,,ii  #aae? ,,congress  #a/ ,session    
,s4 #bbb  ,,9 ,,! ,,s5ate ,,( ,,!       
,,unit$ ,,/ates  ,janu>y #bd1 #bjag ,mr4
 ,paul introduc$ ! foll[+ bill2 :i* 0   
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to repeal          
provisions ( ! ,pati5t ,protection &    
,af=dable ,c>e ,act & provide private   
heal? insurance re=m1 & = o!r purposes4 
#a4 ,%ort title  ,?is ,act may be cit$ z
 ! ,obamac>e ,replacem5t ,act4  #b4     
,table ( cont5ts ,! table ( cont5ts =   
?is ,act is z foll[s3 ,sec4 #a4 ,%ort   
title4 ,sec4 #b4 ,table ( cont5ts4      
,,title ,i--,repeals ,sec4 #aja4 ,repeal
 ( individual & employ] m&ates4 ,sec4   
#ajb4 ,repeal ( ,public ,heal? ,s]vice  
,act provisions4 ,sec4 #ajc4 ,repeal (  
,pati5t ,protection & ,af=dable ,c>e    
,act provisions4 ,sec4 #ajd4 ,con=m+ &  
te*nical am5dm5ts4 ,,title              
,,ii--,taxation re=m ,subtitle          
,a--,equaliz+ tax treatm5t (            
non-,employ] provid$ heal? insurance    
,sec4 #bja4 ,tax d$uction = heal?       

insurance premiums4 ,sec4 #bjb4         
,refundable tax cr$it = payroll taxes   
attributable to heal? insurance         
premiums4 ,subtitle ,b--,heal? sav+s    
acc\nts ,sec4 #baa4 ,repeal (           
contribution limitations4 ,sec4 #bab4   
,fre$om f m&ate4 ,sec4 #bac4 ,all[ance (
 di/ributions = prescription &          
ov]-!-c\nt] m$ic9es & drugs4 ,sec4 #bad4
 ,pur*ase ( heal? insurance f ,,hsa4    
,sec4 #bae4 ,special rule = c]ta9 m$ical
 exp5ses incurr$ be=e e/abli%m5t (      
acc\nt4 ,sec4 #baf4 ,adm9i/rative error 
correction be=e due date ( return4 ,sec4
 #bag4 ,all[+ ,,hsa rollov] to *ild or  
p>5t ( acc\nt hold]4 ,sec4 #bah4 ,cr$it 
= contributions to an ,,hsa4 ,sec4 #bai4
 ,equival5t bankruptcy protections =    
heal? sav+s acc\nts z retirem5t funds4  
,subtitle ,c--,m$ical exp5ses ,sec4     
#bba4 ,c]ta9 ex]cise equipm5t & physical
 fitness programs treat$ z m$ical c>e4  
,sec4 #bbb4 ,c]ta9 nutritional & diet>y 
supplem5ts to be treat$ z m$ical c>e4   
,sec4 #bbc4 ,c]ta9 provid] fees to be   

treat$ z m$ical c>e4 ,sec4 #bbd4        
,cl>ification ( treatm5t ( capitat$     
prim>y c>e paym5ts z am\nts paid =      
m$ical c>e4 ,subtitle ,d--,miscellane\s 
,sec4 #bca4 ,contributions ( m$ic>e     
b5efici>ies p>ticipat+ 9 m$ic>e         
advantage ,,msa4 ,sec4 #bcb4 ,physician 
*>ity & uncomp5sat$ c>e d$uction4       
,,title ,,iii--,individual heal?        
insurance re=m ,sec4 #cja4 ,pool re=m = 
individual memb]%ip expansion4 ,sec4    
#cjb4 ,coop]ative gov]n+ ( individual   
heal? insurance cov]age4 ,,title        
,,iv--,association heal? plans ,sec4    
#dja4 ,rules gov]n+ association heal?   
plans4 ,sec4 #djb4 ,cl>ification (      
treatm5t ( s+le employ] arrangem5ts4    
,sec4 #djc4 ,en=cem5t provisions relat+ 
to association heal? plans4 ,sec4 #djd4 
,coop]ation betwe5 ,f$]al & ,/ate       
au?orities4 ,sec4 #dje4 ,effective date 
& transitional & o!r rules4 ,,title     
,v--,m$icaid re=m ,sec4 #eja4 ,increas+ 
,/ate flexibility to conduct ,m$icaid   
waiv]s4 ,,title ,,vi--,miscellane\s     

provisions ,sec4 #fja4 ,quality heal?   
c>e coalition4 ,sec4 #fjb4 ,c]ta9 m$ical
 /op-loss insurance obta9$ by c]ta9 plan
 sponsors ( gr\p heal? plans n includ$  
"u ! def9ition ( heal? insurance        
cov]age4  ,i ,repeals  #aja4 ,repeal (  
individual & employ] m&ates  7a7 ,repeal
 ( individual m&ate ,section #ejjj;,a ( 
! ,int]nal ,rev5ue ,code ( #aihf is     
am5d$ by add+ at ! end ! foll[+3  7h7   
,t]m9ation ,?is section %all n apply )  
respect to any mon? beg9n+ aft] ! date (
 enactm5t ( ! ,obamac>e ,replacem5t     
,act4  4  7b7 ,repeal ( employ] m&ate   
,section #dihj;,h ( ! ,int]nal ,rev5ue  
,code ( #aihf is am5d$ by add+ at ! end 
! foll[+3  7e7 ,t]m9ation ,?is section  
%all n apply ) respect to any mon?      
beg9n+ aft] ! date ( enactm5t ( !       
,obamac>e ,replacem5t ,act4  4  #ajb4   
,repeal ( ,public ,heal? ,s]vice ,act   
provisions  7a7 ,repeal ,! foll[+       
provisions ( title ,,xxvii ( ! ,public  
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg et seq47 are repeal$3  7#a7     

,section #bgja 7#db ,u4,s4,c4 #cjj;gg74 
7#b7 ,section #bgjb 7#db ,u4,s4,c4      
#cjj;gg-#a74  7#c7 ,section #bgjc 7#db  
,u4,s4,c4 #cjj;gg-#b74  7#d7 ,section   
#bgjd 7#db ,u4,s4,c4 #cjj;gg-#c74  7#e7 
,section #bgje 7#db ,u4,s4,c4           
#cjj;gg-#d74  7#f7 ,section #bgjg 7#db  
,u4,s4,c4 #cjj;gg-#f74  7#g7 ,section   
#bgjh 7#db ,u4,s4,c4 #cjj;gg-#g74  7#h7 
,section #bgaa 7#db ,u4,s4,c4           
#cjj;gg-#aa74  7#i7 ,section #bgab 7#db 
,u4,s4,c4 #cjj;gg-#ab74  7#aj7 ,section 
#bgac 7#db ,u4,s4,c4 #cjj;gg-#ac74      
7#aa7 ,section #bgae 7#db ,u4,s4,c4     
#cjj;gg-#ae74  7#ab7 ,section #bgae;,a  
7#db ,u4,s4,c4 #cjj;gg-#ae;a74  7#ac7   
,section #bgaf 7#db ,u4,s4,c4           
#cjj;gg-#af74  7#ad7 ,section #bgah 7#db
 ,u4,s4,c4 #cjj;gg-#ah74  7#ae7 ,section
 #bgai 7#db ,u4,s4,c4 #cjj;gg-#ai74     
7#af7 ,section #bgai;,a 7#db ,u4,s4,c4  
#cjj;gg-#ai;a74  7#ag7 ,section #bgid   
7#db ,u4,s4,c4 #cjj;gg-#id71 relat+ to  
ensur+ t consum]s get value = _! doll>s4
  7b7 ,re9/at+ pre-,,ppaca law ,sections

 #bgja1 #bgjb1 #bgaa1 & #bgab ( !       
,public ,heal? ,s]vice ,act z 9 effect  
on ! day be=e ! date ( enactm5t ( !     
,pati5t ,protection & ,af=dable ,c>e    
,act 7,public ,law #aaa-adh7 %all be    
re/or$ or reviv$ z if su* ,act _h n be5 
enact$ 7subject to p>agraphs 7#a71 7#b71
 7#f71 & 7#g7 ( subsection 7c774  7c7   
,r$esignations & transf]s ,! foll[+     
provisions ( title ,,xxvii ( ! ,public  
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg et seq47 %all be r$esignat$ &   
transf]r$ z foll[s3  7#a7 ,section      
#bgja1 z re/or$ or reviv$ "u subsection 
7b71 %all be transf]r$ s z to appe> z ! 
fir/ section 9 subp>t ,i ( "p ,a4  7#b7 
,section #bgjb1 z re/or$ or reviv$ "u   
subsection 7b71 %all be transf]r$ s z to
 appe> aft] su* section #bgja4  7#c7    
,section #bgjf 7#db ,u4,s4,c4           
#cjj;gg-#e7 %all be r$esignat$ z section
 #bgjc & transf]r$ s z to appe> aft] su*
 section #bgjb4  7#d7 ,section #bgji    
7#db ,u4,s4,c4 #cjj;gg-#h71 relat+ to   
cov]age = individuals p>ticipat+ 9      

approv$ cl9ical trials1 %all be         
r$esignat$ z section #bgjd & transf]r$ s
 z to appe> aft] section #bgjc 7z s     
r$esignat$74  7#e7 ,section #bgji 7#db  
,u4,s4,c4 #cjj;gg-#i71 relat+ to        
disclosure ( in=mation1 %all be         
r$esignat$ z section #bgje & transf]r$ s
 z to appe> aft] section #bgjd 7z s     
r$esignat$74  7#f7 ,section #bgaa1 z    
re/or$ or reviv$ "u subsection 7b71 %all
 be r$esignat$ z section #bgjf &        
transf]r$ s z to appe> aft] section     
#bgje 7z s r$esignat$74  7#g7 ,section  
#bgab1 z re/or$ or reviv$ "u subsection 
7b71 %all be r$esignat$ z section #bgjg 
& transf]r$ s z to appe> aft] section   
#bgjf 7z s r$esignat$74  7#h7 ,section  
#bgad 7#db ,u4,s4,c4 #cjj;gg-#ad7 %all  
be r$esignat$ z section #bgaa &         
transf]r$ s z to appe> z ! fir/ section 
"u subp>t ,,ii ( "p ,a4  7#i7 ,section  
#bgag 7#db ,u4,s4,c4 #cjj;gg-#ag7 %all  
be r$esignat$ z section #bgab &         
transf]r$ s z to appe> aft] section     
#bgaa 7z s r$esignat$74  7d7 ,effective 

dates  7#a7 ,9 g5]al ,except z provid$ 9
 p>agraph 7#b71 ! repeals "u subsection 
7a7 %all take effect on ! date (        
enactm5t ( ?is ,act & %all apply to plan
 ye>s beg9n+ aft] su* date ( enactm5t4  
7#b7 ,delay$ effective dates ,! repeals 
"u p>agraphs 7#b71 7#c71 7#d71 & 7#e7 ( 
subsection 7a71 ! provisions re/or$ or  
reviv$ "u subsection 7b71 & ! con=m+    
am5dm5t 9 section #ajd7;a77#b7 %all be  
effective = plan ye>s beg9n+ on ,janu>y 
#a1 #bjai1 & 7not)/&+ subsection 7c77 ! 
provisions ( law repeal$ by su*         
p>agraphs ( subsection 7a7 or am5d$ by  
su* con=m+ am5dm5t %all cont9ue to rema9
 9 effect until su* date4  #ajc4 ,repeal
 ( ,pati5t ,protection & ,af=dable ,c>e 
,act provisions  7a7 ,9 g5]al ,section  
#acab7;c7 ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjcb7;c77 is repeal$4  7b7 ,repeal (  
#c-,mon? grace p]iod = non-paym5t       
premiums ,clause 7iv7 ( section         
#adab7;c77#b77;,b7 ( ! ,pati5t          
,protection & ,af=dable ,c>e ,act is    

am5d$ by /rik+ nonpaym5t ( premiums by !
 insur$ & all t foll[s & ins]t+         
nonpaym5t ( premiums by ! insur$1 notify
 ! ,secret>y ( su* nonpaym5t44  7c7     
,effective date ,?is section1 & !       
am5dm5ts made by ?is section1 %all take 
effect on ! date ( enactm5t ( ?is ,act &
 %all apply to plan ye>s & taxable ye>s 
beg9n+ aft] su* date ( enactm5t4  #ajd4 
,con=m+ & te*nical am5dm5ts  7a7 ,,phsa 
provisions ,title ,,xxvii ( ! ,public   
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg et seq47 is am5d$-- 7#a7 9      
section #bgbd7;c7 7#db ,u4,s4,c4        
#cjj;gg-#bc7;c771 by /rik+ 7o!r ?an     
section #bgjd7 & ins]t+ 7o!r ?an section
 #bgbe72  7#b7 9 section #bgda7;b77#c7  
7#db ,u4,s4,c4 #cjj;gg-#da7;a77#c771 by 
/rik+ #bgab & ins]t+ #bgjg2  7#c7 9     
section #bgea7;a7 7#db ,u4,s4,c4        
#cjj;gg-#ea7;a771 by /rik+ #bgjd &      
ins]t+ #bgbe2  7#d7 9 section #bgeb 7#db
 ,u4,s4,c4 #cjj;gg-#eb71 by /rik+ #bgjf 
& ins]t+ #bgbg2 &  7#e7 9 section #bgec 
7#db ,u4,s4,c4 #cjj;gg-#ed71 relat+ to  

cov]age ( dep5d5t /ud5ts on m$ically    
necess>y leave ( abs5ce1 by /rik+ #bgjg 
& ins]t+ #bgbh4  7b7 ,,ppaca provisions 
,! ,pati5t ,protection & ,af=dable ,c>e 
,act 7,public ,law #aaa-adh7 is am5d$-- 
7#a7 9 section #aajc7;b77#a7 7#db       
,u4,s4,c4 #ahjjc7;b77#a77--  7,a7 by    
/rik+ ! p]c5tage ( total premium rev5ue 
exp5d$ on noncl9ical co/s 7z report$ "u 
section #bgah7;a7 ( ! ,public ,heal?    
,s]vice ,act712 &  7,b7 by /rik+ & be   
consi/5t ) ! /&>ds adopt$ = ! uni=m     
explanation ( cov]age z provid$ = 9     
section #bgae ( ! ,public ,heal? ,s]vice
 ,act2  7#b7 9 section #abea7;a7 7#db   
,u4,s4,c4 #ahjaa7;a771 by /rik+         
p>agraphs 7#c7 & 7#d71 & ins]t+ !       
foll[+3  7#c7 ,application ( c]ta9      
provisions ,section #bgaa ( ! ,public   
,heal? ,s]vice ,act 7relat+ to ext5sion 
( dep5d5t cov]age7 %all apply to        
gr&fa!r$ heal? plans = plan ye>s beg9n+ 
) ! fir/ plan ye> to :i* su* provisions 
w\ld o!rwise apply4  2  7#c7 9 section  
#acja7;a77#d7 7#db ,u4,s4,c4            

#ahjba7;a77#d771 by /rik+ section       
#bgja7;a77#b7 ( ! ,public ,heal? ,s]vice
 ,act & ins]t+ section #bgja7;a77#b7 ( !
 ,public ,heal? ,s]vice ,act z 9 effect 
on ! day be=e ! date ( enactm5t ( !     
,obamac>e ,replacem5t ,act or z det]m9$ 
by ! ,secret>y2  7#d7 9 section         
#acjb7;e77#a77;,b77i7 7#db ,u4,s4,c4    
#ahjbb7;e77#a77;,b77i771 by /rik+       
7except z provid$ = 9 section #bgac72   
7#e7 9 section #acaa 7#db ,u4,s4,c4     
#ahjca7--  7,a7 9 subsection 7c7-- 7i7 9
 p>agraph 7#a77;,b71 by /rik+ 79 a mann]
 consi/5t ) applicable network adequacy 
provisions "u section #bgjb7;c7 ( !     
,public ,heal? ,s]vice ,act72 &  7ii7 9 
p>agraph 7#e71 by /rik+ to ! uni=m      
outl9e ( cov]age ! plan is requir$ to   
provide "u section #bgaf ( ! ,public    
,heal? ,s]vice ,act &2  7,b7 9          
subsection 7d77#d77;,e71 by /rik+ 1     
includ+ ! use ( ! uni=m outl9e ( cov]age
 e/abli%$ "u section #bgae ( ! ,public  
,heal? ,s]vice ,act2  7,c7 9 subsection 
7e77#b71 by /rik+ 1 & ! in=mation & !   

recomm5dations & all t foll[s ?r\gh     
premium increases712 &  7,d7 9          
subsection 7f77#b77;,b71 by ins]t+ be=e 
! p]iod z 9 effect on ! day be=e ! date 
( enactm5t ( ! ,obamac>e ,replacem5t    
,act or z det]m9$ by ! ,secret>y2 &     
7#f7 9 section #accd7;a77#b71 by ins]t+ 
be=e ! p]iod z 9 effect on ! day be=e ! 
date ( enactm5t ( ! ,obamac>e           
,replacem5t ,act4  7c7 ,,erisa          
provisions ,section #gae ( ! ,employee  
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #aahe;d7 is am5d$--
  7#a7 9 subsection 7a7-- 7,a7 by /rik+ 
7a7 ,g5]al ,rule & all t foll[s ?r\gh ! 
provisions ( "p ,a 9 p>agraph 7#a7 &    
ins]t+ ,! provisions ( "p ,a2 &  7,b7 by
 /rik+ z if includ$ 9 ?is subp>t2 & 9   
p>agraph 7#a7 & all t foll[s ?r\gh to ! 
ext5t t 9 p>agraph 7#b7 & ins]t+ z if   
includ$ 9 ?is subp>t4 ,to ! ext5t t2 &  
7#b7 by /rik+ subsection 7b74  7d7 ,,irc
 provisions ,! ,int]nal ,rev5ue ,code ( 
#aihf is am5d$-- 7#a7 9 section         
#cf;,b7b77#c77;,c7--  7,a7 9 ! fir/     

s5t5ce1 by /rik+ & ! premium 0 adju/$   
only = ! age ( ea* su* individual 9 !   
mann] all[$ "u section #bgja ( ! ,public
 ,heal? ,s]vice ,act2 &  7,b7 by /rik+ !
 second s5t5ce2  7#b7 9 section         
#hcc7;c71 by /rik+ p>agraph 7#e72 &     
7#c7 9 section #ihae-- 7,a7 9 subsection
 7a7--  7i7 by /rik+ 7a7 ,g5]al ,rule & 
all t foll[s ?r\gh ! provisions ( "p ,a 
9 p>agraph 7#a7 & ins]t+ ,! provisions (
 "p ,a2 &  7ii7 by /rik+ z if includ$ 9 
?is subp>t2 & 9 p>agraph 7#a7 & all t   
foll[s ?r\gh to ! ext5t t 9 p>agraph    
7#b7 & ins]t+ z if includ$ 9 ?is subp>t4
 ,to ! ext5t t2 &  7,b7 by /rik+        
subsection 7b74  7e7 ,social ,security  
,act ,section #aicg7;b77#f77;,a7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acifu-#g7;b77#f77;,a77 is am5d$ by     
/rik+ #bgje7;a7 & ins]t+ #bgbf7;a74  7f7
 ,effective date ,except z provid$ 9    
section #ajb7;d77#b71 ?is section & !   
am5dm5ts made by ?is section %all take  
effect on ! date ( enactm5t ( ?is ,act &
 %all apply to plan ye>s & taxable ye>s 

beg9n+ aft] su* date ( enactm5t4  ,,ii  
,taxation re=m  ,a ,equaliz+ tax        
treatm5t ( non-,employ] provid$ heal?   
insurance  #bja4 ,tax d$uction = heal?  
insurance premiums  7a7 ,9 g5]al ,"p    
,,vii ( sub*apt] ,b ( *apt] #a ( !      
,int]nal ,rev5ue ,code ( #aihf is am5d$ 
by r$esignat+ section #bbd z section    
#bbe & by ins]t+ aft] section #bbb !    
foll[+ new section3  #bbd4 ,heal?       
insurance premiums  7a7 ,9 g5]al ,!re   
%all be all[$ z a d$uction ! am\nt (    
premiums paid by ! taxpay] = heal?      
insurance cov]age 7z def9$ 9 section    
#ihcb7 ( ! taxpay]1 ! taxpay]'s sp\se1  
or any dep5d5t 7z def9$ 9 section #aeb1 
det]m9$ )\t reg>d to subsections        
7b77#a71 7b77#b71 & 7d77#a77;,b7 !re(7 (
 ! taxpay]4  7b7 ,coord9ation provisions
  7#a7 ,premium assi/ance cr$it         
,subsection 7a7 %all n apply ) respect  
to s mu* ( any premium = :i* a cr$it has
 be5 all[$ "u section #cf;,b4  7#b7     
,ar*] ,m,s,as & ,h,s,as ,subsection 7a7 
%all n apply ) respect to any am\nt :i* 

is treat$ z a qualifi$ m$ical exp5se "u 
ei!r section #bbj7;d7 or #bbc7;c74  7#c7
 ,d$uction = m$ical exp5ses ,= purposes 
( det]m9+ ! am\nt ( ! d$uction "u       
section #bac1 any am\nt = :i* a d$uction
 is all[$ "u subsection 7a7 %all n be   
treat$ z an exp5se paid = m$ical c>e4  4
  7b7 ,d$uction available above ! l9e   
,section #fb7;a7 ( ! ,int]nal ,rev5ue   
,code ( #aihf is am5d$ by ins]t+ aft]   
p>agraph 7#ba7 ! foll[+ new p>agraph3   
7#bb7 ,heal? insurance premiums ,!      
d$uction all[$ by section #bbd4  4  7c7 
,con=m+ am5dm5ts  7#a7 ,section         
#ce7;g77#b7 ( ! ,int]nal ,rev5ue ,code (
 #aihf is am5d$ by /rik+ or #bac &      
ins]t+ #bac1 or #bbd4  7#b7 ,section    
#afb7l77#c7 ( su* ,code is am5d$ by     
ins]t+ or #bbd7;a7 aft] #bac7;a74  7#c7 
,! table ( sections = "p ,,vii (        
sub*apt] ,b ( *apt] #a ( su* ,code is   
am5d$ by r$esignat+ ! item relat+ to    
section #bbd z relat+ to section #bbe & 
by ins]t+ aft] ! item relat+ to section 
#bbc ! foll[+ new item3  ,sec4 #bbd4    

,heal? insurance premiums4  4  7d7      
,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ,decemb] #ca1 #bjaf4  #bjb4 
,refundable tax cr$it = payroll taxes   
attributable to heal? insurance premiums
  7a7 ,9 g5]al ,subp>t ,c ( "p ,,iv (   
sub*apt] ,a ( *apt] #a ( ! ,int]nal     
,rev5ue ,code ( #aihf is am5d$ by add+  
at ! end ! foll[+ new section3  #cf;,c4 
,refund ( payroll taxes attributable to 
heal? insurance premiums  7a7 ,all[ance 
( cr$it ,!re %all be all[$ z a cr$it    
aga9/ ! tax impos$ by ?is subtitle = any
 taxable ye> an am\nt equal to !        
applicable p]c5tage ( ! premiums paid by
 ! taxpay] = heal? insurance cov]age 7z 
def9$ 9 section #ihcb7 ( ! taxpay]1 !   
taxpay]'s sp\se1 or any dep5d5t 7z def9$
 9 section #aeb1 det]m9$ )\t reg>d to   
subsections 7b77#a71 7b77#b71 &         
7d77#a77;,b7 !re(7 ( ! taxpay]4  7b7    
,applicable p]c5tage ,= purposes (      
subsection 7a71 ! t]m applicable        
p]c5tage means ! p]c5tage equal to ! sum

 ( ! rates ( 9 effect "u subsections 7a7
 & 7b7 ( section #caja4  7c7 ,limitation
 ,! am\nt ( ! cr$it all[$ "u subsection 
7a7 %all n exce$ ! excess (-- 7#a7 !    
social security taxes 7z def9$ 9 section
 #bd7;d77 ( ! taxpay] = ! taxable ye>1  
r$uc$ by  7#b7 ! sum ( ! cr$its all[$ "u
 section #bd7;d7 & #cb = ! taxable ye>4 
4  7b7 ,con=m+ am5dm5ts  7#a7 ,p>agraph 
7#b7 ( section #acbd7;b7 ( title #ca1   
,unit$ ,/ates ,code1 is am5d$ by ins]t+ 
1 #cf;,c aft] #cf;,b4  7#b7 ,! table (  
sections = subp>t ,c ( "p ,,iv (        
sub*apt] ,a ( *apt] #a ( ! ,int]nal     
,rev5ue ,code ( #aihf is am5d$ by ins]t+
 aft] ! item relat+ to section #cf;,b ! 
foll[+ new item3  ,sec4 #cf;,c4 ,refund 
( payroll taxes attributable to heal?   
insurance premiums4  4  7c7 ,effective  
date ,! am5dm5ts made by ?is section    
%all apply to taxable ye>s beg9n+ aft]  
,decemb] #ca1 #bjaf4  ,b ,heal? sav+s   
acc\nts  #baa4 ,repeal ( contribution   
limitations  7a7 ,9 g5]al ,subsection   
7b7 ( section #bbc ( ! ,int]nal ,rev5ue 

,code ( #aihf is am5d$ to read z foll[s3
  7b7 ,d5ial ( d$uction to dep5d5ts ,no 
d$uction %all be all[$ "u ?is section to
 any individual ) respect to :om a      
d$uction "u section #aea is all[able to 
ano!r taxpay] = a taxable ye> beg9n+ 9 !
 cal5d> ye> 9 :i* su* individual's      
taxable ye> beg9s4  4  7b7 ,con=m+      
am5dm5ts  7#a7 ,subp>agraph 7,a7 (      
section #bbc7;d77#a7 ( ! ,int]nal       
,rev5ue ,code ( #aihf is am5d$-- 7,a7 by
 /rik+ subsection 7f77#e7 & ins]t+      
subsection 7f77#d71 &  7,b7 by /rik+    
accept$-- & all t foll[s & ins]t+       
accept$ unless x is 9 ca%44  7#b7       
,subsection 7f7 ( section #bbc ( su*    
,code is am5d$ by /rik+ p>agraph 7#c7 & 
by r$esignat+ p>agraphs 7#d7 ?r\gh 7#h7 
z p>agraphs 7#c7 ?r\gh 7#g71            
respectively4  7#c7 ,subsection 7g7 (   
section #bbc ( su* ,code is am5d$-- 7,a7
 by /rik+ subsections 7b77#b7 &         
7c77#b77;,a7 bo? places x appe>s &      
ins]t+ subsection 7c77#b77;,a71 &  7,b7 
by am5d+ subp>agraph 7,b7 to read z     

foll[s3  7,b7 ! co/-(-liv+ adju/m5t     
det]m9$ "u section #a7;f77#c7 = ! cal5d>
 ye> 9 :i* su* taxable ye> beg9s det]m9$
 by sub/itut+ cal5d> ye> #bjjc = cal5d> 
ye> #aiib4  4  7#d7 ,section #bf7;b77#b7
 ( su* ,code is am5d$-- 7,a7 by /rik+ 1 
#bbc7;b77#h77;,b77i77,,ii71 9           
subp>agraph 7,s71 &  7,b7 by /rik+      
#bbc7;f77#d7 9 subp>agraph 7,u7 & ins]t+
 #bbc7;f77#c74  7#e7 ,p>agraph 7#a7 (   
section #ajf7;d7 ( su* ,code is am5d$ by
 /rik+ "u an accid5t or heal? plan & all
 t foll[s & ins]t+ "u an accid5t or     
heal? plan44  7#f7 ,subp>agraph 7,c7 (  
section #ajf7;e77#d7 ( su* ,code is     
am5d$ by /rik+ #bbc7;f77#e7 & ins]t+    
#bbc7;f77#d74  7#g7 ,subp>agraph 7,c7 ( 
section #djh7;d77#i7 ( su* ,code is     
am5d$--  7,a7 by /rik+ ,limitations4-- 9
 ! head+ & all t foll[s ?r\gh 7ii7      
,"o-"t transf]4-- 9 clause 7ii71 &      
ins]t+ ,"o-"t transf]4--1  7,b7 by      
r$esignat+ subclauses 7,i7 & 7,,ii7 z   
clauses 7i7 & 7ii7 & mov+ su* clauses #b
 ems to ! left1 &  7,c7 by /rik+        

subclause 7,,ii7 9 clause 7i71 z s      
r$esignat$1 & ins]t+ clause 7ii74  7#h7 
,section #digc ( su* ,code is am5d$ by  
/rik+ subsection 7g7 & by r$esignat+    
subsection 7h7 z subsection 7g74  7c7   
,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ! date ( ! enactm5t ( ?is   
,act4  #bab4 ,fre$om f m&ate  7a7 ,9    
g5]al ,section #bbc ( ! ,int]nal ,rev5ue
 ,code ( #aihf1 z am5d$ by section #baa1
 is fur!r am5d$ by /rik+ subsections 7c7
 & 7g7 & by r$esignat+ subsections 7d71 
7e71 7f71 & 7h7 z subsections 7c71 7d71 
7e71 & 7f71 respectively4  7b7 ,con=m+  
am5dm5ts  7#a7 ,subsection 7a7 ( section
 #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf
 is am5d$ to read z foll[s3  7a7        
,d$uction all[$ ,9 ! case ( an          
individual1 !re %all be all[$ z a       
d$uction = ! taxable ye> an am\nt equal 
to ! aggregate am\nt paid 9 ca% dur+ su*
 taxable ye> by or on behalf ( su*      
individual to a heal? sav+s acc\nt ( su*
 individual4  4  7#b7 ,subsection       

7c77#a77;,a7 ( section #bbc ( su* ,code1
 z am5d$ by section #baa & r$esignat$ by
 subsection 7a71 is fur!r am5d$ by /rik+
 subsection 7f77#d7 & ins]t+ subsection 
7e77#d74  7#c7 ,subp>agraph 7,u7 (      
section #bf7;b77#b7 ( su* ,code1 z am5d$
 by section #baa1 is fur!r am5d$ by     
/rik+ section #bbc7;f77#c7 & ins]t+     
section #bbc7;e77#c74  7#d7 ,sections   
#ce7;g77#c71 #bbj7;f77#e77;,a71         
#hdh7;e77#a77;,b77v71 #digc7;a77#e71 &  
#fjea7;a77#ab7 ( su* ,code are ea* am5d$
 by /rik+ section #bbc7;d7 ea* place x  
appe>s & ins]t+ section #bbc7;c74  7#e7 
,section #ajf7;d77#a7 ( su* ,code is    
am5d$-- 7,a7 by /rik+ :o is an eligible 
individual 7z def9$ 9 section           
#bbc7;c77#a771 &  7,b7 by /rik+ section 
#bbc7;d7 & ins]t+ section #bbc7;c74     
7#f7 ,section #ajf7;e7 ( su* ,code is   
am5d$--  7,a7 by /rik+ p>agraphs 7#c7 & 
7#d7 & by r$esignat+ p>agraph 7#e7 z    
p>agraph 7#d71  7,b7 by ins]t+ aft]     
p>agraph 7#b7 ! foll[+ new p>agraph3    
7#c7 ,treatm5t z rollov] contribution ,a

 qualifi$ ,,hsa di/ribution %all be     
treat$ z a rollov] contribution describ$
 9 section #bbc7;e77#d74  1 &  7,c7 by  
/rik+ to any eligible individual cov]$  
"u a high d$uctible heal? plan ( !      
employ] 9 p>agraph 7#d77;,b77ii7 7z s   
r$esignat$7 & ins]t+ to any employee )  
respect to :om a heal? sav+s acc\nt has 
be5 e/abli%$4  7#g7 ,section            
#djh7;d77#i77;,a7 ( su* ,code is am5d$  
by /rik+ :o is an eligible individual 7z
 def9$ 9 section #bbc7;c77 &4  7#h7     
,section #hgg;,a7g77#f7 ( su* ,code is  
am5d$ by /rik+ #bbc7;f77#d7 & ins]t+    
#bbc7;e77#d74  7#i7 ,section #dige ( su*
 ,code is am5d$--  7,a7 9 subsection    
7c77#f7-- 7i7 by /rik+ section #bbc7;d7 
& ins]t+ section #bbc7;c71 &  7ii7 by   
/rik+ section #bbc7;e77#b7 & ins]t+     
section #bbc7;d77#b71 &  7,b7 9         
subsection 7e77#a77;,e71 by /rik+       
section #bbc7;d7 & ins]t+ section       
#bbc7;c74  7#aj7 ,subsection 7b7 (      
section #dihj;,g ( su* ,code is am5d$ to
 read z foll[s3  7b7 ,rules &           

requirem5ts  7#a7 ,9 g5]al ,an employ]  
meets ! requirem5ts ( ?is subsection =  
any cal5d> ye> if ! employ] makes       
available comp>able contributions to !  
heal? sav+s acc\nts ( all comp>able     
p>ticipat+ employees = ea* cov]age p]iod
 dur+ su* cal5d> ye>4  7#b7 ,comp>able  
contributions  7,a7 ,9 g5]al ,= purposes
 ( p>agraph 7#a71 ! t]m comp>able       
contributions means contributions-- 7i7 
:i* are ! same am\nt1 or  7ii7 if !     
employees are cov]$ by a heal? plan1 :i*
 are ! same p]c5tage ( ! annual         
d$uctible limit "u ! plan cov]+ !       
employees4  7,b7 ,"p-ye> employees ,9 ! 
case ( an employee :o is employ$ by !   
employ] = only a portion ( ! cal5d> ye>1
 a contribution to ! heal? sav+s acc\nt 
( su* employee %all be treat$ z         
comp>able if x is an am\nt :i* be>s !   
same ratio to ! comp>able am\nt 7det]m9$
 )\t reg>d to ?is subp>agraph7 z su*    
portion be>s to ! entire cal5d> ye>4    
7#c7 ,comp>able p>ticipat+ employees ,= 
purposes ( p>agraph 7#a71 ! t]m         

comp>able p>ticipat+ employees means all
 employees :o are cov]$ 7if at all7 "u !
 same heal? plan ( ! employ] & h ! same 
category ( cov]age4 ,= purposes ( !     
prec$+ s5t5ce1 ! categories ( cov]age   
are self-only & family cov]age4  7#d7   
,"p-"t employees  7,a7 ,9 g5]al         
,p>agraph 7#c7 %all be appli$ sep>ately 
) respect to "p-"t employees & o!r      
employees4  7,b7 ,"p-"t employee ,=     
purposes ( subp>agraph 7,a71 ! t]m "p-"t
 employee means any employee :o is      
cu/om>ily employ$ = few] ?an #cj h\rs p]
 week4  4  7#aa7 ,section #dihj;,g7d7 ( 
su* ,code is am5d$ by /rik+ section     
#dihj;,e & ins]t+ ?is section4  7#ab7   
,section #ffic7;a77#b77;,c7 ( su* ,code 
is am5d$ by /rik+ section #bbc7;h7 &    
ins]t+ section #bbc7;f74  7c7 ,effective
 date ,! am5dm5ts made by ?is section   
%all apply to taxable ye>s beg9n+ aft] !
 date ( ! enactm5t ( ?is ,act4  #bac4   
,all[ance ( di/ributions = prescription 
& ov]-!-c\nt] m$ic9es & drugs  7a7      
,h,s,as ,p>agraph 7#b77;,a7 ( section   

#bbc7;c7 ( ! ,int]nal ,rev5ue ,code (   
#aihf1 z r$esignat$ by section #bab1 is 
am5d$ by /rik+ ! la/ s5t5ce !re( &      
ins]t+ ! foll[+3 ,su* t]m %all include  
an am\nt paid = any prescription or     
ov]-!-c\nt] m$ic9e or drug44  7b7 ,ar*] 
,m,s,as ,section #bbj7;d77#b77;,a7 ( !  
,int]nal ,rev5ue ,code ( #aihf is am5d$ 
by /rik+ ! la/ s5t5ce !re( & ins]t+ !   
foll[+3 ,su* t]m %all include an am\nt  
paid = any prescription or ov]-!-c\nt]  
m$ic9e or drug44  7c7 ,heal? flexible   
sp5d+ arrangem5ts & heal? reimbursem5t  
arrangem5ts ,subsection 7f7 ( section   
#ajf ( ! ,int]nal ,rev5ue ,code ( #aihf 
is am5d$ to read z foll[s3  7f7         
,reimbursem5ts = all m$ic9es & drugs ,= 
purposes ( ?is section & section #aje1  
reimbursem5t = exp5ses incurr$ = any    
prescription or ov]-!-c\nt] m$ic9e or   
drug %all be treat$ z a reimbursem5t =  
m$ical exp5ses4  4  7d7 ,effective dates
  7#a7 ,di/ributions f sav+s acc\nts ,! 
am5dm5ts made by subsections 7a7 & 7b7  
%all apply to am\nts paid 9 taxable ye>s

 beg9n+ aft] ! date ( ! enactm5t ( ?is  
,act4  7#b7 ,reimbursem5ts ,! am5dm5t   
made by subsection 7c7 %all apply to    
exp5ses incurr$ 9 plan ye>s beg9n+ aft] 
! date ( ! enactm5t ( ?is ,act4  #bad4  
,pur*ase ( heal? insurance f ,,hsa  7a7 
,9 g5]al ,p>agraph 7#b7 ( section       
#bbc7;c7 ( ! ,int]nal ,rev5ue ,code (   
#aihf1 z r$esignat$ by section #bab1 is 
am5d$ by /rik+ subp>agraphs 7,b7 & 7,c74
  7b7 ,con=m+ am5dm5t  ,p>agraph 7#b7 ( 
section #bbc7;c7 ( ! ,int]nal ,rev5ue   
,code ( #aihf1 z am5d$ by ! prec$+      
sections ( ?is subtitle1 is fur!r am5d$ 
by /rik+ & any dep5d5t 7z def9$ 9       
section #aeb1 det]m9$ )\t reg>d to      
subsections 7b77#a71 7b77#b71 &         
7d77#a77;,b7 !re(7 ( su* individual &   
ins]t+ any dep5d5t 7z def9$ 9 section   
#aeb1 det]m9$ )\t reg>d to subsections  
7b77#a71 7b77#b71 & 7d77#a77;,b7 !re(7 (
 su* individual1 & any *ild 7z def9$ 9  
section #aeb7;f77#a77 ( su* individual  
:o has n atta9$ ! age ( #bg be=e ! end (
 su* individual's taxable ye>4  7c7     

,effective date ,! am5dm5ts made by ?is 
section %all apply ) respect to         
insurance pur*as$ aft] ! date ( !       
enactm5t ( ?is ,act 9 taxable ye>s      
beg9n+ aft] su* date4  #bae4 ,special   
rule = c]ta9 m$ical exp5ses incurr$ be=e
 e/abli%m5t ( acc\nt  7a7 ,9 g5]al      
,p>agraph 7#b7 ( section #bbc7;c7 ( !   
,int]nal ,rev5ue ,code ( #aihf1 z am5d$ 
& r$esignat$ by ! prec$+ sections ( ?is 
subtitle1 is fur!r am5d$ by add+ at !   
end ! foll[+ new subp>agraph3  7,b7     
,c]ta9 m$ical exp5ses incurr$ be=e      
e/abli%m5t ( acc\nt treat$ z qualifi$   
,an exp5se %all n fail to be treat$ z a 
qualifi$ m$ical exp5se solely because   
su* exp5se 0 incurr$ be=e ! e/abli%m5t (
 ! heal? sav+s acc\nt if su* exp5se 0   
incurr$--  7i7 dur+ ei!r-- 7,i7 !       
taxable ye> 9 :i* ! heal? sav+s acc\nt 0
 e/abli%$1 or  7,,ii7 ! prec$+ taxable  
ye>1 9 ! case ( a heal? sav+s acc\nt    
e/abli%$ aft] ! taxable ye> 9 :i* su*   
exp5se 0 incurr$ b be=e ! "t prescrib$  
by law = fil+ ! return = su* taxable ye>

 7n includ+ ext5sions !re(71 &  7ii7 =  
m$ical c>e :i* 7b = ! fact t x 0 incurr$
 be=e ! e/abli%m5t ( ! acc\nt7 o!rwise  
meets ! requirem5ts ( ! prec$+          
subp>agraphs4  4  7b7 ,effective date ,!
 am5dm5t made by ?is section %all apply 
to taxable ye>s beg9n+ aft] ! date ( !  
enactm5t ( ?is ,act4  #baf4             
,adm9i/rative error correction be=e due 
date ( return  7a7 ,9 g5]al ,p>agraph   
7#c7 ( section #bbc7;f7 ( ! ,int]nal    
,rev5ue ,code ( #aihf1 z 9 effect on !  
day be=e ! date ( ! enactm5t ( ?is ,act1
 is am5d$ by add+ at ! end ! foll[+ new 
subp>agraph3  7,d7 ,exception =         
adm9i/rative errors correct$ be=e due   
date ( return ,subp>agraph 7,a7 %all n  
apply if any paym5t or di/ribution is   
made to correct an adm9i/rative1        
cl]ical1 or payroll contribution error &
 if--  7i7 su* di/ribution is receiv$ by
 ! individual on or be=e ! la/ day      
prescrib$ by law 7includ+ ext5sions (   
"t7 = fil+ su* individual's return = su*
 taxable ye>1 &  7ii7 su* di/ribution is

 accompani$ by ! am\nt ( net income     
attributable to su* contribution4  ,any 
net income describ$ 9 clause 7ii7 %all  
be includ$ 9 ! gross income ( !         
individual = ! taxable ye> 9 :i* x is   
receiv$4  4  7b7 ,effective date ,!     
am5dm5t made by ?is section %all take   
effect on ! date ( ! enactm5t ( ?is     
,act4  #bag4 ,all[+ ,,hsa rollov] to    
*ild or p>5t ( acc\nt hold]  7a7 ,9     
g5]al ,p>agraph 7#g77;,a7 ( section     
#bbc7;e7 ( ! ,int]nal ,rev5ue ,code (   
#aihf1 z r$esignat$ by ! prec$+ sections
 ( ?is subtitle1 is am5d$--  7#a7 by    
ins]t+ 1 *ild1 p>5t1 or gr&p>5t aft]    
surviv+ sp\se1  7#b7 by ins]t+ 1 *ild1  
p>5t1 or gr&p>5t1 z ! case may be1 aft] 
! sp\se1  7#c7 by ins]t+ 1 *ild1 p>5t1  
or gr&p>5t aft] sp\se 9 ! head+ !re(1 & 
7#d7 by add+ at ! end ! foll[+3 ,9 !    
case ( a *ild :o acquires su*           
b5efici>y's int]e/ & ) respect to :om a 
d$uction "u section #aea is all[able to 
ano!r taxpay] = a taxable ye> beg9n+ 9 !
 cal5d> ye> 9 :i* su* individual's      

taxable ye> beg9s1 su* heal? sav+s      
acc\nt %all be treat$ z a heal? sav+s   
acc\nt ( su* *ild44  7b7 ,effective date
 ,! am5dm5ts made by ?is section %all   
apply to taxable ye>s beg9n+ aft] ! date
 ( ! enactm5t ( ?is ,act4  #bah4 ,cr$it 
= contributions to an ,,hsa  7a7 ,9     
g5]al ,subp>t ,a ( "p ,,iv ( sub*apt] ,a
 ( *apt] #a ( ! ,int]nal ,rev5ue ,code (
 #aihf is am5d$ by ins]t+ aft] section  
#be;,d ! foll[+ new section3  #be;,e4   
,contributions to a heal? sav+s acc\nt  
7a7 ,all[ance ( cr$it ,9 ! case ( an    
individual1 !re %all be all[$ z a cr$it 
aga9/ ! tax impos$ by ?is subtitle = !  
taxable ye> an am\nt equal to s mu* ( ! 
qualifi$ ,,hsa contributions ( !        
individual z does n exce$ #e1jjj        
7#aj1jjj 9 ! case ( a jo9t return74  7b7
 ,qualifi$ ,,hsa contribution  7#a7 ,9  
g5]al ,= purposes ( ?is section1 ! t]m  
qualifi$ ,,hsa contribution means an    
am\nt paid 9 ca% dur+ ! taxable ye> by  
or on behalf ( an individual to a heal? 
sav+s acc\nt 7z def9$ 9 section         

#bbc7;c77 ( su* individual4  7#b7       
,exception = am\nts n us$ = qualifi$    
m$ical exp5ses ,! am\nt tak5 into acc\nt
 z qualifi$ ,,hsa contributions ( !     
individual "u p>agraph 7#a7 = a taxable 
ye> %all be r$uc$ by ! am\nt ( any      
di/ribution f su* heal? sav+s acc\nt    
dur+ su* taxable ye> :i* is n us$       
exclusively to pay ! qualifi$ m$ical    
exp5ses ( ! acc\nt b5efici>y 7)9 ! mean+
 ( section #bbc7;e77#b774  7c7          
,coord9ation ) d$uction ,= coord9ation  
rule1 see section #bbc7;b77#a74  4  7b7 
,cl]ical am5dm5t ,! table ( sections =  
subp>t ,a ( "p ,,iv ( sub*apt] ,a (     
*apt] #a ( ! ,int]nal ,rev5ue ,code (   
#aihf is am5d$ by ins]t+ aft] ! item    
relat+ to section #be;,d ! foll[+ new   
item3  ,sec4 #be;,e4 ,contributions to a
 heal? sav+s acc\nt4  4  7c7 ,con=m+    
am5dm5t ,subsection 7b7 ( section #bbc (
 ! ,int]nal ,rev5ue ,code ( #aihf1 z    
am5d$ by section #baa1 is fur!r am5d$ to
 read z foll[s3  7b7 ,special rules     
7#a7 ,coord9ation ) cr$it ,! am\nt tak5 

into acc\nt "u subsection 7a7 ) respect 
to any individual %all be r$uc$ 7b n    
bel[ z]o7 by ! am\nt ( any cr$it all[$  
"u section #be;,e = qualifi$ ,,hsa      
contributions ) respect to ! individual4
  7#b7 ,d5ial ( d$uction to dep5d5ts ,no
 d$uction %all be all[$ "u ?is section  
to any individual ) respect to :om a    
d$uction "u section #aea is all[able to 
ano!r taxpay] = a taxable ye> beg9n+ 9 !
 cal5d> ye> 9 :i* su* individual's      
taxable ye> beg9s4  4  7d7 ,effective   
date ,! am5dm5ts made by ?is section    
%all apply to taxable ye>s beg9n+ aft] !
 date ( ! enactm5t ( ?is ,act4  #bai4   
,equival5t bankruptcy protections =     
heal? sav+s acc\nts z retirem5t funds   
7a7 ,9 g5]al ,section #ebb ( title #aa1 
,unit$ ,/ates ,code1 is am5d$ by add+ at
 ! end ! foll[+ new subsection3  7r7    
,treatm5t ( heal? sav+s acc\nts ,=      
purposes ( ?is section1 any heal? sav+s 
acc\nt 7z describ$ 9 section #bbc ( !   
,int]nal ,rev5ue ,code ( #aihf7 %all be 
treat$ 9 ! same mann] z an individual   

retirem5t acc\nt describ$ 9 section #djh
 ( su* ,code4  4  7b7 ,effective date ,!
 am5dm5t made by ?is section %all apply 
to cases comm5c+ "u title #aa1 ,unit$   
,/ates ,code1 aft] ! date ( ! enactm5t (
 ?is ,act4  ,c ,m$ical exp5ses  #bba4   
,c]ta9 ex]cise equipm5t & physical      
fitness programs treat$ z m$ical c>e    
7a7 ,9 g5]al ,subsection 7d7 ( section  
#bac ( ! ,int]nal ,rev5ue ,code ( #aihf 
is am5d$ by add+ at ! end ! foll[+ new  
p>agraph3  7#ab7 ,ex]cise equipm5t &    
physical fitness activity  7,a7 ,9 g5]al
 ,! t]m m$ical c>e %all include am\nts  
paid--  7i7 = equipm5t = use 9 a program
 7includ+ a self-direct$ program7 (     
physical ex]cise or physical activity1  
7ii7 to p>ticipate1 or receive          
in/ruction1 9 a program ( physical      
ex]cise1 nutrition1 or heal? coa*+      
7includ+ a self-direct$ program71 &     
7iii7 = memb]%ip at a fitness facility4 
7,b7 ,ov]all doll> limitation  7i7 ,9   
g5]al ,am\nts treat$ z m$ical c>e "u    
subp>agraph 7,a7 %all n exce$ #a1jjj )  

respect to any individual = any taxable 
ye>4  7ii7 ,exception ,clause 7i7 %all n
 apply = purposes ( det]m9+ :e!r exp5ses
 reimburs$ ?r\gh a heal? flexible sp5d+ 
arrangem5t subject to section           
#abe7;i77#a7 are incurr$ = m$ical c>e4  
7,c7 ,limitations relat$ to sports &    
fitness equipm5t ,am\nts paid = equipm5t
 describ$ 9 subp>agraph 7,a77i7 %all be 
treat$ z m$ical c>e only--  7i7 if su*  
equipm5t is utiliz$ exclusively =       
p>ticipation 9 fitness1 ex]cise1 sport1 
or o!r physical activity programs1  7ii7
 if su* equipm5t is n app>el or footwe>1
 &  7iii7 9 ! case ( any item ( sports  
equipm5t 7o!r ?an ex]cise equipm5t71 to 
! ext5t ! am\nt paid = su* item does n  
exce$ #bej4  7,d7 ,fitness facility ,=  
purposes ( subp>agraph 7,a77iii71 ! t]m 
fitness facility means a facility--  7i7
 :i* provides in/ruction 9 a program (  
physical ex]cise1 (f]s facilities = !   
pres]vation1 ma9t5ance1 enc\ragem5t1 or 
developm5t ( physical fitness1 or s]ves 
z ! site ( su* a program ( a ,/ate or   

local gov]nm5t1  7ii7 :i* is n a private
 club own$ & op]at$ by its memb]s1      
7iii7 :i* does n (f] golf1 hunt+1 sail+1
 or rid+ facilities1  7iv7 ^: heal? or  
fitness facility is n incid5tal to its  
ov]all function & purpose1 &  7v7 :i* is
 fully compliant ) ! ,/ate (            
jurisdiction & ,f$]al anti-discrim9ation
 laws4  4  7b7 ,limitation n ,to apply =
 c]ta9 purposes  7#a7 ,heal? sav+s      
acc\nts ,subp>agraph 7,a7 ( section     
#bbc7;c77#b7 ( ! ,int]nal ,rev5ue ,code 
( #aihf1 z am5d$ & r$esignat$ by        
subtitle ,b1 is fur!r am5d$ by ins]t+ 1 
det]m9$ )\t reg>d to p>agraph 7#ab77;,b7
 !re(7 aft] m$ical c>e 7z def9$ 9       
section #bac7;d74  7#b7 ,ar*] ,m,s,as   
,subp>agraph 7,a7 ( section #bbj7;d77#b7
 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z  
am5d$ by subtitle ,b1 is fur!r am5d$ by 
ins]t+ 1 det]m9$ )\t reg>d to p>agraph  
7#ab77;,b7 !re( aft] m$ical c>e 7z def9$
 9 section #bac7;d74  7c7 ,effective    
date ,! am5dm5ts made by ?is section    
%all apply to taxable ye>s beg9n+ aft] !

 date ( ! enactm5t ( ?is ,act4  #bbb4   
,c]ta9 nutritional & diet>y supplem5ts  
to be treat$ z m$ical c>e  7a7 ,9 g5]al 
,subsection 7d7 ( section #bac ( !      
,int]nal ,rev5ue ,code ( #aihf1 z am5d$ 
by section #bba1 is fur!r am5d$ by add+ 
at ! end ! foll[+ new p>agraph3  7#ac7  
,nutritional & diet>y supplem5ts  7,a7  
,9 g5]al ,! t]m m$ical c>e %all include 
am\nts paid to pur*ase h]bs1 vitam9s1   
m9]als1 homeopa?ic rem$ies1 meal        
replacem5t products1 & o!r diet>y &     
nutritional supplem5ts4  7,b7           
,limitation ,am\nts treat$ z m$ical c>e 
"u subp>agraph 7,a7 %all n exce$ #a1jjj 
) respect to any individual = any       
taxable ye>4  7,c7 ,meal replacem5t     
product ,= purposes ( ?is p>agraph1 !   
t]m meal replacem5t product means any   
product t--  7i7 is p]mitt$ to be>      
label+ mak+ a claim describ$ 9 section  
#djc7r77#c7 ( ! ,f$]al ,food1 ,drug1 &  
,cosmetic ,act1 &  7ii7 is p]mitt$ to   
claim "u su* section t su* product is l[
 9 fat & is a good s\rce ( prote91 fib]1

 & multiple ess5tial vitam9s & m9]als4  
7,d7 ,exception ,subp>agraph 7,b7 %all n
 apply = purposes ( det]m9+ :e!r exp5ses
 reimburs$ ?r\gh a heal? flexible sp5d+ 
arrangem5t subject to section           
#abe7;i77#a7 are incurr$ = m$ical c>e4  
4  7b7 ,limitation n ,to apply = c]ta9  
purposes  7#a7 ,heal? sav+s acc\nts     
,subp>agraph 7,a7 ( section #bbc7;c77#b7
 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z  
am5d$ & r$esignat$ by ?is ,act1 is am5d$
 by /rik+ p>agraph 7#ab77;,b7 & ins]t+  
p>agraphs 7#ab77;,b7 & 7#ac77;,b74  7#b7
 ,ar*] ,m,s,as ,subp>agraph 7,a7 (      
section #bbj7;d77#b71 z am5d$ by ?is    
,act1 is am5d$ by /rik+ p>agraph        
7#ab77;,b7 & ins]t+ p>agraphs 7#ab77;,b7
 & 7#ac77;,b74  7c7 ,effective date ,!  
am5dm5ts made by ?is section %all apply 
to taxable ye>s beg9n+ aft] ! date ( !  
enactm5t ( ?is ,act4  #bbc4 ,c]ta9      
provid] fees to be treat$ z m$ical c>e  
7a7 ,9 g5]al ,subsection 7d7 ( section  
#bac ( ! ,int]nal ,rev5ue ,code ( #aihf1
 z am5d$ by sections #bba & #bbb1 is    

am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#ad7 ,p]iodic provid] fees  
,! t]m m$ical c>e %all include-- 7,a7   
p]iodic fees paid to a prim>y c>e       
physician = a def9$ set ( m$ical s]vices
 or ! "r to receive m$ical s]vices on an
 z-ne$$ basis1 &  7,b7 pre-paid prim>y  
c>e s]vices design$ to scre5 =1         
diagnose1 cure1 mitigate1 treat1 or     
prev5t disease & promote wellness4  4   
7b7 ,exception = flexible sp5d+ acc\nts 
,section #abe ( ! ,int]nal ,rev5ue ,code
 ( #aihf is am5d$ by r$esignat+         
subsections 7k7 & 7l7 z subsections 7l7 
& 7m71 respectively1 & by ins]t+ aft]   
subsection 7j7 ! foll[+ new subsection3 
7k7 ,special rule ) respect to heal?    
flexible sp5d+ arrangem5ts ,= purposes (
 apply+ ?is section ) respect to any    
heal? flexible sp5d+ arrangem5t1 am\nts 
describ$ 9 section #bac7;d77#ad7 %all n 
be consid]$ insurance4  4  7c7          
,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ! date ( ! enactm5t ( ?is   

,act4  #bbd4 ,cl>ification ( treatm5t ( 
capitat$ prim>y c>e paym5ts z am\nts    
paid = m$ical c>e  7a7 ,9 g5]al         
,subsection 7d7 ( section #bac ( !      
,int]nal ,rev5ue ,code ( #aihf1 z am5d$ 
by ! prec$+ provisions ( ?is ,act1 is   
am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#ae7 ,treatm5t ( capitat$   
prim>y c>e paym5ts ,capitat$ prim>y c>e 
paym5ts %all be treat$ z am\nts paid =  
m$ical c>e4  4  7b7 ,effective date ,!  
am5dm5t made by ?is section %all apply  
to taxable ye>s beg9n+ aft] ! date ( !  
enactm5t ( ?is ,act4  ,d ,miscellane\s  
#bca4 ,contributions ( m$ic>e           
b5efici>ies p>ticipat+ 9 m$ic>e         
advantage ,,msa  7a7 ,9 g5]al ,section  
#ach7;b7 ( ! ,int]nal ,rev5ue ,code (   
#aihf is am5d$ by /rik+ p>agraph 7#b7 & 
by r$esignat+ p>agraphs 7#c7 & 7#d7 z   
p>agraphs 7#b7 & 7#c71 respectively4    
7b7 ,effective date ,! am5dm5t made by  
?is section %all apply to taxable ye>s  
beg9n+ aft] ! date ( ! enactm5t ( ?is   
,act4  #bcb4 ,physician *>ity &         

uncomp5sat$ c>e d$uction  7a7 ,9 g5]al  
,"p ,,vi ( sub*apt] ,b ( *apt] #a ( !   
,int]nal ,rev5ue ,code ( #aihf is am5d$ 
by add+ at ! end ! foll[+ new section3  
#aii;,a4 ,physician *>ity & uncomp5sat$ 
c>e  7a7 ,9 g5]al ,9 ! case ( a         
physician1 !re %all be all[$ z a        
d$uction = ! taxable ye> an am\nt equal 
to ! sum (--  7#a7 ! am\nt su* physician
 w\ld h o!rwise *>g$ = qualifi$ *>ity   
c>e provid$ by su* physician dur+ su*   
taxable ye>1 &  7#b7 ! am\nt ( any debt 
ow$ to su* physician = physicians'      
s]vices :i* becomes wor?less dur+ su*   
taxable ye>4  7b7 ,def9itions ,=        
purposes ( ?is section-- 7#a7 ,physician
 ,! t]m physician has ! mean+ giv5 to   
su* t]m 9 section #ahfa7r7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#aciex7r774  7#b7 ,qualifi$ *>ity c>e ,!
 t]m qualifi$ *>ity c>e means           
physicians' s]vices provid$ on a        
volunte] or pro bono basis 7n includ+   
any s]vices = :i* an am\nt 0 *>g$ b n   
paid74  7#c7 ,physicians' s]vices ,! t]m

 physicians' s]vices has ! mean+ giv5   
su* t]m 9 section #ahfa7q7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#aciex7q774  7c7 ,limitations  7#a7     
,s]vice *>ge limitation ,! am\nt det]m9$
 "u subsection 7a7 ) respect to any     
s]vices or debt--  7,a7 %all be r$uc$ by
 any reimbursem5t receiv$ by ! physician
 = su* s]vices or debt1 &  7,b7 %all n  
exce$ ! economic index ref]r$ to 9 !    
f\r? s5t5ce ( section #ahdb7;b77#c7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acieu7b77#c77 applicable to ! qualifi$ 
*>ity c>e provid$ or ! s]vices provid$ )
 respect to :i* ! debt relates4  ,9 !   
case ( physicians' s]vices to :i* su*   
economic index is n applicable1 !       
,secret>y1 9 consultation ) ! ,secret>y 
( ,heal? & ,human ,s]vices1 %all use    
data on uncomp5sat$ c>e = purposes ( !  
limitation "u subp>agraph 7,b71 & may   
adju/ su* data s z to be an appropriate 
proxy1 includ+ 79 ! case ( qualifi$     
*>ity c>e7 a d[nw>d adju/m5t to elim9ate
 bad debt data f uncomp5sat$ c>e data4  

7#b7 ,ov]all limitation ,! am\nt all[$ z
 a d$uction "u subsection 7a7 = any     
taxable ye> %all n exce$ an am\nt equal 
to #aj p]c5t ( ! gross income ( !       
taxpay] = ! taxable ye> d]iv$ f !       
taxpay]'s provision ( physicians'       
s]vices4  7d7 ,d5ial ( d\ble b5efit ,no 
d$uction %all be all[$ "u section #aff  
or any o!r provision ( ?is title = !    
am\nt ( any bad debt tak5 into acc\nt "u
 subsection 7a77#b7 7z r$uc$1 if        
applicable1 "u subsection 7c774  4  7b7 
,cl]ical am5dm5t ,! table ( sections =  
"p ,,vi ( sub*apt] ,b ( *apt] #a ( !    
,int]nal ,rev5ue ,code ( #aihf is am5d$ 
by add+ at ! end ! foll[+ new item3     
,sec4 #aii;,a4 ,physician *>ity &       
uncomp5sat$ c>e4  4  7c7 ,effective date
 ,! am5dm5ts made by ?is section %all   
apply to taxable ye>s beg9n+ aft] ! date
 ( ! enactm5t ( ?is ,act4  ,,iii        
,individual heal? insurance re=m  #cja4 
,pool re=m = individual memb]%ip        
expansion ,! ,public ,heal? ,s]vice ,act
 is am5d$ by ins]t+ aft] title ,,xxxiii 

! foll[+ new title3  ,,xxxiv ,pool ,re=m
 = ,individual ,memb]%ip ,expansion     
#cdjj4 ,purpose ,! purpose ( ?is title  
is to provide1 ?r\gh ! e/abli%m5t (     
indep5d5t heal? pools 7ref]r$ to 9 ?is  
title z ,,ihp71 = ! re=m (1 & expansion 
( enrollm5t 91 heal? insurance cov]age =
 individuals & small employ]s4  #cdja4  
,def9ition ( indep5d5t heal? pool  7a7  
,9 ,g5]al ,= purposes ( ?is title1 !    
t]ms individual heal? pool & ,,ihp mean 
a legal nonpr(it entity t meets ! foll[+
 requirem5ts3 7#a7 ,organization ,!     
,,ihp--  7,a7 has be5 =m$ & ma9ta9$ 9   
good fai? = a purpose t includes !      
=mation ( a risk pool 9 ord] to (f]     
heal? insurance cov]age to its memb]s2  
7,b7 does n condition memb]%ip 9 ! ,,ihp
 on any heal? /atus-relat$ factor relat+
 to an individual 7includ+ an employee (
 an employ] or a dep5d5t ( an employee72
  7,c7 does n make heal? insurance      
cov]age (f]$ ?r\gh ! ,,ihp available o!r
 ?an 9 connection ) a memb] ( ! ,,ihp2  
7,d7 is n a heal? insurance issu]2 &    

7,e7 does n receive any consid]ation    
directly or indirectly f any heal?      
insurance issu] 9 connection ) !        
enrollm5t ( any individuals1 or         
employees ( employ]s1 9 any heal?       
insurance cov]age1 except 9 conjunction 
) s]vices (f]$ ?r\gh ! ,,ihp4  7#b7     
,(f]+ heal? b5efits cov]age  7,a7       
,diff]5t gr\ps ,! ,,ihp1 9 conjunction )
 ^? heal? insurance issu]s t (f] heal?  
b5efits cov]age ?r\gh ! ,,ihp1 makes    
available heal? b5efits cov]age 9 !     
mann] describ$ 9 subsection 7b7 to all  
memb]s ( ! ,,ihp & ! dep5d5ts ( su*     
memb]s 7&1 9 ! case ( small employ]s1   
employees & _! dep5d5ts7 9 ! mann]      
describ$ 9 subsection 7c77#b7 at rates t
 are e/abli%$ by ! heal? insurance issu]
 on a policy or product specific basis &
 t may v>y = individuals cov]$ ?r\gh an 
,,ihp4  7,b7 ,nondiscrim9ation 9 cov]age
 (f]$  7i7 ,9 g5]al ,subject to clause  
7ii71 ! ,,ihp may n (f] heal? b5efits   
cov]age to a memb] ( an ,,ihp unless !  
same cov]age is (f]$ to all su* memb]s (

 ! ,,ihp4  7ii7 ,con/ruction ,no?+ 9 ?is
 title %all be con/ru$ z requir+ or     
p]mitt+ a heal? insurance issu] to      
provide cov]age outside ! s]vice area ( 
! issu]1 z approv$ "u ,/ate law1 or     
prev5t+ a heal? insurance issu] f       
und]writ+ or f exclud+ or limit+ !      
cov]age on any individual1 subject to ! 
requirem5t ( section #bgda 7relat+ to   
gu>ante$ availability ( individual heal?
 insurance cov]age to c]ta9 individuals 
) prior gr\p cov]age74  7,c7 ,no        
assumption ( insurance risk by ,,ihp ,! 
,,ihp provides heal? b5efits cov]age    
only ?r\gh contracts ) heal? insurance  
issu]s & does n assume insurance risk ) 
respect to su* cov]age4  7#c7           
,geographic areas ,no?+ 9 ?is title %all
 be con/ru$ z prev5t+ ! e/abli%m5t &    
op]ation ( m ?an "o ,,ihp 9 a geographic
 area or z limit+ ! numb] ( ,i,h,ps t   
may op]ate 9 any area4  7#d7 ,provision 
( adm9i/rative s]vices to pur*as]s ,!   
,,ihp may provide adm9i/rative s]vices =
 memb]s4 ,su* s]vices may include       

acc\nt+1 bill+1 & enrollm5t in=mation4  
7b7 ,heal? b5efits cov]age requirem5ts  
7#a7 ,compliance ) consum] protection   
requirem5ts ,except z provid$ 9 section 
#cdjb1 any heal? b5efits cov]age (f]$   
?r\gh an ,,ihp-- 7,a7 %all be issu$ by a
 heal? insurance issu] t meets all      
applicable ,/ate /&>ds relat+ to consum]
 protection2  7,b7 %all be approv$ or   
o!rwise p]mitt$ to be (f]$ "u ,/ate law2
 &  7,c7 may n impose any exclusion ( a 
specific disease f su* cov]age4  7#b7   
,wellness bonuses = heal? promotion     
,no?+ 9 ?is title %all be con/ru$ z     
preclud+ a heal? insurance issu] (f]+   
heal? b5efits cov]age ?r\gh an ,,ihp f  
e/abli%+ premium disc\nts or rebates =  
memb]s or f modify+ o!rwise applicable  
copaym5ts or d$uctibles 9 return =      
adh]5ce to programs ( heal? promotion & 
disease prev5tion s long z su* programs 
are agre$ to 9 advance by ! ,,ihp &     
comply ) all o!r provisions ( ?is title 
& d n discrim9ate among simil>ly situat$
 memb]s4  7c7 ,memb]s2 heal? insurance  

issu]s  7#a7 ,memb]s  7,a7 ,9 g5]al ,"u 
rules e/abli%$ to c>ry out ?is title1 ) 
respect to an individual or small       
employ] :o is a memb] ( an ,,ihp1 !     
individual may enroll = heal? b5efits   
cov]age 7includ+ cov]age = dep5d5ts (   
su* individual7 or ! employ] may enroll 
employees = heal? b5efits cov]age       
7includ+ cov]age = dep5d5ts ( su*       
employees7 (f]$ by a heal? insurance    
issu] ?r\gh ! ,,ihp4  7,b7 ,rules =     
enrollm5t ,no?+ 9 ?is p>agraph %all     
preclude an ,,ihp f e/abli%+ rules (    
enrollm5t & re5rollm5t ( memb]s4 ,su*   
rules %all be appli$ consi/5tly to all  
memb]s )9 ! ,,ihp & %all n be bas$ 9 any
 mann] on heal? /atus-relat$ factors4   
7#b7 ,heal? insurance issu]s ,! contract
 betwe5 an ,,ihp & a heal? insurance    
issu] %all provide1 ) respect to a memb]
 enroll$ ) heal? b5efits cov]age (f]$ by
 ! issu] ?r\gh ! ,,ihp1 = ! paym5t to ! 
issu] ( ! premiums 7if any7 collect$ by 
! ,,ihp = heal? insurance cov]age (f]$  
by ! issu]4  #cdjb4 ,application ( c]ta9

 laws & requirem5ts  7a7 ,preemption (  
,/ate laws re/rict+ =mation ( ,i,h,ps   
,any ,/ate law or regulation relat+ to !
 composition or organization ( an ,,ihp 
is preempt$ to ! ext5t ! law or         
regulation is inconsi/5t ) ! provisions 
( ?is title4  7b7 ,preemption ( ,/ate   
requirem5ts relat+ to heal? b5efit      
cov]age  7#a7 ,b5efit requirem5ts  7,a7 
,9 g5]al ,subject to subp>agraph 7,b71  
,/ate laws are sup]s$$1 & %all n apply  
to heal? b5efits cov]age made available 
?r\gh an ,,ihp1 ins(> z su* laws impose 
b5efit requirem5ts = su* cov]age1       
includ+ requirem5ts relat+ to cov]age ( 
specific provid]s1 specific s]vices or  
conditions1 or ! am\nt1 duration1 or    
scope ( b5efits4  7,b7 ,exception =     
,f$]ally impos$ requirem5ts & =         
requirem5ts prohibit+ disease-specific  
exclusions ,subp>agraph 7,a7 %all n     
apply to a requirem5t to ! ext5t !      
requirem5t-- 7i7 implem5ts title ,,xxvii
 or o!r ,f$]al law2 or  7ii7 prohibits  
imposition ( an exclusion ( a specific  

disease f heal? b5efits cov]age4  7#b7  
,o!r requirem5ts prev5t+ (f]+ ( cov]age 
?r\gh an ,,ihp ,/ate laws are sup]s$$1 &
 %all n apply to heal? b5efits cov]age  
made available ?r\gh an ,,ihp1 ins(> z  
su* laws impose any o!r requirem5ts     
7includ+ limitations on comp5sation     
arrangem5ts7 t1 directly or indirectly1 
preclude 7or h ! effect ( preclud+7 !   
(f]+ ( su* cov]age ?r\gh an ,,ihp1 if ! 
,,ihp meets ! requirem5ts ( ?is title4  
7c7 ,preemption ( ,/ate premium rat+    
requirem5ts ,/ate laws are sup]s$$1 &   
%all n apply to ! premiums impos$ =     
heal? b5efits cov]age made available    
?r\gh an ,,ihp1 ins(> z su* laws impose 
re/rictions on ! v>iation ( premiums    
among su* cov]age (f]$ to memb]s ( !    
,,ihp4  #cdjc4 ,def9itions ,= purposes (
 ?is title3 7#a7 ,dep5d5t ,! t]m        
dep5d5t1 z appli$ to heal? insurance    
cov]age (f]$ by a heal? insurance issu] 
lic5s$ 7or o!rwise regulat$7 9 a ,/ate1 
%all h ! mean+ appli$ to su* t]m )      
respect to su* cov]age "u ! laws ( !    

,/ate relat+ to su* cov]age & su* an    
issu]4 ,su* t]m may include ! sp\se &   
*ildr5 ( ! individual involv$4  7#b7    
,heal? b5efits cov]age ,! t]m heal?     
b5efits cov]age has ! mean+ giv5 ! t]m  
heal? insurance cov]age 9 section       
#bgia7;b77#a71 & does n include except$ 
b5efits 7z def9$ 9 section #bgia7;c774  
7#c7 ,heal? insurance issu] ,! t]m heal?
 insurance issu] has ! mean+ giv5 su*   
t]m 9 section #bgia7;b77#b74  7#d7      
,heal? /atus-relat$ factor ,! t]m heal? 
/atus-relat$ factor has ! mean+ giv5 su*
 t]m 9 section #bgia7;d77#i74  7#e7     
,memb] ,! t]m memb] means1 ) respect to 
an ,,ihp1 an individual or small employ]
 :o is a memb] ( ! legal entity describ$
 9 section #cdja7;a77#a7 to :i* ! ,,ihp 
is (f]+ cov]age4  7#f7 ,small employ] ,!
 t]m small employ] has ! mean+ giv5 su* 
t]m 9 section #gab7;c77#a77;,b7 ( !     
,employee ,retirem5t ,income ,security  
,act ( #aigd4  4  #cjb4 ,coop]ative     
gov]n+ ( individual heal? insurance     
cov]age  7a7 ,9 ,g5]al ,title ,,xxvii ( 

! ,public ,heal? ,s]vice ,act 7#db      
,u4,s4,c4 #cjj;gg et seq47 is am5d$ by  
add+ at ! end ! foll[+ new "p3  ,d      
,coop]ative ,gov]n+ ( ,individual ,heal?
 ,insurance ,cov]age  #bgie4 ,def9itions
 ,9 ?is "p3  7#a7 ,prim>y /ate ,! t]m   
prim>y ,/ate means1 ) respect to        
individual heal? insurance cov]age (f]$ 
by a heal? insurance issu]1 ! ,/ate     
designat$ by ! issu] z ! ,/ate ^: cov]$ 
laws %all gov]n ! heal? insurance issu] 
9 ! sale ( su* cov]age "u ?is "p4 ,an   
issu]1 ) respect to a p>ticul> policy1  
may only designate "o su* ,/ate z its   
prim>y ,/ate ) respect to all su*       
cov]age x (f]s4 ,su* an issu] may n     
*ange ! designat$ prim>y ,/ate ) respect
 to individual heal? insurance cov]age  
once ! policy is issu$1 except t su* a  
*ange may be made ^u r5ewal ( ! policy4 
,) respect to su* designat$ ,/ate1 !    
issu] is deem$ to be do+ bus9ess 9 t    
,/ate4  7#b7 ,second>y /ate ,! t]m      
second>y ,/ate means1 ) respect to      
individual heal? insurance cov]age (f]$ 

by a heal? insurance issu]1 any ,/ate t 
is n ! prim>y ,/ate4 ,9 ! case ( a heal?
 insurance issu] t is sell+ a policy 91 
or to a resid5t (1 a second>y ,/ate1 !  
issu] is deem$ to be do+ bus9ess 9 t    
second>y ,/ate4  7#c7 ,heal? insurance  
issu] ,! t]m heal? insurance issu] has !
 mean+ giv5 su* t]m 9 section           
#bgia7;b77#b71 except t su* an issu] mu/
 be lic5s$ 9 ! prim>y ,/ate & be        
qualifi$ to sell individual heal?       
insurance cov]age 9 t ,/ate4  7#d7      
,individual heal? insurance cov]age ,!  
t]m individual heal? insurance cov]age  
means heal? insurance cov]age (f]$ 9 !  
individual m>ket1 z def9$ 9 section     
#bgia7;e77#a74  7#e7 ,applicable /ate   
au?ority ,! t]m applicable ,/ate        
au?ority means1 ) respect to a heal?    
insurance issu] 9 a ,/ate1 ! ,/ate      
insurance commission] or (ficial or     
(ficials designat$ by ! ,/ate to en=ce !
 requirem5ts ( ?is title = ! ,/ate )    
respect to ! issu]4  7#f7 ,haz>d\s      
f9ancial condition ,! t]m haz>d\s       

f9ancial condition means t1 bas$ on its 
pres5t or reasonably anticipat$ f9ancial
 condition1 a heal? insurance issu] is  
unlikely to be able--  7,a7 to meet     
obligations to policyhold]s ) respect to
 kn[n claims & reasonably anticipat$    
claims2 or  7,b7 to pay o!r obligations 
9 ! normal c\rse ( bus9ess4  7#g7 ,cov]$
 laws  7,a7 ,9 g5]al ,! t]m cov]$ laws  
means ! laws1 rules1 regulations1       
agreem5ts1 & ord]s gov]n+ ! insurance   
bus9ess p]ta9+ to--  7i7 individual     
heal? insurance cov]age issu$ by a heal?
 insurance issu]2  7ii7 ! (f]1 sale1    
rat+ 7includ+ m$ical und]writ+71 r5ewal1
 & issuance ( individual heal? insurance
 cov]age to an individual2  7iii7 !     
provision to an individual 9 relation to
 individual heal? insurance cov]age (   
heal? c>e & insurance relat$ s]vices2   
7iv7 ! provision to an individual 9     
relation to individual heal? insurance  
cov]age ( managem5t1 op]ations1 &       
inve/m5t activities ( a heal? insurance 
issu]2 &  7v7 ! provision to an         

individual 9 relation to individual     
heal? insurance cov]age ( loss control &
 claims adm9i/ration = a heal? insurance
 issu] ) respect to liability = :i* !   
issu] provides insurance4  7,b7         
,exception ,su* t]m does n include any  
law1 rule1 regulation1 agreem5t1 or ord]
 gov]n+ ! use ( c>e or co/ managem5t    
te*niques1 includ+ any requirem5t relat$
 to provid] contract+1 network access or
 adequacy1 heal? c>e data collection1 or
 quality assurance4  7#h7 ,/ate ,! t]m  
,/ate means ! #ej ,/ates & includes !   
,di/rict ( ,columbia1 ,pu]to ,rico1 !   
,virg9 ,isl&s1 ,guam1 ,am]ican ,samoa1 &
 ! ,nor!rn ,m>iana ,isl&s4  7#i7 ,unfair
 claims settlem5t practices ,! t]m      
unfair claims settlem5t practices means 
only ! foll[+ practices3 7,a7 ,kn[+ly   
misrepres5t+ to claimants & insur$      
individuals relevant facts or policy    
provisions relat+ to cov]age at issue4  
7,b7 ,fail+ to ackn[l$ge ) reasonable   
promptness p]t95t communications )      
respect to claims aris+ "u policies4    

7,c7 ,fail+ to adopt & implem5t         
reasonable /&>ds = ! prompt inve/igation
 & settlem5t ( claims aris+ "u policies4
  7,d7 ,fail+ to effectuate prompt1     
fair1 & equitable settlem5t ( claims    
submitt$ 9 :i* liability has become     
reasonably cle>4  7,e7 ,refus+ to pay   
claims )\t conduct+ a reasonable        
inve/igation4  7,f7 ,fail+ to affirm or 
d5y cov]age ( claims )9 a reasonable    
p]iod ( "t aft] hav+ complet$ an        
inve/igation relat$ to ^? claims4  7,g7 
,a patt]n or practice ( compell+ insur$ 
individuals or _! b5efici>ies to        
in/itute suits to recov] am\nts due "u  
its policies by (f]+ sub/antially less  
?an ! am\nts ultimately recov]$ 9 suits 
br\ght by !m4  7,h7 ,a patt]n or        
practice ( attempt+ to settle or settl+ 
claims = less ?an ! am\nt t a reasonable
 p]son w\ld believe ! insur$ individual 
or 8 or h] b5efici>y 0 entitl$ by       
ref]5ce to writt5 or pr9t$ adv]tis+     
mat]ial accompany+ or made "p ( an      
application4  7,i7 ,attempt+ to settle  

or settl+ claims on ! basis ( an        
application t 0 mat]ially alt]$ )\t     
notice to1 or k or cons5t (1 ! insur$4  
7,j7 ,fail+ to provide =ms necess>y to  
pres5t claims )9 #ae cal5d> days (      
reque/s ) reasonable explanations reg>d+
 _! use4  7,k7 ,attempt+ to cancel a    
policy 9 less "t ?an t prescrib$ 9 !    
policy or by ! law ( ! prim>y ,/ate4    
7#aj7 ,fraud & abuse ,! t]m fraud &     
abuse means an act or omission committ$ 
by a p]son :o1 kn[+ly & ) int5t to      
defraud1 commits1 or conceals any       
mat]ial in=mation conc]n+1 "o or m ( !  
foll[+3  7,a7 ,pres5t+1 caus+ to be     
pres5t$1 or prep>+ ) k or belief t x w  
be pres5t$ to or by an insur]1 a        
re9sur]1 or brok] or its ag5t1 false    
in=mation z "p (1 9 support (1 or       
conc]n+ a fact mat]ial to "o or m ( !   
foll[+3  7i7 ,an application = !        
issuance or r5ewal ( an insurance policy
 or re9surance contract4  7ii7 ,! rat+ (
 an insurance policy or re9surance      
contract4  7iii7 ,a claim = paym5t or   

b5efit pursuant to an insurance policy  
or re9surance contract4  7iv7 ,premiums 
paid on an insurance policy or          
re9surance contract4  7v7 ,paym5ts made 
9 accordance ) ! t]ms ( an insurance    
policy or re9surance contract4  7vi7 ,a 
docum5t fil$ ) ! commission] or ! *ief  
insurance regulatory (ficial ( ano!r    
jurisdiction4  7vii7 ,! f9ancial        
condition ( an insur] or re9sur]4       
7viii7 ,! =mation1 acquisition1 m]g]1   
reconsolidation1 dissolution or )drawal 
f "o or m l9es ( insurance or re9surance
 9 all or "p ( a ,/ate by an insur] or  
re9sur]4  7ix7 ,! issuance ( writt5     
evid5ce ( insurance4  7x7 ,! re9/atem5t 
( an insurance policy4  7,b7            
,solicitation or acceptance ( new or    
r5ewal insurance risks on behalf ( an   
insur]1 re9sur]1 or o!r p]son engag$ 9 !
 bus9ess ( insurance by a p]son :o kn[s 
or %\ld "k t ! insur] or o!r p]son      
responsible = ! risk is insolv5t at ! "t
 ( ! transaction4  7,c7 ,transaction ( !
 bus9ess ( insurance 9 violation ( laws 

requir+ a lic5se1 c]tificate ( au?ority1
 or o!r legal au?ority = ! transaction (
 ! bus9ess ( insurance4  7,d7 ,attempt  
to commit1 aid+ or abett+ 9 ! commission
 (1 or conspiracy to commit ! acts or   
omissions specifi$ 9 ?is p>agraph4      
#bgif4 ,application ( law  7a7 ,9 ,g5]al
 ,! cov]$ laws ( ! prim>y ,/ate %all    
apply to individual heal? insurance     
cov]age (f]$ by a heal? insurance issu] 
9 ! prim>y ,/ate & 9 any second>y ,/ate1
 b only if ! cov]age & issu] comply ) ! 
conditions ( ?is section ) respect to ! 
(f]+ ( cov]age 9 any second>y ,/ate4    
7b7 ,exemptions ,f ,cov]$ ,laws 9 a     
,second>y ,/ate ,except z provid$ 9 ?is 
section1 a heal? insurance issu] )      
respect to its (f]1 sale1 rat+ 7includ+ 
m$ical und]writ+71 r5ewal1 & issuance ( 
individual heal? insurance cov]age 9 any
 second>y ,/ate is exempt f any cov]$   
laws ( ! second>y ,/ate 7& any rules1   
regulations1 agreem5ts1 or ord]s s\ght  
or issu$ by su* ,/ate "u or relat$ to   
su* cov]$ laws7 to ! ext5t t su* laws   

w\ld--  7#a7 make unlawful1 or regulate1
 directly or indirectly1 ! op]ation ( ! 
heal? insurance issu] op]at+ 9 !        
second>y ,/ate1 except t any second>y   
,/ate may require su* an issu]--  7,a7  
to pay1 on a nondiscrim9atory basis1    
applicable premium & o!r taxes 7includ+ 
high risk pool assessm5ts7 :i* are levi$
 on insur]s & surplus l9es insur]s1     
brok]s1 or policyhold]s "u ! laws ( !   
,/ate2  7,b7 to regi/] ) & designate !  
,/ate insurance commission] z its ag5t  
solely = ! purpose ( receiv+ s]vice (   
legal docum5ts or process2  7,c7 to     
submit to an exam9ation ( its f9ancial  
condition by ! ,/ate insurance          
commission] 9 any ,/ate 9 :i* ! issu] is
 do+ bus9ess to det]m9e ! issu]'s       
f9ancial condition1 if--  7i7 ! ,/ate   
insurance commission] ( ! prim>y ,/ate  
has n done an exam9ation )9 ! p]iod     
recomm5d$ by ! ,national ,association ( 
,insurance ,commission]s2 &  7ii7 any   
su* exam9ation is conduct$ 9 accordance 
) ! exam9]s' h&book ( ! ,national       

,association ( ,insurance ,commission]s 
& is coord9at$ to avoid unju/ifi$       
duplication & unju/ifi$ repetition2     
7,d7 to comply ) a lawful ord] issu$--  
7i7 9 a del9qu5cy proce$+ comm5c$ by !  
,/ate insurance commission] if !re has  
be5 a f9d+ ( f9ancial impairm5t "u      
subp>agraph 7,c72 or  7ii7 9 a volunt>y 
dissolution proce$+2  7,e7 to comply )  
an injunction issu$ by a c\rt ( compet5t
 jurisdiction1 ^u a petition by ! ,/ate 
insurance commission] alleg+ t ! issu]  
is 9 haz>d\s f9ancial condition2  7,f7  
to p>ticipate1 on a nondiscrim9atory    
basis1 9 any insurance insolv5cy gu>anty
 association or simil> association to   
:i* a heal? insurance issu] 9 ! ,/ate is
 requir$ to belong2  7,g7 to comply )   
any ,/ate law reg>d+ fraud & abuse 7z   
def9$ 9 section #bgie7aj771 except t if 
! ,/ate seeks an injunction reg>d+ !    
conduct describ$ 9 ?is subp>agraph1 su* 
injunction mu/ be obta9$ f a c\rt (     
compet5t jurisdiction2  7,h7 to comply )
 any ,/ate law reg>d+ unfair claims     

settlem5t practices 7z def9$ 9 section  
#bgie7i772 or  7,i7 to comply ) !       
applicable requirem5ts = indep5d5t      
review "u section #bgih ) respect to    
cov]age (f]$ 9 ! ,/ate2  7#b7 require   
any individual heal? insurance cov]age  
issu$ by ! issu] to be c\nt]sign$ by an 
insurance ag5t or brok] resid+ 9 t      
second>y ,/ate2 or  7#c7 o!rwise        
discrim9ate aga9/ ! issu] issu+         
insurance 9 bo? ! prim>y ,/ate & 9 any  
second>y ,/ate4  7c7 ,cle> & ,conspicu\s
 ,disclosure ,a heal? insurance issu]   
%all provide ! foll[+ notice1 9 #ab-po9t
 bold type1 9 any insurance cov]age (f]$
 9 a second>y ,/ate "u ?is "p by su* a  
heal? insurance issu] & at r5ewal ( !   
policy1 ) ! #e blank spaces !re9 be+    
appropriately fill$ ) ! "n ( ! heal?    
insurance issu]1 ! "n ( ! prim>y ,/ate1 
! "n ( ! second>y ,/ate1 ! "n ( !       
second>y ,/ate1 & ! "n ( ! second>y     
,/ate1 respectively1 = ! cov]age        
conc]n$3  ,notice ,?is policy is issu$  
by  & is gov]n$ by ! laws & regulations 

( ! 1 & x has met all ! laws ( t ,/ate z
 det]m9$ by t ,/ate's ,dep>tm5t (       
,insurance4 ,?is policy may be less     
exp5sive ?an o!rs because x is n subject
 to all ( ! insurance laws & regulations
 ( ! 1 includ+ cov]age ( "s s]vices or  
b5efits m&at$ by ! law ( ! 4            
,additionally1 ?is policy is n subject  
to all ( ! consum] protection laws or   
re/rictions on rate *anges ( ! 4 ,z )   
all insurance products1 be=e pur*as+ ?is
 policy1 y %\ld c>efully review ! policy
 & det]m9e :at heal? c>e s]vices !      
policy cov]s & :at b5efits x provides1  
includ+ any exclusions1 limitations1 or 
conditions = su* s]vices or b5efits4 4  
7d7 ,prohibition on ,c]ta9              
,reclassifications & ,premium ,increases
  7#a7 ,9 g5]al ,= purposes ( ?is       
section1 a heal? insurance issu] t      
provides individual heal? insurance     
cov]age to an individual "u ?is "p 9 a  
prim>y or second>y ,/ate may n ^u       
r5ewal--  7,a7 move or reclassify !     
individual insur$ "u ! heal? insurance  

cov]age f ! class su* individual is 9 at
 ! "t ( issue ( ! contract bas$ on !    
heal?-/atus relat$ factors ( !          
individual2 or  7,b7 increase ! premiums
 assess$ ! individual = su* cov]age bas$
 on a heal? /atus-relat$ factor or *ange
 ( a heal? /atus-relat$ factor or ! pa/ 
or prospective claim exp]i5ce ( ! insur$
 individual4  7#b7 ,con/ruction ,no?+ 9 
p>agraph 7#a7 %all be con/ru$ to        
prohibit a heal? insurance issu]-- 7,a7 
f t]m9at+ or discont9u+ cov]age or a    
class ( cov]age 9 accordance )          
subsections 7b7 & 7c7 ( section #bgdb2  
7,b7 f rais+ premium rates = all policy 
hold]s )9 a class bas$ on claims        
exp]i5ce2  7,c7 f *ang+ premiums or (f]+
 disc\nt$ premiums to individuals :o    
engage 9 wellness activities at int]vals
 prescrib$ by ! issu]1 if su* premium   
*anges or inc5tives--  7i7 are disclos$ 
to ! consum] 9 ! insurance contract2    
7ii7 are bas$ on specific wellness      
activities t are n applicable to all    
individuals2 &  7iii7 are n obta9able by

 all individuals to :om cov]age is (f]$2
  7,d7 f re9/at+ laps$ cov]age2 or  7,e7
 f retroactively adju/+ ! rates *>g$ an 
insur$ individual if ! initial rates 7  
set bas$ on mat]ial misrepres5tation by 
! individual at ! "t ( issue4  7e7      
,prior ,(f]+ ( ,policy 9 ,prim>y ,/ate  
,a heal? insurance issu] may n (f] =    
sale individual heal? insurance cov]age 
9 a second>y ,/ate unless t cov]age is  
curr5tly (f]$ = sale 9 ! prim>y ,/ate4  
7f7 ,lic5s+ ( ,ag5ts or ,brok]s = ,heal?
 ,insurance ,issu]s ,any ,/ate may      
require t a p]son act+1 or (f]+ to act1 
z an ag5t or brok] = a heal? insurance  
issu] ) respect to ! (f]+ ( individual  
heal? insurance cov]age obta9 a lic5se f
 t ,/ate1 ) commissions or o!r          
comp5sation subject to ! provisions ( ! 
laws ( t ,/ate1 except t a ,/ate may n  
impose any qualification or requirem5t  
:i* discrim9ates aga9/ a nonresid5t ag5t
 or brok]4  7g7 ,docum5ts = ,submission 
to ,/ate ,insurance ,commission] ,ea*   
heal? insurance issu] issu+ individual  

heal? insurance cov]age 9 bo? prim>y &  
second>y ,/ates %all submit--  7#a7 to !
 insurance commission] ( ea* ,/ate 9 :i*
 x int5ds to (f] su* cov]age1 be=e x may
 (f] individual heal? insurance cov]age 
9 su* ,/ate--  7,a7 a copy ( ! plan (   
op]ation or feasibility /udy or any     
simil> /atem5t ( ! policy be+ (f]$ & its
 cov]age 7:i* %all include ! "n ( its   
prim>y ,/ate & its pr9cipal place (     
bus9ess72  7,b7 writt5 notice ( any     
*ange 9 its designation ( its prim>y    
,/ate2 &  7,c7 writt5 notice f ! issu] (
 ! issu]'s compliance ) all ! laws ( !  
prim>y ,/ate2 &  7#b7 to ! insurance    
commission] ( ea* second>y ,/ate 9 :i* x
 (f]s individual heal? insurance        
cov]age1 a copy ( ! issu]'s qu>t]ly     
f9ancial /atem5t submitt$ to ! prim>y   
,/ate1 :i* /atem5t %all be c]tifi$ by an
 indep5d5t public acc\ntant & conta9 a  
/atem5t ( op9ion on loss & loss adju/m5t
 exp5se res]ves made by--  7,a7 a memb] 
( ! ,am]ican ,academy ( ,actu>ies2 or   
7,b7 a qualifi$ loss res]ve speciali/4  

7h7 ,p[] ( ,c\rts ,to ,enjo9 ,conduct   
,no?+ 9 ?is section %all be con/ru$ to  
affect ! au?ority ( any ,f$]al or ,/ate 
c\rt to enjo9--  7#a7 ! solicitation or 
sale ( individual heal? insurance       
cov]age by a heal? insurance issu] to   
any p]son or gr\p :o is n eligible = su*
 insurance2 or  7#b7 ! solicitation or  
sale ( individual heal? insurance       
cov]age t violates ! requirem5ts ( ! law
 ( a second>y ,/ate :i* are describ$ 9  
subp>agraphs 7,a7 ?r\gh 7,h7 ( section  
#bgif7;b77#a74  7i7 ,p[] ( ,second>y    
,/ates ,to ,take ,adm9i/rative ,action  
,no?+ 9 ?is section %all be con/ru$ to  
affect ! au?ority ( any ,/ate to enjo9  
conduct 9 violation ( t ,/ate's laws    
describ$ 9 section #bgif7;b77#a74  7j7  
,/ate ,p[]s ,to ,en=ce ,/ate ,laws  7#a7
 ,9 g5]al ,subject to ! provisions (    
subsection 7b77#a77;,g7 7relat+ to      
injunctions7 & p>agraph 7#b71 no?+ 9 ?is
 section %all be con/ru$ to affect !    
au?ority ( any ,/ate to make use ( any (
 its p[]s to en=ce ! laws ( su* ,/ate ) 

respect to :i* a heal? insurance issu]  
is n exempt "u subsection 7b74  7#b7    
,c\rts ( compet5t jurisdiction ,if a    
,/ate seeks an injunction reg>d+ !      
conduct describ$ 9 p>agraphs 7#a7 & 7#b7
 ( subsection 7h71 su* injunction mu/ be
 obta9$ f a ,f$]al or ,/ate c\rt (      
compet5t jurisdiction4  7k7 ,/ates'     
,au?ority ,to ,sue ,no?+ 9 ?is section  
%all affect ! au?ority ( any ,/ate to   
br+ action 9 any ,f$]al or ,/ate c\rt4  
7l7 ,g5]ally ,applicable ,laws ,no?+ 9  
?is section %all be con/ru$ to affect ! 
applicability ( ,/ate laws g5]ally      
applicable to p]sons or corporations4   
7m7 ,gu>ante$ ,availability ( ,cov]age  
to ,,hipaa ,eligible ,individuals ,to ! 
ext5t t a heal? insurance issu] is (f]+ 
cov]age 9 a prim>y ,/ate t does n       
accommodate resid5ts ( second>y ,/ates  
or does n provide a work+ me*anism =    
resid5ts ( a second>y ,/ate1 & ! issu]  
is (f]+ cov]age "u ?is "p 9 su* second>y
 ,/ate :i* has n adopt$ a qualifi$ high 
risk pool z its acceptable alt]native   

me*anism 7z def9$ 9 section             
#bgdd7;c77#b771 ! issu] %all1 ) respect 
to any individual heal? insurance       
cov]age (f]$ 9 a second>y ,/ate "u ?is  
"p1 comply ) ! gu>ante$ availability    
requirem5ts = eligible individuals 9    
section #bgda4  #bgig4 ,prim>y ,/ate mu/
 meet ,f$]al floor be=e issu] may sell  
into second>y ,/ates ,a heal? insurance 
issu] may n (f]1 sell1 or issue         
individual heal? insurance cov]age 9 a  
second>y ,/ate if ! ,/ate insurance     
commission] does n use a risk-bas$      
capital =mula = ! det]m9ation ( capital 
& surplus requirem5ts = all heal?       
insurance issu]s4  #bgih4 ,indep5d5t    
ext]nal appeals proc$ures  7a7 ,"r to   
,ext]nal ,appeal ,a heal? insurance     
issu] may n (f]1 sell1 or issue         
individual heal? insurance cov]age 9 a  
second>y ,/ate "u ! provisions ( ?is    
title unless--  7#a7 bo? ! second>y     
,/ate & ! prim>y ,/ate h legislation or 
regulations 9 place e/abli%+ an         
indep5d5t review process = individuals  

:o are cov]$ by individual heal?        
insurance cov]age2 or  7#b7 9 any case 9
 :i* ! requirem5ts ( p>agraph 7#a7 are n
 met ) respect to ! ei!r ( su* ,/ates1 !
 issu] provides an indep5d5t review     
me*anism sub/antially id5tical 7z       
det]m9$ by ! applicable ,/ate au?ority (
 su* ,/ate7 to t prescrib$ 9 ! ,heal?   
,c>ri] ,ext]nal ,review ,model ,act ( ! 
,national ,association ( ,insurance     
,commission]s = all individuals :o      
pur*ase insurance cov]age "u ! t]ms (   
?is "p1 except t1 "u su* me*anism1 !    
review is conduct$ by an indep5d5t      
m$ical review]1 or a panel ( su*        
review]s1 ) respect to :om ! requirem5ts
 ( subsection 7b7 are met4  7b7         
,qualifications ( ,indep5d5t ,m$ical    
,review]s ,9 ! case ( any indep5d5t     
review me*anism ref]r$ to 9 subsection  
7a77#b73 7#a7 ,9 g5]al ,9 ref]r+ a d5ial
 ( a claim to an indep5d5t m$ical       
review]1 or to any panel ( su* review]s1
 to conduct indep5d5t m$ical review1 !  
issu] %all ensure t--  7,a7 ea*         

indep5d5t m$ical review] meets !        
qualifications describ$ 9 p>agraphs 7#b7
 & 7#c72  7,b7 ) respect to ea* review1 
ea* review] meets ! requirem5ts (       
p>agraph 7#d7 & ! review]1 or at lea/ #a
 review] on ! panel1 meets ! requirem5ts
 describ$ 9 p>agraph 7#e72 &  7,c7      
comp5sation provid$ by ! issu] to ea*   
review] is consi/5t ) p>agraph 7#f74    
7#b7 ,lic5sure & exp]tise ,ea* indep5d5t
 m$ical review] %all be a physician     
7allopa?ic or o/eopa?ic7 or heal? c>e   
pr(essional :o--  7,a7 is appropriately 
cr$5tial$ or lic5s$ 9 "o or m ,/ates to 
deliv] heal? c>e s]vices2 &  7,b7       
typically treats ! condition1 makes !   
diagnosis1 or provides ! type ( treatm5t
 "u review4  7#c7 ,indep5d5ce  7,a7 ,9  
g5]al ,subject to subp>agraph 7,b71 ea* 
indep5d5t m$ical review] 9 a case %all--
 7i7 n be a relat$ p>ty 7z def9$ 9      
p>agraph 7#g772  7ii7 n h a mat]ial     
familial1 f9ancial1 or pr(essional      
relation%ip ) su* a p>ty2 &  7iii7 n    
o!rwise h a conflict ( int]e/ ) su* a   

p>ty 7z det]m9$ "u regulations74  7,b7  
,exception ,no?+ 9 subp>agraph 7,a7 %all
 be con/ru$ to-- 7i7 prohibit an        
individual1 solely on ! basis (         
affiliation ) ! issu]1 f s]v+ z an      
indep5d5t m$ical review] if--  7,i7 a   
non-affiliat$ individual is n reasonably
 available2  7,,ii7 ! affiliat$         
individual is n involv$ 9 ! provision ( 
items or s]vices 9 ! case "u review2    
7,,iii7 ! fact ( su* an affiliation is  
disclos$ to ! issu] & ! enrollee 7or    
au?oriz$ repres5tative7 & nei!r p>ty    
objects2 &  7,,iv7 ! affiliat$          
individual is n an employee ( ! issu] & 
does n provide s]vices exclusively or   
prim>ily to or on behalf ( ! issu]2     
7ii7 prohibit an individual :o has /aff 
privileges at ! in/itution :]e !        
treatm5t involv$ takes place f s]v+ z an
 indep5d5t m$ical review] m]ely on !    
basis ( su* affiliation if ! affiliation
 is disclos$ to ! issu] & ! enrollee 7or
 au?oriz$ repres5tative71 & nei!r p>ty  
objects2 or  7iii7 prohibit receipt (   

comp5sation by an indep5d5t m$ical      
review] f an entity if ! comp5sation is 
provid$ consi/5t ) p>agraph 7#f74  7#d7 
,practic+ heal? c>e pr(essional 9 same  
field  7,a7 ,9 g5]al ,9 a case involv+  
treatm5t1 or ! provision ( items or     
s]vices-- 7i7 by a physician1 a review] 
%all be a practic+ physician 7allopa?ic 
or o/eopa?ic7 ( ! same or simil>        
specialty1 z a physician :o1 act+ )9 !  
appropriate scope ( practice )9 ! ,/ate 
9 :i* ! s]vice is provid$ or r5d]$1     
typically treats ! condition1 makes !   
diagnosis1 or provides ! type ( treatm5t
 "u review2 or  7ii7 by a non-physician 
heal? c>e pr(essional1 ! review]1 or at 
lea/ #a memb] ( ! review panel1 %all be 
a practic+ non-physician heal? c>e      
pr(essional ( ! same or simil> specialty
 z ! non-physician heal? c>e pr(essional
 :o1 act+ )9 ! appropriate scope (      
practice )9 ! ,/ate 9 :i* ! s]vice is   
provid$ or r5d]$1 typically treats !    
condition1 makes ! diagnosis1 or        
provides ! type ( treatm5t "u review4   

7,b7 ,practic+ def9$ ,= purposes ( ?is  
p>agraph1 ! t]m practic+ means1 )       
respect to an individual :o is a        
physician or o!r heal? c>e pr(essional1 
t ! individual provides heal? c>e       
s]vices to individual pati5ts on av]age 
at lea/ #b days p] week4  7#e7 ,p$iatric
 exp]tise ,9 ! case ( an ext]nal review 
relat+ to a *ild1 a review] %all h      
exp]tise "u p>agraph 7#b7 9 p$iatrics4  
7#f7 ,limitations on review] comp5sation
 ,comp5sation provid$ by ! issu] to an  
indep5d5t m$ical review] 9 connection ) 
a review "u ?is section %all--  7,a7 n  
exce$ a reasonable level2 &  7,b7 n be  
cont+5t on ! decision r5d]$ by !        
review]4  7#g7 ,relat$ p>ty def9$ ,=    
purposes ( ?is section1 ! t]m relat$    
p>ty means1 ) respect to a d5ial ( a    
claim "u a cov]age relat+ to an         
enrollee1 any ( ! foll[+3  7,a7 ,! issu]
 involv$1 or any fiduci>y1 (fic]1       
director1 or employee ( ! issu]4  7,b7  
,! enrollee 7or au?oriz$ repres5tative74
  7,c7 ,! heal? c>e pr(essional t       

provides ! items or s]vices involv$ 9 ! 
d5ial4  7,d7 ,! in/itution at :i* !     
items or s]vices 7or treatm5t7 involv$ 9
 ! d5ial are provid$4  7,e7 ,!          
manufactur] ( any drug or o!r item t is 
includ$ 9 ! items or s]vices involv$ 9 !
 d5ial4  7,f7 ,any o!r p>ty det]m9$ "u  
any regulations to h a sub/antial int]e/
 9 ! d5ial involv$4  7#h7 ,def9itions ,=
 purposes ( ?is subsection-- 7,a7       
,enrollee ,! t]m enrollee means1 )      
respect to heal? insurance cov]age (f]$ 
by a heal? insurance issu]1 an          
individual enroll$ ) ! issu] to receive 
su* cov]age4  7,b7 ,heal? c>e           
pr(essional ,! t]m heal? c>e pr(essional
 means an individual :o is lic5s$1      
accr$it$1 or c]tifi$ "u ,/ate law to    
provide specifi$ heal? c>e s]vices & :o 
is op]at+ )9 ! scope ( su* lic5sure1    
accr$itation1 or c]tification4  #bgii4  
,en=cem5t  7a7 ,9 ,g5]al ,subject to    
subsection 7b71 ) respect to specific   
individual heal? insurance cov]age !    
prim>y ,/ate = su* cov]age has sole     

jurisdiction to en=ce ! prim>y ,/ate's  
cov]$ laws 9 ! prim>y ,/ate & any       
second>y ,/ate4  7b7 ,second>y ,/ate's  
,au?ority ,no?+ 9 subsection 7a7 %all be
 con/ru$ to affect ! au?ority ( a       
second>y ,/ate to en=ce its laws z set  
=? 9 ! exception specifi$ 9 section     
#bgif7;b77#a74  7c7 ,c\rt ,int]pretation
 ,9 review+ action initiat$ by !        
applicable second>y ,/ate au?ority1 !   
c\rt ( compet5t jurisdiction %all apply 
! cov]$ laws ( ! prim>y ,/ate4  7d7     
,notice ( ,compliance ,failure ,9 ! case
 ( individual heal? insurance cov]age   
(f]$ 9 a second>y ,/ate t fails to      
comply ) ! cov]$ laws ( ! prim>y ,/ate1 
! applicable ,/ate au?ority ( ! second>y
 ,/ate may notify ! applicable ,/ate    
au?ority ( ! prim>y ,/ate4  4  7b7      
,effective ,date ,! am5dm5t made by     
subsection 7a7 %all apply to individual 
heal? insurance cov]age (f]$1 issu$1 or 
sold aft] ! date t is "o ye> aft] ! date
 ( ! enactm5t ( ?is ,act4  7c7 ,,gao    
,ongo+ ,/udy & ,reports  7#a7 ,/udy ,!  

,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all conduct an ongo+ /udy conc]n+ !    
effect ( ! am5dm5t made by subsection   
7a7 on--  7,a7 ! numb] ( un9sur$ &      
und]9sur$2  7,b7 ! availability & co/ ( 
heal? insurance policies = individuals )
 pre-exi/+ m$ical conditions2  7,c7 !   
availability & co/ ( heal? insurance    
policies g5]ally2  7,d7 ! elim9ation or 
r$uction ( diff]5t types ( b5efits "u   
heal? insurance policies (f]$ 9 diff]5t 
,/ates2 &  7,e7 cases ( fraud or abuse  
relat+ to heal? insurance cov]age (f]$  
"u su* am5dm5t & ! resolution ( su*     
cases4  7#b7 ,annual reports ,!         
,comptroll] ,g5]al %all submit to       
,congress an annual report1 aft] ! end (
 ea* ( ! #e ye>s foll[+ ! effective date
 ( ! am5dm5t made by subsection 7a71 on 
! ongo+ /udy conduct$ "u p>agraph 7#a74 
,,iv ,association heal? plans  #dja4    
,rules gov]n+ association heal? plans   
7a7 ,9 ,g5]al ,subtitle ,b ( title ,i ( 
! ,employee ,retirem5t ,income ,security
 ,act ( #aigd is am5d$ by add+ aft] "p  

#g ! foll[+ new "p3  #h ,rules gov]n+   
association heal? plans  #hja4          
,association heal? plans  7a7 ,9 ,g5]al 
,= purposes ( ?is "p1 ! t]m association 
heal? plan means a gr\p heal? plan ^:   
sponsor is 7or is deem$ "u ?is "p to be7
 describ$ 9 subsection 7b74  7b7        
,sponsor%ip ,! sponsor ( a gr\p heal?   
plan is describ$ 9 ?is subsection if su*
 sponsor-- 7#a7 is organiz$ & ma9ta9$ 9 
good fai?1 ) a con/itution & bylaws     
specifically /at+ its purpose & provid+ 
= p]iodic meet+s on at lea/ an annual   
basis1 z a bona fide trade association1 
a bona fide indu/ry association 7includ+
 a rural electric coop]ative association
 or a rural telephone coop]ative        
association71 a bona fide pr(essional   
association1 or a bona fide *amb] (     
comm]ce 7or simil> bona fide bus9ess    
association1 includ+ a corporation or   
simil> organization t op]ates on a      
coop]ative basis 7)9 ! mean+ ( section  
#acha ( ! ,int]nal ,rev5ue ,code (      
#aihf771 = sub/antial purposes o!r ?an t

 ( obta9+ or provid+ m$ical c>e2  7#b7  
is e/abli%$ z a p]man5t entity :i*      
receives ! active support ( its memb]s &
 requires = memb]%ip paym5t on a p]iodic
 basis ( dues or paym5ts necess>y to    
ma9ta9 eligibility = memb]%ip 9 !       
sponsor2 &  7#c7 does n condition       
memb]%ip1 su* dues or paym5ts1 or       
cov]age "u ! plan on ! basis ( heal?    
/atus-relat$ factors ) respect to !     
employees ( its memb]s 7or affiliat$    
memb]s71 or ! dep5d5ts ( su* employees1 
& does n condition su* dues or paym5ts  
on ! basis ( gr\p heal? plan            
p>ticipation4  ,any sponsor consi/+ ( an
 association ( entities :i* meet !      
requirem5ts ( p>agraphs 7#a71 7#b71 &   
7#c7 %all be deem$ to be a sponsor      
describ$ 9 ?is subsection4  #hjb4       
,c]tification ( association heal? plans 
7a7 ,9 ,g5]al ,! applicable au?ority    
%all prescribe by regulation a proc$ure 
"u :i*1 subject to subsection 7b71 !    
applicable au?ority %all c]tify         
association heal? plans :i* apply =     

c]tification z meet+ ! requirem5ts ( ?is
 "p4  7b7 ,/&>ds ,"u ! proc$ure         
prescrib$ pursuant to subsection 7a71 9 
! case ( an association heal? plan t    
provides at lea/ "o b5efit option :i*   
does n consi/ ( heal? insurance cov]age1
 ! applicable au?ority %all c]tify su*  
plan z meet+ ! requirem5ts ( ?is "p only
 if ! applicable au?ority is satisfi$ t 
! applicable requirem5ts ( ?is "p are   
met 7or1 ^u ! date on :i* ! plan is to  
comm5ce op]ations1 w be met7 ) respect  
to ! plan4  7c7 ,requirem5ts ,applicable
 to ,c]tifi$ ,plans ,an association     
heal? plan ) respect to :i* c]tification
 "u ?is "p is 9 effect %all meet !      
applicable requirem5ts ( ?is "p1        
effective on ! date ( c]tification 7or1 
if lat]1 on ! date on :i* ! plan is to  
comm5ce op]ations74  7d7 ,requirem5ts = 
,cont9u$ ,c]tification ,! applicable    
au?ority may provide by regulation =    
cont9u$ c]tification ( association heal?
 plans "u ?is "p4  7e7 ,class           
,c]tification = ,fully ,insur$ ,plans ,!

 applicable au?ority %all e/abli% a     
class c]tification proc$ure =           
association heal? plans "u :i* all      
b5efits consi/ ( heal? insurance        
cov]age4 ,"u su* proc$ure1 ! applicable 
au?ority %all provide = ! grant+ (      
c]tification "u ?is "p to ! plans 9 ea* 
class ( su* association heal? plans ^u  
appropriate fil+ "u su* proc$ure 9      
connection ) plans 9 su* class & paym5t 
( ! prescrib$ fee "u section #hjg7;a74  
7f7 ,c]tification ( ,self-,insur$       
,association ,heal? ,plans ,an          
association heal? plan :i* (f]s "o or m 
b5efit options :i* d n consi/ ( heal?   
insurance cov]age may be c]tifi$ "u ?is 
"p only if su* plan consi/s (--  7#a7 a 
plan :i* (f]$ su* cov]age on ! date ( ! 
enactm5t ( ! ,obamac>e ,replacem5t ,act2
  7#b7 a plan "u :i* ! sponsor does n   
re/rict memb]%ip to "o or m trades &    
bus9esses or indu/ries & ^: eligible    
p>ticipat+ employ]s repres5t a broad    
cross-section ( trades & bus9esses or   
indu/ries2 or  7#c7 a plan ^: eligible  

p>ticipat+ employ]s repres5t "o or m    
trades or bus9esses1 or "o or m         
indu/ries1 consi/+ ( any ( ! foll[+3    
agriculture2 equipm5t & automobile      
deal]%ips2 b>b]+ & cosmetology2 c]tifi$ 
public acc\nt+ practices2 *ild c>e2     
con/ruction2 dance1 !atrical & or*e/ra  
productions2 dis9fect+ & pe/ control2   
f9ancial s]vices2 fi%+2 food s]vice     
e/abli%m5ts2 hospitals2 labor           
organizations2 logg+2 manufactur+       
7metals72 m9+2 m$ical & d5tal practices2
 m$ical laboratories2 pr(essional       
consult+ s]vices2 sanit>y s]vices2      
transportation 7local & freight72       
w>eh\s+2 :olesal+_/di/ribut+2 or any o!r
 trade or bus9ess or indu/ry :i* has be5
 indicat$ z hav+ av]age or above-av]age 
risk or heal? claims exp]i5ce by reason 
( ,/ate rate fil+s1 d5ials ( cov]age1   
propos$ premium rate levels1 or o!r     
means demon/rat$ by su* plan 9          
accordance ) regulations4  #hjc4        
,requirem5ts relat+ to sponsors & bo>ds 
( tru/ees  7a7 ,sponsor ,! requirem5ts (

 ?is subsection are met ) respect to an 
association heal? plan if ! sponsor has 
met 7or is deem$ "u ?is "p to h met7 !  
requirem5ts ( section #hja7;b7 = a      
cont9u\s p]iod ( n less ?an #c ye>s end+
 ) ! date ( ! application = c]tification
 "u ?is "p4  7b7 ,bo>d ( ,tru/ees ,!    
requirem5ts ( ?is subsection are met )  
respect to an association heal? plan if 
! foll[+ requirem5ts are met3  7#a7     
,fiscal control ,! plan is op]at$1      
pursuant to a tru/ agreem5t1 by a bo>d (
 tru/ees :i* has complete fiscal control
 ov] ! plan & :i* is responsible = all  
op]ations ( ! plan4  7#b7 ,rules (      
op]ation & f9ancial controls ,! bo>d (  
tru/ees has 9 effect rules ( op]ation & 
f9ancial controls1 bas$ on a #c-ye> plan
 ( op]ation1 adequate to c>ry out ! t]ms
 ( ! plan & to meet all requirem5ts (   
?is title applicable to ! plan4  7#c7   
,rules gov]n+ relation%ip to p>ticipat+ 
employ]s & to contractors  7,a7 ,bo>d   
memb]%ip  7i7 ,9 g5]al ,except z provid$
 9 clauses 7ii7 & 7iii71 ! memb]s ( !   

bo>d ( tru/ees are individuals select$ f
 individuals :o are ! own]s1 (fic]s1    
directors1 or employees ( ! p>ticipat+  
employ]s or :o are p>tn]s 9 ! p>ticipat+
 employ]s & actively p>ticipate 9 !     
bus9ess4  7ii7 ,limitation  7,i7 ,g5]al 
rule ,except z provid$ 9 subclauses     
7,,ii7 & 7,,iii71 no su* memb] is an    
own]1 (fic]1 director1 or employee (1 or
 p>tn] 91 a contract adm9i/rator or o!r 
s]vice provid] to ! plan4  7,,ii7       
,limit$ exception = provid]s ( s]vices  
solely on behalf ( ! sponsor ,(fic]s or 
employees ( a sponsor :i* is a s]vice   
provid] 7o!r ?an a contract adm9i/rator7
 to ! plan may be memb]s ( ! bo>d if !y 
con/itute n m ?an #be p]c5t ( ! memb]%ip
 ( ! bo>d & !y d n provide s]vices to ! 
plan o!r ?an on behalf ( ! sponsor4     
7,,iii7 ,treatm5t ( provid]s ( m$ical   
c>e ,9 ! case ( a sponsor :i* is an     
association ^: memb]%ip consi/s prim>ily
 ( provid]s ( m$ical c>e1 subclause 7,i7
 %all n apply 9 ! case ( any s]vice     
provid] describ$ 9 subclause 7,i7 :o is 

a provid] ( m$ical c>e "u ! plan4  7iii7
 ,c]ta9 plans exclud$ ,clause 7i7 %all n
 apply to an association heal? plan :i* 
is 9 exi/5ce on ! date ( ! enactm5t ( ! 
,obamac>e ,replacem5t ,act4  7,b7 ,sole 
au?ority ,! bo>d has sole au?ority "u ! 
plan to approve applications =          
p>ticipation 9 ! plan & to contract ) a 
s]vice provid] to adm9i/] ! day-to-day  
affairs ( ! plan4  7c7 ,treatm5t (      
,fran*ise ,networks ,9 ! case ( a gr\p  
heal? plan :i* is e/abli%$ & ma9ta9$ by 
a fran*is] = a fran*ise network consi/+ 
( its fran*isees--  7#a7 ! requirem5ts (
 subsection 7a7 & section #hja7;a7 %all 
be deem$ met if su* requirem5ts w\ld    
o!rwise be met if ! fran*is] 7 deem$ to 
be ! sponsor ref]r$ to 9 section        
#hja7;b71 su* network 7 deem$ to be an  
association describ$ 9 section #hja7;b71
 & ea* fran*isee 7 deem$ to be a memb]  
7( ! association & ! sponsor7 ref]r$ to 
9 section #hja7;b72 &  7#b7 !           
requirem5ts ( section #hjd7;a77#a7 %all 
be deem$ met4  ,! ,secret>y may by      

regulation def9e = purposes ( ?is       
subsection ! t]ms fran*is]1 fran*ise    
network1 & fran*isee4  #hjd4            
,p>ticipation & cov]age requirem5ts  7a7
 ,cov]$ ,employ]s & ,individuals ,!     
requirem5ts ( ?is subsection are met )  
respect to an association heal? plan if1
 "u ! t]ms ( ! plan--  7#a7 ea*         
p>ticipat+ employ] mu/ be-- 7,a7 a memb]
 ( ! sponsor2  7,b7 ! sponsor2 or  7,c7 
an affiliat$ memb] ( ! sponsor ) respect
 to :i* ! requirem5ts ( subsection 7b7  
are met1  except t1 9 ! case ( a sponsor
 :i* is a pr(essional association or o!r
 individual-bas$ association1 if at lea/
 "o ( ! (fic]s1 directors1 or employees 
( an employ]1 or at lea/ "o ( !         
individuals :o are p>tn]s 9 an employ] &
 :o actively p>ticipates 9 ! bus9ess1 is
 a memb] or su* an affiliat$ memb] ( !  
sponsor1 p>ticipat+ employ]s may also   
include su* employ]2 &  7#b7 all        
individuals comm5c+ cov]age "u ! plan   
aft] c]tification "u ?is "p mu/ be--    
7,a7 active or retir$ own]s 7includ+    

self-employ$ individuals71 (fic]s1      
directors1 or employees (1 or p>tn]s 91 
p>ticipat+ employ]s2 or  7,b7 !         
b5efici>ies ( individuals describ$ 9    
subp>agraph 7,a74  7b7 ,cov]age (       
,previ\sly ,un9sur$ ,employees ,9 ! case
 ( an association heal? plan 9 exi/5ce  
on ! date ( ! enactm5t ( ! ,obamac>e    
,replacem5t ,act1 an affiliat$ memb] ( !
 sponsor ( ! plan may be (f]$ cov]age "u
 ! plan z a p>ticipat+ employ] only if--
  7#a7 ! affiliat$ memb] 0 an affiliat$ 
memb] on ! date ( c]tification "u ?is   
"p2 or  7#b7 dur+ ! #ab-mon? p]iod      
prec$+ ! date ( ! (f]+ ( su* cov]age1 ! 
affiliat$ memb] has n ma9ta9$ or        
contribut$ to a gr\p heal? plan )       
respect to any ( its employees :o w\ld  
o!rwise be eligible to p>ticipate 9 su* 
association heal? plan4  7c7 ,individual
 ,m>ket ,unaffect$ ,! requirem5ts ( ?is 
subsection are met ) respect to an      
association heal? plan if1 "u ! t]ms ( !
 plan1 no p>ticipat+ employ] may provide
 heal? insurance cov]age 9 ! individual 

m>ket = any employee n cov]$ "u ! plan  
:i* is simil> to ! cov]age              
contemporane\sly provid$ to employees ( 
! employ] "u ! plan1 if su* exclusion ( 
! employee f cov]age "u ! plan is bas$  
on a heal? /atus-relat$ factor ) respect
 to ! employee & su* employee w\ld1 b = 
su* exclusion on su* basis1 be eligible 
= cov]age "u ! plan4  7d7 ,prohibition (
 ,discrim9ation ,aga9/ ,employ]s &      
,employees ,eligible ,to ,p>ticipate ,! 
requirem5ts ( ?is subsection are met )  
respect to an association heal? plan    
if-- 7#a7 "u ! t]ms ( ! plan1 all       
employ]s meet+ ! prec$+ requirem5ts (   
?is section are eligible to qualify z   
p>ticipat+ employ]s = all geographically
 available cov]age options1 unless1 9 ! 
case ( any su* employ]1 p>ticipation or 
contribution requirem5ts ( ! type ref]r$
 to 9 section #bgaa ( ! ,public ,heal?  
,s]vice ,act are n met2  7#b7 ^u reque/1
 any employ] eligible to p>ticipate is  
furni%$ in=mation reg>d+ all cov]age    
options available "u ! plan2 &  7#c7 !  

applicable requirem5ts ( sections #gja1 
#gjb1 & #gjc are met ) respect to !     
plan4  #hje4 ,o!r requirem5ts relat+ to 
plan docum5ts1 contribution rates1 &    
b5efit options  7a7 ,9 ,g5]al ,!        
requirem5ts ( ?is section are met )     
respect to an association heal? plan if 
! foll[+ requirem5ts are met3  7#a7     
,cont5ts ( gov]n+ in/rum5ts ,! in/rum5ts
 gov]n+ ! plan include a writt5         
in/rum5t1 meet+ ! requirem5ts ( an      
in/rum5t requir$ "u section             
#djb7;a77#a71 :i*--  7,a7 provides t !  
bo>d ( tru/ees s]ves z ! nam$ fiduci>y  
requir$ = plans "u section #djb7;a77#a7 
& s]ves 9 ! capacity ( a plan           
adm9i/rator 7ref]r$ to 9 section        
#c7af77;,a772  7,b7 provides t ! sponsor
 ( ! plan is to s]ve z plan sponsor     
7ref]r$ to 9 section #c7af77;,b772 &    
7,c7 incorporates ! requirem5ts (       
section #hjf4  7#b7 ,contribution rates 
mu/ be nondiscrim9atory  7,a7 ,!        
contribution rates = any p>ticipat+     
small employ] d n v>y on ! basis ( any  

heal? /atus-relat$ factor 9 relation to 
employees ( su* employ] or _!           
b5efici>ies & d n v>y on ! basis ( !    
type ( bus9ess or indu/ry 9 :i* su*     
employ] is engag$4  7,b7 ,no?+ 9 ?is    
title or any o!r provision ( law %all be
 con/ru$ to preclude an association     
heal? plan1 or a heal? insurance issu]  
(f]+ heal? insurance cov]age 9          
connection ) an association heal? plan1 
f--  7i7 sett+ contribution rates bas$  
on ! claims exp]i5ce ( ! plan2 or  7ii7 
v>y+ contribution rates = small employ]s
 9 a ,/ate to ! ext5t t su* rates c\ld  
v>y us+ ! same me?odology employ$ 9 su* 
,/ate = regulat+ premium rates 9 ! small
 gr\p m>ket ) respect to heal? insurance
 cov]age (f]$ 9 connection ) bona fide  
associations 7)9 ! mean+ ( section      
#bgia7;d77#c7 ( ! ,public ,heal? ,s]vice
 ,act71  subject to ! requirem5ts (     
section #gjb7;b7 relat+ to contribution 
rates4  7#c7 ,floor = numb] ( cov]$     
individuals ) respect to c]ta9 plans ,if
 any b5efit option "u ! plan does n     

consi/ ( heal? insurance cov]age1 ! plan
 has z ( ! beg9n+ ( ! plan ye> n few]   
?an #a1jjj p>ticipants & b5efici>ies4   
7#d7 ,m>ket+ requirem5ts  7,a7 ,9 g5]al 
,if a b5efit option :i* consi/s ( heal? 
insurance cov]age is (f]$ "u ! plan1    
,/ate-lic5s$ insurance ag5ts %all be us$
 to di/ribute to small employ]s cov]age 
:i* does n consi/ ( heal? insurance     
cov]age 9 a mann] comp>able to ! mann] 9
 :i* su* ag5ts are us$ to di/ribute     
heal? insurance cov]age4  7,b7          
,/ate-lic5s$ insurance ag5ts ,= purposes
 ( subp>agraph 7,a71 ! t]m ,/ate-lic5s$ 
insurance ag5ts means "o or m ag5ts :o  
are lic5s$ 9 a ,/ate & are subject to ! 
laws ( su* ,/ate relat+ to lic5sure1    
qualification1 te/+1 exam9ation1 &      
cont9u+ education ( p]sons au?oriz$ to  
(f]1 sell1 or solicit heal? insurance   
cov]age 9 su* ,/ate4  7#e7 ,regulatory  
requirem5ts ,su* o!r requirem5ts z !    
applicable au?ority det]m9es are        
necess>y to c>ry out ! purposes ( ?is   
"p1 :i* %all be prescrib$ by !          

applicable au?ority by regulation4  7b7 
,ability ( ,association ,heal? ,plans   
,to ,design ,b5efit ,options ,subject to
 section #ead7;d71 no?+ 9 ?is "p or any 
provision ( ,/ate law 7z def9$ 9 section
 #ead7;c77#a77 %all be con/ru$ to       
preclude an association heal? plan1 or a
 heal? insurance issu] (f]+ heal?       
insurance cov]age 9 connection ) an     
association heal? plan1 f ex]cis+ its   
sole discretion 9 select+ ! specific    
items & s]vices consi/+ ( m$ical c>e to 
be includ$ z b5efits "u su* plan or     
cov]age1 except 7subject to section     
#ead7 9 ! case ( 7#a7 any law to ! ext5t
 t x is n preempt$ "u section           
#gca7;a77#a7 ) respect to matt]s gov]n$ 
by section #gaa1 #gab1 or #gac1 or 7#b7 
any law ( ! ,/ate ) :i* fil+ & approval 
( a policy type (f]$ by ! plan 0        
initially obta9$ to ! ext5t t su* law   
prohibits an exclusion ( a specific     
disease f su* cov]age4  #hjf4 ,ma9t5ance
 ( res]ves & provisions = solv5cy =     
plans provid+ heal? b5efits 9 addition  

to heal? insurance cov]age  7a7 ,9      
,g5]al ,! requirem5ts ( ?is section are 
met ) respect to an association heal?   
plan if-- 7#a7 ! b5efits "u ! plan      
consi/ solely ( heal? insurance cov]age2
 or  7#b7 if ! plan provides any        
additional b5efit options :i* d n consi/
 ( heal? insurance cov]age1 ! plan--    
7,a7 e/abli%es & ma9ta9s res]ves )      
respect to su* additional b5efit        
options1 9 am\nts recomm5d$ by !        
qualifi$ heal? actu>y1 consi/+ (--  7i7 
a res]ve suffici5t = une>n$             
contributions2  7ii7 a res]ve suffici5t 
= b5efit liabilities :i* h be5 incurr$1 
:i* h n be5 satisfi$1 & = :i* risk (    
loss has n yet be5 transf]r$1 & =       
expect$ adm9i/rative co/s ) respect to  
su* b5efit liabilities2  7iii7 a res]ve 
suffici5t = any o!r obligations ( !     
plan2 &  7iv7 a res]ve suffici5t = a    
m>g9 ( error & o!r fluctuations1 tak+   
into acc\nt ! specific circum/ances ( ! 
plan2 &  7,b7 e/abli%es & ma9ta9s       
aggregate & specific excess_//op loss   

insurance & solv5cy indemnification1 )  
respect to su* additional b5efit options
 = :i* risk ( loss has n yet be5        
transf]r$1 z foll[s3  7i7 ,! plan %all  
secure aggregate excess_//op loss       
insurance = ! plan ) an atta*m5t po9t   
:i* is n great] ?an #abe p]c5t ( expect$
 gross annual claims4 ,! applicable     
au?ority may by regulation provide =    
upw>d adju/m5ts 9 ! am\nt ( su* p]c5tage
 9 specifi$ circum/ances 9 :i* ! plan   
specifically provides = & ma9ta9s       
res]ves 9 excess ( ! am\nts requir$ "u  
subp>agraph 7,a74  7ii7 ,! plan %all    
secure specific excess_//op loss        
insurance = ! plan ) an atta*m5t po9t   
:i* is at lea/ equal to an am\nt        
recomm5d$ by ! plan's qualifi$ heal?    
actu>y4 ,! applicable au?ority may by   
regulation provide = adju/m5ts 9 ! am\nt
 ( su* insurance 9 specifi$ circum/ances
 9 :i* ! plan specifically provides = & 
ma9ta9s res]ves 9 excess ( ! am\nts     
requir$ "u subp>agraph 7,a74  7iii7 ,!  
plan %all secure indemnification        

insurance = any claims :i* ! plan is    
unable to satisfy by reason ( a plan    
t]m9ation4  ,any p]son issu+ to a plan  
insurance describ$ 9 clause 7i71 7ii71  
or 7iii7 ( subp>agraph 7,b7 %all notify 
! ,secret>y ( any failure ( premium     
paym5t m]it+ cancellation ( ! policy    
prior to und]tak+ su* a cancellation4   
,any regulations prescrib$ by !         
applicable au?ority pursuant to clause  
7i7 or 7ii7 ( subp>agraph 7,b7 may all[ 
= su* adju/m5ts 9 ! requir$ levels (    
excess_//op loss insurance z ! qualifi$ 
heal? actu>y may recomm5d1 tak+ into    
acc\nt ! specific circum/ances ( ! plan4
  7b7 ,m9imum ,surplus 9 ,addition to   
,claims ,res]ves ,9 ! case ( any        
association heal? plan describ$ 9       
subsection 7a77#b71 ! requirem5ts ( ?is 
subsection are met if ! plan e/abli%es &
 ma9ta9s surplus 9 an am\nt at lea/     
equal to--  7#a7 #ejj1jjj2 or  7#b7 su* 
great] am\nt 7b n great] ?an #b1jjj1jjj7
 z may be set =? 9 regulations prescrib$
 by ! applicable au?ority1 consid]+ !   

level ( aggregate & specific excess_//op
 loss insurance provid$ ) respect to su*
 plan & o!r factors relat$ to solv5cy   
risk1 su* z ! plan's project$ levels (  
p>ticipation or claims1 ! nature ( !    
plan's liabilities1 & ! types ( assets  
available to assure t su* liabilities   
are met4  7c7 ,additional ,requirem5ts  
,9 ! case ( any association heal? plan  
describ$ 9 subsection 7a77#b71 !        
applicable au?ority may provide su*     
additional requirem5ts relat+ to        
res]ves1 excess_//op loss insurance1 &  
indemnification insurance z ! applicable
 au?ority consid]s appropriate4 ,su*    
requirem5ts may be provid$ by regulation
 ) respect to any su* plan or any class 
( su* plans4  7d7 ,adju/m5ts =          
,excess_/,/op ,loss ,insurance ,!       
applicable au?ority may provide =       
adju/m5ts to ! levels ( res]ves o!rwise 
requir$ "u subsections 7a7 & 7b7 )      
respect to any plan or class ( plans to 
take into acc\nt excess_//op loss       
insurance provid$ ) respect to su* plan 

or plans4  7e7 ,alt]native ,means (     
,compliance ,! applicable au?ority may  
p]mit an association heal? plan describ$
 9 subsection 7a77#b7 to sub/itute1 =   
all or "p ( ! requirem5ts ( ?is section 
7except subsection 7a77#b77;,b77iii771  
su* security1 gu>antee1 hold-h>mless    
arrangem5t1 or o!r f9ancial arrangem5t z
 ! applicable au?ority det]m9es to be   
adequate to enable ! plan to fully meet 
all its f9ancial obligations on a timely
 basis & is o!rwise no less protective (
 ! int]e/s ( p>ticipants & b5efici>ies  
?an ! requirem5ts = :i* x is sub/itut$4 
,! applicable au?ority may take into    
acc\nt1 = purposes ( ?is subsection1    
evid5ce provid$ by ! plan or sponsor :i*
 demon/rates an assumption ( liability )
 respect to ! plan4 ,su* evid5ce may be 
9 ! =m ( a contract ( indemnification1  
li51 bond+1 insurance1 lett] ( cr$it1   
rec\rse "u applicable t]ms ( ! plan 9 ! 
=m ( assessm5ts ( p>ticipat+ employ]s1  
security1 or o!r f9ancial arrangem5t4   
7f7 ,measures ,to ,ensure ,cont9u$      

,paym5t ( ,b5efits by ,c]ta9 ,plans 9   
,di/ress  7#a7 ,paym5ts by c]ta9 plans  
to association heal? plan fund  7,a7 ,9 
g5]al ,9 ! case ( an association heal?  
plan describ$ 9 subsection 7a77#b71 !   
requirem5ts ( ?is subsection are met if 
! plan makes paym5ts into ! ,association
 ,heal? ,plan ,fund "u ?is subp>agraph  
:5 !y are due4 ,su* paym5ts %all consi/ 
( annual paym5ts 9 ! am\nt ( #e1jjj1 &1 
9 addition to su* annual paym5ts1 su*   
supplem5tal paym5ts z ! ,secret>y may   
det]m9e to be necess>y "u p>agraph 7#b74
 ,paym5ts "u ?is p>agraph are payable to
 ! ,fund at ! "t det]m9$ by ! ,secret>y4
 ,initial paym5ts are due 9 advance (   
c]tification "u ?is "p4 ,paym5ts %all   
cont9ue to accrue until a plan's assets 
are di/ribut$ pursuant to a t]m9ation   
proc$ure4  7,b7 ,p5alties = failure to  
make paym5ts ,if any paym5t is n made by
 a plan :5 x is due1 a late paym5t *>ge 
( n m ?an #ajj p]c5t ( ! paym5t :i* 0 n 
timely paid %all be payable by ! plan to
 ! ,fund4  7,c7 ,cont9u$ duty ( !       

secret>y ,! ,secret>y %all n cease to   
c>ry out ! provisions ( p>agraph 7#b7 on
 acc\nt ( ! failure ( a plan to pay any 
paym5t :5 due4  7#b7 ,paym5ts by        
secret>y to cont9ue excess_//op loss    
insurance cov]age & indemnification     
insurance cov]age = c]ta9 plans ,9 any  
case 9 :i* ! applicable au?ority        
det]m9es t !re is1 or t !re is reason to
 believe t !re w be3 7,a7 a failure to  
take necess>y corrective actions "u     
section #hji7;a7 ) respect to an        
association heal? plan describ$ 9       
subsection 7a77#b72 or 7,b7 a t]m9ation 
( su* a plan "u section #hji7;b7 or     
#haj7;b77#h7 7&1 if ! applicable        
au?ority is n ! ,secret>y1 c]tifies su* 
det]m9ation to ! ,secret>y71 ! ,secret>y
 %all det]m9e ! am\nts necess>y to make 
paym5ts to an insur] 7designat$ by !    
,secret>y7 to ma9ta9 9 =ce excess_//op  
loss insurance cov]age or               
indemnification insurance cov]age = su* 
plan1 if ! ,secret>y det]m9es t !re is a
 reasonable expectation t1 )\t su*      

paym5ts1 claims w\ld n be satisfi$ by   
reason ( t]m9ation ( su* cov]age4 ,!    
,secret>y %all1 to ! ext5t provid$ 9    
advance 9 appropriation ,acts1 pay su*  
am\nts s det]m9$ to ! insur] designat$  
by ! ,secret>y4  7#c7 ,association heal?
 plan fund  7,a7 ,9 g5]al ,!re is       
e/abli%$ 9 ! ,treasury a fund to be kn[n
 z ! ,association ,heal? ,plan ,fund4 ,!
 ,fund %all be available = mak+ paym5ts 
pursuant to p>agraph 7#b74 ,! ,fund %all
 be cr$it$ ) paym5ts receiv$ pursuant to
 p>agraph 7#a77;,a71 p5alties receiv$   
pursuant to p>agraph 7#a77;,b71 & e>n+s 
on inve/m5ts ( am\nts ( ! ,fund "u      
subp>agraph 7,b74  7,b7 ,inve/m5t ,:5ev]
 ! ,secret>y det]m9es t ! moneys ( !    
fund are 9 excess ( curr5t ne$s1 !      
,secret>y may reque/ ! inve/m5t ( su*   
am\nts z ! ,secret>y det]m9es advisable 
by ! ,secret>y ( ! ,treasury 9          
obligations issu$ or gu>ante$ by !      
,unit$ ,/ates4  7g7 ,excess_/,/op ,loss 
,insurance ,= purposes ( ?is section3   
7#a7 ,aggregate excess_//op loss        

insurance ,! t]m aggregate excess_//op  
loss insurance means1 9 connection ) an 
association heal? plan1 a contract--    
7,a7 "u :i* an insur] 7meet+ su* m9imum 
/&>ds z ! applicable au?ority may       
prescribe by regulation7 provides =     
paym5t to ! plan ) respect to aggregate 
claims "u ! plan 9 excess ( an am\nt or 
am\nts specifi$ 9 su* contract2  7,b7   
:i* is gu>ante$ r5ewable2 &  7,c7 :i*   
all[s = paym5t ( premiums by any ?ird   
p>ty on behalf ( ! insur$ plan4  7#b7   
,specific excess_//op loss insurance ,! 
t]m specific excess_//op loss insurance 
means1 9 connection ) an association    
heal? plan1 a contract-- 7,a7 "u :i* an 
insur] 7meet+ su* m9imum /&>ds z !      
applicable au?ority may prescribe by    
regulation7 provides = paym5t to ! plan 
) respect to claims "u ! plan 9         
connection ) a cov]$ individual 9 excess
 ( an am\nt or am\nts specifi$ 9 su*    
contract 9 connection ) su* cov]$       
individual2  7,b7 :i* is gu>ante$       
r5ewable2 &  7,c7 :i* all[s = paym5t (  

premiums by any ?ird p>ty on behalf ( ! 
insur$ plan4  7h7 ,indemnification      
,insurance ,= purposes ( ?is section1 ! 
t]m indemnification insurance means1 9  
connection ) an association heal? plan1 
a contract-- 7#a7 "u :i* an insur]      
7meet+ su* m9imum /&>ds z ! applicable  
au?ority may prescribe by regulation7   
provides = paym5t to ! plan ) respect to
 claims "u ! plan :i* ! plan is unable  
to satisfy by reason ( a t]m9ation      
pursuant to section #hji7;b7 7relat+ to 
m&atory t]m9ation72  7#b7 :i* is        
gu>ante$ r5ewable & noncancellable = any
 reason 7except z ! applicable au?ority 
may prescribe by regulation72 &  7#c7   
:i* all[s = paym5t ( premiums by any    
?ird p>ty on behalf ( ! insur$ plan4    
7i7 ,res]ves ,= purposes ( ?is section1 
! t]m res]ves means1 9 connection ) an  
association heal? plan1 plan assets :i* 
meet ! fiduci>y /&>ds "u "p #d & su*    
additional requirem5ts reg>d+ liquidity 
z ! applicable au?ority may prescribe by
 regulation4  7j7 ,solv5cy ,/&>ds ,work+

 ,gr\p  7#a7 ,9 g5]al ,)9 #ij days aft] 
! date ( ! enactm5t ( ! ,obamac>e       
,replacem5t ,act1 ! applicable au?ority 
%all e/abli% a ,solv5cy ,/&>ds ,work+   
,gr\p4 ,9 prescrib+ ! initial           
regulations "u ?is section1 ! applicable
 au?ority %all take into acc\nt !       
recomm5dations ( su* ,work+ ,gr\p4  7#b7
 ,memb]%ip ,! ,work+ ,gr\p %all consi/ (
 n m ?an #ae memb]s appo9t$ by !        
applicable au?ority4 ,! applicable      
au?ority %all include among p]sons      
invit$ to memb]%ip on ! ,work+ ,gr\p at 
lea/ "o ( ea* ( ! foll[+3  7,a7 ,a      
repres5tative ( ! ,national ,association
 ( ,insurance ,commission]s4  7,b7 ,a   
repres5tative ( ! ,am]ican ,academy (   
,actu>ies4  7,c7 ,a repres5tative ( !   
,/ate gov]nm5ts1 or _! int]e/s4  7,d7 ,a
 repres5tative ( exi/+ self-insur$      
arrangem5ts1 or _! int]e/s4  7,e7 ,a    
repres5tative ( associations ( ! type   
ref]r$ to 9 section #hja7;b77#a71 or _! 
int]e/s4  7,f7 ,a repres5tative (       
multiemploy] plans t are gr\p heal?     

plans1 or _! int]e/s4  #hjg4            
,requirem5ts = application & relat$     
requirem5ts  7a7 ,fil+ ,fee ,"u !       
proc$ure prescrib$ pursuant to section  
#hjb7;a71 an association heal? plan %all
 pay to ! applicable au?ority at ! "t ( 
fil+ an application = c]tification "u   
?is "p a fil+ fee 9 ! am\nt ( #e1jjj1   
:i* %all be available 9 ! case ( !      
,secret>y1 to ! ext5t provid$ 9         
appropriation ,acts1 = ! sole purpose ( 
adm9i/]+ ! c]tification proc$ures       
applicable ) respect to association     
heal? plans4  7b7 ,in=mation ,to ,be    
,includ$ 9 ,application = ,c]tification 
,an application = c]tification "u ?is "p
 meets ! requirem5ts ( ?is section only 
if x includes1 9 a mann] & =m :i* %all  
be prescrib$ by ! applicable au?ority by
 regulation1 at lea/ ! foll[+ in=mation3
  7#a7 ,id5tify+ in=mation ,! names &   
addresses (-- 7,a7 ! sponsor2 &  7,b7 ! 
memb]s ( ! bo>d ( tru/ees ( ! plan4     
7#b7 ,/ates 9 :i* plan int5ds to d      
bus9ess ,! ,/ates 9 :i* p>ticipants &   

b5efici>ies "u ! plan are to be locat$ &
 ! numb] ( !m expect$ to be locat$ 9 ea*
 su* ,/ate4  7#c7 ,bond+ requirem5ts    
,evid5ce provid$ by ! bo>d ( tru/ees t !
 bond+ requirem5ts ( section #dab w be  
met z ( ! date ( ! application or 7if   
lat]7 comm5cem5t ( op]ations4  7#d7     
,plan docum5ts ,a copy ( ! docum5ts     
gov]n+ ! plan 7includ+ any bylaws & tru/
 agreem5ts71 ! summ>y plan description1 
& o!r mat]ial describ+ ! b5efits t w be 
provid$ to p>ticipants & b5efici>ies "u 
! plan4  7#e7 ,agreem5ts ) s]vice       
provid]s ,a copy ( any agreem5ts betwe5 
! plan & contract adm9i/rators & o!r    
s]vice provid]s4  7#f7 ,fund+ report ,9 
! case ( association heal? plans provid+
 b5efits options 9 addition to heal?    
insurance cov]age1 a report sett+ =?    
in=mation ) respect to su* additional   
b5efit options det]m9$ z ( a date )9 !  
#abj-;day p]iod end+ ) ! date ( !       
application1 includ+ ! foll[+3  7,a7    
,res]ves ,a /atem5t1 c]tifi$ by ! bo>d (
 tru/ees ( ! plan1 & a /atem5t (        

actu>ial op9ion1 sign$ by a qualifi$    
heal? actu>y1 t all applicable          
requirem5ts ( section #hjf are or w be  
met 9 accordance ) regulations :i* !    
applicable au?ority %all prescribe4     
7,b7 ,adequacy ( contribution rates ,a  
/atem5t ( actu>ial op9ion1 sign$ by a   
qualifi$ heal? actu>y1 :i* sets =? a    
description ( ! ext5t to :i*            
contribution rates are adequate to      
provide = ! paym5t ( all obligations & !
 ma9t5ance ( requir$ res]ves "u ! plan =
 ! #ab-mon? p]iod beg9n+ ) su* date )9  
su* #abj-;day p]iod1 tak+ into acc\nt ! 
expect$ cov]age & exp]i5ce ( ! plan4 ,if
 ! contribution rates are n fully       
adequate1 ! /atem5t ( actu>ial op9ion   
%all indicate ! ext5t to :i* ! rates are
 inadequate & ! *anges ne$$ to ensure   
adequacy4  7,c7 ,curr5t & project$ value
 ( assets & liabilities ,a /atem5t (    
actu>ial op9ion sign$ by a qualifi$     
heal? actu>y1 :i* sets =? ! curr5t value
 ( ! assets & liabilities accumulat$ "u 
! plan & a projection ( ! assets1       

liabilities1 income1 & exp5ses ( ! plan 
= ! #ab-mon? p]iod ref]r$ to 9          
subp>agraph 7,b74 ,! income /atem5t %all
 id5tify sep>ately ! plan's adm9i/rative
 exp5ses & claims4  7,d7 ,co/s ( cov]age
 to be *>g$ & o!r exp5ses ,a /atem5t ( !
 co/s ( cov]age to be *>g$1 includ+ an  
itemization ( am\nts = adm9i/ration1    
res]ves1 & o!r exp5ses associat$ ) !    
op]ation ( ! plan4  7,e7 ,o!r in=mation 
,any o!r in=mation z may be det]m9$ by !
 applicable au?ority1 by regulation1 z  
necess>y to c>ry out ! purposes ( ?is   
"p4  7c7 ,fil+ ,notice ( ,c]tification  
,) ,/ates ,a c]tification grant$ "u ?is 
"p to an association heal? plan %all n  
be effective unless writt5 notice ( su* 
c]tification is fil$ ) ! applicable     
,/ate au?ority ( ea* ,/ate 9 :i* at lea/
 #be p]c5t ( ! p>ticipants & b5efici>ies
 "u ! plan are locat$4 ,= purposes ( ?is
 subsection1 an individual %all be      
consid]$ to be locat$ 9 ! ,/ate 9 :i* a 
kn[n address ( su* individual is locat$ 
or 9 :i* su* individual is employ$4  7d7

 ,notice ( ,mat]ial ,*anges ,9 ! case ( 
any association heal? plan c]tifi$ "u   
?is "p1 descriptions ( mat]ial *anges 9 
any in=mation :i* 0 requir$ to be       
submitt$ ) ! application = !            
c]tification "u ?is "p %all be fil$ 9   
su* =m & mann] z %all be prescrib$ by ! 
applicable au?ority by regulation4 ,!   
applicable au?ority may require by      
regulation prior notice ( mat]ial *anges
 ) respect to specifi$ matt]s :i* might 
s]ve z ! basis = susp5sion or revocation
 ( ! c]tification4  7e7 ,report+        
,requirem5ts = ,c]ta9 ,association      
,heal? ,plans ,an association heal? plan
 c]tifi$ "u ?is "p :i* provides b5efit  
options 9 addition to heal? insurance   
cov]age = su* plan ye> %all meet !      
requirem5ts ( section #ajc by fil+ an   
annual report "u su* section :i* %all   
include in=mation describ$ 9 subsection 
7b77#f7 ) respect to ! plan ye> &1      
not)/&+ section #ajd7;a77#a71 %all be   
fil$ ) ! applicable au?ority n lat] ?an 
#ij days aft] ! close ( ! plan ye> 7or  

on su* lat] date z may be prescrib$ by !
 applicable au?ority74 ,! applicable    
au?ority may require by regulation su*  
int]im reports z x consid]s appropriate4
  7f7 ,engagem5t ( ,qualifi$ ,heal?     
,actu>y ,! bo>d ( tru/ees ( ea*         
association heal? plan :i* provides     
b5efits options 9 addition to heal?     
insurance cov]age & :i* is apply+ =     
c]tification "u ?is "p or is c]tifi$ "u 
?is "p %all engage1 on behalf ( all     
p>ticipants & b5efici>ies1 a qualifi$   
heal? actu>y :o %all be responsible = ! 
prep>ation ( ! mat]ials compris+        
in=mation necess>y to be submitt$ by a  
qualifi$ heal? actu>y "u ?is "p4 ,!     
qualifi$ heal? actu>y %all utilize su*  
assumptions & te*niques z are necess>y  
to enable su* actu>y to =m an op9ion z  
to :e!r ! cont5ts ( ! matt]s report$ "u 
?is "p--  7#a7 are 9 ! aggregate        
reasonably relat$ to ! exp]i5ce ( ! plan
 & to reasonable expectations2 &  7#b7  
repres5t su* actu>y's be/ e/imate (     
anticipat$ exp]i5ce "u ! plan4  ,!      

op9ion by ! qualifi$ heal? actu>y %all  
be made ) respect to1 & %all be made a  
"p (1 ! annual report4  #hjh4 ,notice   
requirem5ts = volunt>y t]m9ation ,except
 z provid$ 9 section #hji7;b71 an       
association heal? plan :i* is or has be5
 c]tifi$ "u ?is "p may t]m9ate 7^u or at
 any "t aft] cessation ( accruals 9     
b5efit liabilities7 only if ! bo>d (    
tru/ees1 n less ?an #fj days be=e !     
propos$ t]m9ation date--  7#a7 provides 
to ! p>ticipants & b5efici>ies a writt5 
notice ( int5t to t]m9ate /at+ t su*    
t]m9ation is int5d$ & ! propos$         
t]m9ation date2  7#b7 develops a plan = 
w9d+ up ! affairs ( ! plan 9 connection 
) su* t]m9ation 9 a mann] :i* w result 9
 timely paym5t ( all b5efits = :i* !    
plan is obligat$2 &  7#c7 submits su*   
plan 9 writ+ to ! applicable au?ority4  
,actions requir$ "u ?is section %all be 
tak5 9 su* =m & mann] z may be prescrib$
 by ! applicable au?ority by regulation4
  #hji4 ,corrective actions & m&atory   
t]m9ation  7a7 ,actions ,to ,avoid      

,depletion ( ,res]ves ,an association   
heal? plan :i* is c]tifi$ "u ?is "p &   
:i* provides b5efits o!r ?an heal?      
insurance cov]age %all cont9ue to meet !
 requirem5ts ( section #hjf1            
irrespective ( :e!r su* c]tification    
cont9ues 9 effect4 ,! bo>d ( tru/ees (  
su* plan %all det]m9e qu>t]ly :e!r !    
requirem5ts ( section #hjf are met4 ,9  
any case 9 :i* ! bo>d det]m9es t !re is 
reason to believe t !re is or w be a    
failure to meet su* requirem5ts1 or !   
applicable au?ority makes su* a         
det]m9ation & s notifies ! bo>d1 ! bo>d 
%all imm$iately notify ! qualifi$ heal? 
actu>y engag$ by ! plan1 & su* actu>y   
%all1 n lat] ?an ! end ( ! foll[+ mon?1 
make su* recomm5dations to ! bo>d =     
corrective action z ! actu>y det]m9es   
necess>y to ensure compliance ) section 
#hjf4 ,n lat] ?an #cj days aft] receiv+ 
f ! actu>y recomm5dations = corrective  
actions1 ! bo>d %all notify ! applicable
 au?ority 79 su* =m & mann] z !         
applicable au?ority may prescribe by    

regulation7 ( su* recomm5dations ( !    
actu>y = corrective action1 toge!r ) a  
description ( ! actions 7if any7 t !    
bo>d has tak5 or plans to take 9        
response to su* recomm5dations4 ,! bo>d 
%all !reaft] report to ! applicable     
au?ority1 9 su* =m & frequ5cy z !       
applicable au?ority may specify to !    
bo>d1 reg>d+ corrective action tak5 by !
 bo>d until ! requirem5ts ( section #hjf
 are met4  7b7 ,m&atory ,t]m9ation ,9   
any case 9 :i*-- 7#a7 ! applicable      
au?ority has be5 notifi$ "u subsection  
7a7 7or by an issu] ( excess_//op loss  
insurance or indemnity insurance        
pursuant to section #hjf7;a77 ( a       
failure ( an association heal? plan :i* 
is or has be5 c]tifi$ "u ?is "p & is    
describ$ 9 section #hjf7;a77#b7 to meet 
! requirem5ts ( section #hjf & has n be5
 notifi$ by ! bo>d ( tru/ees ( ! plan t 
corrective action has re/or$ compliance 
) su* requirem5ts2 &  7#b7 ! applicable 
au?ority det]m9es t !re is a reasonable 
expectation t ! plan w cont9ue to fail  

to meet ! requirem5ts ( section #hjf1  !
 bo>d ( tru/ees ( ! plan %all1 at !     
direction ( ! applicable au?ority1      
t]m9ate ! plan &1 9 ! c\rse ( !         
t]m9ation1 take su* actions z !         
applicable au?ority may require1 includ+
 satisfy+ any claims ref]r$ to 9 section
 #hjf7;a77#b77;,b77iii7 & recov]+ = !   
plan any liability "u subsection        
7a77#b77;,b77iii7 or 7e7 ( section #hjf1
 z necess>y to ensure t ! affairs ( !   
plan w be1 to ! maximum ext5t possible1 
w\nd up 9 a mann] :i* w result 9 timely 
provision ( all b5efits = :i* ! plan is 
obligat$4  #haj4 ,tru/ee%ip by !        
,secret>y ( insolv5t association heal?  
plans provid+ heal? b5efits 9 addition  
to heal? insurance cov]age  7a7         
,appo9tm5t ( ,secret>y z ,tru/ee =      
,insolv5t ,plans ,:5ev] ! ,secret>y     
det]m9es t an association heal? plan :i*
 is or has be5 c]tifi$ "u ?is "p & :i*  
is describ$ 9 section #hjf7;a77#b7 w be 
unable to provide b5efits :5 due or is  
o!rwise 9 a f9ancially haz>d\s          

condition1 z %all be def9$ by !         
,secret>y by regulation1 ! ,secret>y    
%all1 ^u notice to ! plan1 apply to !   
appropriate ,unit$ ,/ates di/rict c\rt =
 appo9tm5t ( ! ,secret>y z tru/ee to    
adm9i/] ! plan = ! duration ( !         
insolv5cy4 ,! plan may appe> z a p>ty & 
o!r int]e/$ p]sons may int]v5e 9 !      
proce$+s at ! discretion ( ! c\rt4 ,!   
c\rt %all appo9t su* ,secret>y tru/ee if
 ! c\rt det]m9es t ! tru/ee%ip is       
necess>y to protect ! int]e/s ( !       
p>ticipants & b5efici>ies or provid]s ( 
m$ical c>e or to avoid any unreasonable 
det]ioration ( ! f9ancial condition ( ! 
plan4 ,! tru/ee%ip ( su* ,secret>y %all 
cont9ue until ! conditions describ$ 9 ! 
fir/ s5t5ce ( ?is subsection are rem$i$ 
or ! plan is t]m9at$4  7b7 ,p[]s z      
,tru/ee ,! ,secret>y1 ^u appo9tm5t z    
tru/ee "u subsection 7a71 %all h ! p[]--
 7#a7 to d any act au?oriz$ by ! plan1  
?is title1 or o!r applicable provisions 
( law to be done by ! plan adm9i/rator  
or any tru/ee ( ! plan2  7#b7 to require

 ! transf] ( all 7or any "p7 ( ! assets 
& records ( ! plan to ! ,secret>y z     
tru/ee2  7#c7 to inve/ any assets ( !   
plan :i* ! ,secret>y holds 9 accordance 
) ! provisions ( ! plan1 regulations    
prescrib$ by ! ,secret>y1 & applicable  
provisions ( law2  7#d7 to require !    
sponsor1 ! plan adm9i/rator1 any        
p>ticipat+ employ]1 & any employee      
organization repres5t+ plan p>ticipants 
to furni% any in=mation ) respect to !  
plan :i* ! ,secret>y z tru/ee may       
reasonably ne$ 9 ord] to adm9i/] ! plan2
  7#e7 to collect = ! plan any am\nts   
due ! plan & to recov] reasonable       
exp5ses ( ! tru/ee%ip2  7#f7 to comm5ce1
 prosecute1 or def5d on behalf ( ! plan 
any suit or proce$+ involv+ ! plan2     
7#g7 to issue1 publi%1 or file su*      
notices1 /atem5ts1 & reports z may be   
requir$ by ! ,secret>y by regulation or 
requir$ by any ord] ( ! c\rt2  7#h7 to  
t]m9ate ! plan 7or provide = its        
t]m9ation 9 accordance ) section        
#hji7;b77 & liquidate ! plan assets1 to 

re/ore ! plan to ! responsibility ( !   
sponsor1 or to cont9ue ! tru/ee%ip2     
7#i7 to provide = ! enrollm5t ( plan    
p>ticipants & b5efici>ies "u appropriate
 cov]age options2 &  7#aj7 to d su* o!r 
acts z may be necess>y to comply ) ?is  
title or any ord] ( ! c\rt & to protect 
! int]e/s ( plan p>ticipants &          
b5efici>ies & provid]s ( m$ical c>e4    
7c7 ,notice ( ,appo9tm5t ,z soon z      
practicable aft] ! ,secret>y's appo9tm5t
 z tru/ee1 ! ,secret>y %all give notice 
( su* appo9tm5t to--  7#a7 ! sponsor &  
plan adm9i/rator2  7#b7 ea* p>ticipant2 
7#c7 ea* p>ticipat+ employ]2 &  7#d7 if 
applicable1 ea* employee organization   
:i*1 = purposes ( collective b>ga9+1    
repres5ts plan p>ticipants4  7d7        
,additional ,duties ,except to ! ext5t  
inconsi/5t ) ! provisions ( ?is title1  
or z may be o!rwise ord]$ by ! c\rt1 !  
,secret>y1 ^u appo9tm5t z tru/ee "u ?is 
section1 %all be subject to ! same      
duties z ^? ( a tru/ee "u section #gjd (
 title #aa1 ,unit$ ,/ates ,code1 & %all 

h ! duties ( a fiduci>y = purposes ( ?is
 title4  7e7 ,o!r ,proce$+s ,an         
application by ! ,secret>y "u ?is       
subsection may be fil$ not)/&+ ! p5d5cy 
9 ! same or any o!r c\rt ( any          
bankruptcy1 mortgage =eclosure1 or      
equity receiv]%ip proce$+1 or any       
proce$+ to reorganize1 cons]ve1 or      
liquidate su* plan or its prop]ty1 or   
any proce$+ to en=ce a li5 aga9/ prop]ty
 ( ! plan4  7f7 ,jurisdiction ( ,c\rt   
7#a7 ,9 g5]al ,^u ! fil+ ( an           
application = ! appo9tm5t z tru/ee or ! 
issuance ( a decree "u ?is section1 !   
c\rt to :i* ! application is made %all h
 exclusive jurisdiction ( ! plan involv$
 & its prop]ty :]ev] locat$ ) ! p[]s1 to
 ! ext5t consi/5t ) ! purposes ( ?is    
section1 ( a c\rt ( ! ,unit$ ,/ates hav+
 jurisdiction ov] cases "u *apt] #aa (  
title #aa1 ,unit$ ,/ates ,code4 ,p5d+ an
 adjudication "u ?is section su* c\rt   
%all /ay1 & ^u appo9tm5t by x ( !       
,secret>y z tru/ee1 su* c\rt %all       
cont9ue ! /ay (1 any p5d+ mortgage      

=eclosure1 equity receiv]%ip1 or o!r    
proce$+ to reorganize1 cons]ve1 or      
liquidate ! plan1 ! sponsor1 or prop]ty 
( su* plan or sponsor1 & any o!r suit   
aga9/ any receiv]1 cons]vator1 or tru/ee
 ( ! plan1 ! sponsor1 or prop]ty ( !    
plan or sponsor4 ,p5d+ su* adjudication 
& ^u ! appo9tm5t by x ( ! ,secret>y z   
tru/ee1 ! c\rt may /ay any proce$+ to   
en=ce a li5 aga9/ prop]ty ( ! plan or ! 
sponsor or any o!r suit aga9/ ! plan or 
! sponsor4  7#b7 ,v5ue ,an action "u ?is
 section may be br\ght 9 ! judicial     
di/rict :]e ! sponsor or ! plan         
adm9i/rator resides or does bus9ess or  
:]e any asset ( ! plan is situat$4 ,a   
di/rict c\rt 9 :i* su* action is br\ght 
may issue process ) respect to su*      
action 9 any o!r judicial di/rict4  7g7 
,p]sonnel ,9 accordance ) regulations   
:i* %all be prescrib$ by ! ,secret>y1 ! 
,secret>y %all appo9t1 reta91 &         
comp5sate acc\ntants1 actu>ies1 & o!r   
pr(essional s]vice p]sonnel z may be    
necess>y 9 connection ) ! ,secret>y's   

s]vice z tru/ee "u ?is section4  #haa4  
,/ate assessm5t au?ority  7a7 ,9 ,g5]al 
,not)/&+ section #ead1 a ,/ate may      
impose by law a contribution tax on an  
association heal? plan describ$ 9       
section #hjf7;a77#b71 if ! plan comm5c$ 
op]ations 9 su* ,/ate aft] ! date ( !   
enactm5t ( ! ,obamac>e ,replacem5t ,act4
  7b7 ,contribution ,tax ,= purposes (  
?is section1 ! t]m contribution tax     
impos$ by a ,/ate on an association     
heal? plan means any tax impos$ by su*  
,/ate if-- 7#a7 su* tax is comput$ by   
apply+ a rate to ! am\nt ( premiums or  
contributions1 ) respect to individuals 
cov]$ "u ! plan :o are resid5ts ( su*   
,/ate1 :i* are receiv$ by ! plan f      
p>ticipat+ employ]s locat$ 9 su* ,/ate  
or f su* individuals2  7#b7 ! rate ( su*
 tax does n exce$ ! rate ( any tax      
impos$ by su* ,/ate on premiums or      
contributions receiv$ by insur]s or     
heal? ma9t5ance organizations = heal?   
insurance cov]age (f]$ 9 su* ,/ate 9    
connection ) a gr\p heal? plan2  7#c7   

su* tax is o!rwise nondiscrim9atory2 &  
7#d7 ! am\nt ( any su* tax assess$ on ! 
plan is r$uc$ by ! am\nt ( any tax or   
assessm5t o!rwise impos$ by ! ,/ate on  
premiums1 contributions1 or bo? receiv$ 
by insur]s or heal? ma9t5ance           
organizations = heal? insurance cov]age1
 aggregate excess_//op loss insurance 7z
 def9$ 9 section #hjf7;g77#a771 specific
 excess_//op loss insurance 7z def9$ 9  
section #hjf7;g77#b771 o!r insurance    
relat$ to ! provision ( m$ical c>e "u ! 
plan1 or any comb9ation !re( provid$ by 
su* insur]s or heal? ma9t5ance          
organizations 9 su* ,/ate 9 connection )
 su* plan4  #hab4 ,def9itions & rules ( 
con/ruction  7a7 ,def9itions ,= purposes
 ( ?is "p-- 7#a7 ,gr\p heal? plan ,! t]m
 gr\p heal? plan has ! mean+ provid$ 9  
section #gcc7;a77#a7 7aft] apply+       
subsection 7b7 ( ?is section74  7#b7    
,m$ical c>e ,! t]m m$ical c>e has !     
mean+ provid$ 9 section #gcc7;a77#b74   
7#c7 ,heal? insurance cov]age ,! t]m    
heal? insurance cov]age has ! mean+     

provid$ 9 section #gcc7;b77#a74  7#d7   
,heal? insurance issu] ,! t]m heal?     
insurance issu] has ! mean+ provid$ 9   
section #gcc7;b77#b74  7#e7 ,applicable 
au?ority ,! t]m applicable au?ority     
means ! ,secret>y1 except t1 9          
connection ) any ex]cise ( ! ,secret>y's
 au?ority reg>d+ :i* ! ,secret>y is     
requir$ "u section #ejf7;d7 to consult )
 a ,/ate1 su* t]m means ! ,secret>y1 9  
consultation ) su* ,/ate4  7#f7 ,heal?  
/atus-relat$ factor ,! t]m heal?        
/atus-relat$ factor has ! mean+ provid$ 
9 section #gcc7;d77#b74  7#g7           
,individual m>ket  7,a7 ,9 g5]al ,! t]m 
individual m>ket means ! m>ket = heal?  
insurance cov]age (f]$ to individuals   
o!r ?an 9 connection ) a gr\p heal?     
plan4  7,b7 ,treatm5t ( v small gr\ps   
7i7 ,9 g5]al ,subject to clause 7ii71   
su* t]m includes cov]age (f]$ 9         
connection ) a gr\p heal? plan t has    
few] ?an #b p>ticipants z curr5t        
employees or p>ticipants describ$ 9     
section #gcb7;d77#c7 on ! fir/ day ( !  

plan ye>4  7ii7 ,/ate exception ,clause 
7i7 %all n apply 9 ! case ( heal?       
insurance cov]age (f]$ 9 a ,/ate if su* 
,/ate regulates ! cov]age describ$ 9 su*
 clause 9 ! same mann] & to ! same ext5t
 z cov]age 9 ! small gr\p m>ket 7z def9$
 9 section #bgia7;e77#e7 ( ! ,public    
,heal? ,s]vice ,act7 is regulat$ by su* 
,/ate4  7#h7 ,p>ticipat+ employ] ,! t]m 
p>ticipat+ employ] means1 9 connection )
 an association heal? plan1 any employ]1
 if any individual :o is an employee (  
su* employ]1 a p>tn] 9 su* employ]1 or a
 self-employ$ individual :o is su*      
employ] 7or any dep5d5t1 z def9$ "u !   
t]ms ( ! plan1 ( su* individual7 is or 0
 cov]$ "u su* plan 9 connection ) !     
/atus ( su* individual z su* an         
employee1 p>tn]1 or self-employ$        
individual 9 relation to ! plan4  7#i7  
,applicable /ate au?ority ,! t]m        
applicable ,/ate au?ority means1 )      
respect to a heal? insurance issu] 9 a  
,/ate1 ! ,/ate insurance commission] or 
(ficial or (ficials designat$ by ! ,/ate

 to en=ce ! requirem5ts ( title ,,xxvii 
( ! ,public ,heal? ,s]vice ,act = !     
,/ate involv$ ) respect to su* issu]4   
7#aj7 ,qualifi$ heal? actu>y ,! t]m     
qualifi$ heal? actu>y means an          
individual :o is a memb] ( ! ,am]ican   
,academy ( ,actu>ies ) exp]tise 9 heal? 
c>e4  7#aa7 ,affiliat$ memb] ,! t]m     
affiliat$ memb] means1 9 connection ) a 
sponsor-- 7,a7 a p]son :o is o!rwise    
eligible to be a memb] ( ! sponsor b :o 
elects an affiliat$ /atus ) ! sponsor1  
7,b7 9 ! case ( a sponsor ) memb]s :i*  
consi/ ( associations1 a p]son :o is a  
memb] ( any su* association & elects an 
affiliat$ /atus ) ! sponsor1 or  7,c7 9 
! case ( an association heal? plan 9    
exi/5ce on ! date ( ! enactm5t ( !      
,obamac>e ,replacem5t ,act1 a p]son     
eligible to be a memb] ( ! sponsor or "o
 ( its memb] associations4  7#ab7 ,l>ge 
employ] ,! t]m l>ge employ] means1 9    
connection ) a gr\p heal? plan ) respect
 to a plan ye>1 an employ] :o employ$ an
 av]age ( at lea/ #ea employees on      

bus9ess days dur+ ! prec$+ cal5d> ye> & 
:o employs at lea/ #b employees on !    
fir/ day ( ! plan ye>4  7#ac7 ,small    
employ] ,! t]m small employ] means1 9   
connection ) a gr\p heal? plan ) respect
 to a plan ye>1 an employ] :o is n a    
l>ge employ]4  7b7 ,rules ( ,con/ruction
  7#a7 ,employ]s & employees ,= purposes
 ( det]m9+ :e!r a plan1 fund1 or program
 is an employee welf>e b5efit plan :i*  
is an association heal? plan1 & =       
purposes ( apply+ ?is title 9 connection
 ) su* plan1 fund1 or program s det]m9$ 
to be su* an employee welf>e b5efit     
plan--  7,a7 9 ! case ( a p>tn]%ip1 !   
t]m employ] 7z def9$ 9 section #c7e77   
includes ! p>tn]%ip 9 relation to !     
p>tn]s1 & ! t]m employee 7z def9$ 9     
section #c7f77 includes any p>tn] 9     
relation to ! p>tn]%ip2 &  7,b7 9 ! case
 ( a self-employ$ individual1 ! t]m     
employ] 7z def9$ 9 section #c7e77 & !   
t]m employee 7z def9$ 9 section #c7f77  
%all include su* individual4  7#b7      
,plans1 funds1 & programs treat$ z      

employee welf>e b5efit plans ,9 ! case (
 any plan1 fund1 or program :i* 0       
e/abli%$ or is ma9ta9$ = ! purpose (    
provid+ m$ical c>e 7?r\gh ! pur*ase (   
insurance or o!rwise7 = employees 7or _!
 dep5d5ts7 cov]$ !reund] & :i*          
demon/rates to ! ,secret>y t all        
requirem5ts = c]tification "u ?is "p    
w\ld be met ) respect to su* plan1 fund1
 or program if su* plan1 fund1 or       
program 7 a gr\p heal? plan1 su* plan1  
fund1 or program %all be treat$ =       
purposes ( ?is title z an employee      
welf>e b5efit plan on & aft] ! date (   
su* demon/ration4  7#c7 ,exception =    
c]ta9 b5efits ,! requirem5ts ( ?is "p   
%all n apply to a gr\p heal? plan 9     
relation to its provision ( except$     
b5efits1 z def9$ 9 section #gcc7;c74  4 
7b7 ,con=m+ ,am5dm5ts to ,preemption    
,rules  7#a7 ,section #ead7;b77#f7 ( su*
 ,act 7#bi ,u4,s4,c4 #aadd7;b77#f77 is  
am5d$ by add+ at ! end ! foll[+ new     
subp>agraph3  7,e7 ,! prec$+            
subp>agraphs ( ?is p>agraph d n apply ) 

respect to any ,/ate law 9 ! case ( an  
association heal? plan :i* is c]tifi$ "u
 "p #h4  4  7#b7 ,section #ead ( su*    
,act 7#bi ,u4,s4,c4 #aadd7 is am5d$--   
7,a7 9 subsection 7b77#d71 by /rik+     
,subsection 7a7 & ins]t+ ,subsections   
7a7 & 7d72  7,b7 9 subsection 7b77#e71  
by /rik+ subsection 7a7 9 subp>agraph   
7,a7 & ins]t+ subsection 7a7 ( ?is      
section & subsections 7a77#b77;,b7 & 7b7
 ( section #hje1 & by /rik+ subsection  
7a7 9 subp>agraph 7,b7 & ins]t+         
subsection 7a7 ( ?is section or         
subsection 7a77#b77;,b7 or 7b7 ( section
 #hje2  7,c7 by r$esignat+ subsection   
7d7 z subsection 7e72 &  7,d7 by ins]t+ 
aft] subsection 7c7 ! foll[+ new        
subsection3  7d7 7#a7 ,except z provid$ 
9 subsection 7b77#d71 ! provisions ( ?is
 title %all sup]s$e any & all ,/ate laws
 ins(> z !y may n[ or h]eaft] preclude1 
or h ! effect ( preclud+1 a heal?       
insurance issu] f (f]+ heal? insurance  
cov]age 9 connection ) an association   
heal? plan :i* is c]tifi$ "u "p #h4     

7#b7 ,except z provid$ 9 p>agraphs 7#d7 
& 7#e7 ( subsection 7b7 ( ?is section-- 
7,a7 ,9 any case 9 :i* heal? insurance  
cov]age ( any policy type is (f]$ "u an 
association heal? plan c]tifi$ "u "p #h 
to a p>ticipat+ employ] op]at+ 9 su*    
,/ate1 ! provisions ( ?is title %all    
sup]s$e any & all laws ( su* ,/ate ins(>
 z !y may preclude a heal? insurance    
issu] f (f]+ heal? insurance cov]age ( !
 same policy type to o!r employ]s op]at+
 9 ! ,/ate :i* are eligible = cov]age "u
 su* association heal? plan1 :e!r or n  
su* o!r employ]s are p>ticipat+ employ]s
 9 su* plan4  7,b7 ,9 any case 9 :i*    
heal? insurance cov]age ( any policy    
type is (f]$ 9 a ,/ate "u an association
 heal? plan c]tifi$ "u "p #h & ! fil+1 )
 ! applicable ,/ate au?ority 7z def9$ 9 
section #hab7;a77#i771 ( ! policy =m 9  
connection ) su* policy type is approv$ 
by su* ,/ate au?ority1 ! provisions (   
?is title %all sup]s$e any & all laws ( 
any o!r ,/ate 9 :i* heal? insurance     
cov]age ( su* type is (f]$1 ins(> z !y  

may preclude1 ^u ! fil+ 9 ! same =m &   
mann] ( su* policy =m ) ! applicable    
,/ate au?ority 9 su* o!r ,/ate1 !       
approval ( ! fil+ 9 su* o!r ,/ate4  7#c7
 ,no?+ 9 subsection 7b77#f77;,e7 or !   
prec$+ provisions ( ?is subsection %all 
be con/ru$1 ) respect to heal? insurance
 issu]s or heal? insurance cov]age1 to  
sup]s$e or impair ! law ( any ,/ate--   
7,a7 provid+ solv5cy /&>ds or simil>    
/&>ds reg>d+ ! adequacy ( insur]        
capital1 surplus1 res]ves1 or           
contributions1 or  7,b7 relat+ to prompt
 paym5t ( claims4  7#d7 ,= additional   
provisions relat+ to association heal?  
plans1 see subsections 7a77#b77;,b7 &   
7b7 ( section #hje4  7#e7 ,= purposes ( 
?is subsection1 ! t]m association heal? 
plan has ! mean+ provid$ 9 section      
#hja7;a71 & ! t]ms heal? insurance      
cov]age1 p>ticipat+ employ]1 & heal?    
insurance issu] h ! mean+s provid$ su*  
t]ms 9 section #hab1 respectively4  4   
7#c7 ,section #ead7;b77#f77;,a7 ( su*   
,act 7#bi ,u4,s4,c4 #aadd7;b77#f77;,a77 

is am5d$--  7,a7 9 clause 7i77,,ii71 by 
/rik+ & at ! end2  7,b7 9 clause 7ii7-- 
7i7 by ins]t+ & :i* does n provide      
m$ical c>e 7)9 ! mean+ ( section        
#gcc7;a77#b771 aft] arrangem5t12 &  7ii7
 by /rik+ title4 & ins]t+ title1 &2 &   
7,c7 by add+ at ! end ! foll[+ new      
clause3  7iii7 subject to subp>agraph   
7,e71 9 ! case ( any o!r employee welf>e
 b5efit plan :i* is a multiple employ]  
welf>e arrangem5t & :i* provides m$ical 
c>e 7)9 ! mean+ ( section #gcc7;a77#b771
 any law ( any ,/ate :i* regulates      
insurance may apply4  4  7#d7 ,section  
#ead7;e7 ( su* ,act 7z r$esignat$ by    
p>agraph 7#b77;,c77 is am5d$-- 7,a7 by  
/rik+ ,no?+ & ins]t+ 7#a7 ,except z     
provid$ 9 p>agraph 7#b71 no?+2 &  7,b7  
by add+ at ! end ! foll[+ new p>agraph3 
7#b7 ,no?+ 9 any o!r provision ( law    
enact$ on or aft] ! date ( ! enactm5t ( 
! ,obamac>e ,replacem5t ,act %all be    
con/ru$ to alt]1 am5d1 modify1          
invalidate1 impair1 or sup]s$e any      
provision ( ?is title1 except by        

specific cross-ref]5ce to ! affect$     
section4  4  7c7 ,plan ,sponsor ,section
 #c7af77;,b7 ( su* ,act 7#bi ,u4,s4,c4  
#ajb7af77;,b77 is am5d$ by add+ at ! end
 ! foll[+ new s5t5ce3 ,su* t]m also     
includes a p]son s]v+ z ! sponsor ( an  
association heal? plan "u "p #h (       
subtitle ,b44  7d7 ,disclosure (        
,solv5cy ,protections ,relat$ to        
,self-,insur$ & ,fully ,insur$ ,options 
,"u ,association ,heal? ,plans ,section 
#ajb7;b7 ( su* ,act 7#bi ,u4,s4,c4      
#ajbb7;b77 is am5d$ by add+ at ! end !  
foll[+3 ,an association heal? plan %all 
include 9 its summ>y plan description1 9
 connection ) ea* b5efit option1 a      
description ( ! =m ( solv5cy or gu>antee
 fund protection secur$ pursuant to ?is 
,act or applicable ,/ate law1 if any44  
7e7 ,sav+s ,clause ,section #gca7;c7 (  
su* ,act is am5d$ by ins]t+ or "p #h    
aft] ?is "p4  7f7 ,report to ! ,congress
 ,reg>d+ ,c]tification ( ,self-,insur$  
,association ,heal? ,plans ,n lat] ?an  
,janu>y #a1 #bjah1 ! ,secret>y ( ,labor 

%all report to ! ,committee on          
,education & ! ,work=ce ( ! ,h\se (     
,repres5tatives & ! ,committee on       
,heal?1 ,education1 ,labor1 & ,p5sions (
 ! ,s5ate ! effect association heal?    
plans h _h1 if any1 on r$uc+ ! numb] (  
un9sur$ individuals4  7g7 ,cl]ical      
,am5dm5t ,! table ( cont5ts 9 section #a
 ( ! ,employee ,retirem5t ,income       
,security ,act ( #aigd is am5d$ by      
ins]t+ aft] ! item relat+ to section    
#gcd ! foll[+ new items3  ,"p #h--,rules
 ,gov]n+ ,association ,heal? ,plans#hja4
 ,association heal? plans4#hjb4         
,c]tification ( association heal?       
plans4#hjc4 ,requirem5ts relat+ to      
sponsors & bo>ds ( tru/ees4#hjd4        
,p>ticipation & cov]age                 
requirem5ts4#hje4 ,o!r requirem5ts      
relat+ to plan docum5ts1 contribution   
rates1 & b5efit options4#hjf4 ,ma9t5ance
 ( res]ves & provisions = solv5cy =     
plans provid+ heal? b5efits 9 addition  
to heal? insurance cov]age4#hjg4        
,requirem5ts = application & relat$     

requirem5ts4#hjh4 ,notice requirem5ts = 
volunt>y t]m9ation4#hji4 ,corrective    
actions & m&atory t]m9ation4#haj4       
,tru/ee%ip by ! ,secret>y ( insolv5t    
association heal? plans provid+ heal?   
b5efits 9 addition to heal? insurance   
cov]age4#haa4 ,/ate assessm5t           
au?ority4#hab4 ,def9itions & rules (    
con/ruction4  4  #djb4 ,cl>ification (  
treatm5t ( s+le employ] arrangem5ts     
,section #c7dj77;,b7 ( ! ,employee      
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #ajjb7dj77;,b77 is 
am5d$--  7#a7 9 clause 7i71 by ins]t+   
aft] control gr\p1 ! foll[+3 except t1 9
 any case 9 :i* ! b5efit ref]r$ to 9    
subp>agraph 7,a7 consi/s ( m$ical c>e 7z
 def9$ 9 section #hab7;a77#b771 two or m
 trades or bus9esses1 :e!r or n         
incorporat$1 %all be deem$ a s+le       
employ] = any plan ye> ( su* plan1 or   
any fiscal ye> ( su* o!r arrangem5t1 if 
su* trades or bus9esses are )9 ! same   
control gr\p dur+ su* ye> or at any "t  
dur+ ! prec$+ #a-ye> p]iod12  7#b7 9    

clause 7iii71 by /rik+ 7iii7 !          
det]m9ation & ins]t+ ! foll[+3  7iii7   
7,i7 9 any case 9 :i* ! b5efit ref]r$ to
 9 subp>agraph 7,a7 consi/s ( m$ical c>e
 7z def9$ 9 section #hab7;a77#b771 !    
det]m9ation ( :e!r a trade or bus9ess is
 "u common control ) ano!r trade or     
bus9ess %all be det]m9$ "u regulations (
 ! ,secret>y apply+ pr9ciples consi/5t &
 coext5sive ) ! pr9ciples appli$ 9      
det]m9+ :e!r employees ( two or m trades
 or bus9esses are treat$ z employ$ by a 
s+le employ] "u section #djja7;b71      
except t1 = purposes ( ?is p>agraph1 an 
int]e/ ( great] ?an #be p]c5t may n be  
requir$ z ! m9imum int]e/ necess>y =    
common control1 or  7,,ii7 9 any o!r    
case1 ! det]m9ation  2  7#c7 by         
r$esignat+ clauses 7iv7 & 7v7 z clauses 
7v7 & 7vi71 respectively2 &  7#d7 by    
ins]t+ aft] clause 7iii7 ! foll[+ new   
clause3  7iv7 9 any case 9 :i* ! b5efit 
ref]r$ to 9 subp>agraph 7,a7 consi/s (  
m$ical c>e 7z def9$ 9 section           
#hab7;a77#b771 9 det]m9+1 aft] !        

application ( clause 7i71 :e!r b5efits  
are provid$ to employees ( two or m     
employ]s1 ! arrangem5t %all be treat$ z 
hav+ only "o p>ticipat+ employ] if1 aft]
 ! application ( clause 7i71 ! numb] (  
individuals :o are employees & =m]      
employees ( any "o p>ticipat+ employ] & 
:o are cov]$ "u ! arrangem5t is great]  
?an #ge p]c5t ( ! aggregate numb] ( all 
individuals :o are employees or =m]     
employees ( p>ticipat+ employ]s & :o are
 cov]$ "u ! arrangem5t1  4  #djc4       
,en=cem5t provisions relat+ to          
association heal? plans  7a7 ,crim9al   
,p5alties = ,c]ta9 ,willful             
,misrepres5tations ,section #eja ( !    
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4 #aaca7 is   
am5d$ by add+ at ! end ! foll[+ new     
subsection3  7c7 ,any p]son :o willfully
 falsely repres5ts1 to any employee1 any
 employee's b5efici>y1 any employ]1 !   
,secret>y1 or any ,/ate1 a plan or o!r  
arrangem5t e/abli%$ or ma9ta9$ = !      
purpose ( (f]+ or provid+ any b5efit    

describ$ 9 section #c7a7 to employees or
 _! b5efici>ies z--  7#a7 be+ an        
association heal? plan :i* has be5      
c]tifi$ "u "p #h2  7#b7 hav+ be5        
e/abli%$ or ma9ta9$ "u or pursuant to "o
 or m collective b>ga9+ agreem5ts :i*   
are rea*$ pursuant to collective b>ga9+ 
describ$ 9 section #h7;d7 ( ! ,national 
,labor ,relations ,act 7#bi ,u4,s4,c4   
#aeh7;d77 or p>agraph ,f\r? ( section #b
 ( ! ,railway ,labor ,act 7#de ,u4,s4,c4
 #aeb1 p>agraph ,f\r?7 or :i* are rea*$ 
pursuant to labor-managem5t negotiations
 "u simil> provisions ( ,/ate public    
employee relations laws2 or  7#c7 be+ a 
plan or arrangem5t describ$ 9 section   
#c7dj77;,a77i71  %all1 ^u conviction1 be
 imprison$ n m ?an #e ye>s1 be f9$ "u   
title #ah1 ,unit$ ,/ates ,code1 or bo?4 
4  7b7 ,cease ,activities ,ord]s        
,section #ejb ( su* ,act 7#bi ,u4,s4,c4 
#aacb7 is am5d$ by add+ at ! end !      
foll[+ new subsection3  7n7 ,association
 ,heal? ,plan ,cease & ,desi/ ,ord]s    
7#a7 ,9 g5]al ,subject to p>agraph 7#b71

 ^u application by ! ,secret>y %[+ !    
op]ation1 promotion1 or m>ket+ ( an     
association heal? plan 7or simil>       
arrangem5t provid+ b5efits consi/+ (    
m$ical c>e 7z def9$ 9 section           
#gcc7;a77#b777 t--  7,a7 is n c]tifi$ "u
 "p #h1 is subject "u section           
#ead7;b77#f7 to ! insurance laws ( any  
,/ate 9 :i* ! plan or arrangem5t (f]s or
 provides b5efits1 & is n lic5s$1       
regi/]$1 or o!rwise approv$ "u !        
insurance laws ( su* ,/ate2 or  7,b7 is 
an association heal? plan c]tifi$ "u "p 
#h & is n op]at+ 9 accordance ) !       
requirem5ts "u "p #h = su* c]tification1
  a di/rict c\rt ( ! ,unit$ ,/ates %all 
ent] an ord] requir+ t ! plan or        
arrangem5t cease activities4  7#b7      
,exception ,p>agraph 7#a7 %all n apply 9
 ! case ( an association heal? plan or  
o!r arrangem5t if ! plan or arrangem5t  
%[s t--  7,a7 all b5efits "u x ref]r$ to
 9 p>agraph 7#a7 consi/ ( heal?         
insurance cov]age2 &  7,b7 ) respect to 
ea* ,/ate 9 :i* ! plan or arrangem5t    

(f]s or provides b5efits1 ! plan or     
arrangem5t is op]at+ 9 accordance )     
applicable ,/ate laws t are n sup]s$$ "u
 section #ead4  7#c7 ,additional        
equitable relief ,! c\rt may grant su*  
additional equitable relief1 includ+ any
 relief available "u ?is title1 z x     
deems necess>y to protect ! int]e/s ( ! 
public & ( p]sons hav+ claims = b5efits 
aga9/ ! plan4  4  7c7 ,responsibility = 
,claims ,proc$ure ,section #ejc ( su*   
,act 7#bi ,u4,s4,c4 #aacc7 is am5d$--   
7#a7 by ins]t+ 7a7 ,9 g5]al4-- be=e ,9  
accordance2 &  7#b7 by add+ at ! end !  
foll[+ new subsection3  7b7 ,association
 ,heal? ,plans ,! t]ms ( ea* association
 heal? plan :i* is or has be5 c]tifi$ "u
 "p #h %all require ! bo>d ( tru/ees or 
! nam$ fiduci>y 7z applicable7 to ensure
 t ! requirem5ts ( ?is section are met 9
 connection ) claims fil$ "u ! plan4  4 
#djd4 ,coop]ation betwe5 ,f$]al & ,/ate 
au?orities ,section #ejf ( ! ,employee  
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #aacf7 is am5d$ by 

add+ at ! end ! foll[+ new subsection3  
7d7 ,consultation ,) ,/ates ,) ,respect 
to ,association ,heal? ,plans  7#a7     
,agreem5ts ) /ates ,! ,secret>y %all    
consult ) ! ,/ate recogniz$ "u p>agraph 
7#b7 ) respect to an association heal?  
plan reg>d+ ! ex]cise (--  7,a7 !       
,secret>y's au?ority "u sections #ejb & 
#ejd to en=ce ! requirem5ts =           
c]tification "u "p #h2 &  7,b7 !        
,secret>y's au?ority to c]tify          
association heal? plans "u "p #h 9      
accordance ) regulations ( ! ,secret>y  
applicable to c]tification "u "p #h4    
7#b7 ,recognition ( prim>y domicile /ate
 ,9 c>ry+ out p>agraph 7#a71 ! ,secret>y
 %all ensure t only "o ,/ate w be       
recogniz$1 ) respect to any p>ticul>    
association heal? plan1 z ! ,/ate ) :i* 
consultation is requir$4 ,9 c>ry+ out   
?is p>agraph--  7,a7 9 ! case ( a plan  
:i* provides heal? insurance cov]age 7z 
def9$ 9 section #hab7;a77#c771 su* ,/ate
 %all be ! ,/ate ) :i* fil+ & approval (
 a policy type (f]$ by ! plan 0         

initially obta9$2 &  7,b7 9 any o!r     
case1 ! ,secret>y %all take into acc\nt 
! places ( resid5ce ( ! p>ticipants &   
b5efici>ies "u ! plan & ! ,/ate 9 :i* ! 
tru/ is ma9ta9$4  4  #dje4 ,effective   
date & transitional & o!r rules  7a7    
,effective ,date ,! am5dm5ts made by ?is
 subtitle %all take effect #a ye> aft] !
 date ( ! enactm5t ( ?is ,act4 ,!       
,secret>y ( ,labor %all fir/ issue all  
regulations necess>y to c>ry out !      
am5dm5ts made by ?is subtitle )9 #a ye> 
aft] ! date ( ! enactm5t ( ?is ,act4    
7b7 ,treatm5t ( ,c]ta9 ,exi/+ ,heal?    
,b5efits ,programs  7#a7 ,9 g5]al ,9 any
 case 9 :i*1 z ( ! date ( ! enactm5t (  
?is ,act1 an arrangem5t is ma9ta9$ 9 a  
,/ate = ! purpose ( provid+ b5efits     
consi/+ ( m$ical c>e = ! employees &    
b5efici>ies ( its p>ticipat+ employ]s1  
at lea/ #bjj p>ticipat+ employ]s make   
contributions to su* arrangem5t1 su*    
arrangem5t has be5 9 exi/5ce = at lea/  
#aj ye>s1 & su* arrangem5t is lic5s$ "u 
! laws ( "o or m ,/ates to provide su*  

b5efits to its p>ticipat+ employ]s1 ^u !
 fil+ ) ! applicable au?ority 7z def9$ 9
 section #hab7;a77#e7 ( ! ,employee     
,retirem5t ,income ,security ,act (     
#aigd 7z am5d$ by ?is subtitle77 by !   
arrangem5t ( an application =           
c]tification ( ! arrangem5t "u "p #h (  
subtitle ,b ( title ,i ( su* ,act--     
7,a7 su* arrangem5t %all be deem$ to be 
a gr\p heal? plan = purposes ( title ,i 
( su* ,act2  7,b7 ! requirem5ts (       
sections #hja7;a7 & #hjc7;a7 ( !        
,employee ,retirem5t ,income ,security  
,act ( #aigd %all be deem$ met ) respect
 to su* arrangem5t2  7,c7 ! requirem5ts 
( section #hjc7;b7 ( su* ,act %all be   
deem$ met1 if ! arrangem5t is op]at$ by 
a bo>d ( directors :i*--  7i7 is elect$ 
by ! p>ticipat+ employ]s1 ) ea* employ] 
hav+ "o vote2 &  7ii7 has complete      
fiscal control ov] ! arrangem5t & :i* is
 responsible = all op]ations ( !        
arrangem5t2  7,d7 ! requirem5ts (       
section #hjd7;a7 ( su* ,act %all be     
deem$ met ) respect to su* arrangem5t2 &

  7,e7 ! arrangem5t may be c]tifi$ by   
any applicable au?ority ) respect to its
 op]ations 9 any ,/ate only if x op]ates
 9 su* ,/ate on ! date ( c]tification4  
,! provisions ( ?is subsection %all     
cease to apply ) respect to any su*     
arrangem5t at su* "t aft] ! date ( !    
enactm5t ( ?is ,act z ! applicable      
requirem5ts ( ?is subsection are n met )
 respect to su* arrangem5t4  7#b7       
,def9itions ,= purposes ( ?is           
subsection1 ! t]ms gr\p heal? plan1     
m$ical c>e1 & p>ticipat+ employ] %all h 
! mean+s provid$ 9 section #hab ( !     
,employee ,retirem5t ,income ,security  
,act ( #aigd1 except t ! ref]5ce 9      
subsection 7a77#h7 ( su* section to an  
association heal? plan %all be deem$ a  
ref]5ce to an arrangem5t ref]r$ to 9 ?is
 subsection4  ,v ,m$icaid re=m  #eja4   
,increas+ ,/ate flexibility to conduct  
,m$icaid waiv]s ,section #aaae7;a77#a7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acae7;a77#a77 is am5d$--  7#a7 by     
/rik+ #afjb1 or #aijb & ins]t+ or #afjb2

 &  7#b7 by ins]t+ & %all waive         
compliance ) section #aijb1 aft] z !    
case may be14  ,,vi ,miscellane\s       
provisions  #fja4 ,quality heal? c>e    
coalition  7a7 ,application ( ! ,f$]al  
antitru/ laws to heal? c>e pr(essionals 
negotiat+ ) heal? plans  7#a7 ,9 g5]al  
,any heal? c>e pr(essionals :o are      
engag$ 9 negotiations ) a heal? plan    
reg>d+ ! t]ms ( any contract "u :i* !   
pr(essionals provide heal? c>e items or 
s]vices = :i* b5efits are provid$ "u su*
 plan %all1 9 connection ) su*          
negotiations1 be exempt f ! ,f$]al      
antitru/ laws4  7#b7 ,limitation  7,a7  
,no new "r = collective cessation (     
s]vice ,! exemption provid$ 9 p>agraph  
7#a7 %all n conf] any new "r to         
p>ticipate 9 any collective cessation ( 
s]vice to pati5ts n already p]mitt$ by  
exi/+ law4  7,b7 ,no *ange 9 ,national  
,labor ,relations ,act ,?is section     
applies only to heal? c>e pr(essionals  
exclud$ f ! ,national ,labor ,relations 
,act 7#bi ,u4,s4,c4 #aea et seq474 ,no?+

 9 ?is section %all be con/ru$ z *ang+  
or am5d+ any provision ( ! ,national    
,labor ,relations ,act1 or z affect+ !  
/atus ( any gr\p ( p]sons "u t ,act4    
7#c7 ,no application to ,f$]al programs 
,no?+ 9 ?is section %all apply to       
negotiations betwe5 heal? c>e           
pr(essionals & heal? plans p]ta9+ to    
b5efits provid$ "u any ( ! foll[+3  7,a7
 ,! ,m$ic>e program "u title ,,xviii ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#acie et seq474  7,b7 ,! ,m$icaid       
program "u title ,,xix ( ! ,social      
,security ,act 7#db ,u4,s4,c4 #acif et  
seq474  7,c7 ,! ,/ate ,*ildr5's ,heal?  
,insurance ,program "u title ,,xxi ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acig;aa et seq474  7,d7 ,*apt] #ee (   
title #aj1 ,unit$ ,/ates ,code 7relat+  
to m$ical & d5tal c>e = memb]s ( !      
uni=m$ s]vices74  7,e7 ,*apt] #ag (     
title #ch1 ,unit$ ,/ates ,code 7relat+  
to ,vet]ans' m$ical c>e74  7,f7 ,*apt]  
#hi ( title #e1 ,unit$ ,/ates ,code     
7relat+ to ! ,f$]al ,employees ,heal?   

,b5efits program74  7,g7 ,! ,indian     
,heal? ,c>e ,improvem5t ,act 7#be       
,u4,s4,c4 #afja et seq474  7b7          
,def9itions ,9 ?is section1 ! foll[+    
def9itions %all apply3  7#a7 ,antitru/  
laws ,! t]m antitru/ laws-- 7,a7 has !  
mean+ giv5 x 9 subsection 7a7 ( ! fir/  
section ( ! ,clayton ,act 7#ae ,u4,s4,c4
 #ab7;a771 except t su* t]m includes    
section #e ( ! ,f$]al ,trade ,commission
 ,act 7#ae ,u4,s4,c4 #de7 to ! ext5t su*
 section applies to unfair me?ods (     
competition2 &  7,b7 includes any ,/ate 
law simil> to ! laws ref]r$ to 9        
subp>agraph 7,a74  7#b7 ,gr\p heal? plan
 ,! t]m gr\p heal? plan means an        
employee welf>e b5efit plan to ! ext5t t
 ! plan provides m$ical c>e 7includ+    
items & s]vices paid = z m$ical c>e7 to 
employees or _! dep5d5ts 7z def9$ "u !  
t]ms ( ! plan7 directly or ?r\gh        
insurance1 reimbursem5t1 or o!rwise4    
7#c7 ,gr\p heal? plan1 heal? insurance  
issu] ,! t]ms gr\p heal? plan & heal?   
insurance issu] include a ?ird-p>ty     

adm9i/rator or o!r p]son act+ = or on   
behalf ( su* plan or issu]4  7#d7 ,heal?
 c>e s]vices ,! t]m heal? c>e s]vices   
means any s]vices = :i* paym5t may be   
made "u a heal? plan1 includ+ s]vices   
relat$ to ! deliv]y or adm9i/ration (   
su* s]vices4  7#e7 ,heal? c>e           
pr(essional ,! t]m heal? c>e pr(essional
 means any individual or entity t       
provides heal? c>e items or s]vices1    
treatm5t1 assi/ance ) activities ( daily
 liv+1 or m$ications to pati5ts & :o1 to
 ! ext5t requir$ by ,/ate or ,f$]al law1
 possesses specializ$ tra9+ t conf]s    
exp]tise 9 ! provision ( su* items or   
s]vices1 treatm5t1 assi/ance1 or        
m$ications4  7#f7 ,heal? insurance      
cov]age ,! t]m heal? insurance cov]age  
means b5efits consi/+ ( m$ical c>e      
7provid$ directly1 ?r\gh insurance or   
reimbursem5t1 or o!rwise & includ+ items
 & s]vices paid = z m$ical c>e7 "u any  
hospital or m$ical s]vice policy or     
c]tificate1 hospital or m$ical s]vice   
plan contract1 or heal? ma9t5ance       

organization contract (f]$ by a heal?   
insurance issu]4  7#g7 ,heal? insurance 
issu] ,! t]m heal? insurance issu] means
 an insurance company1 insurance s]vice1
 or insurance organization 7includ+ a   
heal? ma9t5ance organization7 t is      
lic5s$ to engage 9 ! bus9ess ( insurance
 9 a ,/ate & t is subject to ,/ate law  
regulat+ insurance4 ,su* t]m does n     
include a gr\p heal? plan4  7#h7 ,heal? 
ma9t5ance organization ,! t]m heal?     
ma9t5ance organization means-- 7,a7 a   
f$]ally qualifi$ heal? ma9t5ance        
organization 7z def9$ 9 section         
#acja7;a7 ( ! ,public ,heal? ,s]vice    
,act 7#db ,u4,s4,c4 #cjj;e7a7772  7,b7  
an organization recogniz$ "u ,/ate law z
 a heal? ma9t5ance organization2 or     
7,c7 a simil> organization regulat$ "u  
,/ate law = solv5cy 9 ! same mann] & to 
! same ext5t z su* a heal? ma9t5ance    
organization4  7#i7 ,heal? plan ,! t]m  
heal? plan means a gr\p heal? plan or a 
heal? insurance issu] t is (f]+ heal?   
insurance cov]age4  7#aj7 ,m$ical c>e ,!

 t]m m$ical c>e means am\nts paid =--   
7,a7 ! diagnosis1 cure1 mitigation1     
treatm5t1 or prev5tion ( disease1 or    
am\nts paid = ! purpose ( affect+ any   
/ructure or function ( ! body2 &  7,b7  
transportation prim>ily = & ess5tial to 
receiv+ items & s]vices ref]r$ to 9     
subp>agraph 7,a74  7#aa7 ,p]son ,! t]m  
p]son includes a ,/ate or unit ( local  
gov]nm5t4  7#ab7 ,/ate ,! t]m ,/ate     
includes ! sev]al ,/ates1 ! ,di/rict (  
,columbia1 ,pu]to ,rico1 ! ,virg9 ,isl&s
 ( ! ,unit$ ,/ates1 ,guam1 ,am]ican     
,samoa1 & ! ,commonweal? ( ! ,nor!rn    
,m>iana ,isl&s4  7c7 ,effective date    
,?is section %all take effect on ! date 
( ! enactm5t ( ?is ,act & %all n apply )
 respect to conduct occurr+ be=e su*    
date4  #fjb4 ,c]ta9 m$ical /op-loss     
insurance obta9$ by c]ta9 plan sponsors 
( gr\p heal? plans n includ$ "u !       
def9ition ( heal? insurance cov]age  7a7
 ,,phsa ,section #bgia7;b77#a7 ( !      
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #cjj;gg-#ia7;b77#a77 is am5d$ 

by add+ at ! end ! foll[+ new s5t5ce3   
,su* t]m %all n include a /op loss      
policy obta9$ by a self-insur$ heal?    
plan or a plan sponsor ( a gr\p heal?   
plan t self-insures ! heal? risks ( its 
plan p>ticipants to reimburse ! plan or 
sponsor = losses t ! plan or sponsor    
incurs 9 provid+ heal? or m$ical b5efits
 to su* plan p>ticipants 9 excess ( a   
pr$et]m9$ level set =? 9 ! /op loss     
policy obta9$ by su* plan or sponsor44  
7b7 ,,erisa ,section #gcc7;b77#a7 ( !   
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4             
#aaia;b7b77#a77 is am5d$ by add+ at !   
end ! foll[+ new s5t5ce3 ,su* t]m %all n
 include a /op loss policy obta9$ by a  
self-insur$ heal? plan or a plan sponsor
 ( a gr\p heal? plan t self-insures !   
heal? risks ( its plan p>ticipants to   
reimburse ! plan or sponsor = losses t !
 plan or sponsor incurs 9 provid+ heal? 
or m$ical b5efits to su* plan           
p>ticipants 9 excess ( a pr$et]m9$ level
 set =? 9 ! /op loss policy obta9$ by   

su* plan or sponsor44  7c7 ,,irc        
,section #ihcb7;b77#a77;,a7 ( ! ,int]nal
 ,rev5ue ,code ( #aihf is am5d$ by add+ 
at ! end ! foll[+ new s5t5ce3 ,su* t]m  
%all n include a /op loss policy obta9$ 
by a self-insur$ heal? plan or a plan   
sponsor ( a gr\p heal? plan t           
self-insures ! heal? risks ( its plan   
p>ticipants to reimburse ! plan or      
sponsor = losses t ! plan or sponsor    
incurs 9 provid+ heal? or m$ical b5efits
 to su* plan p>ticipants 9 excess ( a   
pr$et]m9$ level set =? 9 ! /op loss     
policy obta9$ by su* plan or sponsor44