,,ii #aae? ,,congress #b;d ,session ,s4 #behb ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,m>* #ba1 #bjah ,ms4 ,w>r5 7= h]self1 ,ms4 ,hassan1 ,mr4 ,s&]s1 ,ms4 ,h>ris1 ,ms4 ,baldw91 & ,mrs4 ,gillibr&7 introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,f9ance ,a ,,bill ,to provide heal? insurance re=m1 & = o!r purposes4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,consum] ,heal? ,insurance ,protection ,act ( #bjah4 #b4 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title4 ,sec4 #b4 ,table ( cont5ts4 ,,title ,i--,limit+ insur] pr(its & prev5t+ unreasonable premium increases ,sec4 #aja4 ,m$ical loss ratio4 ,sec4 #ajb4 ,ensur+ t consum]s get value = _! doll>s4 ,sec4 #ajc4 ,effective date4 ,,title ,,ii--,mak+ heal? insurance cov]age af=dable ,sec4 #bja4 ,enhancem5t ( premium assi/ance cr$it4 ,sec4 #bjb4 ,enhancem5ts = r$uc$ co/-%>+4 ,sec4 #bjc4 ,cap on prescription drug co/-%>+4 ,sec4 #bjd4 ,/&>diz$ options 9 ! bronze1 silv]1 & gold levels ( cov]age4 ,sec4 #bje4 ,cl>ification reg>d+ det]m9ation ( af=dability ( employ]-sponsor$ m9imum ess5tial cov]age4 ,,title ,,iii--,ensur+ access to c>e ,sec4 #cja4 ,network adequacy requirem5ts4 ,sec4 #cjb4 ,ensur+ adequate cov]age 9 areas ) few] ?an #c heal? insurance issu]s (f]+ qualifi$ heal? plans on ! ,/ate ,ex*ange4 ,sec4 #cjc4 ,enrollm5t 9 ,ex*anges4 ,sec4 #cjd4 ,m>ket+ & outrea* = ,ex*anges op]at$ by ! ,secret>y4 ,sec4 #cje4 ,navigator program4 ,,title ,,iv--,/r5g!n+ consum] heal? insurance protections ,sec4 #dja4 ,prohibit+ discrim9atory premiums bas$ on tobacco use4 ,sec4 #djb4 ,heal? insurance consum] in=mation4 ,sec4 #djc4 ,pati5t protections4 ,sec4 #djd4 ,limitation on balance bill+ = em]g5cy s]vices4 ,sec4 #dje4 ,notification ( provid] t]m9ations4 ,sec4 #djf4 ,%ort-t]m limit$ duration heal? insurance cov]age4 ,sec4 #djg4 ,protect+ ess5tial heal? b5efits4 ,sec4 #djh4 ,association heal? plans4 ,i ,limit+ insur] pr(its & prev5t+ unreasonable premium increases #aja4 ,m$ical loss ratio ,section #bgah7;b77#a77;,a77ii7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7;b77#a77;,a77ii77 is am5d$ by /rik+ #hj ea* place x appe>s & ins]t+ #he4 #ajb4 ,ensur+ t consum]s get value = _! doll>s ,section #bgid ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#id7 is am5d$-- 7#a7 9 subsection 7a7-- 7,a7 9 p>agraph 7#a71 by /rik+ subsection 7b77#b77;,a7 & ins]t+ subsections 7b77#b77;,a7 & 7b77#c72 & 7,b7 9 p>agraph 7#b71 by add+ at ! end ! foll[+3 ,not)/&+ any o!r provision ( law1 a heal? insurance issu] may n exclude f su* disclosure in=mation t is a trade secret or comm]cial or f9ancial in=mation describ$ 9 section #eeb7;b77#d7 ( title #e1 ,unit$ ,/ates ,code42 7#b7 9 subsection 7b7-- 7,a7 9 p>agraph 7#b77;,a71 by ins]t+ & p>agraph 7#c7 aft] subsection 7a77#b72 & 7,b7 by add+ at ! end ! foll[+3 7#c7 ,prohibit+ unreasonable increases 7,a7 ,9 g5]al ,beg9n+ ) plan ye>s beg9n+ 9 #bjbj1 ! ,secret>y1 or a ,/ate pursuant to an effective rate review program meet+ ! requirem5ts "u p>agraph 7#d7-- 7i7 %all1 consi/5t ) subsection 7a77#b7 & p>agraph 7#b71 review increases 9 heal? insurance premiums t are subject to review pursuant to section #aed4bjj ( title #de1 ,code ( ,f$]al ,regulations 7or any successor regulation71 & det]m9e :e!r su* increases are unreasonable2 & 7ii7 may prohibit a heal? insurance issu] f implem5t+ su* an increase t is unreasonable4 7,b7 ,unreasonable increases ,9 det]m9+ :e!r an increase 9 heal? insurance premiums is unreasonable "u subp>agraph 7,a77i7-- 7i7 ! ,secret>y %all consid] :e!r ! increase is excessive1 unju/ifi$1 discrim9atory1 or inadequate2 & 7ii7 ! ,/ate1 pursuant to an effective rate review program meet+ ! requirem5ts "u p>agraph 7#d71 %all apply applicable ,/ate law = mak+ su* det]m9ation4 7#d7 ,/ate effective rate review programs ,a ,/ate effective rate review program meets ! requirem5ts "u ?is p>agraph if-- 7,a7 ! program c>ries out ! reviews describ$ 9 p>agraph 7#c77;,a77i7 & ensures t su* reviews are a mean+ful1 effective1 & timely review ( ! data & docum5tation 7includ+ any contracts or docum5ts describ$ 9 subp>agraph 7,e77 submitt$ by heal? insurance issu]s 9 support ( propos$ increases 9 heal? insurance premiums2 7,b7 su* reviews include an exam9ation (-- 7i7 ! af=dability ( propos$ increases 9 heal? insurance premiums2 7ii7 ! quality improvem5t activities c>ri$ out by heal? insurance issu]s propos+ ! increases2 & 7iii7 ! co/ conta9m5t activities ( heal? insurance issu]s propos+ ! increases2 7,c7 ! program e/abli%es a me*anism = receiv+ public comm5ts on propos$ increases 9 heal? insurance premiums review$ by ! ,/ate2 7,d7 su* reviews include a review ( all public comm5ts receiv$ "u subp>agraph 7,c72 7,e7 ! program requires ea* heal? insurance issu] propos+ an increase 9 heal? insurance premiums to submit to ! ,/ate any provid] contracts t may be affect$1 includ+ any docum5ts incorporat$ by ref]5ce into su* contracts2 & 7,f7 ! program requires ! ,/ate to provide ! ,secret>y its det]m9ation ( :e!r ea* increase review$ is unreasonable1 9 a =m & mann] prescrib$ by ! ,secret>y4 2 & 7#c7 9 subsection 7c7-- 7,a7 9 p>agraph 7#a7-- 7i7 9 ! head+1 by /rik+ #bjaj ?r\gh #bjad & ins]t+ #bjbj ?r\gh #bjbd2 & 7ii7 9 ! matt] prec$+ subp>agraph 7,a71 by /rik+ #bjaj & ins]t+ #bjbj2 & 7,b7 9 p>agraph 7#b77;,b71 by /rik+ #bjad & ins]t+ #bjbd4 #ajc4 ,effective date ,! am5dm5ts made by ?is title %all apply to plan ye>s beg9n+ aft] ,decemb] #ca1 #bjai4 ,,ii ,mak+ heal? insurance cov]age af=dable #bja4 ,enhancem5t ( premium assi/ance cr$it 7a7 ,use ( gold level plan = b5*m>k 7#a7 ,9 g5]al ,clause 7i7 ( section #cf;,b7b77#b77;,b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ applicable second l[e/ co/ silv] plan & ins]t+ applicable second l[e/ co/ gold plan4 7#b7 ,con=m+ am5dm5t relat$ to af=dability ,section #cf;,b7c77#d77;,c77i77,i7 ( su* ,code is am5d$ by /rik+ second l[e/ co/ silv] plan & ins]t+ second l[e/ co/ gold plan4 7#c7 ,o!r con=m+ am5dm5ts ,subp>agraphs 7,b7 & 7,c7 ( section #cf;,b7b77#c7 ( su* ,code are ea* am5d$ by /rik+ silv] plan ea* place x appe>s 9 ! text & ! head+ & ins]t+ gold plan4 7b7 ,expansion ( eligibility = refundable cr$its = cov]age "u qualifi$ heal? plans 7#a7 ,9 g5]al ,section #cf;,b7c77#a77;,a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ b does n exce$ #djj p]c5t4 7#b7 ,con=m+ am5dm5ts relat+ to recapture ( excess advanc$ paym5ts ,clause 7i7 ( section #cf;,b7f77#b77;,b7 ( su* ,code is am5d$-- 7,a7 by /rik+ ,9 ! case ( & all t foll[s ?r\gh ! am\nt ( & ins]t+ ,! am\nt (2 & 7,b7 by /rik+ b less ?an #djj 9 ! table !re94 7c7 ,det]m9ation ( applicable p]c5tage 7#a7 ,9 g5]al ,subp>agraph 7,a7 ( section #cf;,b7b77#c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 7,a7 ,applicable p]c5tage ,! applicable p]c5tage = any taxable ye> %all be ! p]c5tage su* t ! applicable p]c5tage = any taxpay] ^: h\sehold income is )9 an income ti] specifi$ 9 ! foll[+ table %all increase1 on a slid+ scale 9 a l9e> mann]1 f ! initial premium p]c5tage to ! f9al premium p]c5tage specifi$ 9 su* table = su* income ti]3 ,9 ! case ( h\sehold income 7express$ z a p]c5t ( pov]ty l9e7 )9 ! foll[+ income ti]3,! initial premium p]c5tage is--,! f9al premium p]c5tage is--#ajj ?r\gh #accj4ja4jacc ?r\gh #aeja4jb4jaej ?r\gh #bjjb4jd4jbjj ?r\gh #bejd4jf4jbej ?r\gh #cjjf4jg4jcjj ?r\gh #djjg4jh4e,ov] #djjh4eh4e 4 7#b7 ,con=m+ am5dm5ts ,subsections 7c77#b77;,c77iv7 & 7c77#d77;,f7 ( section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf are ea* am5d$ by ins]t+ 7z 9 effect be=e ! date ( ! enactm5t ( ! ,consum] ,heal? ,insurance ,protection ,act ( #bjah7 aft] subsection 7b77#c77;,a77ii74 7d7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjai4 #bjb4 ,enhancem5ts = r$uc$ co/-%>+ 7a7 ,modification ( am\nt 7#a7 ,9 g5]al ,section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjga7 is am5d$-- 7,a7 9 subsection 7b77#a71 by /rik+ silv] & ins]t+ gold2 7,b7 by am5d+ subsection 7c77#a77;,b7 to read z foll[s3 7,b7 ,coord9ation ) actu>ial limits ,! ,secret>y %all ensure ! r$uction "u ?is p>agraph %all n result 9 ! plan's %>e ( ! total all[$ co/s ( b5efits provid$ "u ! plan becom+ less ?an-- 7i7 #ie p]c5t 9 ! case ( an eligible insur$ describ$ 9 p>agraph 7#b77;,a72 7ii7 #ij p]c5t 9 ! case ( an eligible insur$ describ$ 9 p>agraph 7#b77;,b72 & 7iii7 #he p]c5t 9 ! case ( an eligible insur$ describ$ 9 p>agraph 7#b77;,c74 2 & 7,c7 by am5d+ subsection 7c77#b7 to read z foll[s3 7#b7 ,additional r$uction ,! ,secret>y %all e/abli% proc$ures "u :i* ! issu] ( a qualifi$ heal? plan to :i* ?is section applies %all fur!r r$uce co/-%>+ "u ! plan 9 a mann] suffici5t to-- 7,a7 9 ! case ( an eligible insur$ ^: h\sehold income is n less ?an #ajj p]c5t b n m ?an #bjj p]c5t ( ! pov]ty l9e = a family ( ! size involv$1 increase ! plan's %>e ( ! total all[$ co/s ( b5efits provid$ "u ! plan to #ie p]c5t ( su* co/s2 7,b7 9 ! case ( an eligible insur$ ^: h\sehold income is m ?an #bjj p]c5t b n m ?an #cjj p]c5t ( ! pov]ty l9e = a family ( ! size involv$1 increase ! plan's %>e ( ! total all[$ co/s ( b5efits provid$ "u ! plan to #ij p]c5t ( su* co/s2 & 7,c7 9 ! case ( an eligible insur$ ^: h\sehold income is m ?an #cjj p]c5t b n m ?an #djj p]c5t ( ! pov]ty l9e = a family ( ! size involv$1 increase ! plan's %>e ( ! total all[$ co/s ( b5efits provid$ "u ! plan to #he p]c5t ( su* co/s4 4 7#b7 ,effective date ,! am5dm5ts made by ?is subsection %all apply to plan ye>s beg9n+ aft] ,decemb] #ca1 #bjai4 7b7 ,fund+ ,section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjga7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7g7 ,fund+ ,out ( any funds 9 ! ,treasury n o!rwise appropriat$1 !re are appropriat$ to ! ,secret>y su* sums z may be necess>y = paym5ts "u ?is section4 4 #bjc4 ,cap on prescription drug co/-%>+ 7a7 ,qualifi$ heal? plans ,section #acjb7;c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjbb7;c77 is am5d$-- 7#a7 9 p>agraph 7#c77;,a77i71 by ins]t+ 7includ+ co/-%>+ ) respect to prescription drugs cov]$ by ! plan7 aft] copaym5ts2 & 7#b7 by add+ at ! end ! foll[+3 7#e7 ,prescription drug co/-%>+ 7,a7 #bjbj ,= plan ye>s beg9n+ 9 #bjbj1 ! co/-%>+ incurr$ "u a heal? plan ) respect to prescription drugs cov]$ by ! plan %all n exce$ #bej p] mon? = ea* enroll$ individual1 or #ejj = ea* family4 7,b7 #bjba & lat] 7i7 ,9 g5]al ,9 ! case ( any plan ye> beg9n+ 9 a cal5d> ye> aft] #bjbj1 ! limitation "u ?is p>agraph %all be equal to ! applicable doll> am\nt "u subp>agraph 7,a7 = plan ye>s beg9n+ 9 #bjbj1 increas$ by an am\nt equal to ! product ( t am\nt & ! m$ical c>e compon5t ( ! consum] price index = all urban consum]s 7z publi%$ by ! ,bureau ( ,labor ,/ati/ics7 = t ye>4 7ii7 ,adju/m5t to am\nt ,if ! am\nt ( any increase "u clause 7i7 is n a multiple ( #e1 su* increase %all be r\nd$ to ! next l[e/ multiple ( #e4 4 7b7 ,gr\p heal? plans ,section #bgjg7;b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#f7;b77 is am5d$ by /rik+ p>agraph 7#a7 ( section #acjb7;c7 & ins]t+ p>agraphs 7#a7 & 7#e7 ( section #acjb7;c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act4 7c7 ,effective date ,! am5dm5ts made by subsections 7a7 & 7b7 %all take effect ) respect to plans beg9n+ aft] ,decemb] #ca1 #bjai4 #bjd4 ,/&>diz$ options 9 ! bronze1 silv]1 & gold levels ( cov]age 7a7 ,9 g5]al ,section #acja7;a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjba7;a77 is am5d$-- 7#a7 9 p>agraph 7#a77;,c7-- 7,a7 9 clause 7iii71 by /rik+ 2 & & ins]t+ 22 7,b7 by r$esignat+ clause 7iv7 z clause 7v72 & 7,c7 by ins]t+ aft] clause 7iii7 ! foll[+3 7iv7 7,i7 agrees to (f] ! /&>diz$ option e/abli%$ = ! ,/ate "u p>agraph 7#e7 = ea* level ( cov]age (f]$ by ! issu] t is ! bronze1 silv]1 or gold level ( cov]age2 & 7,,ii7 ) respect to (f]+ cov]age t is ! bronze1 silv]1 or gold level ( cov]age on an ,ex*ange t is op]at$ by ! ,secret>y1 agrees to (f] only /&>diz$ options e/abli%$ = ! ,/ate "u p>agraph 7#e7 & n any o!r plan = su* levels ( cov]age2 & 2 & 7#b7 by add+ at ! end ! foll[+3 7#e7 ,/&>diz$ options 7,a7 ,def9ition ( /&>diz$ option ,9 ?is section1 ! t]m /&>diz$ option means a qualifi$ heal? plan-- 7i7 ) a /&>diz$ co/-%>+ /ructure e/abli%$ by ! applicable ,/ate1 or ! ,secret>y1 9 accordance ) ?is p>agraph2 & 7ii7 t is (f]$ on an ,ex*ange4 7,b7 ,e/abli%m5t 7i7 ,/ate ,ea* ,/ate may e/abli% a /&>diz$ option = ! bronze1 silv]1 & gold levels ( cov]age4 7ii7 ,secret>y ,! ,secret>y %all e/abli% a /&>diz$ option 9 a ,/ate = any level ( cov]age describ$ 9 clause 7i7 = :i* ! ,/ate has n e/abli%$ a /&>diz$ option4 7iii7 ,updates ,! ,secret>y %all annually update any /&>diz$ option e/abli%$ by ! ,secret>y "u clause 7ii74 7,c7 ,d$uctible-exempt s]vices 7i7 ,9 g5]al ,except z provid$ 9 clause 7ii71 ea* /&>diz$ option e/abli%$ by ! ,secret>y "u subp>agraph 7,b77ii7 %all include cov]age ( ea* ( ! foll[+ z d$uctible-exempt s]vices3 7,i7 ,all prim>y c>e visits & speciali/ visits4 7,,ii7 ,all m5tal heal? & sub/ance use disord] outpati5t s]vices4 7,,iii7 ,all drugs approv$ "u section #eje7;j7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act & biological products lic5s$ "u section #cea7k7 ( ! ,public ,heal? ,s]vice ,act4 7,,iv7 ,all urg5t c>e s]vices4 7ii7 ,bronze & silv] levels ( cov]age ,! ,secret>y may alt] ! s]vices t %all be cov]$ z d$uctible-exempt s]vices "u clause 7i7 = /&>diz$ options 9 ! bronze & silv] levels ( cov]age4 7,d7 ,display ,ea* ,ex*ange op]at$ by a ,/ate %all pref]5tially display ! /&>diz$ options (f]$ 9 su* ,/ate on ! website ( ! ,ex*ange4 4 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply to plans beg9n+ aft] ,decemb] #ca1 #bjai4 #bje4 ,cl>ification reg>d+ det]m9ation ( af=dability ( employ]-sponsor$ m9imum ess5tial cov]age 7a7 ,special rule = employ]-,sponsor$ m9imum ess5tial cov]age ,clause 7i7 ( section #cf;,b7c77#b77;,c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 7i7 ,cov]age mu/ be af=dable 7,i7 ,9 g5]al ,except z provid$ 9 clause 7iii71 an individual %all n be treat$ z eligible = m9imum ess5tial cov]age if su* cov]age consi/s ( an eligible employ]-sponsor$ plan 7z def9$ 9 section #ejjj;,a7f77#b77 & ! requir$ contribution ) respect to ! plan exce$s #h4e p]c5t ( ! applicable taxpay]'s h\sehold income4 7,,ii7 ,requir$ contribution ) respect to employee ,9 ! case ( ! employee eligible to enroll 9 ! plan1 ! requir$ contribution = purposes ( subclause 7,i7 is ! employee's requir$ contribution 7)9 ! mean+ ( section #ejjj;,a7e77#a77;,b77i77 ) respect to ! plan4 7,,iii7 ,requir$ contribution ) respect to family memb]s ,9 ! case ( an individual :o is eligible to enroll 9 ! plan by reason ( a relation%ip ! individual be>s to ! employee1 ! requir$ contribution = purposes ( subclause 7,i7 is ! employee's requir$ contribution 7)9 ! mean+ ( section #ejjj;,a7e77#a77;,b77i71 det]m9$ by sub/itut+ family = self-only7 ) respect to ! plan4 4 7b7 ,con=m+ am5dm5ts 7#a7 ,clause 7ii7 ( section #cf;,b7c77#b77;,c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+3 ,?is clause %all also apply to an individual :o is eligible to enroll 9 ! plan by reason ( a relation%ip ! individual be>s to ! employee44 7#b7 ,clause 7iii7 ( section #cf;,b7c77#b77;,c7 ( su* ,code is am5d$ by /rik+ ! la/ s5t5ce ( clause 7i7 & ins]t+ clause 7i77,,iii74 7#c7 ,clause 7iv7 ( section #cf;,b7c77#b77;,c7 ( su* ,code is am5d$ by /rik+ clause 7i77,,ii7 & ins]t+ clause 7i77,i74 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjai4 ,,iii ,ensur+ access to c>e #cja4 ,network adequacy requirem5ts 7a7 ,9 g5]al ,section #acaa7;c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca7;c77 is am5d$-- 7#a7 9 p>agraph 7#a77;,b71 by ins]t+ & p>agraph 7#g7 & 9 accordance ) p>agraph 7#h7 aft] ,public ,heal? ,s]vice ,act2 & 7#b7 by add+ at ! end ! foll[+3 7#g7 ,network adequacy requirem5ts 7,a7 ,9 g5]al ,a qualifi$ heal? plan %all meet ! network adequacy /&>ds e/abli%$ by ! ,secret>y "u subp>agraph 7,b71 except z provid$ 9 subp>agraphs 7,b77ii7 & 7,c74 7,b7 ,f$]al /&>ds & review 7i7 ,/&>d 7,i7 ,e/abli%m5t ,! ,secret>y %all e/abli% a network adequacy /&>d bas$ on access to 9-network provid]s = qualifi$ heal? plans1 except = ^? plans describ$ 9 subp>agraph 7,c74 ,su* /&>d %all include requirem5ts = ! m9imum numb] & type ( 9-network provid]s available1 ! geographical location ( su* provid]s1 ! av]age di/ance & travel "t requir$ = pati5ts to visit su* provid]s1 & ! av]age appo9tm5t wait times = s]vices cov]$ by ! plan4 7,,ii7 ,m$ic>e ,advantage organizations ,! network adequacy /&>d e/abli%$ "u subclause 7,i7 %all1 at a m9imum1 be equival5t to ! requirem5ts = access to s]vices applicable to ,m$ic>e ,advantage organizations (f]+ ,m$ic>e ,advantage plans "u "p ,c ( title ,,xviii ( ! ,social ,security ,act4 7ii7 ,ju/ification ,a qualifi$ heal? plan t fails to meet ! /&>d e/abli%$ "u clause 7i7 may satisfy ! requirem5t "u subp>agraph 7,a7 by provid+ ! ,secret>y ) a reasonable ju/ification = ! v>iance f su* /&>d1 bas$ on factors su* z ! availability ( provid]s & v>iables reflect$ 9 local patt]ns ( heal? c>e4 7iii7 ,review ,! ,secret>y %all e/abli% a process = review+ ! network adequacy ( qualifi$ heal? plans1 except = ^? plans review$ by ! ,/ate 9 accordance ) subp>agraph 7,c77ii74 7,c7 ,/ate /&>d 7i7 ,9 g5]al ,9 ! case ( a qualifi$ heal? plan (f]$ 9 a ,/ate t has implem5t$ a quantifiable network adequacy metric t ! ,secret>y det]m9es is an acceptable metric commonly us$ 9 ! heal? insurance indu/ry to measure network adequacy1 su* qualifi$ heal? plan may satisfy ! requirem5t "u subp>agraph 7,a7 by meet+ ! network adequacy /&>ds ( su* ,/ate bas$ on su* metric4 7ii7 ,review ,a ,/ate ) an acceptable metric describ$ 9 clause 7i7 may review ! network adequacy ( qualifi$ heal? plans (f]$ 9 su* ,/ate 9 a process e/abli%$ by ! ,/ate4 7#h7 ,cov]age ( out-(-network ess5tial heal? b5efits 7,a7 ,9 g5]al ,a qualifi$ heal? plan %all provide1 to an individual enroll$ 9 su* plan1 cov]age ( any s]vice provid$ by an out-(-network provid] if-- 7i7 cov]age ( su* s]vice w\ld o!rwise be provid$ by ! plan if ! s]vice 0 provid$ by an 9-network provid]2 7ii7 ! s]vice is includ$ 9 ! ess5tial heal? b5efits package describ$ 9 section #acjb7;a72 & 7iii7 ! s]vice _c be provid$ to ! individual by an 9-network provid] )9 a reasonable timeframe or )9 a reasonable di/ance & travel "t4 7,b7 ,co/-%>+ ,a qualifi$ heal? plan t provides cov]age ( a s]vice provid$ by an out-(-network provid] "u subp>agraph 7,a7 %all provide su* cov]age ) ! same co/-%>+ requirem5ts z if ! s]vice 0 provid$ by an 9-network provid]4 4 7b7 ,effective date ,! am5dm5ts made by subsection 7a7 %all apply to plans beg9n+ aft] ,decemb] #ca1 #bjai4 7c7 ,grants = ,/ate network adequacy reviews 7#a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices %all c>ry out a program to aw>d grants to ,/ates dur+ ! #e-ye> p]iod beg9n+ ) fiscal ye> #bjbj to assi/ su* ,/ates 9 develop+ a metric to measure network adequacy z describ$ 9 subp>agraph 7,c77i7 ( section #acaa7;c77#g7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca7;c77#g77 & to c>ry out ! reviews describ$ 9 subp>agraph 7,c77ii7 ( su* section4 7#b7 ,au?orization ( appropriations ,!re are au?oriz$ to be appropriat$ = fiscal ye>s #bjbj ?r\gh #bjbd su* sums z may be necess>y to c>ry out ! grant program "u ?is subsection4 #cjb4 ,ensur+ adequate cov]age 9 areas ) few] ?an #c heal? insurance issu]s (f]+ qualifi$ heal? plans on ! ,/ate ,ex*ange 7a7 ,requirem5ts = ,m$ic>e ,advantage organizations 7#a7 ,9 g5]al ,section #aheg7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#e7 ,requirem5t = c]ta9 ,m$ic>e ,advantage organizations t (f] an ,,ma plan 9 an applicable area to also (f] qualifi$ heal? plans 9 ! applicable area 7,a7 ,9 g5]al ,a contract "u ?is section ) an ,,ma organization describ$ 9 subp>agraph 7,b7 %all require ! organization to1 9 ea* applicable area 9 :i* ! organization (f]s an ,,ma plan1 also (f]1 ?r\gh ! individual m>ket 9 ! ,ex*ange op]at+ 9 ! ,/ate1 at lea/ "o qualifi$ heal? plan 9 ! silv] level ( cov]age & at lea/ "o qualifi$ heal? plan 9 ! gold level ( cov]age1 z describ$ 9 section #acjb7;d7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act4 7,b7 ,,ma organizations describ$ ,an ,,ma organization describ$ 9 ?is subp>agraph is an ,,ma organization t1 9 addition to (f]+ an ,,ma plan 9 an applicable area1 (f]s heal? insurance cov]age 9 ! gr\p m>ket or individual m>ket 9 ! ,/ate b does n (f] su* cov]age ?r\gh ! ,ex*ange op]at+ 9 ! ,/ate4 7,c7 ,notification ,! ,secret>y1 or ! ,/ate 9 ! case ( an ,,ma organization (f]+ an ,,ma plan 9 an applicable area 9 a ,/ate ) an ,ex*ange op]at$ by ! ,/ate1 %all notify ea* ,,ma organization t is requir$ to (f] a qualifi$ heal? plan "u subp>agraph 7,a7 = a plan ye> ( su* requirem5t4 ,su* notification %all be provid$ ea* ye>-- 7i7 beg9n+ ) respect to ! requirem5t = plan ye>s beg9n+ aft] ,decemb] #ca1 #bjai2 & 7ii7 n less ?an #a ye> prior to ! rate fil+ deadl9e = ! plan ye> = ! ,ex*ange op]at+ 9 ! ,/ate 9 :i* ! ,,ma organization w be requir$ to (f] su* plan4 7,d7 ,waiv] ,! ,secret>y1 or ! ,/ate 9 ! case ( an ,,ma organization (f]+ an ,,ma plan 9 an applicable area 9 a ,/ate ) an ,ex*ange op]at$ by ! ,/ate1 may waive ! requirem5t "u subp>agraph 7,a7 if-- 7i7 by ! fir/ day ( ! plan ye>1 ! numb] ( heal? insurance issu]s (f]+ a qualifi$ heal? plan ?r\gh ! individual m>ket 9 ! ,ex*ange has increas$ su* t ! applicable area no long] has few] ?an #c heal? insurance issu]s (f]+ a qualifi$ heal? plan ?r\gh ! individual m>ket 9 ! ,ex*ange op]at+ 9 ! ,/ate2 or 7ii7 ! ,secret>y1 or ! ,/ate 9 su* a case1 det]m9es t ! requirem5t "u subp>agraph 7,a7 w\ld cause ! ,,ma organization to become insolv5t4 7,e7 ,def9itions ,9 ?is p>agraph3 7i7 ,applicable area ,! t]m applicable area means an area 9 :i*1 at ! "t ! ,secret>y or ! ,/ate s5ds ! notification "u subp>agraph 7,c71 few] ?an #c heal? insurance issu]s (f] a qualifi$ heal? plan ?r\gh ! individual m>ket 9 ! ,ex*ange op]at+ 9 ! ,/ate4 7ii7 ,ex*ange ,! t]m ,ex*ange means an ,am]ican ,heal? ,b5efit ,ex*ange e/abli%$ "u section #acaa or section #acba ( ! ,pati5t ,protection & ,af=dable ,c>e ,act4 7iii7 ,gr\p m>ket ,! t]m gr\p m>ket has ! mean+ giv5 su* t]m 9 section #acjd ( ! ,pati5t ,protection & ,af=dable ,c>e ,act4 7iv7 ,heal? insurance cov]age ,! t]m heal? insurance cov]age has ! mean+ giv5 ! t]m 9 section #bgia7;b7 ( ! ,public ,heal? ,s]vice ,act4 7v7 ,individual m>ket ,! t]m individual m>ket has ! mean+ giv5 su* t]m 9 section #acjd ( ! ,pati5t ,protection & ,af=dable ,c>e ,act4 7vi7 ,qualifi$ heal? plan ,! t]m qualifi$ heal? plan has ! mean+ giv5 t t]m 9 section #acja7;a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act4 4 7#b7 ,effective date ,! am5dm5t made by ?is subsection %all apply to contracts ent]$ into or r5ew$ aft] ,decemb] #ca1 #bjai4 7b7 ,requirem5ts = ,m$icaid manag$ c>e organizations 7#a7 ,9 g5]al ,section #aijc7m77#b77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7m77#b77;,a77 is am5d$-- 7,a7 9 clause 7xii71 by /rik+ 2 & & ins]t+ a semicolon2 7,b7 by realign+ ! left m>g9 ( clause 7xiii7 to align ) ! left m>g9 ( clause 7xii72 7,c7 9 clause 7xiii71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7,d7 by ins]t+ aft] clause 7xiii7 ! foll[+3 7xiv7 su* contract requires t ! entity meets ! requirem5ts describ$ 9 section #aheg7;e77#e7 9 ! same mann] z su* requirem5ts apply to an ,,ma organization4 4 7#b7 ,effective date ,! am5dm5ts made by ?is subsection %all apply to contracts ent]$ into or r5ew$ aft] ,decemb] #ca1 #bjai4 #cjc4 ,enrollm5t 9 ,ex*anges 7a7 ,op5 enrollm5t & special enrollm5t p]iods ,section #acaa7;c77#f7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca7;c77#f77 is am5d$-- 7#a7 9 subp>agraph 7,b71 by ins]t+ t are n less ?an #h weeks aft] op5 enrollm5t p]iods2 7#b7 9 subp>agraph 7,c71 by /rik+ 2 & & ins]t+ 22 7#c7 9 subp>agraph 7,d71 by /rik+ ! p]iod & ins]t+ 2 &2 & 7#d7 by add+ at ! end ! foll[+3 7,e7 a special enrollm5t p]iod = individuals enroll$ 9 a plan t makes significant provid] t]m9ations dur+ ! plan ye>1 z det]m9$ 9 accordance ) regulations promulgat$ by ! ,secret>y4 4 7b7 ,consum] protections reg>d+ automatic re-,enrollm5t ,"p #b ( subtitle ,d ( title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca et seq47 is am5d$ by add+ at ! end ! foll[+3 #acad4 ,consum] protections reg>d+ automatic re-enrollm5t 7a7 ,cons5t ,to avoid automatic re-,enrollm5t = individuals los+ eligibility = premium tax cr$its ,! ,secret>y %all e/abli% a process to all[ an individual1 :o is enroll+ 9 a qualifi$ heal? plan ?r\gh an ,ex*ange & :om ! ,ex*ange e/imates is eligible to receive a premium tax cr$it "u section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf1 to provide cons5t to ! ,ex*ange to n automatically re-enroll ! individual 9 su* qualifi$ heal? plan 7or a comp>able qualifi$ heal? plan 9 a case describ$ 9 subsection 7b77 = ! foll[+ plan ye> if dur+ ! plan ye> ! ,ex*ange e/imates t ! individual has become no long] eligible to receive su* cr$it4 7b7 ,notice reg>d+ discont9u$ plans ,9 ! case ( an individual :o is enroll$ 9 a qualifi$ heal? plan ?r\gh an ,ex*ange = a plan ye> t w n be (f]$ ?r\gh su* ,ex*ange = ! foll[+ plan ye>1 ! ,ex*ange ?r\gh :i* su* plan is (f]$ %all1 prior to ! op5 enrollm5t p]iod = ! foll[+ plan ye>1 s5d ! individual a notice /at+-- 7#a7 t ! qualifi$ heal? plan 9 :i* ! individual is enroll$ w n be (f]$ ?r\gh su* ,ex*ange = ! foll[+ plan ye>2 7#b7 t unless ! individual takes action1 ! individual w be enroll$ 9 a comp>able qualifi$ heal? plan = ! foll[+ plan ye>2 7#c7 ! e/imat$ am\nt ( premiums = su* comp>able qualifi$ heal? plan2 & 7#d7 cle> in=mation on ! eligibility ( ! individual = a special enrollm5t p]iod4 7c7 ,notice reg>d+ automatic re-,enrollm5t ,any notice reg>d+ automatic re-enrollm5t s5t by an ,ex*ange to an individual enroll$ 9 a qualifi$ heal? plan %all be provid$ to ! individual 9 ! language t ! individual has indicat$ to ! ,ex*ange z ! pref]r$ language ( ! individual4 4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to plan ye>s beg9n+ aft] ! date ( enactm5t ( ?is ,act4 7d7 ,/udy ,! ,secret>y %all conduct a /udy t exam9es ! practices us$ by ! ,ex*anges = notify+ consum]s ( automatic re-enrollm5t 9 qualifi$ heal? plans & id5tifies /rategies =-- 7#a7 improv+ automatic re-enrollm5t & r5ewal notifications2 7#b7 improv+ ! ability to rea* consum]s 9 provid+ su* notices2 7#c7 increas+ consum] compreh5sion ( su* notices2 & 7#d7 enc\rag+ consum]s to-- 7,a7 update in=mation t w affect eligibility = premium tax cr$its "u section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf & ! am\nt ( su* cr$its2 & 7,b7 %op = qualifi$ heal? plans t w be/ meet _! ne$s ?r\gh ! ,ex*ange op]at+ 9 _! ,/ate4 #cjd4 ,m>ket+ & outrea* = ,ex*anges op]at$ by ! ,secret>y ,"p #b ( subtitle ,d ( title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca et seq471 z am5d$ by section #cjc7;b71 is fur!r am5d$ by add+ at ! end ! foll[+3 #acae4 ,m>ket+ & outrea* = ,ex*anges op]at$ by ! ,secret>y 7a7 ,9 g5]al ,out ( ! funds appropriat$ "u subsection 7b71 ! ,secret>y %all conduct a m>ket+ & outrea* program ) respect to qualifi$ heal? plans (f]$ 9 ,ex*anges op]at$ by ! ,secret>y 9 ord] to enc\rage enrollm5t 9 su* plans4 7b7 ,appropriation 7#a7 ,enc\rag+ enrollm5t = plan ye> #bjai ,!re is appropriat$ to ! ,secret>y1 out ( any moneys 9 ! ,treasury n o!rwise appropriat$1 #dhj1jjj1jjj to c>ry out ! m>ket+ & outrea* program "u subsection 7a7 ) respect to enc\rag+ enrollm5t = qualifi$ heal? plans t beg9 9 cal5d> ye> #bjai4 7#b7 ,enc\rag+ enrollm5t = subsequ5t plan ye>s ,to c>ry out ! m>ket+ & outrea* program "u subsection 7a7 ) respect to enc\rag+ enrollm5t = qualifi$ heal? plans t beg9 9 ea* ( cal5d> ye>s #bjbj ?r\gh #bjbd1 !re is appropriat$ to ! ,secret>y prior to ea* su* cal5d> ye>1 out ( any moneys 9 ! ,treasury n o!rwise appropriat$1 an am\nt equal to ! am\nt appropriat$ "u ?is subsection = ! prior cal5d> ye> increas$ by #d p]c5t = ea* su* cal5d> ye>4 7#c7 ,availability ,! am\nts appropriat$ "u p>agraphs 7#a7 & 7#b7 %all rema9 available until exp5d$4 4 #cje4 ,navigator program ,section #acaa7;i7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca7;i77 is am5d$-- 7#a7 9 p>agraph 7#b7-- 7,a7 9 subp>agraph 7,b71 by /rik+ & o!r entities & ins]t+ & o!r entities 7su* z ,indian tribes1 tribal organizations1 urban ,indian organizations1 & ,/ate or local human s]vice ag5cies72 & 7,b7 by add+ at ! end ! foll[+3 7,c7 ,pref]5ce ,an ,ex*ange %all ensure t1 ea* ye>1 x aw>ds a grant "u p>agraph 7#a7 to-- 7i7 at lea/ "o entity describ$ 9 ?is p>agraph t is a community & consum]-focus$ nonpr(it gr\p2 & 7ii7 at lea/ "o entity describ$ 9 subp>agraph 7,b71 :i* may include ano!r community & consum]-focus$ nonpr(it gr\p4 2 7#b7 9 p>agraph 7#c7-- 7,a7 9 subp>agraph 7,d71 by /rik+ 2 & & ins]t+ 22 7,b7 9 subp>agraph 7,e71 by /rik+ ! p]iod & ins]t+ 2 &2 & 7,c7 by add+ at ! end ! foll[+3 7,f7 provide t>get$ assi/ance to individuals likely to qualify = a special enrollm5t p]iod "u subp>agraph 7,c71 7,d71 or 7,e7 ( subsection 7c77#f74 2 & 7#c7 9 p>agraph 7#d77;,a7-- 7,a7 9 ! matt] prec$+ clause 7i71 by /rik+ n2 7,b7 9 clause 7i7-- 7i7 by ins]t+ n be=e be2 & 7ii7 by /rik+ 2 or & ins]t+ 22 7,c7 9 clause 7ii7-- 7i7 by ins]t+ n be=e receive2 & 7ii7 by /rik+ ! p]iod & ins]t+ 22 & 7,d7 by add+ at ! end ! foll[+3 7iii7 ma9ta9 physical pres5ce 9 ! ,/ate ( ! ,ex*ange s z to all[ 9-p]son assi/ance to consum]s2 & 7iv7 n provide comp5sation to an employee employ$ by ! navigator bas$ on ! numb] ( individuals ! employee assi/s 9 enroll+ 9 qualifi$ heal? plans4 4 ,,iv ,/r5g!n+ consum] heal? insurance protections #dja4 ,prohibit+ discrim9atory premiums bas$ on tobacco use 7a7 ,9 g5]al ,section #bgja7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg7a77#a77;,a77 is am5d$-- 7#a7 9 clause 7ii71 by ins]t+ & aft] ! semicolon2 & 7#b7 by /rik+ clause 7iv74 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply to plan ye>s beg9n+ aft] ,decemb] #ca1 #bjai4 #djb4 ,heal? insurance consum] in=mation ,section #bgic ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ic7 is am5d$-- 7#a7 9 subsection 7d7-- 7,a7 9 ! second s5t5ce1 by /rik+ & %all %>e & ins]t+ 1 %all %>e2 & 7,b7 by /rik+ ! p]iod at ! end ( second s5t5ce & ins]t+ 1 & 7n lat] ?an #b ye>s aft] ! date ( enactm5t ( ! ,consum] ,heal? ,insurance ,protection ,act ( #bjah7 %all make su* data available to ! public 9 a se>*able =mat on an int]net website e/abli%$ by ! ,secret>y42 & 7#b7 9 subsection 7e7-- 7,a7 9 p>agraph 7#a71 by /rik+ #cj1jjj1jjj = ! fir/ fiscal ye> = :i* ?is section applies & ins]t+ #ej1jjj1jjj = ea* ( fiscal ye>s #bjbj ?r\gh #bjbd2 & 7,b7 9 p>agraph 7#b71 by /rik+ ea* fiscal ye> foll[+ ! fiscal ye> describ$ 9 p>agraph 7#a7 & ins]t+ fiscal ye> #bjbe & ea* fiscal ye> !reaft]4 #djc4 ,pati5t protections 7a7 ,9 g5]al ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is am5d$-- 7#a7 9 subsection 7b7-- 7,a7 9 p>agraph 7#a71 by /rik+ p>agraph 7#b77;,b7 & ins]t+ p>agraph 7#c77;,b72 7,b7 by r$esignat+ p>agraph 7#b7 z p>agraph 7#c72 & 7,c7 by ins]t+ aft] p>agraph 7#a7 ! foll[+3 7#b7 ,reimbursem5t ,a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all reimburse an out-(-network provid] provid+ em]g5cy s]vices to an individual enroll$ 9 su* plan or cov]age at an am\nt equal to ! greate/ (-- 7,a7 ! m$ian am\nt negotiat$ ) 9-network provid]s = ! em]g5cy s]vice2 7,b7 ! am\nt = ! em]g5cy s]vice calculat$ us+ ! same me?od ! plan or issu] g5]ally uses to det]m9e paym5ts = out-(-network s]vices2 or 7,c7 ! am\nt t w\ld be paid to a provid] ( s]vices or suppli] ) respect to ! furni%+ ( su* s]vice "u title ,,xviii ( ! ,social ,security ,act4 2 & 7#b7 by add+ at ! end ! foll[+3 7e7 ,cov]age ( s]vices by out-(-,network provid]s bas$ on plan or issu] error 7#a7 ,9 g5]al ,a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all provide cov]age ( a s]vice provid$ by an out-(-network provid] to an individual enroll$ 9 su* plan or cov]age if-- 7,a7 ! plan or issu] w\ld h provid$ cov]age = ! s]vice if ! s]vice 0 provid$ by an 9-network provid]2 & 7,b7 9 *oos+ su* provid]1 ! individual reasonably reli$ on a mat]ially inaccurate1 incomplete1 or mislead+ /atem5t ( in=mation conta9$ 9 a directory1 compil$ by ! plan or issu]1 ( 9-network provid]s4 7#b7 ,co/-%>+ ,a gr\p heal? plan or heal? insurance issu] t provides cov]age ( a s]vice provid$ by an out-(-network provid] "u p>agraph 7#a7 %all provide su* cov]age ) ! same co/-%>+ requirem5ts z if ! s]vice 0 provid$ by an 9-network provid]4 7f7 ,cov]age = enrollees 9 active c\rse ( treatm5t 7#a7 ,9 g5]al ,a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all1 at ! reque/ ( an individual enroll$ 9 su* plan or cov]age & subject to p>agraph 7#c71 provide cov]$ s]vices 7z def9$ 9 p>agraph 7#d77 by an out-(-network provid] = su* individual 9 accordance ) p>agraph 7#b7 if-- 7,a7 ! individual is receiv+ an active c\rse ( treatm5t f su* out-(-network provid] t 0 occurr+ :ile ! individual 0 enroll$ 9 a diff]5t heal? plan (f]$ by su* plan or issu] = ! prior plan ye> t has be5 discont9u$ by su* plan or issu]1 includ+ a case :]e su* plan is )drawn f ! m>ket1 & su* provid] 0 an 9-network provid] "u su* diff]5t heal? plan2 or 7,b7 ! individual is receiv+ an active c\rse ( treatm5t f su* out-(-network provid] = a plan ye> 9 :i* ! provid] 0 an 9-network provid] ( ! plan or issu] b became a t]m9at$ provid] ) respect to su* plan or issu] = su* plan ye>4 7#b7 ,duration & rates ( cov]age 7,a7 ,duration ,! cov]age = an active c\rse ( treatm5t describ$ 9 p>agraph 7#a7 %all be cont9u$ until ! e>li] (-- 7i7 ! date on :i* ! treatm5t is complete2 or 7ii7 ! date t is #ahj days foll[+ ! date on :i*-- 7,i7 9 ! case ( an individual describ$ 9 subp>agraph 7,a7 ( p>agraph 7#a71 ! individual enrolls 9 su* gr\p heal? plan or heal? insurance cov]age2 or 7,,ii7 9 ! case ( an individual describ$ 9 subp>agraph 7,b7 ( p>agraph 7#a71 ! contract ( ! t]m9at$ provid] ) ! gr\p heal? plan or heal? insurance issu] is no long] 9 effect4 7,b7 ,co/-%>+ ,! cov]age = an active c\rse ( treatm5t provid$ by an out-(-network provid] z describ$ 9 p>agraph 7#a7 %all be provid$ ) co/-%>+ requirem5ts t are ! same z if su* cov]age 0 provid$ by an 9-network provid]4 7#c7 ,reque/ = cont9uity ( c>e ,any reque/ made "u p>agraph 7#a7 %all be subject to any int]nal or ext]nal grievance or appeals process ( ! plan or issu]1 9 accordance ) any applicable ,/ate or ,f$]al law4 7#d7 ,def9itions ,= purposes ( ?is subsection3 7,a7 ,active c\rse ( treatm5t ,! t]m active c\rse ( treatm5t means any ( ! foll[+ t is occurr+ on ! fir/ day on :i*1 ) respect to an individual describ$ 9 p>agraph 7#a77;,a71 ! individual's prior heal? plan describ$ 9 su* p>agraph has be5 discont9u$ by ! plan or issu] or1 ) respect to an individual describ$ 9 p>agraph 7#a77;,b71 ! provid] provid+ ! treatm5t becomes a t]m9at$ provid]3 7i7 ,an ongo+ c\rse ( treatm5t = a life-?reat5+ condition1 s]i\s acute condition1 or s]i\s *ronic condition4 7ii7 ,s]vices provid$ ) respect to pregnancy1 includ+ until ! completion ( po/p>tum c>e directly relat$ to ! deliv]y4 7iii7 ,an ongo+ c\rse ( treatm5t = a *ild betwe5 bir? & #cf mon?s4 7iv7 ,! p]=mance ( a surg]y or o!r proc$ure t1 prior to ! applicable "t describ$ 9 ?is subp>agraph1 has be5 au?oriz$ by ! plan or cov]age z "p ( a docum5t$ c\rse ( treatm5t = su* individual & has be5 recomm5d$ & docum5t$ by ! provid] = su* individual4 7,b7 ,cov]$ s]vices ,! t]m cov]$ s]vices means s]vices t-- 7i7 w\ld be cov]$ by ! gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age if su* s]vices 7 provid$ by an 9-network provid]2 & 7ii7 are = an active c\rse ( treatm5t4 7,c7 ,t]m9at$ provid] ,! t]m t]m9at$ provid] means a provid] t _h a contract = p>ticipation ) ! plan or cov]age dur+ a plan ye> :ile ! individual 0 enroll$ 9 su* plan or cov]age & receiv+ cov]$ s]vices f su* provid] &1 dur+ su* plan ye>1 ! plan or issu] t]m9ates su* contract or does n r5ew su* contract = ! rema9d] ( ! plan ye>4 ,su* t]m does n include-- 7i7 any provid] t volunt>ily t]m9ates or does n r5ew su* contract = ! rema9d] ( ! plan ye>2 & 7ii7 any provid] ^: contract ) ! plan or issu] has t]m9at$1 or 0 n r5ew$1 = ! rema9d] ( ! plan ye> = reasons relat+ to a m$ical discipl9>y cause or fraud or o!r crim9al activity4 7g7 ,limitations on *anges 9 cov]age ( prescription drugs 7#a7 ,9 g5]al ,a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all n1 dur+ a plan ye>1 take any ( ! foll[+ actions ) respect to cov]age = su* plan ye>3 7,a7 ,remov+ a prescription drug f a =mul>y ( prescription drugs cov]$ by su* plan or issu]1 except z provid$ 9 p>agraph 7#b77;,c74 7,b7 ,increas+ ! obligation ( an enrollee ) respect to co/-%>+1 z def9$ 9 section #acjb7;c77#c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act1 requir$ = a prescription drug cov]$ by su* plan or issu]4 7#b7 ,rule ( con/ruction ,no?+ 9 ?is subsection %all prohibit a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age f1 dur+ a plan ye>1 tak+ any ( ! foll[+ actions ) respect to cov]age = su* plan ye>3 7,a7 ,*ang+ ! policy ( ! plan or issu] to require an enrollee to use a g5]ic sub/itution = a br&$ prescription drug4 7,b7 ,add+ a new prescription drug to a =mul>y ( prescription drugs cov]$ by su* plan or issu]4 7,c7 ,remov+ a prescription drug f su* a =mul>y due to pati5t safety conc]ns1 a prescription drug recall1 or ! removal ( a prescription drug f int]/ate comm]ce z det]m9$ necess>y by ! ,secret>y4 4 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply to plan ye>s beg9n+ aft] ,decemb] #ca1 #bjai4 #djd4 ,limitation on balance bill+ = em]g5cy s]vices 7a7 ,9 g5]al ,a heal? c>e provid] t provides any em]g5cy s]vice to an individual enroll$ 9 a gr\p heal? plan1 gr\p heal? insurance cov]age1 or individual heal? insurance cov]age & t is n an 9-network provid] ( su* plan or cov]age %all n impose a *>ge on su* individual = su* em]g5cy s]vice1 o!r ?an any co/-%>+ t w\ld o!rwise be applicable if ! physician 0 an 9-network provid] ( su* plan or cov]age4 7b7 ,en=cem5t ,! ,secret>y may impose a civil monet>y p5alty1 9 ! same mann] z su* p5alties are au?oriz$ "u section #aabh;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a7 = violations ( balance bill+ prohibitions "u "p ,b ( title ,,xviii ( su* ,act 7#db ,u4,s4,c4 #acie;j et seq471 on any provid] t violates ! requirem5t "u subsection 7a74 7c7 ,def9itions ,9 ?is section3 7#a7 ,co/-%>+ ,! t]m co/-%>+ has ! mean+ giv5 ! t]m 9 section #acjb7;c77#c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjbb7;c77#c774 7#b7 ,em]g5cy s]vice ,! t]m em]g5cy s]vice has ! mean+ giv5 su* t]m 9 section #bgai;,a7b77#c77;,b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7b77#c77;,b774 7#c7 ,gr\p heal? plan1 gr\p heal? insurance cov]age1 & individual heal? insurance cov]age ,! t]ms gr\p heal? plan1 gr\p heal? insurance cov]age1 & individual heal? insurance cov]age h ! mean+s giv5 su* t]ms 9 section #bgia ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ia74 7#d7 ,secret>y ,! t]m ,secret>y means ! ,secret>y ( ,heal? & ,human ,s]vices4 7d7 ,effective date ,?is section %all apply to plan ye>s beg9n+ aft] ,decemb] #ca1 #bjai4 #dje4 ,notification ( provid] t]m9ations ,title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 is am5d$ by ins]t+ aft] section #bgbh 7#db ,u4,s4,c4 #cjj;gg-#bh7 ! foll[+3 #bgbi4 ,notification ( provid] t]m9ations 7a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjai1 a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all in=m individuals enroll$ 9 su* plan or cov]age1 :o are describ$ 9 subsection 7b71 ( ! t]m9ation ( any provid] z an 9-network provid] "u ! plan or cov]age4 ,su* notice %all be provid$ n lat] ?an #cj days prior to ! t]m9ation4 7b7 ,individuals ,! individuals describ$ 9 ?is subsection are any pati5ts :o h se5 a provid] describ$ 9 subsection 7a7 on a regul> basis or :o h receiv$ prim>y c>e f ! provid]4 4 #djf4 ,%ort-t]m limit$ duration heal? insurance cov]age 7a7 ,9 g5]al ,section #bgia7;b77#e7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ia7;b77#e77 is am5d$ by /rik+ b does n include & ins]t+ includ+4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to plan ye>s beg9n+ aft] ,decemb] #ca1 #bjai4 #djg4 ,protect+ ess5tial heal? b5efits ,section #acjb7;b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjbb7;b77 is am5d$-- 7#a7 9 p>agraph 7#b77;,b7 & p>agraph 7#c71 by /rik+ 7#d77;,h7 ea* place x appe>s & ins]t+ 7#d77;,i72 & 7#b7 9 p>agraph 7#d7-- 7,a7 9 subp>agraph 7,a71 by ins]t+ & cov]age 9 e category is includ$ be=e ! semicolon2 7,b7 by r$esignat+ subp>agraphs 7,e7 ?r\gh 7,h7 z subp>agraphs 7,f7 ?r\gh 7,i71 respectively2 & 7,c7 by ins]t+ aft] subp>agraph 7,d7 ! foll[+3 7,e7 ensure t1 to be treat$ z provid+ cov]age = ! ess5tial heal? b5efits describ$ 9 p>agraph 7#a71 a qualifi$ heal? plan-- 7i7 %all n sub/itute b5efits across ! v>i\s categories describ$ 9 p>agraph 7#a72 7ii7 %all provide a wide v>iety ( classes ( prescription drugs on ! prescription drug =mul>y ( su* plan2 7iii7 %all1 if a m$ically necess>y drug is n on ! prescription drug =mul>y ( su* plan1 all[ individuals enroll$ 9 su* plan to h access to ! drug ?r\gh an exceptions process e/abli%$ by ! plan2 & 7iv7 %all provide cov]age ( habilitative s]vices at p>ity ) rehabilitative s]vices1 9 accordance ) regulations promulgat$ by ! ,secret>y4 4 #djh4 ,association heal? plans 7a7 ,treatm5t ( association heal? plans 7#a7 ,association heal? plan def9$ ,= purposes ( ?is subsection1 ! t]m association heal? plan means any heal? insurance cov]age t is provid$ to an association1 b n relat$ to employm5t1 & sold to individuals ?r\gh su* association4 7#b7 ,treatm5t z individual heal? insurance cov]age ,= purposes ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq471 "p #g ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aaha et seq471 *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf1 & title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 heal? insurance cov]age (f]$ ?r\gh an association heal? plan %all be treat$ z individual heal? insurance cov]age if-- 7,a7 ! cov]age is (f]$ to a memb] ( ! association o!r ?an 9 connection ) a gr\p heal? plan2 or 7,b7 ! cov]age is (f]$ to a memb] ( ! association t is an employ] ma9ta9+ a gr\p heal? plan t has few] ?an #b p>ticipants :o are employees on ! fir/ day ( ! plan ye>4 7#c7 ,treatm5t z heal? insurance cov]age 9 ! small gr\p m>ket ,= purposes ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq471 "p #g ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aaha et seq471 *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf1 & title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 heal? insurance cov]age (f]$ ?r\gh an association heal? plan %all1 subject to p>agraph 7#b77;,b71 be treat$ z heal? insurance cov]age 9 ! small gr\p m>ket if ! cov]age is (f]$ to a memb] ( ! association 9 connection ) a gr\p heal? plan (f]$ to employ]s t are small employ]s1 z def9$ 9 su* applicable ,act or ,code4 7#d7 ,preemption ,an association heal? plan %all be treat$ z individual heal? insurance cov]age 9 accordance ) p>agraph 7#b7 or heal? insurance cov]age 9 ! small gr\p m>ket 9 accordance ) p>agraph 7#c7 not)/&+ any applicable ,/ate law4 7#e7 ,effective date ,?is subsection %all apply to plan ye>s beg9n+ aft] ,decemb] #ca1 #bjai4 7b7 ,propos$ rule reg>d+ ! def9ition ( employ] "u ,,erisa 7#a7 ,def9ition ( ,janu>y #e1 #bjah1 propos$ rule ,9 ?is subsection1 ! t]m ,janu>y #e1 #bjah1 propos$ rule means ! propos$ rule ( ! ,dep>tm5t ( ,labor entitl$ ,def9ition ( ,employ] ,"u ,section #c7e7 ( ,,erisa--,association ,heal? ,plans 7#hc ,f$4 ,reg4 #fad71 or any f9al rule promulgat$ ) respect to su* propos$ rule4 7#b7 ,en=cem5t ,beg9n+ on ! date ( enactm5t ( ?is ,act1 ! ,janu>y #e1 #bjah1 propos$ rule %all cease to h any =ce or effect4 ,9 ! case t ! ,janu>y #e1 #bjah1 propos$ rule is a f9al rule on ! date ( enactm5t ( ?is ,act1 ! ,secret>y ( ,labor %all cease to en=ce su* f9al rule4