,act are sev]able f ea* o!r z a matt] ( ,f$]al law4 ,if any application ( any provision 9 ?is ,act to any p]son or gr\p ( p]sons or circum/ances is f\nd by a c\rt to be invalid1 ! rema9d] ( ?is ,act & ! application ( ! ,act's provisions to all o!r p]sons & circum/ances may n be affect$4 ,c ,t>get$ ,re=ms #aba4 ,limitation on removal ( ,m$ic>e ,advantage provid]s by ,,ma organizations 7a7 ,limitation ,section #aheb7;d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;d77 is am5d$ by add+ at ! end ! foll[+3 7#g7 ,limitation on removal ( provid]s f ma plans by ,,ma organizations 7,a7 ,removal ( provid]s ) cause ,beg9n+ ) plan ye> #bjai1 except z provid$ 9 subp>agraph 7,c71 an ,,ma organization (f]+ an ,,ma plan may only remove a provid] ( s]vices or a suppli] f a network ( su* plan if ! organization has cause to remove su* provid] or suppli]4 7,b7 ,cause to remove provid]s 7i7 ,9 g5]al ,an ,,ma organization (f]+ an ,,ma plan has cause to remove a provid] ( s]vices or a suppli] f a network ( su* plan if ! ,secret>y det]m9es t ! provid] or suppli] is-- 7,i7 m$ically neglig5t2 7,,ii7 9 violation ( any legal or contractual requirem5t applicable to ! provid] or suppli] act+ )9 ! lawful scope ( practice1 includ+ any p>ticipation or o!r requirem5t applicable to su* provid] or suppli] "u ?is title or "u any contractual t]m = su* plan2 or 7,,iii7 o!rwise unfit to furni% items & s]vices 9 accordance ) requirem5ts ( ?is title4 7ii7 ,consid]ation ( co/ to ma organizations ,= purposes ( subp>agraph 7,a71 co/ to an ,,ma organization (f]+ an ,,ma plan due to ! p>ticipation ( a provid] ( s]vices or suppli] 9 a network ( su* plan does n con/itute cause = ! ,,ma organization to remove su* provid] or suppli] f ! network mid-ye>1 & su* co/ may n be consid]$ z a factor 9 favor ( a det]m9ation t su* organization has cause to remove ! provid]4 7,c7 ,exception ,) respect to ea* upcom+ plan ye>1 beg9n+ ) plan ye> #bjai1 an ,,ma organization (f]+ an ,,ma plan may only remove a provid] ( s]vices or suppli] f a network ( su* plan = reasons n specifi$ 9 subp>agraph 7,b77i7 be=e ! date t is #fj days be=e ! fir/ day ( ! annual coord9at$ election p]iod = su* plan ye> "u section #ahea7;e77#c74 7,d7 ,notice & appeal process 7i7 ,9 g5]al ,any removal ( a provid] ( s]vices or suppli] f a network ( an ,,ma plan may occur only aft] ! completion ( a fair notice & appeal process t ! ,secret>y %all e/abli% by regulation4 ,su* process %all require ! ,,ma organization to provide to su* provid] or suppli] & to ! ,secret>y an explanation ( ! reason or reasons = ! removal4 7ii7 ,application 7,i7 ,application ( new process ,9 ! case ( a removal ( a provid] ( s]vices or suppli] f a network ( an ,,ma plan occurr+ on or aft] ! effective date publi%$ 9 a f9al rule = su* fair notice & appeal process1 su* process %all apply 9 lieu ( ! process = ! t]m9ation or susp5sion ( a provid] contract "u section #dbb4bjb7;a7 ( title #db1 ,code ( ,f$]al ,regulations4 7,,ii7 ,cont9uation ( old process ,9 ! case ( a removal ( a provid] ( s]vices or suppli] f a network ( an ,,ma plan occurr+ be=e su* effective date1 ! process = ! t]m9ation or susp5sion ( a provid] contract "u section #dbb4bjb7;a7 ( title #db1 ,code ( ,f$]al ,regulations1 %all apply4 7,e7 ,p>ticipant notice & protection 7i7 ,notice to p>ticipants ( provid] removal ,n less ?an #fj days be=e ! date on :i* a provid] ( s]vices or suppli] is remov$ f a network ( an ,,ma plan1 ! ,,ma organization (f]+ su* plan %all provide writt5 notification ( ! removal to ea* individual enroll$ 9 su* plan receiv+ items or s]vices f ! provid] or suppli] dur+ ! plan ye> 9 effect on ! date ( removal or dur+ ! previ\s plan ye>4 ,su* notification %all include at ! m9imum-- 7,i7 ! names & telephone numb]s ( available 9-network provid]s ( s]vices & suppli]s (f]+ items & s]vices t are ! same or simil> to ! items & s]vices (f]$ by ! remov$ provid] or suppli]2 7,,ii7 in=mation reg>d+ ! options available to an individual enroll$ 9 su* plan to reque/ ! cont9uation ( m$ical treatm5t or !rapy ) ! remov$ provid] or suppli]2 & 7,,iii7 "o or m cu/om] s]vice telephone numb]s t an individual enroll$ 9 su* plan may access to obta9 in=mation reg>d+ *anges to ! network ( ! plan4 7ii7 ,annual notice ( *ange ,9 addition to provid+ ! notification ( removal z requir$ "u clause 7i71 ! ,,ma organization (f]+ su* ,,ma plan %all include su* notification 9 ! annual notice ( *ange = ! ,,ma plan = ! upcom+ plan ye>4 7iii7 ,cont9uity ( c>e ,9 any case 9 :i* a provid] ( s]vices or suppli] is remov$ f a network ( an ,,ma plan1 su* plan %all ensure t ! removal satisfies ! cont9uity ( c>e requirem5ts "u p>agraph 7#a77;,a7 ) respect to ea* individual enroll$ 9 su* plan receiv+ items or s]vices f ! provid] or suppli] dur+ ! plan ye> 9 effect on ! date ( removal or dur+ ! previ\s plan ye>4 7,f7 ,rule ( con/ruction ,no?+ 9 ?is p>agraph %all be con/ru$ z affect+ ! ability ( a provid] ( s]vices or suppli] to decl9e to p>ticipate 9 a network ( an ,,ma plan4 7#h7 ,transp>5cy 9 measures us$ by ma organizations to e/abli% or modify provid] networks 7,a7 ,9 g5]al ,beg9n+ ) plan ye> #bjai1 an ,,ma organization (f]+ an ,,ma plan %all include ! in=mation describ$ 9 subp>agraph 7,b7-- 7i7 9 ! annual bid in=mation submitt$ by ! ,,ma organization ) respect to ! ,,ma plan "u section #ahed2 & 7ii7 on ! ,int]net ,web ,site = ! ,,ma plan4 7,b7 ,in=mation describ$ ,! in=mation describ$ 9 ?is subp>agraph is ! foll[+3 7i7 ,in=mation reg>d+ ! measures us$ by ! ,,ma organization to e/abli% or modify ! provid] network ( ! ,,ma plan1 includ+ measures ( ! quality & effici5cy ( provid]s4 ,su* in=mation %all include ! specifications1 me?odology1 & sample size ( su* measures4 7ii7 ,o!r in=mation relat$ to ! e/abli%m5t or modification ( su* provid] network t ! ,secret>y det]m9es appropriate4 7,c7 ,limitation ,! in=mation describ$ 9 subp>agraph 7,b7 %all n include any individually id5tifiable in=mation ( any provid] or suppli] ( s]vices4 4 7b7 ,en=cem5t 7#a7 ,sanctions = noncompliance ,section #aheg7;g77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;g77#a77 is am5d$-- 7,a7 9 subp>agraph 7,j71 by /rik+ or2 7,b7 by r$esignat+ subp>agraph 7,k7 z subp>agraph 7,l72 7,c7 by ins]t+ aft] subp>agraph 7,j7 ! foll[+ new subp>agraph3 7,k7 fails to comply ) section #aheb7;d77#g7 or #aheb7;d77#h72 or 2 & 7,d7 9 subp>agraph 7,l7 7z s r$esignat$71 by /rik+ ?r\gh 7,j7 & ins]t+ ?r\gh 7,k74 7#b7 ,sanctions n applicable to "p d ,title ,,xviii ( ! ,social ,security ,act is am5d$-- 7,a7 9 section #ahfj;,d-#ab7;b77#c77;,e7 7#db ,u4,s4,c4 #aciew-#aab7;b77#c77;,e771 by /rik+ p>agraph 7#a77;,f7 & ins]t+ p>agraphs 7#a77;,f7 & 7#a77,k72 & 7,b7 9 section #ahid7;e77#f77;,b7 7#db ,u4,s4,c4 #acie;eee7e77#f77;,b771 by ins]t+ 7o!r ?an p>agraph 7#a77,k7 ( su* section7 aft] #aheg7;g77#a74 7c7 ,m$ic>e advantage plan comp>e tool ,n lat] ?an "o ye> aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all take su* measures z are necess>y to ensure t ! ,m$ic>e ,advantage ,comp>e ,tool takes into acc\nt ! pref]5ces & utilization ne$s ( su* individuals4 #abb4 ,network adequacy 7a7 ,9 g5]al ,section #aheb7;d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;d77 is am5d$ by add+ at ! end ! foll[+3 7#i7 ,network adequacy requirem5ts ,beg9n+ 9 plan ye> #bjai1 not)/&+ any o!r provision ( law1 ! foll[+ %all apply3 7,a7 ,provid] availability ,:5 e/abli%+ a plan network1 a ,m$ic>e ,advantage organization (f]+ an ,,ma plan %all1 among o!r factors det]m9$ by ! ,secret>y1 consid] ! foll[+3 7i7 ,! anticipat$ enrollm5t 9 ! plan4 7ii7 ,! expect$ types ( s]vices provid$ & utilization ( s]vices by enrollees "u ! plan4 7iii7 ,! numb] & types ( provid]s ne$$ to provide su* s]vices4 7iv7 ,! numb] ( network provid]s :o are n accept+ new pati5ts4 7v7 ,! location ( provid]s & enrollees4 7vi7 ,! full-"t equival5t availability ( a provid] to provide su* s]vices4 7,b7 ,provision ( c>e 9 a timely mann] ,a ,m$ic>e ,advantage organization (f]+ an ,,ma plan %all ensure t provid]s are able to provide s]vices 9 a timely mann]1 z def9$ by ! ,secret>y1 "u ! plan4 7,c7 ,application ( network access adequacy /&>ds ,9 apply+ ! network access adequacy /&>ds pursuant to p>agraph 7#a71 ! ,secret>y %all seek input f pati5t advocacy gr\ps1 provid]s ( s]vices & suppli]s1 & ,,ma plans "u ?is "p4 7,d7 ,c]tification ,ea* plan ye>1 a ,m$ic>e ,advantage organization %all c]tify to ! ,secret>y1 ) respect to ea* ,,ma plan (f]$ by ! organization1 t ! provid]s1 includ+ speciali/s & subspeciali/s1 9 ! plan network are able to provide ! s]vices requir$ "u ! organization's contract ) ! ,secret>y "u section #aheg ) respect to ! (f]+ ( su* plan & to meet ! ne$s ( ! enrollees )9 ! plan s]vice area dur+ ! ye>4 7,e7 ,annual report+ ,ea* plan ye>1 a ,m$ic>e ,advantage organization %all report to ! ,secret>y ! foll[+ ) respect to ea* ,,ma plan (f]$ by ! organization3 7i7 ,av]age wait "t ,! av]age wait "t = prim>y & specialty c>e = enrollees "u ! plan4 7ii7 ,utilization ( out-(-network provid]s ,! utilization ( out-(-network provid]s "u ! plan4 7iii7 ,av]age co/ p] pati5t ,! av]age annual sp5d+ p] pati5t = prim>y & specialty c>e = enrollees "u ! plan4 7,f7 ,c]tification ,9 advance ( ! annual1 coord9at$ election p]iod "u section #ahea7;e77#c71 a ,m$ic>e ,advantage organization %all c]tify to ! ,secret>y ! accuracy ( provid] directories = ea* plan (f]$ by ! organization4 7,g7 ,network review ,! ,secret>y %all ensure t ! network ( ea* ,,ma plan (f]$ by a ,m$ic>e ,advantage organization meets ! network adequacy guidel9es e/abli%$ "u ?is p>agraph & "u section #dbb4aab7;a77#d7 ( title #db1 ,code ( ,f$]al ,regulations 7or any successor regulation to su* section71 at lea/ once e #c ye>s or :5 a mat]ial *ange 9 network occurs4 4 7b7 ,en=cem5t ,section #aheg7;g77#a77,k7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;g77#a77,k771 z add$ by section #b7;b71 is am5d$ by /rik+ or #aheb7;d77#h7 & ins]t+ 1 #aheb7;d77#h71 or #aheb7;d77#i74 #abc4 ,elim9at+ ! #bd-mon? wait+ p]iod = ,m$ic>e cov]age = individuals ) disabilities 7a7 ,9 g5]al ,section #bbf7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #dbf7;b77 is am5d$-- 7#a7 9 p>agraph 7#b77;,a71 by /rik+ 1 & has = #bd cal5d> mon?s be5 entitl$ to12 7#b7 9 p>agraph 7#b77;,b71 by /rik+ 1 & has be5 = n less ?an #bd mon?s12 7#c7 9 p>agraph 7#b77;,c77ii71 by /rik+ 1 includ+ ! requirem5t t he has be5 entitl$ to ! specifi$ b5efits = #bd mon?s12 7#d7 9 ! fir/ s5t5ce1 by /rik+ = ea* mon? beg9n+ ) ! lat] ( 7,i7 ,july #aigc or 7,,ii7 ! tw5ty-fif? mon? ( 8 entitlem5t or /atus z a qualifi$ railroad retirem5t b5efici>y describ$ 9 p>agraph 7#b71 & & ins]t+ = ea* mon? = :i* ! individual meets ! requirem5ts ( p>agraph 7#b71 beg9n+ ) ! mon? foll[+ ! mon? 9 :i* ! individual meets ! requirem5ts ( su* p>agraph1 &2 & 7#e7 9 ! second s5t5ce1 by /rik+ ! tw5ty-fif? mon? ( 8 entitlem5t & all t foll[s ?r\gh p>agraph 7#b77;,c7 &4 7b7 ,con=m+ am5dm5ts 7#a7 ,section #bbf ,section #bbf ( ! ,social ,security ,act 7#db ,u4,s4,c4 #dbf7 is am5d$ by-- 7,a7 /rik+ subsections 7e77#a77;,b71 7f71 & 7h72 & 7,b7 r$esignat+ subsections 7g7 & 7i7 z subsections 7f7 & 7g71 respectively4 7#b7 ,m$ic>e description ,section #ahaa7b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;c7#b77 is am5d$ by /rik+ h be5 entitl$ = n less ?an #bd mon?s & ins]t+ are entitl$4 7#c7 ,m$ic>e cov]age ,section #ahcg7;g77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciep7g77#a77 is am5d$ by /rik+ #be? mon? ( & ins]t+ mon? foll[+ ! fir/ mon? (4 7#d7 ,railroad retirem5t sy/em ,section #g7;d77#b77;ii7 ( ! ,railroad ,retirem5t ,act ( #aigd 7#de ,u4,s4,c4 #bca;f7d77#b77;ii77 is am5d$-- 7,a7 by /rik+ has be5 entitl$ to an annuity & ins]t+ is entitl$ to an annuity2 7,b7 by /rik+ 1 = n less ?an #bd mon?s2 & 7,c7 by /rik+ c\ld h be5 entitl$ = #bd cal5d> mon?s1 &4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to insurance b5efits "u title ,,xviii ( ! ,social ,security ,act ) respect to items & s]vices furni%$ 9 mon?s beg9n+ aft] ! date ( enactm5t ( ?is ,act4 #abd4 ,employ] heal? plan options 7a7 ,def9ition ,a qualify+ employ] sponsor$ plan is-- 7#a7 a gov]nm5tal plan 7)9 ! mean+ ( section #bgia7;d77#h7 ( ! ,public ,heal? ,s]vice ,act72 or 7#b7 any o!r plan or cov]age t meets ! b5efits crit]ia ( title ,,xxii ( ! ,social ,security ,act1 z add$ by section #aaa1 & ! crit]ia "u subsection 7b71 t provides heal? cov]age t is equival5t to an actu>ial value ( at lea/ #hj p]c5t & makes a premium contribution ( at lea/ #gj p]c5t4 7b7 ,obligation ,l>ge employ]s %all1 ) respect to any full-"t employee ( su* employ]-- 7#a7 (f] a qualify+ employ] sponsor$ plan to su* employee1 9 accordance ) subsection 7c72 or 7#b7 make a contribution ( #h p]c5t ( _! annual payroll to ! ,m$ic>e ,tru/ ,fund "u title ,,xxii ( ! ,social ,security ,act4 7c7 ,employee *oice ,an employee may opt out ( a qualify+ employ] sponsor$ plan z satisfi$ by subsection 7b77#a7 9 ord] to enroll 9 ,m$ic>e = ,am]ica4 ,! employ] %all be exempt f ! contribution specifi$ 9 subsection 7b77#b74 ,! ,secret>y ( ,heal? & ,human ,s]vices %all h au?ority to set /&>ds = det]m9+ :e!r employ]s or insur]s are und]tak+ any actions to affect ! risk pool )9 ,m$ic>e = ,am]ica by induc+ individuals to decl9e cov]age "u a qualify+ employ] sponsor$ plan & in/ead to enroll 9 ,m$ic>e = ,am]ica4 ,an employ] violat+ su* /&>ds %all be treat$ z n meet+ ! requirem5ts ( subsection 7a74 7d7 ,special rules 7#a7 ,annual payroll ,= purposes ( ?is p>agraph1 ! t]m annual payroll means1 ) respect to any employ] = any cal5d> ye>1 ! aggregate wages paid by ! employ] dur+ su* cal5d> ye>4 7#b7 ,aggregation rules ,relat$ employ]s & pr$ecessors %all be treat$ z a s+le employ] = purposes ( ?is subsection4 7#c7 ,r$uction = "p-"t employees ,9 ! case ( a "p-"t employee1 ! employ] contribution requirem5ts ( p>agraph 7#a7 %all be treat$ z satisfi$ if ! employ] contribution ) respect to su* employee is n less ?an ! "p-"t employm5t ratio ( ! contribution requir$ "u p>agraph 7#a74 7#d7 ,rules relat$ to "p-"t employm5t ,= purposes ( ?is subsection-- 7,a7 ,"p-"t employee ,! t]m "p-"t employee means1 ) respect to any mon?1 an employee :o works on av]age few] ?an #cj h\rs p] week4 7,b7 ,"p-"t employm5t ratio ,! t]m "p-"t employm5t ratio means1 ) respect to a "p-"t employee ( an employ] 9 a mon?1 a fraction-- 7i7 ! num]ator ( :i* is ! numb] ( h\rs 9 ! employee's normal "w week1 & 7ii7 ! d5om9ator ( :i* is #cj h\rs4 7,c7 ,special rules ,"u rules prescrib$ by ! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,secret>y ( ! ,treasury1 9 ! case ( an employee = an employ] ^: def9$ "w week = full-"t employees is less ?an #cj h\rs1 any ref]5ce 9 ?is subsection to #cj h\rs is deem$ a ref]5ce to ! numb] ( h\rs 9 ! "w week s def9$4 7,d7 ,conv]sion to h\rs ( employm5t ,! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,secret>y ( ! ,treasury1 %all e/abli% rules = ! conv]sion ( comp5sation to h\rs ( employm5t1 = purposes ( ?is subsection 9 ! case ( employees t receive comp5sation on a sal>i$ basis1 or on ! basis ( a commission1 or o!r cont+5t or bonus basis1 r ?an bas$ on an h\rly wage4 7e7 ,tim+ & ,mann] ,ea* employ] t makes a f9ancial contribution "u subsection 7b77#b7 "u ?is section 7o!r ?an ) respect to cov]age "u a gr\p heal? plan7 %all pay su* contribution 9 a =m & mann]1 specifi$ by ! ,secret>y ( ! ,treasury1 bas$ ^u ! =m & mann] 9 :i* employ] excise taxes are requir$ to be paid "u section #caaa ( ! ,int]nal ,rev5ue ,code ( #aihf4 7f7 ,non-,discrim9ation 7#a7 ,9 g5]al ,except z o!rwise provid$ = 9 ?is title 7or an am5dm5t made by ?is title71 an individual %all n1 on ! gr\nd prohibit$ "u title ,,vi ( ! ,civil ,rights ,act ( #aifd 7#db ,u4,s4,c4 #bjjj;d et seq471 title ,,ix ( ! ,education ,am5dm5ts ( #aigb 7#bj ,u4,s4,c4 #afha et seq471 ! ,age ,discrim9ation ,act ( #aige 7#db ,u4,s4,c4 #faja et seq471 or section #ejd ( ! ,rehabilitation ,act ( #aigc 7#bi ,u4,s4,c4 #gid71 be exclud$ f p>ticipation 91 be d5i$ ! b5efits (1 or be subject$ to discrim9ation "u1 any heal? program or activity1 any "p ( :i* is receiv+ ,f$]al f9ancial assi/ance1 includ+ cr$its1 subsidies1 or contracts ( insurance1 or "u any program or activity t is adm9i/]$ by an ,executive ,ag5cy or any entity e/abli%$ "u ?is title 7or am5dm5ts7 or any employ]-sponsor$ insurance4 7#b7 ,cont9u$ ,application ( ,laws ,no?+ 9 ?is title 7or an am5dm5t made by ?is title7 %all be con/ru$ to invalidate or limit ! rights1 rem$ies1 proc$ures1 or legal /&>ds available to individuals aggriev$ "u title ,,vi ( ! ,civil ,rights ,act ( #aifd 7#db ,u4,s4,c4 #bjjj;d et seq471 title ,,vii ( ! ,civil ,rights ,act ( #aifd 7#db ,u4,s4,c4 #bjjj;e et seq471 title ,,ix ( ! ,education ,am5dm5ts ( #aigb 7#bj ,u4,s4,c4 #afha et seq471 section #ejd ( ! ,rehabilitation ,act ( #aigc 7#bi ,u4,s4,c4 #gid71 or ! ,age ,discrim9ation ,act ( #aige 7#db ,u4,s4,c4 #faa et seq471 or to sup]s$e ,/ate laws t provide additional protections aga9/ discrim9ation on any basis describ$ 9 p>agraph 7#a74 7#c7 ,regulations ,! ,secret>y ( ,heal? & ,human ,s]vices may promulgate regulations to implem5t ?is subsection4 #abe4 ,prohibition on /ep !rapy & prior au?orization "u gr\p heal? plans ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7e7 ,prohibition aga9/ /ep !rapy & prior au?orization ,beg9n+ ) ! fir/ plan ye> foll[+ ! date ( ! enactm5t ( ?is subsection1 a gr\p heal? plan may n require a prior au?orization det]m9ation = cov]age ( any b5efit "u su* plan & may n apply treatm5t limitations ?r\gh ! use ( /ep !rapy protocols4 4 #abf4 ,m$ic>e outpati5t obs]vation s]vices ,section #ahfa7;i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7i77 is am5d$ by add+ at ! end ! foll[+3 ,= purposes ( ?is subsection1 an individual receiv+ outpati5t obs]vation s]vices %all be deem$ to be an inpati5t dur+ su* p]iod1 & ! date su* individual ceases receiv+ su* s]vices %all be deem$ ! hospital dis*>ge date 7unless su* individual is admitt$ z a hospital inpati5t at ! end ( su* p]iod744 #abg4 ,abortion cov]age ,not)/&+ any o!r provision ( law1 ,f$]al funds may be us$ to provide = abortion s]vices "u any heal? program "u any ( ! foll[+3 7#a7 ,indian ,heal? ,s]vice4 7#b7 ,b5efits provid$ to wom5 vet]ans4 7#c7 ,b5efits provid$ ?r\gh ! ,unit$ ,/ates ,immigration & ,cu/oms ,en=cem5t to wom5 9 det5tion c5t]s "u ! jurisdiction ( su* ag5cy4 ,,ii ,tax ,provisions #bja4 ,sunset ( ,public ,law #aae-ig 7a7 ,9 g5]al ,all provisions (1 & am5dm5ts made by1 ,public ,law #aae-ig %all n apply to cal5d>1 taxable1 plan1 or limitation ye>s beg9n+ aft] ,decemb] #bb1 #bjag4 7b7 ,application ( c]ta9 laws ,! ,int]nal ,rev5ue ,code ( #aihf %all be appli$ & adm9i/]$ to ye>s describ$ 9 subsection 7a7 z if ! provisions & am5dm5ts describ$ 9 subsection 7a7 _h nev] be5 enact$4 #bjb4 ,surtax ,!re is h]eby impos$ a tax ( #e p]c5t on ! adju/$ gross income ( ea* taxpay] to ! ext5t su* income exce$s #ejj1jjj4 #bjc4 ,basis ( prop]ty acquir$ f a dec$5t 7a7 ,9 g5]al ,section #ajad ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ p]son1 be & all t foll[s ?r\gh ! p]iod at ! end & ins]t+ ! foll[+3 p]son1 be ! basis 9 ! h&s ( ! dec$5t44 7b7 ,effective date ,! am5dm5ts made by ?is section to prop]ty acquir$ or pass$ aft] ! date ( enactm5t ( ?is ,act4 #bjd4 ,m$ic>e payroll tax 7a7 ,9 g5]al ,section #caja7;b77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #j4i p]c5t & ins]t+ #d p]c5t4 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply ) respect to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #bje4 ,net inve/m5t income tax 7a7 ,9 g5]al ,section #adaa7;a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #c4h p]c5t ea* place su* t]m appe>s & ins]t+ #f4i p]c5t4 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply ) respect to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #bjf4 ,t]m9ation ( heal? sav+s acc\nts ,section #bbc7;a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by ins]t+ aft] dur+ su* taxable ye> ! foll[+3 & be=e ,decemb] #ca1 #bjai4 #bjg4 ,t]m9ation ( flexible sp5d+ arrangem5ts ,section #abe7;i77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ may n elect = any taxable ye> to h sal>y r$uction contributions 9 excess ( #b1ejj made to su* arrangem5t & ins]t+ ! foll[+3 may n elect to h sal>y r$uction contributions made to su* arrangem5t-- 7,a7 = taxable ye>s beg9n+ be=e ,janu>y #a1 #bjbj1 9 excess ( #b1ejj1 & 7,b7 = taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjai1 9 excess ( #j4 4 #bjh4 ,increase 9 excise tax on small cig>s & cig>ettes & o!r tobacco products 7a7 ,small cig>s ,section #egja7;a77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #ej4cc & ins]t+ #ajj4ff4 7b7 ,cig>ettes ,section #egja7;b7 ( su* ,code is am5d$-- 7#a7 by /rik+ #ej4cc 9 p>agraph 7#a7 & ins]t+ #ajj4ff1 & 7#b7 by /rik+ #aje4fi 9 p>agraph 7#b7 & ins]t+ #baa4ch4 7c7 ,pipe tobacco ,section #egja7;f7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #b4hcaa c5ts & ins]t+ #ej4jj4 7d7 ,roll-,y\r-,own tobacco ,section #egja7;g7 ( su* ,code is am5d$ by /rik+ #bd4gh & ins]t+ #di4ef4 7e7 ,l>ge cig>s ,p>agraph 7#b7 ( section #egja7;a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #eb4ge p]c5t & all t foll[s ?r\gh ! p]iod & ins]t+ #bd4gh p] p\nd 7& a proportionate tax at ! l rate on all fractional p>ts ( a p\nd7 b n less ?an #e4jcc c5ts p] cig>44 7f7 ,smokeless tobacco 7#a7 ,9 g5]al ,section #egja7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7,a7 9 p>agraph 7#a71 by /rik+ #a4ea & ins]t+ #bh4jd1 7,b7 9 p>agraph 7#b71 by /rik+ #ej4cc c5ts & ins]t+ #ab4db1 & 7,c7 by add+ at ! end ! foll[+3 7#c7 ,smokeless tobacco sold 9 discrete s+le-use units ,on discrete s+le-use units1 #ajg4fe p] ea* #a1jjj s+le-use units4 4 7#b7 ,discrete s+le-use unit ,section #egjb7m7 ( su* ,code is am5d$-- 7,a7 9 p>agraph 7#a71 by /rik+ or *ew+ tobacco & ins]t+ *ew+ tobacco1 discrete s+le-use unit2 7,b7 9 p>agraphs 7#b7 & 7#c71 by ins]t+ t is n a discrete s+le-use unit be=e ! p]iod 9 ea* su* p>agraph2 & 7,c7 by add+ at ! end ! foll[+3 7#d7 ,discrete s+le-use unit ,! t]m discrete s+le-use unit means any product conta9+ tobacco t-- 7,a7 is n int5d$ to be smok$1 & 7,b7 is 9 ! =m ( a loz5ge1 tablet1 pill1 p\*1 dissolvable /rip1 or o!r discrete s+le-use or s+le-dose unit4 4 #bji4 ,excise tax on alcohol 7a7 ,di/ill$ ,spirits ,section #ejja7;a77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #ac4ej & ins]t+ #af4jj4 7b7 ,w9e 7#a7 ,section #ejda7;b77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #a4jg p] w9e gallon & ins]t+ #af4jj p] pro( gallon4 7#b7 ,section #ejda7;b77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #a4eg p] w9e gallon & ins]t+ #af4jj p] pro( gallon4 7#c7 ,section #ejda7;b77#c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #c4ae p] w9e gallon & ins]t+ #af4jj p] pro( gallon4 7#d7 ,section #ejda7;b77#d7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #c4dj p] w9e gallon & ins]t+ #af4jj p] pro( gallon4 7#e7 ,section #ejda7;b77#e7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #c4cj p] w9e gallon & ins]t+ #af4jj p] pro( gallon4 7#f7 ,section #ejda7;b77#c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #bb4f c5ts p] w9e gallon & ins]t+ #af4jj p] pro( gallon4 7c7 ,be] ,section #ejea7;,b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #ah = p] b>rel & ins]t+ #af p] pro( gallon4 #baj4 ,tax on sug>$ dr9ks 7a7 ,9 g5]al ,sub*apt] ,d ( *apt] #cb ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by ins]t+ aft] "p ,i ! foll[+ new "p3 ,,ii ,sug>-,sweet5$ bev]ages ,sec4 #daga4 ,imposition ( tax4 ,sec4 #dagb4 ,def9itions4 ,sec4 #dagc4 ,special rules4 #daga4 ,imposition ( tax 7a7 ,9 g5]al ,!re is h]eby impos$ a tax on ! sale or transf] ( any specifi$ sug>-sweet5$ bev]age product by ! manufactur]1 produc]1 or import] !re(4 7b7 ,rate ( tax ,! rate ( tax impos$ "u subsection 7a7 %all be equal to "o c5t p] #d4b grams ( caloric sweet5] conta9$ 9 su* specifi$ sug>-sweet5$ bev]age product4 7c7 ,p]sons liable = tax ,! manufactur]1 produc]1 or import] ref]r$ to 9 subsection 7a7 %all be liable = ! tax impos$ by su* subsection4 #dagb4 ,def9itions 7a7 ,specifi$ sug>-,sweet5$ bev]age product ,= purposes ( ?is "p-- 7#a7 ,9 g5]al ,= purposes ( ?is "p1 ! t]m specifi$ sug>-sweet5$ bev]age product means-- 7,a7 any liquid int5d$ = human consumption :i* conta9s a caloric sweet5]1 & 7,b7 any liquid1 or solid mixture ( +r$i5ts1 :i*-- 7i7 conta9s a caloric sweet5]1 & 7ii7 is int5d$ = use z an +r$i5t 9 a liquid describ$ 9 subp>agraph 7,a74 7#b7 ,exceptions ,! foll[+ %all n be treat$ z liquids describ$ 9 p>agraph 7#a77;,a73 7,a7 ,any liquid ! prim>y +r$i5ts ( :i* are milk or soy1 rice1 or simil> plant-bas$ milk sub/itute4 7,b7 ,any liquid compos$ entirely ( "o or m ( ! foll[+3 7i7 ,! orig9al liquid result+ f ! press+ ( fruit or vegetables4 7ii7 ,! liquid result+ f ! recon/itution ( fruit or vegetable juice conc5trate4 7iii7 ,! liquid result+ f ! re/oration ( wat] to dehydrat$ fruit or vegetable juice4 7,c7 ,infant =mula4 7,d7 ,any liquid products manufactur$ = use z-- 7i7 an oral nutritional !rapy = p]sons :o _c absorb or metabolize diet>y nutri5ts f food or bev]ages1 7ii7 a s\rce ( necess>y nutrition us$ due to a m$ical condition1 or 7iii7 an oral electrolyte solution = infants & *ildr5 =mulat$ to prev5t dehydration due to illness4 7,e7 ,any liquid ) respect to :i* tax is impos$ "u *apt] #ea 7relat+ to di/ill$ spirits1 w9es1 & be]7 or "u section #gfeb by reason ( ! tax impos$ "u *apt] #ea be+ impos$ on l articles ( dome/ic manufacture4 7b7 ,caloric sweet5] ,= purposes ( ?is "p1 ! t]m caloric sweet5] means monosac*>ides1 disac*>ides1 & high-fructose corn syrup4 #dagc4 ,special rules 7a7 ,sweet5] tax$ only once ,9 ! case ( any specifi$ sug>-sweet5$ bev]age product :i* is manufactur$ or produc$ by includ+ "o or m o!r specifi$ sug>-sweet5$ bev]age products1 no tax %all be impos$ "u ?is section on any caloric sweet5] conta9$ 9 ! result+ specifi$ sug>-sweet5$ bev]age product if tax 0 previ\sly impos$ "u ?is section on su* caloric sweet5] :5 conta9$ 9 ! specifi$ sug>-sweet5$ bev]age product s includ$4 7b7 ,inflation adju/m5t ,9 ! case ( any sale aft] ,decemb] #ca1 #bjae1 ! "o c5t am\nt 9 section #daga7;b7 %all be increas$ by an am\nt equal to-- 7#a7 su* am\nt1 multipli$ by 7#b7 ! co/-(-liv+ adju/m5t det]m9$ "u section #a7;f77#c7 = ! cal5d> ye> 9 :i* su* sale occurs1 det]m9$ by sub/itut+ cal5d> ye> #bjad = cal5d> ye> #aiib 9 subp>agraph 7,b7 !re(4 ,any increase det]m9$ "u ?is subsection %all be r\nd$ to ! ne>e/ multiple ( "o-t5? ( a c5t4 4 7b7 ,con=m+ am5dm5ts 7#a7 ,section #dbba7;a7 is am5d$ by add+ at ! end ! foll[+3 ,p>agraphs 7#a71 7#d71 7#e71 & 7#f7 %all n apply to ! tax impos$ "u section #daga44 7#b7 ,! table ( p>ts = sub*apt] ,d ( *apt] #cb ( su* ,code is am5d$ by ins]t+ aft] ! item relat+ to "p ,i ! foll[+ new item3 ,"p ,,ii--,sug>-,sweet5$ bev]ages 4 7c7 ,rev5ues us$ = prev5tion1 treatm5t1 & rese>* ( diet-,relat$ heal? conditions 9 priority populations 7#a7 ,transf] to prev5tion & public heal? fund ,!re are h]eby appropriat$ to ! ,prev5tion & ,public ,heal? ,fund creat$ "u section #djjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 79 addition to any o!r am\nts appropriat$ to su* ,fund7 am\nts equival5t to taxes receiv$ 9 ! ,treasury "u "p ,,ii ( sub*apt] ,d ( *apt] #cb4 ,rules simil> to ! rules ( section #ifja ( ! ,int]nal ,rev5ue ,code ( #aihf %all apply ) respect to am\nts appropriat$ "u ?is p>agraph4 7#b7 ,re/riction on use ( funds ,not)/&+ subsections 7c7 & 7d7 ( section #djjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act1 am\nts appropriat$ to ! ,prev5tion & ,public ,heal? ,fund "u p>agraph 7#a7 may be transf]r$ to acc\nts 9 ! ,dep>tm5t ( ,heal? & ,human ,s]vices only = ! purpose ( mak+ exp5ditures = programs & rese>* design$ to r$uce ! human & economic co/s ( diabetes1 obesity1 d5tal c>ies1 & o!r diet-relat$ heal? conditions 9 priority populations 7)9 ! mean+ ( section #ija7;c7 ( ! ,public ,heal? ,s]vice ,act74 7d7 ,effective date 7#a7 ,9 g5]al ,except z provid$ 9 p>agraph 7#b71 ! am5dm5ts made by ?is section %all take effect on ! date ( ! enactm5t ( ?is ,act4 7#b7 ,excise tax ,! am5dm5ts made by subsections 7a7 & 7b7 %all apply to sales aft] ! date ( ! enactm5t ( ?is ,act4 ,,iii ,drug-,relat$ ,provisions #cja4 ,e/abli%m5t ( ! prescription drug & m$ical device review bo>d ,!re is e/abli%$ 9 ! ,dep>tm5t ( ,heal? & ,human ,s]vices a bo>d to be kn[n z ! ,prescription ,drug & ,m$ical ,device ,price ,review ,bo>d 79 ?is ,act ref]r$ to z ! ,bo>d74 #cjb4 ,memb]%ip2 /aff 7a7 ,memb]s ,! ,bo>d %all be compos$ ( ! memb]s z foll[s3 7#a7 ,! ,assi/ant ,secret>y = ,plann+ & ,evaluation ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices 7or ! ,assi/ant ,secret>y's designee74 7#b7 ,! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices or1 beg9n+ ) #bjbb1 ! ,adm9i/rator ( ! ,c5t] = ,m$ic>e 7or ! ,adm9i/rator's designee74 7#c7 ,! ,assi/ant ,director = ! ,heal? ,s]vices ,division ( ! ,f$]al ,bureau ( ,prisons 7or ! ,assi/ant ,director's designee74 7#d7 ,! ,secret>y ( ,def5se 7or ! ,secret>y's designee74 7#e7 ,! ,secret>y ( ,vet]ans ,affairs 7or ! ,secret>y's designee74 7#f7 ,! ,commission] ( ,food & ,drugs 7or ! ,commission]'s designee74 7#g7 ,! ,director ( ! ,national ,in/itutes ( ,heal?4 7b7 ,*airp]son ,! ,bo>d %all designate #a memb] ( ! ,bo>d to s]ve z ! *airp]son4 7c7 ,director & /aff 7#a7 ,director ,! ,bo>d %all h a director :o %all be appo9t$ by ! *airp]son ( ! ,bo>d1 subject to rules prescrib$ by ! ,bo>d4 7#b7 ,/aff ,! director may appo9t & fix ! pay ( su* additional p]sonnel z ! *airp]son consid]s appropriate1 subject to rules prescrib$ by ! ,bo>d4 7#c7 ,applicability ( c]ta9 civil s]vice laws ,! director & /aff ( ! ,bo>d %all be appo9t$ subject to ! provisions ( title #e1 ,unit$ ,/ates ,code1 gov]n+ appo9tm5ts 9 ! competitive s]vice1 & %all be paid 9 accordance ) ! requirem5ts ( *apt] #ea & sub*apt] ,,iii ( *apt] #ec ( su* title relat+ to classification & ,g5]al ,s*$ule pay rates2 except t an individual s appo9t$ may n receive pay 9 excess ( ! maximum annual rate ( basic pay payable = grade ,,gs-#ae ( ! ,g5]al ,s*$ule4 7d7 ,assi/ance = ! bo>d ,subject to section #cjf7;g71 9 c>ry+ out ?is title1 ! ,bo>d-- 7#a7 may seek assi/ance f outside exp]ts 9 ! fields ( consum] advocacy1 m$ic9e1 ph>macology1 ph>macy1 & prescription drug reimbursem5t2 & 7#b7 %all e/abli% & ma9ta9 an advisory gr\p & a /akehold] gr\p = purposes ( seek+ su* assi/ance4 7e7 ,initial meet+ ,! ,bo>d %all hold its initial meet+ n lat] ?an #ij days aft] ! date ( ! enactm5t ( ?is ,act4 #cjc4 ,report+ requirem5ts 7a7 ,report+ by manufactur]s ,! ,bo>d %all require ea* manufactur] ( a prescription drug or m$ical device t is sold 9 ! ,unit$ ,/ates to submit to ! ,bo>d on a p]iodic basis1 at a level ( specificity det]m9$ by ! ,bo>d to be necess>y to make a det]m9ation "u section #cjd1 ! foll[+ in=mation ) respect to ! report+ p]iod3 7#a7 ,ea* type ( prescription drug & m$ical device t is sold by ! manufactur] or an affiliate ( ! manufactur]-- 7,a7 9 ! ,unit$ ,/ates2 or 7,b7 9 a c\ntry t is a memb] ( ! ,organization = ,economic ,co-op]ation & ,developm5t4 7#b7 ,! price *>g$ by ! manufactur] & ! affiliate = ! prescription drug or m$ical device 9 ! ,unit$ ,/ates & 9 any su* c\ntry1 z applicable4 7#c7 ,! co/s ( ! manufactur] & ! affiliate to produce & m>ket ! prescription drug or m$ical device = sale 9 ! ,unit$ ,/ates & 9 any su* c\ntry1 z applicable4 7b7 ,report+ by ,,cbo ,! ,director ( ! ,congressional ,budget ,(fice %all submit an annual report to ! ,bo>d on tr5ds 9 ! prices *>g$ = prescription drugs & m$ical devices4 #cjd4 ,prohibition aga9/ excessive price 7a7 ,prohibition ,beg9n+ on ! effective date ( ! regulation requir$ by subsection 7b71 ! manufactur] ( a prescription drug or m$ical device %all n *>ge an excessive price1 z det]m9$ pursuant to su* regulation1 = su* drug or device4 7b7 ,=mula ,! ,bo>d %all by regulation prescribe a =mula = det]m9+ :e!r ! av]age manufactur] price ( su* drug or device ov] an annual qu>t] is an excessive price4 7c7 ,det]m9ation ( excessive price ,if ! ,bo>d det]m9es1 on its own initiative or 9 response to a petition submitt$ "u subsection 7d71 t ! manufactur] ( a prescription drug or m$ical device *>ges an excessive price = su* drug or device 9 violation ( subsection 7a7-- 7#a7 ! ,bo>d %all give ! manufactur]-- 7,a7 notice ( su* violation2 & 7,b7 subject to subsection 7d71 a p]iod to correct su* violation2 & 7#b7 if ! manufactur] fails to correct ! violation by ! end ( su* p]iod1 ! manufactur] %all be subject to section #cje1 section #aibg7;c77#b77;,e7 ( ! ,social ,security ,act 7z add$ by subsection 7c7 ( section #cje71 & section #daib ( ! ,int]nal ,rev5ue ,code ( #aihf1 z add$ by subsection 7d7 ( section #cje4 7d7 ,petitions ,any p]son may petition ! ,bo>d to make a det]m9ation "u subsection 7c7 reg>d+ ! pric+ ( a prescription drug or m$ical device4 ,n lat] ?an #ij days aft] ! date ( receipt ( su* a petition1 ! ,bo>d %all-- 7#a7 make a det]m9ation "u subsection 7c7 reg>d+ su* pric+2 or 7#b7 decl9e to make su* a det]m9ation4 7e7 ,cont9u+ violation ,! ,bo>d %all n be requir$ to give a manufactur] an opportunity to correct a violation1 z describ$ 9 subsection 7c77#a77;,b71 be=e ! manufactur] becomes subject to ! provisions describ$ 9 subsection 7c77#b7 = su* violation1 if-- 7#a7 ! ,bo>d has already provid$ su* an opportunity to correct to ! manufactur]2 & 7#b7 ! ,bo>d f9ds t ! violation ( subsection 7a7 is a cont9uation ( an e>li] violation ) respect to :i* su* an opportunity 0 provid$4 7f7 ,consid]ations ,! =mula requir$ by subsection 7a7 %all at a m9imum take into consid]ation-- 7#a7 ! av]age manufactur] price ( ! prescription drug or m$ical device ov] ! respective annual qu>t] or qu>t]s2 7#b7 ! av]age manufactur] price ( o!r prescription drugs or m$ical devices 9 ! same !rapeutic class ov] ! same qu>t] or qu>t]s2 7#c7 ! av]age price at :i* ! prescription drug or m$ical device & o!r prescription drugs & m$ical devices 9 ! same !rapeutic class h be5 sold by manufactur]s 9 c\ntries o!r ?an ! ,unit$ ,/ates2 7#d7 ! co/s associat$ ) produc+ & m>ket+ ! prescription drug or m$ical device1 ! value ( ! drug or device to pati5ts :]e suffici5t data is available to det]m9e su* value1 ! total ,f$]al inve/m5t 9 ! developm5t ( ! drug or device1 ! size ( ! pati5t population receiv+ ! drug or device1 & o!r factors det]m9ative z to ! true co/ ( production2 & 7#e7 :e!r ! price ( ! prescription drug or m$ical device increas$ dur+ any annual qu>t] by a p]c5tage t is m ?an #b p]c5t great] ?an ! ,,cpi increase p]c5tage 7z def9$ 9 section #bae7;i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #dae77 = ! respective annual qu>t]4 #cje4 ,en=cem5t provisions 7a7 ,r$uc$ pat5t t]m ,if ! ,bo>d f9ds t ! manufactur] ( a prescription drug or m$ical device1 :o is also an own] ( a pat5t = su* drug or device1 *>g$ an excessive price = su* drug or device 9 violation ( section #cjd7;a71 ! ,bo>d may-- 7#a7 r$uce ! t]m1 by n m ?an #e ye>s1 ( any pat5t issu$ "u title #ce1 ,unit$ ,/ates ,code1 relat+ to su* drug or device2 or 7#b7 if ! t]m ( ea* pat5t = su* drug or device has expir$1 r$uce ! t]m1 by n m ?an #e ye>s1 ( ano!r pat5t own$ by ! pat5t own] relat+ to a prescription drug or m$ical device4 7b7 ,civil p5alties ,if ! ,bo>d det]m9es "u section #cjd7;c7 t a manufactur] ( a prescription drug or m$ical device *>g$ an excessive price = a prescription drug or m$ical device 9 violation ( section #cjd7;a71 ! ,bo>d may impose a civil p5alty on ! manufactur] ( n m ?an #aj p]c5t ( ! manufactur]'s gross sales ( ! drug or device dur+ ! p]iod beg9n+ on ! date on :i* an excessive price is fir/ *>g$ & end+ on ! date on :i* ! manufactur] ceases to *>ge an excessive price4 7c7 ,en=cem5t ?r\gh increas$ m$icaid rebates 7#a7 ,9 g5]al ,section #aibg7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#h7;c77#b77 is am5d$-- 7,a7 9 subp>agraph 7,a71 by ins]t+ 1 subject to subp>agraph 7,e71 aft] increas$ by2 & 7,b7 by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,disc\rag+ excessive prices 7i7 ,9 g5]al ,9 ! case ( a manufactur] ( a s+le s\rce drug or an innovator multiple s\rce drug ) a rebate agreem5t "u ?is section1 if ! ,prescription ,drug & ,m$ical ,device ,price ,review ,bo>d e/abli%$ "u section #cja ( ! ,m$ic>e = ,am]ica ,act det]m9es "u section #cjd7;a7 ( su* ,act t su* manufactur] *>g$1 ) respect to a #cj-;day p]iod1 an excessive price = su* drug1 & ! ,bo>d det]m9es "u clause 7ii7 to apply an increas$ am\nt describ$ 9 su* clause ) respect to su* manufactur] & drug1 ! am\nt ( ! rebate det]m9$ "u subp>agraph 7,a7 = su* manufactur] & drug %all be1 subject to subp>agraph 7,d71 increas$ by su* am\nt = ! #d rebate p]iods foll[+ su* #cj-;day p]iod4 7ii7 ,increas$ am\nt det]m9ation ,= purposes ( clause 7i71 if ! ,bo>d describ$ 9 su* clause makes su* a det]m9ation "u su* section #cjd7;a71 ) respect to a manufactur] & drug describ$ 9 su* clause1 ! ,bo>d may det]m9e an increas$ am\nt to apply ) respect to su* manufactur] & drug & rebate p]iod describ$ 9 su* clause4 ,su* increas$ am\nt may n exce$ ! rebate am\nt t w\ld o!rwise be appli$ to su* manufactur] & drug "u ?is section = su* rebate p]iod1 )\t reg>d to ?is subp>agraph4 4 7#b7 ,effective date ,?is subsection & ! am5dm5ts made by ?is subsection %all apply ) respect to rebate agreem5ts ent]$ into aft] ! date t is #fj days aft] ! date ( ! enactm5t ( ?is ,act4 7d7 ,tax on excess prescription drug & m$ical device pr(its 7#a7 ,det]m9ation ( am\nt ,if ! ,bo>d det]m9es "u section #cjd7;a7 t a manufactur]1 produc]1 or import] ( a prescription drug or m$ical device *>g$ an excessive price = su* prescription drug or m$ical device dur+ a taxable ye>1 ! ,bo>d may det]m9e "u ?is p>agraph a reasonable price = su* drug or device = su* taxable ye>4 7#b7 ,imposition ( tax 7,a7 ,9 g5]al ,! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by ins]t+ aft] section #daia ! foll[+ new section3 #daib4 ,excessive prescription drug & m$ical device price 7a7 ,9 g5]al ,!re is h]eby impos$ on ! sale ( any prescription drug or m$ical device by ! manufactur]1 produc]1 or import] a tax equal to ! diff]5ce betwe5 ! price at :i* su* drug or device is s sold & ! reasonable price det]m9$ by ! ,prescription ,drug & ,m$ical ,device ,price ,review ,bo>d "u section #cje7;d77#a7 ( ! ,m$ic>e = ,am]ica ,act = su* drug or device = ! taxable ye> = sales aft] ! det]m9ation4 7b7 ,prescription drug or m$ical device ,= purposes ( ?is section1 ! t]m prescription drug or m$ical device means any prescription drug 7z def9$ 9 section #ijjh ( ! ,pati5t ,protection & ,af=dable ,c>e ,act7 or device 7z def9$ 9 section #bja7;h7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act7 int5d$ = humans4 4 7,b7 ,cl]ical am5dm5t ,! table ( p>ts = *apt] #cb ( su* ,code is am5d$-- 7i7 9 ! item relat+ to sub*apt] ,e1 by /rik+ ,m$ical & ins]t+ ,drugs & m$ical1 & 7ii7 by ins]t+ aft] ! item relat+ to section #daia ! foll[+ new item3 #daib4 ,excessive prescription drug & m$ical device price 4 7#c7 ,effective date ,?is subsection & ! am5dm5ts made by ?is subsection %all apply ) respect to sales aft] ,decemb] #ca1 #bjah4 #cjf4 ,au?ority 7a7 ,obta9+ (ficial data ,! *airp]son ( ! ,bo>d may secure directly f any ,f$]al ag5cy in=mation necess>y to enable ! ,bo>d to c>ry out its duties4 ,^u reque/ ( ! *airp]son1 ! head ( ! ag5cy %all furni% su* in=mation to ! ,bo>d to ! ext5t su* in=mation is n prohibit$ f disclosure by law4 7b7 ,mails ,! ,bo>d may use ! ,unit$ ,/ates mails 9 ! same mann] & "u ! same conditions z o!r ,f$]al ag5cies4 7c7 ,adm9i/rative support s]vices ,^u ! reque/ ( ! *airp]son ( ! ,bo>d1 ! ,adm9i/rator ( ,g5]al ,s]vices %all provide to ! ,bo>d1 on a reimbursable basis1 ! adm9i/rative support s]vices necess>y = ! ,bo>d to c>ry out its duties4 7d7 ,contract au?ority ,! ,bo>d may contract ) & comp5sate gov]nm5t & private ag5cies or p]sons = ! purpose ( conduct+ rese>*1 surveys1 & o!r s]vices necess>y to enable ! ,bo>d to c>ry out its duties4 7e7 ,inve/igations ,! ,bo>d may make su* inve/igations z x consid]s necess>y to det]m9e :e!r !re is or may be a violation ( any regulation promulgat$ "u ?is ,act & may require or p]mit any p]son to file ) x a /atem5t 9 writ+1 "u oa? or o!rwise z ! ,bo>d %all det]m9e1 z to all ! facts & circum/ances conc]n+ ! matt] to be inve/igat$4 7f7 ,subpo5a p[] 7#a7 ,9 g5]al ,! ,bo>d may issue subpo5as requir+ ! att5dance & te/imony ( witnesses & ! production ( any evid5ce relat+ to any matt] "u inve/igation by ! ,bo>d4 ,! att5dance ( witnesses & ! production ( evid5ce may be requir$ f any place )9 ! ,unit$ ,/ates at any designat$ place ( he>+ )9 ! ,unit$ ,/ates4 7#b7 ,failure to obey a subpo5a ,if a p]son refuses to obey a subpo5a issu$ "u p>agraph 7#a71 ! ,bo>d may apply to a ,unit$ ,/ates di/rict c\rt = an ord] requir+ t p]son to appe> be=e ! ,bo>d to give te/imony1 produce evid5ce1 or bo?1 relat+ to ! matt] "u inve/igation4 ,! application may be made )9 ! judicial di/rict :]e ! he>+ is conduct$ or :]e t p]son is f\nd1 resides1 or transacts bus9ess4 ,any failure to obey ! ord] ( ! c\rt may be puni%$ by ! c\rt z civil contempt4 7#c7 ,s]vice ( subpo5as ,! subpo5as ( ! ,bo>d %all be s]v$ 9 ! mann] provid$ = subpo5as issu$ by a ,unit$ ,/ates di/rict c\rt "u ! ,f$]al ,rules ( ,civil ,proc$ure = ! ,unit$ ,/ates di/rict c\rts4 7#d7 ,s]vice ( process ,all process ( any c\rt to :i* application is made "u p>agraph 7#b7 may be s]v$ 9 ! judicial di/rict 9 :i* ! p]son requir$ to be s]v$ resides or may be f\nd4 7#e7 ,notice ,^u issu+ any subpo5a "u ?is subsection1 ! ,bo>d %all give notice ( su* issuance to ! appropriate committees ( ,congress1 includ+ ! ,committee on ,appropriations ( ! ,h\se ( ,repres5tatives & ! ,committee on ,appropriations ( ! ,s5ate4 7g7 ,confid5tiality ,no?+ 9 ?is title %all be con/ru$ z au?oriz+ ! ,bo>d to disclose any in=mation t is a trade secret or confid5tial in=mation subject to section #eeb7;b77#d7 ( title #e1 ,unit$ ,/ates ,code1 or section #aije ( title #ah1 ,unit$ ,/ates ,code4 #cjg4 ,regulations 7a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! date ( ! initial meet+ held "u section #cjb7;e71 ! ,bo>d %all issue f9al regulations to c>ry out ?is ,act4 7b7 ,notice & comm5t requirem5t ,! regulations develop$ "u subsection 7a7 %all be issu$ 9 accordance ) ! notice & comm5t proc$ures e/abli%$ "u section #eec ( title #e1 ,unit$ ,/ates ,code4 #cjh4 ,report to ,f$]al ag5cies ,n lat] ?an #a ye> aft] ! effective date ( ! regulations "u section #cjg & annually !reaft]1 ! ,bo>d %all submit to ea* ,f$]al ag5cy t disp5ses or makes paym5ts = ! disp5s+ ( prescription drugs or m$ical devices a report conta9+-- 7#a7 a li/ ( ea* prescription drug & m$ical device = :i* an excessive price 0 *>g$ dur+ ! prec$+ cal5d> ye>1 z det]m9$ by ! ,bo>d "u section #cjd2 7#b7 recomm5dations to ! ,f$]al ag5cy aga9/ disp5s+ or mak+ paym5ts = ! disp5s+ ( ! prescription drug or m$ical device2 & 7#c7 recomm5dations to ! ,f$]al ag5cy to sub/itute1 9 place ( any drug or device li/$ pursuant to p>agraph 7#a71 a simil> prescription drug or m$ical device t is n sold at an excessive price4 #cji4 ,def9itions ,9 ?is title3 7#a7 ,! t]m affiliate means1 ) respect to a manufactur]1 any entity t controls1 is controll$ by1 or is "u common control ) su* manufactur]4 7#b7 ,! t]m av]age manufactur] price means ! av]age price *>g$ by ! manufactur] ( a prescription drug or m$ical device1 z applicable1 = sales ( ! drug or device by ! manufactur] 9 ! ,unit$ ,/ates ov] ! respective annual qu>t]4 7#c7 ,! t]m m$ical device means a device 7z def9$ 9 section #bja ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cba774 7#d7 ,! t]m prescription drug means a drug 7z def9$ 9 section #bja ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cba77 t is subject to section #ejc7;b77#a7 ( su* ,act 7#ba ,u4,s4,c4 #cec7;b77#a774 #caj4 ,moratorium on direct-to-consum] drug adv]tis+ ,! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cja et seq47 is am5d$-- 7#a7 9 section #cja 7#ba ,u4,s4,c4 #cca71 by add+ at ! end ! foll[+3 7eee7 ,! conduct ( direct-to-consum] adv]tis+ ( a drug 9 violation ( section #ejf;,j4 2 & 7#b7 9 *apt] ,v1 by ins]t+ aft] section #ejf;,i 7#ba ,u4,s4,c4 #cef;f7 ! foll[+3 #ejf;,j4 ,direct-to-consum] drug adv]tis+ 7a7 ,prohibitions 7#a7 ,fir/ ?ree ye>s 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 no p]son %all conduct direct-to-consum] adv]tis+ ( a drug = :i* an application is submitt$ "u section #eje7;b7 be=e ! end ( ! #c-ye> p]iod beg9n+ on ! date ( ! approval ( su* application4 7,b7 ,waiv] ,! ,secret>y may waive ! application ( subp>agraph 7,a7 to a drug dur+ ! ?ird ye> ( ! #c-ye> p]iod describ$ 9 su* subp>agraph if-- 7i7 ! sponsor ( ! drug submits an application to ! ,secret>y pursuant to subp>agraph 7,c72 & 7ii7 ! ,secret>y1 aft] consid]+ ! application & any accompany+ mat]ials1 det]m9es t direct-to-consum] adv]tis+ ( ! drug w\ld h an affirmative value to public heal?4 7,c7 ,application = waiv] ,to seek a waiv] "u subp>agraph 7,b71 ! sponsor ( a drug %all submit an application to ! ,secret>y at su* "t1 9 su* mann]1 & conta9+ su* in=mation z ! ,secret>y may require4 7#b7 ,subsequ5t ye>s ,! ,secret>y may prohibit direct-to-consum] adv]tis+ ( a drug dur+ ! p]iod beg9n+ at ! end ( ! #c-ye> p]iod describ$ 9 p>agraph 7#a77;,a7 if ! ,secret>y det]m9es t ! drug has significant adv]se heal? effects bas$ on po/-approval /udies1 risk-b5efit analyses1 adv]se ev5t reports1 ! sci5tific lit]ature1 any cl9ical or obs]vational /udies1 or any o!r appropriate res\rce4 7b7 ,regulations ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is section1 ! ,secret>y %all revise ! regulations promulgat$ "u ?is ,act gov]n+ drug adv]tisem5ts to ! ext5t necess>y to implem5t ?is section4 7c7 ,rule ( con/ruction ,?is section %all n be con/ru$ to dim9i% ! au?ority ( ! ,secret>y to prohibit or regulate direct-to-consum] adv]tis+ ( drugs "u o!r provisions ( law4 4 #caa4 ,report+ on ju/ification = drug price increases ,title ,,iii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bda et seq47 is am5d$ by add+ at ! end ! foll[+3 ,w ,,drug ,,price ,,report+2 ,,drug ,,value ,,fund #cii,,oo4 ,report+ on ju/ification = drug price increases 7a7 ,def9itions ,9 ?is section3 7#a7 ,manufactur] ,! t]m manufactur] means ! p]son-- 7,a7 t holds ! application = a drug approv$ "u section #eje ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act or ! lic5se issu$ "u section #cea ( ! ,public ,heal? ,s]vice ,act2 or 7,b7 :o is responsible = sett+ ! price = ! drug4 7#b7 ,qualify+ drug ,! t]m qualify+ drug means any drug t is approv$ "u subsection 7c7 or 7j7 ( section #eje ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act or lic5s$ "u subsection 7a7 or 7k7 ( section #cea ( ?is ,act-- 7,a7 t has a :olesale acquisition co/ ( #ajj or m p] mon? supply or p] a c\rse ( treatm5t t la/s less ?an a mon? & is-- 7i7 7,i7 subject to section #ejc7;b77#a7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act2 or 7,,ii7 commonly adm9i/]$ by hospitals 7z det]m9$ by ! ,secret>y72 7ii7 n designat$ z a drug = a r>e disease or condition "u section #ebf ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act2 & 7iii7 n designat$ by ! ,secret>y z a vacc9e2 & 7,b7 = :i*1 dur+ ! previ\s cal5d> ye>1 at lea/ #a doll> ( ! total am\nt ( sales 7 = individuals enroll$ "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 or "u a ,/ate ,m$icaid plan "u title ,,xix ( su* ,act 7#db ,u4,s4,c4 #acif et seq47 or "u a waiv] ( su* plan4 7#c7 ,:olesale acquisition co/ ,! t]m :olesale acquisition co/ has ! mean+ giv5 t t]m 9 section #ahdg;,a7c77#f77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c;a7c77#f77;,b774 7b7 ,report 7#a7 ,report requir$ ,! manufactur] ( a qualify+ drug %all submit a report to ! ,secret>y = ea* price increase ( a qualify+ drug t w result 9 an increase 9 ! :olesale acquisition co/ ( t drug t is equal to-- 7,a7 #aj p]c5t or m ov] a #ab-mon? p]iod2 or 7,b7 #be p]c5t or m ov] a #cf-mon? p]iod4 7#b7 ,report deadl9e ,ea* report describ$ 9 p>agraph 7#a7 %all be submitt$ to ! ,secret>y n lat] ?an #cj days prior to ! plann$ effective date ( su* price increase4 7c7 ,cont5ts ,a report "u subsection 7b7 %all1 at a m9imum1 include-- 7#a7 ) respect to ! qualify+ drug-- 7,a7 ! p]c5tage by :i* ! manufactur] w raise ! :olesale acquisition co/ ( ! drug on ! plann$ effective date ( su* price increase2 7,b7 a ju/ification =1 & description (1 ea* manufactur]'s price increase t occurr$ dur+ ! #ab-mon? p]iod describ$ 9 subsection 7b77#a77;,a7 or ! #cf-mon? p]iod describ$ 9 subsection 7b77#a77;,b71 z applicable2 7,c7 ! id5tity ( ! initial develop] ( ! drug2 7,d7 a description ( ! hi/ory ( ! manufactur]'s price increases = ! drug s9ce ! approval ( ! application = ! drug "u section #eje ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act or ! issuance ( ! lic5se = ! drug "u section #cea1 or s9ce ! manufactur] acquir$ su* approv$ application or lic5se2 7,e7 ! curr5t li/ price ( ! drug2 7,f7 ! total exp5ditures ( ! manufactur] on-- 7i7 mat]ials & manufactur+ = su* drug2 & 7ii7 acquir+ pat5ts & lic5s+ = su* drug2 7,g7 ! p]c5tage ( total exp5ditures ( ! manufactur] on rese>* & developm5t = su* drug t 0 d]iv$ f ,f$]al funds2 7,h7 ! total exp5ditures ( ! manufactur] on rese>* & developm5t = su* drug t is us$ =-- 7i7 basic & precl9ical rese>*2 7ii7 cl9ical rese>*2 7iii7 new drug developm5t2 7iv7 pursu+ new or exp&$ indications = su* drug ?r\gh supplem5tal applications "u section #eje ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act2 & 7v7 c>ry+ out po/m>ket requirem5ts relat$ to su* drug1 includ+ ^? "u section #eje7o77#c7 ( su* ,act2 7,i7 ! total rev5ue & ! net pr(it g5]at$ f ! qualify+ drug = ea* cal5d> ye> s9ce ! approval ( ! application = ! drug "u section #eje ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act or ! issuance ( ! lic5se = ! drug "u section #cea1 or s9ce ! manufactur] acquir$ su* approv$ application or lic5se2 & 7,j7 ! total co/s associat$ ) m>ket+ & adv]tis+ = ! qualify+ drug2 7#b7 ) respect to ! manufactur]-- 7,a7 ! total rev5ue & ! net pr(it ( ! manufactur] = ! #ab-mon? p]iod describ$ 9 subsection 7b77#a77;,a7 or ! #cf-mon? p]iod describ$ 9 subsection 7b77#a77;,b71 z applicable2 7,b7 all /ock-bas$ p]=mance metrics us$ by ! manufactur] to det]m9e executive comp5sation = ! #ab-mon? p]iod describ$ 9 subsection 7b77#a77;,a7 or ! #cf-mon? p]iod describ$ 9 subsection 7b77#a77;,b71 z applicable2 & 7,c7 any additional in=mation ! manufactur] *ooses to provide relat$ to drug pric+ decisions1 su* z total exp5ditures on-- 7i7 drug rese>* & developm5t2 or 7ii7 cl9ical trials on drugs t fail$ to receive approval by ! ,food & ,drug ,adm9i/ration2 & 7#c7 su* o!r relat$ in=mation z ! ,secret>y consid]s appropriate4 7d7 ,civil p5alty ,any manufactur] ( a qualify+ drug t fails to submit a report = ! drug z requir$ by ?is section %all be subject to a civil p5alty ( #ajj1jjj = ea* day on :i* ! violation cont9ues4 7e7 ,public po/+ 7#a7 ,9 g5]al ,subject to p>agraph 7#c71 n lat] ?an #cj days aft] ! submission ( a report "u subsection 7b71 ! ,secret>y %all po/ ! report on ! public website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 7#b7 ,=mat ,9 develop+ ! =mat ( su* report = public po/+1 ! ,secret>y %all consult /akehold]s1 includ+ b5efici>y gr\ps1 & %all seek fe$back on ! cont5t & =mat f consum] advocates & readability exp]ts to ensure su* public reports are us]-fri5dly to ! public & are writt5 9 pla9 language t consum]s c readily und]/&4 7#c7 ,trade secrets & confid5tial in=mation ,9 c>ry+ out ?is section1 ! ,secret>y %all en=ce applicable law conc]n+ ! protection ( confid5tial comm]cial in=mation & trade secrets4 #cii,,oo-#a4 ,use ( civil p5alty am\nts ,! ,secret>y %all collect ! civil p5alties "u section #cii,,oo1 9 addition to any o!r am\nts available1 & )\t fur!r appropriation1 & %all use su* funds to c>ry out activities describ$ 9 ?is "p & to improve consum] & provid] in=mation ab\t drug value & drug price transp>5cy4 #cii,,oo-#b4 ,annual report to ,congress 7a7 ,9 g5]al ,subject to subsection 7b71 ! ,secret>y %all submit to ,congress1 & po/ on ! public website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices 9 a way t is easy to use & und]/&1 an annual report-- 7#a7 summ>iz+ ! in=mation report$ pursuant to section #cii,,oo2 & 7#b7 includ+ copies ( ! reports & support+ detail$ economic analyses submitt$ pursuant to su* section4 7b7 ,trade secrets & confid5tial in=mation ,9 c>ry+ out ?is section1 ! ,secret>y %all en=ce applicable law conc]n+ ! protection ( confid5tial comm]cial in=mation & trade secrets4 4