,,ib ,union ,cal5d> ,no4 #ehg #aaf? ,,congress #b;d ,session ,h4 ,r4 #bcbh ,report ,no4 #aaf-ccb1 ,"p ,i ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,april #ae1 #bjai,mr4 ,o',hall]an 7= himself & ,ms4 ,/efanik7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce ,decemb] #i1 #bjai,report$ ) am5dm5ts & ref]r$ to ! ,committee on ,transportation & ,infra/ructure = a p]iod end+ n lat] ?an ,janu>y #bi1 #bjbj1 = consid]ation ( su* provisions ( ! bill z fall )9 ! jurisdiction ( t committee pursuant to clause #a7r7 ( rule ,x,strike out all aft] ! enact+ clause & ins]t ! "p pr9t$ 9 italic ,janu>y #bi1 #bjbj,ref]ral to ! ,committee on ,transportation & ,infra/ructure ext5d$ = a p]iod end+ n lat] ?an ,febru>y #ai1 #bjbj ,febru>y #ai1 #bjbj,ref]ral to ! ,committee on ,transportation & ,infra/ructure ext5d$ = a p]iod end+ n lat] ?an ,april #bc1 #bjbj ,april #bc1 #bjbj,ref]ral to ! ,committee on ,transportation & ,infra/ructure ext5d$ = a p]iod end+ n lat] ?an ,july #ca1 #bjbj ,july #ca1 #bjbj,ref]ral to ! ,committee on ,transportation & ,infra/ructure ext5d$ = a p]iod end+ n lat] ?an ,septemb] #ba1 #bjbj ,septemb] #ba1 #bjbj,ref]ral to ! ,committee on ,transportation & ,infra/ructure ext5d$ = a p]iod end+ n lat] ?an ,novemb] #bj1 #bjbj ,novemb] #ag1 #bjbj,ref]ral to ! ,committee on ,transportation & ,infra/ructure ext5d$ = a p]iod end+ n lat] ?an ,decemb] #ca1 #bjbj ,decemb] #ca1 #bjbj;,additional sponsors3 ,mr4 ,swalwell ( ,cali=nia1 ,mr4 ,espaillat1 ,ms4 ,gabb>d1 ,ms4 ,om>1 ,ms4 ,mc,collum1 ,mr4 ,smi? ( ,wa%+ton1 ,mr4 ,khanna1 ,mr4 ,coh51 ,mr4 ,grijalva1 ,mr4 ,c\rtney1 ,mrs4 ,h>tzl]1 ,ms4 ,muc>sel-,p[ell1 ,ms4 ,jayapal1 ,ms4 ,ku/] ( ,new ,hamp%ire1 ,mrs4 ,davis ( ,cali=nia1 ,mr4 ,ru%1 ,mr4 ,lip9ski1 ,mr4 ,engel1 ,mr4 ,s*iff1 ,mr4 ,cicill9e1 ,mr4 ,s]rano1 ,mr4 ,l>s5 ( ,wa%+ton1 ,mr4 ,kri%namoor?i1 ,mr4 ,pet]s1 ,ms4 ,lee ( ,cali=nia1 ,mr4 ,kilm]1 ,mr4 ,s*rad]1 ,mr4 ,turn]1 ,mr4 ,k+ ( ,new ,york1 ,mr4 ,y>mu?1 ,mr4 ,vela1 ,mr4 ,heck1 ,mr4 ,la,malfa1 ,mr4 ,"y1 ,mr4 ,delgado1 ,mr4 ,tipton1 ,ms4 ,johnson ( ,texas1 ,mr4 ,ha/+s1 ,mr4 ,sires1 ,ms4 ,blunt ,ro*e/]1 ,mr4 ,b]gman1 ,mrs4 ,watson ,coleman1 ,mr4 ,johnson ( ,georgia1 ,mr4 ,cole1 ,mr4 ,gomez1 ,ms4 ,kelly ( ,ill9ois1 ,miss ,rice ( ,new ,york1 ,mr4 ,zeld91 ,mr4 ,ne:\se1 ,mr4 ,rodney ,davis ( ,ill9ois1 ,ms4 ,cl>ke ( ,new ,york1 ,mr4 ,de,fazio1 ,mr4 ,nadl]1 ,mr4 ,meeks1 ,mr4 ,/iv]s1 ,mrs4 ,c>olyn ,b4 ,maloney ( ,new ,york1 ,mr4 ,rose ( ,new ,york1 ,mr4 ,lamborn1 ,mr4 ,bald]son1 ,mr4 ,fleis*mann1 ,mr4 ,gallego1 ,ms4 ,s*ak[sky1 ,mr4 ,wel*1 ,mrs4 ,l[ey1 ,ms4 ,ocasio-,cortez1 ,mr4 ,sean ,patrick ,maloney ( ,new ,york1 ,ms4 ,bass1 ,mr4 ,norman1 ,mr4 ,takano1 ,mr4 ,lujn1 ,mr4 ,rask91 ,ms4 ,judy ,*u ( ,cali=nia1 ,mr4 ,lev9 ( ,mi*igan1 ,mrs4 ,d+ell1 ,ms4 ,p+ree1 ,mr4 ,t$ ,lieu ( ,cali=nia1 ,ms4 ,torres ,small ( ,new ,mexico1 ,mr4 ,de,saulnier1 ,mr4 ,katko1 ,mr4 ,sablan1 ,ms4 ,roybal-,all>d1 ,mr4 ,bi%op ( ,utah1 ,mr4 ,griffi?1 ,mrs4 ,radewag51 ,mr4 ,bo/1 ,mr4 ,wald51 ,mr4 ,/anton1 ,mr4 ,correa1 ,ms4 ,l(gr51 ,mr4 ,curtis1 ,mr4 ,l[5?al1 ,ms4 ,slotk91 ,ms4 ,f9k5au]1 ,mr4 ,fo/]1 ,mr4 ,langev91 ,mrs4 ,bu/os1 ,ms4 ,kaptur1 ,mr4 ,/ew>t1 ,mr4 ,huffman1 ,mr4 ,s*neid]1 ,mr4 ,mc,adams1 ,ms4 ,velzquez1 ,ms4 ,jackson ,lee1 ,mr4 ,soto1 ,mr4 ,coop]1 ,mr4 ,au/9 ,scott ( ,georgia1 ,ms4 ,und]wood1 ,mr4 ,br9disi1 ,mr4 ,/aub]1 ,mr4 ,cleav]1 ,mr4 ,pet]son1 ,mr4 ,mc,nerney1 ,mr4 ,keat+1 ,ms4 ,spanb]g]1 ,mr4 ,p]lmutt]1 ,mr4 ,aguil>1 ,mr4 ,cox ( ,cali=nia1 ,mr4 ,h>d] ( ,cali=nia1 ,ms4 ,k5dra ,s4 ,horn ( ,oklahoma1 ,mr4 ,price ( ,nor? ,c>ol9a1 ,mrs4 ,mill]1 ,mr4 ,van ,drew1 ,mr4 ,fitzpatrick1 ,mr4 ,cisn]os1 ,mr4 ,l>son ( ,connecticut1 ,mrs4 ,dem+s1 & ,mrs4 ,hayes ,decemb] #ca1 #bjbj;,committee on ,transportation & ,infra/ructure dis*>g$2 committ$ to ! ,committee ( ! ,:ole ,h\se on ! ,/ate ( ! ,union & ord]$ to be printed,for text ( introduc$ bill1 see copy ( bill z introduc$ on ,april #ae1 #bjai ,a ,,bill ,to reau?orize & ext5d fund+ = community heal? c5t]s & ! ,national ,heal? ,s]vice ,corps4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,reau?oriz+ & ,ext5d+ ,am]ica's ,community ,heal? ,act or ! ,,rea* ,act4 7b7 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4,title ,i--,public ,heal? ,extenders,sec4 #aja4 ,ext5sion = community heal? c5t]s1 ! ,national ,heal? ,s]vice ,corps1 & tea*+ heal? c5t]s t op]ate ,,gme programs4,sec4 #ajb4 ,ext5sion = special diabetes programs4,sec4 #ajc4 ,ext5sion ( ,p]sonal ,responsibility ,education ,program4,sec4 #ajd4 ,ext5sion ( sexual risk avoidance education program4,title ,,ii--,m$ic>e ,extenders,sec4 #bja4 ,ext5sion ( ! "w geographic index floor "u ! ,m$ic>e program4,sec4 #bjb4 ,ext5sion ( fund+ outrea* & assi/ance = l[-income programs4,sec4 #bjc4 ,ext5sion ( fund+ = quality measure endorsem5t1 input1 & selection "u ! ,m$ic>e program4,sec4 #bjd4 ,ext5sion ( ! ,indep5d5ce at ,home ,m$ical ,practice ,demon/ration ,program "u ! ,m$ic>e program4,sec4 #bje4 ,ext5sion ( appropriations & transf]s to ! ,pati5t-,c5t]$ ,outcomes ,rese>* ,tru/ ,fund2 ext5sion ( c]ta9 heal? insurance fees4,sec4 #bjf4 ,transitional cov]age & retroactive ,m$ic>e "p ,d cov]age = c]ta9 l[-income b5efici>ies4,sec4 #bjg4 ,heal? ,equity & ,access = ,return+ ,troops & ,s]vicememb]s ,act ( #bjai4,sec4 #bjh4 ,exclusion ( complex rehabilitative manual :eel*airs f ,m$ic>e competitive acquisition program2 ,non-application ( ,m$ic>e fee-s*$ule adju/m5ts = c]ta9 :eel*air accessories & cu%ions4,title ,,iii--,m$icaid ,provisions,sec4 #cja4 ,modification ( r$uctions 9 ,m$icaid ,,d% allotm5ts4,sec4 #cjb4 ,public availability ( hospital upp] paym5t limit demon/rations4,sec4 #cjc4 ,report by ,comptroll] ,g5]al4,sec4 #cjd4 ,s5se ( ,congress reg>d+ ! ne$ to develop a m p]man5t legislative solution to provide ! t]ritories ) a reliable & consi/5t s\rce ( ,f$]al fund+ "u ! ,m$icaid program4,title ,,iv--,no ,surprises ,act,sec4 #dja4 ,%ort title4,sec4 #djb4 ,prev5t+ surprise m$ical bills4,sec4 #djc4 ,gov]nm5t ,acc\ntability ,(fice /udy on pr(it- & rev5ue-%>+ 9 heal? c>e4,sec4 #djd4 ,/ate ,all ,pay] ,claims ,databases4,sec4 #dje4 ,air ambulance co/ data report+ program4,sec4 #djf4 ,report by ,secret>y ( ,labor4,sec4 #djg4 ,bill+ /atute ( limitations4,sec4 #djh4 ,,gao report on impact ( surprise bill+ provisions4,sec4 #dji4 ,report by ! ,secret>y ( ,heal? & ,human ,s]vices4,title ,v--,t]ritories ,heal? ,c>e ,improvem5t ,act,sec4 #eja4 ,%ort title4,sec4 #ejb4 ,m$icaid paym5ts = ,pu]to ,rico & ! o!r t]ritories = c]ta9 fiscal ye>s4,sec4 #ejc4 ,application ( c]ta9 requirem5ts "u ,m$icaid program to c]ta9 t]ritories4,sec4 #ejd4 ,additional program integrity requirem5ts4 ,i ,public ,heal? ,ext5d]s #aja4 ,ext5sion = community heal? c5t]s1 ! ,national ,heal? ,s]vice ,corps1 & tea*+ heal? c5t]s t op]ate ,,gme programs 7a7 ,community ,heal? ,c5t]s ,section #ajejc7;b77#a77;,f7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #bed;b-#b7;b77#a77;,f77 is am5d$ by /rik+ fiscal ye> #bjai & ins]t+ ea* ( fiscal ye>s #bjai ?r\gh #bjbc4 7b7 ,national ,heal? ,s]vice ,corps ,section #ajejc7;b77#b77;,f7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #bed;b-#b7;b77#b77;,f77 is am5d$ by /rik+ #bjah & #bjai & ins]t+ #bjai ?r\gh #bjbc4 7c7 ,tea*+ heal? c5t]s t op]ate graduate m$ical education programs ,section #cdj;,h7g77#a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bef;h7g77#a77 is am5d$ by /rik+ #bjah & #bjai & ins]t+ #bjai ?r\gh #bjbc4 7d7 ,application ,am\nts appropriat$ = a program pursuant to ! am5dm5ts made by subsection 7a71 7b71 or 7c7 = fiscal ye>s #bjbj ?r\gh #bjbc are subject to ! requirem5ts & limitations ( ! mo/ rec5tly enact$ regul> or full-ye> cont9u+ appropriations ,act or resolution 7z ( ! date ( obligation ( curr5t funds7 applicable to ! respective program4 #ajb4 ,ext5sion = special diabetes programs 7a7 ,reau?orization ( special diabetes programs = ,type ,i diabetes ,section #ccj;,b7b77#b77;,d7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bed;c-#b7;b77#b77;,d77 is am5d$ by /rik+ ea* ( fiscal ye>s #bjah & #bjai & ins]t+ fiscal ye>s #bjai ?r\gh #bjbc4 7b7 ,reau?orization ( special diabetes programs = ,indians = diabetes s]vices ,section #ccj;,c7c77#b77;,d7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bed;c-#c7;c77#b77;,d77 is am5d$ by /rik+ fiscal ye>s #bjah & #bjai & ins]t+ fiscal ye>s #bjai ?r\gh #bjbc4 #ajc4 ,ext5sion ( ,p]sonal ,responsibility ,education ,program ,section #eac ( ! ,social ,security ,act 7#db ,u4,s4,c4 #gac7 is am5d$-- 7#a7 9 p>agraphs 7#a77;,a7 & 7#d77;,a7 ( subsection 7a71 by /rik+ #bjai & ins]t+ #bjbc ea* place x appe>s2 7#b7 9 subsection 7a77#d77;,b77i71 by /rik+ #bjai & ins]t+ #bjbc2 & 7#c7 9 subsection 7f71 by /rik+ #bjai & ins]t+ #bjbc4 #ajd4 ,ext5sion ( sexual risk avoidance education program ,section #eaj ( ! ,social ,security ,act 7#db ,u4,s4,c4 #gaj7 is am5d$ by /rik+ fiscal ye>s #bjah & #bjai ea* place x appe>s 9 subsections 7a77#a71 7a77#b77;,a71 7f77#a7 & 7f77#b7 & ins]t+ fiscal ye>s #bjai ?r\gh #bjbc4 ,,ii ,m$ic>e ,ext5d]s #bja4 ,ext5sion ( ! "w geographic index floor "u ! ,m$ic>e program ,section #ahdh7;e77#a77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77#a77;,e77 is am5d$ by /rik+ #bjbj & ins]t+ #bjbc4 #bjb4 ,ext5sion ( fund+ outrea* & assi/ance = l[-income programs 7a7 ,additional fund+ = ,/ate heal? insurance programs ,subsection 7a77#a77;,b7 ( section #aai ( ! ,m$ic>e ,improvem5ts = ,pati5ts & ,provid]s ,act ( #bjjh 7#db ,u4,s4,c4 #acie;b-#c note71 z am5d$ by section #ccjf ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 section #faj ( ! ,am]ican ,taxpay] ,relief ,act ( #bjab 7,public ,law #aab-bdj71 section #aaaj ( ! ,pa?way = ,,sgr ,re=m ,act ( #bjac 7,public ,law #aac-fg71 section #aaj ( ! ,protect+ ,access to ,m$ic>e ,act ( #bjad 7,public ,law #aac-ic71 section #bjh ( ! ,m$ic>e ,access & ,,*ip ,reau?orization ,act ( #bjae 7,public ,law #aad-aj71 & section #ejbjg ( ! ,bip>tisan ,budget ,act ( #bjah 7,public ,law #aae-abc71 is am5d$-- 7#a7 9 clause 7vii71 by /rik+ & at ! end2 7#b7 9 clause 7viii71 by /rik+ & at ! end2 7#c7 9 clause 7ix71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#d7 by ins]t+ aft] clause 7ix7 ! foll[+ new clause3 7x7 = ea* ( fiscal ye>s #bjbj ?r\gh #bjbb1 ( #ae1jjj1jjj4 4 7b7 ,additional fund+ = area ag5cies on ag+ ,subsection 7b77#a77;,b7 ( su* section #aai1 z s am5d$1 is am5d$-- 7#a7 9 clause 7vii71 by /rik+ & at ! end2 7#b7 9 clause 7viii71 by /rik+ & at ! end2 7#c7 9 clause 7ix71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#d7 by ins]t+ aft] clause 7ix7 ! foll[+ new clause3 7x7 = ea* ( fiscal ye>s #bjbj ?r\gh #bjbb1 ( #ae1jjj1jjj4 4 7c7 ,additional fund+ = ag+ & disability res\rce c5t]s ,subsection 7c77#a77;,b7 ( su* section #aai1 z s am5d$1 is am5d$-- 7#a7 9 clause 7vii71 by /rik+ & at ! end2 7#b7 9 clause 7viii71 by /rik+ & at ! end2 7#c7 9 clause 7ix71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#d7 by ins]t+ aft] clause 7ix7 ! foll[+ new clause3 7x7 = ea* ( fiscal ye>s #bjbj ?r\gh #bjbb1 ( #e1jjj1jjj4 4 7d7 ,additional fund+ = contract ) ! national c5t] = b5efits & outrea* enrollm5t ,subsection 7d77#b7 ( su* section #aai1 z s am5d$1 is am5d$-- 7#a7 9 clause 7vii71 by /rik+ & at ! end2 7#b7 9 clause 7viii71 by /rik+ & at ! end2 7#c7 9 clause 7ix71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#d7 by ins]t+ aft] clause 7ix7 ! foll[+ new clause3 7x7 = ea* ( fiscal ye>s #bjbj ?r\gh #bjbb1 ( #ae1jjj1jjj4 4 #bjc4 ,ext5sion ( fund+ = quality measure endorsem5t1 input1 & selection "u ! ,m$ic>e program 7a7 ,9 g5]al ,section #ahij7;d77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa7d77#b77 is am5d$-- 7#a7 by /rik+ & #g1ejj1jjj & ins]t+ #g1ejj1jjj2 & 7#b7 by /rik+ & #bjai4 & ins]t+ & #bjai1 & #cj1jjj1jjj = ea* ( fiscal ye>s #bjbj ?r\gh #bjbb44 7b7 ,input = removal ( measures ,section #ahij7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa7b77 is am5d$ by ins]t+ aft] p>agraph 7#c7 ! foll[+3 7#d7 ,removal ( ,measures ,! entity may1 ?r\gh ! multi/akehold] gr\ps conv5$ "u p>agraph 7#g77;,a71 provide input to ! ,secret>y on quality & effici5cy measures describ$ 9 p>agraph 7#g77;,b7 t c\ld be consid]$ = removal4 4 7c7 ,prioritization ( measure endorsem5t ,section #ahij7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;aaa7b771 z am5d$ by subsection 7b71 is fur!r am5d$ by add+ at ! end ! foll[+3 7#i7 ,prioritization ( measure endorsem5t ,! entity-- 7,a7 dur+ ! p]iod beg9n+ on ! date ( ! enactm5t ( ?is p>agraph & end+ on ,decemb] #ca1 #bjbc1 %all prioritize ! endorsem5t ( measures relat+ to mat]nal morbidity & mortality by ! entity ) a contract "u subsection 7a7 9 connection ) endorsem5t ( measures describ$ 9 p>agraph 7#b72 & 7,b7 on & aft] ,janu>y #a1 #bjbd1 may prioritize ! endorsem5t ( su* measures by su* entity4 4 #bjd4 ,ext5sion ( ! ,indep5d5ce at ,home ,m$ical ,practice ,demon/ration ,program "u ! ,m$ic>e program 7a7 ,9 g5]al ,section #ahff;,e7e77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc-#e7;e77#a77 is am5d$ by /rik+ #g-ye> & ins]t+ #aj-ye>4 7b7 ,effective date ,! am5dm5t made by subsection 7a7 %all take effect z if includ$ 9 ! enactm5t ( ,public ,law #aaa-adh4 #bje4 ,ext5sion ( appropriations & transf]s to ! ,pati5t-,c5t]$ ,outcomes ,rese>* ,tru/ ,fund2 ext5sion ( c]ta9 heal? insurance fees 7a7 ,9 g5]al 7#a7 ,int]nal ,rev5ue ,code ,section #ieaa ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7,a7 9 subsection 7b77#a77;,e71 by /rik+ #bjad & all t foll[s ?r\gh #bjai & ins]t+ #bjad ?r\gh #bjbb2 7,b7 9 subsection 7d77#b77;,a71 by /rik+ #bjai & ins]t+ #bjbb2 & 7,c7 9 subsection 7f71 by /rik+ #bjai & ins]t+ #bjbb4 7#b7 ,title ,,xi ,section #aahc7;a77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;e-#b7;a77#b77 is am5d$ by /rik+ #bjad & all t foll[s ?r\gh #bjai & ins]t+ #bjad ?r\gh #bjbb4 7b7 ,ext5sion ( c]ta9 heal? insurance fees 7#a7 ,heal? insurance policies ,section #dcge7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #bjai & ins]t+ #bjbb4 7#b7 ,self-insur$ heal? plans ,section #dcgf7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ #bjai & ins]t+ #bjbb4 #bjf4 ,transitional cov]age & retroactive ,m$ic>e "p ,d cov]age = c]ta9 l[-income b5efici>ies ,section #ahfj;,d-#ad ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7 is am5d$-- 7#a7 by r$esignat+ subsection 7e7 z subsection 7f72 & 7#b7 by add+ aft] subsection 7d7 ! foll[+ new subsection3 7e7 ,limit$ income newly eligible transition program 7#a7 ,9 g5]al ,beg9n+ n lat] ?an ,janu>y #a1 #bjba1 ! ,secret>y %all c>ry out a program to provide transitional cov]age = cov]$ "p ,d drugs = ,,li ,,net eligible individuals 9 accordance ) ?is subsection4 7#b7 ,,li net eligible individual def9$ ,= purposes ( ?is subsection1 ! t]m ,,li ,,net eligible individual means a "p ,d eligible individual :o-- 7,a7 meets ! requirem5ts ( clauses 7ii7 & 7iii7 ( subsection 7a77#c77;,a72 & 7,b7 has n yet enroll$ 9 a prescription drug plan or an ,,ma-,,pd plan1 or1 :o has s enroll$1 b ) respect to :om cov]age "u su* plan has n yet tak5 effect4 7#c7 ,transitional cov]age ,= purposes ( ?is subsection1 ! t]m transitional cov]age means1 ) respect to an ,,li ,,net eligible individual-- 7,a7 imm$iate access to cov]$ "p ,d drugs at ! po9t ( sale dur+ ! p]iod t beg9s on ! fir/ day ( ! mon? su* individual is det]m9$ to meet ! requirem5ts ( clauses 7ii7 & 7iii7 ( subsection 7a77#c77;,a7 & ends on ! date t cov]age "u a prescription drug plan or ,,ma-,,pd plan takes effect ) respect to su* individual2 & 7,b7 9 ! case ( an ,,li ,,net eligible individual :o is a full-b5efit dual eligible individual 7z def9$ 9 section #aice7;c77#f77 or a recipi5t ( supplem5tal security income b5efits "u title ,,xvi1 retroactive cov]age 79 ! =m ( reimbursem5t ( ! am\nts t w\ld h be5 paid "u ?is "p _h su* individual be5 enroll$ 9 a prescription drug plan or ,,ma-,,pd plan7 ( cov]$ "p ,d drugs pur*as$ by su* individual dur+ ! p]iod t beg9s on ! date t is ! lat] (-- 7i7 ! date t su* individual 0 fir/ eligible = a l[-income subsidy "u ?is "p2 or 7ii7 ! date t is #cf mon?s prior to ! date su* individual enrolls 9 a prescription drug plan or ,,ma-,,pd plan1 & ends on ! date t cov]age "u su* plan takes effect4 7#d7 ,program adm9i/ration 7,a7 ,s+le po9t ( contact ,! ,secret>y %all1 to ! ext5t feasible1 adm9i/] ! program "u ?is subsection ?r\gh a contract ) a s+le program adm9i/rator4 7,b7 ,b5efit design ,! ,secret>y %all ensure t ! transitional cov]age provid$ to ,,li ,,net eligible individuals "u ?is subsection-- 7i7 provides access to all cov]$ "p ,d drugs "u an op5 =mul>y2 7ii7 p]mits all ph>macies det]m9$ by ! ,secret>y to be 9 good /&+ to process claims "u ! program2 7iii7 is consi/5t ) su* requirem5ts z ! ,secret>y consid]s necess>y to improve pati5t safety & ensure appropriate disp5s+ ( m$ication2 & 7iv7 meets su* o!r requirem5ts z ! ,secret>y may e/abli%4 7#e7 ,relation%ip to o!r provisions ( ?is title2 waiv] au?ority 7,a7 ,9 g5]al ,! foll[+ provisions %all n apply ) respect to ! program "u ?is subsection3 7i7 ,p>agraphs 7#a7 & 7#c77;,b7 ( section #ahfj;,d-#d7;a7 7relat+ to dissem9ation ( g5]al in=mation2 availability ( in=mation on *anges 9 =mul>y ?r\gh ! int]net74 7ii7 ,subp>agraphs 7,a7 & 7,b7 ( section #ahfj;,d-#d7;b77#c7 7relat+ to requirem5ts on developm5t & application ( =mul>ies2 =mul>y developm5t74 7iii7 ,p>agraphs 7#a77;,c7 & 7#b7 ( section #ahfj;,d-#d7;c7 7relat+ to m$ication !rapy managem5t program74 7,b7 ,waiv] au?ority ,! ,secret>y may waive su* o!r requirem5ts ( titles ,,xi & ?is title z may be necess>y to c>ry out ! purposes ( ! program e/abli%$ "u ?is subsection4 4 #bjg4 ,heal? ,equity & ,access = ,return+ ,troops & ,s]vicememb]s ,act ( #bjai 7a7 ,modification ( requirem5t = c]ta9 =m] memb]s ( ! ,arm$ ,=ces to enroll 9 ,m$ic>e ,"p ,b to be eligible = ,,tric>e = ,life 7#a7 ,,tric>e eligibility 7,a7 ,9 g5]al ,subsection 7d7 ( section #ajhf ( title #aj1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 7,a7 ,! requirem5t 9 p>agraph 7#b77;,a7 to enroll 9 ! supplem5t>y m$ical insurance program "u "p ,b ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;j et seq47 %all n apply to a p]son describ$ 9 subp>agraph 7,b7 dur+ any mon? 9 :i* su* p]son is n entitl$ to a b5efit describ$ 9 subp>agraph 7,a7 ( section #bbf7;b77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #dbf7;b77#b77 if su* p]son has receiv$ ! c\nsel+ & in=mation "u subp>agraph 7,c74 7,b7 ,a p]son describ$ 9 ?is subp>agraph is a p]son-- 7i7 :o is "u #fe ye>s ( age2 7ii7 :o is entitl$ to hospital insurance b5efits "u "p ,a ( title ,,xviii ( ! ,social ,security ,act pursuant to subp>agraph 7,a7 or 7,c7 ( section #bbf7;b77#b7 ( su* ,act 7#db ,u4,s4,c4 #dbf7;b77#b772 7iii7 ^: entitlem5t to a b5efit describ$ 9 subp>agraph 7,a7 ( su* section has t]m9at$ due to p]=mance ( sub/antial ga9ful activity2 & 7iv7 :o is retir$ "u *apt] #fa ( ?is title4 7,c7 ,! ,secret>y ( ,def5se %all coord9ate ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,commission] ( ,social ,security to notify p]sons describ$ 9 subp>agraph 7,b7 (1 & provide in=mation & c\nsel+ reg>d+1 ! effects ( n enroll+ 9 ! supplem5t>y m$ical insurance program "u "p ,b ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;j et seq471 z describ$ 9 subp>agraph 7,a74 4 7,b7 ,con=m+ am5dm5t ,p>agraph 7#b77;,a7 ( su* subsection is am5d$ by /rik+ is enroll$ & ins]t+ except z provid$ by p>agraph 7#f71 is enroll$4 7,c7 ,id5tification ( p]sons ,section #aaaj;a ( su* title is am5d$ by add+ at ! end ! foll[+ new subsection3 7c7 ,c]ta9 individuals n requir$ ,to enroll 9 ,m$ic>e ,"p ,b ,9 c>ry+ out subsection 7a71 ! ,secret>y ( ,def5se %all coord9ate ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,commission] ( ,social ,security to-- 7#a7 id5tify p]sons describ$ 9 subp>agraph 7,b7 ( section #ajhf7;d77#f7 ( ?is title2 & 7#b7 provide in=mation & c\nsel+ pursuant to subp>agraph 7,c7 ( su* section4 4 7#b7 ,non-,application ( ,m$ic>e ,"p ,b late enrollm5t p5alty ,section #ahci7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acier7b77 is am5d$1 9 ! second s5t5ce1 by ins]t+ or mon?s = :i* ! individual c demon/rate t ! individual is an individual describ$ 9 p>agraph 7#f77;,b7 ( section #ajhf7;d7 ( title #aj1 ,unit$ ,/ates ,code1 :o is enroll$ 9 ! ,,tric>e program pursuant to su* section aft] an individual describ$ 9 section #ahcg7k77#c74 7#c7 ,report ,n lat] ?an ,octob] #a1 #bjbd1 ! ,secret>y ( ,def5se1 ! ,secret>y ( ,heal? & ,human ,s]vices1 & ! ,commission] ( ,social ,security %all jo9tly submit to ! ,committees on ,arm$ ,s]vices ( ! ,h\se ( ,repres5tatives & ! ,s5ate1 ! ,committee on ,ways & ,means & ! ,committee on ,en]gy & ,comm]ce ( ! ,h\se ( ,repres5tatives1 & ! ,committee on ,f9ance ( ! ,s5ate a report on ! implem5tation ( section #ajhf7;d77#f7 ( title #aj1 ,unit$ ,/ates ,code1 z add$ by p>agraph 7#a74 ,su* report %all include1 ) respect to ! p]iod cov]$ by ! report-- 7,a7 ! numb] ( individuals enroll$ 9 ,,tric>e = ,life :o are n enroll$ 9 ! supplem5t>y m$ical insurance program "u "p ,b ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;j et seq47 by reason ( su* section #ajhf7;d77#f72 & 7,b7 ! numb] ( individuals :o-- 7i7 are retir$ f ! ,arm$ ,=ces "u *apt] #fa ( title #aj1 ,unit$ ,/ates ,code2 7ii7 are entitl$ to hospital insurance b5efits "u "p ,a ( title ,,xviii ( ! ,social ,security ,act pursuant to receiv+ b5efits = #bd mon?s z describ$ 9 subp>agraph 7,a7 or 7,c7 ( section #bbf7;b77#b7 ( su* ,act 7#db ,u4,s4,c4 #dbf7;b77#b772 & 7iii7 because ( su* entitlem5t1 are no long] enroll$ 9 ,,tric>e ,/&>d1 ,,tric>e ,prime1 ,,tric>e ,extra1 or ,,tric>e ,select "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code4 7#d7 ,deposit ( sav+s into ,m$ic>e improvem5t fund ,section #ahih7;b77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;iii7b77#a77 is am5d$ by /rik+ dur+ & aft] fiscal ye> #bjba1 #j & ins]t+ dur+ & aft] fiscal ye> #bjbd1 #e1jjj1jjj4 7#e7 ,application ,! am5dm5ts made by p>agraphs 7#a7 & 7#b7 %all apply ) respect to a p]son :o1 on or aft] ,octob] #a1 #bjbc1 is a p]son describ$ 9 section #ajhf7;d77#f77;,b7 ( title #aj1 ,unit$ ,/ates ,code1 z add$ by p>agraph 7#a74 7b7 ,cov]age ( c]ta9 ,,dna specim5 prov5ance assay te/s "u ,m$ic>e 7#a7 ,b5efit 7,a7 ,cov]age ,section #ahfa ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7 is am5d$-- 7i7 9 subsection 7s77#b7-- 7,i7 9 subp>agraph 7,,gg71 by /rik+ & at ! end2 7,,ii7 9 subp>agraph 7,,hh71 by /rik+ ! p]iod & ins]t+ 2 &2 & 7,,iii7 by add+ at ! end ! foll[+ new subp>agraph3 7,,ii7 a pro/ate canc] ,,dna ,specim5 ,prov5ance ,assay te/ 7,,dspa te/7 7z def9$ 9 subsection 7kkk772 2 & 7ii7 by add+ at ! end ! foll[+ new subsection3 7kkk7 ,pro/ate canc] ,,dna ,specim5 ,prov5ance ,assay ,te/ ,! t]m pro/ate canc] ,,dna ,specim5 ,prov5ance ,assay ,te/ 7,,dspa te/7 means a te/ t1 aft] a det]m9ation ( canc] 9 "o or m pro/ate biopsy specim5s obta9$ f an individual1 assesses ! id5tity ( ! ,,dna 9 su* specim5s by comp>+ su* ,,dna ) ! ,,dna t 0 sep>ately tak5 f su* individual at ! "t ( ! biopsy4 4 7,b7 ,exclusion f cov]age ,section #ahfb7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77#a77 is am5d$-- 7i7 9 subp>agraph 7,o71 by /rik+ & at ! end2 7ii7 9 subp>agraph 7,p71 by /rik+ ! semicolon at ! end & ins]t+ 1 &2 & 7iii7 by add+ at ! end ! foll[+ new subp>agraph3 7,q7 9 ! case ( a pro/ate canc] ,,dna ,specim5 ,prov5ance ,assay te/ 7,,dspa te/7 7z def9$ 9 section #ahfa7kkk771 unless su* te/ is furni%$ on or aft] ,janu>y #a1 #bjba1 & be=e ,janu>y #a1 #bjbf1 & su* te/ is ord]$ by ! physician :o furni%$ ! pro/ate canc] biopsy t obta9$ ! specim5 te/$2 4 7#b7 ,paym5t am\nt & relat$ requirem5ts ,section #ahcd ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7x7 ,pro/ate canc] ,,dna ,specim5 ,prov5ance ,assay te/s 7#a7 ,paym5t = cov]$ te/s 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 ! paym5t am\nt = a pro/ate canc] ,,dna ,specim5 ,prov5ance ,assay te/ 7,,dspa te/7 7z def9$ 9 section #ahfa7kkk77 %all be #bjj4 ,su* paym5t %all be paym5t = all ( ! specim5s obta9$ f ! biopsy furni%$ to an individual t are te/$4 7,b7 ,limitation ,paym5t = a ,,dspa te/ "u subp>agraph 7,a7 may only be made on an assignm5t-relat$ basis4 7,c7 ,prohibition on sep>ate paym5t ,no sep>ate paym5t %all be made = obta9+ ,,dna t 0 sep>ately tak5 f an individual at ! "t ( a biopsy describ$ 9 subp>agraph 7,a74 7#b7 ,,hcpcs code & modifi] assignm5t 7,a7 ,9 g5]al ,! ,secret>y %all assign "o or m ,,hcpcs codes to a pro/ate canc] ,,dna ,specim5 ,prov5ance ,assay te/ & may use a modifi] to facilitate mak+ paym5t "u ?is section = su* te/4 7,b7 ,id5tification ( ,,dna mat* on claim ,! ,secret>y %all require an indication on a claim = a pro/ate canc] ,,dna ,specim5 ,prov5ance ,assay te/ ( :e!r ! ,,dna ( ! pro/ate biopsy specim5s mat* ! ,,dna ( ! individual diagnos$ ) pro/ate canc]4 ,su* indication may be made ?r\gh use ( a ,,hcpcs code1 a modifi]1 or o!r means1 z det]m9$ appropriate by ! ,secret>y4 7#c7 ,,dna mat* review 7,a7 ,9 g5]al ,! ,secret>y %all review at lea/ ?ree ye>s ( claims "u "p ,b = pro/ate canc] ,,dna ,specim5 ,prov5ance ,assay te/s to id5tify :e!r ! ,,dna ( ! pro/ate biopsy specim5s mat* ! ,,dna ( ! individuals diagnos$ ) pro/ate canc]4 7,b7 ,po/+ on int]net website ,n lat] ?an ,july #a1 #bjbc1 ! ,secret>y %all po/ on ! int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ! f9d+s ( ! review conduct$ "u subp>agraph 7,a74 4 7#c7 ,co/-,%>+ ,section #ahcc7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a77 is am5d$-- 7,a7 by /rik+ & 7,,cc7 & ins]t+ 7,,cc72 & 7,b7 by ins]t+ be=e ! semicolon at ! end ! foll[+3 1 & 7,,dd7 ) respect to a pro/ate canc] ,,dna ,specim5 ,prov5ance ,assay te/ 7,,dspa te/7 7z def9$ 9 section #ahfa7kkk771 ! am\nt paid %all be an am\nt equal to #hj p]c5t ( ! less] ( ! actual *>ge = ! te/ or ! am\nt specifi$ "u section #ahcd7x74 #bjh4 ,exclusion ( complex rehabilitative manual :eel*airs f ,m$ic>e competitive acquisition program2 ,non-application ( ,m$ic>e fee-s*$ule adju/m5ts = c]ta9 :eel*air accessories & cu%ions 7a7 ,exclusion ( complex rehabilitative manual :eel*airs f competitive acquisition program ,section #ahdg7;a77#b77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c7;a77#b77;,a77 is am5d$-- 7#a7 by ins]t+ 1 complex rehabilitative manual :eel*airs 7z det]m9$ by ! ,secret>y71 & c]ta9 manual :eel*airs 7id5tifi$1 z ( ,octob] #a1 #bjah1 by ,,hcpcs codes ,e#abce1 ,e#abcf1 ,e#abcg1 ,e#abch1 & ,k#jjjh or any successor to su* codes7 aft] gr\p #c or high]2 & 7#b7 by /rik+ su* :eel*airs & ins]t+ su* complex rehabilitative p[] :eel*airs1 complex rehabilitative manual :eel*airs1 & c]ta9 manual :eel*airs4 7b7 ,non-,application ( ,m$ic>e fee s*$ule adju/m5ts = :eel*air accessories & seat & back cu%ions :5 furni%$ 9 connection ) complex rehabilitative manual :eel*airs 7#a7 ,9 g5]al ,not)/&+ any o!r provision ( law1 ! ,secret>y ( ,heal? & ,human ,s]vices %all n1 dur+ ! p]iod beg9n+ on ,janu>y #a1 #bjbj1 & end+ on ,decemb] #ca1 #bjbj1 use in=mation on ! paym5t det]m9$ "u ! competitive acquisition programs "u section #ahdg ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c7 to adju/ ! paym5t am\nt t w\ld o!rwise be recogniz$ "u section #ahcd7;a77#a77;,b77ii7 ( su* ,act 7#db ,u4,s4,c4 #aciem7a77#a77;,b77ii77 = :eel*air accessories 7includ+ seat+ sy/ems7 & seat & back cu%ions :5 furni%$ 9 connection ) complex rehabilitative manual :eel*airs 7z det]m9$ by ! ,secret>y71 & c]ta9 manual :eel*airs 7id5tifi$1 z ( ,octob] #a1 #bjah1 by ,,hcpcs codes ,e#abce1 ,e#abcf1 ,e#abcg1 ,e#abch1 & ,k#jjjh or any successor to su* codes74 7#b7 ,implem5tation ,not)/&+ any o!r provision ( law1 ! ,secret>y may implem5t ?is subsection by program in/ruction or o!rwise4 ,,iii ,m$icaid ,provisions #cja4 ,modification ( r$uctions 9 ,m$icaid ,,d% allotm5ts ,section #aibc7;f77#g77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#d7;f77#g77;,a77 is am5d$-- 7#a7 9 clause 7i71 9 ! matt] prec$+ subclause 7,i71 by /rik+ #bjbj & ins]t+ #bjbb2 & 7#b7 9 clause 7ii7-- 7,a7 9 subclause 7,i71 by /rik+ #bjbj & ins]t+ #bjbb2 & 7,b7 9 subclause 7,,ii71 by /rik+ = ea* ( fiscal ye>s #bjba ?r\gh #bjbe & ins]t+ = ea* ( fiscal ye>s #bjbc ?r\gh #bjbe4 #cjb4 ,public availability ( hospital upp] paym5t limit demon/rations ,section #aijc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7bb7 ,public availability ( hospital upp] paym5t limit demon/rations ,! ,secret>y %all make publicly available upp] paym5t limit demon/rations = hospital s]vices t a ,/ate submits ) respect to a fiscal ye> ( ! ,/ate 7beg9n+ ) ,/ate fiscal ye> #bjbb7 to ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 4 #cjc4 ,report by ,comptroll] ,g5]al ,n lat] ?an ! date t is #ba mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all id5tify & report to ,congress policy consid]ations = legislative action ) respect to e/abli%+ an equitable =mula = det]m9+ disproportionate %>e hospital allotm5ts = ,/ates "u section #aibc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#d7 t takes into acc\nt ! foll[+ factors3 7#a7 ,! level ( uncomp5sat$ c>e co/s ( hospitals 9 a ,/ate4 7#b7 ,exp5ditures ( a ,/ate ) respect to hospitals1 includ+ paym5t adju/m5ts made "u su* section #aibc to disproportionate %>e hospitals 7z def9$ "u ! ,/ate plan "u title ,,xix ( su* ,act 7#db ,u4,s4,c4 #acif et seq47 pursuant to subsection 7a77#a77;,a7 ( su* section #aibc71 upp] paym5t limit supplem5tal paym5ts1 & o!r relat$ paym5ts t hospitals may receive f ! ,/ate4 7#c7 ,/ate policy decisions t may affect ! level ( uncomp5sat$ c>e co/s ( hospitals 9 a ,/ate4 #cjd4 ,s5se ( ,congress reg>d+ ! ne$ to develop a m p]man5t legislative solution to provide ! t]ritories ) a reliable & consi/5t s\rce ( ,f$]al fund+ "u ! ,m$icaid program ,x is ! s5se ( ,congress t-- 7#a7 ! t]ritories ( ,am]ican ,samoa1 ! ,commonweal? ( ! ,nor!rn ,m>iana ,isl&s1 ,guam1 ,pu]to ,rico1 & ! ,unit$ ,/ates ,virg9 ,isl&s are curr5tly subject to ,f$]al fund+ caps = _! ,m$icaid programs2 7#b7 z a result ( ^! ,f$]al fund+ caps1 :i* h n be5 adju/$ ov] "t1 ! t]ritories cont9ue to /ruggle 9 manag+ _! ,m$icaid programs1 includ+ plann+ = _! respective f9ancial obligations & manag+ heal? c>e s]vices = l[-income adults1 *ildr51 pregnant wom51 eld]ly adults1 & p]sons ) disabilities2 7#c7 to address ?is disp>ate fund+ treatm5t & to provide ! t]ritories ) "s measure ( relief1 ,congress has _h to enact legislation six times 9 ! la/ #ae ye>s1 includ+ multiple tempor>y increases 9 ! ,f$]al fund+ caps1 high] ,f$]al m$ical assi/ance p]c5tage rates1 & billions ( doll>s 9 supplem5tal block grants2 7#d7 ! supplem5tal fund+ provid$ to ! t]ritories "u title ,v ) respect to _! ,m$icaid programs cont9ues ,congress' commitm5t to ensur+ ! su/a9ability ( ^! critically important programs & ! p ^! programs s]ve2 & 7#e7 a m p]man5t legislative solution mu/ be develop$ 9 ord] to provide ! t]ritories ) a reliable & consi/5t s\rce ( ,f$]al fund+ "u _! ,m$icaid programs s t ! t]ritories c cont9ue to meet ! heal? c>e ne$s ( vuln]able populations4 ,,iv ,no ,surprises ,act #dja4 ,%ort title ,?is title may be cit$ z ! ,no ,surprises ,act4 #djb4 ,prev5t+ surprise m$ical bills 7a7 ,cov]age ( em]g5cy s]vices ,section #bgai;,a7b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7b77 is am5d$-- 7#a7 9 p>agraph 7#a7-- 7,a7 9 ! matt] prec$+ subp>agraph 7,a7-- 7i7 by /rik+ a gr\p heal? plan1 or a heal? insurance issu] (f]+ gr\p or individual heal? insurance issu]1 & ins]t+ a heal? plan 7z def9$ 9 subsection 7e77#b77;,a772 7ii7 by ins]t+ or1 = plan ye> #bjba or a subsequ5t plan ye>1 ) respect to em]g5cy s]vices 9 an indep5d5t free/&+ em]g5cy dep>tm5t 7z def9$ 9 p>agraph 7#c77;,d77 aft] em]g5cy dep>tm5t ( a hospital2 7iii7 by /rik+ ! plan or issu] & ins]t+ ! plan2 & 7iv7 by /rik+ p>agraph 7#b77;,b7 & ins]t+ p>agraph 7#c77;,c72 7,b7 9 subp>agraph 7,b71 by ins]t+ or a p>ticipat+ em]g5cy facility1 z applicable1 aft] p>ticipat+ provid]2 & 7,c7 9 subp>agraph 7,c7-- 7i7 9 ! matt] prec$+ clause 7i71 by ins]t+ by a nonp>ticipat+ provid] or a nonp>ticipat+ em]g5cy facility aft] enrollee2 7ii7 by /rik+ clause 7i72 7iii7 by /rik+ 7ii77,i7 su* s]vices & ins]t+ 7i7 su* s]vices2 7iv7 by /rik+ :]e ! provid] ( s]vices does n h a contractual relation%ip ) ! plan = ! provid+ ( s]vices2 7v7 by /rik+ em]g5cy dep>tm5t s]vices receiv$ f provid]s :o d h su* a contractual relation%ip ) ! plan2 & & ins]t+ em]g5cy s]vices receiv$ f p>ticipat+ provid]s & p>ticipat+ em]g5cy facilities ) respect to su* plan22 7vi7 by /rik+ 7,,ii7 if su* s]vices & all t foll[s ?r\gh 7 provid$ 9-network2 & ins]t+ ! foll[+3 7ii7 ! co/-%>+ requirem5t 7express$ z a copaym5t am\nt or co9surance rate7 is n great] ?an ! requirem5t t w\ld apply if su* s]vices 7 provid$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility2 2 & 7vii7 by add+ at ! end ! foll[+ new clauses3 7iii7 su* requirem5t is calculat$ z if ! total am\nt t w\ld h be5 *>g$ = su* s]vices by su* p>ticipat+ provid] or p>ticipat+ em]g5cy facility 7 equal to-- 7,i7 9 ! case ( su* s]vices furni%$ 9 a ,/ate describ$ 9 p>agraph 7#c77;,h77ii71 ! m$ian contract$ rate 7z def9$ 9 p>agraph 7#c77;,e77i77 = su* s]vices2 & 7,,ii7 9 ! case ( su* s]vices furni%$ 9 a ,/ate describ$ 9 p>agraph 7#c77;,h77i71 ! less] (-- 7aa7 ! am\nt det]m9$ by su* ,/ate = su* s]vices 9 accordance ) ! me?od describ$ 9 su* p>agraph2 & 7bb7 ! m$ian contract$ rate 7z s def9$7 = su* s]vices2 7iv7 ! heal? plan pays to su* provid] or facility1 respectively1 ! am\nt by :i* ! recogniz$ am\nt 7z def9$ 9 p>agraph 7#c77;,h77 = su* s]vices exce$s ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii772 & 7v7 any co/-%>+ paym5ts made by ! p>ticipant1 b5efici>y1 or enrollee ) respect to su* em]g5cy s]vices s furni%$ %all be c\nt$ t[>d any 9-network d$uctible or out-(-pocket maximums appli$ "u ! plan 7& su* 9-network d$uctible %all be appli$7 9 ! same mann] z if su* co/-%>+ paym5ts 7 ) respect to em]g5cy s]vices furni%$ by a p>ticipat+ provid] & a p>ticipat+ em]g5cy facility2 & 2 7#b7 by r$esignat+ p>agraph 7#b7 z p>agraph 7#c72 7#c7 by ins]t+ aft] p>agraph 7#a7 ! foll[+ new p>agraph3 7#b7 ,audit process = m$ian contract$ rates 7,a7 ,9 g5]al ,n lat] ?an ,july #a1 #bjbj1 ! ,secret>y1 9 consultation ) appropriate ,/ate ag5cies1 %all e/abli% ?r\gh rulemak+ a process1 9 accordance ) subp>agraph 7,b71 "u :i* heal? plans are audit$ by su* ,secret>ies to ensure t-- 7i7 su* plans are 9 compliance ) ! requirem5t ( apply+ a m$ian contract$ rate "u ?is section2 & 7ii7 t su* m$ian contract$ rate s appli$ satisfies ! def9ition "u p>agraph 7#c77;,e7 ) respect to ! ye> involv$1 includ+ ) respect to a heal? plan describ$ 9 clause 7ii7 ( su* p>agraph4 7,b7 ,audit samples ,"u ! process e/abli%$ pursuant to subp>agraph 7,a71 ! ,secret>y-- 7i7 %all conduct audits describ$ 9 su* subp>agraph1 ) respect to a ye> 7beg9n+ ) #bjba71 ( a sample ) respect to su* ye> ( claims data f n m ?an #be heal? plans2 & 7ii7 may audit any heal? plan if ! ,secret>y has receiv$ any compla9t ab\t su* plan t involves ! compliance ( ! plan ) ei!r ( ! requirem5ts describ$ 9 clauses 7i7 & 7ii7 ( su* subp>agraph4 2 & 7#d7 9 p>agraph 7#c71 z r$esignat$ by p>agraph 7#b7 ( ?is subsection-- 7,a7 9 ! matt] prec$+ subp>agraph 7,a71 by ins]t+ & subsection 7e7 aft] ?is subsection2 7,b7 by r$esignat+ subp>agraphs 7,a7 ?r\gh 7,c7 z subp>agraphs 7,b7 ?r\gh 7,d71 respectively2 7,c7 by ins]t+ be=e subp>agraph 7,b71 z r$esignat$ by subp>agraph 7,b7 ( ?is p>agraph1 ! foll[+ new subp>agraph3 7,a7 ,em]g5cy dep>tm5t ( a hospital ,! t]m em]g5cy dep>tm5t ( a hospital includes a hospital outpati5t dep>tm5t t provides em]g5cy s]vices4 2 7,d7 by am5d+ subp>agraph 7,c71 z r$esignat$ by subp>agraph 7,b7 ( ?is p>agraph1 to read z foll[s3 7,c7 ,em]g5cy s]vices 7i7 ,9 g5]al ,! t]m em]g5cy s]vices1 ) respect to an em]g5cy m$ical condition1 means-- 7,i7 a m$ical scre5+ exam9ation 7z requir$ "u section #ahfg ( ! ,social ,security ,act1 or z w\ld be requir$ "u su* section if su* section appli$ to an indep5d5t free/&+ em]g5cy dep>tm5t7 t is )9 ! capability ( ! em]g5cy dep>tm5t ( a hospital or ( an indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 includ+ ancill>y s]vices r\t9ely available to ! em]g5cy dep>tm5t to evaluate su* em]g5cy m$ical condition2 & 7,,ii7 )9 ! capabilities ( ! /aff & facilities available at ! hospital or ! indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 su* fur!r m$ical exam9ation & treatm5t z are requir$ "u section #ahfg ( su* ,act1 or z w\ld be requir$ "u su* section if su* section appli$ to an indep5d5t free/&+ em]g5cy dep>tm5t1 to /abilize ! pati5t4 7ii7 ,inclusion ( po//abilization s]vices ,= purposes ( ?is subsection & section #bgii1 9 ! case ( an individual enroll$ 9 a heal? plan :o is furni%$ s]vices describ$ 9 clause 7i7 by a provid] or facility to /abilize su* individual ) respect to an em]g5cy m$ical condition1 ! t]m em]g5cy s]vices %all include su* items & s]vices 9 addition to ^? describ$ 9 clause 7i7 t su* a provid] or facility det]m9es are ne$$ to be furni%$ 7aft] su* /abilization b dur+ su* visit 9 :i* su* individual is s /abiliz$7 to su* individual1 unless ea* ( ! foll[+ conditions are met3 7,i7 ,su* a provid] or facility det]m9es su* individual is able to travel us+ nonm$ical transportation or nonem]g5cy m$ical transportation4 7,,ii7 ,su* provid] furni%+ su* additional items & s]vices is 9 compliance ) section #bgii;,a7d7 ) respect to su* items & s]vices4 2 7,e7 by r$esignat+ subp>agraph 7,d71 z r$esignat$ by subp>agraph 7,b7 ( ?is p>agraph1 z subp>agraph 7,i72 & 7,f7 by ins]t+ aft] subp>agraph 7,c71 z r$esignat$ by subp>agraph 7,b7 ( ?is p>agraph1 ! foll[+ new subp>agraphs3 7,d7 ,indep5d5t free/&+ em]g5cy dep>tm5t ,! t]m indep5d5t free/&+ em]g5cy dep>tm5t means a facility t-- 7i7 is geographically sep>ate & di/9ct & lic5s$ sep>ately f a hospital "u applicable ,/ate law2 & 7ii7 provides em]g5cy s]vices4 7,e7 ,m$ian contract$ rate 7i7 ,9 g5]al ,! t]m m$ian contract$ rate means1 ) respect to an item or s]vice & a heal? plan 7z def9$ 9 subsection 7e77#b77;,a77-- 7,i7 = #bjba1 ! m$ian ( ! negotiat$ rates recogniz$ by ! sponsor or issu] ( su* plan 7det]m9$ ) respect to all su* plans ( su* sponsor or su* issu] t are )9 ! same l9e ( bus9ess7 z ! total maximum paym5t 7includ+ ! co/-%>+ am\nt impos$ = su* s]vices 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii7 ( p>agraph 7#a77;,c7 or subp>agraphs 7,a7 & 7,b7 ( subsection 7e77#a71 z applicable7 & ! am\nt to be paid by ! plan or issu]7 "u su* plans 9 #bjai = ! same or a simil> item or s]vice t is provid$ by a provid] 9 ! same or simil> specialty & provid$ 9 ! geographic region 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u section #djb7;e7 ( ! ,no ,surprises ,act1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] #bjai & #bjbj2 & 7,,ii7 = #bjbb & ea* subsequ5t ye>1 ! m$ian contract$ rate det]m9$ "u ?is clause = ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 7ii7 ,special rule ,! ,secret>y %all provide pursuant to rulemak+ describ$ 9 section #djb7;e7 ( ! ,no ,surprises ,act t-- 7,i7 if ! sponsor or issu] ( a heal? plan does n h suffici5t in=mation to calculate a m$ian contract$ rate = an item or s]vice or provid] type1 or am\nt (1 claims = items or s]vices 7z det]m9$ by ! ,secret>y7 provid$ 9 a p>ticul> geographic area 7o!r ?an 9 a case describ$ 9 item 7bb771 su* sponsor or issu] %all demon/rate t su* sponsor or issu] w use any database free ( conflicts ( int]e/ t has suffici5t in=mation reflect+ all[$ am\nts paid to a heal? c>e provid] = relevant s]vices provid$ 9 ! applicable geographic region 7su* z ,/ate ,all ,pay] ,claims ,databases 7z def9$ 9 section #djd7;d7 ( su* ,act771 & t su* sponsor or issu] w use any su* database to det]m9e a m$ian contract$ rate & cov] ! co/ ( access+ any su* database2 & 7,,ii7 9 ! case ( a sponsor or issu] (f]+ a heal? plan 9 a geographic region t did n (f] any heal? plan 9 su* region dur+ #bjai1 su* sponsor or issu] %all use a me?odology e/abli%$ by ! ,secret>y = det]m9+ ! m$ian contract$ rate = items & s]vices cov]$ by su* plan = ! fir/ ye> 9 :i* su* plan is (f]$ 9 su* region1 & t1 = ea* succe$+ ye>1 ! m$ian contract$ rate = su* items & s]vices "u su* plan %all be ! m$ian contract$ rate = su* items & s]vices "u su* plan = ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 7,f7 ,nonp>ticipat+ em]g5cy facility2 p>ticipat+ em]g5cy facility 7i7 ,nonp>ticipat+ em]g5cy facility ,! t]m nonp>ticipat+ em]g5cy facility means1 ) respect to an item or s]vice & a heal? plan1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t does n h a contractual relation%ip ) ! plan 7or1 if applicable1 issu] (f]+ ! plan7 = furni%+ su* item or s]vice "u ! plan4 7ii7 ,p>ticipat+ em]g5cy facility ,! t]m p>ticipat+ em]g5cy facility means1 ) respect to an item or s]vice & a heal? plan1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t has a contractual relation%ip ) ! plan 7or1 if applicable1 issu] (f]+ ! plan7 = furni%+ su* item or s]vice "u ! plan4 7,g7 ,nonp>ticipat+ provid]s2 p>ticipat+ provid]s 7i7 ,nonp>ticipat+ provid] ,! t]m nonp>ticipat+ provid] means1 ) respect to an item or s]vice & a heal? plan1 a physician or o!r heal? c>e provid] :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o does n h a contractual relation%ip ) ! plan 7or1 if applicable1 issu] (f]+ ! plan7 = furni%+ su* item or s]vice "u ! plan4 7ii7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a heal? plan1 a physician or o!r heal? c>e provid] :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o has a contractual relation%ip ) ! plan 7or1 if applicable1 issu] (f]+ ! plan7 = furni%+ su* item or s]vice "u ! plan4 7,h7 ,recogniz$ am\nt ,! t]m recogniz$ am\nt means1 ) respect to an item or s]vice-- 7i7 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate t has 9 effect a ,/ate law t provides = a me?od = det]m9+ ! am\nt ( paym5t t is requir$ to be cov]$ by a heal? plan regulat$ by su* ,/ate 9 ! case ( a p>ticipant1 b5efici>y1 or enrollee cov]$ "u su* plan & receiv+ su* item or s]vice f a nonp>ticipat+ provid] or facility1 n m ?an ! am\nt det]m9$ 9 accordance ) su* law plus ! co/-%>+ am\nt impos$ "u ! plan = su* item or s]vice 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii7 ( p>agraph 7#a77;,c7 or subp>agraphs 7,a7 & 7,b7 ( subsection 7e77#a71 z applicable72 or 7ii7 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate t does n h 9 effect su* a law1 an am\nt t is at lea/ ! m$ian contract$ rate 7z def9$ 9 subp>agraph 7,e77i7 & det]m9$ 9 accordance ) rulemak+ describ$ 9 section #djb7;e7 ( ! ,no ,surprises ,act7 = su* item or s]vice4 4 7b7 ,cov]age ( non-em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities2 indep5d5t dispute resolution process ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is am5d$ by add+ at ! end ! foll[+ new subsections3 7e7 ,cov]age ( non-em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7#a7 ,9 g5]al ,subject to p>agraph 7#c71 9 ! case ( items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7b7 applies7 furni%$ to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan 7z def9$ 9 p>agraph 7#b77;,a77 by a nonp>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77i77 dur+ a visit 7z def9$ by ! ,secret>y 9 accordance ) p>agraph 7#b77;,c77 at a p>ticipat+ heal? c>e facility 7z def9$ 9 p>agraph 7#b77;,b771 ) respect to su* plan1 ! plan-- 7,a7 %all n impose on su* p>ticipant1 b5efici>y1 or enrollee a co/-%>+ am\nt 7express$ z a copaym5t am\nt or co9surance rate7 = su* items & s]vices s furni%$ t is great] ?an ! co/-%>+ am\nt t w\ld apply "u su* plan _h su* items or s]vices be5 furni%$ by a p>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77ii772 7,b7 %all calculate su* co/-%>+ am\nt z if ! am\nt t w\ld h be5 *>g$ = su* items & s]vices by su* p>ticipat+ provid] 7 equal to-- 7i7 9 ! case ( su* items & s]vices furni%$ 9 a ,/ate describ$ 9 subsection 7b77#c77;,h77ii71 ! m$ian contract$ rate 7z def9$ 9 subsection 7b77#c77;,e77i77 = su* items & s]vices2 & 7ii7 9 ! case ( su* items & s]vices furni%$ 9 a ,/ate describ$ 9 subsection 7b77#c77;,h77i71 ! less] (-- 7,i7 ! am\nt det]m9$ by su* ,/ate = su* items & s]vices 9 accordance ) ! me?od describ$ 9 su* subsection2 & 7,,ii7 ! m$ian contract$ rate 7z s def9$7 = su* items & s]vices2 7,c7 %all pay to su* provid] furni%+ su* items & s]vices to su* p>ticipant1 b5efici>y1 or enrollee ! am\nt by :i* ! recogniz$ am\nt 7z def9$ 9 subsection 7b77#c77;,h77 = su* items & s]vices exce$s ! co/-%>+ am\nt impos$ "u ! plan = su* items & s]vices 7z det]m9$ 9 accordance ) subp>agraphs 7,a7 & 7,b772 & 7,d7 %all c\nt t[>d any 9-network d$uctible or out-(-pocket maximums appli$ "u ! plan any co/-%>+ paym5ts made by ! p>ticipant1 b5efici>y1 or enrollee 7& su* 9-network d$uctible %all be appli$7 ) respect to su* items & s]vices s furni%$ 9 ! same mann] z if su* co/-%>+ paym5ts 7 ) respect to items & s]vices furni%$ by a p>ticipat+ provid]4 7#b7 ,def9itions ,9 ?is subsection & subsection 7b73 7,a7 ,heal? plan ,! t]m heal? plan means a gr\p heal? plan & heal? insurance cov]age (f]$ by a hea? insurance issu] 9 ! gr\p or individual m>ket & includes a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act74 7,b7 ,p>ticipat+ heal? c>e facility 7i7 ,9 g5]al ,! t]m p>ticipat+ heal? c>e facility means1 ) respect to an item or s]vice & a heal? plan1 a heal? c>e facility describ$ 9 clause 7ii7 t has a contractual relation%ip ) ! plan 7or1 if applicable1 issu] (f]+ ! plan7 = furni%+ su* item or s]vice4 7ii7 ,heal? c>e facility describ$ ,a heal? c>e facility describ$ 9 ?is clause is ea* ( ! foll[+3 7,i7 ,a hospital 7z def9$ 9 #ahfa7;e7 ( ! ,social ,security ,act74 7,,ii7 ,a critical access hospital 7z def9$ 9 section #ahfa7mm7 ( su* ,act74 7,,iii7 ,an ambulatory surgical c5t] 7z def9$ 9 section #ahcc7;i77#a77;,a7 ( su* ,act74 7,,iv7 ,a laboratory4 7,v7 ,a radiology facility or imag+ c5t]4 7,c7 ,dur+ a visit ,! t]m dur+ a visit %all1 ) respect to items & s]vices furni%$ to an individual at a p>ticipat+ heal? c>e facility1 include equipm5t & devices1 telem$ic9e s]vices1 imag+ s]vices1 laboratory s]vices1 & su* o!r items & s]vices z ! ,secret>y may specify1 reg>dless ( :e!r or n ! provid] furni%+ su* items or s]vices is at ! facility4 7#c7 ,exception ,p>agraph 7#a7 %all n apply to a heal? plan 9 ! case ( items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7b7 applies7 furni%$ to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan 7z def9$ 9 p>agraph 7#b77;,a77 by a nonp>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77i77 dur+ a visit 7z def9$ by ! ,secret>y 9 accordance ) p>agraph 7#b77;,c77 at a p>ticipat+ heal? c>e facility 7z def9$ 9 p>agraph 7#b77;,b77 if su* provid] is 9 compliance ) section #bgii;,a7d7 ) respect to su* items & s]vices4 7f7 ,indep5d5t dispute resolution process 7#a7 ,e/abli%m5t 7,a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is subsection1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor1 %all e/abli% by regulation an indep5d5t dispute resolution process 7ref]r$ to 9 ?is subsection z ! ,,idr process7 "u :i*-- 7i7 a nonp>ticipat+ provid] 7z def9$ 9 subp>agraph 7,g7 ( subsection 7b77#c771 nonp>ticipat+ em]g5cy facility 7z def9$ 9 subp>agraph 7,f7 ( su* subsection71 or heal? plan 7z def9$ 9 subsection 7e77#b77;,a77 may submit a reque/ = resolution by an entity c]tifi$ "u p>agraph 7#b7 79 ?is subsection ref]r$ to z a c]tifi$ ,,idr entity7 ( a specifi$ claim2 & 7ii7 9 ! case a settlem5t describ$ 9 subp>agraph 7,b7 ( p>agraph 7#d7 is n rea*$ ) respect to su* claim1 su* entity s resolves su* claim 9 accordance ) su* p>agraph4 7,b7 ,def9itions ,9 ?is subsection3 7i7 ,specifi$ claim 7,i7 ,9 g5]al ,subject to subclause 7,,ii71 ! t]m specifi$ claim means a claim by a nonp>ticipat+ provid]1 a nonp>ticipat+ em]g5cy facility1 or a heal? plan ) respect to qualify+ items & s]vices 7z def9$ 9 clause 7ii77 furni%$ by su* provid] or facility 9 a ,/ate describ$ 9 subp>agraph 7,h77ii7 ( subsection 7b77#c7 = :i* a heal? plan is requir$ to make paym5t pursuant to subsection 7b77#a7 or subsection 7e77#a7-- 7aa7 t su* paym5t %\ld be increas$ or decreas$2 & 7bb7 t is made n lat] ?an-- 7,,aa7 9 ! case ( su* a claim fil$ by su* a provid] or facility1 ! date on :i* ! appeal ) respect to su* items & s]vices describ$ 9 clause 7ii77,i77aa77,,aa7 has be5 resolv$ 7or ! date t is #cj days aft] su* appeal is fil$1 :i*ev] is e>li]72 or 7,,bb7 9 ! case ( su* a claim fil$ by su* plan1 ! date on :i* ! p]iod describ$ 9 clause 7ii77,i77bb77,,bb7 ) respect to su* items & s]vices elapses4 7,,ii7 ,limitation on packag+ ( items & s]vices 9 a specifi$ claim ,! t]m specifi$ claim %all n include1 9 ! case su* claim is made by su* provid]1 facility1 or plan ) respect to multiple items & s]vices1 any claim ) respect to items & s]vices furni%$ by su* provid] or facility if-- 7aa7 su* items & s]vices 7 n furni%$ by ! same provid] or facility2 7bb7 paym5t = su* items & s]vices made pursuant to subsection 7b77#a7 or subsection 7e77#a7 0 made by multiple heal? plans2 7cc7 su* items & s]vices are n relat$ to ! treatm5t ( ! same condition2 or 7dd7 su* items & s]vices 7 n furni%$ )9 #cj days ( ! date ( ! e>lie/ item or s]vice furni%$ t is includ$ 9 su* claim4 7ii7 ,qualify+ items & s]vices 7,i7 ,9 g5]al ,subject to subclause 7,,ii71 ! t]m qualify+ items & s]vices means-- 7aa7 ) respect to a specifi$ claim made by a nonp>ticipat+ provid] or nonp>ticipat+ em]g5cy facility1 items & s]vices furni%$ by su* provid] or facility = :i* a heal? plan is requir$ to make paym5t pursuant to subsection 7b77#a7 or subsection 7e77#a71 b only if-- 7,,aa7 su* items & s]vices are includ$ 9 an appeal fil$ "u su* plan's int]nal appeals process n lat] ?an #cj days aft] su* paym5t is receiv$2 & 7,,bb7 su* appeal "u su* plan's int]nal appeals process has be5 resolv$1 or a #cj-;day p]iod has elaps$ s9ce su* appeal 0 s fil$2 & 7bb7 ) respect to a specifi$ claim made by a heal? plan1 items & s]vices furni%$ by su* a provid] or facility = :i* su* heal? plan is requir$ to make paym5t pursuant to subsection 7b77#a7 or subsection 7e77#a71 b only if-- 7,,aa7 su* plan submits a notice to su* provid] or facility n lat] ?an #cj days aft] su* provid] or facility receives su* paym5t t su* plan disputes ! am\nt ( su* paym5t ) respect to su* items & s]vices2 & 7,,bb7 a #cj-;day p]iod has elaps$ s9ce ! submission ( su* notice4 7,,ii7 ,limitation ,! t]m qualify+ items & s]vices %all n include an item or s]vice furni%$ 9 a geographic area dur+ a ye> by su* provid] or facility = :i* a heal? plan is requir$ to make paym5t pursuant to subsection 7b77#a7 or subsection 7e77#a7 if ! m$ian contract$ rate 7z def9$ 9 subsection 7b77#c77;,e77 "u su* plan = su* ye> ) respect to su* item or s]vice furni%$ by su* a provid] or su* a facility 9 su* area does n exce$-- 7aa7 ) respect to an item or s]vice furni%$ dur+ #bjba1 #a1bej2 & 7bb7 ) respect to an item or s]vice furni%$ dur+ a subsequ5t ye>1 ! am\nt specifi$ "u ?is subclause = ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 7#b7 ,c]tification ( entities 7,a7 ,process ( c]tification ,! process describ$ 9 p>agraph 7#a7 %all include a c]tification process "u :i* eligible entities may be c]tifi$ to c>ry out ! ,,idr process4 7,b7 ,eligibility 7i7 ,9 g5]al ,= purposes ( subp>agraph 7,a71 an eligible entity is an entity t is a nongov]nm5tal entity t agrees to comply ) ! fee limitations describ$ 9 clause 7ii74 7ii7 ,fee limitation ,= purposes ( clause 7i71 ! fee limitations describ$ 9 ?is clause are limitations e/abli%$ by ! ,secret>y on ! am\nt a c]tifi$ ,,idr entity may *>ge a nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 or heal? plan = s]vices furni%$ by su* entity ) respect to ! resolution ( a specifi$ claim ( su* provid]1 facility1 or plan "u ! process describ$ 9 p>agraph 7#a74 7#c7 ,selection ( c]tifi$ ,,idr entity = a specifi$ claim ,) respect to ! resolution ( a specifi$ claim "u ! ,,idr process1 ! heal? plan & ! nonp>ticipat+ provid] or ! nonp>ticipat+ em]g5cy facility 7z applicable7 involv$ %all agree on a c]tifi$ ,,idr entity to resolve su* claim4 ,9 ! case t su* plan & su* provid] or facility 7z applicable7 _c s agree1 su* an entity %all be select$ by ! ,secret>y at r&om4 7#d7 ,paym5t det]m9ation 7,a7 ,tim+ ,a c]tifi$ ,,idr entity select$ "u p>agraph 7#c7 by a heal? plan & a nonp>ticipat+ provid] or a nonp>ticipat+ em]g5cy facility 7z applicable7 ) respect to a specifi$ claim %all1 subject to subp>agraph 7,b71 n lat] ?an #cj days aft] be+ s select$1 det]m9e ! total reimbursem5t t %\ld h be5 made = items & s]vices includ$ 9 su* claim 9 accordance ) subp>agraph 7,c74 7,b7 ,settlem5t 7i7 ,9 g5]al ,if su* entity det]m9es t a settlem5t betwe5 ! heal? plan & ! provid] or facility is likely ) respect to a specifi$ claim1 ! entity may direct ! p>ties to attempt1 = a p]iod n to exce$ #aj days1 a good fai? negotiation = a settlem5t ( su* claim4 7ii7 ,tim+ ,! p]iod = a settlem5t describ$ 9 clause 7i7 %all accrue t[>ds ! #cj-;day p]iod describ$ 9 subp>agraph 7,a74 7,c7 ,det]m9ation ( am\nt 7i7 ,9 g5]al ,! heal? plan & ! nonp>ticipat+ provid] or nonp>ticipat+ em]g5cy facility 7z applicable7 %all1 ) respect to a specifi$ claim1 ea* submit to ! c]tifi$ ,,idr entity a f9al (f] ( paym5t or reimbursem5t 7z applicable7 ) respect to items & s]vices :i* are ! subject ( ! specifi$ claim4 ,su* entity %all det]m9e :i* su* (f] is ! mo/ reasonable 9 accordance ) clause 7ii74 7ii7 ,consid]ations 9 det]m9ation 7,i7 ,9 g5]al ,9 det]m9+ :i* f9al (f] is ! mo/ reasonable "u clause 7i71 ! c]tifi$ ,,idr entity %all consid]-- 7aa7 ! m$ian contract$ rates 7z def9$ 9 subsection 7b77#c77;,e77 = items or s]vices t are comp>able to ! items & s]vices includ$ 9 ! specifi$ claim & t are furni%$ 9 ! same geographic area 7z def9$ by ! ,secret>y = purposes ( su* subsection7 z su* items & s]vices 7n includ+ any facility fees ) respect to su* rates72 & 7bb7 ! circum/ances describ$ 9 subclause 7,,ii71 if any in=mation ) respect to su* circum/ances is submitt$ by ei!r p>ty4 7,,ii7 ,additional circum/ances ,= purposes ( subclause 7,i77bb71 ! circum/ances describ$ 9 ?is subclause are1 ) respect to items & s]vices includ$ 9 ! specifi$ claim ( a nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 or heal? plan1 ! foll[+3 7aa7 ,! level ( tra9+1 education1 exp]i5ce1 & quality & outcomes measurem5ts ( ! provid] or facility t furni%$ su* items & s]vices4 7bb7 ,any o!r ext5uat+ circum/ances ) respect to ! furni%+ ( su* items & s]vices t relate to ! acuity ( ! individual receiv+ su* items & s]vices or ! complexity ( furni%+ su* items & s]vices to su* individual4 7,,iii7 ,prohibition on consid]ation ( bill$ *>ges ,9 det]m9+ :i* f9al (f] is ! mo/ reasonable "u clause 7i7 ) respect to items & s]vices furni%$ by a provid] or facility & includ$ 9 a specifi$ claim1 ! c]tifi$ ,,idr entity may n consid] ! am\nt t w\ld h be5 bill$ by su* provid] or facility ) respect to su* items & s]vices _h ! provisions ( section #bgii or #bgii;,a 7z applicable7 n appli$4 7iii7 ,effect ( det]m9ation ,a det]m9ation ( a c]tifi$ ,,idr entity "u clause 7i7-- 7,i7 %all be b9d+2 & 7,,ii7 %all n be subject to judicial review1 except 9 a case describ$ 9 any ( p>agraphs 7#a7 ?r\gh 7#d7 ( section #aj7;a7 ( title #i1 ,unit$ ,/ates ,code4 7iv7 ,co/s ( indep5d5t dispute resolution process ,9 ! case ( a specifi$ claim made by a nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 or heal? plan & submitt$ to a c]tifi$ ,,idr entity-- 7,i7 if su* entity makes a det]m9ation ) respect to su* claim "u clause 7i71 ! p>ty ^: (f] is n *os5 "u su* clause %all be responsible = pay+ all fees *>g$ by su* entity2 & 7,,ii7 if ! p>ties rea* a settlem5t ) respect to su* claim prior to su* a det]m9ation1 su* fees %all be divid$ equally betwe5 ! p>ties1 unless ! p>ties o!rwise agree4 7v7 ,paym5t ,n lat] ?an #cj days aft] a det]m9ation describ$ 9 clause 7i7 is made ) respect to a specifi$ claim ( a nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 or heal? plan-- 7,i7 9 ! case t su* det]m9ation f9ds t ! am\nt paid ) respect to su* specifi$ claim by ! heal? plan %\ld h be5 great] ?an ! am\nt s paid1 su* plan %all pay directly to ! provid] or facility 7z applicable7 ! diff]5ce betwe5 ! am\nt s paid & ! am\nt s det]m9$2 & 7,,ii7 9 ! case t su* det]m9ation f9ds t ! am\nt paid ) respect to su* specifi$ claim by ! heal? plan %\ld h be5 less ?an ! am\nt s paid1 ! provid] or facility 7z applicable7 %all pay directly to ! plan ! diff]5ce betwe5 ! am\nt s paid & ! am\nt s det]m9$4 7#e7 ,publication ( in=mation relat+ to disputes 7,a7 ,9 g5]al ,= #bjba & ea* subsequ5t ye>1 ! ,secret>y & ! ,secret>y ( ,labor %all publi% on ! public website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices & ! ,dep>tm5t ( ,labor1 respectively-- 7i7 ! numb] ( specifi$ claims fil$ dur+ su* ye>2 7ii7 ! numb] ( su* claims ) respect to :i* a f9al det]m9ation 0 made "u p>agraph 7#d77;,c77i72 & 7iii7 ! in=mation describ$ 9 subp>agraph 7,b7 ) respect to ea* specifi$ claim ) respect to :i* su* a decision 0 s made4 7,b7 ,in=mation ) respect to specifi$ claims ,= purposes ( subp>agraph 7,a71 ! in=mation describ$ 9 ?is subp>agraph is1 ) respect to a specifi$ claim ( a nonp>ticiapt+ provid]1 nonp>ticipat+ em]g5cy facility1 or heal? plan-- 7i7 a description ( ea* item & s]vice includ$ 9 su* claim2 7ii7 ! am\nt ( ! (f] submitt$ "u p>agraph 7#d77;,c77i7 by ! heal? plan & by ! nonp>ticipat+ provid] or nonp>ticipat+ em]g5cy facility 7z applicable72 7iii7 :e!r ! (f] select$ by ! c]tifi$ ,,idr entity "u su* p>agraph 0 ! (f] submitt$ by su* plan or by su* provid] or facility 7z applicable7 & ! am\nt ( su* (f] s select$2 & 7iv7 ! category & practice specialty ( ea* su* provid] or facility involv$ 9 furni%+ su* items & s]vices4 7,c7 ,confid5tiality ( p>ties ,none ( ! in=mation publi%$ "u ?is p>agraph may specify ! id5tity ( a heal? plan1 provid]1 facility1 or individual ) respect to a specifi$ claim4 4 7c7 ,provid] directory requirem5ts2 disclosure on pati5t protections ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act1 z am5d$ by subsection 7b71 is fur!r am5d$ by add+ at ! end ! foll[+ new subsections3 7g7 ,provid] directory in=mation requirem5ts 7#a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is subsection1 ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all-- 7,a7 e/abli% ! v]ification process describ$ 9 p>agraph 7#b72 7,b7 e/abli% ! response protocol describ$ 9 p>agraph 7#c72 7,c7 e/abli% ! database describ$ 9 p>agraph 7#d72 & 7,d7 include 9 any pr9t directory conta9+ provid] directory in=mation ) respect to su* plan or su* cov]age ! in=mation describ$ 9 p>agraph 7#e74 7#b7 ,v]ification process ,! v]ification process describ$ 9 ?is p>agraph is1 ) respect to a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age1 a process-- 7,a7 "u :i* n less frequ5tly ?an once e #ij days1 su* plan or su* issu] 7z applicable7 v]ifies & updates ! provid] directory in=mation includ$ on ! database describ$ 9 p>agraph 7#d7 ( su* plan or issu] ( ea* heal? c>e provid] & heal? c>e facility includ$ 9 su* database2 & 7,b7 t e/abli%es a proc$ure = ! removal ( su* a provid] or facility ) respect to :i* su* plan or issu] has be5 unable to v]ify su* in=mation dur+ a p]iod specifi$ by ! plan or issu]4 7#c7 ,response protocol ,! response protocol describ$ 9 ?is p>agraph is1 9 ! case ( an individual enroll$ "u a gr\p heal? plan or gr\p or individual heal? insurance cov]age (f]$ by a heal? insurance issu] :o reque/s in=mation on :e!r a heal? c>e provid] or heal? c>e facility has a contractual relation%ip to furni% items & s]vices "u su* plan or su* cov]age1 a protocol "u :i* su* plan or su* issu] 7z applicable71 9 ! case su* reque/ is made ?r\gh a telephone call-- 7,a7 responds to su* individual z soon z practicable & 9 no case lat] ?an #a bus9ess day aft] su* call is receiv$ ?r\gh a writt5 electronic communication2 & 7,b7 reta9s su* communication 9 su* individual's file = at lea/ #b ye>s foll[+ su* response4 7#d7 ,database ,! database describ$ 9 ?is p>agraph is1 ) respect to a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age1 a database on ! public website ( su* plan or issu] t conta9s-- 7,a7 a li/ ( ea* heal? c>e provid] & heal? c>e facility ) :i* su* plan or su* issu] has a contractual relation%ip = furni%+ items & s]vices "u su* plan or su* cov]age2 & 7,b7 provid] directory in=mation ) respect to ea* su* provid] & facility4 7#e7 ,in=mation ,! in=mation describ$ 9 ?is p>agraph is1 ) respect to a pr9t directory conta9+ provid] directory in=mation ) respect to a gr\p heal? plan or individual or gr\p heal? insurance cov]age (f]$ by a heal? insurance issu]1 a notification t su* in=mation conta9$ 9 su* directory 0 accurate z ( ! date ( publication ( su* directory & t an individual enroll$ "u su* plan or su* cov]age %\ld consult ! database describ$ 9 p>agraph 7#d7 ) respect to su* plan or su* cov]age or contact su* plan or ! issu] ( su* cov]age to obta9 ! mo/ curr5t provid] directory in=mation ) respect to su* plan or su* cov]age4 7#f7 ,def9ition ,= purposes ( ?is subsection1 ! t]m provid] directory in=mation includes1 ) respect to a gr\p heal? plan & a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age1 ! "n1 address1 specialty1 & telephone numb] ( ea* heal? c>e provid] or heal? c>e facility ) :i* su* plan or su* issu] has a contractual relation%ip = furni%+ items & s]vices "u su* plan or su* cov]age4 7h7 ,disclosure on pati5t protections ,ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all make publicly available1 & 7if applicable7 po/ on a public website ( su* plan or issu]-- 7#a7 in=mation 9 pla9 language on-- 7,a7 ! requirem5ts & prohibitions appli$ "u sections #bgii & #bgii;,a 7relat+ to prohibitions on balance bill+ 9 c]ta9 circum/ances72 7,b7 if provid$ = "u applicable ,/ate law1 any o!r requirem5ts on provid]s & facilities reg>d+ ! am\nts su* provid]s & facilities may1 ) respect to an item or s]vice1 *>ge a p>ticipant1 b5efici>y1 or enrollee ( su* plan or cov]age ) respect to :i* su* a provid] or facility does n h a contractual relation%ip = furni%+ su* item or s]vice "u ! plan or cov]age aft] receiv+ paym5t f ! plan or cov]age = su* item or s]vice & any applicable co/-%>+ paym5t f su* p>ticipant1 b5efici>y1 or enrollee2 & 7,c7 ! requirem5ts appli$ "u subsections 7b7 & 7e72 & 7#b7 in=mation on contact+ appropriate ,/ate & ,f$]al ag5cies 9 ! case t an individual believes t su* a provid] or facility has violat$ any requirem5t describ$ 9 p>agraph 7#a7 ) respect to su* individual4 4 7d7 ,prev5t+ c]ta9 cases ( balance bill+ ,title ,,xxvii ( ! ,public ,heal? ,s]vice ,act is am5d$ by add+ at ! end ! foll[+ new "p3 ,d ,prev5t+ ,c]ta9 ,cases ( ,balance ,bill+ #bgii4 ,balance bill+ 9 cases ( em]g5cy s]vices 7a7 ,9 g5]al ,9 ! case ( a p>ticipant1 b5efici>y1 or enrollee ) b5efits "u a heal? plan :o is furni%$ on or aft] ,janu>y #a1 #bjba1 em]g5cy s]vices ) respect to an em]g5cy m$ical condition dur+ a visit at an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t-- 7#a7 ! em]g5cy dep>tm5t ( a hospital or indep5d5t free/&+ em]g5cy dep>tm5t %all n hold ! p>ticipant1 b5efici>y1 or enrollee liable = a paym5t am\nt = su* em]g5cy s]vices s furni%$ t is m ?an ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii7 ( section #bgai;,a7b77#a77;,c772 & 7#b7 a heal? c>e provid] %all n hold su* p>ticipant1 b5efici>y1 or enrollee liable = a paym5t am\nt = an em]g5cy s]vice furni%$ to su* individual by su* provid] ) respect to su* em]g5cy m$ical condition & visit = :i* ! individual receives em]g5cy s]vices at ! hospital or em]g5cy dep>tm5t t is m ?an ! co/-%>+ am\nt = su* s]vices furni%$ by ! provid] 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii7 ( section #bgai;,a7b77#a77;,c774 7b7 ,def9itions ,9 ?is section3 7#a7 ,! t]ms em]g5cy dep>tm5t ( a hospital1 em]g5cy m$ical condition1 em]g5cy s]vices1 & indep5d5t free/&+ em]g5cy dep>tm5t h ! mean+s giv5 su* t]ms1 respectively1 9 section #bgai;,a7b77#c74 7#b7 ,! t]m heal? plan has ! mean+ giv5 su* t]m 9 section #bgai;,a7e74 7#c7 ,! t]m dur+ a visit %all h su* mean+ z appli$ to su* t]m = purposes ( section #bgai;,a7e74 #bgii;,a4 ,balance bill+ 9 cases ( non-em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7a7 ,9 g5]al ,subject to subsection 7b71 9 ! case ( a p>ticipant1 b5efici>y1 or enrollee ) b5efits "u a heal? plan 7z def9$ 9 section #bgii7;b77 :o is furni%$ on or aft] ,janu>y #a1 #bjba1 items or s]vices 7o!r ?an em]g5cy s]vices to :i* section #bgii applies7 at a p>ticipat+ heal? c>e facility by a nonp>ticipat+ provid]1 su* provid] %all n hold su* p>ticipant1 b5efici>y1 or enrollee liable = a paym5t am\nt = su* an item or s]vice furni%$ by su* provid] dur+ a visit at su* facility t is m ?an ! co/-%>+ am\nt = su* item or s]vice 7z det]m9$ 9 accordance ) subp>agraphs 7,a7 & 7,b7 ( section #bgai;,a7e77#a774 7b7 ,exception 7#a7 ,9 g5]al ,subsection 7a7 %all n apply to a nonp>ticipat+ provid] 7o!r ?an a specifi$ provid] at a p>ticipat+ heal? c>e facility71 ) respect to items or s]vices furni%$ by ! provid] to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan1 if ! provid] is 9 compliance ) ! notice & cons5t requirem5ts ( subsection 7d74 7#b7 ,specifi$ provid] def9$ ,= purposes ( p>agraph 7#a71 ! t]m specifi$ provid]1 ) respect to a p>ticipat+ heal? c>e facility-- 7,a7 means a facility-bas$ provid]1 includ+ em]g5cy m$ic9e provid]s1 ane/hesiologi/s1 pa?ologi/s1 radiologi/s1 neonatologi/s1 assi/ant surgeons1 hospitali/s1 int5sivi/s1 or o!r provid]s z det]m9$ by ! ,secret>y2 & 7,b7 includes1 ) respect to an item or s]vice1 a nonp>ticipat+ provid] if !re is no p>ticipat+ provid] at su* facility :o c furni% su* item or s]vice4 7c7 ,cl>ification ,9 ! case ( a nonp>ticipat+ provid] 7o!r ?an a specifi$ provid] at a p>ticipat+ heal? c>e facility7 t complies ) ! notice & cons5t requirem5ts ( subsection 7d7 ) respect to an item or s]vice 7ref]r$ to 9 ?is subsection z a cov]$ item or s]vice71 su* notice & cons5t requirem5ts may n be con/ru$ z apply+ ) respect to any item or s]vice t is furni%$ z a result ( un=ese5 m$ical ne$s t arise at ! "t su* cov]$ item or s]vice is furni%$4 7d7 ,compliance ) notice & cons5t requirem5ts 7#a7 ,9 g5]al ,a nonp>ticipat+ provid] or nonp>ticipat+ facility is 9 compliance ) ?is subsection1 ) respect to items or s]vices furni%$ by ! provid] or facility to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan1 if ! provid] 7or1 if applicable1 ! p>ticipat+ heal? c>e facility on behalf ( su* provid]7 or nonp>ticipat+ facility-- 7,a7 provides to ! p>ticipant1 b5efici>y1 or enrollee 7or to an au?oriz$ repres5tative ( ! p>ticipant1 b5efici>y1 or enrollee7 on ! date on :i* ! individual is furni%$ su* items or s]vices &1 9 ! case t ! p>ticipant1 b5efici>y1 or enrollee makes an appo9tm5t to be furni%$ su* items or s]vices1 on su* date ! appo9tm5t is made-- 7i7 an oral explanation ( ! writt5 notice describ$ 9 clause 7ii72 & 7ii7 a writt5 notice specifi$ by ! ,secret>y1 n lat] ?an ,july #a1 #bjbj1 ?r\gh guidance 7:i* %all be updat$ z det]m9$ necess>y by ! ,secret>y7 t-- 7,i7 conta9s ! in=mation requir$ "u p>agraph 7#b72 & 7,,ii7 is sign$ & dat$ by ! p>ticipant1 b5efici>y1 or enrollee 7or by an au?oriz$ repres5tative ( ! p>ticipant1 b5efici>y1 or enrollee7 &1 ) respect to items or s]vices to be furni%$ by su* a provid] t are n po//abilization s]vices describ$ 9 section #bgai;,a7b77#c77;,c77ii71 is s sign$ & dat$ n less ?an #gb h\rs prior to ! p>ticipant1 b5efici>y1 or enrollee be+ furni%$ su* items or s]vices by su* provid]2 & 7,b7 obta9s f ! p>ticipant1 b5efici>y1 or enrollee 7or f su* an au?oriz$ repres5tative7 ! cons5t describ$ 9 p>agraph 7#c74 7#b7 ,in=mation requir$ "u writt5 notice ,= purposes ( p>agraph 7#a77;,a77ii77,i71 ! in=mation describ$ 9 ?is p>agraph1 ) respect to a nonp>ticipat+ provid] or nonp>ticipat+ facility & a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan1 is ea* ( ! foll[+3 7,a7 ,notification1 z applicable1 t ! heal? c>e provid] is a nonp>ticipat+ provid] ) respect to ! heal? plan or ! heal? c>e facility is a nonp>ticipat+ facility ) respect to ! heal? plan4 7,b7 ,notification ( ! e/imat$ am\nt t su* provid] or facility may *>ge ! p>ticipant1 b5efici>y1 or enrollee = su* items & s]vices involv$4 7,c7 ,9 ! case ( a nonp>ticipat+ facility1 a li/ ( any p>ticipat+ provid]s at ! facility :o are able to furni% su* items & s]vices involv$ & notification t ! p>ticipant1 b5efici>y1 or enrollee may be ref]r$1 at _! option1 to su* a p>ticipat+ provid]4 7#c7 ,cons5t describ$ ,= purposes ( p>agraph 7#a77;,b71 ! cons5t describ$ 9 ?is p>agraph1 ) respect to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan :o is to be furni%$ items or s]vices by a nonp>ticipat+ provid] or nonp>ticipat+ facility1 is a docum5t specifi$ by ! ,secret>y ?r\gh rulemak+ t-- 7,a7 is sign$ by ! p>ticipant1 b5efici>y1 or enrollee 7or by an au?oriz$ repres5tative ( ! p>ticipant1 b5efici>y1 or enrollee7 &1 ) respect to items or s]vices to be furni%$ by su* a provid] or facility t are n po//abilization s]vices describ$ 9 section #bgai;,a7b77#c77;,c77ii71 is s sign$ n less ?an #gb h\rs prior to ! p>ticipant1 b5efici>y1 or enrollee be+ furni%$ su* items or s]vices by su* provid] or facility2 7,b7 ackn[l$ges t ! p>ticipant1 b5efici>y1 or enrollee has be5-- 7i7 provid$ ) a writt5 e/imate & an oral explanation ( ! *>ge t ! p>ticipant1 b5efici>y1 or enrollee w be assess$ = ! items or s]vices anticipat$ to be furni%$ to ! p>ticipant1 b5efici>y1 or enrollee by su* provid] or facility2 & 7ii7 in=m$ t ! paym5t ( su* *>ge by ! p>ticipant1 b5efici>y1 or enrollee may n accrue t[>d meet+ any limitation t ! heal? plan places on co/-%>+2 & 7,c7 docum5ts ! cons5t ( ! p>ticipant1 b5efici>y1 or enrollee to-- 7i7 be furni%$ ) su* items or s]vices by su* provid] or facility2 & 7ii7 9 ! case t ! individual is s furni%$ su* items or s]vices1 be *>g$ an am\nt t may be great] ?an ! am\nt t w\ld o!rwise be *>g$ ! individual if furni%$ by a p>ticipat+ provid] or p>ticipat+ facility ) respect to su* items or s]vices & plan4 7e7 ,ret5tion ( c]ta9 docum5ts ,a nonp>ticipat+ provid] 7or1 9 ! case ( a nonp>ticipat+ provid] at a p>ticipat+ heal? c>e facility1 su* facility7 or nonp>ticipat+ facility t obta9s f a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan 7or an au?oriz$ repres5tative ( su* p>ticipant1 b5efici>y1 or enrollee7 a writt5 notice 9 accordance ) subsection 7c77#a77;ii71 ) respect to furni%+ an item or s]vice to su* p>ticipant1 b5efici>y1 or enrollee1 %all reta9 su* notice = at lea/ a #b-ye> p]iod aft] ! date on :i* su* item or s]vice is s furni%$4 7f7 ,def9itions ,9 ?is section3 7#a7 ,! t]ms nonp>ticipat+ provid] & p>ticipat+ provid] h ! mean+s giv5 su* t]ms1 respectively1 9 subsection 7b77#c7 ( section #bgai;,a4 7#b7 ,! t]ms p>ticipat+ heal? c>e facility & heal? plan h ! mean+s giv5 su* t]ms1 respectively1 9 subsection 7e77#b7 ( section #bgai;,a4 7#c7 ,! t]m nonp>ticipat+ facility means-- 7,a7 ) respect to em]g5cy s]vices 7z def9$ 9 section #bgai;,a7b77#c77;,c77i77 & a heal? plan1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t does n h a contractual relation%ip ) ! plan 7or1 if applicable1 issu] (f]+ ! plan7 = furni%+ su* s]vices "u ! plan2 & 7,b7 ) respect to po//abilization s]vices describ$ 9 section #bgai;,a7b77#c77;,c77ii7 & a heal? plan1 an em]g5cy dep>tm5t ( a hospital 7or o!r dep>tm5t ( su* hospital71 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t does n h a contractual relation%ip ) ! plan 7or1 if applicable1 issu] (f]+ ! plan7 = furni%+ su* s]vices "u ! plan4 7#d7 ,! t]m p>ticipat+ facility means-- 7,a7 ) respect to em]g5cy s]vices 7z def9$ 9 section #bgai;,a7b77#c77;,c77i77 & a heal? plan1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t has a contractual relation%ip ) ! plan 7or1 if applicable1 issu] (f]+ ! plan7 = furni%+ su* s]vices "u ! plan2 & 7,b7 ) respect to po//abilization s]vices describ$ 9 section #bgai;,a7b77#c77;,c77ii7 & a heal? plan1 an em]g5cy dep>tm5t ( a hospital 7or o!r dep>tm5t ( su* hospital71 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t has a contractual relation%ip ) ! plan 7or1 if applicable1 issu] (f]+ ! plan7 = furni%+ su* s]vices "u ! plan4 #bgii;,b4 ,provid] requirem5ts ) respect to provid] directory in=mation ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is section1 ea* heal? c>e provid] & heal? c>e facility %all e/abli% a process "u :i* su* provid] or facility transmits1 to ea* heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age & gr\p heal? plan ) :i* su* provid] or facility has 9 effect a contractual relation%ip = furni%+ items & s]vices "u su* cov]age or su* plan1 provid] directory in=mation 7z def9$ 9 section #bgai;,a7g77#f77 ) respect to su* provid] or facility1 z applicable4 ,su* provid] or facility %all s transmit su* in=mation to su* issu] (f]+ su* cov]age or su* gr\p heal? plan-- 7#a7 :5 ! provid] or facility ent]s into su* a relation%ip ) respect to su* cov]age (f]$ by su* issu] or ) respect to su* plan2 7#b7 :5 ! provid] or facility t]m9ates su* relation%ip ) respect to su* cov]age (f]$ by su* issu] or ) respect to su* plan2 7#c7 :5 !re are any o!r mat]ial *anges to su* provid] directory in=mation ( ! provid] or facility ) respect to su* cov]age (f]$ by su* issu] or ) respect to su* plan2 & 7#d7 at any o!r "t 7includ+ ^u ! reque/ ( su* issu] or plan7 det]m9$ appropriate by ! provid]1 facility1 or ! ,secret>y4 #bgii;,c4 ,provid] requirem5t ) respect to public provision ( in=mation ,ea* heal? c>e provid] & heal? c>e facility %all make publicly available1 & 7if applicable7 po/ on a public website ( su* provid] or facility-- 7#a7 in=mation 9 pla9 language on-- 7,a7 ! requirem5ts & prohibitions ( su* provid] or facility "u sections #bgii & #bgii;,a 7relat+ to prohibitions on balance bill+ 9 c]ta9 circum/ances72 & 7,b7 if provid$ = "u applicable ,/ate law1 any o!r requirem5ts on su* provid] or facility reg>d+ ! am\nts su* provid] or facility may1 ) respect to an item or s]vice1 *>ge a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan 7z def9$ 9 section #bgai;,a7e77#b77 ) respect to :i* su* provid] or facility does n h a contractual relation%ip = furni%+ su* item or s]vice "u ! plan aft] receiv+ paym5t f ! plan = su* item or s]vice & any applicable co/-%>+ paym5t f su* p>ticipant1 b5efici>y1 or enrollee2 & 7#b7 in=mation on contact+ appropriate ,/ate & ,f$]al ag5cies 9 ! case t an individual believes t su* provid] or facility has violat$ any requirem5t describ$ 9 p>agraph 7#a7 ) respect to su* individual4 #bgii;,d4 ,en=cem5t 7a7 ,/ate en=cem5t 7#a7 ,/ate au?ority ,ea* ,/ate may require a provid] or heal? c>e facility subject to ! requirem5ts ( sections #bgai;,a7f71 #bgii1 #bgii;,a1 #bgii;,b1 or #bgii;,c to satisfy su* requirem5ts applicable to ! provid] or facility4 7#b7 ,failure to implem5t requirem5ts ,9 ! case ( a det]m9ation by ! ,secret>y t a ,/ate has fail$ to sub/antially en=ce ! requirem5ts specifi$ 9 p>agraph 7#a7 ) respect to applicable provid]s & facilities 9 ! ,/ate1 ! ,secret>y %all en=ce su* requirem5ts "u subsection 7b7 ins(> z !y relate to violations ( su* requirem5ts occurr+ 9 su* ,/ate4 7b7 ,secret>ial en=cem5t au?ority 7#a7 ,9 g5]al ,if a provid] or facility is f\nd to be 9 violation specifi$ 9 subsection 7a77#a7 by ! ,secret>y1 ! ,secret>y may apply a civil monet>y p5alty ) respect to su* provid] or facility 9 an am\nt n to exce$ #aj1jjj p] violation4 ,! provisions ( subsections 7c71 7d71 7e71 7g71 7h71 7k71 & 7l7 ( section #aabh;,a ( ! ,social ,security ,act %all apply to a civil monet>y p5alty or assessm5t "u ?is subsection 9 ! same mann] z su* provisions apply to a p5alty1 assessm5t1 or proce$+ "u subsection 7a7 ( su* section4 7#b7 ,limitation ,! provisions ( p>agraph 7#a7 %all apply to en=cem5t ( a provision 7or provisions7 specifi$ 9 subsection 7a77#a7 only z provid$ "u subsection 7a77#b74 7#c7 ,compla9t process ,! ,secret>y %all1 ?r\gh rulemak+1 e/abli% a process to receive consum] compla9ts ( violations ( su* provisions & resolve su* compla9ts )9 #fj days ( receipt ( su* compla9ts4 7#d7 ,exception ,! ,secret>y %all waive ! p5alties describ$ "u p>agraph 7#a7 ) respect to a facility or provid] :o does n kn[+ly violate1 & %\ld n h reasonably kn[n x violat$1 section #bgii or #bgii;,a ) respect to a p>ticipant1 b5efici>y1 or enrollee1 if su* facility or practition]1 )9 #cj days ( ! violation1 )draws ! bill t 0 9 violation ( su* provision & reimburses ! heal? plan or enrollee1 z applicable1 9 an am\nt equal to ! diff]5ce betwe5 ! am\nt bill$ & ! am\nt all[$ to be bill$ "u ! provision1 plus int]e/1 at an int]e/ rate det]m9$ by ! ,secret>y4 7#e7 ,h>d%ip exemption ,! ,secret>y may e/abli% a h>d%ip exemption to ! p5alties "u ?is subsection4 7c7 ,cont9u$ ,applicability ( ,/ate ,law ,! sections specifi$ 9 subsection 7a77#a7 %all n be con/ru$ to sup]s$e any provision ( ,/ate law :i* e/abli%es1 implem5ts1 or cont9ues 9 effect any requirem5t or prohibition except to ! ext5t t su* requirem5t or prohibition prev5ts ! application ( a requirem5t or prohibition ( su* a section4 4 7e7 ,rulemak+ = m$ian contract$ rates ,n lat] ?an ,july #a1 #bjbj1 ! ,secret>y ( ,heal? & ,human ,s]vices1 jo9tly ) ! ,secret>y ( ,labor1 %all e/abli% ?r\gh rulemak+-- 7#a7 ! me?odology ! sponsor or issu] ( a heal? plan 7z def9$ 9 subsection 7e7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 z add$ by subsection 7b7 ( ?is section7 %all use to det]m9e ! m$ian contract$ rate 7z def9$ 9 section #bgai;,a7b7 ( su* ,act1 z am5d$ by subsection 7a7 ( ?is section71 diff]5tiat+ by bus9ess l9e2 7#b7 ! in=mation su* sponsor or issu] %all %>e ) ! nonp>ticipat+ provid] 7z def9$ 9 su* section7 involv$ :5 mak+ su* a det]m9ation2 & 7#c7 ! geographic regions appli$ = purposes ( subp>agraph 7,e7 ( section #bgai;,a7b77#c71 z am5d$ by subsection 7a7 ( ?is section1 tak+ into acc\nt ! ne$s ( rural & und]s]v$ areas1 includ+ heal? pr(essional %ortage areas4 ,su* rulemak+ %all take into acc\nt paym5ts t are made by su* sponsor or issu] t are n on a fee-=-s]vice basis4 ,su* me?odology may acc\nt = relevant paym5t adju/m5ts t take into acc\nt facility type 7includ+ high] acuity sett+s & ! case-mix ( v>i\s facility types7 t are o!rwise tak5 into acc\nt = purposes ( det]m9+ paym5t am\nts ) respect to p>ticipat+ facilities4 7f7 ,effective date ,! am5dm5ts made by subsections 7a7 & 7b7 %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjba4 #djc4 ,gov]nm5t ,acc\ntability ,(fice /udy on pr(it- & rev5ue-%>+ 9 heal? c>e 7a7 ,/udy ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a /udy to-- 7#a7 describe :at is kn[n ab\t pr(it- & rev5ue-%>+ relation%ips 9 ! comm]cial heal? c>e m>kets1 includ+ ^? relation%ips t-- 7,a7 involve "o or m-- 7i7 physician gr\ps t practice )9 a hospital includ$ 9 ! pr(it- or rev5ue-%>+ relation%ip1 or ref] pati5ts to su* hospital2 7ii7 laboratory1 radiology1 or ph>macy s]vices t are deliv]$ to privately insur$ pati5ts ( su* hospital2 7iii7 surgical s]vices2 7iv7 hospitals or gr\p pur*as+ organizations2 or 7v7 rehabilitation or physical !rapy facilities or s]vices2 & 7,b7 include rev5ue- or pr(it-%>+ :e!r ?r\gh a jo9t v5ture1 managem5t or pr(essional s]vices agreem5t1 or o!r =m ( ga9-%>+ contract2 7#b7 describe ,f$]al ov]sight ( su* relation%ips1 includ+ au?orities ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices & ! ,f$]al ,trade ,commission to review su* relation%ips & _! pot5tial to increase co/s = pati5ts1 & id5tify limitations 9 su* ov]sight2 & 7#c7 z appropriate1 make recomm5dations to improve ,f$]al ov]sight ( su* relation%ips4 7b7 ,report ,n lat] ?an #b ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all prep>e & submit a report on ! /udy conduct$ "u subsection 7a7 to ! ,committee on ,heal?1 ,education1 ,labor1 & ,p5sions ( ! ,s5ate & ! ,committee on ,education & ,labor & ,committee on ,en]gy & ,comm]ce ( ! ,h\se ( ,repres5tatives4 #djd4 ,/ate ,all ,pay] ,claims ,databases 7a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices %all make "o-"t grants to eligible ,/ates = ! purposes describ$ 9 subsection 7b74 7b7 ,uses ,a ,/ate may use a grant receiv$ "u subsection 7a7 = "o ( ! foll[+ purposes3 7#a7 ,to e/abli% an ,all ,pay] ,claims ,database = ! ,/ate4 7#b7 ,to ma9ta9 an exi/+ ,all ,pay] ,claims ,databases = ! ,/ate4 7c7 ,eligibility ,to be eligible to receive a grant "u subsection 7a71 a ,/ate %all submit to ! ,secret>y an application at su* "t1 9 su* mann]1 & conta9+ su* in=mation z ! ,secret>y specifies4 ,su* in=mation %all include1 ) respect to an ,all ,pay] ,claims ,database = ! ,/ate1 at lea/ specifics on h[ ! ,/ate w ensure uni=m data collection ?r\gh ! database & ! security ( su* data submitt$ to & ma9ta9$ 9 ! database4 7d7 ,all ,pay] ,claims ,database ,= purposes ( ?is section1 ! t]m ,all ,pay] ,claims ,database means1 ) respect to a ,/ate1 a ,/ate database t may include m$ical claims1 ph>macy claims1 d5tal claims1 & eligibility & provid] files1 :i* are collect$ f private & public pay]s4 7e7 ,au?orization ( appropriations ,to c>ry out ?is section1 !re are au?oriz$ to be appropriat$ #ej1jjj1jjj1 to rema9 available until exp5d$4 #dje4 ,air ambulance co/ data report+ program 7a7 ,co/ data report+ program 7#a7 ,9 g5]al ,n lat] ?an #f mon?s aft] ! date ( ! promulgation ( ! rule "u subsection 7c71 & annually !reaft]1 a provid] ( em]g5cy air m$ical s]vices %all submit to ! ,secret>y ( ,heal? & ,human ,s]vices ! in=mation specifi$ 9 subsection 7b7 ) respect to ! prec$+ #ahj-;day p]iod 79 ! case ( ! initial p]iod7 & ! prec$+ #a-ye> p]iod 79 ea* subsequ5t p]iod74 7#b7 ,publication ,n lat] ?an #ahj days aft] ! date ! ,secret>y ( ,heal? & ,human ,s]vices receives f a provid] describ$ 9 p>agraph 7#a7 ! in=mation specifi$ 9 subsection 7b71 ! ,secret>y %all make publicly available su* in=mation4 7b7 ,specifi$ in=mation ,in=mation describ$ 9 subsection 7a7 is-- 7#a7 in=mation1 ) respect to a claim = an item or s]vice-- 7,a7 id5tifi$ z paid by heal? insurance cov]age (f]$ 9 ! gr\p or individual m>ket or a gr\p heal? plan 7includ+ a self-insur$ plan72 7,b7 id5tifi$ z paid = non-em]g5t transport requir+ prior au?orization & em]g5t transport2 7,c7 id5tifi$ z paid = hospital-affiliat$ provid]s & indep5d5t provid]s2 7,d7 id5tifi$ z paid = rural transport & urban transport2 7,e7 id5tifi$ z provid$ us+ rotor transport & fix$ w+ transport2 & 7,f7 id5tifi$ z furni%$ by a provid] ( em]g5cy air m$ical s]vices t has a contractual relation%ip ) ! plan or cov]age ( an individual = :i* su* item or s]vice is provid$ & su* a provid] t does n h a contractual relation%ip ) ! plan or cov]age or su* an individual2 & 7#b7 co/ data = an air ambulance s]vice furni%$ by su* a provid] ( em]g5cy air m$ical s]vices t ! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) suppli]s & provid]s ( su* s]vices1 det]m9es appropriate1 sep>at$ by ! co/ ( air travel & ! co/ ( em]g5cy m$ical s]vices & supplies4 7c7 ,rulemak+ ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all det]m9e ! =m & mann] = submitt+ ! in=mation describ$ 9 subsection 7b7 ?r\gh notice & comm5t rulemak+4 7d7 ,civil monet>y p5alties 7#a7 ,9 g5]al ,a provid] ( em]g5cy air m$ical s]vices :o violates ! requirem5ts ( subsection 7a77#a7 %all be subject to a civil monet>y p5alty ( n m ?an #aj1jjj = ea* act con/itut+ su* violation4 7#b7 ,proc$ure ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a71 o!r ?an subsections 7a7 & 7b7 & ! fir/ s5t5ce ( subsection 7c77#a7 ( su* subsection1 %all apply to civil monet>y p5alties "u ?is subsection 9 ! same mann] z su* provisions apply to a p5alty or proce$+ "u su* section4 7e7 ,report+ 7#a7 ,secret>y ( ,heal? & ,human ,s]vices ,n lat] ?an ,july #a1 #bjbc1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit to ,congress a report summ>iz+ ! in=mation & data specifi$ 9 subsection 7b74 7#b7 ,comptroll] ,g5]al ,n lat] ?an ,july #a1 #bjbc1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report t includes-- 7,a7 an analysis ( ! co/ v>iation ( provid]s ( em]g5cy air ambulance s]vices by geography & /atus2 & 7,b7 any o!r recomm5dations ! ,comptroll] ,g5]al det]m9es appropriate1 :i* may include a recomm5dation ( an adequate am\nt ( reimbursem5t = su* s]vices t reflects op]ational co/s ( su* provid]s 9 ord] to pres]ve access to em]g5cy air ambulance s]vices4 7f7 ,limitation ,! in=mation publicly disclos$ "u subsection 7a7 & ! reports "u subsection 7f7 may n conta9 any propriet>y in=mation4 #djf4 ,report by ,secret>y ( ,labor ,n lat] ?an "o ye> aft] ! date ( ! enactm5t ( ?is ,act1 & annually !reaft] = ea* ( ! foll[+ #e ye>s1 ! ,secret>y ( ,labor %all-- 7#a7 conduct a /udy (-- 7,a7 ! effects ( ! provisions (1 includ+ am5dm5ts made by1 ?is ,act on premiums & out-(-pocket co/s 9 gr\p heal? plans1 includ+ out-(-pocket co/s t are p]mitt$ by reason ( compliance ) section #bgii;,a7d7 ( ! ,public ,heal? ,s]vice ,act1 z add$ by section #b7;d72 7,b7 ! adequacy ( provid] networks 9 gr\p heal? plans2 & 7,c7 su* o!r effects ( su* provisions1 & am5dm5ts1 z ! ,secret>y deems relevant2 & 7#b7 submit a report on su* /udy to ! ,committee on ,heal?1 ,education1 ,labor1 & ,p5sions ( ! ,s5ate & ! ,committee on ,education & ,labor & ! ,committee on ,en]gy & ,comm]ce ( ! ,h\se ( ,repres5tatives4 #djg4 ,bill+ /atute ( limitations ,not)/&+ any o!r provision ( law1 a heal? c>e provid] or heal? c>e facility 7or heal? insurance issu] (f]+ heal? insurance cov]age or gr\p heal? plan7 may n initiate a process to seek reimbursem5t f an individual = a s]vice furni%$ by su* provid] or facility to su* individual m ?an a ye> aft] su* date ( s]vice4 ,any provid]1 facility1 issu]1 or plan t bills an individual 9 violation ( ! previ\s s5t5ce %all be subject to a civil monet>y p5alty 9 su* am\nt z specifi$ by ! ,secret>y ( ,heal? & ,human ,s]vices4 #djh4 ,,gao report on impact ( surprise bill+ provisions ,n lat] ?an #c ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report conta9+ ! foll[+3 7#a7 ,:at is kn[n ab\t ! impacts ( ! provisions ( ?is ,act1 includ+ ! am5dm5ts made by ?is ,act1 on ! incid5ce & preval5ce ( ! furni%+ ( items & s]vices to individuals enroll$ "u a gr\p heal? plan or heal? insurance cov]age by heal? c>e provid]s & heal? c>e facilities t d n h a contractual relation%ip ) su* plan or su* cov]age 7z applicable7 = furni%+ su* items & s]vices to su* an individual4 7#b7 ,:at is kn[n ab\t su* impacts on provid] %ortages & accessibility to su* provid]s1 focus+ on rural & m$ically und]s]v$ communities4 7#c7 ,! numb] ( grants t h be5 aw>d$ "u section #djd 7relat+ to ,/ate ,all ,pay] ,claims ,databases7 & = :at purposes ,/ates h us$ funds made available "u su* grants4 7#d7 ,an analysis ( h[ data made available ?r\gh ,/ate ,all ,pay] ,claims ,databases receiv+ fund+ "u su* grants has be5 us$4 #dji4 ,report by ! ,secret>y ( ,heal? & ,human ,s]vices ,n lat] ?an "o ye> aft] ! date ( ! enactm5t ( ?is ,act1 & annually !reaft] = ea* ( ! foll[+ #e ye>s1 ! ,secret>y ( ,heal? & ,human ,s]vices %all-- 7#a7 conduct a /udy (-- 7,a7 ! effects ( ! provisions (1 includ+ am5dm5ts made by1 ?is ,act on premiums & out-(-pocket co/s ) respect to individual heal? insurance cov]age & small gr\p heal? plans2 7,b7 ! adequacy ( provid] networks ) respect to individual heal? insurance cov]age & small gr\p heal? plans1 tak+ into consid]ation maximum travel "t & di/ance2 & 7,c7 su* o!r effects ( su* provisions1 & am5dm5ts1 z ! ,secret>y deems relevant2 & 7#b7 submit a report on su* /udy to ! ,committee on ,heal?1 ,education1 ,labor1 & ,p5sions ( ! ,s5ate & ! ,committee on ,education & ,labor & ! ,committee on ,en]gy & ,comm]ce ( ! ,h\se ( ,repres5tatives4 ,v ,t]ritories ,heal? ,c>e ,improvem5t ,act #eja4 ,%ort title ,?is title may be cit$ z ! ,t]ritories ,heal? ,c>e ,improvem5t ,act4 #ejb4 ,m$icaid paym5ts = ,pu]to ,rico & ! o!r t]ritories = c]ta9 fiscal ye>s 7a7 ,treatm5t ( cap ,section #aajh7;g7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acjh7;g77 is am5d$-- 7#a7 9 p>agraph 7#b7-- 7,a7 9 ! matt] prec$+ subp>agraph 7,a71 by /rik+ subject to & section #acbc7;a77#b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act p>agraphs 7#c7 & 7#e7 & ins]t+ subject to section #acbc7;a77#b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act & p>agraphs 7#c7 & 7#e72 7,b7 9 subp>agraph 7,a7-- 7i7 by /rik+ ,pu]to ,rico %all n exce$ ! sum ( & ins]t+ ,pu]to ,rico %all n exce$-- 7i7 except z provid$ 9 clause 7ii71 ! sum ( 2 7ii7 by /rik+ #ajj1jjj2 & ins]t+ #ajj1jjj2 &2 & 7iii7 by add+ at ! end ! foll[+ new clause3 7ii7 = ea* ( fiscal ye>s #bjbj ?r\gh #bjbc1 ! am\nt specifi$ 9 p>agraph 7#f7 = ea* su* fiscal ye>2 2 7,c7 9 subp>agraph 7,b7-- 7i7 by /rik+ ! ,virg9 ,isl&s %all n exce$ ! sum ( & ins]t+ ! ,virg9 ,isl&s %all n exce$-- 7i7 except z provid$ 9 clause 7ii71 ! sum ( 2 7ii7 by /rik+ #aj1jjj2 & ins]t+ #aj1jjj2 &2 & 7iii7 by add+ at ! end ! foll[+ new clause3 7ii7 = ea* ( fiscal ye>s #bjbj ?r\gh #bjbe1 #abf1jjj1jjj2 2 7,d7 9 subp>agraph 7,c7-- 7i7 by /rik+ ,guam %all n exce$ ! sum ( & ins]t+ ,guam %all n exce$-- 7i7 except z provid$ 9 clause 7ii71 ! sum ( 2 7ii7 by /rik+ #aj1jjj2 & ins]t+ #aj1jjj2 &2 & 7iii7 by add+ at ! end ! foll[+ new clause3 7ii7 = ea* ( fiscal ye>s #bjbj ?r\gh #bjbe1 #abg1jjj1jjj2 2 7,e7 9 subp>agraph 7,d7-- 7i7 by /rik+ ! ,nor!rn ,m>iana ,isl&s %all n exce$ ! sum ( & ins]t+ ! ,nor!rn ,m>iana ,isl&s %all n exce$-- 7i7 except z provid$ 9 clause 7ii71 ! sum ( 2 & 7ii7 by add+ at ! end ! foll[+ new clause3 7ii7 = ea* ( fiscal ye>s #bjbj ?r\gh #bjbe1 #fj1jjj1jjj2 & 2 & 7,f7 9 subp>agraph 7,e7-- 7i7 by /rik+ ,am]ican ,samoa %all n exce$ ! sum ( & ins]t+ ,am]ican ,samoa %all n exce$-- 7i7 except z provid$ 9 clause 7ii71 ! sum ( 2 7ii7 by /rik+ #aj1jjj4 & ins]t+ #aj1jjj2 &2 & 7iii7 by add+ at ! end ! foll[+ new clause3 7ii7 = ea* ( fiscal ye>s #bjbj ?r\gh #bjbe1 #hd1jjj1jjj4 2 & 7#b7 by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,application to ,pu]to ,rico = fiscal ye>s #bjbj ?r\gh #bjbc ,= purposes ( p>agraph 7#b77;,a77ii71 ! am\nt specifi$ 9 ?is p>agraph is-- 7,a7 = fiscal ye> #bjbj1 #b1hbc1ahh1jjj2 7,b7 = fiscal ye> #bjba1 #b1iai1jgb1jjj2 7,c7 = fiscal ye> #bjbb1 #c1jab1faj1jjj2 & 7,d7 = fiscal ye> #bjbc1 #c1aad1cca1jjj4 4 7b7 ,treatm5t ( fund+ "u enhanc$ allotm5t program ,section #aice7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#e7;e77 is am5d$-- 7#a7 9 p>agraph 7#a77;,b71 by /rik+ if ! ,/ate & ins]t+ subject to p>agraph 7#d71 if ! ,/ate2 7#b7 by r$esignat+ p>agraph 7#d7 z p>agraph 7#e72 & 7#c7 by ins]t+ aft] p>agraph 7#c7 ! foll[+ new p>agraph3 7#d7 ,treatm5t ( fund+ = c]ta9 fiscal ye>s 7,a7 ,pu]to ,rico ,not)/&+ p>agraph 7#a77;,b71 9 ! case t ,pu]to ,rico e/abli%es & submits to ! ,secret>y a plan describ$ 9 p>agraph 7#b7 ) respect to any ( fiscal ye>s #bjbj ?r\gh #bjbc1 ! am\nt specifi$ 9 p>agraph 7#c7 = ,pu]to ,rico = su* a ye> %all be tak5 into acc\nt 9 apply+ subp>agraph 7,a77ii7 ( section #aajh7;g77#b7 = su* ye>4 7,b7 ,o!r t]ritories ,not)/&+ p>agraph 7#a77;,b71 9 ! case t ! ,virg9 ,isl&s1 ,guam1 ! ,nor!rn ,m>iana ,isl&s1 or ,am]ican ,samoa e/abli%es & submits to ! ,secret>y a plan describ$ 9 p>agraph 7#b7 ) respect to any ( fiscal ye>s #bjbj ?r\gh #bjbe1 ! am\nt specifi$ 9 p>agraph 7#c7 = ! ,virg9 ,isl&s1 ,guam1 ! ,nor!rn ,m>iana ,isl&s1 or ,am]ican ,samoa1 z ! case may be1 %all be tak5 into acc\nt 9 apply+1 z applicable1 subp>agraph 7,b77ii71 7,c77ii71 7,d77ii71 or 7,e77ii7 ( section #aajh7;g77#b7 = su* ye>4 4 7c7 ,increas$ ,,fmap ,section #aije ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7b77 is am5d$-- 7#a7 9 subsection 7b71 by /rik+ & 7aa7 & ins]t+ 7aa71 & 7ff72 & 7#b7 by add+ at ! end ! foll[+ new subsection3 7ff7 ,tempor>y increase 9 ,,fmap = t]ritories = c]ta9 fiscal ye>s 7#a7 ,pu]to ,rico ,not)/&+ subsection 7b7 & subject to subsection 7z77#b71 ! ,f$]al m$ical assi/ance p]c5tage = ,pu]to ,rico %all be equal to-- 7,a7 #hc p]c5t = fiscal ye>s #bjbj & #bjba2 & 7,b7 #gf p]c5t = fiscal ye>s #bjbb & #bjbc4 7#b7 ,virg9 ,isl&s ,not)/&+ subsection 7b7 & subject to subsection 7z77#b71 ! ,f$]al m$ical assi/ance p]c5tage = ! ,virg9 ,isl&s %all be equal to-- 7,a7 #ajj p]c5t = fiscal ye> #bjbj2 7,b7 #hc p]c5t = fiscal ye>s #bjba ?r\gh #bjbd2 & 7,c7 #gf p]c5t = fiscal ye> #bjbe4 7#c7 ,o!r t]ritories ,not)/&+ subsection 7b7 & subject to subsection 7z77#b71 ! ,f$]al m$ical assi/ance p]c5tage = ,guam1 ! ,nor!rn ,m>iana ,isl&s1 & ,am]ican ,samoa %all be equal to-- 7,a7 #ajj p]c5t = fiscal ye>s #bjbj & #bjba2 7,b7 #hc p]c5t = fiscal ye>s #bjbb ?r\gh #bjbd2 & 7,c7 #gf p]c5t = fiscal ye> #bjbe4 4 7d7 ,annual report ,section #aajh7;g7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acjh7;g771 z am5d$ by subsection 7a71 is fur!r am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#g7 ,annual report 7,a7 ,9 g5]al ,n lat] ?an ! date t is #ahj days aft] ! end ( ea* fiscal ye> 7beg9n+ ) fiscal ye> #bjbj & end+ ) fiscal ye> #bjbe71 9 ! case t a specifi$ t]ritory receives a ,m$icaid cap increase1 or an increase 9 ! ,f$]al m$ical assi/ance p]c5tage = su* t]ritory "u section #aije7;ff71 = su* fiscal ye>1 su* t]ritory %all submit to ! ,*air & ,rank+ ,memb] ( ! ,committee on ,en]gy & ,comm]ce ( ! ,h\se ( ,repres5tatives & ! ,*air & ,rank+ ,memb] ( ! ,committee on ,f9ance ( ! ,s5ate a report t describes h[ su* t]ritory has us$ su* ,m$icaid cap increase1 or su* increase 9 ! ,f$]al m$ical assi/ance p]c5tage1 z applicable1 to increase access to heal? c>e "u ! ,/ate ,m$icaid plan ( su* t]ritory "u title ,,xix 7or a waiv] ( su* plan74 ,su* report may include-- 7i7 ! ext5t to :i* su* t]ritory has1 ) respect to su* plan 7or waiv]7-- 7,i7 increas$ paym5ts to heal? c>e provid]s2 7,,ii7 increas$ cov]$ b5efits2 7,,iii7 exp&$ heal? c>e provid] networks2 or 7,,iv7 improv$ 9 any o!r mann] ! c>ry+ out ( su* plan 7or waiv]72 & 7ii7 any o!r in=mation z det]m9$ necess>y by su* t]ritory4 7,b7 ,def9itions ,9 ?is p>agraph3 7i7 ,m$icaid cap increase ,! t]m ,m$icaid cap increase means1 ) respect to a specifi$ t]ritory & fiscal ye>1 any increase 9 ! am\nts o!rwise det]m9$ "u ?is subsection = su* t]ritory = su* fiscal ye> by reason ( ! am5dm5ts made by section #ejb7;a7 ( ! ,t]ritories ,heal? ,c>e ,improvem5t ,act4 7ii7 ,specifi$ t]ritory ,! t]m specifi$ t]ritory means ,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1 ! ,nor!rn ,m>iana ,isl&s1 & ,am]ican ,samoa4 4 #ejc4 ,application ( c]ta9 requirem5ts "u ,m$icaid program to c]ta9 t]ritories 7a7 ,application ( paym5t error rate measurem5t requirem5ts to ,pu]to ,rico ,section #aijc7u77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7u77#d77 is am5d$-- 7#a7 by /rik+ to ,pu]to ,rico1 ,guam & ins]t+ to ,guam2 & 7#b7 by /rik+ or ,am]ican ,samoa4 & ins]t+ or ,am]ican ,samoa1 or1 = fiscal ye>s be=e fiscal ye> #bjbc1 to ,pu]to ,rico44 7b7 ,application ( asset v]ification program requirem5ts to ,pu]to ,rico & ,virg9 ,isl&s ,section #aidj7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifw7a77 is am5d$-- 7#a7 9 p>agraph 7#c77;,a71 by add+ at ! end ! foll[+ new clause3 7iii7 ,implem5tation 9 ,pu]to ,rico & ,virg9 ,isl&s ,! ,secret>y %all require ,pu]to ,rico to implem5t an asset v]ification program "u ?is subsection by ! end ( fiscal ye> #bjbb & ! ,virg9 ,isl&s to implem5t su* a program by ! end ( fiscal ye> #bjbc4 2 & 7#b7 9 p>agraph 7#d7-- 7,a7 9 ! p>agraph head+1 by /rik+ ,exemption ( t]ritories & ins]t+ ,exemption ( c]ta9 t]ritories2 & 7,b7 by /rik+ & ! ,di/rict ( ,columbia & ins]t+ 1 ! ,di/rict ( ,columbia1 ,pu]to ,rico1 & ! ,virg9 ,isl&s4 7c7 ,application ( c]ta9 data report+ & program integrity requirem5ts to ,nor!rn ,m>iana ,isl&s1 ,am]ican ,samoa1 & ,guam 7#a7 ,9 g5]al ,section #aijb ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7qq7 ,application ( c]ta9 data report+ & program integrity requirem5ts to ,nor!rn ,m>iana ,isl&s1 ,am]ican ,samoa1 & ,guam ,n lat] ?an ,octob] #a1 #bjbc1 ! ,nor!rn ,m>iana ,isl&s1 ,am]ican ,samoa1 & ,guam %all-- 7#a7 implem5t me?ods1 satisfactory to ! ,secret>y1 = ! collection & report+ ( reliable data to ! ,trans=m$ ,m$icaid ,/ati/ical ,in=mation ,sy/em 7,t-,,msis7 7or a successor sy/em72 & 7#b7 demon/rate progress 9 e/abli%+ a ,/ate m$icaid fraud control unit describ$ 9 section #aijc7q74 4 7#b7 ,con=m+ am5dm5t ,section #aijb7;j7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7j77 is am5d$-- 7,a7 by /rik+ or ! requirem5t & ins]t+ 1 ! requirem5t2 & 7,b7 by ins]t+ be=e ! p]iod at ! end ! foll[+3 1 or ! requirem5t "u subsection 7qq77#a7 7relat+ to data report+74 #ejd4 ,additional program integrity requirem5ts 7a7 ,audit relat+ to fraud1 wa/e1 & abuse ,n soon] ?an ! date t is "o ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices 7ref]r$ to 9 ?is section z ! ,inspector ,g5]al7 %all conduct an audit ( ,pu]to ,rico ) respect to any "p ( ! adm9i/ration ( ,pu]to ,rico's ,/ate plan "u title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 7or a waiv] ( su* plan71 su* z contract+ protocols1 d5ials ( c>e1 & f9ancial managem5t1 t ! ,inspector ,g5]al det]m9es to be at high risk = wa/e1 fraud1 or abuse4 7b7 ,plan = audits & inve/igations ( contract+ practices ,n lat] ?an ! date t is "o ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,inspector ,g5]al %all develop & submit to ,congress a plan = audit+ & inve/igat+ contract+ practices relat+ to ,pu]to ,rico's ,/ate plan "u title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 7or a waiv] ( su* plan74 7c7 ,report on contract+ ov]sight & approval ,n lat] ?an ! date t is two ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all issue1 & submit to ! ,*air & ,rank+ ,memb] ( ! ,committee on ,en]gy & ,comm]ce ( ! ,h\se ( ,repres5tatives & ! ,*air & ,rank+ ,memb] ( ! ,committee on ,f9ance ( ! ,s5ate1 a report on contract+ ov]sight & approval ) respect to ,pu]to ,rico's ,/ate plan "u title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 7or a waiv] ( su* plan74 ,su* report %all-- 7#a7 exam9e-- 7,a7 ! process us$ by ,pu]to ,rico to evaluate bids & aw>d contracts "u su* plan 7or waiv]72 7,b7 :i* contracts are n subject to competitive bidd+ or reque/s = proposals "u su* plan 7or waiv]72 & 7,c7 ov]sight by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices ( contracts aw>d$ "u su* plan 7or waiv]72 & 7#b7 include any recomm5dations = ,congress1 ! ,secret>y ( ,heal? & ,human ,s]vices1 or ,pu]to ,rico relat+ to *anges t ! ,inspector ,g5]al det]m9es necess>y to improve ! program integrity ( su* plan 7or waiv]74 7d7 ,reevaluation ( waiv]s ( ,m$icaid fraud control unit requirem5t ,n lat] ?an ! date t is "o ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all-- 7#a7 reevaluate any waiv] approv$ 7& 9 effect z ( ! date ( ! enactm5t ( ?is ,act7 = ,guam1 ! ,nor!rn ,m>iana ,isl&s1 or ,am]ican ,samoa "u subsection 7a77#fa7 or subsection 7j7 ( section #aijb ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7 ) respect to ! requirem5t to e/abli% a ,/ate m$icaid fraud control unit 7z describ$ 9 section #aijc7q7 ( su* ,act 7#db ,u4,s4,c4 #acif;b7q772 & 7#b7 det]m9e :e!r any su* waiv] %\ld cont9ue to be approv$ ) respect to ,guam1 ! ,nor!rn ,m>iana ,isl&s1 or ,am]ican ,samoa1 respectively1 aft] ,octob] #a1 #bjbc4 7e7 ,sy/em = track+ ,f$]al fund+ provid$ to ,pu]to ,rico ,section #aijb ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a71 z am5d$ by section #ejc7;c71 is fur!r am5d$ by add+ at ! end ! foll[+ new subsection3 7rr7 ,program integrity requirem5ts = ,pu]to ,rico 7#a7 ,sy/em = track+ ,f$]al fund+ provid$ to ,pu]to ,rico 7,a7 ,9 g5]al ,pu]to ,rico %all e/abli% & ma9ta9 a sy/em = track+ any am\nts paid by ! ,f$]al ,gov]nm5t to ,pu]to ,rico ) respect to ! ,/ate plan ( ,pu]to ,rico 7or a waiv] ( su* plan74 ,"u su* sy/em1 ,pu]to ,rico %all ensure t in=mation is available1 ) respect to ea* qu>t] 9 a fiscal ye> 7beg9n+ ) ! fir/ qu>t] beg9n+ on or aft] ! date t is "o ye> aft] ! date ( ! enactm5t ( ?is subsection71 on ! foll[+3 7i7 ,9 ! case ( a qu>t] o!r ?an ! fir/ qu>t] ( su* fiscal ye>-- 7,i7 ! total am\nt exp5d$ by ,pu]to ,rico dur+ any previ\s qu>t] ( su* fiscal ye> "u ! ,/ate plan ( ,pu]to ,rico 7or a waiv] ( su* plan72 & 7,,ii7 a description ( h[ su* am\nt 0 s exp5d$4 7ii7 ,! total am\nt t ,pu]to ,rico expects to exp5d dur+ ! qu>t] "u ! ,/ate plan ( ,pu]to ,rico 7or a waiv] ( su* plan71 & a description ( h[ ,pu]to ,rico expects to exp5d su* am\nt4 7,b7 ,report to ,,cms ,= ea* qu>t] ) respect to :i* ,pu]to ,rico is requir$ "u subp>agraph 7,a7 to ensure t in=mation describ$ 9 su* subp>agraph is available1 ,pu]to ,rico %all submit to ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a report on su* in=mation = su* qu>t]4 7#b7 ,submission ( docum5tation on contracts ^u reque/ ,pu]to ,rico %all1 ^u reque/1 submit to ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices all docum5tation reque/$ ) respect to contracts aw>d$ "u ! ,/ate plan ( ,pu]to ,rico 7or a waiv] ( su* plan74 4 ,am5d ! title s z to read3 ,a bill to reau?orize & ext5d fund+ = critical public heal? programs t improve access to heal? c>e & /r5g!n ! heal? c>e work=ce1 to ext5d provisions ( ! ,m$ic>e program1 to /r5g!n ! ,m$icaid program 9 ! t]ritories1 to protect heal? c>e consum]s f surprise bill+ practices1 & = o!r purposes44 ,decemb] #ca1 #bjbj;,committee on ,transportation & ,infra/ructure dis*>g$2 committ$ to ! ,committee ( ! ,:ole ,h\se on ! ,/ate ( ! ,union & ord]$ to be pr9t$