,,ii #aaf? ,,congress #a/ ,session ,s4 #aabi ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,april #aj1 #bjai,mr4 ,s&]s 7= himself1 ,ms4 ,baldw91 ,mr4 ,blum5?al1 ,mr4 ,book]1 ,mrs4 ,gillibr&1 ,ms4 ,h>ris1 ,mr4 ,leahy1 ,mr4 ,m>key1 ,mr4 ,m]kley1 ,mr4 ,s*atz1 ,mr4 ,udall1 ,ms4 ,w>r51 ,mr4 ,:iteh\se1 ,ms4 ,hirono1 & ,mr4 ,he9ri*7 introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,f9ance ,a ,,bill ,to e/abli% a ,m$ic>e-=-all national heal? insurance program4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,m$ic>e = ,all ,act ( #bjai4 7b7 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4 ,title ,i--,e/abli%m5t ( ! ,univ]sal ,m$ic>e ,program2 ,univ]sal ,entitlem5t2 ,enrollm5t ,sec4 #aja4 ,e/abli%m5t ( ! ,univ]sal ,m$ic>e ,program4 ,sec4 #ajb4 ,univ]sal entitlem5t4 ,sec4 #ajc4 ,fre$om ( *oice4 ,sec4 #ajd4 ,non-discrim9ation4 ,sec4 #aje4 ,enrollm5t4 ,sec4 #ajf4 ,effective date ( b5efits4 ,sec4 #ajg4 ,prohibition aga9/ duplicat+ cov]age4 ,title ,,ii--,compreh5sive ,b5efits1 ,includ+ ,prev5tive ,b5efits & ,b5efits = ,long-,t]m ,c>e ,sec4 #bja4 ,compreh5sive b5efits4 ,sec4 #bjb4 ,no co/-%>+4 ,sec4 #bjc4 ,exclusions & limitations4 ,sec4 #bjd4 ,cov]age ( in/itutional long-t]m c>e s]vices "u ,m$icaid4 ,sec4 #bje4 ,prohibit+ recov]y ( correctly paid ,m$icaid b5efits4 ,sec4 #bjf4 ,/ate /&>ds4 ,title ,,iii--,provid] ,p>ticipation ,sec4 #cja4 ,provid] p>ticipation & /&>ds4 ,sec4 #cjb4 ,qualifications = provid]s4 ,sec4 #cjc4 ,use ( private contracts4 ,title ,,iv--,adm9i/ration ,subtitle ,a--,g5]al ,adm9i/ration ,provisions ,sec4 #dja4 ,adm9i/ration4 ,sec4 #djb4 ,consultation4 ,sec4 #djc4 ,regional adm9i/ration4 ,sec4 #djd4 ,b5efici>y ombudsman4 ,sec4 #dje4 ,complem5t>y conduct ( relat$ heal? programs4 ,subtitle ,b--,control ,ov] ,fraud & ,abuse ,sec4 #daa4 ,application ( ,f$]al sanctions to all fraud & abuse "u ,univ]sal ,m$ic>e ,program4 ,title ,v--,quality ,assessm5t ,sec4 #eja4 ,quality /&>ds4 ,sec4 #ejb4 ,address+ heal? c>e disp>ities4 ,title ,,vi--,heal? ,budget2 ,paym5ts2 ,co/ ,conta9m5t ,measures ,subtitle ,a--,budget+ ,sec4 #fja4 ,national heal? budget4 ,subtitle ,b--,paym5ts to ,provid]s ,sec4 #faa4 ,paym5ts to in/itutional & individual provid]s4 ,sec4 #fab4 ,ensur+ accurate valuation ( s]vices "u ! ,m$ic>e physician fee s*$ule4 ,sec4 #fac4 ,(fice ( prim>y heal? c>e4 ,sec4 #fad4 ,paym5ts = prescription drugs & approv$ devices & equipm5t4 ,title ,,vii--,univ]sal ,m$ic>e ,tru/ ,fund ,sec4 #gja4 ,univ]sal ,m$ic>e ,tru/ ,fund4 ,title ,,viii--,con=m+ ,am5dm5ts to ! ,employee ,retirem5t ,income ,security ,act ( #aigd ,sec4 #hja4 ,prohibition ( employee b5efits duplicative ( b5efits "u ! ,univ]sal ,m$ic>e ,program2 coord9ation 9 case ( work]s' comp5sation4 ,sec4 #hjb4 ,repeal ( cont9uation cov]age requirem5ts "u ,,erisa & c]ta9 o!r requirem5ts relat+ to gr\p heal? plans4 ,sec4 #hjc4 ,effective date ( title4 ,title ,,ix--,additional ,con=m+ ,am5dm5ts ,sec4 #ija4 ,relation%ip to exi/+ ,f$]al heal? programs4 ,sec4 #ijb4 ,sunset ( provisions relat$ to ! ,/ate ,ex*anges4 ,title ,x--,transition ,subtitle ,a--,transitional ,m$ic>e ,buy-,9 ,option & ,transitional ,public ,option ,sec4 #ajja4 ,l[]+ ! ,m$ic>e age4 ,sec4 #ajjb4 ,e/abli%m5t ( ! ,m$ic>e transition plan4 ,subtitle ,b--,transitional ,m$ic>e ,re=ms ,sec4 #ajaa4 ,m$ic>e protection aga9/ high out-(-pocket exp5ditures = fee-=-s]vice b5efits & elim9ation ( p>ts ,a & ,b deductibles4 ,sec4 #ajab4 ,r$uction 9 ,m$ic>e "p ,d annual out-(-pocket ?re%old & elim9ation ( co/-%>+ above t ?re%old4 ,sec4 #ajac4 ,cov]age ( d5tal & vision s]vices & he>+ aids & exam9ations "u ,m$ic>e "p ,b4 ,sec4 #ajad4 ,elim9at+ ! #bd-mon? wait+ p]iod = ,m$ic>e cov]age = individuals ) disabilities4 ,sec4 #ajae4 ,gu>ante$ issue ( ,m$igap policies4 ,subtitle ,c--,private ,heal? ,insurance ,availability ,dur+ ,transitional ,p]iod ,sec4 #ajba4 ,cont9uity ( c>e4 ,title ,,xi--,miscellane\s ,sec4 #aaja4 ,updat+ res\rce limits = ,supplem5tal ,security ,income eligibility 7,,ssi74 ,sec4 #aajb4 ,def9itions4 ,i ,e/abli%m5t ( ! ,univ]sal ,m$ic>e ,program2 ,univ]sal ,entitlem5t2 ,enrollm5t #aja4 ,e/abli%m5t ( ! ,univ]sal ,m$ic>e ,program ,!re is h]eby e/abli%$ a national heal? insurance program to provide compreh5sive protection aga9/ ! co/s ( heal? c>e & heal?-relat$ s]vices1 9 accordance ) ! /&>ds specifi$ 91 or e/abli%$ "u1 ?is ,act4 #ajb4 ,univ]sal entitlem5t 7a7 ,9 g5]al ,e individual :o is a resid5t ( ! ,unit$ ,/ates is entitl$ to b5efits = heal? c>e s]vices "u ?is ,act4 ,! ,secret>y %all promulgate a rule t provides crit]ia = det]m9+ resid5cy = eligibility purposes "u ?is ,act4 7b7 ,treatm5t ( o!r individuals ,! ,secret>y-- 7#a7 may make eligible = b5efits = heal? c>e s]vices "u ?is ,act o!r individuals n describ$ 9 subsection 7a7 & regulate _! eligibility to ensure t e p]son 9 ! ,unit$ ,/ates has access to heal? c>e2 & 7#b7 %all promulgate a rule1 consi/5t ) ,f$]al immigration laws1 to prev5t an individual f travel+ to ! ,unit$ ,/ates = ! sole purpose ( obta9+ heal? c>e s]vices provid$ "u ?is ,act4 #ajc4 ,fre$om ( *oice ,any individual entitl$ to b5efits "u ?is ,act may obta9 heal? s]vices f any in/itution1 ag5cy1 or individual qualifi$ to p>ticipate "u ?is ,act4 #ajd4 ,non-discrim9ation 7a7 ,9 g5]al ,no p]son %all1 on ! basis ( race1 color1 national orig91 age1 disability1 or sex1 includ+ sex /]eotyp+1 g5d] id5tity1 sexual ori5tation1 & pregnancy & relat$ m$ical conditions 7includ+ t]m9ation ( pregnancy71 be exclud$ f p>ticipation 91 be d5i$ ! b5efits (1 or be subject$ to discrim9ation by any p>ticipat+ provid] z def9$ 9 section #cja1 or any entity conduct+1 adm9i/]+1 or fund+ a heal? program or activity1 includ+ contracts ( insurance1 pursuant to ?is ,act4 7b7 ,claims ( discrim9ation 7#a7 ,9 g5]al ,! ,secret>y %all e/abli% a proc$ure = adjudication ( adm9i/rative compla9ts alleg+ a violation ( subsection 7a74 7#b7 ,jurisdiction ,any p]son aggriev$ by a violation ( subsection 7a7 by a cov]$ entity may file suit 9 any di/rict c\rt ( ! ,unit$ ,/ates hav+ jurisdiction ( ! p>ties4 7#c7 ,damages ,if ! c\rt f9ds a violation ( subsection 7a71 ! c\rt may grant comp5satory & punitive damages1 decl>atory relief1 injunctive relief1 attorneys' fees & co/s1 or o!r relief z appropriate4 #aje4 ,enrollm5t 7a7 ,9 g5]al ,! ,secret>y %all provide a me*anism = ! enrollm5t ( individuals eligible = b5efits "u ?is ,act4 ,! me*anism %all-- 7#a7 include a process = ! automatic enrollm5t ( individuals at ! "t ( bir? 9 ! ,unit$ ,/ates or ^u ! e/abli%m5t ( resid5cy 9 ! ,unit$ ,/ates2 7#b7 provide = ! enrollm5t1 z ( ! date describ$ 9 section #ajf1 ( all individuals :o are eligible to be enroll$ z ( su* date2 & 7#c7 include a process = ! enrollm5t ( individuals made eligible = heal? c>e s]vices "u section #ajb7;b74 7b7 ,issuance ( ,univ]sal ,m$ic>e c>ds ,9 conjunction ) an individual's enrollm5t = b5efits "u ?is ,act1 ! ,secret>y %all provide = ! issuance ( a ,univ]sal ,m$ic>e c>d t %all be us$ = purposes ( id5tification & process+ ( claims = b5efits "u ?is program4 ,! c>d %all n include an individual's ,social ,security numb]4 #ajf4 ,effective date ( b5efits 7a7 ,9 g5]al ,except z provid$ 9 subsection 7b71 b5efits %all fir/ be available "u ?is ,act = items & s]vices furni%$ on ,janu>y #a ( ! f\r? cal5d> ye> t beg9s aft] ! date ( enactm5t ( ?is ,act4 7b7 ,cov]age = *ildr5 7#a7 ,9 g5]al ,= any eligible individual :o has n yet atta9$ ! age ( #ai1 b5efits %all fir/ be available "u ?is ,act = items & s]vices furni%$ on ,janu>y #a ( ! fir/ cal5d> ye> t beg9s aft] ! date ( enactm5t ( ?is ,act4 7#b7 ,option to cont9ue 9 o!r cov]age dur+ transition p]iod ,any p]son :o is eligible to receive b5efits z describ$ 9 p>agraph 7#a7 may opt to ma9ta9 any cov]age describ$ 9 section #ija1 private heal? insurance cov]age1 or cov]age (f]$ pursuant to subtitle ,a ( title ,x 7includ+ ! am5dm5ts made by su* subtitle7 until ! effective date describ$ 9 subsection 7a74 #ajg4 ,prohibition aga9/ duplicat+ cov]age 7a7 ,9 g5]al ,beg9n+ on ! effective date describ$ 9 section #ajf7;a71 x %all be unlawful =-- 7#a7 a private heal? insur] to sell heal? insurance cov]age t duplicates ! b5efits provid$ "u ?is ,act2 or 7#b7 an employ] to provide b5efits = an employee1 =m] employee1 or ! dep5d5ts ( an employee or =m] employee t duplicate ! b5efits provid$ "u ?is ,act4 7b7 ,con/ruction ,no?+ 9 ?is ,act %all be con/ru$ z prohibit+ ! sale ( heal? insurance cov]age = any additional b5efits n cov]$ by ?is ,act1 includ+ additional b5efits t an employ] may provide to employees or _! dep5d5ts1 or to =m] employees or _! dep5d5ts4 ,,ii ,compreh5sive ,b5efits1 ,includ+ ,prev5tive ,b5efits & ,b5efits = ,long-,t]m ,c>e #bja4 ,compreh5sive b5efits 7a7 ,9 g5]al ,subject to ! o!r provisions ( ?is title & titles ,,iv ?r\gh ,,ix1 individuals enroll$ = b5efits "u ?is ,act are entitl$ to h paym5t made by ! ,secret>y to an eligible provid] = ! foll[+ items & s]vices if m$ically necess>y or appropriate = ! ma9t5ance ( heal? or = ! diagnosis1 treatm5t1 or rehabilitation ( a heal? condition3 7#a7 ,hospital s]vices1 includ+ inpati5t & outpati5t hospital c>e1 includ+ #bd-;h\r-a-day em]g5cy s]vices & inpati5t prescription drugs4 7#b7 ,ambulatory pati5t s]vices4 7#c7 ,prim>y & prev5tive s]vices1 includ+ *ronic disease managem5t4 7#d7 ,prescription drugs1 m$ical devices1 biological products1 includ+ outpati5t prescription drugs1 m$ical devices1 & biological products4 7#e7 ,m5tal heal? & sub/ance abuse treatm5t s]vices1 includ+ inpati5t c>e4 7#f7 ,laboratory & diagno/ic s]vices4 7#g7 ,compreh5sive reproductive1 mat]nity1 & newborn c>e4 7#h7 ,p$iatrics1 includ+ e>ly & p]iodic scre5+1 diagno/ic1 & treatm5t s]vices 7z def9$ 9 section #aije7r7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7r7774 7#i7 ,oral heal?1 audiology1 & vision s]vices4 7#aj7 ,%ort-t]m rehabilitative & habilitative s]vices & devices4 7#aa7 ,em]g5cy s]vices & transportation4 7#ab7 ,necess>y transportation to receive heal? c>e s]vices = individuals ) disabilities & l[-income individuals4 7#ac7 ,home & community-bas$ long-t]m s]vices & supports 7to be provid$ 9 accordance ) ! requirem5ts = home & community-bas$ sett+s "u sections #dda4ecj & #dda4gaj ( title #db1 ,code ( ,f$]al ,regulations71 includ+-- 7,a7 s]vices describ$ 9 p>agraphs 7#g71 7#h71 7#ac71 7#ai71 & 7#bd7 ( section #aije7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a772 7,b7 home & community-bas$ s]vices describ$ 9 subsection 7c77#d77;,b7 ( section #aiae ( ! ,social ,security ,act 7includ+ habilitation s]vices def9$ 9 subsection 7c77#e7 ( su* section72 7,c7 self-direct$ home & community-bas$ s]vices describ$ 9 subsection 7i7 ( section #aiae ( ! ,social ,security ,act2 7,d7 self-direct$ p]sonal assi/ance s]vices 7z def9$ 9 subsection 7j77#d77;,a7 ( section #aiae ( ! ,social ,security ,act72 & 7,e7 home & community-bas$ att5dant s]vices & supports describ$ 9 subsection 7k7 ( section #aiae ( ! ,social ,security ,act4 7b7 ,revision & adju/m5t ,! ,secret>y %all1 on a regul> basis1 evaluate :e!r ! b5efits package %\ld be improv$ or adju/$ to promote ! heal? ( b5efici>ies1 acc\nt = *anges 9 m$ical practice or new in=mation f m$ical rese>*1 or respond to o!r relevant developm5ts 9 heal? sci5ce1 & %all make recomm5dations to ,congress reg>d+ any su* improvem5ts or adju/m5ts4 7c7 ,complem5t>y & integrative m$ic9e 7#a7 ,9 g5]al ,9 c>ry+ out subsection 7b71 ! ,secret>y %all consult ) ! p]sons describ$ 9 p>agraph 7#a7 ) respect to-- 7,a7 id5tify+ specific complem5t>y & integrative m$ic9e practices t1 on ! basis ( rese>* f9d+s or promis+ cl9ical int]v5tions1 are appropriate to include 9 ! b5efits package2 & 7,b7 id5tify+ b>ri]s to ! effective provision & integration ( su* practices into ! deliv]y ( heal? c>e1 & id5tify+ me*anisms = ov]com+ su* b>ri]s4 7#b7 ,consultation ,9 accordance ) p>agraph 7#a71 ! ,secret>y %all consult )-- 7,a7 ! ,director ( ! ,national ,c5t] = ,complem5t>y & ,integrative ,heal?2 7,b7 ! ,commission] ( ,food & ,drugs2 7,c7 in/itutions ( high] education1 private rese>* in/itutes1 & individual rese>*]s ) ext5sive exp]i5ce 9 complem5t>y & integrative m$ic9e & ! integration ( su* practices into ! deliv]y ( heal? c>e2 7,d7 nationally recogniz$ provid]s ( complem5t>y & integrative m$ic9e2 & 7,e7 su* o!r (ficials1 entities1 & individuals ) exp]tise on complem5t>y & integrative m$ic9e z ! ,secret>y det]m9es appropriate4 7d7 ,/ates may provide additional b5efits ,individual ,/ates may provide additional b5efits = ! resid5ts ( su* ,/ates at ! exp5se ( ! ,/ate4 #bjb4 ,no co/-%>+ 7a7 ,9 g5]al ,! ,secret>y %all ensure t no co/-%>+1 includ+ d$uctibles1 co9surance1 copaym5ts1 or simil> *>ges1 be impos$ on an individual = any b5efits provid$ "u ?is ,act1 except z describ$ 9 subsection 7b74 7b7 ,exceptions ,! ,secret>y may set a co/-%>+ s*$ule = prescription drugs & biological products-- 7#a7 provid$ t-- 7,a7 su* s*$ule is evid5ce-bas$ & enc\rages ! use ( g5]ic drugs2 7,b7 su* co/-%>+ does n apply to prev5tive drugs2 7,c7 su* co/-%>+ does n exce$ #bjj annually p] individual1 adju/$ annually = inflation2 & 7,d7 su* co/-%>+ is n impos$ on individuals ) a h\sehold income equal to or bel[ #bjj p]c5t ( ! pov]ty l9e = a family ( ! size involv$2 & 7#b7 "u :i* ! ,secret>y may exempt br&-"n drugs f consid]ation 9 det]m9+ :e!r an individual has rea*$ any out-(-pocket limit if a g5]ic v]sion ( su* drug is available4 7c7 ,no balance bill+ ,not)/&+ contracts 9 accordance ) section #cjc1 no provid] may impose a *>ge to an enroll$ individual = cov]$ s]vices = :i* b5efits are provid$ "u ?is ,act4 #bjc4 ,exclusions & limitations 7a7 ,9 g5]al ,b5efits = s]vices are n available "u ?is ,act unless ! s]vices meet ! /&>ds specifi$ 9 section #bja7;a71 z def9$ by ! ,secret>y4 7b7 ,treatm5t ( exp]im5tal s]vices & drugs 7#a7 ,9 g5]al ,9 apply+ subsection 7a71 ! ,secret>y %all make national cov]age det]m9ations ) respect to s]vices t are exp]im5tal 9 nature4 ,su* det]m9ations %all be consi/5t ) ! national cov]age det]m9ation process z def9$ 9 section #ahfi7;f77#a77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7f77#a77;,b774 7#b7 ,appeals process ,! ,secret>y %all e/abli% a process by :i* individuals c appeal cov]age decisions4 ,! process %all1 z mu* z is feasible1 foll[ process = appeals "u ! ,m$ic>e program describ$ 9 section #ahfi ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff74 7c7 ,application ( practice guidel9es ,9 ! case ( s]vices = :i* ! ,dep>tm5t ( ,heal? & ,human ,s]vices has recogniz$ a national practice guidel9e1 ! s]vices are consid]$ to meet ! /&>ds specifi$ 9 section #bja7;a7 if !y h be5 provid$ 9 accordance ) su* guidel9e4 ,= purposes ( ?is subsection1 a s]vice %all be consid]$ to h be5 provid$ 9 accordance ) a practice guidel9e if ! heal? c>e provid] provid+ ! s]vice ex]cis$ appropriate pr(essional discretion to deviate f ! guidel9e 9 a mann] au?oriz$ or anticipat$ by ! guidel9e4 #bjd4 ,cov]age ( in/itutional long-t]m c>e s]vices "u ,m$icaid ,title ,,xix ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 is am5d$ by ins]t+ ! foll[+ section aft] section #aidf3 #aidg4 ,/ate ,plan = ,provid+ ,in/itutional ,long-,t]m ,c>e ,s]vices 7a7 ,9 g5]al ,= qu>t]s beg9n+ on or aft] date on :i* b5efits are fir/ available "u section #ajf7;a7 ( ! ,m$ic>e = ,all ,act ( #bjai1 not)/&+ any o!r provision ( ?is title-- 7#a7 a ,/ate plan = m$ical assi/ance %all provide = mak+ m$ical assi/ance available = s]vices t are in/itutional long-t]m c>e s]vices 9 a mann] consi/5t ) ?is section2 & 7#b7 no paym5t to a ,/ate %all be made "u ?is title ) respect to exp5ditures incurr$ by ! ,/ate 9 provid+ m$ical assi/ance on or aft] su* date = s]vices t are n-- 7,a7 in/itutional long-t]m c>e s]vices2 or 7,b7 o!r s]vices = :i* b5efits are n available "u ! ,m$ic>e = ,all ,act ( #bjai & :i* are furni%$ "u a ,/ate plan = m$ical assi/ance :i* provid$ = m$ical assi/ance = su* s]vices on ,septemb] #a1 #bjah4 7b7 ,in/itutional long-,t]m c>e s]vices def9$ ,9 ?is section1 ! t]m in/itutional long-t]m c>e s]vices means ! foll[+3 7#a7 ,nurs+ facility s]vices = individuals #ba ye>s ( age or ov] describ$ 9 subp>agraph 7,a7 ( section #aije7;a77#d74 7#b7 ,inpati5t s]vices = individuals #fe ye>s ( age or ov] provid$ 9 an in/itution = m5tal disease describ$ 9 section #aije7;a77#ad74 7#c7 ,int]m$iate c>e facility s]vices describ$ 9 section #aije7;a77#ae74 7#d7 ,inpati5t psy*iatric hospital s]vices = individuals "u age #ba describ$ 9 section #aije7;a77#af74 7#e7 ,nurs+ facility s]vices describ$ 9 section #aije7;a77#bi74 7c7 ,ma9t5ance ( ef=t 7#a7 ,eligibility /&>ds 7,a7 ,9 g5]al ,beg9n+ on ! date describ$ 9 subsection 7a71 no paym5t may be made "u section #aijc ) respect to m$ical assi/ance provid$ "u a ,/ate plan = m$ical assi/ance if ! ,/ate adopts income1 res\rce1 or o!r /&>ds & me?odologies = purposes ( det]m9+ an individual's eligibility = m$ical assi/ance "u ! ,/ate plan t are m re/rictive ?an ^? appli$ z ( ,janu>y #a1 #bjai4 7,b7 ,index+ ( am\nts ( income & res\rce /&>ds ,9 det]m9+ :e!r a ,/ate has adopt$ income or res\rce /&>ds t are m re/rictive ?an ! /&>ds :i* appli$ z ( ,janu>y #a1 #bjai1 ! ,secret>y %all deem ! am\nt ( any su* /&>d t 0 appli$ z ( su* date to be increas$ by ! p]c5tage increase 9 ! m$ical c>e compon5t ( ! consum] price index = all urban consum]s 7,u4,s4 city av]age7 f ,septemb] ( #bjah to ,septemb] ( ! fiscal ye> = :i* ! ,secret>y is mak+ su* det]m9ation4 7#b7 ,exp5ditures 7,a7 ,9 g5]al ,= ea* fiscal ye> or portion ( a fiscal ye> t occurs dur+ ! p]iod t beg9s on ! fir/ day ( ! fir/ fiscal qu>t] t beg9s on or aft] ! date on :i* b5efits are fir/ available "u section #ajf7;a7 ( ! ,m$ic>e = ,all ,act ( #bjai1 z a condition ( receiv+ paym5ts "u section #aijc7;a71 a ,/ate %all make exp5ditures = m$ical assi/ance = s]vices t are in/itutional long-t]m c>e s]vices 9 an am\nt t is n less ?an ! exp5diture floor det]m9$ = ! ,/ate & fiscal ye> 7or portion ( a fiscal ye>7 "u subp>agraph 7,b74 7,b7 ,exp5diture floor 7i7 ,9 g5]al ,= ea* fiscal ye> or portion ( a fiscal ye> describ$ 9 subp>agraph 7,a71 ! ,secret>y %all det]m9e = ea* ,/ate an exp5diture floor t %all be equal to-- 7,i7 ! am\nt ( ! ,/ate's exp5ditures = fiscal ye> #bjah on m$ical assi/ance = in/itutional long-t]m c>e s]vices2 increas$ by 7,,ii7 ! gr[? factor det]m9$ "u subclause 7ii74 7ii7 ,gr[? factor ,= ea* fiscal ye> or portion ( a fiscal ye> describ$ 9 subp>agraph 7,a71 ! ,secret>y %all1 n lat] ?an ,septemb] #a ( ! fiscal ye> prec$+ su* fiscal ye> or portion ( a fiscal ye>1 det]m9e a gr[? factor = ea* ,/ate t takes into acc\nt-- 7,i7 ! p]c5tage increase 9 heal? c>e co/s 9 ! ,/ate2 7,,ii7 ! total am\nt exp5d$ by ! ,/ate = ! previ\s fiscal ye> on m$ical assi/ance = in/itutional long-t]m c>e s]vices2 7,,iii7 ! increase1 if any1 9 ! total population ( ! ,/ate f ,july ( #bjah to ,july ( ! fiscal ye> prec$+ ! fiscal ye> involv$2 7,,iv7 ! increase1 if any1 9 ! population ( individuals ag$ #fe & old] ( ! ,/ate f ,july ( #bjah to ,july ( ! fiscal ye> prec$+ ! fiscal ye> involv$2 & 7,v7 ! decrease1 if any1 9 ! population ( ! ,/ate t requires m$ical assi/ance = in/itutional long-t]m c>e s]vices t is attributable to ! availability ( cov]age = ! s]vices describ$ 9 section #bja7;a77#ac7 ( ! ,m$ic>e = ,all ,act ( #bjai4 7iii7 ,proration rule ,any am\nt det]m9$ "u ?is subp>agraph = a portion ( a fiscal ye> %all be prorat$ bas$ on ! l5g? ( su* portion ( a fiscal ye> relative to a complete fiscal ye>4 7d7 ,nonapplication ( c]ta9 requirem5ts ,beg9n+ on ! date describ$ 9 subsection 7a71 any provision ( ?is title requir+ a ,/ate plan = m$ical assi/ance to make available m$ical assi/ance = s]vices t are n in/itutional long-t]m c>e s]vices or s]vices describ$ 9 section #ija7;a77#c77;,a77ii7 ( ! ,m$ic>e = ,all ,act ( #bjai %all h no effect4 4 #bje4 ,prohibit+ recov]y ( correctly paid ,m$icaid b5efits ,section #aiag ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifp7 is am5d$-- 7#a7 by am5d+ subsection 7a7 to read z foll[s3 7a7 ,no li5 may be impos$ aga9/ ! prop]ty ( any individual prior to 8 dea? on acc\nt ( m$ical assi/ance paid or to be paid on 8 behalf "u ! ,/ate plan1 except pursuant to ! judgm5t ( a c\rt on acc\nt ( b5efits incorrectly paid on behalf ( su* individual4 2 & 7#b7 by am5d+ subsection 7b7 to read z foll[s3 7b7 ,no adju/m5t or recov]y ( any m$ical assi/ance correctly paid on behalf ( an individual "u ! ,/ate plan may be made4 4 #bjf4 ,/ate /&>ds 7a7 ,9 g5]al ,no?+ 9 ?is ,act %all prohibit individual ,/ates f sett+ additional /&>ds1 ) respect to eligibility1 b5efits1 & m9imum provid] /&>ds1 consi/5t ) ! purposes ( ?is ,act1 provid$ t su* /&>ds d n re/rict eligibility or r$uce access to b5efits or s]vices4 7b7 ,re/rictions on provid]s ,) respect to any individuals or entities c]tifi$ to provide s]vices cov]$ "u section #bja7;a77#g71 a ,/ate may n prohibit an individual or entity f p>ticipat+ 9 ! program "u ?is ,act1 = reasons o!r ?an ! ability ( ! individual or entity to provide su* s]vices4 ,,iii ,provid] ,p>ticipation #cja4 ,provid] p>ticipation & /&>ds 7a7 ,9 g5]al ,an individual or o!r entity furni%+ any cov]$ s]vice "u ?is ,act is n a qualifi$ provid] unless ! individual or entity-- 7#a7 is a qualifi$ provid] ( ! s]vices "u section #cjb2 7#b7 has fil$ ) ! ,secret>y a p>ticipation agreem5t describ$ 9 subsection 7b72 & 7#c7 meets1 z applicable1 su* o!r qualifications & conditions ) respect to a provid] ( s]vices "u title ,,xviii ( ! ,social ,security ,act z describ$ 9 section #ahff ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc74 7b7 ,requirem5ts 9 p>ticipation agreem5t 7#a7 ,9 g5]al ,a p>ticipation agreem5t describ$ 9 ?is subsection betwe5 ! ,secret>y & a provid] %all provide at lea/ = ! foll[+3 7,a7 ,s]vices to eligible p]sons w be furni%$ by ! provid] )\t discrim9ation1 9 accordance ) section #ajd7;a74 ,no?+ 9 ?is subp>agraph %all be con/ru$ z requir+ ! provision ( a type or class ( s]vices t are outside ! scope ( ! provid]'s normal practice4 7,b7 ,no *>ge w be made to any enroll$ individual = any cov]$ s]vices o!r ?an = paym5t au?oriz$ by ?is ,act4 7,c7 ,! provid] agrees to furni% su* in=mation z may be reasonably requir$ by ! ,secret>y1 9 accordance ) uni=m report+ /&>ds e/abli%$ "u section #dja7;b77#a71 =-- 7i7 quality review by designat$ entities2 7ii7 mak+ paym5ts "u ?is ,act1 includ+ ! exam9ation ( records z may be necess>y = ! v]ification ( in=mation on :i* su* paym5ts are bas$2 7iii7 /ati/ical or o!r /udies requir$ = ! implem5tation ( ?is ,act2 & 7iv7 su* o!r purposes z ! ,secret>y may specify4 7,d7 ,9 ! case ( a provid] t is n an individual1 ! provid] agrees n to employ or use = ! provision ( heal? s]vices any individual or o!r provid] t has _h a p>ticipation agreem5t "u ?is subsection t]m9at$ = cause4 7,e7 ,9 ! case ( a provid] paid "u a fee-=-s]vice basis1 ! provid] agrees to submit bills & any requir$ support+ docum5tation relat+ to ! provision ( cov]$ s]vices )9 #cj days aft] ! date ( provid+ su* s]vices4 7#b7 ,t]m9ation ( p>ticipation agreem5t 7,a7 ,9 g5]al ,p>ticipation agreem5ts may be t]m9at$1 ) appropriate notice-- 7i7 by ! ,secret>y = failure to meet ! requirem5ts ( ?is ,act2 or 7ii7 by a provid]4 7,b7 ,t]m9ation process ,provid]s %all be provid$ notice & a reasonable opportunity to correct defici5cies be=e ! ,secret>y t]m9ates an agreem5t unless a m imm$iate t]m9ation is requir$ = public safety or simil> reasons4 7,c7 ,provid] protections 7i7 ,prohibition ,! ,secret>y may n t]m9ate a p>ticipation agreem5t or 9 any o!r way discrim9ate aga9/1 or cause to be discrim9at$ aga9/1 any cov]$ provid] or au?oriz$ repres5tative ( ! provid]1 on acc\nt ( su* provid] or repres5tative-- 7,i7 provid+1 caus+ to be provid$1 or be+ ab\t to provide or cause to be provid$ to ! provid]1 ! ,f$]al ,gov]nm5t1 or ! attorney g5]al ( a ,/ate in=mation relat+ to any violation (1 or any act or omission ! provid] or repres5tative reasonably believes to be a violation (1 any provision ( ?is title 7or an am5dm5t made by ?is title72 7,,ii7 te/ify+ or be+ ab\t to te/ify 9 a proce$+ conc]n+ su* violation2 7,,iii7 assi/+ or p>ticipat+1 or be+ ab\t to assi/ or p>ticipate1 9 su* a proce$+2 or 7,,iv7 object+ to1 or refus+ to p>ticipate 91 any activity1 policy1 practice1 or assign$ task t ! provid] or repres5tative reasonably believes to be 9 violation ( any provision ( ?is ,act 7includ+ any am5dm5t made by ?is ,act71 or any ord]1 rule1 regulation1 /&>d1 or ban "u ?is ,act 7includ+ any am5dm5t made by ?is ,act74 7ii7 ,compla9t proc$ure ,a provid] or repres5tative :o believes t he or %e has be5 discrim9at$ aga9/ 9 violation ( ?is section may seek relief 9 accordance ) ! proc$ures1 notifications1 burd5s ( pro(1 rem$ies1 & /atutes ( limitation set =? 9 section #bjhg7;b7 ( title #ae1 ,unit$ ,/ates ,code4 #cjb4 ,qualifications = provid]s 7a7 ,9 g5]al ,a heal? c>e provid] is consid]$ to be qualifi$ to provide cov]$ s]vices if ! provid] is lic5s$ or c]tifi$ & meets-- 7#a7 all ! requirem5ts ( ,/ate law to provide su* s]vices2 & 7#b7 applicable requirem5ts ( ,f$]al law to provide su* s]vices4 7b7 ,m9imum provid] /&>ds 7#a7 ,9 g5]al ,! ,secret>y %all e/abli%1 evaluate1 & update national m9imum /&>ds to ensure ! quality ( s]vices provid$ "u ?is ,act & to monitor ef=ts by ,/ates to ensure ! quality ( su* s]vices4 ,a ,/ate may also e/abli% additional m9imum /&>ds :i* provid]s %all meet ) respect to s]vices provid$ 9 su* ,/ate4 7#b7 ,national m9imum /&>ds ,! national m9imum /&>ds "u p>agraph 7#a7 %all be e/abli%$ = in/itutional provid]s ( s]vices & individual heal? c>e practition]s4 ,except z ! ,secret>y may specify 9 ord] to c>ry out ?is ,act1 a hospital1 skill$ nurs+ facility1 or o!r in/itutional provid] ( s]vices %all meet /&>ds = su* a provid] "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq474 ,su* /&>ds also may include1 :]e appropriate1 elem5ts relat+ to-- 7,a7 adequacy & quality ( facilities2 7,b7 tra9+ & compet5ce ( p]sonnel 7includ+ cont9u+ education requirem5ts72 7,c7 compreh5siv5ess ( s]vice2 7,d7 cont9uity ( s]vice2 7,e7 pati5t satisfaction1 includ+ wait+ "t & access to s]vices2 & 7,f7 p]=mance /&>ds1 includ+ organization1 facilities1 /ructure ( s]vices1 effici5cy ( op]ation1 & outcome 9 palliation1 improvem5t ( heal?1 /abilization1 cure1 or rehabilitation4 7#c7 ,transition 9 application ,if ! ,secret>y provides = additional requirem5ts = provid]s "u ?is subsection1 any su* additional requirem5t %all be implem5t$ 9 a mann] t provides = a reasonable p]iod dur+ :i* a previ\sly qualifi$ provid] is p]mitt$ to meet su* an additional requirem5t4 7#d7 ,ability to provide s]vices ,) respect to any entity or provid] c]tifi$ to provide s]vices describ$ 9 section #bja7;a77#g71 ! ,secret>y may n prohibit su* entity or provid] f p>ticipat+ = reasons o!r ?an its ability to provide su* s]vices4 7c7 ,f$]al provid]s ,any provid] qualifi$ to provide heal? c>e s]vices ?r\gh ! ,dep>tm5t ( ,vet]ans ,affairs or ,indian ,heal? ,s]vice is a qualify+ provid] "u ?is section ) respect to any individual :o qualifies = su* s]vices "u applicable ,f$]al law4 #cjc4 ,use ( private contracts 7a7 ,9 g5]al ,subject to ! provisions ( ?is subsection1 no?+ 9 ?is ,act %all prohibit an in/itutional or individual provid] f ent]+ into a private contract ) an enroll$ individual = any item or s]vice-- 7#a7 = :i* no claim = paym5t is to be submitt$ "u ?is ,act2 & 7#b7 = :i* ! provid] receives-- 7,a7 no reimbursem5t "u ?is ,act directly or on a capitat$ basis2 & 7,b7 receives no am\nt = su* item or s]vice f an organization :i* receives reimbursem5t = su* items or s]vice "u ?is ,act directly or on a capitat$ basis4 7b7 ,b5efici>y protections 7#a7 ,9 g5]al ,subsection 7a7 %all n apply to any contract unless-- 7,a7 ! contract is 9 writ+ & is sign$ by ! b5efici>y be=e any item or s]vice is provid$ pursuant to ! contract2 7,b7 ! contract conta9s ! items describ$ 9 p>agraph 7#b72 & 7,c7 ! contract is n ent]$ into at a "t :5 ! b5efici>y is fac+ an em]g5cy heal? c>e situation4 7#b7 ,items requir$ to be includ$ 9 contract ,any contract to provide items & s]vices to :i* subsection 7a7 applies %all cle>ly indicate to ! b5efici>y t by sign+ su* contract ! b5efici>y-- 7,a7 agrees n to submit a claim 7or to reque/ t ! provid] submit a claim7 "u ?is ,act = su* items or s]vices ev5 if su* items or s]vices are o!rwise cov]$ by ?is ,act2 7,b7 agrees to be responsible1 :e!r ?r\gh insurance (f]$ "u section #ajg7;b7 or o!rwise1 = paym5t ( su* items or s]vices & und]/&s t no reimbursem5t w be provid$ "u ?is ,act = su* items or s]vices2 7,c7 ackn[l$ges t no limits "u ?is ,act apply to am\nts t may be *>g$ = su* items or s]vices2 7,d7 if ! provid] is a non-p>ticipat+ provid]1 ackn[l$ges t ! b5efici>y has ! "r to h su* items or s]vices provid$ by o!r provid]s = :om paym5t w\ld be made "u ?is ,act2 & 7,e7 ackn[l$ges t ! provid] is provid+ s]vices outside ! scope ( ! program "u ?is ,act4 7c7 ,provid] requirem5ts 7#a7 ,9 g5]al ,subsection 7a7 %all n apply to any contract unless an affidavit describ$ 9 p>agraph 7#b7 is 9 effect dur+ ! p]iod any item or s]vice is to be provid$ pursuant to ! contract4 7#b7 ,affidavit ,an affidavit is describ$ 9 ?is subp>agraph %all-- 7,a7 id5tify ! practition]1 & be sign$ by su* practition]2 7,b7 provide t ! practition] w n submit any claim "u ?is title = any item or s]vice provid$ to any b5efici>y 7& w n receive any reimbursem5t or am\nt describ$ 9 p>agraph 7#a77;,b7 = any su* item or s]vice7 dur+ ! #a-ye> p]iod beg9n+ on ! date ! affidavit is sign$2 & 7,c7 be fil$ ) ! ,secret>y no lat] ?an #aj days aft] ! fir/ contract to :i* su* affidavit applies is ent]$ into4 7#c7 ,en=cem5t ,if a physician or practition] sign+ an affidavit describ$ 9 p>agraph 7#b7 kn[+ly & willfully submits a claim "u ?is title = any item or s]vice provid$ dur+ ! #a-ye> p]iod describ$ 9 p>agraph 7#b77;,b7 7or receives any reimbursem5t or am\nt describ$ 9 subsection 7a77#b7 = any su* item or s]vice7 ) respect to su* affidavit-- 7,a7 ?is subsection %all n apply ) respect to any items & s]vices provid$ by ! physician or practition] pursuant to any contract on & aft] ! date ( su* submission & be=e ! end ( su* p]iod2 & 7,b7 no paym5t %all be made "u ?is title = any item or s]vice furni%$ by ! physician or practition] dur+ ! p]iod describ$ 9 clause 7i7 7& no reimbursem5t or paym5t ( any am\nt describ$ 9 subsection 7a77#b7 %all be made = any su* item or s]vice74 ,,iv ,adm9i/ration ,a ,g5]al ,adm9i/ration ,provisions #dja4 ,adm9i/ration 7a7 ,g5]al duties ( ! ,secret>y 7#a7 ,9 g5]al ,! ,secret>y %all develop policies1 proc$ures1 guidel9es1 & requirem5ts to c>ry out ?is ,act1 includ+ relat$ to-- 7,a7 eligibility = b5efits2 7,b7 enrollm5t2 7,c7 b5efits provid$2 7,d7 provid] p>ticipation /&>ds & qualifications1 z describ$ 9 title ,,iii2 7,e7 levels ( fund+2 7,f7 me?ods = det]m9+ am\nts ( paym5ts to provid]s ( cov]$ s]vices1 consi/5t ) subtitle ,b2 7,g7 ! det]m9ation ( m$ical necessity & appropriat5ess ) respect to cov]age ( c]ta9 s]vices2 7,h7 plann+ = capital exp5ditures & s]vice deliv]y2 7,i7 plann+ = heal? pr(essional education fund+2 7,j7 enc\rag+ ,/ates to develop regional plann+ me*anisms2 & 7,k7 any o!r regulations necess>y to c>ry out ! purpose ( ?is ,act4 7#b7 ,regulations ,regulations au?oriz$ by ?is ,act %all be issu$ by ! ,secret>y 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 7b7 ,uni=m report+ /&>ds2 annual report2 /udies 7#a7 ,uni=m report+ /&>ds 7,a7 ,9 g5]al ,! ,secret>y %all e/abli% uni=m ,/ate report+ requirem5ts & national /&>ds to ensure an adequate national database conta9+ in=mation p]ta9+ to heal? s]vices practition]s1 approv$ provid]s1 ! co/s ( facilities & practition]s provid+ su* s]vices1 ! quality ( su* s]vices1 ! outcomes ( su* s]vices1 & ! equity ( heal? among population gr\ps4 ,su* /&>ds %all include1 to ! maximum ext5t feasible )\t compromis+ pati5t privacy1 heal? outcome measures1 & to ! maximum ext5t feasible )\t excessively burd5+ provid]s1 ! measures describ$ 9 subp>agraphs 7,d7 ?r\gh 7,f7 ( subsection 7a77#a74 7,b7 ,reports ,! ,secret>y %all regul>ly analyze in=mation report$ to x & %all def9e rules & proc$ures to all[ rese>*]s1 s*ol>s1 heal? c>e provid]s1 & o!rs to access & analyze data = purposes consi/5t ) quality & outcomes rese>*1 )\t compromis+ pati5t privacy4 7#b7 ,annual report ,beg9n+ ,janu>y #a ( ! second ye> beg9n+ aft] ! effective date ( ?is ,act1 ! ,secret>y %all annually report to ,congress on ! foll[+3 7,a7 ,! /atus ( implem5tation ( ! ,act4 7,b7 ,enrollm5t "u ?is ,act4 7,c7 ,b5efits "u ?is ,act4 7,d7 ,exp5ditures & f9anc+ "u ?is ,act4 7,e7 ,co/-conta9m5t measures & a*ievem5ts "u ?is ,act4 7,f7 ,quality assurance4 7,g7 ,heal? c>e utilization patt]ns1 includ+ any *anges attributable to ! program4 7,h7 ,*anges 9 ! p]-capita co/s ( heal? c>e4 7,i7 ,diff]5ces 9 ! heal? /atus ( ! populations ( ! diff]5t ,/ates1 includ+ income & racial *>act]i/ics1 & o!r population heal? inequities4 7,j7 ,progress on quality & outcome measures1 & long-range plans & goals = a*ievem5ts 9 su* areas4 7,k7 ,necess>y *anges 9 ! education ( heal? p]sonnel4 7,l7 ,plans = improv+ s]vice to m$ically und]s]v$ populations4 7,m7 ,transition problems z a result ( implem5tation ( ?is ,act4 7,n7 ,opportunities = improvem5ts "u ?is ,act4 7#c7 ,/ati/ical analyses & o!r /udies ,! ,secret>y may1 ei!r directly or by contract-- 7,a7 make /ati/ical & o!r /udies1 on a nationwide1 regional1 ,/ate1 or local basis1 ( any aspect ( ! op]ation ( ?is ,act2 7,b7 develop & te/ me?ods ( paym5t or deliv]y z x may consid] necess>y or promis+ = ! evaluation1 or = ! improvem5t1 ( ! op]ation ( ?is ,act2 & 7,c7 develop me?odological /&>ds = evid5ce-bas$ policymak+4 7c7 ,audits 7#a7 ,9 g5]al ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct an audit ( ! ,bo>d e fif? fiscal ye> foll[+ ! effective date ( ?is ,act to det]m9e ! effectiv5ess ( ! program 9 c>ry+ out ! duties "u subsection 7a74 7#b7 ,reports ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit a report to ,congress conc]n+ ! results ( ea* audit conduct$ "u ?is subsection4 #djb4 ,consultation ,! ,secret>y %all consult ) ,f$]al ag5cies1 ,indian tribes & urban ,indian heal? organizations1 & private entities1 su* z pr(essional societies1 national associations1 nationally recogniz$ associations ( exp]ts1 m$ical s*ools & academic heal? c5t]s1 consum] & pati5t gr\ps1 & labor & bus9ess organizations 9 ! =mulation ( guidel9es1 regulations1 policy initiatives1 & in=mation ga!r+ to ensure ! broade/ & mo/ in=m$ input 9 ! adm9i/ration ( ?is ,act4 ,no?+ 9 ?is ,act %all prev5t ! ,secret>y f adopt+ guidel9es develop$ by su* a private entity if1 9 ! ,secret>y's judgm5t1 su* guidel9es are g5]ally accept$ z reasonable & prud5t & consi/5t ) ?is ,act4 #djc4 ,regional adm9i/ration 7a7 ,coord9ation ) regional (fices ,! ,secret>y %all e/abli% & ma9ta9 regional (fices to promote adequate access to1 & effici5t use (1 t]ti>y c>e facilities1 equipm5t1 & s]vices4 ,:]ev] possible1 ! ,secret>y %all incorporate regional (fices ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices = ?is purpose4 7b7 ,appo9tm5t ( regional & ,/ate directors ,9 ea* su* regional (fice !re %all be-- 7#a7 "o regional director appo9t$ by ! ,secret>y2 7#b7 = ea* ,/ate 9 ! region1 a deputy director2 & 7#c7 "o deputy director to repres5t ! ,native ,am]ican & ,alaska ,native tribes 9 ! region4 7c7 ,regional (fice duties ,regional (fices %all be responsible =-- 7#a7 provid+ an annual ,/ate heal? c>e ne$s assessm5t report to ! ,secret>y1 aft] a ?or\gh exam9ation ( heal? ne$s1 9 consultation ) public heal? (ficials1 cl9icians1 pati5ts1 & pati5t advocates2 7#b7 recomm5d+ *anges 9 provid] reimbursem5t or paym5t = deliv]y ( heal? s]vices 9 ! ,/ates )9 ! region2 & 7#c7 e/abli%+ a quality assurance me*anism 9 ! ,/ate 9 ord] to m9imize bo? "u-utilization & ov]-utilization & to ensure t all provid]s meet high-quality /&>ds4 #djd4 ,b5efici>y ombudsman 7a7 ,9 g5]al ,! ,secret>y %all appo9t a ,b5efici>y ,ombudsman :o %all h exp]tise & exp]i5ce 9 ! fields ( heal? c>e & education (1 & assi/ance to1 individuals entitl$ to b5efits "u ?is ,act4 7b7 ,duties ,! ,b5efici>y ,ombudsman %all-- 7#a7 receive compla9ts1 grievances1 & reque/s = in=mation submitt$ by individuals entitl$ to b5efits "u ?is ,act ) respect to any aspect ( ! ,univ]sal ,m$ic>e ,program2 7#b7 provide assi/ance ) respect to compla9ts1 grievances1 & reque/s ref]r$ to 9 subp>agraph 7a71 includ+-- 7,a7 assi/ance 9 collect+ relevant in=mation = su* individuals1 to seek an appeal ( a decision or det]m9ation made by a regional (fice or ! ,secret>y2 & 7,b7 assi/ance to su* individuals 9 pres5t+ in=mation "u relat+ to co/-%>+2 & 7#c7 submit annual reports to ,congress & ! ,secret>y t describe ! activities ( ! ,(fice & t include su* recomm5dations = improvem5t 9 ! adm9i/ration ( ?is ,act z ! ,ombudsman det]m9es appropriate4 ,! ,ombudsman %all n s]ve z an advocate = any increases 9 paym5ts or new cov]age ( s]vices1 b may id5tify issues & problems 9 paym5t or cov]age policies4 #dje4 ,complem5t>y conduct ( relat$ heal? programs ,9 p]=m+ functions ) respect to heal? p]sonnel education & tra9+1 heal? rese>*1 environm5tal heal?1 disability insurance1 vocational rehabilitation1 ! regulation ( food & drugs1 & all o!r matt]s p]ta9+ to heal?1 ! ,secret>y %all direct ! activities ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices t[>d contributions to ! heal? ( ! p complem5t>y to ?is ,act4 ,b ,control ,ov] ,fraud & ,abuse #daa4 ,application ( ,f$]al sanctions to all fraud & abuse "u ,univ]sal ,m$ic>e ,program ,! foll[+ sections ( ! ,social ,security ,act %all apply to ?is ,act 9 ! same mann] z !y apply to ,/ate m$ical assi/ance plans "u title ,,xix ( su* ,act3 7#a7 ,section #aabh 7relat+ to exclusion ( individuals & entities74 7#b7 ,section #aabh;,a 7civil monet>y p5alties74 7#c7 ,section #aabh;,b 7crim9al p5alties74 7#d7 ,section #aabd 7relat+ to disclosure ( own]%ip & relat$ in=mation74 7#e7 ,section #aabf 7relat+ to disclosure ( c]ta9 own]s74 ,v ,quality ,assessm5t #eja4 ,quality /&>ds 7a7 ,9 g5]al ,all /&>ds & quality measures "u ?is ,act %all be p]=m$ by ! ,c5t] = ,cl9ical ,/&>ds & ,quality ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices 7ref]r$ to 9 ?is title z ! ,c5t]71 9 coord9ation ) ! ,ag5cy = ,heal?c>e ,rese>* & ,quality & o!r (fices ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 7b7 ,duties ( ! c5t] ,! ,c5t] %all p]=m ! foll[+ duties3 7#a7 ,practice guidel9es ,! ,c5t] %all review & evaluate ea* practice guidel9e develop$ "u "p ,b ( title ,,ix ( ! ,public ,heal? ,s]vice ,act4 ,! ,c5t] %all det]m9e :e!r ! guidel9e %\ld be recogniz$ z a national practice guidel9e4 7#b7 ,/&>ds ( quality1 p]=mance measures1 & m$ical review crit]ia ,! ,c5t] %all review & evaluate ea* /&>d ( quality1 p]=mance measure1 & m$ical review crit]ion develop$ "u "p ,b ( title ,,ix ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bii et seq474 ,! ,c5t] %all det]m9e :e!r ! /&>d1 measure1 or crit]ion is appropriate = use 9 assess+ or review+ ! quality ( s]vices provid$ by heal? c>e in/itutions or heal? c>e pr(essionals4 ,9 evaluat+ su* /&>ds1 ! ,c5t] %all consid] ! evid5ti>y basis = ! /&>d1 & ! validity1 reliability1 & feasibility ( measur+ ! /&>d4 7#c7 ,pr(il+ ( patt]ns ( practice2 id5tification ( outli]s ,! ,c5t] %all adopt me?odologies = pr(il+ ! patt]ns ( practice ( heal? c>e pr(essionals & = id5tify+ & notify+ outli]s4 7#d7 ,crit]ia = entities conduct+ quality reviews ,! ,c5t] %all develop m9imum crit]ia = compet5ce = entities t c qualify to conduct ongo+ & cont9u\s ext]nal quality reviews 9 ! adm9i/rative regions4 ,su* crit]ia %all require su* an entity to be adm9i/ratively indep5d5t ( ! individual or bo>d t adm9i/]s ! region & %all ensure t su* entities d n provide f9ancial inc5tives to review]s to favor "o patt]n ( practice ov] ano!r4 ,! ,c5t] %all ensure coord9ation & report+ by su* entities to ensure national consi/5cy 9 quality /&>ds4 7#e7 ,report+ ,! ,c5t] %all report to ! ,secret>y annually specifically on f9d+s f outcomes rese>* & developm5t ( practice guidel9es t may affect ! ,secret>y's det]m9ation ( cov]age ( s]vices "u section #dja7;a77#a77;,g74 #ejb4 ,address+ heal? c>e disp>ities 7a7 ,evaluat+ data collection approa*es ,! ,c5t] %all evaluate approa*es = ! collection ( data "u ?is ,act1 to be p]=m$ 9 conjunction ) exi/+ quality report+ requirem5ts & programs "u ?is ,act1 t all[ = ! ongo+1 accurate1 & timely collection ( data on disp>ities 9 heal? c>e s]vices & p]=mance on ! basis ( race1 e?nicity1 g5d]1 geography1 or socioeconomic /atus4 ,9 conduct+ su* evaluation1 ! ,secret>y %all consid] ! foll[+ objectives3 7#a7 ,protect+ pati5t privacy4 7#b7 ,m9imiz+ ! adm9i/rative burd5s ( data collection & report+ on provid]s "u ?is ,act4 7#c7 ,improv+ ,univ]sal ,m$ic>e ,program data on race1 e?nicity1 g5d]1 geography1 & socioeconomic /atus4 7b7 ,reports to ,congress 7#a7 ,report on evaluation ,n lat] ?an #ah mon?s aft] ! date on :i* b5efits fir/ become available z describ$ 9 section #ajf7;a71 ! ,c5t] %all submit to ,congress & ! ,secret>y a report on ! evaluation conduct$ "u subsection 7a74 ,su* report %all1 tak+ into consid]ation ! results ( su* evaluation-- 7,a7 id5tify approa*es 7includ+ def9+ me?odologies7 = id5tify+ & collect+ & evaluat+ data on heal? c>e disp>ities on ! basis ( race1 e?nicity1 g5d]1 geography1 or socioeconomic /atus "u ! ,univ]sal ,m$ic>e ,program2 & 7,b7 include recomm5dations on ! mo/ effective /rategies & approa*es to report+ quality measures1 z appropriate1 on ! basis ( race1 e?nicity1 g5d]1 geography1 or socioeconomic /atus4 7#b7 ,report on data analyses ,n lat] ?an #d ye>s aft] ! submission ( ! report "u subsection 7b77#a71 & #d ye>s !reaft]1 ! ,c5t] %all submit to ,congress & ! ,secret>y a report t includes recomm5dations = improv+ ! id5tification ( heal? c>e disp>ities bas$ on ! analyses ( data collect$ "u subsection 7c74 7c7 ,implem5t+ effective approa*es ,n lat] ?an #b ye>s aft] ! date on :i* b5efits fir/ become available z describ$ 9 section #ajf7;a71 ! ,secret>y %all implem5t ! approa*es id5tifi$ 9 ! report submitt$ "u subsection 7b77#a7 = ! ongo+1 accurate1 & timely collection & evaluation ( data on heal? c>e disp>ities on ! basis ( race1 e?nicity1 g5d]1 geography1 or socioeconomic /atus4 ,,vi ,heal? ,budget2 ,paym5ts2 ,co/ ,conta9m5t ,measures ,a ,budget+ #fja4 ,national heal? budget 7a7 ,national heal? budget 7#a7 ,9 g5]al ,by n lat] ?an ,septemb] #a ( ea* ye>1 beg9n+ ) ! ye> prior to ! date on :i* b5efits fir/ become available z describ$ 9 section #ajf7;a71 ! ,secret>y %all e/abli% a national heal? budget1 :i* specifies ! total exp5ditures to be made = cov]$ heal? c>e s]vices "u ?is ,act4 7#b7 ,division ( budget into compon5ts ,9 addition to ! co/ ( cov]$ heal? s]vices1 ! national heal? budget %all consi/ ( at lea/ ! foll[+ compon5ts3 7,a7 ,quality assessm5t activities "u title ,v4 7,b7 ,heal? pr(essional education exp5ditures4 7,c7 ,adm9i/rative co/s4 7,d7 ,innovation1 includ+ 9 accordance ) section #aaae;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a74 7,e7 ,op]at+ & o!r exp5ditures n describ$ 9 subp>agraphs 7,a7 ?r\gh 7,d7 7ref]r$ to 9 ?is ,act z ! op]at+ compon5t71 consi/+ ( am\nts n includ$ 9 ! o!r compon5ts4 7,f7 ,capital exp5ditures4 7,g7 ,prev5tion & public heal? activities4 7#c7 ,allocation among compon5ts ,! ,secret>y %all allocate ! budget among ! compon5ts 9 a mann] t-- 7,a7 ensures a fair allocation = quality assessm5t activities2 & 7,b7 ensures t ! heal? pr(essional education exp5diture compon5t is suffici5t to provide = ! am\nt ( heal? pr(essional education exp5ditures suffici5t to meet ! ne$ = cov]$ heal? c>e s]vices4 7#d7 ,tempor>y work] assi/ance ,= up to #e ye>s foll[+ ! date on :i* b5efits fir/ become available z describ$ 9 section #ajf7;a71 up to #a p]c5t ( ! budget may be allocat$ to programs provid+ assi/ance to work]s :o p]=m functions 9 ! adm9i/ration ( ! heal? insurance sy/em & :o may exp]i5ce economic dislocation z a result ( ! implem5tation ( ?is ,act4 7#e7 ,res]ve fund ,! ,secret>y %all e/abli% & ma9ta9 a res]ve fund to respond to ! co/s ( treat+ an epidemic1 p&emic1 natural disa/]1 or o!r su* heal? em]g5cy4 7b7 ,def9itions ,9 ?is section3 7#a7 ,capital exp5ditures ,! t]m capital exp5ditures means exp5ses = ! pur*ase1 lease1 con/ruction1 or r5ovation ( capital facilities & = equipm5t & includes return on equity capital4 7#b7 ,heal? pr(essional education exp5ditures ,! t]m heal? pr(essional education exp5ditures means exp5ditures 9 hospitals & o!r heal? c>e facilities to cov] co/s associat$ ) tea*+ & relat$ rese>* activities4 ,b ,paym5ts to ,provid]s #faa4 ,paym5ts to in/itutional & individual provid]s 7a7 ,application ( paym5t processes "u title ,,xviii ,except z o!rwise provid$ 9 ?is section1 ! ,secret>y %all e/abli%1 by regulation1 fee s*$ules t e/abli% paym5t am\nts = b5efits "u ?is ,act 9 a mann] t is consi/5t ) processes = det]m9+ paym5ts = items & s]vices "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq471 includ+ ! application ( ! provisions (1 & am5dm5ts made by1 section #fab4 7b7 ,application ( curr5t & plann$ paym5t re=ms ,any paym5t re=m activities or demon/rations plann$ or implem5t$ ) respect to su* title ,,xviii z ( ! date ( ! enactm5t ( ?is ,act %all apply to b5efits "u ?is ,act1 includ+ any re=m activities or demon/rations plann$ or implem5t$ "u ! provisions (1 or am5dm5ts made by1 ! ,m$ic>e ,access & ,,*ip ,reau?orization ,act ( #bjae 7,public ,law #aad-aj7 & ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh74 #fab4 ,ensur+ accurate valuation ( s]vices "u ! ,m$ic>e physician fee s*$ule 7a7 ,/&>diz$ & docum5t$ review process ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,p7 ,/&>diz$ & docum5t$ review process 7i7 ,9 g5]al ,n lat] ?an "o ye> aft] ! date ( enactm5t ( ?is subp>agraph1 ! ,secret>y %all e/abli%1 docum5t1 & make publicly available a /&>diz$ process = review+ ! relative values ( physicians' s]vices "u ?is p>agraph4 7ii7 ,m9imum requirem5ts ,! /&>diz$ process %all include1 at a m9imum1 me?ods & crit]ia = id5tify+ s]vices = review1 prioritiz+ ! review ( s]vices1 review+ /akehold] recomm5dations1 & id5tify+ additional res\rces to be consid]$ dur+ ! review process4 4 7b7 ,plann$ & docum5t$ use ( funds ,section #ahdh7;c77#b77,m7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acjew-#d7;c77#b77,m77 is am5d$ by add+ at ! end ! foll[+ new clause3 7x7 ,plann$ & docum5t$ use ( funds ,= ea* fiscal ye> 7beg9n+ ) ! fir/ fiscal ye> beg9n+ on or aft] ! date ( enactm5t ( ?is clause71 ! ,secret>y %all provide to ,congress a writt5 plan = us+ ! funds provid$ "u clause 7ix7 to collect & use in=mation on physicians' s]vices 9 ! det]m9ation ( relative values "u ?is subp>agraph4 4 7c7 ,int]nal track+ ( reviews 7#a7 ,9 g5]al ,n lat] ?an "o ye> aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y %all submit to ,congress a propos$ plan = sy/ematically & int]nally track+ its review ( ! relative values ( physicians' s]vices1 su* z by e/abli%+ an int]nal database1 "u section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 z am5d$ by ?is section4 7#b7 ,m9imum requirem5ts ,! proposal %all include1 at a m9imum1 plans & a timel9e = a*iev+ ! ability to sy/ematically & int]nally track ! foll[+3 7,a7 ,:51 h[1 & by :om s]vices are id5tifi$ = review4 7,b7 ,:5 s]vices are review$ or :5 new s]vices are add$4 7,c7 ,! res\rces1 evid5ce1 data1 & recomm5dations us$ 9 reviews4 7,d7 ,:5 relative values are adju/$4 7,e7 ,! rationale = f9al relative value decisions4 7d7 ,frequ5cy ( review ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is am5d$-- 7#a7 9 subp>agraph 7,b77i71 by /rik+ #e & ins]t+ #d2 & 7#b7 9 subp>agraph 7,k77i77,i71 by /rik+ p]iodically & ins]t+ annually4 7e7 ,consultation ) ,m$ic>e ,paym5t ,advisory ,commission 7#a7 ,9 g5]al ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is am5d$-- 7,a7 9 subp>agraph 7,b77i71 by ins]t+ 9 consultation ) ! ,m$ic>e ,paym5t ,advisory ,commission1 aft] ,! ,secret>y12 & 7,b7 9 subp>agraph 7,k77i77,i71 z am5d$ by subsection 7d77#b71 by ins]t+ 1 9 coord9ation ) ! ,m$ic>e ,paym5t ,advisory ,commission1 aft] annually4 7#b7 ,con=m+ am5dm5ts ,section #ahje ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;b-#f7 is am5d$-- 7,a7 9 subsection 7b77#a77;,a71 by ins]t+ ! foll[+ be=e ! semicolon at ! end3 & includ+ coord9at+ ) ! ,secret>y 9 accordance ) section #ahdh7;c77#b7 to sy/ematically review ! relative values e/abli%$ = physicians' s]vices1 id5tify pot5tially misvalu$ s]vices1 & propose adju/m5ts to ! relative values = physicians' s]vices2 & 7,b7 9 subsection 7e77#a71 9 ! second s5t5ce1 by ins]t+ or ! ,rank+ ,m9ority ,memb] aft] ! ,*airman4 7f7 ,p]iodic audit by ! ,comptroll] ,g5]al ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 z am5d$ by subsection 7a71 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,q7 ,p]iodic audit by ! ,comptroll] ,g5]al 7i7 ,9 g5]al ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates 79 ?is subp>agraph ref]r$ to z ! ,comptroll] ,g5]al7 %all p]iodically audit ! review by ! ,secret>y ( relative values e/abli%$ "u ?is p>agraph = physicians' s]vices4 7ii7 ,access to in=mation ,! ,comptroll] ,g5]al %all h unre/rict$ access to all delib]ations1 records1 & nonpropriet>y data relat$ to ! activities c>ri$ out "u ?is p>agraph1 9 a timely mann]1 ^u reque/4 4 #fac4 ,(fice ( prim>y heal? c>e 7a7 ,9 g5]al ,!re is e/abli%$ )9 ! ,ag5cy = ,heal?c>e ,rese>* & ,quality an ,(fice ( ,prim>y ,heal? ,c>e1 responsible = coord9at+ ) ! ,secret>y1 ! ,heal? ,res\rces & ,s]vices ,adm9i/ration1 & o!r (fices 9 ! ,dep>tm5t z necess>y1 9 ord] to-- 7#a7 coord9ate heal? pr(essional education policies & goals1 9 consultation ) ! ,secret>y to a*ieve ! national goals specifi$ 9 subsection 7b72 7#b7 develop & ma9ta9 a sy/em to monitor ! numb] & specialties ( individuals ?r\gh _! heal? pr(essional education1 any po/graduate tra9+1 & pr(essional practice2 7#c7 develop1 coord9ate1 & promote policies t exp& ! numb] ( prim>y c>e practition]s1 regi/]$ nurses1 midlevel practition]s1 & d5ti/s2 & 7#d7 recomm5d ! appropriate tra9+1 education1 te*nical assi/ance1 & pati5t advocacy enhancem5ts ( prim>y c>e heal? pr(essionals1 includ+ regi/]$ nurses1 to a*ieve uni=m high-quality & pati5t safety4 7b7 ,national goals ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is ,act1 ! ,(fice ( ,prim>y ,heal? ,c>e %all set =? national goals to increase access to high-quality prim>y heal? c>e1 p>ticul>ly 9 und]s]v$ areas & = und]s]v$ populations4 #fad4 ,paym5ts = prescription drugs & approv$ devices & equipm5t 7a7 ,negotiat$ prices ,! prices to be paid = cov]$ ph>maceuticals1 m$ical supplies1 & m$ically necess>y assi/ive equipm5t %all be negotiat$ annually by ! ,secret>y4 7b7 ,prescription drug =mul>y 7#a7 ,9 g5]al ,! ,secret>y %all e/abli% a prescription drug =mul>y sy/em1 :i* %all enc\rage be/-practices 9 prescrib+ & disc\rage ! use ( ineffective1 dang]\s1 or excessively co/ly m$ications :5 bett] alt]natives are available4 7#b7 ,promotion ( use ( g5]ics ,! =mul>y "u ?is subsection %all promote ! use ( g5]ic m$ications to ! greate/ ext5t possible4 7#c7 ,=mul>y updates & petition rights ,! =mul>y "u ?is subsection %all be updat$ frequ5tly & cl9icians & pati5ts may petition ! ,secret>y to add new ph>maceuticals or to remove ineffective or dang]\s m$ications f ! =mul>y4 7#d7 ,use ( (f-=mul>y m$ications ,! ,secret>y %all promulgate rules reg>d+ ! use ( (f-=mul>y m$ications :i* all[ = pati5t access b d n compromise ! =mul>y4 ,,vii ,univ]sal ,m$ic>e ,tru/ ,fund #gja4 ,univ]sal ,m$ic>e ,tru/ ,fund 7a7 ,9 g5]al ,!re is h]eby creat$ on ! books ( ! ,treasury ( ! ,unit$ ,/ates a tru/ fund to be kn[n z ! ,univ]sal ,m$ic>e ,tru/ ,fund 79 ?is section ref]r$ to z ! ,tru/ ,fund74 ,! ,tru/ ,fund %all consi/ ( su* gifts & beque/s z may be made & su* am\nts z may be deposit$ 91 or appropriat$ to1 su* ,tru/ ,fund z provid$ 9 ?is ,act4 7b7 ,appropriations into tru/ fund 7#a7 ,taxes ,!re are h]eby appropriat$ to ! ,tru/ ,fund = ea* fiscal ye> beg9n+ ) ! fiscal ye> :i* includes ! date on :i* b5efits fir/ become available z describ$ 9 section #ajf1 out ( any moneys 9 ! ,treasury n o!rwise appropriat$1 am\nts equival5t to #ajj p]c5t ( ! net increase 9 rev5ues to ! ,treasury :i* is attributable to ! am5dm5ts made by sections #hja & #ijb4 ,! am\nts appropriat$ by ! prec$+ s5t5ce %all be transf]r$ f "t to "t 7b n less frequ5tly ?an mon?ly7 f ! g5]al fund 9 ! ,treasury to ! ,tru/ ,fund1 su* am\nts to be det]m9$ on ! basis ( e/imates by ! ,secret>y ( ! ,treasury ( ! taxes paid to or deposit$ into ! ,treasury2 & prop] adju/m5ts %all be made 9 am\nts subsequ5tly transf]r$ to ! ext5t prior e/imates 7 9 excess ( or 7 less ?an ! am\nts t %\ld h be5 s transf]r$4 7#b7 ,curr5t program receipts ,not)/&+ any o!r provision ( law1 !re are h]eby appropriat$ to ! ,tru/ ,fund = ea* fiscal ye>1 beg9n+ ) ! fir/ fiscal ye> beg9n+ on or aft] ! effective date ( b5efits "u section #ajf1 ! am\nts t w\ld o!rwise h be5 appropriat$ to c>ry out ! foll[+ programs3 7,a7 ,! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7o!r ?an am\nts attributable to any premiums "u su* title74 7,b7 ,! ,m$icaid program1 "u ,/ate plans approv$ "u title ,,xix ( su* ,act4 7,c7 ,! ,f$]al employees heal? b5efit program1 "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code4 7,d7 ,! ,,tric>e program1 "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code4 7,e7 ,! mat]nal & *ild heal? program 7"u title ,v ( ! ,social ,security ,act71 vocational rehabilitation programs1 programs = drug abuse & m5tal heal? s]vices "u ! ,public ,heal? ,s]vice ,act1 programs provid+ g5]al hospital or m$ical assi/ance1 & any o!r ,f$]al program id5tifi$ by ! ,secret>y1 9 consultation ) ! ,secret>y ( ! ,treasury1 to ! ext5t ! programs provide = paym5t = heal? s]vices ! paym5t ( :i* may be made "u ?is ,act4 7#c7 ,re/rictions %all n apply ,any o!r provision ( law 9 effect on ! date ( enactm5t ( ?is ,act re/rict+ ! use ( ,f$]al funds = any reproductive heal? s]vice %all n apply to monies 9 ! ,tru/ ,fund4 7c7 ,incorporation ( provisions ,! provisions ( subsections 7b7 ?r\gh 7i7 ( section #ahag ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 %all apply to ! ,tru/ ,fund "u ?is section 9 ! same mann] z su* provisions appli$ to ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u su* section #ahag1 except t1 = purposes ( apply+ su* subsections to ?is section1 ! ,bo>d ( ,tru/ees ( ! ,tru/ ,fund %all mean ! ,secret>y4 7d7 ,transf] ( funds ,any am\nts rema9+ 9 ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u section #ahag ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 or ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda ( su* ,act 7#db ,u4,s4,c4 #aciet7 aft] ! paym5t ( claims = items & s]vices furni%$ "u title ,,xviii ( su* ,act h be5 complet$1 %all be transf]r$ into ! ,univ]sal ,m$ic>e ,tru/ ,fund "u ?is section4 ,,viii ,con=m+ ,am5dm5ts to ! ,employee ,retirem5t ,income ,security ,act ( #aigd #hja4 ,prohibition ( employee b5efits duplicative ( b5efits "u ! ,univ]sal ,m$ic>e ,program2 coord9ation 9 case ( work]s' comp5sation 7a7 ,9 g5]al ,"p #e ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aaca et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #ebb4 ,prohibition ( employee b5efits duplicative ( ,univ]sal ,m$ic>e ,program b5efits2 coord9ation 9 case ( work]s' comp5sation 7a7 ,9 g5]al ,subject to subsection 7b71 no employee b5efit plan may provide b5efits t duplicate paym5t = any items or s]vices = :i* paym5t may be made "u ! ,m$ic>e = ,all ,act ( #bjai4 7b7 ,reimbursem5t ,ea* work]s comp5sation c>ri] t is liable = paym5t = work]s comp5sation s]vices furni%$ 9 a ,/ate %all reimburse ! ,univ]sal ,m$ic>e ,program = ! co/ ( su* s]vices4 7c7 ,def9itions ,9 ?is subsection-- 7#a7 ! t]m work]s comp5sation c>ri] means an insurance company t und]write work]s comp5sation m$ical b5efits ) respect to "o or m employ]s & includes an employ] or fund t is f9ancially at risk = ! provision ( work]s comp5sation m$ical b5efits2 7#b7 ! t]m work]s comp5sation m$ical b5efits means1 ) respect to an enrollee :o is an employee subject to ! work]s comp5sation laws ( a ,/ate1 ! compreh5sive m$ical b5efits = "w-relat$ injuries & illnesses provid$ = "u su* laws ) respect to su* an employee2 & 7#c7 ! t]m work]s comp5sation s]vices means items & s]vices includ$ 9 work]s comp5sation m$ical b5efits & includes items & s]vices 7includ+ rehabilitation s]vices & long-t]m-c>e s]vices7 commonly us$ = treatm5t ( "w-relat$ injuries & illnesses4 4 7b7 ,con=m+ am5dm5t ,section #d7;b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajjc7;b77 is am5d$ by add+ at ! end ! foll[+3 ,p>agraph 7#c7 %all apply subject to section #ebb7;b7 7relat+ to reimbursem5t ( ! ,univ]sal ,m$ic>e ,program by work]s comp5sation c>ri]s744 7c7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( su* ,act is am5d$ by ins]t+ aft] ! item relat+ to section #eba ! foll[+ new item3 ,sec #ebb4 ,prohibition ( employee b5efits duplicative ( ,univ]sal ,m$ic>e ,program b5efits2 coord9ation 9 case ( work]s' comp5sation4 4 #hjb4 ,repeal ( cont9uation cov]age requirem5ts "u ,,erisa & c]ta9 o!r requirem5ts relat+ to gr\p heal? plans 7a7 ,9 g5]al ,"p #f ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aafa et seq47 is repeal$4 7b7 ,con=m+ am5dm5ts 7#a7 ,section #ejb7;a7 ( su* ,act 7#bi ,u4,s4,c4 #aacb7;a77 is am5d$-- 7,a7 by /rik+ p>agraph 7#g72 & 7,b7 by r$esignat+ p>agraphs 7#h71 7#i71 & 7#aj7 z p>agraphs 7#g71 7#h71 & 7#i71 respectively4 7#b7 ,section #ejb7;c77#a7 ( su* ,act 7#bi ,u4,s4,c4 #aacb7;c77#a77 is am5d$ by /rik+ p>agraph 7#a7 or 7#d7 ( section #fjf14 7#c7 ,section #ead7;b7 ( su* ,act 7#bi ,u4,s4,c4 #aadd7;b77 is am5d$-- 7,a7 9 p>agraph 7#g71 by /rik+ section #bjf7;d77#c77;,b77i7742 & 7,b7 by /rik+ p>agraph 7#h74 7#d7 ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by /rik+ ! items relat+ to "p #f ( subtitle ,b ( title ,i ( su* ,act4 #hjc4 ,effective date ( title ,! am5dm5ts made by ?is title %all take effect on effective date ( b5efits "u section #ajf7;a74 ,,ix ,additional ,con=m+ ,am5dm5ts #ija4 ,relation%ip to exi/+ ,f$]al heal? programs 7a7 ,m$ic>e1 ,m$icaid1 & ,/ate ,*ildr5's ,heal? ,insurance ,program 7,,s*ip7 7#a7 ,9 g5]al ,not)/&+ any o!r provision ( law1 subject to p>agraphs 7#b7 & 7#c7-- 7,a7 no b5efits %all be available "u title ,,xviii ( ! ,social ,security ,act = any item or s]vice furni%$ beg9n+ on or aft] ! effective date ( b5efits "u section #ajf7;a72 7,b7 no individual is entitl$ to m$ical assi/ance "u a ,/ate plan approv$ "u title ,,xix ( su* ,act = any item or s]vice furni%$ on or aft] su* date2 7,c7 no individual is entitl$ to m$ical assi/ance "u a ,/ate *ild heal? plan "u title ,,xxi ( su* ,act = any item or s]vice furni%$ on or aft] su* date2 & 7,d7 no paym5t %all be made to a ,/ate "u section #aijc7;a7 or #baje7;a7 ( su* ,act ) respect to m$ical assi/ance or *ild heal? assi/ance = any item or s]vice furni%$ on or aft] su* date4 7#b7 ,transition ,9 ! case ( inpati5t hospital s]vices & ext5d$ c>e s]vices dur+ a cont9u\s p]iod ( /ay :i* began be=e ! effective date ( b5efits "u section #ajf1 & :i* _h n end$ z ( su* date1 = :i* b5efits are provid$ "u title ,,xviii ( ! ,social ,security ,act1 "u a ,/ate plan "u title ,,xix ( su* ,act1 or "u a ,/ate *ild heal? plan "u title ,,xxi su* ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all provide = cont9uation ( b5efits "u su* title or plan until ! end ( ! p]iod ( /ay4 7#c7 ,s]vices "u ,m$icaid 7,a7 ,9 g5]al ,?is subsection %all n apply to entitlem5t to m$ical assi/ance provid$ "u title ,,xix ( ! ,social ,security ,act =-- 7i7 in/itutional long-t]m c>e s]vices 7z def9$ 9 section #aidg7;b7 ( su* ,act72 or 7ii7 any o!r s]vice = :i* b5efits are n available "u ?is ,act & :i* is furni%$ "u a ,/ate plan "u title ,,xix ( ! ,social ,security ,act :i* provid$ = m$ical assi/ance = su* s]vice on ,janu>y #a1 #bjai4 7,b7 ,coord9ation betwe5 ,secret>y & ,/ates ,! ,secret>y %all coord9ate ) ! directors ( ,/ate ag5cies responsible = adm9i/]+ ,/ate plans "u title ,,xix ( ! ,social ,security ,act to-- 7i7 id5tify s]vices describ$ 9 subp>agraph 7,a77ii7 ) respect to ea* ,/ate plan2 & 7ii7 ensure t su* s]vices cont9ue to be made available "u su* plan4 7,c7 ,ma9t5ance ( ef=t requirem5t ,) respect to any s]vice describ$ 9 subp>agraph 7,a77ii7 t is made available "u a ,/ate plan "u title ,,xix ( ! ,social ,security ,act1 ! ma9t5ance ( ef=t requirem5ts describ$ 9 section #aidg7;c7 ( su* ,act 7relat$ to eligibility /&>ds & requir$ exp5ditures7 %all apply to su* s]vice 9 ! same mann] t su* requirem5ts apply to in/itutional long-t]m c>e s]vices 7z def9$ 9 section #aidg7;b7 ( su* ,act74 7b7 ,f$]al employees heal? b5efits program ,no b5efits %all be made available "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 = any "p ( a cov]age p]iod occurr+ on or aft] ! effective date4 7c7 ,,tric>e ,no b5efits %all be made available "u sections #ajgi & #ajhf ( title #aj1 ,unit$ ,/ates ,code1 = items or s]vices furni%$ on or aft] ! effective date4 7d7 ,treatm5t ( b5efits = vet]ans & native am]icans 7#a7 ,9 g5]al ,no?+ 9 ?is ,act %all affect ! eligibility ( vet]ans = ! m$ical b5efits & s]vices provid$ "u title #ch1 ,unit$ ,/ates ,code1 or ( ,indians = ! m$ical b5efits & s]vices provid$ by or ?r\gh ! ,indian ,heal? ,s]vice4 7#b7 ,reevaluation ,no reevaluation ( ! ,indian ,heal? ,s]vice %all be und]tak5 )\t consultation ) tribal lead]s & /akehold]s4 #ijb4 ,sunset ( provisions relat$ to ! ,/ate ,ex*anges ,effective on ! date describ$ 9 section #ajf1 ! ,f$]al & ,/ate ,ex*anges e/abli%$ pursuant to title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh7 %all t]m9ate1 & any o!r provision ( law t relies ^u p>ticipation 9 or enrollm5t ?r\gh su* an ,ex*ange1 includ+ su* provisions ( ! ,int]nal ,rev5ue ,code ( #aihf1 %all cease to h =ce or effect4 ,x ,transition ,a ,transitional ,m$ic>e ,buy-,9 ,option & ,transitional ,public ,option #ajja4 ,l[]+ ! ,m$ic>e age 7a7 ,9 g5]al ,title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;c et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #ahii;,c4 ,transitional ,m$ic>e ,buy-,9 ,option = ,c]ta9 ,individuals 7a7 ,option 7#a7 ,9 g5]al ,e individual :o meets ! requirem5ts describ$ 9 p>agraph 7#c7 %all be eligible to enroll "u ?is section4 7#b7 ,"p ,a1 ,b1 & ,d b5efits ,an individual enroll$ "u ?is section is entitl$ to ! same b5efits 7& %all receive ! same protections7 "u ?is title z an individual :o is entitl$ to b5efits "u "p ,a & enroll$ "u p>ts ,b & ,d1 includ+ ! ability to enroll 9 a ,m$ic>e ,advantage plan t provides qualifi$ prescription drug cov]age 7an ,,ma-,,pd plan74 7#c7 ,requirem5ts = eligibility ,! requirem5ts describ$ 9 ?is p>agraph are ! foll[+3 7,a7 ,! individual is a resid5t ( ! ,unit$ ,/ates4 7,b7 ,! individual is-- 7i7 a citiz5 or national ( ! ,unit$ ,/ates2 or 7ii7 an ali5 lawfully admitt$ = p]man5t resid5ce4 7,c7 ,! individual is n o!rwise entitl$ to b5efits "u "p ,a or eligible to enroll "u "p ,a or "p ,b4 7,d7 ,! individual has atta9$ ! applicable ye>s ( age b has n atta9$ #fe ye>s ( age4 7#d7 ,applicable ye>s ( age def9$ ,= purposes ( ?is section1 ! t]m applicable ye>s ( age means-- 7,a7 effective ,janu>y #a ( ! fir/ ye> foll[+ ! date ( enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai1 ! age ( #ee2 7,b7 effective ,janu>y #a ( ! second ye> foll[+ su* date ( enactm5t1 ! age ( #de2 & 7,c7 effective ,janu>y #a ( ! ?ird ye> foll[+ su* date ( enactm5t1 ! age ( #ce4 7b7 ,enrollm5t2 cov]age ,! ,secret>y %all e/abli% enrollm5t p]iods & cov]age "u ?is section consi/5t ) ! pr9ciples = e/abli%m5t ( enrollm5t p]iods & cov]age = individuals "u o!r provisions ( ?is title4 ,! ,secret>y %all e/abli% su* p]iods s t cov]age "u ?is section %all fir/ beg9 on ,janu>y #a ( ! ye> on :i* an individual fir/ becomes eligible to enroll "u ?is section4 7c7 ,premium 7#a7 ,am\nt ( mon?ly premiums ,! ,secret>y %all1 dur+ ,septemb] ( ea* ye> 7beg9n+ ) ! fir/ ,septemb] foll[+ ! date ( enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai71 det]m9e a mon?ly premium = all individuals enroll$ "u ?is section4 ,su* mon?ly premium %all be equal to #a_/ab ( ! annual premium comput$ "u p>agraph 7#b77;,b71 :i* %all apply ) respect to cov]age provid$ "u ?is section = any mon? 9 ! succe$+ ye>4 7#b7 ,annual premium 7,a7 ,comb9$ p] capita av]age = all ,m$ic>e b5efits ,! ,secret>y %all e/imate ! av]age1 annual p] capita am\nt = b5efits & adm9i/rative exp5ses t w be payable "u p>ts ,a1 ,b1 & ,d 7includ+1 z applicable1 "u "p ,c7 9 ! ye> = all individuals enroll$ "u ?is section4 7,b7 ,annual premium ,! annual premium "u ?is subsection = mon?s 9 a ye> is equal to ! av]age1 annual p] capita am\nt e/imat$ "u subp>agraph 7,a7 = ! ye>4 7#c7 ,increas$ premium = c]ta9 "p ,c & ,d plans ,no?+ 9 ?is section %all preclude an individual f *oos+ a ,m$ic>e ,advantage plan or a prescription drug plan :i* requires ! individual to pay an additional am\nt 7because ( supplem5tal b5efits or because x is a m exp5sive plan74 ,9 su* case ! individual w\ld be responsible = ! increas$ mon?ly premium4 7d7 ,paym5t ( premiums 7#a7 ,9 g5]al ,premiums = enrollm5t "u ?is section %all be paid to ! ,secret>y at su* times1 & 9 su* mann]1 z ! ,secret>y det]m9es appropriate4 7#b7 ,deposit ,am\nts collect$ by ! ,secret>y "u ?is section %all be deposit$ 9 ! ,f$]al ,hospital ,insurance ,tru/ ,fund & ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund 7includ+ ! ,m$ic>e ,prescription ,drug ,acc\nt )9 su* ,tru/ ,fund7 9 su* proportion z ! ,secret>y det]m9es appropriate4 7e7 ,n eligible = ,m$ic>e co/-,%>+ assi/ance ,an individual enroll$ "u ?is section %all n be treat$ z enroll$ "u any "p ( ?is title = purposes ( obta9+ m$ical assi/ance = ,m$ic>e co/-%>+ or o!rwise "u title ,,xix4 7f7 ,treatm5t 9 relation to ! ,af=dable ,c>e ,act 7#a7 ,satisfaction ( individual m&ate ,= purposes ( apply+ section #ejjj;,a ( ! ,int]nal ,rev5ue ,code ( #aihf1 ! cov]age provid$ "u ?is section con/itutes m9imum ess5tial cov]age "u subsection 7f77#a77;,a77i7 ( su* section #ejjj;,a4 7#b7 ,eligibility = premium assi/ance ,cov]age provid$ "u ?is section-- 7,a7 %all be treat$ z cov]age "u a qualifi$ heal? plan 9 ! individual m>ket enroll$ 9 ?r\gh ! ,ex*ange :]e ! individual resides = all purposes ( section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf o!r ?an subsection 7c77#b77;,b7 !re(2 & 7,b7 %all n be treat$ z eligibility = o!r m9imum ess5tial cov]age = purposes ( subsection 7c77#b77;,b7 ( su* section #cf;,b4 ,! ,secret>y %all det]m9e ! applicable second l[e/ co/ silv] plan :i* %all apply to cov]age "u ?is section = purposes ( section #cf;,b ( su* ,code4 7#c7 ,eligibility = co/-%>+ subsidies ,= purposes ( apply+ section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjga7-- 7,a7 cov]age provid$ "u ?is section %all be treat$ z cov]age "u a qualifi$ heal? plan 9 ! silv] level ( cov]age 9 ! individual m>ket (f]$ ?r\gh an ,ex*ange2 & 7,b7 ! ,secret>y %all be treat$ z ! issu] ( su* plan4 7g7 ,no effect on b5efits = individuals o!rwise eligible or on ,tru/ funds ,! ,secret>y %all implem5t ! provisions ( ?is section 9 su* a mann] to ensure t su* provisions-- 7#a7 h no effect on ! b5efits "u ?is title = individuals :o are entitl$ to1 or enroll$ =1 su* b5efits o!r ?an ?r\gh ?is section2 & 7#b7 h no negative impact on ! ,f$]al ,hospital ,insurance ,tru/ ,fund or ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund 7includ+ ! ,m$ic>e ,prescription ,drug ,acc\nt )9 su* ,tru/ ,fund74 7h7 ,consultation ,9 promulgat+ regulations to implem5t ?is section1 ! ,secret>y %all consult ) int]e/$ p>ties1 includ+ gr\ps repres5t+ b5efici>ies1 heal? c>e provid]s1 employ]s1 & insurance companies4 4 #ajjb4 ,e/abli%m5t ( ! ,m$ic>e transition plan 7a7 ,9 g5]al ,to c>ry out ! purpose ( ?is section1 = plan ye>s beg9n+ ) ! fir/ plan ye> t beg9s aft] ! date ( enactm5t ( ?is ,act & end+ ) ! effective date describ$ 9 section #ajf1 ! ,secret>y1 act+ ?r\gh ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid 7ref]r$ to 9 ?is section z ! ,adm9i/rator71 %all e/abli%1 & provide = ! (f]+ ?r\gh ! ,ex*anges1 ( a public heal? plan 79 ?is ,act ref]r$ to z ! ,m$ic>e ,transition plan7 t provides af=dable1 high-quality heal? b5efits cov]age ?r\gh\t ! ,unit$ ,/ates4 7b7 ,adm9i/rat+ ! ,m$ic>e transition 7#a7 ,adm9i/rator ,! ,adm9i/rator %all adm9i/] ! ,m$ic>e ,transition plan 9 accordance ) ?is section4 7#b7 ,application ( ,,aca requirem5ts ,consi/5t ) ?is section1 ! ,m$ic>e ,transition plan %all comply ) requirem5ts "u title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7& ! am5dm5ts made by t title7 & title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 t are applicable to qualifi$ heal? plans (f]$ ?r\gh ! ,ex*anges1 subject to ! limitation "u subsection 7e77#b74 7#c7 ,(f]+ ?r\gh ,ex*anges ,! ,m$ic>e ,transition plan %all be made available only ?r\gh ! ,ex*anges1 & %all be available to individuals wi%+ to enroll & to qualifi$ employ]s 7z def9$ 9 section #acab7;f77#b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjcb77 :o wi% to make su* plan available to _! employees4 7#d7 ,eligibility to pur*ase ,any ,unit$ ,/ates resid5t may enroll 9 ! ,m$ic>e ,transition plan4 7c7 ,b5efits2 actu>ial value ,9 c>ry+ out ?is section1 ! ,adm9i/rator %all ensure t ! ,m$ic>e ,transition plan provides-- 7#a7 cov]age = ! b5efits requir$ to be cov]$ "u title ,,ii2 & 7#b7 cov]age ( b5efits t are actu>ially equival5t to #ij p]c5t ( ! full actu>ial value ( ! b5efits provid$ "u ! plan4 7d7 ,provid]s & reimbursem5t rates 7#a7 ,9 g5]al ,) respect to ! reimbursem5t provid$ to heal? c>e provid]s = cov]$ b5efits1 z describ$ 9 section #bja1 provid$ "u ! ,m$ic>e ,transition plan1 ! ,adm9i/rator %all reimburse su* provid]s at rates det]m9$ = equival5t items & s]vices "u ! orig9al ,m$ic>e fee-=-s]vice program "u p>ts ,a & ,b ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;c et seq474 ,= items & s]vices cov]$ "u ! ,m$ic>e ,transition plan b n cov]$ "u su* p>ts ,a & ,b1 ! ,adm9i/rator %all reimburse provid]s at rates set by ! ,adm9i/rator 9 a mann] consi/5t ) ! mann] 9 :i* rates = o!r items & s]vices 7 set "u ! orig9al ,m$ic>e fee-=-s]vice program4 7#b7 ,prescription drugs ,any paym5t rate "u ?is subsection = a prescription drug %all be at a rate negotiat$ by ! ,adm9i/rator ) ! manufactur] ( ! drug4 ,if ! ,adm9i/rator is unable to rea* a negotiat$ agreem5t on su* a reimbursem5t rate1 ! ,adm9i/rator %all e/abli% ! rate at an am\nt equal to ! less] (-- 7,a7 ! price paid by ! ,secret>y ( ,vet]ans ,affairs to procure ! drug "u ! laws adm9i/]$ by ! ,secret>y ( ,vet]ans ,affairs2 7,b7 ! price paid to procure ! drug "u section #habf ( title #ch1 ,unit$ ,/ates ,code2 or 7,c7 ! be/ price det]m9$ "u section #aibg7;c77#a77;,c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#h7;c77#a77;,c77 = ! drug4 7#c7 ,p>ticipat+ provid]s 7,a7 ,9 g5]al ,a heal? c>e provid] t is a p>ticipat+ provid] ( s]vices or suppli] "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 or "u a ,/ate ,m$icaid plan "u title ,,xix ( su* ,act 7#db ,u4,s4,c4 #acif et seq47 on ! date ( enactm5t ( ?is ,act %all be a p>ticipat+ provid] 9 ! ,m$ic>e ,transition plan4 7,b7 ,additional provid]s ,! ,adm9i/rator %all e/abli% a process to all[ heal? c>e provid]s n describ$ 9 subp>agraph 7,a7 to become p>ticipat+ provid]s 9 ! ,m$ic>e ,transition plan4 ,su* process %all be simil> to ! process appli$ to new provid]s "u ! ,m$ic>e program4 7e7 ,premiums 7#a7 ,det]m9ation ,! ,adm9i/rator %all det]m9e ! premium am\nt = enroll+ 9 ! ,m$ic>e ,transition plan1 :i*-- 7,a7 may v>y accord+ to family or individual cov]age1 age1 & tobacco /atus 7consi/5t ) clauses 7i71 7iii71 & 7iv7 ( section #bgja7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg7a77#a77;,a7772 & 7,b7 %all take into acc\nt ! co/-%>+ r$uctions & premium tax cr$its :i* w be available ) respect to ! plan "u section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjga7 & section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by subsection 7g74 7#b7 ,limitation ,v>iation 9 premium rates ( ! ,m$ic>e ,transition plan by rat+ area1 z describ$ 9 clause 7ii7 ( section #bgja7;a77#a77;,a77iii7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg7a77#a77;,a77 is n p]mitt$4 7f7 ,t]m9ation ,?is section %all cease to h =ce or effect on ! effective date describ$ 9 section #ajf4 7g7 ,tax cr$its & co/-,%>+ subsidies 7#a7 ,premium assi/ance tax cr$its 7,a7 ,cr$its all[$ to ,m$ic>e ,transition plan enrollees at or above #dd p]c5t ( pov]ty 9 non-expansion ,/ates ,p>agraph 7#a7 ( section #cf;,b7c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by r$esignat+ subp>agraphs 7,c7 & 7,d7 z subp>agraphs 7,d7 & 7,e71 respectively1 & by ins]t+ aft] subp>agraph 7,b7 ! foll[+ new subp>agraph3 7,c7 ,special rules = ,m$ic>e ,transition plan enrollees 7i7 ,9 g5]al ,9 ! case ( a taxpay] :o is cov]$1 or ^: sp\se or dep5d5t 7z def9$ 9 section #aeb7 is cov]$1 by ! ,m$ic>e ,transition plan e/abli%$ "u section #ajjb7;a7 ( ! ,m$ic>e = ,all ,act ( #bjai = all mon?s 9 ! taxable ye>1 subp>agraph 7,a7 %all be appli$ )\t reg>d to b does n exce$ #djj p]c5t4 7ii7 ,enrollees 9 ,m$icaid non-expansion ,/ates ,9 ! case ( a taxpay] resid+ 9 a ,/ate :i* 7z ( ! date ( ! enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai7 does n provide = eligibility "u clause 7i77,,viii7 or 7ii77,,xx7 ( section #aijb7;a77#aj77;,a7 ( ! ,social ,security ,act = m$ical assi/ance "u title ,,xix ( su* ,act 7or a waiv] ( ! ,/ate plan approv$ "u section #aaae7 :o is cov]$1 or ^: sp\se or dep5d5t 7z def9$ 9 section #aeb7 is cov]$1 by ! ,m$ic>e ,transition plan e/abli%$ "u section #ajjb7;a7 ( ! ,m$ic>e = ,all ,act ( #bjai = all mon?s 9 ! taxable ye>1 subp>agraphs 7,a7 & 7,b7 %all be appli$ by sub/itut+ #j p]c5t = #ajj p]c5t ea* place x appe>s4 4 7,b7 ,premium assi/ance am\nts = taxpay]s enroll$ 9 ,m$ic>e ,transition plan 7i7 ,9 g5]al ,subp>agraph 7,a7 ( section #cf;,b7b77#c7 ( su* ,code is am5d$-- 7,i7 by r$esignat+ clause 7ii7 z clause 7iii72 7,,ii7 by /rik+ clause 7ii7 9 clause 7i7 & ins]t+ clauses 7ii7 & 7iii72 & 7,,iii7 by ins]t+ aft] clause 7i7 ! foll[+ new clause3 7ii7 ,special rules = taxpay]s enroll$ 9 ,m$ic>e ,transition plan ,9 ! case ( a taxpay] :o is cov]$1 or ^: sp\se or dep5d5t 7z def9$ 9 section #aeb7 is cov]$1 by ! ,m$ic>e ,transition plan e/abli%$ "u section #ajjb7;a7 ( ! ,m$ic>e = ,all ,act ( #bjai = all mon?s 9 ! taxable ye>1 ! applicable p]c5tage = any taxable ye> %all be det]m9$ 9 ! same mann] z "u clause 7i71 except t ! foll[+ table %all apply 9 lieu ( ! table conta9$ 9 su* clause3 ,9 ! case ( h\sehold income 7express$ z a p]c5t ( pov]ty l9e7 )9 ! foll[+ income ti]3,! initial premium p]c5tage is--,! f9al premium p]c5tage is-- ,up to #ajj p]c5t#bb #ajj p]c5t up to #ach p]c5t#b4jdb4jd #ach p]c5t up to #aej p]c5t#c4jfd4jh #aej p]c5t & above#d4jhe 4 7ii7 ,con=m+ am5dm5t ,subclause 7,i7 ( clause 7iii7 ( section #cf;,b7b77#c7 ( su* ,code1 z r$esignat$ by subp>agraph 7,a77i71 is am5d$ by ins]t+ 1 & det]m9$ aft] ! application ( clause 7ii7 aft] aft] application ( ?is clause4 7#b7 ,co/-%>+ subsidies ,subsection 7b7 ( section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjga7;b77 is am5d$-- 7,a7 by ins]t+ 1 or 9 ! ,m$ic>e ,transition plan e/abli%$ "u section #ajjb7;a7 ( ! ,m$ic>e = ,all ,act ( #bjai1 aft] cov]age 9 p>agraph 7#a72 7,b7 by r$esignat+ p>agraphs 7#a7 7z s am5d$7 & 7#b7 z subp>agraphs 7,a7 & 7,b71 respectively1 & by mov+ su* subp>agraphs #b ems to ! "r2 7,c7 by /rik+ insur$4--,9 ?is section & ins]t+ 8insur$4-- 7#a7 ,9 g5]al ,9 ?is section 2 7,d7 by /rik+ ! flu% language2 & 7,e7 by add+ at ! end ! foll[+ new p>agraph3 7#b7 ,special rules 7,a7 ,individuals lawfully pres5t ,9 ! case ( an individual describ$ 9 section #cf;,b7c77#a77;,b7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 ! individual %all be treat$ z hav+ h\sehold income equal to #ajj p]c5t ( ! pov]ty l9e = a family ( ! size involv$ = purposes ( apply+ ?is section4 7,b7 ,m$ic>e ,transition plan enrollees 9 ,m$icaid non-expansion ,/ates ,9 ! case ( an individual resid+ 9 a ,/ate :i* 7z ( ! date ( ! enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai7 does n provide = eligibility "u clause 7i77,,viii7 or 7ii77,,xx7 ( section #aijb7;a77#aj77;,a7 ( ! ,social ,security ,act = m$ical assi/ance "u title ,,xix ( su* ,act 7or a waiv] ( ! ,/ate plan approv$ "u section #aaae7 :o enrolls 9 su* ,m$ic>e ,transition plan1 ! prec$+ s5t5ce1 p>agraph 7#a77;,b71 & p>agraphs 7#a77;,a77i7 & 7#b77;,a7 ( subsection 7c7 %all ea* be appli$ by sub/itut+ #j p]c5t = #ajj p]c5t ea* place x appe>s4 7,c7 ,adju/$ co/-%>+ = ,m$ic>e ,transition plan enrollees ,9 ! case ( any individual :o enrolls 9 su* ,m$ic>e ,transition plan1 9 lieu ( ! p]c5tages "u subsection 7c77#a77;,b77i7 & 7c77#b71 ! ,secret>y %all prescribe a me?od ( det]m9+ ! co/-%>+ r$uction = any su* individual su* t ! total ( ! co/-%>+ & ! premiums paid by ! individual "u su* ,m$ic>e ,transition plan does n exce$ ! p]c5tage ( ! total all[$ co/s ( b5efits provid$ "u ! plan equal to ! f9al premium p]c5tage applicable to su* individual "u section #cf;,b7b77#c77;,a77ii7 ( ! ,int]nal ,rev5ue ,code ( #aihf4 4 7h7 ,con=m+ am5dm5ts 7#a7 ,treatm5t z a qualifi$ heal? plan ,section #acja7;a77#b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjba7;a77#b77 is am5d$-- 7,a7 9 ! p>agraph head+1 by ins]t+ 1 ! ,m$ic>e ,transition plan1 be=e &2 & 7,b7 by ins]t+ ,! ,m$ic>e ,transition plan1 be=e & a multi-,/ate plan4 7#b7 ,level play+ field ,section #acbd7;a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjdd7;a77 is am5d$ by ins]t+ ! ,m$ic>e ,transition plan1 be=e or a multi-,/ate qualifi$ heal? plan4 ,b ,transitional ,m$ic>e ,re=ms #ajaa4 ,m$ic>e protection aga9/ high out-(-pocket exp5ditures = fee-=-s]vice b5efits & elim9ation ( p>ts ,a & ,b d$uctibles 7a7 ,protection aga9/ high out-(-,pocket exp5ditures ,title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq471 z am5d$ by section #ajja1 is am5d$ by add+ at ! end ! foll[+ new section3 #ahii;,d4 ,protection ,aga9/ ,high ,out-(-,pocket ,exp5ditures 7a7 ,9 g5]al ,not)/&+ any o!r provision ( ?is title1 9 ! case ( an individual entitl$ to1 or enroll$ =1 b5efits "u "p ,a or enroll$ 9 "p ,b1 if ! am\nt ( ! out-(-pocket co/-%>+ ( su* individual = a ye> 7effective ! ye> beg9n+ ,janu>y #a ( ! ye> foll[+ ! date ( enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai7 equals or exce$s #a1ejj1 ! individual %all n be responsible = additional out-(-pocket co/-%>+ occurr$ dur+ t ye>4 7b7 ,out-(-,pocket co/-,%>+ def9$ 7#a7 ,9 g5]al ,subject to p>agraphs 7#b7 & 7#c71 9 ?is section1 ! t]m out-(-pocket co/-%>+ means1 ) respect to an individual1 ! am\nt ( ! exp5ses incurr$ by ! individual t are attributable to-- 7,a7 co9surance & copaym5ts applicable "u "p ,a or ,b2 or 7,b7 = items & s]vices t w\ld h o!rwise be5 cov]$ "u "p ,a or ,b b = ! exhau/ion ( ^? b5efits4 7#b7 ,c]ta9 co/s n includ$ 7,a7 ,non-cov]$ items & s]vices ,exp5ses incurr$ = items & s]vices :i* are n includ$ 7or treat$ z be+ includ$7 "u "p ,a or ,b %all n be consid]$ incurr$ exp5ses = purposes ( det]m9+ out-(-pocket co/-%>+ "u p>agraph 7#a74 7,b7 ,items & s]vices n furni%$ on an assignm5t-relat$ basis ,if an item or s]vice is furni%$ to an individual "u ?is title & is n furni%$ on an assignm5t-relat$ basis1 any additional exp5ses ! individual incurs above ! am\nt ! individual w\ld h incurr$ if ! item or s]vice 0 furni%$ on an assignm5t-relat$ basis %all n be consid]$ incurr$ exp5ses = purposes ( det]m9+ out-(-pocket co/-%>+ "u p>agraph 7#a74 7#c7 ,s\rce ( paym5t ,= purposes ( p>agraph 7#a71 ! ,secret>y %all consid] exp5ses to be incurr$ by ! individual )\t reg>d to :e!r ! individual or ano!r p]son1 includ+ a ,/ate program or o!r ?ird-p>ty cov]age1 has paid = su* exp5ses4 4 7b7 ,elim9ation ( p>ts ,a & ,b d$uctibles 7#a7 ,"p ,a ,section #ahac7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;e7b77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#d7 ,= ea* ye> 7beg9n+ ,janu>y #a ( ! ye> foll[+ ! date ( enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai71 ! inpati5t hospital d$uctible = ! ye> %all be #j4 4 7#b7 ,"p ,b ,section #ahcc7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7b77 is am5d$1 9 ! fir/ s5t5ce-- 7,a7 by /rik+ & = a subsequ5t ye> & ins]t+ = ea* ( #bjjf ?r\gh ! ye> t includes ! date ( enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai2 & 7,b7 by ins]t+ 1 & #j = ea* ye> subsequ5t ye> aft] #a74 #ajab4 ,r$uction 9 ,m$ic>e "p ,d annual out-(-pocket ?re%old & elim9ation ( co/-%>+ above t ?re%old 7a7 ,r$uction ,section #ahfj;,d-#b7;b77#d77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajb7;b77#d77;,b77 is am5d$-- 7#a7 9 clause 7i71 by /rik+ ,= purposes & ins]t+ ,subject to clause 7iii71 = purposes2 & 7#b7 by add+ at ! end ! foll[+ new clause3 7iii7 ,r$uction 9 ?re%old dur+ transition p]iod 7,i7 ,9 g5]al ,subject to subclause 7,,ii71 = plan ye>s beg9n+ on or aft] ,janu>y #a foll[+ ! date ( enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai & be=e ,janu>y #a ( ! ye> t is #d ye>s foll[+ su* date ( enactm5t1 not)/&+ clauses 7i7 & 7ii71 ! annual out-(-pocket ?re%old specifi$ 9 ?is subp>agraph is equal to #cje4 7,,ii7 ,au?ority to exempt br&-"n drugs if g5]ic available ,9 apply+ subclause 7,i71 ! ,secret>y may exempt co/s incurr$ = a cov]$ "p ,d drug t is an applicable drug "u section #ahfj;,d-#ad;,a7g77#b7 if ! ,secret>y det]m9es t a g5]ic v]sion ( t drug is available4 4 7b7 ,elim9ation ( co/-,%>+ ,section #ahfj;,d-#b7;b77#d77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajb7;b77#d77;,a77 is am5d$-- 7#a7 9 clause 7i7-- 7,a7 by r$esignat+ subclauses 7,i7 & 7,,ii7 z items 7aa7 & 7bb71 respectively2 7,b7 by /rik+ subp>agraph 7,b71 ) co/-%>+ & ins]t+ ! foll[+3 8subp>agraph 7,b7-- 7,i7 = plan ye>s #bjjf ?r\gh ! plan ye> end+ ,decemb] #ca foll[+ ! date ( enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai1 ) co/-%>+ 2 7,c7 9 item 7bb71 z r$esignat$ by subp>agraph 7,a71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7,d7 by add+ at ! end ! foll[+ new subclause3 7,,ii7 = ! plan ye> beg9n+ ,janu>y #a foll[+ ! date ( enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai & ! two subsequ5t plan ye>s1 )\t any co/-%>+4 2 & 7#b7 9 clause 7ii7-- 7,a7 by /rik+ clause 7i77,i7 & ins]t+ clause 7i77,i77aa72 & 7,b7 by add+ at ! end ! foll[+ new s5t5ce3 ,! ,secret>y %all cont9ue to calculate ! doll> am\nts specifi$ 9 clause 7i77,i77aa71 includ+ ) ! adju/m5t "u ?is clause1 aft] plan ye> #bjah = purposes ( #ahfj;,d-#ad7;a77#a77;,d77iii744 7c7 ,con=m+ am5dm5ts to l[-,income subsidy ,section #ahfj;,d-#ad7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7;a77 is am5d$-- 7#a7 9 p>agraph 7#a7-- 7,a7 9 subp>agraph 7,d77iii71 by /rik+ #ahfj;,d-#b7;b77#d77;,a77i77,i7 & ins]t+ #ahfj;,d-#b7;b77#d77;,a77i77,i77aa72 & 7,b7 9 subp>agraph 7,e7-- 7i7 9 ! head+1 by ins]t+ prior to ! elim9ation ( su* co/-%>+ = all individuals aft] ?re%old2 & 7ii7 by /rik+ ,! elim9ation & ins]t+ ,= plan ye>s #bjjf ?r\gh ! plan ye> end+ ,decemb] #ca foll[+ ! date ( enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai1 ! elim9ation2 & 7#b7 9 p>agraph 7#b77;,e7-- 7,a7 9 ! head+1 by ins]t+ prior to ! elim9ation ( su* co/-%>+ = all individuals aft] ?re%old2 7,b7 by /rik+ ,subject to & ins]t+ ,= plan ye>s #bjjf ?r\gh ! plan ye> end+ ,decemb] #ca foll[+ ! date ( enactm5t ( ! ,m$ic>e = ,all ,act ( #bjai1 subject to2 & 7,c7 by /rik+ #ahfj;,d-#b7;b77#d77;,a77i77,i7 & ins]t+ #ahfj;,d-#b7;b77#d77;,a77i77,i77aa74 #ajac4 ,cov]age ( d5tal & vision s]vices & he>+ aids & exam9ations "u ,m$ic>e "p ,b 7a7 ,d5tal s]vices 7#a7 ,removal ( exclusion f cov]age ,section #ahfb7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77 is am5d$ by /rik+ p>agraph 7#ab74 7#b7 ,cov]age 7,a7 ,9 g5]al ,section #ahfa7s77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#b77 is am5d$-- 7i7 9 subp>agraph 7,,gg71 by /rik+ & at ! end2 7ii7 9 subp>agraph 7,,hh71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7iii7 by add+ at ! end ! foll[+ new subp>agraph3 7,,ii7 d5tal s]vices2 4 7,b7 ,paym5t ,section #ahcc7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a77 is am5d$-- 7i7 by /rik+ & be=e 7,,cc72 & 7ii7 by ins]t+ be=e ! semicolon at ! end ! foll[+3 1 & 7,,dd7 ) respect to d5tal s]vices describ$ 9 section #ahfa7s77#b77;,,ii71 ! am\nt paid %all be an am\nt equal to #hj p]c5t ( ! less] ( ! actual *>ge = ! s]vices or ! am\nt det]m9$ "u ! fee s*$ule e/abli%$ "u section #ahdh7;b744 7,c7 ,effective date ,! am5dm5ts made by ?is subsection %all apply to items & s]vices furni%$ on or aft] ,janu>y #a foll[+ ! date ( ! enactm5t ( ?is ,act4 7b7 ,vision s]vices 7#a7 ,9 g5]al ,section #ahfa7s77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#b771 z am5d$ by subsection 7a71 is am5d$-- 7,a7 9 subp>agraph 7,,hh71 by /rik+ & at ! end2 7,b7 9 subp>agraph 7,,ii71 by ins]t+ & at ! end2 & 7,c7 by add+ at ! end ! foll[+ new subp>agraph3 7,,jj7 vision s]vices2 4 7#b7 ,paym5t ,section #ahcc7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a771 z am5d$ by subsection 7a71 is am5d$-- 7,a7 by /rik+ & be=e 7,,dd72 & 7,b7 by ins]t+ be=e ! semicolon at ! end ! foll[+3 1 & 7,,ee7 ) respect to vision s]vices describ$ 9 section #ahfa7s77#b77;,,jj71 ! am\nt paid %all be an am\nt equal to #hj p]c5t ( ! less] ( ! actual *>ge = ! s]vices or ! am\nt det]m9$ "u ! fee s*$ule e/abli%$ "u section #ahdh7;b744 7#c7 ,effective date ,! am5dm5ts made by ?is subsection %all apply to items & s]vices furni%$ on or aft] ,janu>y #a foll[+ ! date ( ! enactm5t ( ?is ,act4 7c7 ,he>+ aids & exam9ations !re= 7#a7 ,9 g5]al ,section #ahfb7;a77#g7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77#g77 is am5d$ by /rik+ he>+ aids or exam9ations !re=14 7#b7 ,effective date ,! am5dm5t made by ?is subsection %all apply to items & s]vices furni%$ on or aft] ,janu>y #a foll[+ ! date ( ! enactm5t ( ?is ,act4 #ajad4 ,elim9at+ ! #bd-mon? wait+ p]iod = ,m$ic>e cov]age = individuals ) disabilities 7a7 ,9 g5]al ,section #bbf7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #dbf7;b77 is am5d$-- 7#a7 9 p>agraph 7#b77;,a71 by /rik+ 1 & has = #bd cal5d> mon?s be5 entitl$ to12 7#b7 9 p>agraph 7#b77;,b71 by /rik+ 1 & has be5 = n less ?an #bd mon?s12 7#c7 9 p>agraph 7#b77;,c77ii71 by /rik+ 1 includ+ ! requirem5t t he has be5 entitl$ to ! specifi$ b5efits = #bd mon?s12 7#d7 9 ! fir/ s5t5ce1 by /rik+ = ea* mon? beg9n+ ) ! lat] ( 7,i7 ,july #aigc or 7,,ii7 ! tw5ty-fif? mon? ( 8 entitlem5t or /atus z a qualifi$ railroad retirem5t b5efici>y describ$ 9 p>agraph 7#b71 & & ins]t+ = ea* mon? = :i* ! individual meets ! requirem5ts ( p>agraph 7#b71 beg9n+ ) ! mon? foll[+ ! mon? 9 :i* ! individual meets ! requirem5ts ( su* p>agraph1 &2 & 7#e7 9 ! second s5t5ce1 by /rik+ ! tw5ty-fif? mon? ( 8 entitlem5t & all t foll[s ?r\gh p>agraph 7#b77;,c7 &4 7b7 ,con=m+ am5dm5ts 7#a7 ,section #bbf ,section #bbf ( ! ,social ,security ,act 7#db ,u4,s4,c4 #dbf7 is am5d$ by-- 7,a7 /rik+ subsections 7e77#a77;,b71 7f71 & 7h72 & 7,b7 r$esignat+ subsections 7g7 & 7i7 z subsections 7f7 & 7g71 respectively4 7#b7 ,m$ic>e description ,section #ahaa7b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;c7#b77 is am5d$ by /rik+ h be5 entitl$ = n less ?an #bd mon?s & ins]t+ are entitl$4 7#c7 ,m$ic>e cov]age ,section #ahcg7;g77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciep7g77#a77 is am5d$ by /rik+ #be? mon? ( & ins]t+ mon? foll[+ ! fir/ mon? (4 7#d7 ,railroad retirem5t sy/em ,section #g7;d77#b77;ii7 ( ! ,railroad ,retirem5t ,act ( #aigd 7#de ,u4,s4,c4 #bca;f7d77#b77;ii77 is am5d$-- 7,a7 by /rik+ has be5 entitl$ to an annuity & ins]t+ is entitl$ to an annuity2 7,b7 by /rik+ 1 = n less ?an #bd mon?s2 & 7,c7 by /rik+ c\ld h be5 entitl$ = #bd cal5d> mon?s1 &4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to insurance b5efits "u title ,,xviii ( ! ,social ,security ,act ) respect to items & s]vices furni%$ 9 mon?s beg9n+ aft] ,decemb] #a foll[+ ! date ( enactm5t ( ?is ,act1 & be=e ,janu>y #a ( ! ye> t is #d ye>s aft] su* date ( enactm5t4 #ajae4 ,gu>ante$ issue ( ,m$igap policies ,section #ahhb ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciess7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7aa7 ,gu>ante$ issue = all ,m$igap-,eligible ,m$ic>e b5efici>ies ,not)/&+ p>agraphs 7#b77;,a7 & 7#b77;,d7 ( subsection 7s7 or any o!r provision ( ?is section1 on or aft] ! date ( enactm5t ( ?is subsection1 ! issu] ( a m$ic>e supplem5tal policy may n d5y or condition ! issuance or effectiv5ess ( a m$ic>e supplem5tal policy1 or discrim9ate 9 ! pric+ ( ! policy1 because ( heal? /atus1 claims exp]i5ce1 receipt ( heal? c>e1 or m$ical condition 9 ! case ( any individual entitl$ to1 or enroll$ =1 b5efits "u "p ,a & enroll$ = b5efits "u "p ,b4 4 ,c ,private ,heal? ,insurance ,availability ,dur+ ,transitional ,p]iod #ajba4 ,cont9uity ( c>e 7a7 ,9 g5]al ,! ,secret>y %all ensure t all individuals enroll$ 91 or :o seek to enroll 91 a gr\p heal? plan1 heal? insurance cov]age (f]$ by a heal? insurance issu]1 or ! plan e/abli%$ "u section #ajjb dur+ ! transition p]iod ( ?is ,act are protect$ f disruptions 9 _! c>e dur+ ! transition p]iod4 7b7 ,public consultation dur+ transition ,! ,secret>y %all consult ) communities & advocacy organizations ( individuals liv+ ) disabilities & o!r pati5t advocacy organizations to ensure ! transition describ$ 9 ?is section takes into acc\nt ! cont9uity ( c>e = individuals ) disabilities1 complex m$ical ne$s1 or *ronic conditions4 7c7 ,def9itions ,9 ?is section1 ! t]ms heal? insurance cov]age1 heal? insurance issu]1 & gr\p heal? plans h ! mean+s giv5 su* t]ms 9 section #bgia ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ia74 ,,xi ,miscellane\s #aaja4 ,updat+ res\rce limits = ,supplem5tal ,security ,income eligibility 7,,ssi7 ,section #afaa7;a77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #achb7;a77#c77 is am5d$-- 7#a7 9 subp>agraph 7,a7-- 7,a7 by /rik+ & aft] ,janu>y #a1 #aihh12 & 7,b7 by ins]t+ 1 & to #f1bjj on ,janu>y #a1 #bjai be=e ! p]iod2 7#b7 9 subp>agraph 7,b7-- 7,a7 by /rik+ & aft] ,janu>y #a1 #aihh12 & 7,b7 by ins]t+ 1 & to #d1ajj on ,janu>y #a1 #bjai be=e ! p]iod2 & 7#c7 by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,beg9n+ ) ,decemb] ( #bjai1 :5ev] ! doll> am\nts 9 effect "u p>agraphs 7#a77;,a7 & 7#b77;,a7 ( ?is subsection are increas$ = a mon? by a p]c5tage "u section #afag7;a77#b71 ea* ( ! doll> am\nts 9 effect "u ?is p>agraph %all be increas$1 effective ) su* mon?1 by ! same p]c5tage 7& r\nd$1 if n a multiple ( #aj1 to ! close/ multiple ( #aj74 ,ea* increase "u ?is subp>agraph %all be bas$ on ! unr\nd$ am\nt = ! prior #ab-mon? p]iod4 4 #aajb4 ,def9itions ,9 ?is ,act-- 7#a7 ! t]m ,secret>y means ! ,secret>y ( ,heal? & ,human ,s]vices2 7#b7 ! t]m ,/ate means a ,/ate1 ! ,di/rict ( ,columbia1 or a t]ritory ( ! ,unit$ ,/ates2 & 7#c7 ! t]m ,unit$ ,/ates %all include ! ,/ates1 ! ,di/rict ( ,columbia1 & ! t]ritories ( ! ,unit$ ,/ates4