,,ii  #aaeth ,,congress  #ast ,session  
,s4 #aia  ,,in ,,the ,,senate ,,of ,,the
 ,,united ,,states  ,january #bc1 #bjag 
,mr4 ,cassidy 7for himself1 ,ms4        
,collins1 ,mrs4 ,capito1 and ,mr4       
,isakson7 introduced the following bill2
 which was read twice and referred to   
the ,committee on ,finance  ,a ,,bill   
,to improve patient choice by allowing  
,states to adopt market-based           
alternatives to the ,affordable ,care   
,act that increase access to affordable 
health insurance and reduce costs while 
ensuring important consumer protections 
and improving patient care4  #a4 ,short 
title2 table of contents  7a7 ,short    
title  ,this ,act may be cited as the   
,patient ,freedom ,act of #bjag4  7b7   
,table of contents ,the table of        
contents for this ,act is as follows3   
,sec4 #a4 ,short title2 table of        
contents4 ,,title ,i--,health reform    
,sec4 #ajj4 ,definitions4 ,subtitle     
,a--,insurance market reform ,sec4 #aja4
 ,ending the one size fits all ,,aca    

approach2 continuing consumer protection
 policies by covering adult children1   
protecting individuals with preexisting 
conditions1 and not applying lifetime or
 annual limits4 ,sec4 #ajb4 ,state      
health insurance options4 ,sec4 #ajc4   
,state alternative option4 ,sec4 #ajd4  
,computation of monthly ,roth ,,hsa     
deposit amount for deposit qualifying   
residents4 ,sec4 #aje4 ,state options   
for improved access to health insurance 
coverage in each ,state4 ,sec4 #ajf4    
,state flexibility in ensuring orderly  
health insurance market outside of an   
,exchange4 ,sec4 #ajg4 ,expanded access 
and patient protections4 ,sec4 #ajh4    
,application of health savings accounts 
in relation to ,medicaid4 ,subtitle     
,b--,provider price transparency ,sec4  
#aba4 ,ensuring access to emergency     
services without excessive charges for  
out-of-network services4 ,,title        
,,ii--,reform of ,tax ,provisions       
,relating to ,health ,care ,subtitle    
,a--,health ,savings ,accounts ,sec4    

#bja4 ,transition to non-deductible     
,h,s,as4 ,sec4 #bjb4 ,treatment of      
direct primary care4 ,sec4 #bjc4        
,treatment of ,,hsa after death of      
account beneficiary4 ,subtitle          
,b--,health ,care ,tax credits ,sec4    
#baa4 ,limited application of ,,ppaca   
health premium credit4 ,sec4 #bab4 ,new 
,roth ,,hsa credit4  ,i ,health reform  
#ajj4 ,definitions ,in this title3  7#a7
 ,patient-grant electing ,state ,the    
term patient-grant electing ,state means
 an electing ,state that specifies under
 section #ajc7;a77#c77;,b7 that it will 
carry out section #ajc7;b7 itself 7and  
not to have section #ajc7;b7 carried out
 by means of the credit under section   
#cf;,c of the ,internal ,revenue ,code  
of #aihf74  7#b7 ,budget neutral ,the   
term budget neutral with respect to     
expenditures provided for in this ,act1 
means the same amount of expenditures as
 are provided for under the ,patient    
,protection and ,affordable ,care ,act  
7,public ,law #aaa-adh74  7#c7 ,,chip   

,the term ,,chip means the ,children's  
,health ,insurance ,program established 
under title ,,xxi of the ,social        
,security ,act 7#db ,u4,s4,c4 #acif et  
seq474  7#d7 ,creditable coverage ,the  
term creditable coverage has the meaning
 given such term in section             
#bgjd7;c77#a7 of the ,public ,health    
,service ,act 7#db ,u4,s4,c4            
#cjj;gg-#c7;c77#a771 as in effect as of 
the day before the date of the enactment
 of this ,act4  7#e7 ,default health    
insurance coverage ,the term default    
health insurance coverage has the       
meaning given such term in section      
#ajg7;c77#b74  7#f7 ,deposit qualifying 
resident ,the term deposit qualifying   
resident has the meaning given such term
 in section #ajc7;b77#b74  7#g7         
,electing state ,the term electing      
,state means a ,state that elects under 
section #ajb7;a77#b7 the alternative    
option described in section #ajc4  7#h7 
,health insurance coverage ,the term    
health insurance coverage has the       

meaning given such term in section      
#bgia7;b77#a7 of the ,public ,health    
,service ,act 7#db ,u4,s4,c4            
#cjj;gg-#ia7;b77#a774  7#i7 ,health     
savings deposit ,the term health savings
 deposit means a deposit made into a    
,roth ,,hsa pursuant to section #ajc4   
7#aj7 ,medicaid ,the term ,medicaid     
means the program under title ,,xix of  
the ,social ,security ,act 7#db         
,u4,s4,c4 #acif et seq474  7#aa7        
,medicare ,the term ,medicare means the 
program under part ,a or ,b of title    
,,xviii of the ,social ,security ,act   
7#db ,u4,s4,c4 #acie et seq474  7#ab7   
,,ppaca ,the term ,,ppaca means the     
,patient ,protection and ,affordable    
,care ,act 7,public ,law #aaa-adh71 as  
in effect on the day before the date of 
the enactment of this ,act1 unless      
otherwise specified4  7#ac7 ,qualified  
health plan coverage ,the term qualified
 health plan coverage means1 with       
respect to residents of a ,state1 health
 insurance coverage that meets          

applicable standards under ,state law1  
which standards need not be the same as 
that previously required of qualified   
health plans under title ,i of ,,ppaca1 
and includes a high deductible health   
plan 7as defined in section #bbc7;c77#b7
 of the ,internal ,revenue ,code of     
#aihf7 and includes coverage under a    
group health plan4  7#ad7 ,qualified    
resident ,the term qualified resident   
means1 with respect to a ,state for a   
month1 an individual who is a resident  
of the ,state as of the first day of the
 month and is a citizen or national of  
the ,united ,states or otherwise        
lawfully residing in the ,state under   
color of law4  7#ae7 ,roth health       
savings account2 ,roth ,,hsa ,the terms 
,roth health savings account and ,roth  
,,hsa mean a ,roth ,,hsa established    
under section #ecj;,a of the ,internal  
,revenue ,code of #aihf4  7#af7         
,secretary ,the term ,secretary means   
the ,secretary of ,health and ,human    
,services4  7#ag7 ,state ,the term      

,state means the #ej ,states and the    
,district of ,columbia4  7#ah7          
,uninsured ,the term uninsured means1   
with respect to an individual1 that the 
individual does not have creditable     
coverage4  ,a ,insurance market reform  
#aja4 ,ending the one size fits all     
,,aca approach2 continuing consumer     
protection policies by covering adult   
children1 protecting individuals with   
preexisting conditions1 and not applying
 lifetime or annual limits  7a7 ,in     
general ,subject to subsections 7b7 and 
7c71 title ,i of the ,patient           
,protection and ,affordable ,care ,act  
7including the amendments made by such  
title7 shall not apply 7and the         
provisions of law amended by such title 
are restored as if such title had not   
been enacted7 in the case of any ,state 
that does not have in effect the        
election described in section           
#ajb7;a77#a74  7b7 ,continuation of     
policies for extension of dependent     
coverage for adult children and         

prohibition of lifetime and annual      
coverage limits2 preservation of black  
lung benefits  7#a7 ,public ,health     
,service ,act provisions                
,notwithstanding subsection 7a71 the    
following sections of the ,public       
,health ,service ,act1 that were added  
or amended by subtitles ,a and ,c of    
title ,i of ,,ppaca1 shall continue to  
apply to group health plans and to      
health insurance coverage offered in the
 individual and group market3  7,a7 ,no 
lifetime or annual limits ,section #bgaa
 7relating to no lifetime or annual     
limits71 except in the case of limited  
benefit insurance4  7,b7 ,dependent     
coverage through age #bf ,section #bgad 
7relating to extension of dependent     
coverage74  7,c7 ,prohibiting           
pre-existing condition exclusions       
,section #bgjd 7relating to prohibition 
on preexisting conditions74  7,d7       
,prohibiting discrimination based on    
health status ,section #bgje 7relating  
to prohibiting discrimination against   

individual participants and             
beneficiaries based on health status71  
subject to subsection 7c74  7,e7        
,preservation of preventive service     
coverage ,section #bgac 7relating to    
coverage of preventive health services71
 if employers do not contribute to the  
individual's ,roth ,,hsa4  7#b7         
,preservation of non-discrimination in  
health care ,subsection 7a7 shall not   
apply with respect to section #aeeg of  
title ,i of the ,patient ,protection and
 ,affordable ,care ,act 7#db ,u4,s4,c4  
#ahaaf74  7#c7 ,preservation of coverage
 of mental health services1 and         
applicability of mental health parity   
,for serious mental illness1 serious    
emotional disturbance1 and substance use
 disorder1 subsection 7a7 shall not     
apply with respect to section           
#acjb7;b77#a77;,e7 of title ,i of the   
,patient ,protection and ,affordable    
,care ,act 7relating to coverage of     
mental health and substance use         
treatment at limited cost sharing7 7#db 

,u4,s4,c4 #ahjbb7;b77#a77;,e774 ,section
 #bgbf of the ,public ,health ,service  
,act shall apply to qualified health    
plans in the same manner and to the same
 extent as such section applies to      
health insurance coverage and group     
health plans4  7#d7 ,preservation of    
black lung benefits for coal miners     
,subsection 7a7 shall not apply with    
respect to section #aeef of title ,i of 
the ,patient ,protection and ,affordable
 ,care ,act 7amending the ,black ,lung  
,benefits ,act74  7#e7 ,preservation of 
,state innovations ,subsection 7a7 shall
 not apply with respect to section #accb
 of title ,i of the ,patient ,protection
 and ,affordable ,care ,act 7#db        
,u4,s4,c4 #ahjeb74  7c7 ,continuation of
 ,federal exchanges ,subsection 7a7     
shall not apply with respect to ,federal
 ,exchanges established pursuant to     
section #acba7;c7 of the ,patient       
,protection and ,affordable ,care ,act  
7#db ,u4,s4,c4 #ahjda7;c77 and such     
,exchanges shall continue to operate as 

provided for by the ,secretary4  #ajb4  
,state health insurance options  7a7 ,in
 general ,each ,state may elect1 through
 written notice to the ,secretary after 
the date of the enactment of this ,act  
and in accordance with this title1 #a of
 the following #c options in relation to
 the implementation of title ,i of the  
,patient ,protection and ,affordable    
,care ,act after the date of enactment  
of this ,act3  7#a7 ,continuing         
implementation of ,,ppaca ,the ,state   
continuing-- 7,a7 the ,federal premium  
and cost-sharing subsidies for coverage 
offered under title ,i of ,,ppaca 7and  
the amendments made thereby71 reduced   
for qualified residents of such ,state  
for any year by the amount 7if any7 by  
which such subsidies would exceed the   
amount of contributions that would have 
been made under section #ajc7;b7 to all 
such residents for such year if the     
,state had elected the option under     
paragraph 7#c72 and  7,b7 all other     
requirements under such title4  7#b7    

,establishing new ,state and            
market-based alternative1 with          
alternative per beneficiary ,federal    
deposit system ,the ,state implementing 
the alternative option described in     
section #ajc1 which includes--  7,a7 the
 waiver of most requirements imposed    
under such title ,i2 and  7,b7 the      
provision of a new1 ,roth ,,hsa- and    
market-based deposit system for         
individuals who do not otherwise qualify
 for ,federal or ,state subsidies for   
health benefits coverage4  7#c7         
,rejection of ,,ppaca ,the ,state       
rejecting title ,i of ,,ppaca 7and the  
amendments made thereby71 except as     
otherwise required in this title4  ,if a
 ,state fails to make an election       
described in this subsection during the 
#a-year period beginning on the date of 
enactment of this ,act1 the ,state shall
 be deemed to have made the election    
described in paragraph 7#b74 ,a ,state  
may1 through written notice to the      
,secretary1 change an election          

previously made under this subsection4  
7b7 ,relation to current ,medicaid ,,aca
 coverage option ,nothing in this       
section shall be construed to change the
 option of a ,state with respect to the 
implementation of ,medicaid ,,aca       
coverage under section                  
#aijb7;a77#aj77;,a77i77,,viii7 of the   
,social ,security ,act 7#db ,u4,s4,c4   
#acif;a7a77#aj77;,a77i77,,viii771 except
 that a ,state that elects not to       
provide medical assistance to           
individuals under such section may make 
such individuals deposit qualifying     
residents under this title4  #ajc4      
,state alternative option  7a7 ,in      
general ,in the case of a ,state that   
elects under section #ajb7;a77#b7 the   
alternative option under this section1  
subject to subsection 7d7 and section   
#ajg1 the following shall apply3  7#a7  
,elimination of individual and employer 
shared responsibility for health care   
tax requirements for residents and      
employees in ,state ,the individual and 

employer health care responsibilities   
under the amendments made by title ,i of
 ,,ppaca 7including under sections      
#ejjj;,a and #dihj;,h of the ,internal  
,revenue ,code of #aihf7 shall no longer
 apply pursuant to section #aja with    
respect to individuals who are residents
 of such ,state and with respect to     
individuals who are employed in such    
,state1 respectively4  7#b7             
,modification of insurance requirements 
,except as specifically provided in this
 title1 the requirements under title ,i 
of ,,ppaca 7including amendments made by
 such title7 relating to health         
insurance coverage offered in the ,state
 shall not apply except to the extent   
specified by the ,state4  7#c7 ,new     
deposit system through funding ,roth    
,h,s,as  7,a7 ,in general ,deposit      
qualifying residents 7as defined in     
subsection 7b77#b77 who are residing in 
the ,state are eligible for a deposit to
 a ,roth ,,hsa that may be used for     
premiums and cost-sharing for health    

insurance coverage in accordance with   
subsection 7b74  7,b7 ,state            
specification of manner of carrying out 
,roth ,,hsa deposit system              
7patient-grant electing state7 ,in      
making the election under this          
subsection1 a ,state shall specify      
whether the ,state will carry out       
subsection 7b7 or if such subsection    
shall be carried out by means of the    
credit under section #cf;,c of the      
,internal ,revenue ,code of #aihf4  7#d7
 ,additional amounts for population     
health initiatives for ,state           
administered ,roth ,,hsa deposit system 
,a patient-grant electing ,state 7as    
defined in section #ajj7a77 is entitled 
to receive additional funding under     
subsection 7c7 for population health    
initiatives4  7b7 ,deposit through      
payment into ,roth ,,hsa for deposit    
qualifying residents  7#a7 ,in general  
,the subsidies described in subsection  
7a77#c7 for an electing ,state shall be 
furnished for each deposit qualifying   

resident through the deposit of a       
contribution into a ,roth ,,hsa of the  
individual in the amount determined     
under section #ajd4 ,for purposes of the
 ,internal ,revenue ,code of #aihf1 the 
amount of any contribution to a ,roth   
,,hsa made under this paragraph shall be
 included in the gross income of the    
individual for whose benefit the ,roth  
,,hsa was established4  7#b7 ,deposit   
qualifying resident defined ,in this    
title1 the term deposit qualifying      
resident means1 with respect to a ,state
 and a month1 an individual-- 7,a7 who  
is a qualified resident 7as defined in  
section #ajj7ad77 of the ,state as of   
the first day of the month 7or such     
other day in the month as the ,secretary
 may specify72  7,b7 with respect to    
whom a ,roth ,,hsa has been established1
 which ,roth ,,hsa may have been        
established by the ,state in carrying   
out this section2  7,c7 who is enrolled 
in qualified health plan coverage 7as   
defined in section #ajj7ac771 which     

enrollment may have been effected by the
 ,state in carrying out this section2   
and  7,d7 who is not eligible for       
coverage under ,medicare1 is not        
enrolled for benefits under ,medicaid or
 ,,chip1 and is not enrolled for        
benefits under chapter #ee of title #aj1
 ,united ,states ,code 7relating to     
,,tricare71 or title #ci of such ,code  
7relating to veterans' benefits7 or     
chapter #hi of title #e of such ,code   
7relating to the ,federal ,employees    
,health ,benefits ,program74  7#c7      
,payment administration  7,a7 ,state ,in
 the case of an electing ,state that    
elects to carry out this subsection     
through the ,state1 the ,secretary shall
 provide for payment to the ,state in   
amounts and in a time and manner        
sufficient to permit the ,state to make 
timely monthly contributions to ,roth   
,h,s,as under this subsection4 ,the     
,secretary may provide for payment to   
the ,state using the payment methodology
 described in subsection 7d7 of section 

#aijc of the ,social ,security ,act for 
payments under subsection 7a7 of such   
section 7applied without regard to any  
,state matching requirement7 and may    
condition such payments upon the        
provision of such information as the    
,secretary may require to ensure the    
proper payments under this subsection4  
,as a condition of receiving payment    
under this section1 a ,state shall      
submit such information1 in such form1  
and manner1 as the ,secretary shall     
specify1 including information necessary
 to make the computations of amounts    
under this section4  7,b7 ,federal ,in  
the case of a ,state electing to carry  
out this subsection other than through  
the ,state1 subsidies described in      
subsection 7a77#c7 shall be provided    
through a refundable tax credit under   
section #cf;,c of the ,internal ,revenue
 ,code of #aihf4  7#d7 ,construction    
,nothing in this subsection shall be    
construed-- 7,a7 to prevent an          
individual from affirmatively electing  

not to have a ,roth ,,hsa established on
 the individual's behalf and not to be  
enrolled in health insurance coverage2  
7,b7 subject to subparagraph 7,a71 to   
prevent a ,state from establishing a    
,roth ,,hsa for each deposit qualifying 
resident who does not otherwise have a  
,roth ,,hsa2  7,c7 subject to           
subparagraph 7,a71 to prevent a ,state  
from establishing a mechanism whereby   
individuals who would be deposit        
qualifying residents but for paragraph  
7#b77;,c7 are enrolled in health        
insurance coverage2 and  7,d7 to prevent
 a ,state from changing its ,state      
,medicaid plan to eliminate coverage    
under section                           
#aijb7;a77#aj77;,a77i77,,viii7 of the   
,social ,security ,act 7#db ,u4,s4,c4   
#acif;a7a77#aj77;,a77i77,,viii771 in    
order that individuals otherwise covered
 under such section may qualify for     
subsidies under this section4  7c7      
,population health initiative funding   
7#a7 ,in general ,in the case of an     

electing ,state for a year1 the ,state  
is entitled to receive payment from the 
,secretary after the end of such year in
 an amount equal to #b percent of the   
actual aggregate amount deposited under 
subsection 7b7 into ,roth ,h,s,as for   
residents of the ,state for the year4   
7#b7 ,use of funds ,amounts paid to a   
,state under paragraph 7#a7 may only be 
used for population health initiatives  
7as defined by the ,secretary74  7#c7   
,entitlement ,paragraph 7#a7 constitutes
 budget authority in advance of         
appropriations ,acts and represents the 
obligation of the ,federal ,government  
to provide for the payment to ,states of
 amounts provided under such paragraph4 
7d7 ,requiring rules for computing      
usual1 customary1 and reasonable 7,,ucr7
 prices ,as a condition for a ,state's  
election of the alternative option under
 this section1 the ,state must provide1 
through its department of insurance or  
equivalent agency1 for establishment of 
rules to carry out section              

#ahfg7;j77#a77;,a77ii7 of the ,social   
,security ,act1 as added by section     
#aba7;a77#b74  #ajd4 ,computation of    
monthly ,roth ,,hsa deposit amount for  
deposit qualifying residents  7a7       
,computation  7#a7 ,in general ,the     
,secretary shall develop a standardized 
methodology to determine consistent with
 this section a monthly ,roth ,,hsa     
deposit amount for deposit qualifying   
residents in each ,state for months in  
each year4 ,subject to paragraphs 7#c7  
and 7#d71 such amount shall be equal to 
#a_/ab of the average per capita annual 
amount computed under subsection 7b7 for
 the ,state for the year1 as adjusted   
for the deposit qualifying resident     
involved--  7,a7 for age and geographic 
area under subsection 7c72 and  7,b7 for
 income under subsection 7d74  7#b7 ,no 
variation based on how deposit amount   
distributed ,such amount shall be the   
same for a deposit qualifying individual
 without regard to whether the          
contribution to the individual's ,roth  

,,hsa is made by a ,state under this    
section or by the ,federal ,government  
through the operation of section #cf;,c 
of the ,internal ,revenue ,code of      
#aihf4  7#c7 ,patient-grant electing    
,state has flexibility to maintain level
 of benefits for current ,,aca          
beneficiaries ,a patient-grant electing 
,state may elect to increase the amount 
of the deposit for all deposit          
qualifying individuals under this       
section to the amounts that the         
,secretary estimates would have been    
paid with respect to such individuals   
under section #cf;,b of the ,internal   
,revenue ,code of #aihf and section     
#adjb of ,,ppaca if those sections had  
remained in effect in the ,state with   
respect to such individuals4 ,such      
election shall be made for a year and   
shall continue from year to year until  
the ,state elects to terminate such     
election4 ,the ,secretary shall1 in     
conjunction with the ,actuary1 ensure   
such changes to the amount of deposit   

for qualifying individuals shall remain 
budget neutral4  7#d7 ,special rule for 
partial deposit for low-income          
individuals with employer-sponsored     
insurance 7,,esi7 ,in the case of an    
individual who is covered under a group 
health plan and with respect to such    
coverage there is a contribution by an  
employer which is excluded from the     
individual's gross income under the     
,internal ,revenue ,code of #aihf1      
insofar as the individual is a deposit  
qualifying resident1 the amount of the  
deposit with respect to the individual  
shall be reduced1 in a manner specified 
by the ,secretary in consultation with  
the ,secretary of the ,treasury and     
taking into account the income of the   
individual's household1 by an amount    
that is approximately equivalent to the 
estimated amount of the reduction in the
 amount of income tax resulting from    
such exclusion 7and any reduction in    
taxes imposed by chapter #ba or chapter 
#b of such ,code by reason of any       

exclusion of such contributions from    
wages and self employment income74  7b7 
,computation of unadjusted average per  
capita annual amount  7#a7 ,for ,states 
that continue ,,ppaca ,medicaid coverage
  7,a7 ,in general ,in the case of a    
,state that provides medical assistance 
under section                           
#aijb7;a77#aj77;,a77i77,,viii7 of the   
,social ,security ,act 7#db ,u4,s4,c4   
#acif;b7a77#aj77;,a77i77,,viii77 during 
a year1 subject to paragraphs 7#c7 and  
7#d71 the ,secretary shall compute an   
average per capita annual amount for the
 ,state for the year equal to--  7i7 the
 amount specified in subparagraph 7,b71 
divided by  7ii7 the average monthly    
number of deposit qualifying residents  
of the ,state in the year4  7,b7 ,amount
 based on ,,ppaca projected ,federal    
expenditures ,the amount specified in   
this subparagraph for a ,state for a    
year is #ie percent of the ,secretary's 
estimate of the total payments that     
would have been made 7assuming the      

existence of a ,state established       
,exchange in the ,state7 under section  
#cf;,b of the ,internal ,revenue ,code  
of #aihf and under section #adjb of     
,,ppaca with respect to all qualified   
residents in the ,state in the year 7or 
taxable year ending with such year1 if  
applicable74 ,the ,secretary shall1 in  
conjunction with the ,actuary1 ensure   
such changes to the amount of deposit   
for qualifying individuals shall remain 
budget neutral4  7#b7 ,for ,states that 
do not provide ,,ppaca ,medicaid        
coverage  7,a7 ,in general ,in the case 
of a ,state not described in paragraph  
7#a7 for a year1 subject to paragraphs  
7#c7 and 7#d71 the ,secretary shall     
compute an average per capita annual    
amount for the ,state for the year equal
 to--  7i7 the amount specified in      
subparagraph 7,b7 for the ,state and    
year1 divided by  7ii7 the average      
monthly number of deposit qualifying    
residents of the ,state in the year4    
7,b7 ,amount based on ,,ppaca and       

,medicaid projected ,federal            
expenditures ,the amount specified in   
this subparagraph for a ,state for a    
year is equal to the sum of-- 7i7 #ie   
percent of the ,secretary's estimate of 
the total payments that would have been 
made 7assuming the existence of a       
,state-established ,exchange in the     
,state7 under section #cf;,b of the     
,internal ,revenue ,code of #aihf and   
under section #adjb of ,,ppaca with     
respect to all qualified residents in   
the year 7or taxable year ending with   
such year1 if applicable72 and  7ii7 the
 ,secretary's estimate of the total     
payments that would have been made to   
the ,state under title ,,xix of the     
,social ,security ,act for individuals  
eligible to be covered under section    
#aijb7;a77#aj77;,a77i77,,viii7 of the   
,social ,security ,act assuming the     
election of a ,state to provide         
,medicaid coverage under such section   
and assuming the applicable ,federal    
medical assistance percentage were #ie  

percent with respect to such            
individuals4  7#c7 ,budget neutral      
adjustment in payments to take into     
account election of higher deposits to  
maintain ,,aca subsidy levels ,if a     
,state makes the election described in  
subsection 7a77#c7 with respect to      
providing higher deposit amounts for    
certain individuals described in such   
subsection1 then the ,secretary shall   
adjust the average per capita annual    
amount under paragraph 7#a7 or 7#b71 as 
applicable to the ,state1 by--  7,a7    
reducing the amount described in        
paragraph 7#a77;,b7 7or1 if applicable1 
paragraph 7#b77;,b77i77 by an amount    
equal to #ie percent of the aggregate   
increased deposit level attributable to 
subsection 7a77#c72 and  7,b7 not       
counting such an individual as a        
qualifying resident for purposes of     
paragraph 7#a77;,a77ii7 7or1 if         
applicable1 paragraph 7#b77;,a77ii774   
,the ,secretary shall1 in conjunction   
with the ,actuary1 ensure changes1 as   

outlined in this subsection1 to the     
amount of deposit for qualifying        
individuals shall remain budget neutral4
  7#d7 ,adjustment for costs of partial 
deposits for low-income ,,esi           
individuals ,the ,secretary shall adjust
 the average per capita annual amount   
under paragraph 7#a7 or 7#b71 as        
applicable to the ,state1 by--  7,a7    
reducing the amount described in        
paragraph 7#a77;,b7 7or1 if applicable1 
paragraph 7#b77;,b77i77 by an amount    
equal to #ie percent of the amount of   
payments under this section that are    
attributable to individuals described in
 subsection 7a77#d72 and  7,b7 not      
counting any individual described in    
subsection 7a77#d7 as a qualifying      
resident for purposes of paragraph      
7#a77;,a77ii7 7or1 if applicable1       
paragraph 7#b77;,a77ii774  7c7          
,adjustment for age1 geographic area1   
and income distribution within state    
7#a7 ,in general ,the ,secretary shall  
apply such adjustments to the per capita

 amount computed under subsection 7b7 as
 is designed to take into account1 in a 
budget neutral manner and based on the  
costs estimated under paragraph 7#b71   
actuarial differences in health care    
costs attributable to individuals in    
different age categories and different  
geographic locations of primary         
residences in the ,state and the        
reductions based on income under        
subsection 7d74 ,no such adjustment     
shall be made based on sex4  7#b7 ,data 
on average costs of services ,not later 
than ,december #ae before the beginning 
of each year1 the ,agency for           
,healthcare ,research and ,quality shall
 estimate the average cost of health    
care for such year for individuals under
 #fe years of age and may estimate how  
such average varies for different       
populations of individuals under age    
#fe4 ,the adjustments under paragraph   
7#a7 for age categories for a year shall
 be based on such estimates made4 ,not  
later than such date1 the ,secretary    

shall prescribe tables for purposes of  
making adjustments based on age under   
paragraph 7#a7 based on such            
determination which shall apply for     
taxable years beginning in the          
succeeding calendar year4  7d7          
,income-,related phase-,out  7#a7 ,in   
general ,the per capita amount as       
computed under subsection 7b7 and       
adjusted and applied to a deposit       
qualifying individual under subsection  
7c7 shall be multiplied by a phase-out  
percentage equal to #ajj percent reduced
 by #a percentage point for each #a1jjj 
7or fraction thereof7 by which the      
taxpayer's modified adjusted gross      
income for the taxable year exceeds     
#ij1jjj 7or1 in the case of a joint     
return1 #aej1jjj71 multiplied1 for a    
taxable year ending in a year beginning 
after ,december #ca1 #bjae1 by the      
cost-of-living adjustment for the year  
as described in section #a7;f77#c7 of   
the ,internal ,revenue ,code of #aihf1  
but substituting #bjae for #aiib in     

subparagraph 7,b7 of such section4  7#b7
 ,zero per capita amount for married    
filing separately ,the per capita amount
 under this section shall be zero in the
 case of a married couple filing        
separately4  #aje4 ,state options for   
improved access to health insurance     
coverage in each ,state  7a7 ,state     
options ,to improve access  7#a7 ,in    
general ,each ,state may carry out any  
of the functions described in this      
section in order to improve the access  
of residents of the ,state to health    
insurance coverage4  7#b7 ,repurposing  
,state ,exchanges ,a ,state may use or  
adapt an ,exchange that the ,state has  
established under title ,i of ,,ppaca to
 carry out any such function4  7#c7     
,repurposing ,federal ,exchange ,the    
,federal ,government shall make         
available to ,states current            
capabilities of the ,federal ,exchange1 
including the ,federal ,data ,services  
,hub and ,agent ,broker ,portal1 to the 
extent requested by a ,state for        

activities related to enrollment of     
citizens of the ,state into health      
insurance coverage4  7b7 ,transparency  
portal ,each ,state may establish and   
operate an open and transparent         
marketplace mechanism whereby qualified 
residents of the ,state can readily     
compare1 through the use of the         
,internet1 the benefits and prices      
between different health insurance      
coverage options made available to them4
  7c7 ,enrollment1 subject to individual
 opt-,out  ,a ,state may provide for the
 enrollment of qualified residents of   
the ,state who are uninsured in default 
health insurance coverage offered under 
section #ajg7;c7 and establishing a     
,roth ,,hsa for such residents who do   
not have a ,roth ,,hsa unless the       
resident has affirmatively elected not  
to be so enrolled and not to have a     
,roth ,,hsa1 respectively4 ,any such    
enrollment under this paragraph shall be
 coordinated with the annual open       
enrollment periods provided under       

section #ajg7;b74  7d7 ,risk mitigation 
mechanisms and reinsurance and          
risk-,corridor programs  7#a7 ,in       
general ,notwithstanding any other      
provision of this title or section      
#bbc7;c77#b7 of the ,internal ,revenue  
,code of #aihf1 a ,state may establish--
  7,a7 mechanisms for risk mitigation or
 risk adjustment in order to limit      
volatility in the premiums based on     
health experience to class-average      
premiums2 and  7,b7 a reinsurance and   
risk-corridor program that involves no  
,federal funds with respect to coverage 
both in the individual market and in the
 small group market4  7#b7 ,basis for   
risk adjustment ,mechanisms and programs
 under paragraph 7#a7 may be based on   
the health status score of each         
individual enrolled in health insurance 
coverage in the individual market and   
not solely based on the aggregate risk  
of the risk pool with respect to each   
plan of health insurance coverage4  7e7 
,modified health status insurance       

mechanism  7#a7 ,in general ,a ,state   
may establish a mechanism for providing 
modified health status insurance in the 
,state to encourage health plans to     
implement adequate benefit designs and  
services for a chronically ill          
individual4  7#b7 ,requirements ,a      
mechanism under paragraph 7#a7 may      
implement the following requirements3   
7,a7 ,during the first open enrollment  
period after the date of enactment of   
this ,act1 an individual health plan    
shall provide coverage for health       
benefits as defined in the health plan  
for a period of #ab months4  7,b7 ,if an
 individual enrolls in a new health plan
 during the open enrollment period at   
the end of the first #ab months of      
coverage under subparagraph 7,a71 the   
plan in which the individual was        
enrolled prior to such period shall be  
responsible for financing #ge percent of
 the health benefits administered to the
 individual under any other health plan 
in which the individual enrolls for the 

initial #c-month period of coverage     
under such other plan4  7,c7 ,during the
 #c-month period described in           
subparagraph 7,b71 the plan in which the
 individual was enrolled prior to such  
period shall receive #ge percent of the 
premiums paid for the individual's      
coverage under the other health plan4   
7,d7 ,during the third open enrollment  
period after the date of enactment of   
this ,act1 and during all subsequent    
open enrollment periods1 a health plan  
that has enrollees terminate their      
coverage in order to enroll in other    
health plans shall be responsible for   
financing #ge percent of the health     
benefits administered to such enrollees 
under the other plans and shall receive 
#ge percent of the premiums paid for    
such enrollees' coverage under such     
other health plans for the first #c     
months of coverage in the new plan year4
  #ajf4 ,state flexibility in ensuring  
orderly health insurance market outside 
of an ,exchange  7a7 ,in general ,with  

respect to health insurance coverage    
offered in a ,state1 the ,state may1 in 
consultation with the ,secretary1 take  
such steps1 such as limiting the        
availability of general open enrollment 
periods1 imposing delays in the         
effectiveness for coverage1 permitting  
differentials in premiums based on age  
and other factors1 as the ,state        
determines necessary in order to ensure 
an orderly market for health insurance  
coverage in the ,state that is not      
offered through an ,exchange4 ,such     
steps may include the establishment of  
an initial open enrollment period during
 which qualified residents may enroll in
 health insurance coverage without the  
imposition of any underwriting as the   
,state determines to be appropriate in  
ensuring initial access to such         
coverage4  7b7 ,flexibility in imposing 
additional requirements ,nothing in this
 section shall be construed as          
preventing a ,state from continuing to  
apply1 to health insurance coverage     

issued in the ,state1 requirements under
 the provisions of title ,,xxvii of the 
,public ,health ,service ,act 7as       
amended by subtitles ,a and ,c of title 
,i of ,,ppaca71 that are not continued  
under section #aja7;b74  7c7 ,state     
flexibility with respect to ,exchanges  
,a ,state may waive such provisions of  
part #b of subtitle ,d of title ,i of   
,,ppaca1 in relation to the             
establishment of an ,exchange in such   
,state1 as the ,state determines        
appropriate in order for the ,state to  
implement and administer a market-based 
system for the availability of health   
insurance coverage throughout the       
,state4  #ajg4 ,expanded access and     
patient protections  7a7 ,in general ,as
 a condition for the election of the    
alternative option under section #ajc in
 a ,state1 the ,state must meet the     
requirements of this section4  7b7      
,annual and other open enrollment       
periods  7#a7 ,in general ,the ,state   
shall require1 in connection with the   

offering of health insurance coverage in
 the individual market in the ,state1   
that there are uniform annual and other 
open enrollment periods 7such as those  
for changes in life events1 changes in  
,state residency1 and involuntary       
changes in eligibility for coverage     
under a group health plan7 in order to  
permit qualified residents to enroll in 
qualified health plan coverage in a     
manner that promotes continuity of      
coverage4 ,such periods shall be        
consistent with the open enrollment     
periods established under title ,i of   
,,ppaca1 as in effect on the day before 
the date of the enactment of this ,act4 
7#b7 ,initial open enrollment period ,in
 addition1 the ,state shall establish an
 initial open enrollment period during  
which qualified residents may enroll in 
qualified health plan coverage without  
the imposition of any underwriting      
described in subsection 7d77#a77;,b74   
,such period shall be a period of not   
less than #de days and shall provide for

 enrollment to become effective on      
,january #a of the year specified by the
 ,state in which such ,state election   
first becomes effective4  7c7 ,offering 
of default health insurance coverage    
7#a7 ,enrollment1 subject to individual 
opt-,out ,subject to paragraph 7#d71 a  
,state may elect to provide for the     
enrollment of residents of the ,state   
who are uninsured in default health     
insurance coverage 7as defined in       
paragraph 7#b77 and establishing a ,roth
 ,,hsa for such residents who do not    
have a ,roth ,,hsa unless the resident  
has affirmatively elected not to be so  
enrolled and not to have such an        
account1 respectively4 ,if a ,state     
makes such an election1 the ,state shall
 permit eligible residents to enroll in 
such coverage on a continuous basis4    
7#b7 ,default health insurance coverage 
defined ,in this subsection1 the term   
default health insurance coverage means1
 with respect to a ,state1 health       
insurance coverage that-- 7,a7 is a high

 deductible health plan 7within the     
meaning of section #bbc7;c77#b7 of the  
,internal ,revenue ,code of #aihf7 with 
prescription drug coverage limited to a 
,tier #a formulary benefit 7as commonly 
understood7 for a limited number of     
chronic conditions 7commonly referred to
 as tier ,i pharmacy benefit72  7,b7    
meets such requirements as may apply to 
qualify for the payment of plan premiums
 from a health savings account under    
section #bbc of such ,code 7such as     
age-related premiums and limitation on  
imposition of preexisting condition     
exclusions72  7,c7 has a provider       
network for covered benefits that is    
adequate 7as determined consistent with 
the guidelines issued by the ,secretary 
relating to provider access requirements
 for ,medicare ,advantage organizations 
under section #aheb7;d7 of the ,social  
,security ,act 7#db ,u4,s4,c4           
#aciew-#bb7;d777 to ensure access to    
health benefits under such plan2  7,d7  
provides for coverage of childhood      

immunizations without cost sharing      
requirements to the extent such         
immunizations have in effect a          
recommendation from the ,advisory       
,committee on ,immunization ,practices  
of the ,centers for ,disease ,control   
and ,prevention with respect to the     
individual involved2 and  7,e7 meets    
such other requirements as the ,state   
may specify4  7#c7 ,roth ,,hsa ,in this 
subsection1 the term ,roth ,,hsa shall  
have the meaning given such term by     
section #ecj;,a7c7 of the ,internal     
,revenue ,code of #aihf4  7#d7 ,simple  
process for individuals to opt-out ,as a
 condition of a ,state providing for the
 enrollment function described in       
paragraph 7#a71 the ,state shall        
establish an easy-to-use and transparent
 means by which individuals may elect   
not to be enrolled in default health    
insurance coverage or to have a ,roth   
,,hsa established on the individual's   
behalf1 or both4  7d7 ,consequences     
respecting continuous coverage  7#a7    

,consequences for not maintaining       
continuous coverage  7,a7 ,avoidance of 
consequences by maintaining continuous  
coverage  7i7 ,in general ,all qualified
 residents of a ,state are eligible     
during the initial open enrollment      
period provided under subsection 7b77#b7
 to enroll in qualified health plan     
coverage and1 thereafter1 to maintain   
continuous coverage in order to avoid   
the adverse consequences described in   
the succeeding provisions of this       
paragraph4  7ii7 ,special enrollment    
periods ,the ,state may provide for     
special enrollment periods based on     
birth1 becoming #bf years of age1 and   
independence from family coverage1      
during which certain individuals will be
 eligible to enroll in qualified health 
plan coverage for purposes of this      
subsection4  7,b7 ,underwriting         
permitted ,in the case of a qualified   
resident of the ,state who fails to     
maintain continuous creditable coverage 
7not including any breaks in coverage of

 less than #fc days71 the ,state shall--
  7i7 permit health insurance issuers   
for the period specified in subparagraph
 7,c7 to medically underwrite 7through  
denial of health insurance coverage1    
application of preexisting condition    
limitations1 differential premiums1 or  
otherwise7 the issuance of health       
insurance coverage1 other than with     
respect to the issuance of default      
health insurance coverage under         
subsection 7c72 and  7ii7 require health
 insurance issuers1 during the          
subsequent #b-year period in the case of
 issuance of health insurance coverage  
other than such default health insurance
 coverage1 to impose a monthly late     
enrollment penalty in the amount        
specified in subparagraph 7,d77i7 and to
 remit the amount of such penalty       
collected to the ,federal ,treasury in  
accordance with subparagraph 7,d77ii74  
7,c7 ,period for application of         
underwriting ,for purposes of           
subparagraph 7,b77i71 the period        

specified in this subparagraph is1 with 
respect to an uninsured individual as of
 a date1 a period 7not to exceed #ah    
months7 equivalent to the number of     
months in the previous #ah-month period 
in which the individual did not have    
continuous creditable coverage described
 in subparagraph 7,b74  7,d7 ,monthly   
late enrollment penalty amount  7i7 ,in 
general ,the monthly late enrollment    
penalty amount specified in this clause 
for a month is equal to the lesser of   
#aj percent or the product of--  7,i7 #a
 percent of the monthly premium amount  
for default health insurance coverage   
with respect to the individual and      
month2 and  7,,ii7 the number of months 
during the #b-year period 7preceding the
 #ah-month period described in          
subparagraph 7,b77i77 in which the      
resident failed to maintain the         
continuous coverage described in        
paragraph 7#a77;,d74  7ii7 ,payment of  
penalty amount to ,federal ,treasury    
,the amount of the monthly late         

enrollment penalty collected under this 
subparagraph shall be paid to the       
,treasury of the ,united ,states in a   
form and manner specified by the        
,secretary of the ,treasury4  7#b7      
,changes in enrollment permitted without
 medical underwriting during annual open
 enrollment periods for those           
maintaining continuous coverage  7,a7   
,during second open enrollment period   
,in the case of a qualified resident who
 maintains continuous coverage 7not     
including any breaks in coverage of less
 than #fc days7 during the period after 
the initial open enrollment period under
 subsection 7b77#b7 and through the     
second annual open enrollment period    
established by the ,state consistent    
with subsection 7b77#a71 the ,state     
shall require health insurance issuers  
to permit such residents during such    
second annual open enrollment period to 
change the qualified health plan        
coverage in which the individual is     
enrolled without medical underwriting4  

7,b7 ,during third and subsequent open  
enrollment periods ,in the case of a    
qualified resident who maintains        
continuous coverage for a period of #ah 
months or longer 7not including any     
breaks in coverage of less than #fc     
days7 as of the initial date of a third 
or subsequent annual open enrollment    
period established by the ,state under  
subsection 7b77#a71 the ,state shall    
require health insurance issuers to     
permit such residents during such an    
open enrollment period to change the    
qualified health plan coverage in which 
the individual is enrolled without      
medical underwriting4  #ajh4            
,application of health savings accounts 
in relation to ,medicaid  7a7 ,in       
general ,title ,,xix of the ,social     
,security ,act 7#db ,u4,s4,c4 #acif et  
seq47 is amended by adding at the end   
the following new section3  #aidg4      
,provisions relating to health savings  
accounts  7a7 ,disregarding ,roth ,,hsa 
in determining assets and income for    

,medicaid eligibility determinations    
other than for long-,term care services 
,the assets in a health savings account 
under section #bbc of the ,internal     
,revenue ,code of #aihf1 and any income 
from such assets in such account1 shall 
be disregarded for purposes of          
determining eligibility for and amount  
of medical assistance under this title1 
other than for purposes of determining  
eligibility for and the amount of       
medical assistance for long-term care   
services 7described in section          
#aiag7;c77#a77;,c77i774  7b7            
,notifications of ,treasury of ,medicaid
 eligibility ,in order to meet the      
requirements of this subsection 7for    
purposes of section #aijb7;a77#gh771 a  
,state shall provide such notice to the 
,secretary of the ,treasury1 in such    
form and manner as the ,secretary shall 
specify1 as may be necessary to identify
 individuals who are eligible for1 and  
receiving1 medical assistance under this
 title in a month in order to carry out 

section #bbc of the ,internal ,revenue  
,code of #aihf4  4  7b7 ,implementation 
of notification requirement through     
,state plan ,section #aijb7;a7 of the   
,social ,security ,act 7#db ,u4,s4,c4   
#acif;a7a77 is amended by inserting     
after paragraph 7#gg7 the following new 
paragraph3  7#gh7 provide for notice in 
accordance with section #aidg7;b7 to the
 ,secretary of the ,treasury of the     
identity of individuals who are eligible
 for and receiving medical assistance   
under this title2  4  7c7 ,effective    
date ,the amendments made by this       
section shall apply to eligibility      
determinations with respect to medical  
assistance for periods beginning on or  
after ,january #a1 #bjah4  ,b ,provider 
price transparency  #aba4 ,ensuring     
access to emergency services without    
excessive charges for out-of-network    
services  7a7 ,in general ,section #ahfg
 of the ,social ,security ,act 7#db     
,u4,s4,c4 #acie;dd7 is amended-- 7#a7 in
 subsection 7d71 by adding at the end   

the following new paragraph3  7#e7      
,enforcement with respect to excessive  
charges ,a hospital1 physician1 or other
 entity that violates the requirements  
of subsection 7j77#a7 with respect to   
the furnishing of items and services is 
subject to a civil money penalty of not 
more than #be1jjj for each such         
violation4 ,the provisions of section   
#aabh;,a 7other than subsections 7a7 and
 7b77 shall apply to a civil money      
penalty under this paragraph in the same
 manner as such provisions apply with   
respect to a penalty or proceeding under
 section #aabh;,a7a74  2 and  7#b7 by   
adding at the end the following new     
subsection3  7j7 ,protections against   
excessive out-of-,network charges for   
emergency services  7#a7 ,in general ,in
 the absence of ,state regulations1 if  
items or services to screen or treat an 
emergency medical condition are         
furnished under this section in a       
participating hospital with respect to  
an individual and the individual has    

not1 directly or through a health       
insurance issuer1 group health plan1 or 
other third party1 negotiated a payment 
rate for such items and services1       
subject to paragraph 7#b71 the charges  
imposed for such items and services may 
not be in excess of the following3  7,a7
 ,physicians' and other professional    
services ,for physicians' services or   
services of a health care provider which
 constitute medical care 7as defined    
under section #bac7;d7 of the ,internal 
,revenue ,code of #aihf1 as in effect   
before the date of the enactment of this
 subsection7 7and including drugs and   
biologicals furnished in conjunction    
with and billed as part of such         
services71 the lesser of--  7i7 the cash
 price for such services posted pursuant
 to section #aba7;b7 of the ,patient    
,freedom ,act of #bjag2 or  7ii7 #he    
percent of the usual1 customary1 and    
reasonable 7,,ucr7 charge for such      
services1 as determined under rules     
established by the department of        

insurance for the ,state in which the   
services are furnished4  7,b7 ,hospital 
services ,for inpatient and outpatient  
hospital services for which payment     
rates are established under this title  
7and including drugs and biologicals    
furnished in conjunction with and billed
 as part of such services71 the lesser  
of--  7i7 the cash price for such       
services posted pursuant to section     
#aba7;b7 of the ,patient ,freedom ,act  
of #bjag2 or  7ii7 #aaj percent of the  
payment rate applicable to such services
 in the case of an individual entitled  
to benefits under part ,a and enrolled  
under part ,b4  7,c7 ,drugs and         
biologicals ,for drugs and other        
pharmaceuticals furnished to which a    
previous subparagraph does not apply1   
the lesser of--  7i7 twice the          
acquisition cost to the hospital or     
other provider for the dose involved2 or
  7ii7 the acquisition cost to the      
hospital or other provider plus #bej4   
,the dollar amount in clause 7ii7 shall 

be increased from year to year          
7beginning with the year after the first
 year in which this subsection applies7 
by the same percentage as the percentage
 increase in the consumer price index   
for all urban consumers 7all items2     
,u4,s4 city average7 for the year       
involved 7as determined by the          
,secretary74 ,any such dollar amount as 
so increased that is not a multiple of  
#e shall be rounded to the nearest      
multiple of #e 7or1 if a multiple of    
#b4ej1 to the next highest multiple of  
#e74  7,d7 ,other items and services    
,for any other items or services1 the   
lesser of-- 7i7 the cash price for such 
items and services posted pursuant to   
section #aba7;b7 of the ,patient        
,freedom ,act of #bjag2 or  7ii7 #aaj   
percent of the payment basis that would 
be applicable to payment for such items 
and services under this title in the    
case of an individual entitled to       
benefits under part ,a and enrolled     
under part ,b4  7#b7 ,special rule for  

items and services furnished as a bundle
 ,in the case of items and services for 
which there is a single price for a     
group or bundle of such items and       
services1 the maximum charge permitted  
under paragraph 7#a7 may not exceed the 
lesser of--  7,a7 the price charged for 
such bundled services2 or  7,b7 the     
aggregate of the maximum charges        
permitted under paragraph 7#a7 with     
respect to items and services included  
in such bundle4  4  7b7 ,reference to   
price disclosure provision  7#a7 ,in    
general ,persons providing medical care 
7as defined in section #bac7;d7 of the  
,internal ,revenue ,code of #aihf1 as in
 effect before the date of the enactment
 of this ,act7 are required to post     
prices under this subsection4  7#b7     
,form of disclosure ,the disclosure of  
prices under this subsection shall be in
 a form and manner specified by the     
,secretary1 in consultation with the    
,secretary of the ,treasury1 and shall  
be designed--  7,a7 to establish a      

single price for related items and      
services in a manner similar to the     
manner in which pricing and payment for 
such items and services is provided     
under the ,medicare program under title 
,,xviii of the ,social ,security ,act   
7#db ,u4,s4,c4 #acie et seq472 and  7,b7
 to make it easy for consumers to       
compare the prices for similar items and
 services furnished by different        
providers4  7c7 ,effective date ,the    
amendments made by this section shall   
apply to charges imposed for items and  
services furnished on or after ,january 
#a1 #bjah4  ,,ii ,reform of ,tax        
,provisions ,relating to ,health ,care  
,a ,health ,savings ,accounts  #bja4    
,transition to non-deductible ,h,s,as   
7a7 ,non-,deductible ,h,s,as ,subchapter
 ,f of chapter #a of the ,internal      
,revenue ,code of #aihf is amended by   
adding at the end the following new     
part3  ,,ix ,health savings accounts    
,sec4 #ecj;,a4 ,roth ,h,s,as4  #ecj;,a4 
,roth ,h,s,as  7a7 ,in general ,with the

 exception of the taxes imposed by      
section #eaa 7relating to imposition of 
tax on unrelated business income of     
charitable organizations71 a ,roth ,,hsa
 shall be exempt from taxation under    
this subtitle4 ,no deduction shall be   
allowed for any contribution to a ,roth 
,,hsa4  7b7 ,dollar limitation  7#a7 ,in
 general ,the aggregate amount of       
contributions for any taxable year to   
all ,roth ,h,s,as maintained for the    
benefit of an individual shall not      
exceed the sum of the monthly           
limitations for any month during such   
taxable year that the individual is an  
eligible individual4  7#b7 ,monthly     
limitation ,the monthly limitation for  
any month is #a_/ab of-- 7,a7 in the    
case of an eligible individual who has  
self-only creditable coverage as of the 
first day of such month1 #e1jjj1 and    
7,b7 in the case of an eligible         
individual who has family creditable    
coverage as of the first day of such    
month1 the amount in effect under       

subparagraph 7,a7 for the taxable year  
multiplied by the number of individuals 
7including the eligible individual7     
covered under such family creditable    
coverage as of such day4  7#c7          
,additional contributions for           
individuals #ee or older ,in the case of
 an individual who has attained age #ee 
before the close of the taxable year1   
the applicable limitation under         
subparagraphs 7,a7 and 7,b7 of paragraph
 7#b7 shall be increased by #a1jjj4     
7#d7 ,coordination with other           
contributions ,the limitation which     
would 7but for this paragraph7 apply    
under this subsection to an individual  
for any taxable year shall be reduced   
7but not below zero7 by the sum of--    
7,a7 the aggregate amount paid for such 
taxable year to ,archer ,m,s,as of such 
individual1 and  7,b7 the aggregate     
amount contributed to ,roth ,h,s,as of  
such individual for such taxable year   
under section #djh7;d77#i74             
,subparagraph 7,a7 shall not apply with 

respect to any individual to whom       
paragraph 7#e7 applies4  7#e7 ,special  
rule for married individuals ,in the    
case of individuals who are married to  
each other1 if either spouse has family 
coverage-- 7,a7 both spouses shall be   
treated as having only such family      
coverage 7and if such spouses each have 
family coverage under different plans1  
as having the family coverage with the  
lowest annual deductible71 and  7,b7 the
 limitation under paragraph 7#a7 7after 
the application of subparagraph 7,a7 and
 without regard to any additional       
contribution amount under paragraph     
7#c77--  7i7 shall be reduced by the    
aggregate amount paid to ,archer ,m,s,as
 of such spouses for the taxable year1  
and  7ii7 after such reduction1 shall be
 divided equally between them unless    
they agree on a different division4     
7#f7 ,denial of deduction to dependents 
,no contribution may be made to a ,roth 
,,hsa under this section by any         
individual with respect to whom a       

deduction under section #aea is         
allowable to another taxpayer for a     
taxable year beginning in the calendar  
year in which such individual's taxable 
year begins4  7#g7 ,medicare eligible   
individuals ,the limitation under this  
subsection for any month with respect to
 an individual shall be zero for the    
first month such individual is entitled 
to benefits under title ,,xviii of the  
,social ,security ,act and for each     
month thereafter4  7#h7 ,increase in    
limit for individuals becoming eligible 
individuals after the beginning of the  
year  7,a7 ,in general ,for purposes of 
computing the limitation under paragraph
 7#a7 for any taxable year1 an          
individual who is an eligible individual
 during the last month of such taxable  
year shall be treated--  7i7 as having  
been an eligible individual during each 
of the months in such taxable year1 and 
7ii7 as having been enrolled1 during    
each of the months such individual is   
treated as an eligible individual solely

 by reason of clause 7i71 in the same   
health plan in which the individual was 
enrolled for the last month of such     
taxable year4  7,b7 ,failure to maintain
 creditable coverage  7i7 ,in general   
,if1 at any time during the testing     
period1 the individual is not an        
eligible individual1 then-- 7,i7 the    
gross income of the individual for the  
taxable year in which occurs the first  
month in the testing period for which   
such individual is not an eligible      
individual shall be increased by the    
aggregate amount of all contributions to
 the ,roth ,,hsa of the individual which
 could not have been made but for       
subparagraph 7,a71 and  7,,ii7 the tax  
imposed by this chapter for any taxable 
year on the individual shall be         
increased by #aj percent of the amount  
of such increase4  7ii7 ,exception for  
disability or death ,clause 7i7 shall   
not apply if the individual ceased to be
 an eligible individual by reason of the
 death of the individual or the         

individual becoming disabled 7within the
 meaning of section #gb7m77#g774  7iii7 
,testing period ,the term testing period
 means the period beginning with the    
last month of the taxable year referred 
to in subparagraph 7,a7 and ending on   
the last day of the #abth month         
following such month4  7#i7 ,limitation 
not to apply to certain contributions   
made under ,patient ,freedom ,act ,any  
contributions made under #ajc7;b7 of the
 ,patient ,freedom ,act of #bjag or as  
provided in section #cf;,c shall not be 
taken into account for purposes of      
determining whether the limitation under
 paragraph 7#a7 has been met4  7c7 ,roth
 ,,hsa ,for purposes of this title--    
7#a7 ,in general ,the term ,roth ,,hsa  
or ,roth health savings account means a 
trust created or organized in the       
,united ,states as a ,roth ,,hsa        
exclusively for the purpose of paying   
the qualified medical expenses of the   
account beneficiary1 but only if the    
written governing instrument creating   

the trust meets the following           
requirements3  7,a7 ,except in the case 
of a rollover contribution described in 
subsection 7e77#e7 or section           
#bbj7;f77#e7 or #bbc7;f77#e71 no        
contribution will be accepted--  7i7    
unless it is in cash1 or  7ii7 to the   
extent such contribution1 when added to 
previous contributions to the trust for 
the calendar year1 exceeds the sum of-- 
7,i7 the dollar amount in effect under  
subsection 7b77#b77;,b71 and  7,,ii7 the
 dollar amount in effect under          
subsection 7b77#c74  7,b7 ,the trustee  
is a bank 7as defined in section        
#djh7n771 an insurance company 7as      
defined in section #haf71 or another    
person who demonstrates to the          
satisfaction of the ,secretary that the 
manner in which such person will        
administer the trust will be consistent 
with the requirements of this section4  
7,c7 ,no part of the trust assets will  
be invested in life insurance contracts4
  7,d7 ,the assets of the trust will not

 be commingled with other property      
except in a common trust fund or common 
investment fund4  7,e7 ,the interest of 
an individual in the balance in his     
account is nonforfeitable4  7#b7        
,qualified medical expenses ,for        
purposes of this section--  7,a7 ,in    
general ,the term qualified medical     
expenses means1 with respect to an      
account beneficiary1 amounts paid by    
such beneficiary for medical care 7as   
defined in section #bac7;d7 as in effect
 on the day before the date of the      
enactment of the ,patient ,freedom ,act 
of #bjag7 for such individual1 the      
spouse of such individual1 and any      
dependent 7as defined in section #aeb1  
determined without regard to subsections
 7b77#a71 7b77#b71 and 7d77#a77;,b7     
thereof7 of such individual1 but only to
 the extent such amounts are not        
compensated for by insurance or         
otherwise4  7,b7 ,limitation on health  
insurance purchased from account ,such  
term shall not include any payment for  

health benefits coverage that is not    
creditable coverage 7within the meaning 
of title ,,xxvii of the ,public ,health 
,service ,act74  7,c7 ,exceptions       
,subparagraph 7,b7 shall not apply to   
any expense for coverage under-- 7i7 a  
health plan during any period of        
continuation coverage required under any
 ,federal law1  7ii7 a qualified        
long-term care insurance contract 7as   
defined in section #ggjb;,b7b771  7iii7 
a health plan during a period in which  
the individual is receiving unemployment
 compensation under any ,federal or     
,state law1 or  7iv7 in the case of an  
account beneficiary who has attained the
 age specified in section #ahaa of the  
,social ,security ,act1 any health      
insurance other than a medicare         
supplemental policy 7as defined in      
section #ahhb of the ,social ,security  
,act74  7#c7 ,account beneficiary ,the  
term account beneficiary means the      
individual on whose behalf the ,roth    
,,hsa was established4  7#d7 ,certain   

rules to apply ,rules similar to the    
following rules shall apply for purposes
 of this section3  7,a7 ,section        
#bai7;f77#c7 7relating to time when     
contributions deemed made74  7,b7       
,section #bai7;f77#e7 7relating to      
employer payments74  7,c7 ,section      
#djh7;g7 7relating to community property
 laws74  7,d7 ,section #djh7;h7         
7relating to custodial accounts74  7#e7 
,account terminations ,rules similar to 
the rules of paragraphs 7#b7 and 7#d7 of
 section #djh7;e7 shall apply to ,roth  
,h,s,as1 and any amount treated as      
distributed under such rules shall be   
treated as not used to pay qualified    
medical expenses4  7d7 ,eligible        
individual ,for purposes of this        
section1 the term eligible individual   
means1 with respect to any month1 any   
individual who is covered under         
creditable coverage 7within the meaning 
of title ,,xxvii of the ,public ,health 
,service ,act7 as of the #ast day of    
such month4  7e7 ,tax treatment of      

distributions  7#a7 ,amounts used for   
qualified medical expenses ,any amount  
paid or distributed out of a ,roth ,,hsa
 which is used exclusively to pay       
qualified medical expenses of any       
account beneficiary shall not be        
includible in gross income in the manner
 provided in section #gb4  7#b7         
,inclusion of amounts not used for      
qualified medical expenses ,any amount  
paid or distributed out of a ,roth ,,hsa
 which is not used exclusively to pay   
the qualified medical expenses of the   
account beneficiary shall be included in
 the gross income of such beneficiary4  
7#c7 ,excess contributions returned     
before due date of return  7,a7 ,in     
general ,if any excess contribution is  
contributed for a taxable year to any   
,roth ,,hsa of an individual1 paragraph 
7#b7 shall not apply to distributions   
from the ,roth ,h,s,as of such          
individual 7to the extent such          
distributions do not exceed the         
aggregate excess contributions to all   

such accounts of such individual for    
such year7 if--  7i7 such distribution  
is received by the individual on or     
before the last day prescribed by law   
7including extensions of time7 for      
filing such individual's return for such
 taxable year1 and  7ii7 such           
distribution is accompanied by the      
amount of net income attributable to    
such excess contribution4  ,any net     
income described in clause 7ii7 shall be
 included in the gross income of the    
individual for the taxable year in which
 it is received4  7,b7 ,excess          
contribution ,for purposes of           
subparagraph 7,a71 the term excess      
contribution means any contribution     
7other than a rollover contribution     
described in paragraph 7#e7 or section  
#bbj7;f77#e7 or #bbc7;f77#e77 which     
exceeds the contribution limitation with
 respect to the individual for the      
taxable year4  7#d7 ,additional tax on  
distributions not used for qualified    
medical expenses  7,a7 ,in general ,the 

tax imposed by this chapter on the      
account beneficiary for any taxable year
 in which there is a payment or         
distribution from a ,roth ,,hsa of such 
beneficiary which is includible in gross
 income under paragraph 7#b7 shall be   
increased by #aj percent of the amount  
which is so includible4  7,b7 ,exception
 for disability or death ,subparagraph  
7,a7 shall not apply if the payment or  
distribution is made after the account  
beneficiary becomes disabled within the 
meaning of section #gb7m77#g7 or dies4  
7,c7 ,exception for distributions after 
medicare eligibility ,subparagraph 7,a7 
shall not apply to any payment or       
distribution after the date on which the
 account beneficiary attains the age    
specified in section #ahaa of the       
,social ,security ,act4  7#e7 ,rollover 
contribution ,an amount is described in 
this paragraph as a rollover            
contribution if it meets the            
requirements of subparagraphs 7,a7 and  
7,b74  7,a7 ,in general ,paragraph 7#b7 

shall not apply to any amount paid or   
distributed from a health savings       
account 7as defined in section #bbc7 or 
a ,roth ,,hsa to the account beneficiary
 to the extent the amount received is   
paid into a ,roth ,,hsa for the benefit 
of such beneficiary not later than the  
#fjth day after the day on which the    
beneficiary receives the payment or     
distribution4  7,b7 ,limitation ,this   
paragraph shall not apply to any amount 
described in subparagraph 7,a7 received 
by an individual from a health savings  
account or a ,roth ,,hsa if1 at any time
 during the #a-year period ending on the
 day of such receipt1 such individual   
received any other amount described in  
subparagraph 7,a7 from a health savings 
account or ,roth ,,hsa which was not    
includible in the individual's gross    
income because of the application of    
this paragraph4  7#f7 ,transfer of      
account incident to divorce ,the        
transfer of an individual's interest in 
a ,roth ,,hsa to an individual's spouse 

or former spouse under a divorce or     
separation instrument described in      
subparagraph 7,a7 of section #ga7;b77#b7
 shall not be considered a taxable      
transfer made by such individual        
notwithstanding any other provision of  
this subtitle1 and such interest shall1 
after such transfer1 be treated as a    
,roth ,,hsa with respect to which such  
spouse is the account beneficiary4  7#g7
 ,treatment after death of account      
beneficiary ,if an individual acquires  
an account beneficiary's interest in a  
health savings account by reason of the 
death of the account beneficiary1 such  
health savings account shall be treated 
as if the individual were the account   
beneficiary4  7f7 ,cost-of-,living      
adjustment  7#a7 ,in general ,in the    
case of any calendar year beginning     
after #bjag1 the #e1jjj dollar amount in
 subsection 7b77#b7 shall be increased  
by an amount equal to--  7,a7 such      
dollar amount1 multiplied by  7,b7 the  
cost-of-living adjustment determined    

under section #a7;f77#c7 for the        
calendar year1 determined--  7i7 by     
substituting calendar year #bjaf for    
calendar year #aiib in subparagraph 7,b7
 thereof1 and  7ii7 by substituting     
,,cpi medical care component for ,,cpi4 
7#b7 ,,cpi medical care component ,for  
purposes of this paragraph1 the term    
,,cpi medical care component means the  
medical care component for the ,consumer
 ,price ,index for ,all ,urban          
,consumers published by the ,department 
of ,labor4  7#c7 ,rounding ,if the      
amount of any increase under the        
preceding sentence is not a multiple of 
#ej1 such increase shall be rounded to  
the next lowest multiple of #ej4  7g7   
,reports ,the ,secretary may require--  
7#a7 the trustee of a ,roth ,,hsa to    
make such reports regarding such account
 to the ,secretary and to the account   
beneficiary with respect to             
contributions1 distributions1 the return
 of excess contributions1 and such other
 matters as the ,secretary determines   

appropriate1 and  7#b7 any person who   
provides an individual with creditable  
coverage to make such reports to the    
,secretary and to the account           
beneficiary with respect to such plan as
 the ,secretary determines appropriate4 
,the reports required by this subsection
 shall be filed at such time and in such
 manner and furnished to such           
individuals at such time and in such    
manner as may be required by the        
,secretary4  4  7b7 ,limit on           
contributions to deductible health      
savings accounts ,section #bbc of such  
,code is amended by adding at the end   
the following new subsection3  7i7      
,limited contributions after #bjaf  7#a7
 ,in general ,no contribution may be    
accepted by a health savings account    
after the date of the enactment of this 
subsection4  7#b7 ,exceptions ,paragraph
 7#a7 shall not apply to a rollover     
contribution described in subsection    
7f77#e74  4  7c7 ,conforming amendments 
7#a7 ,section #bf7;b77#b7 of the        

,internal ,revenue ,code of #aihf is    
amended--  7,a7 in subparagraph 7,s71 by
 striking and #djh7;d77#i77;,d77i77,,ii7
 and inserting                          
#djh7;d77#i77;,d77i77,,ii71 and         
#ecj;,a7b77#h77;,b77i77,,ii71 and  7,b7 
in subparagraph 7,u71 by inserting and  
section #ecj;,a7e77#d7 before the comma 
at the end4  7#b7 ,section #ce7;g77#c7  
of such ,code is amended-- 7,a7 by      
striking or from and inserting 1 from1  
and  7,b7 by inserting or from a ,roth  
,,hsa 7as defined in section #ecj;,a7c77
 after #bbc7;d774  7#c7 ,section        
#bbj7;f77#e77;,a7 of such ,code is      
amended by inserting or a ,roth ,,hsa   
7as defined in section #ecj;,a7c77 after
 #bbc7;d774  7#d7 ,section              
#bbc7;f77#e77;,a7 of such ,code is      
amended by inserting or a ,roth ,,hsa   
7as defined in section #ecj;,a7c77 after
 paid into a health savings account4    
7#e7 ,section #djh7;d77#i7 of such ,code
 is amended by adding at the end the    
following new subparagraph3  7,f7       

,application to ,roth ,h,s,as ,rules    
similar to the rules of the preceding   
subparagraphs of this paragraph shall   
apply with respect to eligible          
individuals 7as defined in section      
#ecj;,a7d77 making contributions to     
,roth ,h,s,as1 except that subparagraph 
7,c7 shall be applied by substituting   
section #ecj;,a7b7 for section #bbc7;b74
  4  7#f7 ,section #hdh7;e77#a77;,b77v7 
of such ,code is amended by inserting or
 a ,roth ,,hsa 7as defined in section   
#ecj;,a7c77 after #bbc7;d774  7#g7      
,section #hgg;,a7e77#b7 of such ,code is
 amended by inserting a ,roth ,,hsa 7as 
defined in section #ecj;,a7c71 after    
#bbc714  7#h7 ,section #digc of such    
,code is amended-- 7,a7 in subsection   
7a71 by striking or at the end of       
paragraph 7#e71 by inserting or at the  
end of paragraph 7#f71 and by inserting 
after paragraph 7#f7 the following new  
paragraph3  7#g7 a ,roth ,,hsa 7within  
the meaning of section #ecj;,a71  1 and 
7,b7 by adding at the end the following 

new subsection3  7j7 ,excess            
contribution to ,roth ,h,s,as ,for      
purposes of this section1 in the case of
 ,roth ,,hsa 7within the meaning of     
section #ecj;,a7c771 the term excess    
contributions means the sum of--  7#a7  
the aggregate amount contributed for the
 taxable year to the accounts 7other    
than a rollover contribution described  
in section #bbj7;f77#e71 #bbc7;f77#e71  
or #ecj;,a7e77#e771 and  7#b7 the amount
 determined under this subsection for   
the preceding taxable year1 reduced by  
the sum of-- 7,a7 the distributions out 
of the accounts which were included in  
gross income under section              
#ecj;,a7e77#b71 and  7,b7 the excess 7if
 any7 of-- 7i7 the maximum amount       
allowable as a contribution under       
section #ecj;,a7b7 for the taxable year1
 over  7ii7 the amount contributed to   
the accounts for the taxable year4  ,for
 purposes of this subsection1 any       
contribution which is distributed out of
 the ,roth ,,hsa in a distribution to   

which section #ecj;,a7e77#c7 applies    
shall be treated as an amount not       
contributed4  4  7#i7 ,section #dige7;c7
 of such ,code is amended by adding at  
the end the following new paragraph3    
7#g7 ,special rule for ,roth ,h,s,as ,an
 individual for whose benefit a ,roth   
,,hsa 7within the meaning of section    
#ecj;,a7c77 is established shall be     
exempt from the tax imposed by this     
section with respect to any transaction 
concerning such account 7which would    
otherwise be taxable under this section7
 if1 with respect to such transaction1  
the account ceases to be a ,roth ,,hsa  
by reason of the application of section 
#ecj;,a7c77#e7 to such account4  4      
7#aj7 ,section #fjea7;a77#ab7 of such   
,code is amended by inserting and to any
 ,roth ,,hsa 7as defined in section     
#ecj;,a7c77 after #bbc7;d774  7#aa7     
,section #ffic7;a77#b7 of such ,code is 
amended by striking and at the end of   
subparagraph 7,e71 by striking the      
period at the end of subparagraph 7,f7  

and inserting 1 and1 and by adding at   
the end the following new subparagraph3 
7,g7 section #ecj;,a7g7 7relating to    
,roth ,h,s,as74  4  7d7 ,clerical       
amendment ,the table of parts for       
subchapter ,f of chapter #a of such     
,code is amended by adding at the end   
the following new item3  ,part ,,ix4    
,roth health savings accounts  4  7e7   
,effective date ,the amendments made by 
this section shall apply to taxable     
years beginning after ,december #ca1    
#bjaf4  #bjb4 ,treatment of direct      
primary care  7a7 ,h,s,as  7#a7 ,roth   
,,hsa ,section #ecj;,a7c77#b77;,a7 of   
the ,internal ,revenue ,code of #aihf1  
as added by this ,act1 is amended by    
adding at the end the following3 ,such  
term shall include the payment of a     
monthly or other prepaid amount for the 
furnishing 7or access to the furnishing7
 by a physician or group of physicians  
of physician professional services 7and 
ancillary services744  7#b7 ,,hsa       
,section #bbc7;d77#b77;,a7 of such ,code

 is amended by adding at the end the    
following3 ,such term shall include the 
payment of a monthly or other prepaid   
amount for the furnishing 7or access to 
the furnishing7 by a physician or group 
of physicians of physician professional 
services 7and ancillary services744  7b7
 ,not treated as health insurance       
coverage  7#a7 ,in general ,for purposes
 of title ,,xxvii of the ,public ,health
 ,service ,act1 subtitle ,b of title ,i 
of the ,employee ,retirement ,income    
,security ,act of #aigd1 ,,ppaca1 and   
this ,act1 the offering of direct       
primary care shall not be treated as the
 offering of health insurance coverage  
and shall not be subject to regulations 
as such coverage under such ,acts4  7#b7
 ,direct primary care defined ,in this  
subsection1 the term direct primary care
 means the furnishing 7or access to the 
furnishing7 by a physician or group of  
physicians of physician professional    
services 7and ancillary services7 in    
return for payment of a monthly or other

 prepaid amount4  #bjc4 ,treatment of   
,,hsa after death of account beneficiary
  7a7 ,in general ,section #bbc7;e77#h7 
of the ,internal ,revenue ,code of      
#aihf1 as redesignated by section       
#bja7;c77#c7 of this ,act1 is amended to
 read as follows3  7#h7 ,treatment after
 death of account beneficiary ,if an    
individual acquires an account          
beneficiary's interest in a health      
savings account by reason of the death  
of the account beneficiary1 such health 
savings account shall be treated as if  
the individual were the account         
beneficiary4  4  7b7 ,effective date    
,the amendment made by this section     
shall apply with respect to interests   
acquired after the date of the enactment
 of this ,act4  ,b ,health ,care ,tax   
credits  #baa4 ,limited application of  
,,ppaca health premium credit  7a7 ,in  
general ,section #cf;,b7c77#a7 of the   
,internal ,revenue ,code of #aihf is    
amended by adding at the end the        
following3  7,e7 ,special rule for      

residents of ,states continuing ,,ppaca 
implementation ,no credit shall be      
allowed under this section to any       
individual who is not a qualified       
resident 7as defined in section #ajj7ae7
 of the ,patient ,freedom ,act of #bjag7
 of a ,state that has elected the option
 under section #ajb7;a77#a7 of such ,act
 in relation to the implementation of   
title ,i of the ,patient ,protection and
 ,affordable ,care ,act4  4  7b7        
,limitation on amount of credit ,section
 #cf;,b7b7 of the ,internal ,revenue    
,code of #aihf is amended by adding at  
the end the following new paragraph3    
7#d7 ,limitation on amount of credit ,in
 the case of any taxable year beginning 
in a calendar year which begins after   
the date of the enactment of this       
paragraph1 the ,secretary shall reduce  
the amount determined under this        
subsection 7determined before the       
application of this paragraph7 for each 
qualified resident 7as defined in       
section #ajj of the ,patient ,freedom   

,act of #bjag7 of a ,state that makes an
 election under section #ajb7;a77#a7 of 
such ,act by an amount equal to--  7,a7 
the amount of the reduction described in
 section #ajb7;a77#a77;,a7 of such ,act 
for such year 7calculated by only taking
 into account credit allowed under this 
section71 divided by  7,b7 the total    
number of such qualified residents of   
such ,state estimated by the ,secretary 
to claim the credit allowed under       
subsection 7a7 for such year4  4  7c7   
,effective date ,the amendments made by 
this section shall apply to taxable     
years beginning after ,january #a1      
#bjah4  #bab4 ,new ,roth ,,hsa credit   
7a7 ,in general ,subpart ,c of part ,,iv
 of subchapter ,a of chapter #a of the  
,internal ,revenue ,code of #aihf is    
amended by inserting after section      
#cf;,b the following new section3       
#cf;,c4 ,roth ,,hsa credit  7a7 ,in     
general ,in the case of a qualifying    
individual1 there shall be allowed as a 
credit against the tax imposed by this  

subtitle for any taxable year1 an amount
 equal to the ,roth ,,hsa credit amount 
of the individual for the taxable year4 
7b7 ,qualifying individual ,for purposes
 of this section1 the term qualifying   
individual means1 with respect to any   
month1 any individual who for such month
 is a deposit qualifying resident 7as   
defined in section #ajc7;b77#b7 of the  
,patient ,freedom ,act of #bjag7 of a   
,state described in section #ajb7;a77#b7
 of such ,act that elects to have       
section #ajc7;b7 of such ,act carried   
out by way of the credit determined     
under this section4  7c7 ,roth ,,hsa    
credit amount ,for purposes of this     
section1 the term ,roth ,,hsa credit    
amount means1 with respect to any       
taxable year1 the sum of the ,roth ,,hsa
 deposit amounts determined under       
section #ajd of the ,patient ,freedom   
,act of #bjag with respect to the       
individual for all months ending during 
the taxable year4  7d7 ,special rules   
,for purposes of this section-- 7#a7    

,reconciliation of credit and advance   
credit  7,a7 ,excess advance payments   
,if the advance payments to an          
individual for a taxable year under     
subsection 7e7 exceed the credit allowed
 by this section with respect to such   
individual for such taxable year1 the   
tax imposed by this chapter for the     
taxable year shall be increased by the  
amount of such excess4  7,b7 ,advance   
payment shortfall ,if the credit allowed
 by this section 7determined without    
regard to this subparagraph7 with       
respect to an individual for a taxable  
year exceeds the advance payments to    
such individual for such taxable year   
under subsection 7e71 the ,secretary    
shall1 in lieu of a credit allowed      
against the tax imposed by this         
subtitle1 make a payment on behalf of   
such individual to such individual's    
health savings account in an amount     
equal to such excess4  7#b7 ,married    
couples must file joint return ,if the  
taxpayer is married 7within the meaning 

of section #ggjc7 at the close of the   
taxable year1 the credit shall be       
allowed under this section only if the  
taxpayer and the taxpayer's spouse file 
a joint return for the taxable year4    
7e7 ,advance payment program  7#a7 ,in  
general ,the ,secretary of the          
,treasury1 in consultation with the     
,secretary of ,health and ,human        
,services1 shall establish a program--  
7,a7 to make advance determinations with
 respect to the eligibility of          
individuals for the credit allowed under
 this section1 and  7,b7 to make advance
 payments of the credit allowed under   
this section directly to the ,roth ,,hsa
 of any such individual so eligible4    
7#b7 ,program requirements ,such program
 shall be established under rules       
similar to the rules of section #adab of
 the ,patient ,protection and           
,affordable ,care ,act1 except that     
advance determinations and advance      
payments shall be made on request of the
 individual with respect to whom the    

determination is to be made and taking  
into account the enrollment process     
7including any opt-out election under   
such process7 established under section 
#aje7;c7 of the ,patient ,freedom ,act  
of #bjag4  7#c7 ,treatment as income    
,the amount of any credit allowed under 
this section shall be included in gross 
income4  4  7b7 ,clerical amendment ,the
 table of sections for such subpart is  
amended by inserting after the item     
relating to section #cf;,b the following
 new item3  ,sec4 #cf;,c4 ,roth ,,hsa   
credit4  4  7c7 ,effective date ,the    
amendments made by this section shall   
apply to taxable years beginning after  
,january #a1 #bjah4