,,ii  #aaf? ,,congress  #b;d ,session   
,s4 #deba  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,augu/ #aa1 #bjbj,mr4  
,w>n] introduc$ ! foll[+ bill2 :i* 0    
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to am5d ! ,pati5t  
,protection & ,af=dable ,c>e ,act to    
r$uce heal? c>e co/s & exp& heal? c>e   
cov]age to m ,am]icans4  #a4 ,%ort title
 ,?is ,act may be cit$ z ! ,heal? ,c>e  
,improvem5t ,act ( #bjbj4  #b4 ,table ( 
cont5ts ,! table ( cont5ts = ?is ,act is
 z foll[s3 ,sec4 #a4 ,%ort title4,sec4  
#b4 ,table ( cont5ts4,,title ,i--,r$uc+ 
heal? c>e co/s & protect+ p ) preexi/+  
conditions,sec4 #aja4 ,improv+          
af=dability by exp&+ premium assi/ance =
 consum]s4,sec4 #ajb4 ,exp&+ af=dability
 = work+ families to fix ! family       
glit*4,sec4 #ajc4 ,e/abli%+ a ,/ate     
,heal? ,insurance ,af=dability &        
,innovation fund4,sec4 #ajd4 ,resc9d+ ! 
%ort-t]m limit$ duration insurance      
regulation4,sec4 #aje4 ,revok+ section  
#accb guidance4,sec4 #ajf4 ,promot+     

consum] outrea* & education4,,title     
,,ii--,enc\rag+ ,m$icaid ,expansion &   
,/r5g!n+ ! ,m$icaid ,program,sec4 #bja4 
,inc5tiviz+ ,m$icaid expansion4,sec4    
#bjb4 ,r$uc+ ! adm9i/rative ,,fmap =    
nonexpansion ,/ates4,sec4 #bjc4 ,/ate   
option to provide #ab mon?s ( po/p>tum  
,m$icaid eligibility4,sec4 #bjd4        
,support+ ,/ate ,m$icaid programs ?r\gh 
economic d[nturns4,sec4 #bje4 ,/ate     
flexibility to use adm9i/rative         
simplification policies =               
enrollm5t4,,title ,,iii--,e/abli%m5t ( a
 ,public ,heal? ,c>e ,option,sec4 #cja4 
,e/abli%m5t ( heal? plan4,sec4 #cjb4    
,availability ( plan4,sec4 #cjc4        
,af=dability4,sec4 #cjd4 ,p>ticipat+    
provid]s4,sec4 #cje4 ,provid] paym5t    
rates4,sec4 #cjf4 ,no effect on ,m$ic>e 
b5efits or ,m$ic>e tru/ funds4,,title   
,,iv--,fair ,m$ic>e ,paym5ts to ,rural  
,providers,sec4 #dja4 ,ensur+ fairness 9
 ,m$ic>e hospital paym5ts4,,title       
,v--,commons5se ,competition & ,access  
to ,heal? ,insurance,sec4 #eja4 ,provid+

 small bus9ess heal? insurance across   
,/ate l9es4,sec4 #ejb4 ,report &        
models4,,title ,,vi--,emp[]+ ,m$ic>e    
,s5iors to ,negotiate ,prescription     
,drug ,prices,sec4 #fja4 ,au?ority to   
negotiate fair prices = ,m$ic>e         
prescription drugs4,,title              
,,vii--,commons5se report+ =            
employers,sec4 #gja4 ,volunt>y          
prospective report+ sy/em4,sec4 #gjb4   
,protection ( dep5d5t privacy4,sec4     
#gjc4 ,electronic /atem5ts4,sec4 #gjd4  
,,gao /udies4,sec4 #gje4 ,tax           
,compliance4,,title ,,viii--,f$]al ,ban 
on ,surprise ,m$ical ,billing,sec4 #hja4
 ,protection aga9/ surprise bills4  ,i  
,r$uc+ heal? c>e co/s & protect+ p )    
preexi/+ conditions  #aja4 ,improv+     
af=dability by exp&+ premium assi/ance =
 consum]s  7a7 ,9 g5]al ,section        
#cf;,b7b77#c77;,a7 ( ! ,int]nal ,rev5ue 
,code ( #aihf is am5d$ to read z foll[s3
  7,a7 ,applicable p]c5tage ,!          
applicable p]c5tage = any taxable ye>   
%all be ! p]c5tage su* t ! applicable   

p]c5tage = any taxpay] ^: h\sehold      
income is )9 an income ti] specifi$ 9 ! 
foll[+ table %all increase1 on a slid+  
scale 9 a l9e> mann]1 f ! initial       
premium p]c5tage to ! f9al premium      
p]c5tage specifi$ 9 su* table = su*     
income ti]3 ,9 ! case ( h\sehold income 
7express$ z a p]c5t ( pov]ty l9e7 )9 !  
foll[+ income ti]3,! initial            
premiump]c5tage is--,! f9al premium     
p]c5tage is--,up to #aej4j              
p]c5t#j4jj4jaej4j p]c5t up to #bjj4j    
p]c5t#j4jc4jbjj4j p]c5t up to #bej4j    
p]c5t#c4jd4jbej4j p]c5t up to #cjj4j    
p]c5t#d4jf4jcjj4j p]c5t up to #djj4j    
p]c5t#f4jh4edjj4j p]c5t & high]#h4eh4e  
4  7b7 ,con=m+ am5dm5t ,section         
#cf;,b7c77#a77;,a7 ( ! ,int]nal ,rev5ue 
,code ( #aihf is am5d$ by /rik+ b does n
 exce$ #djj p]c5t4  7c7 ,effective date 
,! am5dm5ts made by ?is section %all    
apply to taxable ye>s beg9n+ aft]       
,decemb] #ca1 #bjai4  #ajb4 ,exp&+      
af=dability = work+ families to fix !   
family glit*  7a7 ,9 g5]al ,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 ,employees ,an employee %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 & !          
employee's requir$ contribution 7)9 !   
mean+ ( section #ejjj;,a7e77#a77;,b77 ) 
respect to ! plan exce$s #i4e p]c5t ( ! 
employee's h\sehold income4  7,,ii7     
,family memb]s ,an individual :o is     
eligible to enroll 9 an eligible        
employ]-sponsor$ plan 7z def9$ 9 section
 #ejjj;,a7f77#b77 by reason ( a         
relation%ip ! individual be>s to !      
employee %all n be treat$ z eligible =  
m9imum ess5tial cov]age by reason ( su* 
eligibility to enroll if ! employee's   
requir$ contribution 7)9 ! mean+ (      
section #ejjj;,a7e77#a77;,b71 det]m9$ by
 sub/itut+ family = self-only7 ) respect
 to ! plan exce$s #i4e p]c5t ( !        
employee's h\sehold income4  4  7b7     

,con=m+ am5dm5ts  7#a7 ,clause 7ii7 (   
section #cf;,b7c77#b77;,c7 ( ! ,int]nal 
,rev5ue ,code ( #aihf is am5d$ by /rik+ 
,except z provid$ 9 clause 7iii71 an    
employee & ins]t+ ,an individual4  7#b7 
,clause 7iii7 ( section                 
#cf;,b7c77#b77;,c7 ( su* ,code is am5d$ 
by /rik+ ! la/ s5t5ce ( clause 7i7 &    
ins]t+ clause 7i77,,ii74  7#c7 ,clause  
7iv7 ( section #cf;,b7c77#b77;,c7 ( su* 
,code is am5d$ by /rik+ ! #i4e p]c5t "u 
clause 7i77,,ii7 & ins]t+ ! #i4e p]c5t  
"u clauses 7i77,i7 & 7i77,,ii74  7c7    
,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ,decemb] #ca1 #bjba4  #ajc4 
,e/abli%+ a ,/ate ,heal? ,insurance     
,af=dability & ,innovation fund         
,subtitle ,d ( title ,i ( ! ,pati5t     
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjba et seq47 is am5d$ by   
add+ at ! end ! foll[+3  #f ,/ate ,heal?
 ,insurance ,af=dability & ,innovation  
,fund  #acea4 ,e/abli%m5t ( program ,!re
 is h]eby e/abli%$ ! ,/ate ,heal?       

,insurance ,af=dability & ,innovation   
,fund to be adm9i/]$ by ! ,secret>y (   
,heal? & ,human ,s]vices1 act+ ?r\gh !  
,adm9i/rator ( ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices 7ref]r$ to 9 ?is      
section z ! ,adm9i/rator71 to provide   
fund+1 9 accordance ) ?is "p1 to ea* ( !
 #ej ,/ates & ! ,di/rict ( ,columbia    
7ea* ref]r$ to 9 ?is section z a ,/ate7 
beg9n+ on ,janu>y #a1 #bjbb1 = !        
purposes describ$ 9 section #aceb4      
#aceb4 ,use ( funds  7a7 ,9 g5]al ,a    
,/ate %all use ! funds allocat$ to !    
,/ate "u ?is "p = "o ( ! foll[+         
purposes3 7#a7 ,to provide re9surance   
paym5ts to heal? insurance issu]s )     
respect to individuals enroll$ "u       
individual heal? insurance cov]age 7o!r 
?an ?r\gh a plan describ$ 9 subsection  
7b77 (f]$ by su* issu]s4  7#b7 ,to      
provide assi/ance 7o!r ?an ?r\gh paym5ts
 describ$ 9 p>agraph 7#a77 to r$uce     
out-(-pocket co/s1 su* z copaym5ts1     
co9surance1 premiums1 & d$uctibles1 (   
individuals enroll$ "u qualifi$ heal?   

plans (f]$ on ! individual m>ket ?r\gh  
an ,ex*ange4  7#c7 ,/ate ef=ts to       
/reaml9e heal? insurance enrollm5t      
proc$ures 9 ord] to r$uce burd5s on     
consum]s & facilitate great] enrollm5t 9
 heal? insurance cov]age 9 ! individual 
& small gr\p m>kets1 includ+ automatic  
enrollm5t & re5rollm5t (1 or            
pre-populat$ applications =1 individuals
 )\t heal? insurance :o are eligible =  
tax cr$its "u section #cf;,b ( !        
,int]nal ,rev5ue ,code ( #aihf1 ) !     
ability to opt out ( su* enrollm5t4     
7#d7 ,/ate inve/m5t 9 te*nology to      
improve data %>+ & collection = !       
purposes ( facilitat+ great] enrollm5t 9
 heal? insurance cov]age 9 su* m>kets4  
7#e7 ,feasibility /udies to develop     
compreh5sive & coh]5t ,/ate plan =      
increas+ enrollm5t 9 ! individual &     
small gr\p m>ket4  7b7 ,exclusion (     
c]ta9 gr&fa!r$ & transitional plans ,=  
purposes ( subsection 7a71 a plan       
describ$ 9 ?is subsection is ! foll[+3  
7#a7 ,a gr&fa!r$ heal? plan 7z def9$ 9  

section #abea74  7#b7 ,a plan 7commonly 
ref]r$ to z a transitional plan7 cont9u$
 "u ! lett] issu$ by ! ,c5t]s = ,m$ic>e 
,m$icaid ,s]vices on ,novemb] #ad1      
#bjac1 to ! ,/ate ,insurance            
,commission]s outl9+ a transitional     
policy = cov]age 9 ! individual & small 
gr\p m>kets to :i* section #abea does n 
apply1 & "u ! ext5sion ( ! transitional 
policy = su* cov]age set =? 9 !         
,insurance ,/&>ds ,bullet9 ,s]ies       
guidance issu$ by ! ,c5t]s = ,m$ic>e    
,m$icaid ,s]vices on ,m>* #e1 #bjad1    
,febru>y #bi1 #bjaf1 ,febru>y #ac1      
#bjag1 ,april #i1 #bjah1 ,m>* #be1      
#bjai1 & ,janu>y #ca1 #bjbj1 or "u any  
subsequ5t ext5sions !re(4  7#c7 ,/ud5t  
heal? insurance cov]age 7z def9$ 9      
section #adg4ade ( title #de1 ,code (   
,f$]al ,regulations74  #acec4 ,/ate     
eligibility & approval2 default safegu>d
  7a7 ,enc\rag+ ,/ate options =         
allocations  7#a7 ,9 g5]al ,to be       
eligible = an allocation ( funds "u ?is 
"p = a ye> 7beg9n+ ) #bjbb71 a ,/ate    

%all submit to ! ,adm9i/rator an        
application at su* "t 7b1 9 ! case (    
allocations = #bjbb1 n lat] ?an #ij days
 aft] ! date ( ! enactm5t ( ?is "p &1 9 
! case ( allocations = a subsequ5t ye>1 
n lat] ?an ,m>* #a ( ! previ\s ye>7 & 9 
su* =m & mann] z specifi$ by !          
,adm9i/rator conta9+-- 7,a7 a           
description ( h[ ! funds w be us$2 &    
7,b7 su* o!r in=mation z ! ,adm9i/rator 
may require4  7#b7 ,automatic approval  
,an application s submitt$ is approv$   
unless ! ,adm9i/rator notifies ! ,/ate  
submitt+ ! application1 n lat] ?an #fj  
days aft] ! date ( ! submission ( su*   
application1 t ! application has be5    
d5i$ = n be+ 9 compliance ) any         
requirem5t ( ?is "p & ( ! reason = su*  
d5ial4  7#c7 #e-ye> application approval
 ,if an application ( a ,/ate is approv$
 = a purpose describ$ 9 section #aceb = 
a ye>1 su* application %all be treat$ z 
approv$ = su* purpose = ea* ( !         
subsequ5t #d ye>s4  7#d7 ,revocation (  
approval ,! approval ( an application ( 

a ,/ate1 ) respect to a purpose describ$
 9 section #aceb1 may be revok$ if !    
,/ate fails to use funds provid$ to !   
,/ate "u ?is section = su* purpose or   
o!rwise fails to comply ) ! requirem5ts 
( ?is section4  7b7 ,default ,f$]al     
safegu>d  7#a7 #bjbb ,= #bjbb1 9 ! case 
( a ,/ate t does n submit an application
 "u subsection 7a7 by ! #ij-;day        
submission date applicable to su* ye> "u
 subsection 7a77#a7 & 9 ! case ( a ,/ate
 t does submit su* an application by su*
 date t is n approv$1 ! ,adm9i/rator1 9 
consultation ) ! ,/ate insurance        
commission]1 %all1 f ! am\nt calculat$  
"u p>agraph 7#d7 = su* ye>1 c>ry out !  
purpose describ$ 9 p>agraph 7#c7 9 su*  
,/ate = su* ye>4  7#b7 #bjbc & subsequ5t
 ye>s ,= #bjbc or a subsequ5t ye>1 9 !  
case ( a ,/ate t does n h 9 effect an   
approv$ application "u ?is section = su*
 ye>1 ! ,adm9i/rator1 9 consultation ) !
 ,/ate insurance commission]1 %all1 f ! 
am\nt calculat$ "u p>agraph 7#d7 = su*  
ye>1 c>ry out ! purpose describ$ 9      

p>agraph 7#c7 9 su* ,/ate = su* ye>4    
7#c7 ,specifi$ use ,! am\nt describ$ 9  
p>agraph 7#d71 ) respect to #bjbb or a  
subsequ5t ye>1 %all be us$ to c>ry out !
 purpose describ$ 9 section             
#aceb7;a77#a7 9 ea* ,/ate describ$ 9    
p>agraph 7#a7 or 7#b7 = su* ye>1 z      
applicable1 by provid+ re9surance       
paym5ts to heal? insurance issu]s )     
respect to atta*m5t range claims 7z     
def9$ 9 section #aced7;b77#b771 us+ !   
doll> am\nts specifi$ 9 subp>agraph 7,b7
 ( su* section = su* ye> 9 an am\nt     
equal to1 subject to p>agraph 7#e71 !   
p]c5tage 7specifi$ = su* ye> by !       
,secret>y "u su* subp>agraph7 ( ! am\nt 
( su* claims4  7#d7 ,am\nt describ$ ,!  
am\nt describ$ 9 ?is p>agraph1 ) respect
 to #bjbb or a subsequ5t ye>1 is ! am\nt
 equal to ! total sum ( am\nts t !      
,secret>y w\ld o!rwise e/imate "u       
section #aced7;b77#b77;,a77i7 = su* ye> 
= ea* ,/ate describ$ 9 p>agraph 7#a7 or 
7#b7 = su* ye>1 z applicable1 if ea* su*
 ,/ate 7 n s describ$ = su* ye>4  7#e7  

,adju/m5t ,= purposes ( ?is subsection1 
! ,secret>y may apply a p]c5tage "u     
p>agraph 7#c7 ) respect to a ye> t is   
less ?an ! p]c5tage o!rwise specifi$ 9  
section #aced7;b77#b77;,b7 = su* ye>1 if
 ! co/ ( pay+ ! total eligible atta*m5t 
range claims = ,/ates describ$ 9 ?is    
subsection = su* ye> at su* p]c5tage    
o!rwise specifi$ w\ld exce$ ! am\nt     
calculat$ "u p>agraph 7#d7 = su* ye>4   
#aced4 ,allocations  7a7 ,appropriation 
,= ! purpose ( provid+ allocations =    
,/ates "u subsection 7b7 & paym5ts "u   
section #acec7;b7 !re is appropriat$1   
out ( any money 9 ! ,treasury n o!rwise 
appropriat$1 #aj1jjj1jjj1jjj = #bjbb &  
ea* subsequ5t ye>4  7b7 ,allocations    
7#a7 ,paym5t  7,a7 ,9 g5]al ,f am\nts   
appropriat$ "u subsection 7a7 = a ye>1 !
 ,secret>y %all1 ) respect to a ,/ate n 
describ$ 9 section #acec7;b7 = su* ye> &
 n lat] ?an ! date specifi$ "u          
subp>agraph 7,b7 = su* ye>1 allocate =  
su* ,/ate ! am\nt det]m9$ = su* ,/ate & 
ye> "u p>agraph 7#b74  7,b7 ,specifi$   

date ,= purposes ( subp>agraph 7,a71 !  
date specifi$ 9 ?is subp>agraph is-- 7i7
 = #bjbb1 ! date t is #de days aft] !   
date ( ! enactm5t ( ?is "p2 &  7ii7 =   
#bjbc or a subsequ5t ye>1 ,janu>y #a ( !
 respective ye>4  7,c7 ,notifications ( 
allocation am\nts ,= #bjbc & ea*        
subsequ5t ye>1 ! ,secret>y %all notify  
ea* ,/ate ( ! am\nt det]m9$ = su* ,/ate 
"u p>agraph 7#b7 = su* ye> by n lat] ?an
 ,janu>y #a ( ! previ\s ye>4  7#b7      
,allocation am\nt det]m9ations  7,a7 ,9 
g5]al ,= purposes ( p>agraph 7#a71 !    
am\nt det]m9$ "u ?is p>agraph = a ye> = 
a ,/ate describ$ 9 p>agraph 7#a77;,a7 = 
su* ye> is ! am\nt equal to-- 7i7 !     
am\nt t ! ,secret>y e/imates w\ld be    
exp5d$ "u ?is "p = su* ye> on atta*m5t  
range claims ( individuals resid+ 9 su* 
,/ate if su* ,/ate us$ su* funds only = 
! purpose describ$ 9 p>agraph 7#a7 (    
section #aceb7;a7 at ! doll> am\nts &   
p]c5tage specifi$ "u subp>agraph 7,b7 = 
su* ye>2 m9us  7ii7 ! am\nt1 if any1 by 
:i* ! ,secret>y det]m9es-- 7,i7 !       

e/imat$ am\nt ( premium tax cr$its "u   
section #cf;,b ( ! ,int]nal ,rev5ue     
,code ( #aihf t w\ld be attributable to 
individuals resid+ 9 su* ,/ate = su* ye>
 )\t application ( ?is "p2 exce$s       
7,,ii7 ! e/imat$ am\nt ( premium tax    
cr$its "u section #cf;,b ( ! ,int]nal   
,rev5ue ,code ( #aihf t w\ld be         
attributable to individuals resid+ 9 su*
 ,/ate = su* ye> if su* ,/ate 7 a ,/ate 
describ$ 9 section #acec7;b7 = su* ye>4 
,= purposes ( ! previ\s s5t5ce & section
 #acec7;b77#c71 ! t]m atta*m5t range    
claims means1 ) respect to an           
individual1 ! claims = su* individual t 
exce$ a doll> am\nt specifi$ by !       
,secret>y = a ye>1 b d n exce$ a ceil+  
doll> am\nt specifi$ by ! ,secret>y =   
su* ye>1 "u subp>agraph 7,b74  7,b7     
,specifications ,= purposes (           
subp>agraph 7,a7 & section              
#acec7;b77#c71 ! ,secret>y %all det]m9e 
! doll> am\nts & ! p]c5tage to be       
specifi$ "u ?is subp>agraph = a ye> 9 a 
mann] to ensure t ! total am\nt (       

exp5ditures "u ?is "p = su* ye> is      
e/imat$ to equal ! total am\nt          
appropriat$ = su* ye> "u subsection 7a7 
if su* exp5ditures 7 us$ solely = !     
purpose describ$ 9 p>agraph 7#a7 (      
section #aceb7;a7 = atta*m5t range      
claims at ! doll> am\nts & p]c5tage s   
specifi$ = su* ye>4  7#c7 ,availability 
,funds allocat$ to a ,/ate "u ?is       
subsection = a ye> %all rema9 available 
?r\gh ! end ( ! subsequ5t ye>4  4  #ajd4
 ,resc9d+ ! %ort-t]m limit$ duration    
insurance regulation  7a7 ,prohibition  
,! ,secret>y ( ,heal? & ,human ,s]vices1
 ! ,secret>y ( ! ,treasury1 & !         
,secret>y ( ,labor-- 7#a7 may n take any
 action to implem5t1 en=ce1 or o!rwise  
give effect to ! rule entitl$           
,%ort-,t]m1 ,limit$ ,duration ,insurance
 7#hc ,f$4 ,reg4 #chbab 7,augu/ #c1     
#bjah772  7#b7 %all apply any regulation
 revis$ by su* rule z if su* rule _h n  
be5 issu$2 &  7#c7 may n promulgate any 
sub/antially simil> rule4  #aje4 ,revok+
 section #accb guidance  7a7 ,provid+ t 

c]ta9 guidance relat$ to waiv]s = ,/ate 
innovation "u ! ,pati5t ,protection &   
,af=dable ,c>e ,act %all h no =ce or    
effect ,beg9n+ ,july #a1 #bjbj1 !       
,secret>y ( ,heal? & ,human ,s]vices & !
 ,secret>y ( ! ,treasury may n take any 
action to implem5t1 en=ce1 or o!rwise   
give effect to ! guidance entitl$ ,/ate 
,relief & ,emp[]m5t ,waiv]s 7#hc ,f$4   
,reg4 #ecege 7,octob] #bd1 #bjah771     
includ+ any su* action t w\ld-- 7#a7    
result 9 individuals los+ heal?         
insurance cov]age t includes ! ess5tial 
heal? b5efits package 7z def9$ 9        
subsection 7a7 ( section #acjb ( !      
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjbb7;a77 )\t     
reg>d to any waiv] ( any provision ( su*
 package "u a waiv] "u su* section      
#accb71 includ+ ! mat]nity & newborn c>e
 ess5tial heal? b5efit describ$ 9       
subsection 7b77#a77;,d7 ( su* section2  
7#b7 result 9 a decrease 9 ! numb] ( su*
 individuals enroll$ 9 cov]age t is at  
lea/ z compreh5sive z ! cov]age def9$ 9 

section #acjb7;a7 ( ! ,pati5t           
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjbb7;a77 comp>$ to ! numb] 
( su* individuals :o w\ld h be5 s       
enroll$ 9 su* cov]age _h su* action n   
be5 tak52  7#c7 ) respect to individuals
 ) sub/ance use disord]s1 includ+ opioid
 use disord]s1 r$uce ! availability or  
af=dability ( cov]age t is at lea/ z    
compreh5sive z ! cov]age def9$ 9 section
 #acjb7;a7 ( ! ,pati5t ,protection &    
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjbb7;a77 comp>$ to ! availability or 
af=dability1 respectively1 ( su* cov]age
 _h su* action n be5 tak52  7#d7 result1
 ) respect to vuln]able populations     
7includ+ l[-income individuals1 eld]ly  
individuals1 & individuals ) s]i\s heal?
 issues or :o h a great] risk ( develop+
 s]i\s heal? issues71 9 a decrease 9 !  
availability ( cov]age t is at lea/ z   
compreh5sive z ! cov]age def9$ 9 section
 #acjb7;a7 ( ! ,pati5t ,protection &    
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjbb7;a77 ) cov]age & co/-%>+         

protections requir$ "u section          
#accb7;b77#a77;,b7 ( su* ,act 7#db      
,u4,s4,c4 #ahjeb7;b77#a77;,b772  7#e7 ) 
respect to individuals ) preexi/+       
conditions1 r$uce ! af=dability (       
cov]age t is at lea/ z compreh5sive z ! 
cov]age def9$ 9 section #acjb7;a7 ( !   
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjbb7;a77 comp>$  
to ! af=dability ( su* cov]age _h su*   
action n be5 tak52 or  7#f7 result 9    
high] heal? insurance premiums =        
individuals enroll$ 9 heal? insurance   
cov]age t is at lea/ z compreh5sive z ! 
cov]age def9$ 9 section #acjb7;b7 ( su* 
,act 7#db ,u4,s4,c4 #ahjbb7;b771 & !    
,secret>ies may n promulgate any        
sub/antially simil> guidance or rule4   
7b7 ,rule ( con/ruction ,no?+ 9         
subsection 7a7 %all be con/ru$ to affect
 ! approval ( waiv]s "u section #accb ( 
! ,pati5t ,protection & ,af=dable ,c>e  
,act 7#db ,u4,s4,c4 #ahjeb7 t e/abli%   
re9surance programs t are consi/5t ) !  
requirem5ts "u subsection 7b77#a7 ( su* 

section 7#db ,u4,s4,c4 #ahjeb7;b77#a771 
l[] heal? insurance premiums1 & protect 
heal? insurance cov]age = p ) preexi/+  
conditions4  #ajf4 ,promot+ consum]     
outrea* & education  7a7 ,9 g5]al       
,section #acaa7;i7 ( ! ,pati5t          
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjca7;i77 is am5d$-- 7#a7 9 
p>agraph 7#b71 by add+ at ! end ! foll[+
 new subp>agraph3  7,c7 ,selection (    
recipi5ts ,9 ! case ( an ,ex*ange       
e/abli%$ & op]at$ by ! ,secret>y )9 a   
,/ate pursuant to section #acba7;c71 9  
aw>d+ grants "u p>agraph 7#a71 !        
,ex*ange %all-- 7i7 select entities to  
receive su* grants bas$ on an entity's  
demon/rat$ capacity to c>ry out ea* ( ! 
duties specifi$ 9 p>agraph 7#c72  7ii7 n
 take into acc\nt :e!r or n ! entity has
 demon/rat$ h[ ! entity w provide       
in=mation to individuals relat+ to gr\p 
heal? plans (f]$ by a gr\p or           
association ( employ]s describ$ 9       
section #beaj4c-e7;b7 ( title #bi1 ,code
 ( ,f$]al ,regulations 7or any successor

 regulation71 or %ort-t]m limit$        
duration insurance 7z def9$ by !        
,secret>y = purposes ( section          
#bgia7;b77#e7 ( ! ,public ,heal? ,s]vice
 ,act72 &  7iii7 ensure t1 ea* ye>1 !   
,ex*ange aw>ds su* a grant to-- 7,i7 at 
lea/ "o entity describ$ 9 ?is p>agraph t
 is a community & consum]-focus$        
nonpr(it gr\p2 &  7,,ii7 at lea/ "o     
entity describ$ 9 subp>agraph 7,b71 :i* 
may include ano!r community &           
consum]-focus$ nonpr(it gr\p 9 addition 
to any su* gr\p aw>d$ a grant pursuant  
to subclause 7,i74  ,9 aw>d+ su* grants1
 an ,ex*ange may consid] an entity's    
record ) respect to wa/e1 fraud1 & abuse
 = purposes ( ma9ta9+ ! integrity ( su* 
,ex*ange4  2  7#b7 9 p>agraph 7#c7--    
7,a7 by am5d+ subp>agraph 7,c7 to read z
 foll[s3  7,c7 facilitate enrollm5t1    
includ+ ) respect to individuals )      
limit$ ,engli% pr(ici5cy & individuals )
 *ronic illnesses1 9 qualifi$ heal?     
plans1 ,/ate ,m$icaid plans "u title    
,,xix ( ! ,social ,security ,act1 &     

,/ate *ild heal? plans "u title ,,xxi ( 
su* ,act2  2  7,b7 9 subp>agraph 7,d71  
by /rik+ & at ! end2  7,c7 9 subp>agraph
 7,e71 by /rik+ ! p]iod at ! end &      
ins]t+ 2 &2  7,d7 by ins]t+ aft]        
subp>agraph 7,e7 ! foll[+ new           
subp>agraph3  7,f7 provide ref]rals to  
community-bas$ organizations t address  
social ne$s relat$ to heal? outcomes4  2
 &  7,e7 by add+ at ! end ! foll[+ flu% 
text3 ,! duties specifi$ 9 ! prec$+     
s5t5ce may be c>ri$ out by su* a        
navigator at any "t dur+ a ye>4 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+ a semicolon2
  7,c7 9 clause 7ii7-- 7i7 by ins]t+ n  
be=e receive2 &  7ii7 by /rik+ ! p]iod &
 ins]t+ a semicolon2 &  7,d7 by add+ at 
! end ! foll[+ new clauses3  7iii7      
ma9ta9 physical pres5ce 9 ! ,/ate ( !   
,ex*ange s z to all[ 9-p]son assi/ance  
to consum]s2 &  7iv7 receive opioid     
specific education & tra9+ t ensures !  

navigator c be/ educate individuals on  
qualifi$ heal? plans (f]$ ?r\gh an      
,ex*ange1 specifically cov]age "u su*   
plans = opioid heal? c>e treatm5t4  2 & 
7#d7 9 p>agraph 7#f7-- 7,a7 by /rik+    
,grants "u & ins]t+ ! foll[+3  7,a7     
,/ate ex*anges ,grants "u  2 &  7,b7 by 
add+ at ! end ! foll[+ new subp>agraph3 
7,b7 ,f$]al ex*anges ,= purposes ( c>ry+
 out ?is subsection1 ) respect to an    
,ex*ange e/abli%$ & op]at$ by !         
,secret>y )9 a ,/ate pursuant to section
 #acba7;c71 ! ,secret>y %all obligate   
#ajj1jjj1jjj out ( am\nts collect$ ?r\gh
 ! us] fees on p>ticipat+ heal?         
insurance issu]s pursuant to section    
#aef4ej ( title #de1 ,code ( ,f$]al     
,regulations 7or any successor          
regulations71 = fiscal ye> #bjbb & ea*  
subsequ5t fiscal ye>4 ,su* am\nt = a    
fiscal ye> %all rema9 available until   
exp5d$4  4  7b7 ,effective date ,!      
am5dm5ts made by ?is section %all apply 
) respect to plan ye>s beg9n+ on or aft]
 ,janu>y #a1 #bjba4  ,,ii ,enc\rag+     

,m$icaid ,expansion & ,/r5g!n+ !        
,m$icaid ,program  #bja4 ,inc5tiviz+    
,m$icaid expansion  7a7 ,9 g5]al        
,section #aije ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acif;d7y77#a77 is  
am5d$-- 7#a7 9 subsection 7y77#a7-- 7,a7
 9 subp>agraph 7,a71 by /rik+ #bjad1    
#bjae1 & #bjaf & ins]t+ ea* ( ! fir/ #c 
consecutive #ab-mon? p]iods 9 :i* !     
,/ate provides m$ical assi/ance to newly
 eligible individuals2  7,b7 9          
subp>agraph 7,b71 by /rik+ #bjag &      
ins]t+ ! f\r? consecutive #ab-mon? p]iod
 9 :i* ! ,/ate provides m$ical assi/ance
 to newly eligible individuals2  7,c7 9 
subp>agraph 7,c71 by /rik+ #bjah &      
ins]t+ ! fif? consecutive #ab-mon? p]iod
 9 :i* ! ,/ate provides m$ical assi/ance
 to newly eligible individuals2  7,d7 9 
subp>agraph 7,d71 by /rik+ #bjai &      
ins]t+ ! six? consecutive #ab-mon? p]iod
 9 :i* ! ,/ate provides m$ical assi/ance
 to newly eligible individuals2 &  7,e7 
9 subp>agraph 7,e71 by /rik+ #bjbj & ea*
 ye> !reaft] & ins]t+ ! sev5?           

consecutive #ab-mon? p]iod 9 :i* ! ,/ate
 provides m$ical assi/ance to newly     
eligible individuals & ea* su* p]iod    
!reaft]2 &  7#b7 9 subsection           
7z77#b77;,b77i77,,ii71 by ins]t+ 7z 9   
effect on ! day be=e ! date ( enactm5t (
 ! ,heal? ,c>e ,improvem5t ,act ( #bjbj7
 aft] subsection 7y77#a74  7b7          
,effective date ,beg9n+ on ,janu>y #a1  
#bjbb1 ! am5dm5ts made by subsection 7a7
 %all take effect z if includ$ 9 !      
enactm5t ( ! ,pati5t ,protection &      
,af=dable ,c>e ,act 7,public ,law       
#aaa-adh74  #bjb4 ,r$uc+ ! adm9i/rative 
,,fmap = nonexpansion ,/ates ,section   
#aijc ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acif;b7 is am5d$-- 7#a7 9    
subsection 7a77#g71 by ins]t+ subsection
 7bb7 & be=e section #aiai7;g77#c77;,b72
 &  7#b7 by add+ at ! end ! foll[+ new  
subsection3  7bb7 ,r$uction ( ,f$]al    
paym5ts = c]ta9 adm9i/rative co/s (     
nonexpansion ,/ates  7#a7 ,9 g5]al ,9 ! 
case ( a ,/ate t does n provide "u !    
,/ate plan ( su* ,/ate 7or waiv] ( su*  

plan7 = mak+ m$ical assi/ance available 
9 accordance ) section #aijb7k77#a7 to  
all individuals describ$ 9 section      
#aijb7;a77#aj77;i77,,viii7 = a cal5d>   
qu>t] beg9n+ on or aft] ,octob] #a1     
#bjbb1 ! ,secret>y may r$uce ! p]c5tage 
specifi$ 9 subsection 7a77#g7 = am\nts  
describ$ 9 su* subsection exp5d$ dur+   
su* qu>t] by su* ,/ate by ! numb] (     
p]c5tage po9ts specifi$ 9 p>agraph 7#b7 
= su* qu>t]4  7#b7 ,am\nt ( r$uction ,= 
purposes ( p>agraph 7#a71 ! numb] (     
p]c5tage po9ts specifi$ 9 ?is p>agraph =
 a cal5d> qu>t] is ! foll[+3 7,a7 ,= !  
cal5d> qu>t] beg9n+ on ,octob] #a1      
#bjbb1 #j4e4  7,b7 ,= a cal5d> qu>t]    
beg9n+ on or aft] ,janu>y #a1 #bjbc1 &  
end+ be=e ,july #a1 #bjbg1 ! numb] (    
p]c5tage po9ts specifi$ "u ?is p>agraph 
= ! previ\s qu>t]1 plus #j4e4  7,c7 ,= a
 cal5d> qu>t] beg9n+ on or aft] ,july   
#a1 #bjbg1 #aj4  7#c7 ,def9ition ,=     
purposes ( ?is subsection1 ! t]m ,/ate  
means a ,/ate t is "o ( ! #ej ,/ates or 
! ,di/rict ( ,columbia4  4  #bjc4 ,/ate 

option to provide #ab mon?s ( po/p>tum  
,m$icaid eligibility  7a7 ,option ,to   
provide cont9u\s ,m$icaid & ,,*ip       
cov]age = pregnant & po/p>tum wom5  7#a7
 ,m$icaid ,title ,,xix ( ! ,social      
,security ,act 7#db ,u4,s4,c4 #acif et  
seq47 is am5d$-- 7,a7 9 section         
#aijb7l77#a77;,a71 by ins]t+ 7or1 at !  
option ( ! ,/ate1 #cfe-;day p]iod7 aft] 
#fj-;day p]iod2  7,b7 9 section         
#aijb7;e77#f71 by ins]t+ 7or1 at !      
option ( ! ,/ate1 #cfe-;day p]iod7 aft] 
#fj-;day p]iod2  7,c7 9 section         
#aijc7v77#d77;,a77i71 by ins]t+ 7or1 at 
! option ( ! ,/ate1 #cfe-;day p]iod7    
aft] #fj-;day p]iod2 &  7,d7 9 section  
#aije7;a71 9 ! #d? s5t5ce 9 ! matt]     
foll[+ p>agraph 7#cj71 by ins]t+ 7or1 at
 ! option ( ! ,/ate1 #cfe-;day p]iod7   
aft] #fj-;day p]iod4  7#b7 ,,*ip        
,section #baab ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acigll7 is am5d$ by
 ins]t+ 7or1 at ! option ( ! ,/ate1     
#cfe-;day p]iod7 aft] #fj-;day p]iod ea*
 place x appe>s4  7b7 ,requir+ full     

b5efits = pregnant & po/p>tum wom5  7#a7
 ,m$icaid  7,a7 ,9 g5]al ,p>agraph 7#e7 
( section #aijb7;e7 ( ! ,social         
,security ,act 7#bd ,u4,s4,c4           
#acif;a7e77 is am5d$ to read z foll[s3  
7#e7 ,any woman :o is eligible = m$ical 
assi/ance "u ! ,/ate plan or a waiv] (  
su* plan & :o is1 or :o :ile s eligible 
becomes1 pregnant1 %all cont9ue to be   
eligible "u ! plan or waiv] = m$ical    
assi/ance ?r\gh ! end ( ! mon? 9 :i* !  
#fj-;day p]iod 7or1 at ! option ( !     
,/ate1 #cfe-;day p]iod7 7beg9n+ on ! la/
 day ( h] pregnancy7 ends1 reg>dless ( !
 basis = ! woman's eligibility = m$ical 
assi/ance1 includ+ if ! woman's         
eligibility = m$ical assi/ance is on !  
basis ( be+ pregnant4  4  7,b7 ,con=m+  
am5dm5t ,section #aijb7;a77#aj7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#acif;a7a77#aj77 is am5d$ 9 ! matt]     
foll[+ subp>agraph 7,g7 by /rik+ 7,,vii7
 ! m$ical assi/ance & all t foll[s ?r\gh
 complicate pregnancy14  7#b7 ,,*ip     
,section #bajg7;e77#a7 ( ! ,social      

,security ,act 7#db ,u4,s4,c4           
#acig;gg7e77#a77 is am5d$-- 7,a7 by     
r$esignat+ subp>agraphs 7,h7 ?r\gh 7,s7 
z subp>agraphs 7,i7 ?r\gh 7,t71         
respectively2 &  7,b7 by ins]t+ aft]    
subp>agraph 7,g71 ! foll[+3  7,h7       
,section #aijb7;e77#e7 7requir+ #fj-;day
 7or1 at ! option ( ! ,/ate1 #cfe-;day7 
cont9u\s cov]age = pregnant & po/p>tum  
wom574  4  7c7 ,ma9t5ance ( ef=t  7#a7  
,m$icaid ,section #aijb ( ! ,social     
,security ,act 7#db ,u4,s4,c4 #acif;a7  
is am5d$-- 7,a7 9 p>agraph 7#gd71 by    
/rik+ subsection 7gg72 & & ins]t+       
subsections 7gg7 & 7qq722 &  7,b7 by    
add+ at ! end ! foll[+ new subsection3  
7qq7 ,ma9t5ance ( ef=t relat$ to        
l[-,income pregnant wom5 ,= cal5d>      
qu>t]s beg9n+ on or aft] ! effective    
date describ$ 9 section #bjd7;d7 ( !    
,heal? ,c>e ,improvem5t ,act ( #bjbj1 & 
be=e ,janu>y #a1 #bjbc1 no ,f$]al paym5t
 %all be made to a ,/ate "u section     
#aijc7;a7 = am\nts exp5d$ "u a ,/ate    
plan "u ?is title or a waiv] ( su* plan 

if ! ,/ate-- 7#a7 has 9 effect "u su*   
plan eligibility /&>ds1 me?odologies1 or
 proc$ures = individuals describ$ 9     
subsection 7l77#a7 :o are eligible =    
m$ical assi/ance "u ! ,/ate plan or     
waiv] "u subsection                     
7a77#aj77;,a77ii77,,ix7 t are m         
re/rictive ?an ! eligibility /&>ds1     
me?odologies1 or proc$ures1             
respectively1 = su* individuals "u su*  
plan or waiv] t are 9 effect on ! date (
 ! enactm5t ( ?is subsection2 or  7#b7  
provides m$ical assi/ance to individuals
 describ$ 9 subsection 7l77#a7 :o are   
eligible = m$ical assi/ance "u su* plan 
or waiv] "u subsection                  
7a77#aj77;,a77ii77,,ix7 at a level t is 
less ?an ! level at :i* ! ,/ate provides
 su* assi/ance to su* individuals "u su*
 plan or waiv] on ! date ( ! enactm5t ( 
?is subsection4  4  7#b7 ,,*ip ,section 
#baab ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acigll71 z am5d$ by          
subsection 7b71 is fur!r am5d$ by add+  
at ! end ! foll[+ subsection3  7g7      

,ma9t5ance ( ef=t ,= cal5d> qu>t]s      
beg9n+ on or aft] ! effective date      
describ$ 9 section #bjd7;d7 ( ! ,heal?  
,c>e ,improvem5t ,act ( #bjbj1 & be=e   
,janu>y #a1 #bjbc1 no paym5t may be made
 "u section #baje7;a7 ) respect to a    
,/ate *ild heal? plan if ! ,/ate-- 7#a7 
has 9 effect "u su* plan eligibility    
/&>ds1 me?odologies1 or proc$ures =     
t>get$ l[-income pregnant wom5 t are m  
re/rictive ?an ! eligibility /&>ds1     
me?odologies1 or proc$ures1             
respectively1 "u su* plan t are 9 effect
 on ! date ( ! enactm5t ( ?is           
subsection2 or  7#b7 provides           
pregnancy-relat$ assi/ance to t>get$    
l[-income pregnant wom5 "u su* plan at a
 level t is less ?an ! level at :i* !   
,/ate provides su* assi/ance to su* wom5
 "u su* plan on ! date ( ! enactm5t (   
?is subsection4  4  7d7 ,effective date 
7#a7 ,9 g5]al ,except z provid$ "u      
p>agraph 7#b71 ! am5dm5ts made by       
subsections 7a7 & 7b7 %all take effect  
on 7& ! effective date describ$ 9 ?is   

subsection %all be7 ! fir/ day ( !      
cal5d> qu>t] dur+ :i* ! la/ day ( !     
em]g5cy p]iod describ$ 9 section        
#aace7;g77#a77;,b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acbj;b-#e7;g77#a77;,b77 occurs4  7#b7  
,ext5sion ( effective date = ,/ate law  
am5dm5t ,9 ! case ( a ,/ate plan "u     
title ,,xix or ,/ate *ild heal? plan "u 
title ,,xxi ( ! ,social ,security ,act  
7#db ,u4,s4,c4 #acif et seq42 #db       
,u4,s4,c4 #acig;aa et seq47 :i* !       
,secret>y ( ,heal? & ,human ,s]vices    
det]m9es requires ,/ate legislation 7o!r
 ?an legislation appropriat+ funds7 9   
ord] = ! respective plan to meet !      
additional requirem5t impos$ by !       
am5dm5ts made by subsection 7a7 or 7b71 
respectively1 ! respective plan %all n  
be reg>d$ z fail+ to comply ) !         
requirem5ts ( su* title solely on !     
basis ( its failure to meet su*         
applicable additional requirem5t be=e ! 
fir/ day ( ! fir/ cal5d> qu>t] beg9n+   
aft] ! close ( ! fir/ regul> session ( !

 ,/ate legislature t beg9s aft] ! date (
 enactm5t ( ?is ,act4 ,= purposes ( !   
previ\s s5t5ce1 9 ! case ( a ,/ate t has
 a #b-ye> legislative session1 ea* ye> (
 ! session is consid]$ to be a sep>ate  
regul> session ( ! ,/ate legislature4   
#bjd4 ,support+ ,/ate ,m$icaid programs 
?r\gh economic d[nturns  7a7 ,9 g5]al   
,section #aije ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acif;d7 is am5d$-- 
7#a7 9 subsection 7b71 by /rik+ & 7ff7 &
 ins]t+ 7ff71 & 7gg72 &  7#b7 by add+ at
 ! end ! foll[+ new subsection3  7gg7   
,increas$ ,,fmap dur+ economic d[nturns 
7#a7 ,9 g5]al ,if a fiscal qu>t] t beg9s
 on or aft] ,janu>y #a1 #bjbj1 is an    
economic d[nturn qu>t] 7z def9$ 9       
p>agraph 7#b77 ) respect to a ,/ate1 !n 
! ,f$]al m$ical assi/ance p]c5tage      
det]m9$ = ea* ,/ate = su* qu>t] "u      
subsection 7b7 %all be equal to !       
p]c5tage det]m9$ = ! ,/ate & qu>t] "u   
p>agraph 7#c74  7#b7 ,economic d[nturn  
qu>t]  7,a7 ,9 g5]al  7i7 ,9 g5]al ,9   
?is subsection1 ! t]m economic d[nturn  

qu>t] means1 ) respect to a ,/ate1 a    
fiscal qu>t] dur+ :i* ! ,/ate's         
unemploym5t rate = ! qu>t] exce$s !     
p]c5tage det]m9$ = ! ,/ate & qu>t] "u   
clause 7ii74  7ii7 ,?re%old p]c5tage ,! 
p]c5tage det]m9$ "u ?is clause = a ,/ate
 & fiscal qu>t] is ! p]c5tage equal to !
 l[] (-- 7,i7 ! ,/ate unemploym5t rate  
at ! #bj? p]c5tile ( ! di/ribution ( !  
,/ate's qu>t]ly unemploym5t rates = !   
#fj-qu>t] p]iod prec$+ ! qu>t] involv$1 
increas$ by #a p]c5tage po9t2 &  7,,ii7 
! ,/ate's av]age qu>t]ly unemploym5t    
rate = ! #ab-qu>t] p]iod prec$+ ! qu>t] 
involv$1 increas$ by #a p]c5tage po9t4  
7,b7 ,unemploym5t data  7i7 ,9 g5]al    
,except z provid$ 9 clause 7ii71 =      
purposes ( det]m9+ unemploym5t rates = a
 ,/ate & a qu>t] "u ?is p>agraph1 !     
,secret>y %all use data f ! ,local ,area
 ,unemploym5t ,/ati/ics f ! ,bureau (   
,labor ,/ati/ics4  7ii7 ,application to 
c]ta9 t]ritories ,9 ! case ( ! ,virg9   
,isl&s1 ,guam1 ! ,nor!rn ,m>iana ,isl&s1
 ,am]ican ,samoa1 or any o!r            

jurisdiction = :i* suitable data f !    
,local ,area ,unemploym5t ,/ati/ics f ! 
,bureau ( ,labor ,/ati/ics are          
unavailable1 ! ,secret>y %all use data f
 ! ,u-#c unemploym5t measure ( ! ,bureau
 ( ,labor ,/ati/ics to make any necess>y
 det]m9ations "u subp>agraph 7,a74  7#c7
 ,increas$ ,,fmap dur+ economic d[nturn 
qu>t]  7,a7 ,9 g5]al ,dur+ a fiscal     
qu>t] t is an economic d[nturn qu>t] )  
respect to a ,/ate1 ! ,f$]al m$ical     
assi/ance p]c5tage = ! ,/ate & qu>t]    
det]m9$ "u subsection 7b7 %all be equal 
to-- 7i7 ! ,f$]al m$ical assi/ance      
p]c5tage det]m9$ = ! ,/ate & qu>t] "u   
subsection 7b7 )\t reg>d to ?is         
subsection 7b includ+ any increase to   
su* p]c5tage = su* qu>t] made pursuant  
to section #fjjh7;a7 ( ! ,families ,fir/
 ,coronavirus ,response ,act72 increas$ 
by  7ii7 ! numb] ( p]c5tage po9ts 7r\nd$
 to ! ne>e/ t5? ( a p]c5tage po9t7 equal
 to ! product (-- 7,i7 ! numb] (        
p]c5tage po9ts 7r\nd$ to ! ne>e/ t5? ( a
 p]c5tage po9t7 by :i* ! unemploym5t    

rate = ! ,/ate & qu>t] exce$s ! p]c5tage
 det]m9$ = ! ,/ate & qu>t] "u p>agraph  
7#b77;,a77ii72 &  7,,ii7 #d4h4  7,b7    
,rules ( application ,! foll[+ rules    
%all apply ) respect to ! ,f$]al m$ical 
assi/ance p]c5tage det]m9$ = a ,/ate &  
an economic d[nturn qu>t] "u ?is        
subsection3 7i7 ,scope ( application    
,su* ,f$]al m$ical assi/ance p]c5tage   
%all n apply = purposes (-- 7,i7        
disproportionate %>e hospital paym5ts   
describ$ 9 section #aibc2  7,,ii7       
paym5ts "u "p ,d ( title ,,iv2 or       
7,,iii7 any paym5ts "u ?is title t are  
bas$ on a ,f$]al m$ical assi/ance       
p]c5tage det]m9$ = a ,/ate "u subsection
 7aa7 7b only to ! ext5t t su* ,f$]al   
m$ical assi/ance p]c5tage is high] ?an !
 economic recov]y ,,fmap74  7ii7        
,limitation ,9 no case %all-- 7,i7 !    
,f$]al m$ical assi/ance p]c5tage det]m9$
 = a ,/ate & qu>t] pursuant to ?is      
subsection exce$ #ie p]c5t2 or  7,,ii7  
any increase to ! ,f$]al m$ical         
assi/ance p]c5tage det]m9$ = a ,/ate &  

qu>t] pursuant to ?is subsection result 
9 ! application ( a ,f$]al m$ical       
assi/ance p]c5tage t exce$s #ie p]c5t4  
7iii7 ,application to ,,*ip ,not)/&+ !  
fir/ s5t5ce ( section #baje7;b71 !      
application ( ?is subsection may result 
9 ! enhanc$ ,,fmap ( a ,/ate = a fiscal 
ye> "u su* section exce$+ #he p]c5t1 b 9
 no case may ! application ( ?is        
subsection be=e application ( ! second  
s5t5ce ( su* section result 9 ! enhanc$ 
,,fmap ( ! ,/ate exce$+ #ie p]c5t4  7#d7
 ,advance paym5t2 retrospective adju/m5t
  7,a7 ,9 g5]al ,prior to ! beg9n+ ( ea*
 fiscal qu>t] t beg9s on or aft] ,july  
#a1 #bjbj1 ! ,secret>y %all1 ) respect  
to ea* ,/ate-- 7i7 make an initial      
det]m9ation1 bas$ on ! projections made 
= ! ,/ate & qu>t] "u subp>agraph 7,b71 z
 to-- 7,i7 :e!r ! application ( ?is     
subsection is expect$ to result 9 !     
application ( a high] ,f$]al m$ical     
assi/ance p]c5tage = ! ,/ate & qu>t] ?an
 ! p]c5tage t w\ld o!rwise apply )\t    
reg>d to ?is subsection2 &--  7,,ii7 if 

! application ( ?is subsection is       
expect$ to result 9 su* a high] ,f$]al  
m$ical assi/ance p]c5tage = ! ,/ate &   
qu>t]1 :at su* high] p]c5tage is expect$
 to be2 &  7ii7 if ! ,secret>y det]m9es 
"u clause 7i7 t ! application ( ?is     
subsection is expect$ to result 9 !     
application ( a high] ,f$]al m$ical     
assi/ance p]c5tage = ! ,/ate & qu>t] ?an
 ! p]c5tage t w\ld o!rwise apply )\t    
reg>d to ?is subsection-- 7,i7 apply su*
 high] ,f$]al m$ical assi/ance p]c5tage 
( ! ,/ate = purposes ( mak+ paym5ts to !
 ,/ate = am\nts exp5d$ dur+ su* qu>t] z 
m$ical assi/ance "u ! ,/ate plan2 &     
7,,ii7 take into acc\nt su* high] ,f$]al
 m$ical assi/ance p]c5tage ( ! ,/ate =  
purposes ( calculat+ ! enhanc$ ,,fmap = 
! ,/ate & qu>t] "u section #baje7;b74   
7,b7 ,projection ( ,/ate unemploym5t    
rates ,prior to ! beg9n+ ( ea* fiscal   
qu>t] t beg9s on or aft] ,july #a1      
#bjbj1 ! ,secret>y1 act+ ?r\gh ! ,*ief  
,actu>y ( ! ,c5t]s = ,m$ic>e  ,m$icaid  
,s]vices1 %all1 us+ ! mo/ rec5tly       

available data describ$ 9 p>agraph      
7#b77;,b71 make projections ) respect   
to-- 7i7 ! unemploym5t rates = ea* ,/ate
 = su* qu>t]2  7ii7 ! ?re%old p]c5tages 
describ$ 9 p>agraph 7#b77;,a77ii7 = ea* 
,/ate = su* qu>t]2 &  7iii7 ! national  
unemploym5t rate = su* qu>t]4  7,c7     
,retrospective adju/m5t ,z soon z       
practicable aft] f9al unemploym5t data  
becomes available = a fiscal qu>t] t    
beg9s on or aft] ,july #a1 #bjbj1 !     
,secret>y %all1 ) respect to ea* ,/ate--
 7i7 make a f9al det]m9ation ) respect  
to ! application ( ?is subsection =     
purposes ( det]m9+ ! ,f$]al m$ical      
assi/ance p]c5tage & enhanc$ ,,fmap ( ! 
,/ate = ! qu>t]2 &  7ii7 9 accordance ) 
section #aijc7;d77#b7 & section         
#baje7;e71 r$uce or increase ! am\nt    
payable to ! ,/ate "u section #aijc7;a7 
or section #baje = a subsequ5t fiscal   
qu>t] to ! ext5t ( any ov]paym5t or     
und]paym5t "u ei!r su* section :i* !    
,secret>y det]m9es 0 made z a result (  
an incorrect initial det]m9ation "u     

subp>agraph 7,a77i7 ) respect to !      
application ( ?is subsection = purposes 
( det]m9+ ! ,f$]al m$ical assi/ance     
p]c5tage & enhanc$ ,,fmap ( ! ,/ate =   
su* prior fiscal qu>t]4  7#e7           
,retrospective application ( ov]-!-limit
 ,,fmap increases  7,a7 ,9 g5]al ,if a  
,/ate has excess p]c5tage po9ts )       
respect to an economic d[nturn qu>t] &  
an applicable ,,fmap 7z det]m9$ "u      
subp>agraph 7,b771 ! ,/ate may elect to 
apply su* excess p]c5tage po9ts to      
increase su* applicable ,,fmap = "o or m
 qu>t]s dur+ ! look-back p]iod = ! ,/ate
 & economic d[nturn qu>t] 9 accordance )
 ?is p>agraph4  7,b7 ,excess p]c5tage   
po9ts ,= purposes ( ?is p>agraph1 !     
numb] ( excess p]c5tage po9ts = a ,/ate1
 economic d[nturn qu>t]1 & an applicable
 ,,fmap %all be equal to ! numb] (      
p]c5tage po9ts by :i*-- 7i7 ! applicable
 ,,fmap = ! ,/ate & qu>t] 7aft]         
application ( p>agraph 7#c7 b )\t reg>d 
to subp>agraph 7,b77ii7 ( su* p>agraph72
 exce$s  7ii7 #ie p]c5t4  7,c7 ,effect (

 application ( excess p]c5tage po9ts ,if
 a ,/ate elects to apply excess p]c5tage
 po9ts to an applicable ,,fmap to a     
qu>t] dur+ a look-back p]iod "u ?is     
p>agraph1 ! ,secret>y %all det]m9e !    
additional am\nt ( paym5t "u section    
#aijc7;a7 to :i* ! ,/ate w\ld h be5     
entitl$ = su* qu>t] if ! applicable     
,,fmap 7z s increas$7 _h be5 9 effect = 
su* qu>t]1 & %all treat su* additional  
am\nt z an und]paym5t = su* qu>t]4  7,d7
 ,di/ribution ( excess p]c5tage po9ts ,a
 ,/ate t has excess p]c5tage po9ts )    
respect to an economic d[nturn qu>t] &  
applicable ,,fmap may elect to divide   
su* po9ts among m ?an #a qu>t] dur+ !   
look-back p]iod = su* ,/ate & qu>t]     
provid$ t no excess p]c5tage po9t 7or   
fraction ( an excess p]c5tage po9t7 is  
appli$ to ! applicable ,,fmap ( m ?an #a
 qu>t]4  7,e7 ,limitations  7i7 ,no     
increases ov] #ajj p]c5t ,a ,/ate may n 
increase an applicable ,,fmap = any     
qu>t] dur+ a look-back p]iod "u ?is     
p>agraph if su* increase w\ld result 9 !

 applicable ,,fmap = su* qu>t] exce$+   
#ajj p]c5t4  7ii7 ,scope ( application  
,any increase to an applicable ,,fmap ( 
a ,/ate = a fiscal qu>t] "u ?is         
p>agraph-- 7,i7 %all only apply )       
respect to paym5ts = am\nts exp5d$ by ! 
,/ate = m$ical assi/ance = s]vices      
furni%$ dur+ su* qu>t] to :i* su*       
applicable ,,fmap is applicable2 &      
7,,ii7 %all n apply ) respect to paym5ts
 describ$ 9 p>agraph 7#c77;,b77i74  7,f7
 ,def9itions ,9 ?is p>agraph3 7i7       
,applicable ,,fmap ,! t]m applicable    
,,fmap means1 ) respect to a ,/ate &    
fiscal qu>t]-- 7,i7 ! ,f$]al m$ical     
assi/ance p]c5tage det]m9$ = ! ,/ate &  
qu>t] "u subsection 7b72  7,,ii7 !      
,f$]al m$ical assi/ance p]c5tage        
applicable "u subsection 7y72  7,,iii7 !
 ,f$]al m$ical assi/ance p]c5tage       
applicable "u subsection 7z77#b72       
7,,iv7 ! ,f$]al m$ical assi/ance        
p]c5tage det]m9$ = ! ,/ate & qu>t] "u   
subsection 7ff72 or  7,v7 ! enhanc$     
,,fmap det]m9$ = ! ,/ate & qu>t] "u     

section #baje7;b74  7ii7 ,look-back     
p]iod ,! t]m look-back p]iod means1 )   
respect to a ,/ate & a fiscal qu>t] t is
 an economic d[nturn qu>t] = ! ,/ate1 ! 
p]iod ( #d fiscal qu>t]s t ends ) ! f\r?
 qu>t] :i* prec$es ! mo/ rec5t fiscal   
qu>t]s t 0 n an economic d[nturn qu>t] =
 ! ,/ate4  7#f7 ,requirem5t = all ,/ates
 ,?is subsection %all n apply to a ,/ate
 ) respect to a fiscal qu>t]1 if-- 7,a7 
eligibility /&>ds1 me?odologies1 or     
proc$ures "u ! ,/ate plan or a waiv] (  
su* plan are m re/rictive dur+ su* qu>t]
 ?an ! eligibility /&>ds1 me?odologies1 
or proc$ures1 respectively1 "u su* plan 
7or waiv]7 z 9 effect on ! la/ day ( !  
mo/ rec5t fiscal qu>t] t 0 n an economic
 d[nturn qu>t] = ! ,/ate2  7,b7 ! am\nt 
( any premium impos$ by ! ,/ate pursuant
 to section #aiaf or #aiaf;,a dur+ su*  
qu>t]1 ) respect to an individual       
enroll$ "u su* plan 7or waiv]71 exce$s !
 am\nt ( su* premium z ( ! date describ$
 9 subp>agraph 7,a72 or  7,c7 ! ,/ate   
fails to provide t an individual :o is  

enroll$ = b5efits "u su* plan 7or waiv]7
 z ( ! date describ$ 9 subp>agraph 7,a7 
or enrolls = b5efits "u su* plan 7or    
waiv]7 dur+ ! p]iod beg9n+ ) su* date & 
end+ ) ! day be=e ! fir/ day ( ! next   
qu>t] t is n an economic d[nturn qu>t] =
 ! ,/ate %all be treat$ z eligible = su*
 b5efits = n less ?an #ab mon?s aft] su*
 date or 7if lat]7 ! date t su*         
individual s enrolls unless ! individual
 reque/s a volunt>y t]m9ation (         
eligibility or ! individual ceases to be
 a resid5t ( ! ,/ate4  4  7b7 ,exclusion
 ( economic d[nturn ,,fmap increases f  
t]ritorial caps2 special rule = ,,*ip   
allotm5ts  7#a7 ,exclusion f t]ritorial 
caps ,section #aajh ( ! ,social         
,security ,act 7#db ,u4,s4,c4 #acjh7 is 
am5d$-- 7,a7 9 subsection 7f71 9 ! matt]
 prec$+ p>agraph 7#a71 by /rik+         
subsection 7g7 & section                
#aice7;e77#a77;,b7 & ins]t+ subsections 
7g7 & 7h7 & section #aice7;e77#a77;,b72 
&  7,b7 by add+ at ! end ! foll[+3  7h7 
,exclusion f caps ( am\nts attributable 

to economic d[nturn ,,fmap ,any paym5t  
made to a t]ritory = a fiscal ye> 9 :i* 
! ,f$]al m$ical assi/ance p]c5tage = !  
t]ritory is det]m9$ "u section          
#aije7;gg7 %all n be tak5 into acc\nt = 
purposes ( apply+ paym5t limits "u      
subsections 7f7 & 7g7 to ! ext5t t su*  
paym5t exce$s ! am\nt ( ! paym5t t w\ld 
h be5 made to ! t]ritory = ! ye> if !   
,f$]al m$ical assi/ance p]c5tage = !    
t]ritory _h be5 det]m9$ )\t reg>d to su*
 section4  4  7#b7 ,,*ip allotm5ts      
,section #bajd7m7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #acig;dd7m77 is     
am5d$-- 7,a7 9 p>agraph 7#b77;,b71 9 !  
matt] prec$+ clause 7i71 by /rik+       
p>agraphs 7#e7 & 7#g7 & ins]t+ p>agraphs
 7#e71 7#g71 & 7#ab72 &  7,b7 by add+ at
 ! end ! foll[+ new p>agraph3  7#ab7    
,special rule = adju/+ allotm5ts dur+   
fiscal ye>s ) economic d[nturn qu>t]s   
7,a7 ,9 g5]al ,if a fiscal qu>t] occurr+
 dur+ fiscal ye> #bjbj or any succe$+   
fiscal ye> is det]m9$ to be an economic 
d[nturn qu>t] ) respect to a ,/ate 7z   

det]m9$ "u section #aije7;gg77 !n1 z    
soon z practicable aft] su* det]m9ation1
 ! ,secret>y %all increase ! allotm5t = 
! ,/ate & fiscal ye> 9 accordance )     
subp>agraph 7,b74  7,b7 ,am\nt (        
increase  7i7 ,9 g5]al ,! am\nt ( an    
increase to ! allotm5t ( a ,/ate        
describ$ 9 subp>agraph 7,a7 = a fiscal  
ye> %all be equal to ! am\nt by :i*     
,f$]al paym5ts made to ! ,/ate = !      
prec$+ fiscal ye> "u ?is title w\ld h   
be5 increas$ 7)\t reg>d to :e!r su*     
paym5ts w\ld exce$ ! am\nt ( ! ,/ate's  
allotm5t = su* prec$+ fiscal ye>7 if !  
enhanc$ ,,fmap det]m9$ = ! ,/ate = su*  
prec$+ fiscal ye> _h be5 increas$ to !  
same ext5t t ! ,/ate's enhanc$ ,,fmap = 
! fiscal ye> involv$ is expect$ to be   
increas$ z a result ( ! application (   
section #aije7;gg7 relative to ! enhanc$
 ,,fmap t w\ld apply to ! ,/ate = !     
fiscal ye> involv$ )\t ! application (  
su* section4  7ii7 ,inclusion ( project$
 increases ,9 increas+ ! allotm5t ( a   
,/ate = a fiscal ye> "u ?is p>agraph1 ! 

,secret>y may base ! calculation ( su*  
increase on projections made by !       
,secret>y ) respect to-- 7,i7 ! numb] ( 
fiscal qu>t]s dur+ su* fiscal ye> t w be
 economic d[nturn qu>t]s2 &  7,,ii7 !   
effect t ! application ( section        
#aije7;gg7 is expect$ to h on ! enhanc$ 
,,fmap ( ! ,/ate = su* fiscal ye>4  7,c7
 ,disreg>d ( increas$ paym5ts = purposes
 ( future allotm5ts ,any ,f$]al paym5t  
made to a ,/ate "u ?is title = a fiscal 
ye> 9 :i* ! ,f$]al m$ical assi/ance     
p]c5tage = ! ,/ate is det]m9$ "u section
 #aije7;gg7 %all be disreg>d$ :5 det]m9+
 ! allotm5t ( ! ,/ate = any subsequ5t   
ye>1 includ+ = purposes ( apply+ ?is    
p>agraph1 to ! ext5t t su* paym5t exce$s
 ! am\nt ( ! paym5t t w\ld h be5 made to
 ! ,/ate = ! ye> if ! ,f$]al m$ical     
assi/ance p]c5tage = ! ,/ate & ye> _h   
be5 det]m9$ )\t reg>d to su* section4  4
  #bje4 ,/ate flexibility to use        
adm9i/rative simplification policies =  
enrollm5t  7a7 ,p]man5t ext5sion (      
m$icaid & ,,*ip express lane option     

,section #aijb7;e77#ac7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#acif;a7e77#ac77 is am5d$ by /rik+      
subp>agraph 7,i74  7b7 ,ext5d+ express  
lane eligibility to adults ,section     
#aijb7;e77#ac77;,a7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#acif;a7e77#ac77;,a77 is am5d$ by add+  
at ! end ! foll[+ new clause3  7iii7    
,/ate option to ext5d express lane      
eligibility to adults  7,i7 ,9 g5]al ,at
 ! option ( ! ,/ate1 ! ,/ate may apply !
 provisions ( ?is p>agraph ) respect to 
det]m9+ eligibility "u ?is title = an   
eligible individual 7z def9$ 9 subclause
 7,,ii774 ,9 apply+ ?is p>agraph 9 !    
case ( a ,/ate mak+ su* an option1 any  
ref]5ce 9 ?is p>agraph to a *ild )      
respect to ?is title 7o!r ?an a ref]5ce 
to *ild heal? assi/ance7 %all be deem$  
to be a ref]5ce to an eligible          
individual4  7,,ii7 ,eligible individual
 def9$ ,9 ?is clause1 ! t]m eligible    
individual means-- 7aa7 any individual  
7o!r ?an a *ild7 ^: income eligibility  

"u ! ,/ate plan or "u a waiv] ( ! plan =
 m$ical assi/ance is det]m9$ "u p>agraph
 7#ad72 &  7bb7 an individual includ$ 9 
any o!r gr\p ( individuals ! ,secret>y  
det]m9es appropriate4  4  7c7 ,cons5t by
 b5efit utilization ,section            
#aijb7;e77#ac77;,d77i7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acif;a7e77#ac77;,d77i77 is am5d$ by    
ins]t+ by us+ m$ical assi/ance to access
 c>e1 aft] ?r\gh electronic signature14 
7d7 ,/udy & report on options =         
automatic enrollm5t 9 ,m$icaid & ,,*ip  
7#a7 ,/udy ,! ,secret>y ( ,heal? &      
,human ,s]vices1 by grant1 contract1 or 
int]ag5cy ag5cy1 %all conduct a /udy to 
id5tify options =1 & b>ri]s to1 ,/ates  
automatically enroll+ individuals :o1 on
 ! basis ( data & in=mation f income tax
 returns & o!r s\rces1 are likely to be 
eligible = m$ical assi/ance "u ! ,/ate  
,m$icaid plan e/abli%$ "u title ,,xix ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acif et seq47 7or a waiv] ( su* plan7  
or = *ild heal? assi/ance 7or1 if       

applicable1 pregnancy-relat$ assi/ance7 
"u ! ,/ate *ild heal? plan e/abli%$ "u  
title ,,xxi ( ! ,social ,security ,act  
7#db ,u4,s4,c4 #acig;aa et seq47 7or a  
waiv] ( su* plan71 & w\ld n be requir$  
to pay a premium = enrollm5t 9 su* a    
plan or waiv]4  7#b7 ,report ,n lat] ?an
 #a ye> aft] ! date ( enactm5t ( ?is    
,act1 ! ,secret>y ( ,heal? & ,human     
,s]vices %all submit a report to        
,congress on ! results ( ! /udy conduct$
 "u subsection 7a74 ,! report %all      
include ! foll[+3 7,a7 ,an analysis ( ! 
f9ancial1 regulatory1 & legislative     
b>ri]s t limit ! ability ( ,/ates to    
implem5t automatic enrollm5t =          
individuals describ$ 9 subsection 7a74  
7,b7 ,an analysis ( ! ext5t to :i* ,/ate
 implem5tation ( automatic enrollm5t =  
su* individuals w\ld r$uce ! numb] (    
un9sur$ individuals 9 ea* ,/ate4  7,c7  
,recomm5dations = adm9i/rative &        
legislative actions t1 if tak51 w\ld    
elim9ate ! b>ri]s id5tifi$ "u           
subp>agraph 7,a7 & all[ ,/ates to elect 

to automatically enroll individuals     
describ$ 9 subsection 7a7 9 ! ,/ate     
,m$icaid plan e/abli%$ "u title ,,xix ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acif et seq47 7or a waiv] ( su* plan7  
or = *ild heal? assi/ance 7or1 if       
applicable1 pregnancy-relat$ assi/ance7 
"u ! ,/ate *ild heal? plan e/abli%$ "u  
title ,,xxi ( ! ,social ,security ,act  
7#db ,u4,s4,c4 #acig;aa et seq47 7or a  
waiv] ( su* plan74  ,,iii ,e/abli%m5t ( 
a ,public ,heal? ,c>e ,option  #cja4    
,e/abli%m5t ( heal? plan  7a7 ,9 g5]al  
,! ,secret>y %all e/abli% a coord9at$ & 
l[-co/ heal? plan 7ref]r$ to 9 ?is      
section z ! heal? plan7 to provide      
access to quality heal? c>e = enrollees4
  7b7 ,individual m>ket availability ,! 
,secret>y %all make ! heal? plan        
available 9 ! individual m>ket = plan   
ye> #bjbb & ea* subsequ5t plan ye>4  7c7
 ,rulemak+ ,! ,secret>y may promulgate  
su* regulations z may be necess>y to    
c>ry out ?is title4  7d7 ,au?orization (
 appropriations ,!re are au?oriz$ to be 

appropriat$ su* sums z may be necess>y  
to c>ry out ?is title4  #cjb4           
,availability ( plan  7a7 ,eligibility  
,an individual %all be eligible to      
enroll 9 ! heal? plan if su* individual1
 = ! entire p]iod = :i* enrollm5t is    
s\ght-- 7#a7 is a qualifi$ individual )9
 ! mean+ ( section #acab ( ! ,pati5t    
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjcb72  7#b7 is n eligible =
 b5efits "u ! ,m$ic>e program "u title  
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #acie et seq472 &  7#c7 is n  
o!rwise eligible =1 or has be5 o!rwise  
(f]$1 employ]-sponsor$ heal? c>e        
cov]age4  7b7 ,ex*anges ,! heal? plan   
%all be made available ?r\gh !          
,ex*anges1 includ+ ! ,small ,bus9ess    
,heal? ,options ,program ,ex*ange4      
#cjc4 ,af=dability ,! ,secret>y %all    
ensure t cov]age options = ! heal? plan 
are n m co/ly ?an comp>able options (f]$
 on ! ,ex*ange 9 ! applicable m>ket4    
#cjd4 ,p>ticipat+ provid]s  7a7         
,requirem5t ,to p>ticipate 9 ord] ,to be

 enroll$ "u ,m$ic>e ,beg9n+ ,janu>y #a1 
#bjba1 ! ,secret>y may require a heal?  
c>e provid] enroll$ "u ! ,m$ic>e program
 "u section #ahff7;j7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#acie;cc7j77 to be a p>ticipat+ provid] 
"u ! heal? plan4  7b7 ,requirem5t ,to   
p>ticipate 9 ord] ,to p>ticipate 9      
,m$icaid ,beg9n+ ,janu>y #a1 #bjba1 !   
,secret>y may require a heal? c>e       
provid] "u a ,/ate ,m$icaid plan "u     
title ,,xix ( ! ,social ,security ,act  
7#db ,u4,s4,c4 #acif et seq47 to also be
 a p>ticipat+ provid] "u ! heal? plan4  
#cje4 ,provid] paym5t rates ,! ,secret>y
 %all set competitive provid] paym5t    
rates "u ! heal? plan us+ ! be/         
in=mation publically available & data   
o!rwise accessible to ! ,secret>y4 ,!   
,secret>y %all give consid]ation to     
exi/+ provid] paym5t rates = comm]cial  
heal? plans & provid] co/s to deliv]    
c>e1 giv+ special consid]ation to       
increas$ co/s = provid]s to deliv] c>e 9
 rural & m$ically und]s]v$ areas4  #cjf4

 ,no effect on ,m$ic>e b5efits or       
,m$ic>e tru/ funds ,no?+ 9 ?is title    
%all-- 7#a7 affect ! b5efits available  
"u title ,,xviii ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #acie et seq472 or  
7#b7 impact ! ,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$ical ,insurance ,tru/   
,fund "u section #ahda ( ! ,social      
,security ,act 7#db ,u4,s4,c4 #aciet7   
7includ+ ! ,m$ic>e ,prescription ,drug  
,acc\nt )9 su* ,tru/ ,fund74  ,,iv ,fair
 ,m$ic>e ,paym5ts to ,rural ,provid]s   
#dja4 ,ensur+ fairness 9 ,m$ic>e        
hospital paym5ts  7a7 ,hospital inpati5t
 s]vices  7#a7 ,9 g5]al ,section        
#ahhf7;d77#c77;,e77i7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#aciewww7d77#c77;,e77 is am5d$-- 7,a7 9 
clause 7i71 9 ! fir/ s5t5ce1 by /rik+ or
 7iii7 & ins]t+ 1 7iii71 or 7iv72 &     
7,b7 by add+ at ! end ! foll[+ new      
clause3  7iv7 ,area wage index floor    

7,i7 ,9 g5]al ,= dis*>ges occurr+ on or 
aft] ,octob] #a1 #bjbj1 ! area wage     
index applicable "u ?is subp>agraph to  
any hospital :i* is n locat$ 9 a fronti]
 ,/ate 7z def9$ 9 clause 7iii77,,ii77   
may n be less ?an #j4he4  7,,ii7 ,waiv+ 
budget neutrality ,pursuant to ! fif?   
s5t5ce ( clause 7i71 ?is clause %all n  
be appli$ 9 a budget neutral mann]4  4  
7#b7 ,waiv+ budget neutrality  7,a7     
,te*nical am5datory correction ,section 
#ajcbd7;a77#b7 ( ,public ,law #aaa-adh  
is am5d$ by /rik+ ?ird s5t5ce & ins]t+  
fif? s5t5ce4  7,b7 ,waiv] ,section      
#ahhf7;d77#c77;,e77i7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#c77;,e77i77 is am5d$1 9 !   
fif? s5t5ce-- 7i7 by /rik+ & ! am5dm5ts 
& ins]t+ 1 ! am5dm5ts2 &  7ii7 by ins]t+
 1 & ! am5dm5ts made by section         
#dja7;a77#a7 ( ! ,heal? ,c>e ,improvem5t
 ,act ( #bjbj aft] ,c>e ,act4  7b7      
,hospital outpati5t dep>tm5t s]vices    
,section #ahcc7t7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciel7t771 is      

am5d$-- 7#a7 9 p>agraph 7#b77;,d71 by   
/rik+ 7#ai71 ! ,secret>y& ins]t+ 7#ai7 &
 p>agraph 7#bc71 ! ,secret>y2 &  7#b7 by
 add+ at ! end ! foll[+ new p>agraph3   
7#bc7 ,floor on area wage adju/m5t      
factor = hospital outpati5t dep>tm5t    
s]vices ,) respect to cov]$ ,,opd       
s]vices furni%$ on or aft] ,janu>y #a1  
#bjba1 ! area wage adju/m5t factor      
applicable "u ! paym5t sy/em e/abli%$ "u
 ?is subsection to any hospital         
outpati5t dep>tm5t :i* is n locat$ 9 a  
fronti] ,/ate 7z def9$ 9 section        
#ahhf7;d77#c77;,e77iii77,,ii77 may n be 
less ?an #j4he4 ,! prec$+ s5t5ce %all n 
be implem5t$ 9 a budget neutral mann]4  
4  ,v ,commons5se ,competition & ,access
 to ,heal? ,insurance  #eja4 ,provid+   
small bus9ess heal? insurance across    
,/ate l9es ,section #accc7;a77#a77;,a7 (
 ! ,pati5t ,protection & ,af=dable ,c>e 
,act 7#db ,u4,s4,c4 #ahjec7;a77#a77;,a77
 is am5d$ by ins]t+ & small gr\p m>kets 
aft] individual m>kets4  #ejb4 ,report &
 models ,section #accc ( ! ,pati5t      

,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjec7 is am5d$ by add+ at ! 
end ! foll[+3  7b7 ,,naic report &      
models  7#a7 ,9 g5]al ,n lat] ?an       
,decemb] #ca1 #bjba1 ! ,secret>y %all   
reque/ t ! ,national ,association (     
,insurance ,commission]s submit to !    
,secret>y a report conc]n+ heal? plans  
provid$ = "u ?is section4 ,su* report   
%all include-- 7,a7 a description ( !   
*all5ges t ,/ates w\ld face by p]mitt+  
issu]s ( qualifi$ heal? plans to (f] su*
 plans 9 ,/ates o!r ?an ^? ,/ates :]e   
su* plan 0 orig9ally writt5 or issu$2   
7,b7 an assessm5t ( h[ an out-(-,/ate   
insur] w\ld g ab\t build+ an adequate   
provid] network2  7,c7 a description (  
h[ su* *all5ges c\ld be less5$ )\t      
weak5+ ! en=cem5t ( laws & regulations  
describ$ 9 subsection 7a77#a77;,b77i7 9 
any ,/ate t is includ$ 9 a compact "u   
?is section2  7,d7 a description ( !    
commonalities t exi/ 9 ,/ate laws &     
opportunities to all[ issu]s ( qualifi$ 
heal? plans to (f] su* plans 9 ,/ates   

o!r ?an ^? ,/ates :]e su* plan 0        
orig9ally writt5 or issu$2 &  7,e7      
models to be us$ by ,/ates to e/abli% & 
ent] into int]/ate heal? c>e *oice      
compacts "u ?is section1 :i*-- 7i7 may  
include model legislation = use by      
,/ates to enact laws to ent] into su*   
compacts2  7ii7 %all id5tify h[ ,/ates  
w\ld cont9ue to en=ce1 & n weak51 ! laws
 & regulations describ$ 9 subsection    
7a77#a77;,b77i7 9 any ,/ate t is includ$
 9 su* compact2 &  7iii7 %all id5tify h[
 su* models w\ld ensure t !re is no     
violation ( ! conditions = ,secret>ial  
approval "u subsection 7a77#c74  7#b7   
,o!r organizations & entities ,9 mak+ ! 
reque/ "u p>agraph 7#a71 ! ,secret>y may
 also reque/ t ! ,national ,association 
( ,insurance ,commission]s ga!r concepts
 = inclusion 9 ! report "u su* p>agraph 
f organizations & entities t h exp]i5ce 
9 (f]+ qualifi$ heal? plans 9 ,/ates 9  
:i* su* plans 7 n orig9ally issu$4  4   
,,vi ,emp[]+ ,m$ic>e ,s5iors to         
,negotiate ,prescription ,drug ,prices  

#fja4 ,au?ority to negotiate fair prices
 = ,m$ic>e prescription drugs  7a7 ,9   
g5]al ,section #ahfj;,d-#aa ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#aciew-#aaa7 is am5d$ by /rik+          
subsection 7i74  7b7 ,effective date ,! 
am5dm5t made by ?is section %all take   
effect on ! date ( ! enactm5t ( ?is     
,act4  ,,vii ,commons5se report+ =      
employ]s  #gja4 ,volunt>y prospective   
report+ sy/em  7a7 ,9 g5]al ,n lat] ?an 
#a ye> aft] ! date ( ! enactm5t ( ?is   
,act1 ! ,secret>y ( ! ,treasury1 9      
consultation ) ! ,secret>y ( ,heal? &   
,human ,s]vices1 ! ,secret>y ( ,labor1 &
 ! ,adm9i/rator ( ! ,small ,bus9ess     
,adm9i/ration1 %all develop & implem5t  
guidance provid+ = a prospective report+
 sy/em meet+ ! requirem5ts ( subsection 
7b74 ,su* sy/em %all be available = use 
by employ]s on a volunt>y basis beg9n+ n
 lat] ?an ,janu>y #a1 #bjba4  7b7       
,requirem5ts ,! sy/em creat$ "u         
subsection 7a7 %all include-- 7#a7      
volunt>y report+ by ea* p>ticipat+      

employ] t (f]s m9imum ess5tial cov]age  
to its full-"t employees & _! dep5d5ts  
"u an eligible employ]-sponsor$ plan1 n 
lat] ?an #de days be=e ! fir/ day ( !   
annual op5 enrollm5t p]iod "u section   
#acaa7;c77#f77;,b7 ( ! ,pati5t          
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjca7;c77#f77;,b77 = ea*    
cal5d> ye>1 (-- 7,a7 ! "n & employ]     
id5tification numb] = purposes ( section
 #fjef ( ! ,int]nal ,rev5ue ,code (     
#aihf ( ! employ]2  7,b7 a c]tification 
(-- 7i7 :e!r cov]age meet+ ! def9ition (
 m9imum ess5tial cov]age 9 section      
#ejjj;,a7f7 ( ! ,int]nal ,rev5ue ,code (
 #aihf is (f]$ to ! full-"t employees   
7)9 ! mean+ ( section #dihj;,h ( su*    
,code7 ( ! employ]2  7ii7 :e!r su*      
cov]age is (f]$ to "p-"t employees ( !  
employ]2  7iii7 :e!r su* cov]age is (f]$
 to dep5d5ts ( employees2  7iv7 :e!r su*
 cov]age is (f]$ to sp\ses ( employees2 
7v7 :e!r su* cov]age meets ! m9imum     
value requirem5t ( section              
#cf;,b7c77#b77;,c77ii7 ( su* ,code2     

7vi7 :e!r su* cov]age satisfies !       
requirem5ts to qualify = "o ( !         
af=dability safe h>bors promulgat$ by ! 
,secret>y ( ! ,treasury = purposes (    
section #dihj;,h ( su* ,code2 &  7vii7  
:e!r ! employ] reasonably expects to be 
liable = any %>$ responsibility paym5t  
"u section #dihj;,h ( su* ,code = su*   
ye>2  7,c7 ! mon?s dur+ ! prospective   
report+ p]iod t su* cov]age is available
 to individuals describ$ 9 clauses 7i7  
?r\gh 7iv7 ( subp>agraph 7,b72  7,d7 :at
 wait+ p]iods1 if any1 apply ) respect  
to su* cov]age2 &  7,e7 a li/ ( all     
employ] id5tification numb]s ( ! employ]
 = entities t employ employees )9 !     
employ]s control gr\p "u subsection 7b71
 7c71 7m71 or 7o7 ( section #dad ( !    
,int]nal ,rev5ue ,code = #aihf2  7#b7   
processes necess>y to ensure t          
,ex*anges1 ! ,f$]al ,m>ketplace ,data   
,s]vices ,hub1 & ! ,int]nal ,rev5ue     
,s]vice c securely & confid5tially      
access ! in=mation describ$ 9 p>agraph  
7#a7 z necess>y to c>ry out _!          

respective missions1 & to provide to !  
,secret>y ( ,heal? & ,human ,s]vices    
additional in=mation relat+ to          
eligibility det]m9ations = advance      
paym5t ( ! premium tax cr$its "u section
 #cf;,b ( su* ,code & ! co/-%>+         
subsidies "u section #adjb ( ! ,pati5t  
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjga72  7#c7 a process to   
all[ ,ex*anges to foll[ up ) employ]s 9 
ord] to obta9 additional reasonably     
necess>y in=mation relat+ to an         
employee's eligibility = su* advance    
paym5t or su* co/-%>+ subsidies1 & to   
all[ an employee to receive notification
 ( any problem 9 v]ify+ su* eligibility2
 &  7#d7 a process to all[ employ]s us+ 
! sy/em to provide timely updates to !  
,f$]al ,m>ketplace ,data ,s]vices ,hub  
reg>d+ any cancellation ( cov]age or    
significant *ange 9 cov]age = p>ticipat+
 employees t w\ld *ange ! in=mation     
report$ "u p>agraph 7#a74  7c7 ,employ] 
notification ( employee enrollm5t 9     
ex*ange plans ,subp>agraph 7,j7 (       

section #acaa7;d77#d7 ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjca7;d77#d77;,j77 is am5d$ 
by /rik+ to ea* employ] & all t foll[s  
?r\gh 7& ! effective date ( su*         
cessation72 & & ins]t+ to ea* employ]-- 
7i7 ! "n ( ea* employee ( ! employ] :o  
enrolls 9 a qualifi$ heal? plan = a plan
 ye>1 or ^: dep5d5ts enroll 9 su* a     
plan1 at ! "t ( su* enrollm5t2 or  7ii7 
! "n ( ea* employee ( ! employ] describ$
 9 subp>agraph 7,i77ii7 :o ceases       
cov]age "u a qualifi$ heal? plan dur+ a 
plan ye> 7& ! effective date ( su*      
cessation72 &  4  7d7 ,exemption f      
report+ requirem5t "u int]nal rev5ue    
code ( #aihf ,section #fjef ( ! ,int]nal
 ,rev5ue ,code ( #aihf is am5d$ by      
r$esignat+ subsection 7f7 z subsection  
7g7 & by ins]t+ aft] subsection 7e7 !   
foll[+ new subsection3  7f7 ,exemption  
,if1 ?r\gh ! sy/em creat$ pursuant to   
section #gja7;a7 ( ! ,heal? ,c>e        
,improvem5t ,act ( #bjbj1 an employ]    
provides prospective report+ = any      

cal5d> ye> t meets ! requirem5ts (      
section #gja7;b77#a7 ( su* ,act-- 7#a7  
su* employ] %all be treat$ z satisfy+ ! 
return requirem5ts ( subsections 7a7 &  
7b7 = su* ye>2 &  7#b7 su* employ] %all 
be treat$ z satisfy+ ! requirem5ts (    
subsection 7c7 = su* ye> if ! employ]-- 
7,a7 furni%es ! /atem5t describ$ 9 su*  
section to ^? employees ( ! employ] ^:  
names h be5 provid$ to ! employ] by an  
,ex*ange "u section                     
#acaa7;d77#d77;,j77i7 ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act reg>d+
 enrollm5t ( ! employee or a dep5d5t 9 a
 qualifi$ heal? plan 7z def9$ 9 section 
#acja ( su* ,act7 ?r\gh ! ,ex*ange2 &   
7,b7 furni%es a copy ( su* /atem5t )    
respect to su* employees to ! ,secret>y4
  4  7e7 ,?ird-,p>ty fil+ ,an employ]   
may contract ) a ?ird p>ty to make !    
report "u subsection 7b77#a7 )\t affect+
 ! employ]'s treatm5t z hav+ satisfi$ ! 
return requirem5ts ( subsections 7a7 &  
7b7 ( section #fjef ( ! ,int]nal ,rev5ue
 ,code ( #aihf4  7f7 ,access to !       

national directory ( new hires          
,subsection 7i77#c7 ( section #dec ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#fec7 is am5d$ by add+ at ! end ! foll[+
 new s5t5ce3 ,! ,secret>y ( ! ,treasury 
& ! ,secret>y ( ,heal? & ,human ,s]vices
 %all h access to ! in=mation 9 !       
,national ,directory ( ,new ,hires =    
purposes ( adm9i/]+ section #cf;,b &    
#dihj;,h ( ! ,int]nal ,rev5ue ,code (   
#aihf & section #adjb ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjga74 ,subsection 7k77#c7  
%all n apply to in=mation receiv$ =     
purposes ( ! adm9i/ration ( su* sections
 #cf;,b & #dihj;,h ( su* ,code & section
 #adjb ( su* ,act44  7g7 ,improv+       
employee access to accurate ,e,i,ns ,n  
lat] ?an #a ye> aft] ! date ( ! enactm5t
 ( ?is ,act1 ! ,secret>y ( ! ,treasury  
%all develop & implem5t guidance = all[+
 any employee ( an employ] to receive1  
on reque/1 ! employ]'s employ]          
id5tification numb] = purposes ( section
 #fjef ( ! ,int]nal ,rev5ue ,code (     

#aihf4 ,employ]s %all provide !         
employ]'s employ] id5tification numb] = 
purposes ( section #fjef ( ! ,int]nal   
,rev5ue ,code ( #aihf on "o ( ! foll[+  
docum5ts ( ! employ]'s election3 7#a7   
,heal? ,insurance ,m>ketplace ,cov]age  
,options ,notice requir$ "u section     
#ah;,b ( ! ,fair ,labor ,/&>ds ,act4    
7#b7 ,summ>y ( ,b5efits & ,cov]age      
describ$ 9 section #bgae ( ! ,pati5t    
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjga74  7#c7 ,m>ketplace    
,employ] ,cov]age tool4  7#d7 ,annual   
b5efits enrollm5t mat]ials di/ribut$ to 
employees1 includ+ ?r\gh an intranet or 
an onl9e portal accessible by employees4
  7#e7 ,employee pay /atem5ts or ,=m    
,w-#b4  7h7 ,fund+ = volunt>y           
prospective report+ sy/em ,x is ! s5se (
 ,congress t build+ & ma9ta9+ ! volunt>y
 prospective report+ sy/em describ$ 9   
?is section w require appropriations to 
! ,secret>y ( ! ,treasury1 ! ,secret>y (
 ,heal? & ,human ,s]vices1 ! ,secret>y (
 ,labor1 & ! ,adm9i/rator ( ! ,small    

,bus9ess ,adm9i/ration1 & t necess>y    
sums to c>ry out ! requirem5ts ( ?is    
section %\ld be appropriat$ = su*       
purpose4  #gjb4 ,protection ( dep5d5t   
privacy  7a7 ,9 g5]al ,p>agraph 7#a7 (  
section #fjee7;b7 ( ! ,int]nal ,rev5ue  
,code ( #aihf is am5d$ by add+ at ! end 
! foll[+ flu% s5t5ce3 ,= purposes (     
subp>agraph 7,b77i71 9 ! case ( an      
individual o!r ?an ! prim>y insur$1 if !
 heal? insurance issu] or ! employ] is  
unable to collect or ma9ta9 in=mation on
 ! ,t,i,ns ( su* individuals 7o!r ?an = 
purposes ( ?is section71 ! ,secret>y may
 all[ ! individual's full "n & date (   
bir? to be sub/itut$ = ! "n & ,,t94 ,9 !
 ev5t ! ,secret>y all[s ! use ( !       
individual's full "n & date ( bir? 9    
lieu ( ! ,,t91 ! ,social ,security      
,adm9i/ration %all assi/ ! ,int]nal     
,rev5ue ,s]vice 9 provid+ data mat*es to
 det]m9e ! ,,t9 associat$ ) ! "n & date 
( bir? provid$ by ! ,int]nal ,rev5ue    
,s]vice ) respect to su* individual4 4  
7b7 ,effective date ,! am5dm5t made by  

?is section %all apply to returns ! due 
date = :i* is aft] ! date t is #fj days 
aft] ! date ( ! enactm5t ( ?is ,act4    
#gjc4 ,electronic /atem5ts  7a7 ,9 g5]al
 ,subsection 7c7 ( section #fjef ( !    
,int]nal ,rev5ue ,code ( #aihf is am5d$ 
by add+ at ! end ! foll[+ new p>agraph3 
7#c7 ,electronic deliv]y ,an individual 
%all be deem$ to h cons5t$ to receive ! 
/atem5t "u ?is subsection 9 electronic  
=m if su* individual has affirmatively  
cons5t$ at any prior "t1 to ! p]son :o  
is ! employ] ( ! individual dur+ !      
cal5d> ye> to :i* ! /atem5t relates1 to 
receive su* /atem5t 9 electronic =m4 ,! 
prec$+ s5t5ce %all n apply if !         
individual revokes cons5t 9 writ+ )     
respect to ! /atem5t "u ?is subsection4 
4  7b7 ,/atem5ts relat+ to heal?        
insurance cov]age ,subsection 7c7 (     
section #fjee ( ! ,int]nal ,rev5ue ,code
 ( #aihf is am5d$ by add+ at ! end !    
foll[+ new p>agraph3  7#c7 ,electronic  
deliv]y ,an individual %all be deem$ to 
h cons5t$ to receive ! /atem5t "u ?is   

subsection 9 electronic =m if su*       
individual has affirmatively cons5t$ at 
any prior "t1 to ! p]son requir$ to make
 su* /atem5t 7su* z ! provid] ( !       
individual's heal? cov]age71 to receive 
9 electronic =m any private heal?       
in=mation 7su* z electronic heal?       
records71 unless ! individual revokes   
su* cons5t 9 writ+4  4  7c7 ,effective  
date ,! am5dm5ts made by ?is section    
%all apply to /atem5ts ! due date = :i* 
is aft] ,decemb] #ca1 #bjai4  #gjd4     
,,gao /udies  7a7 ,/udy ( fir/ ye>s (   
employ] report+  7#a7 ,9 g5]al ,!       
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all conduct a /udy t evaluates1 )      
respect to ! p]iod beg9n+ on ,janu>y #a1
 #bjae1 & end+ on ,decemb] #ca1 #bjah-- 
7,a7 ! notification ( employ]s by       
,ex*anges e/abli%$ "u title ,i ( !      
,pati5t ,protection & ,af=dable ,c>e    
,act 7,public ,law #aaa-adh7 t a full-"t
 employee ( ! employ] has be5 det]m9$   
eligible = advance paym5t ( premium tax 
cr$its "u section #cf;,b ( ! ,int]nal   

,rev5ue ,code ( #aihf or co/-%>+        
subsidies "u section #adjb ( su* ,act   
7#db ,u4,s4,c4 #ahjga71 includ+         
in=mation reg>d+-- 7i7 ! data elem5ts   
includ$ 9 ! employ] notification2  7ii7 
! process by :i* ! notification =ms 7   
develop$ & s5t to employ]s1 includ+ :e!r
 ! process provid$ = a =mal notice &    
comm5t p]iod2  7iii7 :e!r employ]s      
report t su* notifications provid$      
suffici5t & relevant in=mation = !m to  
make appropriate decisions ab\t :e!r to 
utilize ! appeals process2  7iv7 ! total
 numb] ( notifications s5t to employ]s &
 ! timel9e ( :5 su* notifications 7 s5t2
  7v7 diff]5ces 9 ! notification process
 betwe5 ! m>ketplace facilitat$ by !    
,f$]al ,gov]nm5t & ! ,/ate-,bas$        
,m>ketplaces2 &  7vi7 *all5ges t h aris5
 9 ! notification process1 &            
recomm5dations to address ^! *all5ges2 &
  7,b7 ! ext5t to :i* ! ,secret>y (     
,heal? & ,human ,s]vices has e/abli%$ a 
sep>ate appeals process = employ]s :o   
receiv$ su* a notification to *all5ge ! 

eligibility det]m9ation1 z requir$ by   
section #adaa7;f77#b7 ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjha7;f77#b774  7#b7 ,report
 ,n lat] ?an #a ye> aft] ! date ( !     
enactm5t ( ?is ,act1 ! ,comptroll]      
,g5]al %all submit to ! ,committees on  
,f9ance & ,heal?1 ,education1 ,labor1 & 
,p5sions ( ! ,s5ate & ! ,committees on  
,ways & ,means1 ,en]gy & ,comm]ce1 &    
,education & ,labor ( ! ,h\se (         
,repres5tatives a report on ! results ( 
! /udy conduct$ "u p>agraph 7#a74  7b7  
,/udy ( prospective report+ sy/em  7#a7 
,9 g5]al ,! ,comptroll] ,g5]al ( !      
,unit$ ,/ates %all conduct a /udy t     
evaluates1 ) respect to ! p]iod beg9n+  
on ,janu>y #a1 #bjbj1 & end+ on ,decemb]
 #ca1 #bjbj1 ! functionality ( !        
prospective report+ sy/em e/abli%$      
pursuant to section #gja1 includ+ !     
accuracy ( in=mation collect$1 ! numb] (
 employ]s elect+ to report "u su* sy/em1
 & any *all5ges t h aris5 9 implem5t+   
su* sy/em4  7#b7 ,report ,n lat] ?an    

,july #a1 #bjba1 ! ,comptroll] ,g5]al   
%all submit to ! ,committees on ,f9ance 
& ,heal?1 ,education1 ,labor1 & ,p5sions
 ( ! ,s5ate & ! ,committees on ,ways &  
,means1 ,en]gy & ,comm]ce1 & ,education 
& ,labor ( ! ,h\se ( ,repres5tatives a  
report on ! results ( ! /udy conduct$ "u
 p>agraph 7#a74  #gje4 ,tax ,compliance 
7a7 ,9 g5]al ,section                   
#fgbd7;d77#a77;,b77xxv7 ( ! ,int]nal    
,rev5ue ,code ( #aihf is am5d$ by ins]t+
 or1 9 ! case ( an employ] to :i*       
section #fjef7;f7 applies1 section      
#gja7;b77#a7 ( ! ,heal? ,c>e ,improvem5t
 ,act ( #bjbj be=e 1 or4  7b7 ,effective
 date ,! am5dm5t made by ?is section    
%all apply to returns requir$ to be fil$
 aft] ! date ( ! enactm5t ( ?is ,act4   
,,viii ,f$]al ,ban on ,surprise ,m$ical 
,bill+  #hja4 ,protection aga9/ surprise
 bills  7a7 ,,phsa ,section #bgai;,a ( !
 ,public ,heal? ,s]vice ,act 7#db       
,u4,s4,c4 #cjj;gg-#ai;a7 is am5d$ by    
add+ at ! end ! foll[+3  7e7            
,out-(-,network ancill>y s]vices  7#a7  

,cov]age ( s]vices ,subject to          
subsection 7h71 9 ! case ( an enrollee 9
 a gr\p heal? plan or gr\p or individual
 heal? insurance cov]age :o receives    
out-(-network ancill>y s]vices at an    
9-network facility1 includ+ any ref]rals
 = diagno/ic s]vices1 & su* s]vices w\ld
 be cov]$ "u su* plan or cov]age if     
provid$ 9-network-- 7,a7 ! co/-%>+      
requirem5t 7express$ z a copaym5t am\nt1
 co9surance rate1 or d$uctible7 )       
respect to su* s]vices %all be ! same   
requirem5t t w\ld apply if su* s]vices 7
 provid$ by an 9-network practition]1 & 
any co9surance or d$uctible %all be bas$
 on 9-network rates2 &  7,b7 am\nts paid
 t[>d su* co/-%>+ %all be c\nt$ t[>ds ! 
9-network d$uctible & 9-network         
out-(-pocket maximum am\nt1 z           
applicable1 "u ! plan or cov]age = !    
plan ye>4  7#b7 ,notice be=e provid+    
non-em]g5cy s]vices ,subject to         
subsection 7h71 9 ! case ( an enrollee 9
 a gr\p heal? plan or gr\p or individual
 heal? insurance cov]age :o receives    

out-(-network1 non-em]g5cy s]vices t are
 n ancill>y s]vices1 f an out-(-network 
provid] at an 9-network facility1 & su* 
s]vices w\ld be cov]$ "u su* plan or    
cov]age if provid$ 9-network1 ! co/-%>+ 
requirem5t 7express$ z a copaym5t am\nt1
 co9surance rate1 or d$uctible7 )       
respect to su* s]vices %all be ! same   
requirem5t t w\ld apply if su* s]vices 7
 provid$ by an 9-network practition]1 & 
any co9surance or d$uctible %all be bas$
 on 9-network rates1 unless1 z soon z   
practicable1 & 9 no case lat] ?an #dh   
h\rs prior to provid+ non-em]g5cy       
s]vices t are n ancill>y s]vices-- 7,a7 
! 9-network facility provides to !      
enrollee :o is s*$ul$ to receive su*    
s]vices notice t-- 7i7 is provid$ 9 pap]
 or electronic =m 7& includ+ electronic 
notification :5ev] practicable72  7ii7  
/ates t su* s]vice w be provid$         
out-(-network2  7iii7 includes ! e/imat$
 am\nt t su* practition] or facility may
 *>ge ! enrollee = su* s]vices2 &  7iv7 
provides ! option to affirmatively      

cons5t to receiv+ su* s]vices f su*     
practition] or facility2  7,b7 su*      
enrollee signs su* notice cons5t+ to    
receive su* s]vices f an out-(-network  
provid] at an 9-network facility1 &     
ackn[l$g+ t ! out-(-network s]vices may 
be cov]$ at an out-(-network co/-%>+    
am\nt1 requir+ high] co/-%>+ obligations
 ( ! enrollee ?an if ! s]vice 7 provid$ 
by an 9-network practition] or facility2
 &  7,c7 su* facility ma9ta9s           
docum5tation ( ! enrollee's signature or
 confirmation ( receipt ( su* in=mation 
"u subp>agraph 7,b7 9 ! enrollee's      
pati5t record = #b ye>s aft] ! date (   
s]vices4  7f7 ,cov]age ( out-(-,network 
s]vices = enrollees admitt$ aft] em]g5cy
 s]vices  7#a7 ,protection = enrollees  
admitt$ to ! hospital = em]g5cy s]vices 
prior to /abilization ,9 ! case ( an    
enrollee 9 a gr\p heal? plan or gr\p or 
individual heal? insurance cov]age :o   
receives em]g5cy s]vices1 or mat]nal c>e
 = a woman 9 labor1 9 ! em]g5cy dep>tm5t
 ( an out-(-network facility & has n be5

 /abiliz$ 7)9 ! mean+ ( subsection      
7b77#b77;,c771 if ! pati5t is           
subsequ5tly admitt$ to ! out-(-network  
facility = c>e1 ! co/-%>+ requirem5t    
7express$ z a copaym5t am\nt1 co9surance
 rate1 or d$uctible7 ) respect to any   
out-(-network s]vices provid$ to !      
enrollee prior to be+ /able & 9 a       
condition to receive in=mation "u 7#b71 
is ! same requirem5t t w\ld apply z "u  
subsection 7b77#b77;,c77ii77,,ii74  7#b7
 ,notice & cons5t  7,a7 ,9 g5]al        
,subject to subsection 7h71 9 ! case (  
an enrollee 9 a gr\p heal? plan or gr\p 
or individual heal? insurance cov]age :o
 receives em]g5cy s]vices1 or mat]nal   
c>e = a woman 9 labor1 9 ! em]g5cy      
dep>tm5t ( an out-(-network facility &  
has be5 /abiliz$ 7)9 ! mean+ (          
subsection 7b77#b77;,c771 if ! pati5t is
 subsequ5tly admitt$ to ! out-(-network 
facility = c>e1 ! co/-%>+ requirem5t    
7express$ z a copaym5t am\nt1 co9surance
 rate1 or d$uctible7 ) respect to any   
out-(-network s]vices is ! same         

requirem5t t w\ld apply if su* s]vices 7
 provid$ by an 9-network provid]1 unless
 ! enrollee1 once /able & 9 a condition 
to receive su* in=mation1 includ+ hav+  
suffici5t m5tal capacity-- 7i7 has be5  
provid$ by ! facility1 prior to !       
provision ( any po/-/abilization1       
out-(-network s]vice at su* facility1   
)-- 7,i7 pap] or electronic notification
 t ! practition] or facility is an      
out-(-network heal? c>e provid] & !     
out-(-network rate ( ! provid]1 z       
applicable1 & ! option to affirmatively 
cons5t to receiv+ s]vices f su*         
practition] or facility2 &  7,,ii7 !    
e/imat$ am\nt t su* provid] may *>ge !  
p>ticipant1 b5efici>y1 or enrollee = su*
 s]vices involv$2  7ii7 has be5 provid$ 
by ! plan or cov]age1 prior to !        
provision ( any po/-/abilization1       
out-(-network s]vice at su* facility1   
)-- 7,i7 pap] or electronic notification
 7& includ+ electronic notification     
:5ev] practicable7 t ! practition] or   
facility is an out-(-network heal? c>e  

provid]1 & ! option to affirmatively    
cons5t to receiv+ s]vices f su*         
practition] or facility2  7,,ii7 a li/ (
 9-network practition]s or facilities 9 
! relevant geographic area t c\ld       
provide ! same s]vices1 & an option = a 
ref]ral to su* provid]s2 &  7,,iii7     
in=mation ab\t :e!r prior au?orization  
or o!r c>e managem5t limitations may be 
requir$ 9 advance ( receiv+ 9-network   
s]vices at ! facility2 &  7iii7 has     
ackn[l$g$1 9 writ+1 t ! out-(-network   
s]vices provid$ aft] ! individual has   
be5 /abiliz$ may n be cov]$ or may be   
cov]$ at an out-(-network co/-%>+ am\nt1
 requir+ high] co/-%>+ obligations ( !  
enrollee ?an if ! s]vice 7 provid$ at an
 9-network facility4  7,b7 ,requirem5ts 
( notice ,! notice "u subp>agraph 7,a7  
%all be 9 a =mat det]m9$ by ! ,secret>y 
to give a reasonable layp]son cle>      
compreh5sion ( ! t]ms ( ! agreem5t1     
includ+ all possible f9ancial           
responsibilities1 includ+ ! requirem5ts 
t ! notice-- 7i7 does n exce$ "o page 9 

l5g?2  7ii7 is readily id5tifiable = its
 purpose & z a contract ( cons5t2  7iii7
 cle>ly /ates t cons5t to pot5tial      
out-(-network *>ges is optional & t !   
enrollee has ! *oice to transf] to an   
9-network facility2  7iv7 includes an   
e/imate ( ! am\nt t su* provid] w *>ge !
 p>ticipant1 b5efici>y1 or enrollee =   
su* s]vices involv$2 &  7v7 be available
 9 ! #ae mo/ common languages 9 !       
facility's geographic area1 ) ! facility
 mak+ a good fai? ef=t to provide oral  
notice 9 ! enrollee's prim>y language if
 x is n "o ( su* #ae languages4  7,c7   
,ma9t5ance ( records ,a facility %all   
ma9ta9 docum5tation ( notice giv5 to an 
enrollee pursuant to ?is subsection & ! 
enrollee's confirmation ( receipt ( su* 
in=mation 9 ! enrollee's pati5t record =
 #b ye>s aft] ! date ( s]vices4  7#c7   
,rulemak+ ,n lat] ?an #f mon?s aft] !   
date ( enactm5t ( ?is subsection1 !     
,secret>y %all issue regulations to c>ry
 out ?is subsection1 :i* %all include   
cl>ification on h[ to det]m9e :e!r an   

individual is /abiliz$ & ! tim+ ( !     
notice requir$ "u ?is p>agraph4  7g7    
,prohibition on bill+ m ?an an          
9-,network rate "u c]ta9 circum/ances   
7#a7 ,9 g5]al ,a facility or practition]
 furni%+-- 7,a7 em]g5cy s]vices1 z def9$
 9 subsection 7b77#b71 reg>dless ( !    
,/ate 9 :i* ! pati5t resides2  7,b7     
out-(-network s]vices at an 9-network   
facility describ$ 9 subsection 7e77#a72 
7,c7 out-(-network s]vices at an        
9-network facility describ$ 9 subsection
 7e77#b71 :]e ! notice & cons5t =       
receiv+ su* s]vices out-(-network did n 
meet ! requirem5t ( su* subsection2     
7,d7 s]vices furni%$ by an out-(-network
 provid] aft] an enrollee has be5       
admitt$ to ! hospital = em]g5cy s]vices 
b prior to /abilization1 z describ$ 9   
subsection 7f77#a72 or  7,e7            
out-(-network s]vices furni%$ aft] !    
enrollee has be5 /abiliz$ 7)9 ! mean+ ( 
subsection 7b77#b77;,c771 :]e ! notice &
 option = receiv+ c>e at an alt]nate    
facility requir$ "u subsection 7f77#b7 h

 n be5 provid$ to ! enrollee & !        
enrollee did n give cons5t "u subsection
 7f77#c71  may n bill an enrollee 9 a   
gr\p heal? plan or gr\p or individual   
heal? insurance cov]age = am\nts beyond 
! co/-%>+ am\nt t w\ld apply "u         
subsection 7b77#a77;,c77ii77,,ii71      
7e77#a71 7e77#b71 or 7f71 z applicable4 
7#b7 ,notice ,a facility furni%+ s]vices
 describ$ 9 p>agraph 7#a7 %all provide  
enrollees 9 a gr\p heal? plan or gr\p or
 individual heal? insurance cov]age ) a 
"o-page notice1 9 #af-po9t font1 ^u     
intake at ! em]g5cy room or be+ admitt$ 
at ! facility ( ! prohibition on balance
 bill+ "u p>agraph 7#a7 & :o to contact 
= rec\rse if !y are s5t a balance bill 9
 violation ( su* p>agraph4 ,! facility  
%all be responsible = obta9+ ! signature
 f ! enrollee on su* notice4 ,!         
,secret>y %all issue regulations )9 #f  
mon?s ( ! date ( enactm5t ( ?is         
subsection on ! requirem5ts = ! notice  
"u ?is p>agraph4  7h7 ,ma9ta9+ ,/ate    
surprise bill+ protections  7#a7 ,9     

g5]al ,no?+ 9 ?is section %all prev5t a 
,/ate f e/abli%+ or cont9u+ 9 effect1 ) 
respect to heal? insurance issu]s1      
facilities1 or practition]s1 an alt]nate
 me?od "u ,/ate law = det]m9+ !         
appropriate comp5sation = s]vices       
describ$ 9 subsection 7b71 7e71 or 7f74 
7#b7 ,additional application ,9 ! case (
 gr\p heal? plans or gr\p or individual 
heal? insurance cov]age (f]$ 9 a ,/ate t
 has n e/abli%$ an alt]nate me?od       
describ$ 9 p>agraph 7#a71 su* z         
arbitration or a b5*m>k1 or = s]vices   
describ$ 9 subsection 7b71 7e71 or 7f7 t
 are n cov]$ by su* ,/ate's alt]nate    
me?od describ$ 9 p>agraph 7#a71 !       
provisions ( ?is section %all apply4    
7#c7 ,self-insur$ plans ,subsections    
7b71 7e71 & 7f7 %all apply to a         
self-insur$ gr\p heal? plan t is n      
subject to ,/ate insurance regulation4  
7i7 ,def9itions ,9 ?is section3 7#a7    
,9-network ,! t]m 9-network1 ) respect  
to a gr\p heal? plan or heal? insurance 
cov]age means a provid] t has a         

contractual relation%ip ) ! plan4  7#b7 
,enrollee ,! t]m enrollee1 ) respect to 
heal? insurance cov]age or a gr\p heal? 
plan1 includes a p>ticipant1 dep5d5t1 or
 b5efici>y4  7#c7 ,ancill>y s]vices ,!  
t]m ancill>y s]vices means non-em]g5cy  
c>e t is-- 7,a7 provid$ by              
ane/hesiologi/s1 pa?ologi/s1 em]g5cy    
m$ic9e provid]s1 int5sivi/s1            
radiologi/s1 neonatologi/s1 hospitali/s1
 & assi/ant surgeons1 :e!r ! c>e is     
provid$ by a physician or non-physician 
practition]2  7,b7 a diagno/ic s]vice   
7includ+ radiology & lab s]vices72 or   
7,c7 provid$ by su* o!r specialty       
practition] n typically select$ by !    
pati5ts receiv+ ! c>e1 :i* ! ,secret>y  
may add p]iodically to su* def9ition    
?r\gh rulemak+4  4  7b7 ,en=cem5t (     
balance bill+ prohibitions ,"p ,c (     
title ,,xxvii ( ! ,public ,heal? ,s]vice
 ,act 7#db ,u4,s4,c4 #cjj;gg-#ia et     
seq47 is am5d$ by add+ at ! end !       
foll[+3  #bgie4 ,en=cem5t ( balance     
bill+ prohibitions  7a7 ,9 g5]al        

,subject to subsection 7b71 a facility  
or practition] t violates a requirem5t  
"u section #bgai;,a7g77#a7 or fails to  
provide notice or obta9 cons5t z requir$
 "u subsection 7e77#b7 or 7f77#b7 %all  
be subject to a civil monet>y p5alty ( n
 m ?an #aj1jjj = ea* act con/itut+ su*  
violation4  7b7 ,proc$ure ,! provisions 
( section #aabh;,a ( ! ,social ,security
 ,act1 o!r ?an subsections 7a7 & 7b7 & !
 fir/ s5t5ce ( subsection 7c77#a7 ( su* 
section1 %all apply to civil money      
p5alties "u ?is subsection 9 ! same     
mann] z su* provisions apply to a p5alty
 or proce$+ "u section #aabh;,a ( !     
,social ,security ,act4  7c7 ,safe h>bor
  7#a7 ,9 g5]al ,! ,secret>y %all waive 
! p5alties describ$ "u subsection 7a7 ) 
respect to a facility or1 practition] :o
 does n kn[+ly violate1 & %\ld n h      
reasonably kn[n x violat$1 section      
#bgai;,a7g77#a7 ) respect to an         
enrollee1 if su* facility or            
practition]1 )9 #cj days ( ! violation1 
)draws ! bill t 0 9 violation ( section 

#bgai;,a7g77#a71 &1 z applicable1       
reimburses ! gr\p heal? plan1 heal?     
insurance issu]1 or enrollee1 9 an am\nt
 equal to ! diff]5ce betwe5 ! am\nt     
bill$ & ! am\nt all[$ to be bill$ "u    
section #bgai;,a7g77#a71 plus int]e/1 at
 an int]e/ rate det]m9$ by ! ,secret>y4 
7#b7 ,h>d%ip exemption ,! ,secret>y may 
e/abli% a h>d%ip exemption to ! p5alties
 "u ?is section4  7#c7 ,/ate en=cem5t ,!
 ,secret>y %all waive p5alties "u ?is   
section ) respect to a facility or      
practition] t has already be5 subject to
 en=cem5t action "u ,/ate law = a       
violation describ$ 9 subsection 7a74  4 
7c7 ,application to gr&fa!r$ plans      
,section #abea7;a7 ( ! ,pati5t          
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjaa7;a77 is am5d$ by add+  
at ! end ! foll[+3  7#e7 ,application ( 
additional provisions ,subsections 7b7  
?r\gh 7h7 ( section #bgai;,a ( ! ,public
 ,heal? ,s]vice ,act 7#db ,u4,s4,c4     
#cjj;gg-#ai;a7 %all apply to gr&fa!r$   
heal? plans = plan ye>s beg9n+ ) !      

second plan ye> t beg9s aft] ! date (   
enactm5t ( ?is p>agraph4  4  7d7        
,cov]age "u ,f$]al ,employees ,heal?    
,b5efits ,program ,section #hijd ( title
 #e1 ,unit$ ,/ates ,code1 is am5d$ by   
add+ at ! end ! foll[+3  7c7 ,any heal? 
b5efits plan (f]$ "u ?is *apt] %all be  
treat$ z a gr\p heal? plan or gr\p or   
individual heal? insurance cov]age =    
purposes ( subsections 7e7 ?r\gh 7g7 (  
section #bgai;,a ( ! ,public ,heal?     
,s]vice ,act 7#db ,u4,s4,c4             
#cjj;gg-#ai;a7 7except = p>agraph 7#c7 (
 su* subsection 7g774  4