,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #abac  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,april #aa1 #bjai ,ms4 
,w>r5 7= h]self1 ,mrs4 ,gillibr&1 ,ms4  
,h>ris1 ,ms4 ,baldw91 ,ms4 ,klobu*>1    
,mr4 ,book]1 & ,mr4 ,blum5?al7 introduc$
 ! foll[+ bill2 :i* 0 read twice &      
ref]r$ to ! ,committee on ,f9ance  ,a   
,,bill  ,to provide heal? insurance     
re=m1 & = o!r purposes4  #a4 ,%ort title
  ,?is ,act may be cit$ z ! ,consum]    
,heal? ,insurance ,protection ,act (    
#bjai4  #b4 ,table ( cont5ts ,! table ( 
cont5ts = ?is ,act is z foll[s3  ,sec4  
#a4 ,%ort title4 ,sec4 #b4 ,table (     
cont5ts4 ,,title ,i--,limit+ insur]     
pr(its & prev5t+ unreasonable premium   
increases ,sec4 #aja4 ,m$ical loss      
ratio4 ,sec4 #ajb4 ,ensur+ t consum]s   
get value = _! doll>s4 ,sec4 #ajc4      
,effective date4 ,,title ,,ii--,mak+    
heal? insurance cov]age af=dable ,sec4  
#bja4 ,enhancem5t ( premium assi/ance   
cr$it4 ,sec4 #bjb4 ,enhancem5ts = r$uc$ 
co/-%>+4 ,sec4 #bjc4 ,cap on            

prescription drug co/-%>+4 ,sec4 #bjd4  
,/&>diz$ options 9 ! bronze1 silv]1 &   
gold levels ( cov]age4 ,sec4 #bje4      
,d$uctible-exempt s]vices = gr\p heal?  
plans & gr\p heal? insurance cov]age4   
,sec4 #bjf4 ,cl>ification reg>d+        
det]m9ation ( af=dability (             
employ]-sponsor$ m9imum ess5tial        
cov]age4 ,,title ,,iii--,ensur+ access  
to c>e ,sec4 #cja4 ,network adequacy    
requirem5ts4 ,sec4 #cjb4 ,ensur+        
adequate cov]age 9 areas ) few] ?an #c  
heal? insurance issu]s (f]+ qualifi$    
heal? plans on ! ,/ate ,ex*ange4 ,sec4  
#cjc4 ,enrollm5t 9 ,ex*anges4 ,sec4     
#cjd4 ,m>ket+ & outrea* = ,ex*anges     
op]at$ by ! ,secret>y4 ,sec4 #cje4      
,navigator program4 ,,title             
,,iv--,/r5g!n+ consum] heal? insurance  
protections ,sec4 #dja4 ,prohibit+      
discrim9atory premiums bas$ on tobacco  
use4 ,sec4 #djb4 ,heal? insurance       
consum] in=mation4 ,sec4 #djc4 ,pati5t  
protections4 ,sec4 #djd4 ,limitation on 
balance bill+ = em]g5cy s]vices4 ,sec4  

#dje4 ,notification ( provid]           
t]m9ations4 ,sec4 #djf4 ,%ort-t]m limit$
 duration heal? insurance cov]age4 ,sec4
 #djg4 ,protect+ ess5tial heal? b5efits 
& cov]age ( p$iatric s]vices4 ,sec4     
#djh4 ,association heal? plans4  ,i     
,limit+ insur] pr(its & prev5t+         
unreasonable premium increases  #aja4   
,m$ical loss ratio  ,section            
#bgah7;b77#a77;,a77ii7 ( ! ,public      
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg-#ah7;b77#a77;,a77ii77 is am5d$  
by /rik+ #hj ea* place x appe>s & ins]t+
 #he4  #ajb4 ,ensur+ t consum]s get     
value = _! doll>s ,! fir/ section #bgid 
( ! ,public ,heal? ,s]vice ,act 7#db    
,u4,s4,c4 #cjj;gg-#id71 add$ by section 
#ajjc ( ! ,pati5t ,protection &         
,af=dable ,c>e ,act 7,public ,law       
#aaa-adh71 is am5d$--  7#a7 9 subsection
 7a7-- 7,a7 9 p>agraph 7#a71 by /rik+   
subsection 7b77#b77;,a7 & ins]t+        
subsections 7b77#b77;,a7 & 7b77#c72 &   
7,b7 9 p>agraph 7#b71 by add+ at ! end !
 foll[+3 ,not)/&+ any o!r provision (   

law1 a heal? insurance issu] may n      
exclude f su* disclosure in=mation t is 
a trade secret or comm]cial or f9ancial 
in=mation describ$ 9 section            
#eeb7;b77#d7 ( title #e1 ,unit$ ,/ates  
,code42  7#b7 9 subsection 7b7-- 7,a7 9 
p>agraph 7#b77;,a71 by ins]t+ & p>agraph
 7#c7 aft] subsection 7a77#b72 &  7,b7  
by add+ at ! end ! foll[+3  7#c7        
,prohibit+ unreasonable premium         
increases  7,a7 ,9 g5]al ,beg9n+ ) plan 
ye>s beg9n+ 9 #bjba1 ! ,secret>y1 or a  
,/ate pursuant to an effective rate     
review program meet+ ! requirem5ts "u   
p>agraph 7#d7--  7i7 %all1 consi/5t )   
subsection 7a77#b7 & p>agraph 7#b71     
review increases 9 premiums = heal?     
insurance cov]age t are subject to      
review pursuant to section #aed4bjj (   
title #de1 ,code ( ,f$]al ,regulations  
7or any successor regulation71 & det]m9e
 :e!r su* increases are unreasonable2 & 
7ii7 may prohibit a heal? insurance     
issu] f implem5t+ su* an increase t is  
unreasonable4  7,b7 ,unreasonable       

increases ,9 det]m9+ :e!r an increase 9 
premiums = heal? insurance cov]age is   
unreasonable "u subp>agraph 7,a77i7--   
7i7 ! ,secret>y %all consid] :e!r !     
increase is excessive1 unju/ifi$1       
discrim9atory1 or inadequate2 &  7ii7 ! 
,/ate1 pursuant to an effective rate    
review program meet+ ! requirem5ts "u   
p>agraph 7#d71 %all apply applicable    
,/ate law = mak+ su* det]m9ation4  7#d7 
,/ate effective rate review programs ,a 
,/ate effective rate review program     
meets ! requirem5ts "u ?is p>agraph if--
 7,a7 ! program c>ries out ! reviews    
describ$ 9 p>agraph 7#c77;,a77i7 &      
ensures t su* reviews are mean+ful1     
effective1 & timely reviews ( ! data &  
docum5tation 7includ+ any contracts or  
docum5ts describ$ 9 subp>agraph 7,e77   
submitt$ by heal? insurance issu]s 9    
support ( propos$ increases 9 premiums =
 heal? insurance cov]age2  7,b7 su*     
reviews include an exam9ation (-- 7i7 ! 
af=dability ( propos$ increases 9       
premiums = heal? insurance cov]age2     

7ii7 ! quality improvem5t activities    
c>ri$ out by heal? insurance issu]s     
propos+ ! increases2  7iii7 ! co/       
conta9m5t activities ( heal? insurance  
issu]s propos+ ! increases2 &  7iv7 !   
solv5cy ( ! heal? insurance cov]age2    
7,c7 ! program e/abli%es a me*anism =   
receiv+ public comm5ts on propos$       
increases 9 premiums = heal? insurance  
cov]age review$ by ! ,/ate2  7,d7 su*   
reviews include a review ( all public   
comm5ts receiv$ "u subp>agraph 7,c72    
7,e7 ! program requires ea* heal?       
insurance issu] propos+ an increase 9   
premiums = heal? insurance cov]age to   
submit to ! ,/ate any provid] contracts 
t may be affect$1 includ+ any docum5ts  
incorporat$ by ref]5ce into su*         
contracts2 &  7,f7 ! program requires ! 
,/ate to provide ! ,secret>y its        
det]m9ation ( :e!r ea* increase review$ 
is unreasonable1 9 a =m & mann]         
prescrib$ by ! ,secret>y4  2 &  7#c7 9  
subsection 7c7-- 7,a7 9 p>agraph 7#a7-- 
7i7 9 ! head+1 by /rik+ #bjaj ?r\gh     

#bjad & ins]t+ #bjba ?r\gh #bjbe2 &     
7ii7 9 ! matt] prec$+ subp>agraph 7,a71 
by /rik+ #bjaj & ins]t+ #bjba2 &  7,b7 9
 p>agraph 7#b77;,b71 by /rik+ #bjad &   
ins]t+ #bjbe4  #ajc4 ,effective date ,! 
am5dm5ts made by ?is title %all apply to
 plan ye>s beg9n+ aft] ,decemb] #ca1    
#bjbj4  ,,ii ,mak+ heal? insurance      
cov]age af=dable  #bja4 ,enhancem5t (   
premium assi/ance cr$it  7a7 ,use ( gold
 level plan = b5*m>k  7#a7 ,9 g5]al     
,clause 7i7 ( section #cf;,b7b77#b77;,b7
 ( ! ,int]nal ,rev5ue ,code ( #aihf is  
am5d$ by /rik+ applicable second l[e/   
co/ silv] plan & ins]t+ applicable      
second l[e/ co/ gold plan4  7#b7 ,con=m+
 am5dm5t relat$ to af=dability ,section 
#cf;,b7c77#d77;,c77i77,i7 ( su* ,code is
 am5d$ by /rik+ second l[e/ co/ silv]   
plan & ins]t+ second l[e/ co/ gold plan4
  7#c7 ,o!r con=m+ am5dm5ts             
,subp>agraphs 7,b7 & 7,c7 ( section     
#cf;,b7b77#c7 ( su* ,code are ea* am5d$ 
by /rik+ silv] plan ea* place x appe>s 9
 ! text & ! head+ & ins]t+ gold plan4   

7b7 ,expansion ( eligibility =          
refundable cr$its = cov]age "u qualifi$ 
heal? plans  7#a7 ,9 g5]al ,section     
#cf;,b7c77#a77;,a7 ( ! ,int]nal ,rev5ue 
,code ( #aihf is am5d$ by /rik+ b does n
 exce$ #djj p]c5t4  7#b7 ,con=m+        
am5dm5ts relat+ to recapture ( excess   
advanc$ paym5ts ,clause 7i7 ( section   
#cf;,b7f77#b77;,b7 ( su* ,code is       
am5d$-- 7,a7 by /rik+ ,9 ! case ( & all 
t foll[s ?r\gh ! am\nt ( & ins]t+ ,!    
am\nt (1 &  7,b7 by /rik+ b less ?an    
#djj 9 ! table !re94  7c7 ,det]m9ation (
 applicable p]c5tage  7#a7 ,9 g5]al     
,subp>agraph 7,a7 ( section             
#cf;,b7b77#c7 ( ! ,int]nal ,rev5ue ,code
 ( #aihf is am5d$ to read z foll[s3     
7,a7 ,applicable p]c5tage ,! applicable 
p]c5tage = any taxable ye> %all be !    
p]c5tage su* t ! applicable p]c5tage =  
any taxpay] ^: h\sehold income is )9 an 
income ti] specifi$ 9 ! foll[+ table    
%all increase1 on a slid+ scale 9 a l9e>
 mann]1 f ! initial premium p]c5tage to 
! f9al premium p]c5tage specifi$ 9 su*  

table = su* income ti]3  ,9 ! case (    
h\sehold9come 7express$ z a p]c5t (     
pov]ty l9e7 )9 !foll[+ income ti]3,!    
initialpremiump]c5tage is--,!           
f9alpremiump]c5tage is--  #ajj ?r\gh    
#accja4j #acc ?r\gh #aeja4jb4j #aej     
?r\gh #bjjb4jd4j #bjj ?r\gh #bejd4jf4j  
#bej ?r\gh #cjjf4jg4j #cjj ?r\gh        
#djjg4jh4e ,ov] #djjh4eh4e  4  7#b7     
,con=m+ am5dm5ts ,subsections           
7c77#b77;,c77iv7 & 7c77#d77;,f7 (       
section #cf;,b ( ! ,int]nal ,rev5ue     
,code ( #aihf are ea* am5d$ by ins]t+ 7z
 9 effect be=e ! date ( ! enactm5t ( !  
,consum] ,heal? ,insurance ,protection  
,act ( #bjai7 aft] subsection           
7b77#c77;,a77ii74  7d7 ,reconciliation (
 premium assi/ance cr$it & advance cr$it
 = s+le-,p>5t h\seholds  7#a7 ,9 g5]al  
,clause 7i7 ( section #cf;,b7f77#b77;,b7
 ( ! ,int]nal ,rev5ue ,code ( #aihf is  
am5d$ by /rik+ section #a7;c7 & ins]t+  
subsection 7b7 or 7c7 ( section #a4     
7#b7 ,effective date ,! am5dm5t made by 
?is subsection %all apply to taxable    

ye>s beg9n+ aft] ,decemb] #ca1 #bjai4   
7e7 ,det]m9ation ( premium assi/ance    
cr$it = disabl$ work]s  7#a7 ,9 g5]al   
,section #cf;,b7d77#b7 ( ! ,int]nal     
,rev5ue ,code ( #aihf is am5d$ by ins]t+
 at ! end ! foll[+ new subp>agraph3     
7,c7 ,exclusion ( c]ta9 am\nts receiv$ z
 lump-sum paym5t ,= purposes (          
subp>agraph 7,b71 su* am\nt %all n      
include any portion ( a lump-sum paym5t 
( disability insurance b5efits "u       
section #bbc ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #dbc7 :i* is--  7i7      
receiv$ dur+ ! taxable ye>1 &  7ii7     
attributable to prior taxable ye>s4  4  
7#b7 ,effective date ,! am5dm5t made by 
?is subsection %all apply to taxable    
ye>s beg9n+ aft] ,decemb] #ca1 #bjai4   
7f7 ,effective date ,! am5dm5ts made by 
?is section %all apply to taxable ye>s  
beg9n+ aft] ,decemb] #ca1 #bjbj4  #bjb4 
,enhancem5ts = r$uc$ co/-%>+  7a7       
,modification ( am\nt  7#a7 ,9 g5]al    
,section #adjb ( ! ,pati5t ,protection &
 ,af=dable ,c>e ,act 7#db ,u4,s4,c4     

#ahjga7 is am5d$--  7,a7 9 subsection   
7b77#a71 by /rik+ silv] & ins]t+ gold2  
7,b7 by am5d+ subsection 7c77#a77;,b7 to
 read z foll[s3  7,b7 ,coord9ation )    
actu>ial limits ,! ,secret>y %all ensure
 ! r$uction "u ?is p>agraph %all n      
result 9 ! plan's %>e ( ! total all[$   
co/s ( b5efits provid$ "u ! plan becom+ 
less ?an--  7i7 #ie p]c5t 9 ! case ( an 
eligible insur$ describ$ 9 p>agraph     
7#b77;,a72  7ii7 #ij p]c5t 9 ! case ( an
 eligible insur$ describ$ 9 p>agraph    
7#b77;,b72 &  7iii7 #he p]c5t 9 ! case (
 an eligible insur$ describ$ 9 p>agraph 
7#b77;,c74  2 &  7,c7 by am5d+          
subsection 7c77#b7 to read z foll[s3    
7#b7 ,additional r$uction ,! ,secret>y  
%all e/abli% proc$ures "u :i* ! issu] ( 
a qualifi$ heal? plan to :i* ?is section
 applies %all fur!r r$uce co/-%>+ "u !  
plan 9 a mann] suffici5t to--  7,a7 9 ! 
case ( an eligible insur$ ^: h\sehold   
income is n less ?an #ajj p]c5t b n m   
?an #bjj p]c5t ( ! pov]ty l9e = a family
 ( ! size involv$1 increase ! plan's %>e

 ( ! total all[$ co/s ( b5efits provid$ 
"u ! plan to #ie p]c5t ( su* co/s2  7,b7
 9 ! case ( an eligible insur$ ^:       
h\sehold income is m ?an #bjj p]c5t b n 
m ?an #cjj p]c5t ( ! pov]ty l9e = a     
family ( ! size involv$1 increase !     
plan's %>e ( ! total all[$ co/s (       
b5efits provid$ "u ! plan to #ij p]c5t (
 su* co/s2 &  7,c7 9 ! case ( an        
eligible insur$ ^: h\sehold income is m 
?an #cjj p]c5t b n m ?an #djj p]c5t ( ! 
pov]ty l9e = a family ( ! size involv$1 
increase ! plan's %>e ( ! total all[$   
co/s ( b5efits provid$ "u ! plan to #he 
p]c5t ( su* co/s4  4  7#b7 ,effective   
date  ,! am5dm5ts made by ?is subsection
 %all apply to plan ye>s beg9n+ aft]    
,decemb] #ca1 #bjbj4  7b7 ,fund+        
,section #adjb ( ! ,pati5t ,protection &
 ,af=dable ,c>e ,act 7#db ,u4,s4,c4     
#ahjga7 is am5d$ by add+ at ! end !     
foll[+ new subsection3  7g7 ,fund+ ,out 
( any funds 9 ! ,treasury n o!rwise     
appropriat$1 !re are appropriat$ to !   
,secret>y su* sums z may be necess>y =  

paym5ts "u ?is section4  4  #bjc4 ,cap  
on prescription drug co/-%>+  7a7       
,qualifi$ heal? plans ,section #acjb7;c7
 ( ! ,pati5t ,protection & ,af=dable    
,c>e ,act 7#db ,u4,s4,c4 #ahjbb7;c77 is 
am5d$-- 7#a7 9 p>agraph 7#c77;,a77i71 by
 ins]t+ 1 includ+ co/-%>+ ) respect to  
prescription drugs cov]$ by ! plan aft] 
*>ges2 &  7#b7 by add+ at ! end !       
foll[+3  7#e7 ,prescription drug co/-%>+
  7,a7 #bjba ,= plan ye>s beg9n+ 9      
#bjba1 ! co/-%>+ incurr$ "u a heal? plan
 ) respect to prescription drugs cov]$  
by ! plan %all n exce$ #bej p] mon? =   
ea* enroll$ individual1 or #ejj = ea*   
family4  7,b7 #bjbb & lat]  7i7 ,9 g5]al
 ,9 ! case ( any plan ye> beg9n+ 9 a    
cal5d> ye> aft] #bjba1 ! limitation "u  
?is p>agraph %all be equal to !         
applicable doll> am\nt "u subp>agraph   
7,a7 = plan ye>s beg9n+ 9 #bjba1        
increas$ by an am\nt equal to ! product 
( t am\nt & ! m$ical c>e compon5t ( !   
consum] price index = all urban consum]s
 7z publi%$ by ! ,bureau ( ,labor       

,/ati/ics7 = t ye>4  7ii7 ,adju/m5t to  
am\nt ,if ! am\nt ( any increase "u     
clause 7i7 is n a multiple ( #e1 su*    
increase %all be r\nd$ to ! next l[e/   
multiple ( #e4  4  7b7 ,gr\p heal? plans
 ,section #bgjg7;b7 ( ! ,public ,heal?  
,s]vice ,act 7#db ,u4,s4,c4             
#cjj;gg-#f7;b77 is am5d$-- 7#a7 by /rik+
 annual2 &  7#b7 by /rik+ p>agraph 7#a7 
( section #acjb7;c7 & ins]t+ p>agraphs  
7#a7 & 7#e7 ( section #acjb7;c7 ( !     
,pati5t ,protection & ,af=dable ,c>e    
,act4  7c7 ,effective date ,! am5dm5ts  
made by subsections 7a7 & 7b7 %all take 
effect ) respect to plans beg9n+ aft]   
,decemb] #ca1 #bjbj4  #bjd4 ,/&>diz$    
options 9 ! bronze1 silv]1 & gold levels
 ( cov]age  7a7 ,9 g5]al ,section       
#acja7;a7 ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjba7;a77 is am5d$-- 7#a7 9 p>agraph  
7#a77;,c7--  7,a7 9 clause 7iii71 by    
/rik+ 2 & & ins]t+ 22  7,b7 by          
r$esignat+ clause 7iv7 z clause 7v72 &  
7,c7 by ins]t+ aft] clause 7iii7 !      

foll[+3  7iv7 7,i7 agrees to (f] !      
applicable /&>diz$ option "u p>agraph   
7#e7 = ea* level ( cov]age (f]$ by !    
issu] t is ! bronze1 silv]1 or gold     
level ( cov]age2 &  7,,ii7 ) respect to 
(f]+ cov]age t is ! bronze1 silv]1 or   
gold level ( cov]age ?r\gh an ,ex*ange t
 is op]at$ by ! ,secret>y1 agrees to (f]
 only ! applicable /&>diz$ option "u    
p>agraph 7#e7 & n any o!r plan = su*    
levels ( cov]age2 &  2 &  7#b7 by add+  
at ! end ! foll[+3  7#e7 ,/&>diz$       
options  7,a7 ,def9ition ( /&>diz$      
option ,9 ?is section1 ! t]m /&>diz$    
option means a qualifi$ heal? plan--    
7i7 ) a /&>diz$ co/-%>+ /ructure        
e/abli%$ by ! applicable ,/ate1 or !    
,secret>y1 9 accordance ) ?is p>agraph2 
&  7ii7 t is (f]$ ?r\gh an ,ex*ange4    
7,b7 ,e/abli%m5t  7i7 ,/ate ,ea* ,/ate  
may e/abli% a /&>diz$ option = ! bronze1
 silv]1 & gold levels ( cov]age4  7ii7  
,secret>y ,! ,secret>y %all e/abli% a   
/&>diz$ option 9 a ,/ate = any level (  
cov]age describ$ 9 clause 7i7 = :i* !   

,/ate has n e/abli%$ a /&>diz$ option4  
7iii7 ,updates ,! ,secret>y %all        
annually update any /&>diz$ option      
e/abli%$ by ! ,secret>y "u clause 7ii74 
7,c7 ,d$uctible-exempt s]vices  7i7 ,9  
g5]al ,except z provid$ 9 clause 7ii71  
ea* /&>diz$ option e/abli%$ by !        
,secret>y "u subp>agraph 7,b77ii7 %all  
provide cov]age = & waive ! application 
( a d$uctible =--  7,i7 all prim>y c>e  
visits & speciali/ visits2  7,,ii7 all  
m5tal heal? & sub/ance use disord]      
outpati5t s]vices2  7,,iii7 all drugs   
approv$ "u section #eje7;j7 ( ! ,f$]al  
,food1 ,drug1 & ,cosmetic ,act &        
biological products lic5s$ "u section   
#cea7k7 ( ! ,public ,heal? ,s]vice ,act2
 &  7,,iv7 all urg5t c>e s]vices4  7ii7 
,bronze & silv] levels ( cov]age ,!     
,secret>y may alt] ! s]vices t %all be  
cov]$ z d$uctible-exempt s]vices "u     
clause 7i7 = /&>diz$ options 9 ! bronze 
& silv] levels ( cov]age4  7,d7 ,display
 ,ea* ,ex*ange op]at$ by a ,/ate %all   
pref]5tially display ! /&>diz$ options  

(f]$ 9 su* ,/ate on ! website ( !       
,ex*ange4  4  7b7 ,effective date ,!    
am5dm5ts made by ?is section %all apply 
to plans beg9n+ aft] ,decemb] #ca1      
#bjbj4  #bje4 ,d$uctible-exempt s]vices 
= gr\p heal? plans & gr\p heal?         
insurance cov]age  7a7 ,9 g5]al ,section
 #bgac ( ! ,public ,heal? ,s]vice ,act  
7#db ,u4,s4,c4 #cjj;gg-#ac7 is am5d$ by 
add+ at ! end ! foll[+3  7d7            
,d$uctible-,exempt s]vices = gr\p heal? 
plans & gr\p heal? insurance cov]age    
7#a7 ,9 g5]al ,subject to p>agraph 7#b71
 a gr\p heal? plan & a heal? insurance  
issu] (f]+ gr\p heal? insurance cov]age 
%all1 9 addition to ! requirem5t "u     
subsection 7a71 at a m9imum provide     
cov]age = & waive ! application ( a     
d$uctible =--  7,a7 all prim>y c>e      
visits & speciali/ visits2  7,b7 all    
m5tal heal? & sub/ance use disord]      
outpati5t s]vices2  7,c7 all drugs      
approv$ "u section #eje7;j7 ( ! ,f$]al  
,food1 ,drug1 & ,cosmetic ,act &        
biological products lic5s$ "u section   

#cea7k7 ( ! ,public ,heal? ,s]vice ,act2
 &  7,d7 all urg5t c>e s]vices4  7#b7   
,regulations ,! ,secret>y may issue     
regulations to--  7,a7 assi/ gr\p heal? 
plans & heal? insurance issu]s (f]+ gr\p
 heal? insurance cov]age 9 comply+ )    
p>agraph 7#a72 &  7,b7 alt] ! s]vices t 
%all be cov]$ z d$uctible-exempt s]vices
 "u p>agraph 7#a7 = gr\p heal? plans &  
gr\p heal? insurance cov]age ) levels ( 
cov]age t are design$ to provide b5efits
 t are actu>ially equival5t to #fj or   
#gj p]c5t ( ! full actu>ial value ( !   
b5efits provid$ "u ! plan or cov]age4  4
  7b7 ,effective date ,! am5dm5ts made  
by ?is section %all apply to plans      
beg9n+ aft] ,decemb] #ca1 #bjbj4  #bjf4 
,cl>ification reg>d+ det]m9ation (      
af=dability ( employ]-sponsor$ m9imum   
ess5tial cov]age  7a7 ,special rule =   
employ]-,sponsor$ m9imum ess5tial       
cov]age ,clause 7i7 ( section           
#cf;,b7c77#b77;,c7 ( ! ,int]nal ,rev5ue 
,code ( #aihf is am5d$ to read z foll[s3
  7i7 ,cov]age mu/ be af=dable  7,i7 ,9 

g5]al ,except z provid$ 9 clause 7iii71 
an individual %all n be treat$ z        
eligible = m9imum ess5tial cov]age if   
su* cov]age consi/s ( an eligible       
employ]-sponsor$ plan 7z def9$ 9 section
 #ejjj;,a7f77#b77 & ! requir$           
contribution ) respect to ! plan exce$s 
#h4e p]c5t ( ! applicable taxpay]'s     
h\sehold income4  7,,ii7 ,requir$       
contribution ) respect to employee ,9 ! 
case ( ! employee eligible to enroll 9 !
 plan1 ! requir$ contribution = purposes
 ( subclause 7,i7 is ! employee's       
requir$ contribution 7)9 ! mean+ (      
section #ejjj;,a7e77#a77;,b77i77 )      
respect to ! plan4  7,,iii7 ,requir$    
contribution ) respect to family memb]s 
,9 ! case ( an individual :o is eligible
 to enroll 9 ! plan by reason ( a       
relation%ip ! individual be>s to !      
employee1 ! requir$ contribution =      
purposes ( subclause 7,i7 is !          
employee's requir$ contribution 7)9 !   
mean+ ( section #ejjj;,a7e77#a77;,b77i71
 det]m9$ by sub/itut+ family =          

self-only7 ) respect to ! plan4  4  7b7 
,con=m+ am5dm5ts  7#a7 ,clause 7ii7 (   
section #cf;,b7c77#b77;,c7 ( ! ,int]nal 
,rev5ue ,code ( #aihf is am5d$ by add+  
at ! end ! foll[+3 ,?is clause %all also
 apply to an individual :o is eligible  
to enroll 9 ! plan by reason ( a        
relation%ip ! individual be>s to !      
employee44  7#b7 ,clause 7iii7 ( section
 #cf;,b7c77#b77;,c7 ( su* ,code is am5d$
 by /rik+ ! la/ s5t5ce ( clause 7i7 &   
ins]t+ clause 7i77,,iii74  7#c7 ,clause 
7iv7 ( section #cf;,b7c77#b77;,c7 ( su* 
,code is am5d$ by /rik+ clause 7i77,,ii7
 & ins]t+ clause 7i77,i74  7c7          
,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ,decemb] #ca1 #bjbj4  ,,iii 
,ensur+ access to c>e  #cja4 ,network   
adequacy requirem5ts  7a7 ,9 g5]al      
,section #acaa7;c7 ( ! ,pati5t          
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjca7;c77 is am5d$--  7#a7 9
 p>agraph 7#a77;,b71 by ins]t+ &        
p>agraph 7#g7 & 9 accordance ) p>agraph 

7#h7 aft] ,public ,heal? ,s]vice ,act2 &
  7#b7 by add+ at ! end ! foll[+3  7#g7 
,network adequacy requirem5ts  7,a7 ,9  
g5]al ,a qualifi$ heal? plan %all1 to be
 c]tifi$ "u ?is subsection1 meet !      
network adequacy /&>ds e/abli%$ by !    
,secret>y "u subp>agraph 7,b71 except z 
provid$ 9 subp>agraphs 7,b77ii7 & 7,c74 
7,b7 ,f$]al /&>ds & review  7i7 ,/&>d   
7,i7 ,e/abli%m5t ,! ,secret>y %all1 9   
consultation ) /akehold]s includ+       
p$iatric-specific /akehold]s1 e/abli% a 
network adequacy /&>d bas$ on access to 
9-network provid]s = qualifi$ heal?     
plans1 except = ^? plans describ$ 9     
subp>agraph 7,c74 ,su* /&>d %all--  7aa7
 include requirem5ts = ! m9imum numb] & 
type ( 9-network provid]s available1 !  
geographical location ( su* provid]s1 ! 
av]age di/ance & travel "t requir$ =    
pati5ts to visit su* provid]s1 & !      
av]age appo9tm5t wait times = s]vices   
cov]$ by ! plan2 &  7bb7 acc\nt =       
diff]5ces 9 ! ne$s ( *ildr5 & adults4   
7,,ii7 ,m$ic>e ,advantage organizations 

,! network adequacy /&>d e/abli%$ "u    
subclause 7,i7 %all1 at a m9imum1 be    
equival5t to ! requirem5ts = access to  
s]vices applicable to ,m$ic>e ,advantage
 organizations (f]+ ,m$ic>e ,advantage  
plans "u "p ,c ( title ,,xviii ( !      
,social ,security ,act4  7ii7           
,ju/ification ,a qualifi$ heal? plan t  
fails to meet ! /&>d e/abli%$ "u clause 
7i7 may satisfy ! requirem5t "u         
subp>agraph 7,a7 by provid+ ! ,secret>y 
) a reasonable ju/ification = ! v>iance 
f su* /&>d1 bas$ on factors su* z !     
availability ( provid]s & v>iables      
reflect$ 9 local patt]ns ( heal? c>e4   
7iii7 ,review ,! ,secret>y %all e/abli% 
a process = review+ ! network adequacy (
 qualifi$ heal? plans1 except = ^? plans
 review$ by ! ,/ate 9 accordance )      
subp>agraph 7,c77ii74  7,c7 ,/ate /&>d  
7i7 ,9 g5]al ,9 ! case ( a qualifi$     
heal? plan (f]$ 9 a ,/ate t has         
implem5t$ a quantifiable network        
adequacy metric t ! ,secret>y det]m9es  
is an acceptable metric commonly us$ 9 !

 heal? insurance indu/ry to measure     
network adequacy1 su* qualifi$ heal?    
plan may1 to be c]tifi$ "u ?is          
subsection1 satisfy ! requirem5t "u     
subp>agraph 7,a7 by meet+ ! network     
adequacy /&>ds ( su* ,/ate bas$ on su*  
metric4  7ii7 ,review ,a ,/ate ) an     
acceptable metric describ$ 9 clause 7i7 
may review ! network adequacy ( qualifi$
 heal? plans (f]$ 9 su* ,/ate 9 a       
process e/abli%$ by ! ,/ate4  7#h7      
,cov]age ( out-(-network ess5tial heal? 
b5efits  7,a7 ,9 g5]al ,a qualifi$ heal?
 plan %all1 to be c]tifi$ "u ?is        
subsection1 provide to individuals      
enroll$ 9 su* plan cov]age ( any s]vice 
provid$ by an out-(-network provid] if--
  7i7 cov]age ( su* s]vice w\ld o!rwise 
be provid$ by ! plan if ! s]vice 0      
provid$ by an 9-network provid]2  7ii7 !
 s]vice is includ$ 9 ! ess5tial heal?   
b5efits package describ$ 9 section      
#acjb7;a72 &  7iii7 ! s]vice _c be      
provid$ to ! individual by an 9-network 
provid] )9 a reasonable timeframe or )9 

a reasonable di/ance & travel "t4  7,b7 
,co/-%>+ ,a qualifi$ heal? plan t       
provides cov]age ( a s]vice provid$ by  
an out-(-network provid] "u subp>agraph 
7,a7 %all provide su* cov]age ) ! same  
co/-%>+ requirem5ts z if ! s]vice 0     
provid$ by an 9-network provid]4  4  7b7
 ,effective date ,! am5dm5ts made by    
subsection 7a7 %all apply to plans      
beg9n+ aft] ,decemb] #ca1 #bjbj4  7c7   
,grants = ,/ate network adequacy reviews
  7#a7 ,9 g5]al ,! ,secret>y ( ,heal? & 
,human ,s]vices %all c>ry out a program 
to aw>d grants to ,/ates dur+ ! #e-ye>  
p]iod beg9n+ ) fiscal ye> #bjba to assi/
 su* ,/ates 9 develop+ a metric to      
measure network adequacy z describ$ 9   
subp>agraph 7,c77i7 ( section           
#acaa7;c77#g7 ( ! ,pati5t ,protection & 
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjca7;c77#g77 & to c>ry out ! reviews 
describ$ 9 subp>agraph 7,c77ii7 ( su*   
section4  7#b7 ,au?orization (          
appropriations ,!re are au?oriz$ to be  
appropriat$ = ea* ( fiscal ye>s #bjba   

?r\gh #bjbe su* sums z may be necess>y  
to c>ry out ! grant program "u ?is      
subsection4  7d7 ,report  7#a7 ,9 g5]al 
,n lat] ?an ,decemb] #ca1 #bjbb1 !      
,secret>y %all prep>e1 & submit to      
,congress1 a report conta9+ ! analysis &
 recomm5dations describ$ 9 p>agraph     
7#b74  7#b7 ,analysis & recomm5dations  
,! report "u ?is subsection %all-- 7,a7 
analyze h[ network adequacy & access to 
c>e has *ang$ s9ce ! implem5tation ( ?is
 section1 includ+ ! am5dm5ts made by ?is
 section1 includ+ = *ildr52  7,b7       
include in=mation on ! availability (   
provid]s t are ess5tial community       
provid]s z describ$ 9 section           
#acaa7;c77#a77;,c7 ( ! ,pati5t          
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjca7;c77#a77;,c772 &  7,c7 
provide recomm5dations = su* legislation
 & adm9i/rative actions z ! ,secret>y   
consid]s appropriate to improve network 
adequacy1 includ+ ) respect to access to
 p$iatric s]vices & ess5tial community  
provid]s4  #cjb4 ,ensur+ adequate       

cov]age 9 areas ) few] ?an #c heal?     
insurance issu]s (f]+ qualifi$ heal?    
plans on ! ,/ate ,ex*ange  7a7          
,requirem5ts = ,m$ic>e ,advantage       
organizations  7#a7 ,9 g5]al ,section   
#aheg7;e7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciew-#bg7;e77 is am5d$ 
by add+ at ! end ! foll[+ new p>agraph3 
7#f7 ,requirem5t = c]ta9 ,m$ic>e        
,advantage organizations t (f] an ,,ma  
plan 9 an applicable area to also (f]   
qualifi$ heal? plans 9 ! applicable area
  7,a7 ,9 g5]al ,a contract "u ?is      
section ) an ,,ma organization describ$ 
9 subp>agraph 7,b7 %all require !       
organization to1 9 ea* applicable area 9
 :i* ! organization (f]s an ,,ma plan1  
also (f]1 ?r\gh ! individual m>ket 9 !  
,ex*ange op]at+ 9 ! ,/ate1 at lea/ "o   
qualifi$ heal? plan 9 ! silv] level (   
cov]age & at lea/ "o qualifi$ heal? plan
 9 ! gold level ( cov]age1 z describ$ 9 
section #acjb7;d7 ( ! ,pati5t           
,protection & ,af=dable ,c>e ,act4  7,b7
 ,,ma organizations describ$ ,an ,,ma   

organization describ$ 9 ?is subp>agraph 
is an ,,ma organization t1 9 addition to
 (f]+ an ,,ma plan 9 an applicable area1
 (f]s heal? insurance cov]age 9 ! gr\p  
m>ket or individual m>ket 9 ! ,/ate b   
does n (f] su* cov]age ?r\gh ! ,ex*ange 
op]at+ 9 ! ,/ate4  7,c7 ,notification ,!
 ,secret>y1 or ! ,/ate 9 ! case ( an    
,,ma organization (f]+ an ,,ma plan 9 an
 applicable area 9 a ,/ate ) an ,ex*ange
 op]at$ by ! ,/ate1 %all notify ea* ,,ma
 organization t is requir$ to (f] a     
qualifi$ heal? plan "u subp>agraph 7,a7 
= a plan ye> ( su* requirem5t4 ,su*     
notification %all be provid$ ea* ye>--  
7i7 beg9n+ ) respect to ! requirem5t =  
plan ye>s beg9n+ aft] ,decemb] #ca1     
#bjbj2 &  7ii7 n less ?an #a ye> prior  
to ! rate fil+ deadl9e = ! plan ye> = ! 
,ex*ange op]at+ 9 ! ,/ate 9 :i* ! ,,ma  
organization w be requir$ to (f] su*    
plan4  7,d7 ,waiv] ,! ,secret>y1 or !   
,/ate 9 ! case ( an ,,ma organization   
(f]+ an ,,ma plan 9 an applicable area 9
 a ,/ate ) an ,ex*ange op]at$ by !      

,/ate1 may waive ! requirem5t "u        
subp>agraph 7,a7 if--  7i7 by ! fir/ day
 ( ! plan ye> foll[+ ! det]m9ation1 !   
numb] ( heal? insurance issu]s (f]+ a   
qualifi$ heal? plan ?r\gh ! individual  
m>ket 9 ! ,ex*ange has increas$ su* t ! 
applicable area no long] has few] ?an #c
 heal? insurance issu]s (f]+ a qualifi$ 
heal? plan ?r\gh ! individual m>ket 9 ! 
,ex*ange op]at+ 9 ! ,/ate2 or  7ii7 !   
,secret>y1 or ! ,/ate 9 su* a case1     
det]m9es t ! requirem5t "u subp>agraph  
7,a7 w\ld cause ! ,,ma organization to  
become insolv5t4  7,e7 ,def9itions ,9   
?is p>agraph3 7i7 ,applicable area ,!   
t]m applicable area means an area 9 :i*1
 at ! "t ! ,secret>y or ! ,/ate s5ds !  
notification "u subp>agraph 7,c71 few]  
?an #c heal? insurance issu]s (f] a     
qualifi$ heal? plan ?r\gh ! individual  
m>ket 9 ! ,ex*ange op]at+ 9 ! ,/ate4    
7ii7 ,ex*ange ,! t]m ,ex*ange means an  
,am]ican ,heal? ,b5efit ,ex*ange        
e/abli%$ "u section #acaa or section    
#acba ( ! ,pati5t ,protection &         

,af=dable ,c>e ,act4  7iii7 ,gr\p m>ket 
,! t]m gr\p m>ket has ! mean+ giv5 su*  
t]m 9 section #acjd ( ! ,pati5t         
,protection & ,af=dable ,c>e ,act4  7iv7
 ,heal? insurance cov]age ,! t]m heal?  
insurance cov]age has ! mean+ giv5 ! t]m
 9 section #bgia7;b7 ( ! ,public ,heal? 
,s]vice ,act4  7v7 ,individual m>ket ,! 
t]m individual m>ket has ! mean+ giv5   
su* t]m 9 section #acjd ( ! ,pati5t     
,protection & ,af=dable ,c>e ,act4  7vi7
 ,qualifi$ heal? plan ,! t]m qualifi$   
heal? plan has ! mean+ giv5 t t]m 9     
section #acja7;a7 ( ! ,pati5t           
,protection & ,af=dable ,c>e ,act4  4   
7#b7 ,effective date ,! am5dm5t made by 
?is subsection %all apply to contracts  
ent]$ into or r5ew$ aft] ,decemb] #ca1  
#bjbj4  7b7 ,requirem5ts = m$icaid      
manag$ c>e organizations  7#a7 ,9 g5]al 
,section #aijc7m77#b77;,a7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#acif;b7m77#b77;,a77 is am5d$-- 7,a7 9  
clause 7xii71 by /rik+ 2 & & ins]t+ a   
semicolon2  7,b7 by realign+ ! left m>g9

 ( clause 7xiii7 to align ) ! left m>g9 
( clause 7xii72  7,c7 9 clause 7xiii71  
by /rik+ ! p]iod at ! end & ins]t+ 2 &2 
&  7,d7 by ins]t+ aft] clause 7xiii7 !  
foll[+3  7xiv7 su* contract requires t !
 entity meets ! requirem5ts describ$ 9  
section #aheg7;e77#f7 9 ! same mann] z  
su* requirem5ts apply to an ,,ma        
organization4  4  7#b7 ,effective date  
,! am5dm5ts made by ?is subsection %all 
apply to contracts ent]$ into or r5ew$  
aft] ,decemb] #ca1 #bjbj4  #cjc4        
,enrollm5t 9 ,ex*anges  7a7 ,op5        
enrollm5t & special enrollm5t p]iods    
,section #acaa7;c77#f7 ( ! ,pati5t      
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjca7;c77#f77 is am5d$--    
7#a7 9 subp>agraph 7,b71 by ins]t+ t are
 n less ?an #h weeks aft] op5 enrollm5t 
p]iods2  7#b7 9 subp>agraph 7,c71 by    
/rik+ 2 & & ins]t+ 22  7#c7 9           
subp>agraph 7,d71 by /rik+ ! p]iod &    
ins]t+ 22 &  7#d7 by add+ at ! end !    
foll[+3  7,e7 a special enrollm5t p]iod 
= qualifi$ individuals enroll$ 9 a plan 

t makes significant provid] t]m9ations  
dur+ ! plan ye>1 z det]m9$ 9 accordance 
) regulations promulgat$ by ! ,secret>y2
 &  7,f7 a special enrollm5t p]iod-- 7i7
 = ea* qualifi$ individual :o--  7,i7 is
 det]m9$ by ! ,ex*ange to be eligible = 
a premium assi/ance cr$it "u section    
#cf;,b ( ! ,int]nal ,rev5ue ,code (     
#aihf2 &  7,,ii7 has a h\sehold income n
 9 excess ( #cjj p]c5t ( ! pov]ty l9e = 
! size ( ! family involv$2 &  7ii7 :i*  
%all beg9 on ! date on :i* ! individual 
is det]m9$ by ! ,ex*ange to be eligible 
= a premium assi/ance cr$it "u su*      
section #cf;,b4  4  7b7 ,consum]        
protections reg>d+ automatic            
re-,enrollm5t ,"p #b ( subtitle ,d (    
title ,i ( ! ,pati5t ,protection &      
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjca et seq47 is am5d$ by add+ at !   
end ! foll[+3  #acad4 ,consum]          
protections reg>d+ automatic            
re-enrollm5t  7a7 ,cons5t ,to avoid     
automatic re-,enrollm5t = individuals   
los+ eligibility = premium assi/ance    

cr$its ,! ,secret>y %all e/abli% a      
process to all[ an individual1 :o is    
enroll+ 9 a qualifi$ heal? plan ?r\gh an
 ,ex*ange & :om ! ,ex*ange e/imates is  
eligible to receive a premium assi/ance 
cr$it "u section #cf;,b ( ! ,int]nal    
,rev5ue ,code ( #aihf1 to provide cons5t
 to ! ,ex*ange to n automatically       
re-enroll ! individual 9 su* qualifi$   
heal? plan 7or a comp>able qualifi$     
heal? plan 9 a case describ$ 9          
subsection 7b77 = ! foll[+ plan ye> if  
dur+ ! plan ye> ! ,ex*ange e/imates t ! 
individual has become no long] eligible 
to receive su* cr$it4  7b7 ,notice      
reg>d+ discont9u$ plans ,9 ! case ( an  
individual :o is enroll$ 9 a qualifi$   
heal? plan ?r\gh an ,ex*ange = a plan   
ye> t w n be (f]$ ?r\gh su* ,ex*ange = !
 foll[+ plan ye>1 ! ,ex*ange ?r\gh :i*  
su* plan is (f]$ %all1 prior to ! op5   
enrollm5t p]iod = ! foll[+ plan ye>1 s5d
 ! individual a notice /at+--  7#a7 t ! 
qualifi$ heal? plan 9 :i* ! individual  
is enroll$ w n be (f]$ ?r\gh su*        

,ex*ange = ! foll[+ plan ye>2  7#b7 t   
unless ! individual takes action1 !     
individual w be enroll$ 9 a comp>able   
qualifi$ heal? plan = ! foll[+ plan ye>2
  7#c7 ! e/imat$ am\nt ( premiums = su* 
comp>able qualifi$ heal? plan2 &  7#d7  
cle> in=mation on ! eligibility ( !     
individual = a special enrollm5t p]iod4 
7c7 ,notice reg>d+ automatic            
re-,enrollm5t ,any notice reg>d+        
automatic re-enrollm5t s5t by an        
,ex*ange to an individual enroll$ 9 a   
qualifi$ heal? plan %all be provid$ to !
 individual 9 ! language t ! individual 
has indicat$ to ! ,ex*ange z ! pref]r$  
language ( ! individual4  7d7           
,retroactive t]m9ation  7#a7 ,9 g5]al ,!
 ,secret>y %all e/abli% a process to    
all[ an individual :o is automatically  
re-enroll$ 9 a qualifi$ heal? plan = a  
plan ye> & :o has enroll$ 9 o!r         
cr$itable cov]age = t plan ye> to       
retroactively t]m9ate su* qualifi$ heal?
 plan = su* plan ye>4  7#b7 ,cr$itable  
cov]age ,9 ?is subsection1 ! t]m        

cr$itable cov]age has ! mean+ giv5 ! t]m
 9 section #bgjd7;c77#a7 ( ! ,public    
,heal? ,s]vice ,act4  4  7c7 ,effective 
date ,! am5dm5ts made by ?is section    
%all apply to plan ye>s beg9n+ aft] !   
date ( enactm5t ( ?is ,act4  7d7 ,/udy  
,! ,secret>y %all conduct a /udy t      
exam9es ! practices us$ by ! ,ex*anges =
 notify+ consum]s ( automatic           
re-enrollm5t 9 qualifi$ heal? plans &   
id5tifies /rategies =--  7#a7 improv+   
automatic re-enrollm5t & r5ewal         
notifications2  7#b7 improv+ ! ability  
to rea* consum]s 9 provid+ su* notices2 
7#c7 increas+ consum] compreh5sion ( su*
 notices2 &  7#d7 enc\rag+ consum]s to--
  7,a7 update in=mation t w affect      
eligibility = premium assi/ance cr$its  
"u section #cf;,b ( ! ,int]nal ,rev5ue  
,code ( #aihf & ! am\nt ( su* cr$its2 & 
7,b7 %op = qualifi$ heal? plans t w be/ 
meet _! ne$s ?r\gh ! ,ex*ange op]at+ 9  
_! ,/ate4  #cjd4 ,m>ket+ & outrea* =    
,ex*anges op]at$ by ! ,secret>y ,"p #b (
 subtitle ,d ( title ,i ( ! ,pati5t     

,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjca et seq471 z am5d$ by   
section #cjc7;b71 is fur!r am5d$ by add+
 at ! end ! foll[+3  #acae4 ,m>ket+ &   
outrea* = ,ex*anges op]at$ by !         
,secret>y  7a7 ,9 g5]al ,out ( ! funds  
appropriat$ "u subsection 7b71 !        
,secret>y %all conduct a m>ket+ &       
outrea* program ) respect to qualifi$   
heal? plans (f]$ ?r\gh ,ex*anges op]at$ 
by ! ,secret>y 9 ord] to enc\rage       
enrollm5t 9 su* plans4  7b7             
,appropriations  7#a7 ,enc\rag+         
enrollm5t = plan ye> #bjbj ,!re is      
appropriat$ to ! ,secret>y1 out ( any   
moneys 9 ! ,treasury n o!rwise          
appropriat$1 #dhj1jjj1jjj to c>ry out ! 
m>ket+ & outrea* program "u subsection  
7a7 ) respect to enc\rag+ enrollm5t =   
qualifi$ heal? plans t beg9 9 cal5d> ye>
 #bjbj4  7#b7 ,enc\rag+ enrollm5t =     
subsequ5t plan ye>s ,to c>ry out !      
m>ket+ & outrea* program "u subsection  
7a7 ) respect to enc\rag+ enrollm5t =   
qualifi$ heal? plans t beg9 9 ea* (     

cal5d> ye>s #bjba ?r\gh #bjbe1 !re is   
appropriat$ to ! ,secret>y prior to ea* 
su* cal5d> ye>1 out ( any moneys 9 !    
,treasury n o!rwise appropriat$1 an     
am\nt equal to ! am\nt appropriat$ "u   
?is subsection = ! prior cal5d> ye>     
increas$ by #d p]c5t = ea* su* cal5d>   
ye>4  7#c7 ,availability ,! am\nts      
appropriat$ "u p>agraphs 7#a7 & 7#b7    
%all rema9 available until exp5d$4  4   
#cje4 ,navigator program ,section       
#acaa7;i7 ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjca7;i77 is am5d$--  7#a7 9 p>agraph 
7#b7-- 7,a7 9 subp>agraph 7,b71 by /rik+
 & o!r entities & ins]t+ & o!r entities 
7su* z ,indian tribes1 tribal           
organizations1 urban ,indian            
organizations1 & ,/ate or local human   
s]vice ag5cies72 &  7,b7 by add+ at !   
end ! foll[+3  7,c7 ,pref]5ce ,an       
,ex*ange %all ensure t1 ea* ye>1 x aw>ds
 a grant "u p>agraph 7#a7 to--  7i7 at  
lea/ "o entity describ$ 9 ?is p>agraph t
 is a community & consum]-focus$        

nonpr(it gr\p2 &  7ii7 at lea/ "o entity
 describ$ 9 subp>agraph 7,b71 :i* may   
include ano!r community & consum]-focus$
 nonpr(it gr\p4  2  7#b7 9 p>agraph     
7#c7-- 7,a7 9 subp>agraph 7,d71 by /rik+
 2 & & ins]t+ 22  7,b7 9 subp>agraph    
7,e71 by /rik+ ! p]iod & ins]t+ 2 &2 &  
7,c7 by add+ at ! end ! foll[+3  7,f7   
provide t>get$ assi/ance to individuals 
likely to qualify = a special enrollm5t 
p]iod "u subp>agraph 7,c71 7,d71 or 7,e7
 ( subsection 7c77#f74  2 &  7#c7 9     
p>agraph 7#d77;,a7-- 7,a7 9 ! matt]     
prec$+ clause 7i71 by /rik+ n2  7,b7 9  
clause 7i7-- 7i7 by ins]t+ n be=e be2 & 
7ii7 by /rik+ 2 or & ins]t+ 22  7,c7 9  
clause 7ii7--  7i7 by ins]t+ n be=e     
receive2 &  7ii7 by /rik+ ! p]iod &     
ins]t+ 22 &  7,d7 by add+ at ! end !    
foll[+3  7iii7 ma9ta9 physical pres5ce 9
 ! ,/ate ( ! ,ex*ange s z to all[       
9-p]son assi/ance to consum]s2 &  7iv7 n
 provide comp5sation to an employee     
employ$ by ! navigator bas$ on ! numb] (
 individuals ! employee assi/s 9 enroll+

 9 qualifi$ heal? plans4  4  ,,iv       
,/r5g!n+ consum] heal? insurance        
protections  #dja4 ,prohibit+           
discrim9atory premiums bas$ on tobacco  
use  7a7 ,9 g5]al ,section              
#bgja7;a77#a77;,a7 ( ! ,public ,heal?   
,s]vice ,act 7#db ,u4,s4,c4             
#cjj;gg7a77#a77;,a77 is am5d$-- 7#a7 9  
clause 7ii71 by ins]t+ & aft] !         
semicolon2 &  7#b7 by /rik+ clause 7iv74
  7b7 ,effective date ,! am5dm5ts made  
by ?is section %all apply to plan ye>s  
beg9n+ aft] ,decemb] #ca1 #bjbj4  #djb4 
,heal? insurance consum] in=mation      
,section #bgic ( ! ,public ,heal?       
,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ic7
 is am5d$-- 7#a7 9 subsection 7d7--     
7,a7 9 ! second s5t5ce1 by /rik+ & %all 
%>e & ins]t+ 1 %all %>e2 &  7,b7 by     
/rik+ ! p]iod at ! end ( second s5t5ce &
 ins]t+ 1 & 7n lat] ?an #b ye>s aft] !  
date ( enactm5t ( ! ,consum] ,heal?     
,insurance ,protection ,act ( #bjai7    
%all make su* data available to ! public
 9 a se>*able =mat on an int]net website

 e/abli%$ by ! ,secret>y42 &  7#b7 9    
subsection 7e7-- 7,a7 9 p>agraph 7#a71  
by /rik+ #cj1jjj1jjj = ! fir/ fiscal ye>
 = :i* ?is section applies & ins]t+     
#ej1jjj1jjj = ea* ( fiscal ye>s #bjba   
?r\gh #bjbe2 &  7,b7 9 p>agraph 7#b71 by
 /rik+ ea* fiscal ye> foll[+ ! fiscal   
ye> describ$ 9 p>agraph 7#a7 & ins]t+   
fiscal ye> #bjbf & ea* fiscal ye>       
!reaft]4  #djc4 ,pati5t protections  7a7
 ,9 g5]al ,section #bgai;,a ( ! ,public 
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg-#ai;a7 is am5d$--  7#a7 9       
subsection 7b7-- 7,a7 9 p>agraph 7#a71 9
 ! matt] prec$+ subp>agraph 7,a71 by    
/rik+ p>agraph 7#b77;,b7 & ins]t+       
p>agraph 7#c77;,b72  7,b7 by r$esignat+ 
p>agraph 7#b7 z p>agraph 7#c72  7,c7 by 
ins]t+ aft] p>agraph 7#a7 ! foll[+3     
7#b7 ,reimbursem5t ,a gr\p heal? plan or
 heal? insurance issu] (f]+ gr\p or     
individual heal? insurance cov]age %all 
reimburse an out-(-network provid]      
provid+ em]g5cy s]vices to an individual
 :o is a p>ticipant1 b5efici>y1 or      

enrollee ( su* plan or cov]age at an    
am\nt equal to ! greate/ (--  7,a7 !    
m$ian am\nt negotiat$ ) 9-network       
provid]s = ! em]g5cy s]vice2  7,b7 !    
am\nt = ! em]g5cy s]vice calculat$ us+ !
 same me?od ! plan or issu] uses to     
det]m9e paym5ts = out-(-network s]vices 
t are n em]g5cy s]vices2 or  7,c7 !     
am\nt t w\ld be paid to a provid] (     
s]vices or suppli] ) respect to !       
furni%+ ( su* s]vice "u title ,,xviii ( 
! ,social ,security ,act4  2 &  7,d7 9  
p>agraph 7#c77;,b71 z s r$esignat$-- 7i7
 clause 7i71 by ins]t+ 1 includ+        
ambulance s]vices provid$ by gr\nd or   
air transportation be=e 1 & at ! end2 & 
7ii7 9 clause 7ii71 by /rik+ ! p]iod at 
! end & ins]t+ 1 includ+ ambulance      
s]vices provid$ by gr\nd or air         
transportation42 &  7#b7 by add+ at !   
end ! foll[+3  7e7 ,cov]age ( s]vices by
 out-(-,network provid]s bas$ on plan or
 issu] error  7#a7 ,9 g5]al ,a gr\p     
heal? plan or heal? insurance issu] (f]+
 gr\p or individual heal? insurance     

cov]age %all provide cov]age ( a s]vice 
provid$ by an out-(-network provid] to  
an individual :o is a p>ticipant1       
b5efici>y1 or enrollee ( su* plan or    
cov]age if--  7,a7 ! plan or issu] w\ld 
h provid$ cov]age ( ! s]vice if ! s]vice
 0 provid$ by an 9-network provid]2 &   
7,b7 9 *oos+ su* provid]1 ! individual  
reasonably reli$ on a mat]ially         
inaccurate1 incomplete1 or mislead+     
/atem5t ( in=mation conta9$ 9 a         
directory ( 9-network provid]s compil$  
by ! plan or issu]4  7#b7 ,co/-%>+ ,a   
gr\p heal? plan or heal? insurance issu]
 t provides cov]age ( a s]vice provid$  
by an out-(-network provid] "u p>agraph 
7#a7 %all provide su* cov]age ) ! same  
co/-%>+ requirem5t t w\ld apply if !    
s]vices 7 provid$ 9-network4  7f7       
,cov]age = enrollees 9 active c\rse (   
treatm5t  7#a7 ,9 g5]al ,a gr\p heal?   
plan or heal? insurance issu] (f]+ gr\p 
or individual heal? insurance cov]age   
%all1 at ! reque/ ( an individual :o is 
a p>ticipant1 b5efici>y1 or enrollee (  

su* plan or cov]age & 9 accordance )    
p>agraphs 7#d7 & 7#e71 provide to su*   
individual cov]age ( s]vices = an active
 c\rse ( treatm5t provid$ by a provid] t
 is an out-(-network provid] ) respect  
to su* plan or cov]age if--  7,a7       
cov]age ( su* s]vices w\ld be provid$ "u
 ! gr\p heal? plan or heal? insurance   
cov]age if ! s]vices 7 provid$ by an    
9-network provid]2 &  7,b7 a circum/ance
 describ$ 9 p>agraph 7#c7 applies4  7#b7
 ,co/-%>+ ,a gr\p heal? plan or heal?   
insurance issu] (f]+ gr\p or individual 
heal? insurance cov]age %all ensure t   
any co/-%>+ requirem5ts = cov]age (     
s]vices = an active c\rse ( treatm5t    
provid$ by an out-(-network provid] "u  
p>agraph 7#a7 are ! same requirem5ts z  
if su* s]vices 7 provid$ by an 9-network
 provid]4  7#c7 ,circum/ance ,a         
circum/ance describ$ 9 ?is p>agraph is a
 circum/ance 9 :i*-- 7,a7 ) respect to a
 heal? insurance issu] (f]+ gr\p or     
individual heal? insurance cov]age--    
7i7 ! individual 0 receiv+ s]vices = !  

active c\rse ( treatm5t describ$ 9      
p>agraph 7#a7 f ! out-(-network provid] 
describ$ 9 su* p>agraph dur+ ! prior    
plan ye> :5--  7,i7 ! individual 0 a    
p>ticipant1 b5efici>y1 or enrollee ( a  
diff]5t heal? insurance cov]age (f]$ by 
su* heal? insurance issu]2 &  7,,ii7 su*
 provid] 0 an 9-network provid] )       
respect to su* diff]5t heal? insurance  
cov]age2 &  7ii7 ! heal? insurance issu]
 decid$ to cancel or discont9ue (f]+ su*
 diff]5t heal? insurance cov]age = !    
plan ye> = :i* ! individual makes !     
reque/1 includ+ a case 9 :i* su* diff]5t
 heal? insurance cov]age is )drawn f !  
m>ket = su* plan ye>2 &  7,b7 !         
individual 0 receiv+ s]vices = ! active 
c\rse ( treatm5t describ$ 9 p>agraph    
7#a7 f ! out-(-network provid] describ$ 
9 su* p>agraph :ile ! provid] 0 an      
9-network provid] = ! gr\p heal? plan or
 heal? insurance cov]age = ! plan ye>1  
&1 dur+ su* plan ye>1 ! provid] became a
 t]m9at$ provid] ) respect to su* plan  
or cov]age = ! rema9d] ( su* plan ye>4  

7#d7 ,duration  ,a gr\p heal? plan or   
heal? insurance issu] (f]+ gr\p or      
individual heal? insurance cov]age %all 
provide cov]age ( s]vices = an active   
c\rse ( treatm5t "u p>agraph 7#a7 until 
! e>li] (--  7,a7 ! date on :i* !       
treatm5t is complete2 or  7,b7 ! date t 
is #ahj days foll[+ ! fir/ date on :i* !
 provid] describ$ 9 p>agraph 7#a7 is no 
long] an 9-network provid] ( ! plan or  
cov]age 9 provid+ su* s]vices to !      
individual4  7#e7 ,reque/ = cont9uity ( 
c>e ,a reque/ made "u p>agraph 7#a7 %all
 be subject to any int]nal or ext]nal   
grievance or appeals process ( ! gr\p   
heal? plan or heal? insurance issu]1 9  
accordance ) any applicable ,/ate or    
,f$]al law4  7#f7 ,def9itions ,=        
purposes ( ?is subsection3 7,a7 ,active 
c\rse ( treatm5t ,! t]m active c\rse (  
treatm5t means any ( ! foll[+3  7i7 ,an 
ongo+ c\rse ( treatm5t =-- 7,i7 a       
life-?reat5+ condition2  7,,ii7 a s]i\s1
 acute condition2 or  7,,iii7 a s]i\s1  
*ronic condition4  7ii7 ,c>e provid$ )  

respect to pregnancy1 includ+ until !   
completion ( po/p>tum c>e directly      
relat$ to ! deliv]y4  7iii7 ,an ongo+   
c\rse ( treatm5t = a *ild betwe5 bir? & 
#cf mon?s4  7iv7 ,! p]=mance ( a surg]y 
or o!r proc$ure t1 z docum5t$ prior to !
 "t ! provid] became an out-(-network   
provid] ) respect to ! gr\p heal? plan  
or heal? insurance cov]age--  7,i7 !    
plan or issu] (f]+ su* cov]age au?oriz$ 
z "p ( a c\rse ( treatm5t = !           
individual2 &  7,,ii7 ! provid]         
recomm5d$ = su* individual4  7,b7       
,t]m9at$ provid] ,! t]m t]m9at$         
provid]--  7i7 means a provid] t _h a   
contract ) a gr\p heal? plan or heal?   
insurance issu] (f]+ gr\p or individual 
heal? insurance cov]age to provide      
s]vices z an 9-network provid] ) respect
 to su* plan or cov]age = a plan ye>1 &1
 dur+ su* plan ye>1 ! plan or issu]     
t]m9at$ su* contract or did n r5ew su*  
contract = ! rema9d] ( ! plan ye>2 &    
7ii7 does n include-- 7,i7 any provid] t
 volunt>ily t]m9at$ or did n r5ew su*   

contract = ! rema9d] ( ! plan ye>2 &    
7,,ii7 any provid] ^: contract ) ! plan 
or issu] t]m9at$1 or 0 n r5ew$1 = !     
rema9d] ( ! plan ye> = reasons relat+ to
 a m$ical discipl9>y cause1 fraud1 or   
o!r crim9al activity4  7g7 ,limitations 
on *anges 9 cov]age ( prescription drugs
  7#a7 ,9 g5]al ,a gr\p heal? plan or   
heal? insurance issu] (f]+ gr\p or      
individual heal? insurance cov]age %all 
n1 dur+ a plan ye>1 take any ( ! foll[+ 
actions ) respect to cov]age = su* plan 
ye>3  7,a7 ,remove a prescription drug f
 a =mul>y ( prescription drugs cov]$ by 
su* plan or cov]age1 except z provid$ 9 
p>agraph 7#b77;,c74  7,b7 ,increase !   
obligation ( a p>ticipant1 b5efici>y1 or
 enrollee ) respect to co/-%>+1 z def9$ 
9 section #acjb7;c77#c7 ( ! ,pati5t     
,protection & ,af=dable ,c>e ,act1 = a  
prescription drug cov]$ "u su* plan or  
cov]age4  7#b7 ,rule ( con/ruction ,no?+
 9 ?is subsection %all prohibit a gr\p  
heal? plan or heal? insurance issu] (f]+
 gr\p or individual heal? insurance     

cov]age f1 dur+ a plan ye>1 tak+ any ( !
 foll[+ actions ) respect to cov]age "u 
! plan or heal? insurance cov]age = su* 
plan ye>3  7,a7 ,*ang+ ! policy ( ! plan
 or heal? insurance cov]age to require a
 p>ticipant1 b5efici>y1 or enrollee to  
use a g5]ic sub/itution = a br&$        
prescription drug4  7,b7 ,add+ a new    
prescription drug to a =mul>y (         
prescription drugs cov]$ by su* plan or 
heal? insurance cov]age4  7,c7 ,remov+ a
 prescription drug f su* a =mul>y due to
 pati5t safety conc]ns1 or a            
prescription drug recall1 or remov+ a   
prescription drug f int]/ate comm]ce z  
det]m9$ necess>y by ! ,secret>y4  4  7b7
 ,effective date ,! am5dm5ts made by ?is
 section %all apply to plan ye>s beg9n+ 
aft] ,decemb] #ca1 #bjbj4  #djd4        
,limitation on balance bill+ = em]g5cy  
s]vices  7a7 ,9 g5]al ,a heal? c>e      
provid] t provides any em]g5cy s]vice to
 an individual t is a p>ticipant1       
b5efici>y1 or enrollee ( a gr\p heal?   
plan1 gr\p heal? insurance cov]age1 or  

individual heal? insurance cov]age & t  
is n an 9-network provid] ( su* plan or 
cov]age %all n impose a *>ge on su*     
individual = su* em]g5cy s]vice1 o!r ?an
 any co/-%>+ t w\ld o!rwise be          
applicable if ! heal? c>e provid] 0 an  
9-network provid] ( su* plan or heal?   
insurance cov]age4  7b7 ,en=cem5t ,!    
,secret>y may impose a civil monet>y    
p5alty1 9 ! same mann] z su* p5alties   
are au?oriz$ "u section #aabh;,a ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acbj;a-#g;a7 = violations ( balance    
bill+ prohibitions "u "p ,b ( title     
,,xviii ( su* ,act 7#db ,u4,s4,c4       
#acie;j et seq471 on any provid] t      
violates ! requirem5t "u subsection 7a74
  7c7 ,def9itions ,9 ?is section3 7#a7  
,co/-%>+ ,! t]m co/-%>+ has ! mean+ giv5
 ! t]m 9 section #acjb7;c77#c7 ( !      
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjbb7;c77#c774    
7#b7 ,em]g5cy s]vice ,! t]m em]g5cy     
s]vice has ! mean+ giv5 su* t]m 9       
p>agraph 7#c77;,b7 ( section #bgai;,a7b7

 ( ! ,public ,heal? ,s]vice ,act 7#db   
,u4,s4,c4 #cjj;gg-#ai;a7b771 z am5d$ by 
section #djc7;a74  7#c7 ,gr\p heal?     
plan1 gr\p heal? insurance cov]age1 &   
individual heal? insurance cov]age ,!   
t]ms gr\p heal? plan1 gr\p heal?        
insurance cov]age1 & individual heal?   
insurance cov]age h ! mean+s giv5 su*   
t]ms 9 section #bgia ( ! ,public ,heal? 
,s]vice ,act 7#db ,u4,s4,c4             
#cjj;gg-#ia74  7#d7 ,secret>y ,! t]m    
,secret>y means ! ,secret>y ( ,heal? &  
,human ,s]vices4  7d7 ,effective date   
,?is section %all apply to plan ye>s    
beg9n+ aft] ,decemb] #ca1 #bjbj4  #dje4 
,notification ( provid] t]m9ations      
,subp>t ,,ii ( "p ,a ( title ,,xxvii ( !
 ,public ,heal? ,s]vice ,act 7#db       
,u4,s4,c4 #cjj;gg-#aa et seq47 is am5d$ 
by add+ at ! end ! foll[+3  #bgcj4      
,notification ( provid] t]m9ations  7a7 
,9 g5]al ,beg9n+ ,janu>y #a1 #bjbj1 a   
gr\p heal? plan or heal? insurance issu]
 (f]+ gr\p or individual heal? insurance
 cov]age %all in=m individuals describ$ 

9 subsection 7b7 ( ! t]m9ation ( any    
provid] z an 9-network provid] "u ! plan
 or heal? insurance cov]age4 ,su* notice
 %all be provid$ n lat] ?an #cj days    
prior to ! t]m9ation4  7b7 ,individuals 
,! individuals describ$ 9 ?is subsection
 are any individuals enroll$ 9 ! gr\p   
heal? plan or heal? insurance cov]age   
describ$ 9 subsection 7a7 :o h se5 !    
provid] describ$ 9 su* subsection on a  
regul> basis or :o h receiv$ prim>y c>e 
f su* provid]4  4  #djf4 ,%ort-t]m      
limit$ duration heal? insurance cov]age 
7a7 ,9 g5]al ,section #bgia7;b77#e7 ( ! 
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #cjj;gg-#ia7;b77#e77 is am5d$ 
by /rik+ b does n include & ins]t+      
includ+4  7b7 ,effective date ,! am5dm5t
 made by ?is section %all apply to plan 
ye>s beg9n+ aft] ,decemb] #ca1 #bjbj4   
#djg4 ,protect+ ess5tial heal? b5efits &
 cov]age ( p$iatric s]vices  7a7        
,protect+ ess5tial heal? b5efits        
,section #acjb7;b7 ( ! ,pati5t          
,protection & ,af=dable ,c>e ,act 7#db  

,u4,s4,c4 #ahjbb7;b77 is am5d$--  7#a7 9
 p>agraph 7#b77;,b7 & p>agraph 7#c71 by 
/rik+ 7#d77;,h7 ea* place x appe>s &    
ins]t+ 7#d77;,i72 &  7#b7 9 p>agraph    
7#d7--  7,a7 9 subp>agraph 7,a7-- 7i7 by
 /rik+ su* subsection & ins]t+ su*      
p>agraph2 &  7ii7 by ins]t+ & cov]age 9 
e category is includ$ be=e ! semicolon2 
7,b7 by r$esignat+ subp>agraphs 7,e7    
?r\gh 7,h7 z subp>agraphs 7,f7 ?r\gh    
7,i71 respectively2 &  7,c7 by ins]t+   
aft] subp>agraph 7,d7 ! foll[+3  7,e7   
ensure t1 to be treat$ z provid+ cov]age
 = ! ess5tial heal? b5efits describ$ 9  
p>agraph 7#a71 a qualifi$ heal? plan--  
7i7 %all n sub/itute b5efits betwe5     
categories describ$ su* p>agraph1 z     
describ$ 9 section #aef4aae7;b77#b77;ii7
 ( title #de1 ,code ( ,f$]al            
,regulations1 z 9 effect on ! day be=e !
 date ( enactm5t ( ! ,consum] ,heal?    
,insurance ,protection ,act ( #bjai2    
7ii7 %all provide a wide v>iety (       
classes ( prescription drugs on !       
prescription drug =mul>y ( su* plan2    

7iii7 %all1 if a m$ically necess>y drug 
is n on ! prescription drug =mul>y ( su*
 plan1 all[ individuals enroll$ 9 su*   
plan to h access to ! drug ?r\gh an     
exceptions process e/abli%$ by ! plan2 &
  7iv7 %all n impose limits on cov]age (
 habilitative s]vices & devices t are   
less favorable ?an any su* limits impos$
 on cov]age ( rehabilitative s]vices &  
devices4  4  7b7 ,cov]age ( p$iatric    
s]vices ,! ,secret>y ( ,heal? & ,human  
,s]vices1 9 consultation ) p$iatric     
s]vice provid]s1 %all promulgate a s]ies
 ( recomm5dations = gr\p heal? plans &  
heal? insurance issu]s (f]+ gr\p or     
individual heal? insurance cov]age to   
improve cov]age ( p$iatric s]vices4     
#djh4 ,association heal? plans  7a7     
,treatm5t ( association heal? plans     
7#a7 ,association heal? plan def9$ ,=   
purposes ( ?is subsection1 ! t]m        
association heal? plan means any heal?  
insurance cov]age t is provid$ to an    
association1 b n relat$ to employm5t1 & 
sold to individuals ?r\gh su*           

association4  7#b7 ,treatm5t z          
individual heal? insurance cov]age ,=   
purposes ( title ,,xxvii ( ! ,public    
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg et seq471 "p #g ( subtitle ,b ( 
title ,i ( ! ,employee ,retirem5t       
,income ,security ,act ( #aigd 7#bi     
,u4,s4,c4 #aaha et seq471 *apt] #ajj ( !
 ,int]nal ,rev5ue ,code ( #aihf1 & title
 ,i ( ! ,pati5t ,protection & ,af=dable 
,c>e ,act 7,public ,law #aaa-adh71 heal?
 insurance cov]age (f]$ ?r\gh an        
association heal? plan %all be treat$ z 
individual heal? insurance cov]age if-- 
7,a7 ! cov]age is (f]$ to a memb] ( !   
association o!r ?an 9 connection ) a    
gr\p heal? plan2 or  7,b7 ! cov]age is  
(f]$ to a memb] ( ! association t is an 
employ] ma9ta9+ a gr\p heal? plan t has 
few] ?an #b p>ticipants :o are employees
 on ! fir/ day ( ! plan ye>4  7#c7      
,treatm5t z heal? insurance cov]age 9 ! 
small gr\p m>ket ,= purposes ( title    
,,xxvii ( ! ,public ,heal? ,s]vice ,act 
7#db ,u4,s4,c4 #cjj;gg et seq471 "p #g (

 subtitle ,b ( title ,i ( ! ,employee   
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #aaha et seq471    
*apt] #ajj ( ! ,int]nal ,rev5ue ,code ( 
#aihf1 & title ,i ( ! ,pati5t           
,protection & ,af=dable ,c>e ,act       
7,public ,law #aaa-adh71 heal? insurance
 cov]age (f]$ ?r\gh an association heal?
 plan %all1 subject to p>agraph         
7#b77;,b71 be treat$ z heal? insurance  
cov]age 9 ! small gr\p m>ket if !       
cov]age is (f]$ to a memb] ( !          
association 9 connection ) a gr\p heal? 
plan (f]$ to employ]s t are small       
employ]s1 z def9$ 9 su* applicable ,act 
or ,code4  7#d7 ,preemption ,an         
association heal? plan %all be treat$ z 
individual heal? insurance cov]age 9    
accordance ) p>agraph 7#b7 or heal?     
insurance cov]age 9 ! small gr\p m>ket 9
 accordance ) p>agraph 7#c7 not)/&+ any 
applicable ,/ate law4  7#e7 ,effective  
date ,?is subsection %all apply to plan 
ye>s beg9n+ aft] ,decemb] #ca1 #bjbj4   
7b7 ,dep>tm5t ( ,labor rule reg>d+ !    

def9ition ( employ] "u ,,erisa ,beg9n+ )
 respect to plan ye>s beg9n+ aft]       
,decemb] #ca1 #bjbj1 ! f9al rule ( !    
,dep>tm5t ( ,labor entitl$ ,def9ition ( 
,employ] ,"u ,section #c7e7 (           
,,erisa--,association ,heal? ,plans 7#hc
 ,f$4 ,reg4 #bhiab 7,june #ba1 #bjah77  
%all h no =ce or effect4