,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #iha  ,,9 ,,! ,,s5ate ,,( ,,!       
,,unit$ ,,/ates  ,april #b1 #bjai ,mr4  
,b5net 7= himself1 ,mr4 ,ka9e1 ,mr4     
,c>d91 ,ms4 ,klobu*>1 ,mr4 ,leahy1 ,ms4 
,smi?1 ,ms4 ,/ab5[1 ,ms4 ,h>ris1 ,mr4   
,book]1 ,mr4 ,pet]s1 ,mr4 ,durb91 &     
,mrs4 ,%ahe57 introduc$ ! foll[+ bill2  
:i* 0 read twice & ref]r$ to !          
,committee on ,f9ance  ,a ,,bill  ,to   
e/abli% a public heal? plan4  #a4 ,%ort 
title ,?is ,act may be cit$ z !         
,m$ic>e-,x ,*oice ,act ( #bjai4  #b4    
,e/abli%m5t & adm9i/ration ( a public   
heal? plan ,! ,social ,security ,act is 
am5d$ by add+ at ! end ! foll[+ new     
title3  ,,xxii ,m$ic>e ,ex*ange ,heal?  
,plan  #bbja4 ,e/abli%m5t  7a7          
,e/abli%m5t ( plan  7#a7 ,9 g5]al ,!    
,secret>y %all e/abli% a coord9at$ &    
l[-co/ heal? plan1 to be kn[n z !       
,m$ic>e ,ex*ange heal? plan 7ref]r$ to 9
 ?is section z ! heal? plan7 to provide 
access to quality heal? c>e = enrollees4
  7#b7 ,timeframe  7,a7 ,individual     

m>ket availability  7i7 ,9 g5]al ,9     
accordance ) clause 7ii71 ! ,secret>y   
%all make ! heal? plan available 9 !    
individual m>ket1 9 c]ta9 rat+ areas1 = 
plan ye> #bjba & ea* subsequ5t plan ye>1
 & increase ! availability su* t ! plan 
is available 9 ! individual m>ket to all
 resid5ts ( all rat+ areas 9 ! ,unit$   
,/ates = plan ye> #bjbd & ea* subsequ5t 
plan ye>4  7ii7 ,priority areas ,9      
det]m9+ 9 :i* rat+ areas ! ,secret>y    
initially w make ! heal? plan available1
 ! ,secret>y %all give priority to rat+ 
areas 9 :i*--  7,i7 n m ?an #a heal?    
insurance issu] (f]s plans on !         
applicable ,/ate or ,f$]al ,am]ican     
,heal? ,b5efit ,ex*ange 7ref]r$ to 9 ?is
 title z ! ,ex*ange72 or  7,,ii7 !re is 
a %ortage ( heal? provid]s or lack (    
competition t results 9 a high co/ (    
heal? c>e s]vices1 includ+ heal?        
pr(essional %ortage areas & rural areas4
  7,b7 ,small gr\p m>ket ,! ,secret>y   
%all make ! heal? plan available 9 !    
small gr\p m>ket 9 all rat+ areas = plan

 ye> #bjbe4  7b7 ,e/abli%m5t ( funds    
7#a7 ,plan ,res]ve ,fund  7,a7 ,9 g5]al 
,!re is e/abli%$ 9 ! ,treasury ( !      
,unit$ ,/ates a ,plan ,res]ve ,fund1 to 
be adm9i/]$ by ! ,secret>y ( ,heal? &   
,human ,s]vices1 = purposes ( e/abli%+ !
 ,m$ic>e ,ex*ange heal? plan & adm9i/]+ 
su* plan1 consi/+ ( am\nts appropriat$  
to su* fund4  7,b7 ,appropriation ,!re  
is appropriat$ #a1jjj1jjj1jjj1 out (    
monies 9 ! ,treasury n o!rwise obligat$1
 to ! ,plan ,res]ve ,fund = fiscal ye>  
#bjbj4  7#b7 ,data & ,te*nology ,fund   
,!re is e/abli%$ 9 ! ,treasury ( !      
,unit$ ,/ates a ,data & ,te*nology      
,fund1 to be adm9i/]$ by ! ,secret>y (  
,heal? & ,human ,s]vices1 act+ ?r\gh !  
,*ief ,actu>y ( ! ,c5t]s = ,m$ic>e      
,m$icaid ,s]vices1 = purposes ( updat+  
te*nology & p]=m+ data collection "u    
section #bbje 9 ord] to e/abli%         
appropriate premiums = all geographic   
regions ( ! ,unit$ ,/ates4 ,!re are     
au?oriz$ to be appropriat$ to ! ,data & 
,te*nology ,fund su* sums z may be      

necess>y = fiscal ye> #bjbj4  7c7       
,rulemak+ ,! ,secret>y may promulgate   
su* regulations z may be necess>y to    
c>ry out ?is title4  #bbjb4             
,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$ic>e program "u title
 ,,xviii4  7b7 ,ex*anges ,9 accordance )
 ! timeframe "u section #bbja7;a77#b71 !
 heal? plan %all be made available ?r\gh
 ! ,am]ican ,heal? ,b5efit ,ex*anges    
describ$ 9 sections #acaa & #acba ( !   
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjca1 #ahjda71    
includ+ ! ,small ,bus9ess ,heal?        
,options ,program ,ex*ange4  #bbjc4     
,plan requirem5ts  7a7 ,g5]al           
requirem5ts ,! heal? plan %all comply ) 
all requirem5ts1 z applicable1 (        

subtitle ,d ( title ,i ( ! ,pati5t      
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjba et seq47 & title       
,,xxvii ( ! ,public ,heal? ,s]vice ,act 
7#db ,u4,s4,c4 #cjj;gg et seq47         
applicable to qualifi$ heal? plans1 &   
su* heal? plan %all be a qualifi$ heal? 
plan1 includ+ = purposes ( ! ,int]nal   
,rev5ue ,code ( #aihf4  7b7 ,levels (   
cov]age ,! ,secret>y-- 7#a7 %all make   
available a silv] level & gold level    
v]sion ( ! plan1 9 accordance ) section 
#acja7;a77#a77;,c77ii72 &  7#b7 may make
 available no m ?an #b v]sions ( ! plan 
= ea* ( ! #d levels ( cov]age describ$ 9
 subp>agraphs 7,a7 ?r\gh 7,d7 ( section 
#acjb7;d77#a7 ( ! ,pati5t ,protection & 
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjbb7;d77#a774  #bbjd4 ,adm9i/rative  
contract+  7a7 ,9 g5]al ,! ,secret>y may
 ent] into contracts = ! purpose ( p]=m+
 adm9i/rative functions 7includ+        
functions describ$ 9 subsection 7a77#d7 
( section #ahgd;,a7 ) respect to ! heal?
 plan 9 ! same mann] z ! ,secret>y may  

ent] into contracts "u subsection       
7a77#a7 ( su* section4 ,! ,secret>y %all
 h ! same au?ority ) respect to ! public
 heal? insurance option z ! ,secret>y   
has "u su* subsection 7a77#a7 &         
subsection 7b7 ( section #ahgd;,a )     
respect to title ,,xviii4  7b7 ,transf] 
( insurance risk ,any contract "u       
subsection 7a7 %all n involve ! transf] 
( insurance risk f ! ,secret>y to !     
entity ent]+ into su* contract ) !      
,secret>y1 except 9 ! case ( an         
alt]native paym5t model "u section      
#bbji7;h74  #bbje4 ,data collection     
,subject to all applicable privacy      
requirem5ts1 includ+ ! requirem5ts "u ! 
regulations promulgat$ pursuant to      
section #bfd7;c7 ( ! ,heal? ,insurance  
,portability & ,acc\ntability ,act (    
#aiif 7#db ,u4,s4,c4 #acbj;d-#b note71 !
 ,secret>y may collect data f ,/ate     
insurance commission]s & o!r relevant   
entities to e/abli% rates = premiums & =
 o!r purposes includ+ to improve        
quality1 & r$uce racial1 e?nic1 & o!r   

disp>ities1 ) respect to ! heal? plan4  
#bbjf4 ,premiums2 risk pool  7a7 ,sett+ 
premiums  7#a7 ,9 g5]al ,! ,secret>y    
%all e/abli% premiums = ! heal? plan t  
cov] ! full actu>ial co/ ( (f]+ su*     
plan1 includ+ ! adm9i/rative co/s ( (f]+
 su* plan4 ,su* premiums %all v>y       
geographically & betwe5 ! small gr\p    
m>ket & ! individual m>ket 9 accordance 
) diff]5ces 9 ! co/ ( provid+ su*       
cov]age4 ,if1 = any plan ye>1 ! am\nt   
collect$ 9 premiums exce$s ! am\nt      
requir$ = heal? c>e b5efits &           
adm9i/rative co/s 9 t plan ye>1 su*     
excess am\nts %all rema9 available to ! 
,secret>y to adm9i/] ! heal? plan &     
f9ance b5efici>y co/s 9 subsequ5t ye>s4 
7#b7 ,initial plan ye> ,= plan ye>      
#bjba1 ! ,secret>y %all set premiums = !
 heal? plan = ea* rat+ area 9 :i* !     
heal? plan is available = su* plan ye>1 
tak+ into consid]ation ! premium rates =
 plans (f]$ 9 ea* su* rat+ area = plan  
ye> #bjbj4  7b7 ,risk pool ,aft] plan   
ye> #bjba1 all enrollees 9 ! heal? plan 

)9 a ,/ate %all be memb]s ( a s+le risk 
pool1 except t ! ,secret>y may e/abli%  
sep>ate risk pools = ! individual m>ket 
& small gr\p m>ket if ! ,/ate has n     
ex]cis$ its au?ority "u section         
#acab7;c77#c7 ( ! ,pati5t ,protection & 
,af=dable ,c>e ,act4  #bbjg4            
,reimbursem5t rates  7a7 ,m$ic>e rates  
7#a7 ,9 g5]al ,except z provid$ 9       
p>agraph 7#b7 & subsections 7b7 & 7c7 & 
subject to subsection 7d71 ! ,secret>y  
%all reimburse heal? c>e provid]s       
furni%+ items & s]vices "u ! heal? plan 
at rates det]m9$ = equival5t items &    
s]vices "u ! orig9al ,m$ic>e            
fee-=-s]vice program "u p>ts ,a & ,b (  
title ,,xviii4  7#b7 ,au?ority to       
increase paym5ts rates 9 rural areas ,if
 ! ,secret>y det]m9es appropriate1 !    
,secret>y may increase ! reimbursem5ts  
rates describ$ 9 p>agraph 7#a7 by up to 
#be p]c5t = items & s]vices furni%$ 9   
rural areas 7z def9$ 9 section          
#ahhf7;d77#b77;,d774  7b7 ,prescription 
drugs ,subject to subsection 7d71 paym5t

 rates = prescription drugs %all be at a
 rate negotiat$ by ! ,secret>y4 ,su*    
negotiations may be 9 conjunction )     
negotiations = cov]$ "p ,d drugs "u "p  
,d ( title ,,xviii4  7c7 ,additional    
items & s]vices ,subject to subsection  
7d71 ! ,secret>y %all e/abli%           
reimbursem5t rates = any items & s]vices
 provid$ "u ! heal? plan t are n items &
 s]vices provid$ "u ! orig9al ,m$ic>e   
fee-=-s]vice program "u p>ts ,a & ,b (  
title ,,xviii4  7d7 ,innovative paym5t  
me?ods ,! ,secret>y may utilize         
innovative paym5t me?ods1 includ+       
value-bas$ paym5t arrangem5ts1 9 mak+   
paym5ts = items & s]vices 7includ+      
prescription drugs7 furni%$ "u ! heal?  
plan4  #bbjh4 ,p>ticipat+ provid]s  7a7 
,requirem5t ,to p>ticipate 9 ord] ,to be
 enroll$ "u ,m$ic>e ,subject to         
subsection 7d71 beg9n+ ,janu>y #a1      
#bjba1 a heal? c>e provid] may n be     
enroll$ "u ! ,m$ic>e program "u section 
#ahff7;j7 unless ! provid] is also a    
p>ticipat+ provid] "u ! heal? plan4  7b7

 ,requirem5t ,to p>ticipate 9 ord] ,to  
p>ticipate 9 ,m$icaid ,subject to       
subsection 7d71 beg9n+ ,janu>y #a1      
#bjba1 a heal? c>e provid] may n be a   
p>ticipat+ provid] "u a ,/ate ,m$icaid  
plan "u title ,,xix unless ! provid] is 
also a p>ticipat+ provid] "u ! heal?    
plan4  7c7 ,additional provid]s ,!      
,secret>y %all e/abli% a process to all[
 heal? c>e provid]s n describ$ 9        
subsection 7a7 or 7b7 to become a       
p>ticipat+ provid] "u ! heal? plan4  7d7
 ,opt-,out ,! ,secret>y %all e/abli% a  
process by :i* a heal? c>e provid]      
describ$ 9 subsection 7a7 or 7b7 may opt
 out ( be+ a p>ticipat+ provid] "u !    
heal? plan4  #bbji4 ,deliv]y sy/em re=m 
= an enhanc$ heal? plan  7a7 ,9 g5]al ,=
 plan ye>s beg9n+ ) plan ye> #bjba1 !   
,secret>y may utilize innovative paym5t 
me*anisms & policies to det]m9e paym5ts 
= items & s]vices "u ! heal? plan4 ,!   
paym5t me*anisms & policies "u ?is      
section may include pati5t-c5t]$ m$ical 
home & o!r c>e managem5t paym5ts1       

acc\ntable c>e organizations1 acc\ntable
 communities = heal?1 value-bas$        
pur*as+1 bundl+ ( s]vices1 diff]5tial   
paym5t rates1 p]=mance or utilization   
bas$ paym5ts1 teleheal?1 remote pati5t  
monitor+1 p>tial capitation1 & direct   
contract+ ) provid]s4  7b7 ,requirem5ts 
= innovative paym5ts ,! ,secret>y %all  
design & implem5t ! paym5t me*anisms &  
policies "u ?is section 9 a mann] t--   
7#a7 seeks to-- 7,a7 improve heal?      
outcomes2  7,b7 r$uce heal? disp>ities  
7includ+ racial1 e?nic1 & o!r           
disp>ities72  7,c7 provide effici5t &   
af=dable c>e2  7,d7 address geographic  
v>iation 9 ! provision ( heal? s]vices2 
or  7,e7 prev5t or manage *ronic        
illness2 &  7#b7 promotes c>e t is      
integrat$1 pati5t-c5t]$1 quality1 &     
effici5t4  7c7 ,enc\rag+ ! use ( high   
value s]vices ,to ! ext5t all[$ by !    
b5efit /&>ds appli$ to all heal? b5efits
 plans p>ticipat+ 9 ! ,ex*anges 7z      
describ$ 9 section #bbjb7;b771 ! heal?  
plan may modify co/-%>+ & paym5t rates  

to enc\rage ! use ( s]vices t promote   
heal? & value4  7d7 ,promotion ( deliv]y
 sy/em re=m ,! ,secret>y %all monitor & 
evaluate ! progress ( paym5t & deliv]y  
sy/em re=ms "u ?is section & %all seek  
to implem5t su* re=ms subject to !      
foll[+3  7#a7 ,to ! ext5t t ! ,secret>y 
f9ds a paym5t & deliv]y sy/em re=m      
successful 9 improv+ quality & r$uc+    
co/s1 ! ,secret>y %all implem5t su* re=m
 on z l>ge a geographic scale z         
practical & economical4  7#b7 ,!        
,secret>y may delay ! implem5tation (   
su* a re=m 9 geographic areas 9 :i* su* 
implem5tation w\ld place ! public heal? 
insurance option at a competitive       
disadvantage4  7#c7 ,! ,secret>y may    
prioritize implem5tation ( su* a re=m 9 
high-co/ geographic areas or o!rwise 9  
ord] to r$uce total program co/s or to  
promote high value c>e4  7e7            
,non-,uni=mity p]mitt$ ,no?+ 9 ?is      
section %all prev5t ! ,secret>y f v>y+  
paym5ts bas$ on diff]5t paym5t /ructure 
models 7su* z acc\ntable c>e            

organizations & m$ical homes7 "u ! heal?
 plan = diff]5t geographic areas4  7f7  
,integration ) social s]vices  7#a7 ,9  
g5]al ,! ,secret>y %all e/abli%         
processes &1 :5 appropriate1 collaborate
 ) o!r ag5cies to integrate m$ical c>e  
"u ! heal? plan ) food1 h\s+1           
transportation1 & income assi/ance if ! 
,secret>y det]m9es t su* integration is 
expect$ to--  7,a7 r$uce sp5d+ )\t r$uc+
 ! quality ( pati5t c>e2 or  7,b7       
improve ! quality ( pati5t c>e )\t      
increas+ sp5d+4  7#b7 ,au?orization ( a 
grant program  7,a7 ,9 g5]al ,!         
,secret>y may e/abli% a grant program to
 p]mit broad] exp]im5tation ) acc\ntable
 communities = heal? model4  7,b7       
,eligible recipi5ts ,! ,secret>y may    
aw>d a grant "u ?is section to-- 7i7 an 
in/itution ( high] le>n+ 7z def9$ 9     
section #cdeb7;f7 ( title #ch1 ,unit$   
,/ates ,code72  7ii7 a local educational
 ag5cy 7z def9$ 9 section #haja ( !     
,elem5t>y & ,second>y ,education ,act ( 
#aife7 or heal? c>e ag5cy2  7iii7 a     

nonpr(it entity t ! ,secret>y det]m9es  
has a demon/rat$ hi/ory ( community     
engagem5t2 or  7iv7 any o!r entity1 z ! 
,secret>y det]m9es appropriate4  7,c7   
,use ( funds ,a recipi5t ( a grant "u   
?is section may use ! grant to--  7i7   
support community ne$s assessm5t2  7ii7 
e/abli% social s]vice p>tn]%ips2 or     
7iii7 e/abli% int]active data sy/ems    
across heal? & social s]vice provid]s4  
7,d7 ,au?orization ( appropriations ,!re
 are au?oriz$ to be appropriat$ su* sums
 z may be necess>y to c>ry out ?is      
p>agraph4  7#c7 ,regulations ,if !      
,secret>y e/abli%es a grant program "u  
?is section1 ! ,secret>y %all promulgate
 regulations on--  7,a7 ! evaluation (  
applications = grants "u ! program2 &   
7,b7 adm9i/ration ( ! program4  7g7     
,teleheal? ,! ,secret>y %all ensure !   
integration ( teleheal? tools t increase
 pati5t access to m$ical c>e1 p>ticul>ly
 9 remote or und]s]v$ areas1 if !       
,secret>y det]m9es t su* integration is 
expect$ to--  7#a7 r$uce sp5d+ )\t r$uc+

 ! quality ( pati5t c>e2 or  7#b7       
improve ! quality ( pati5t c>e )\t      
increas+ sp5d+4  7h7 ,alt]native paym5t 
model  7#a7 ,9 g5]al ,! ,secret>y %all  
evaluate ! possibility ( provid+        
inc5tives1 &1 if appropriate1 apply     
inc5tives1 = enrollees 9 ! heal? plan :o
 receive s]vices f provid]s :o are      
p>ticipat+ 9 an alt]native paym5t model 
7z def9$ 9 section #ahcc7z77#c77;,c774  
7#b7 ,au?ority to use apms 9 use "u     
traditional ,m$ic>e ,no?+ 9 ?is section 
%all preclude ! ,secret>y f us+         
alt]native paym5t models 7z s def9$7 "u 
?is title t are 9 use "u title ,,xviii4 
#bbaj4 ,no effect on ,m$ic>e b5efits or 
,m$ic>e ,tru/ ,funds ,no?+ 9 ?is title  
%all-- 7#a7 affect ! b5efits available  
"u title ,,xviii2 or  7#b7 impact !     
,f$]al ,hospital ,insurance ,tru/ ,fund 
"u section #ahag or ! ,f$]al            
,supplem5t>y ,m$ical ,insurance ,tru/   
,fund "u section #ahda 7includ+ !       
,m$ic>e ,prescription ,drug ,acc\nt )9  
su* ,tru/ ,fund74  4  #c4 ,re9surance   

7a7 ,9 g5]al ,! ,secret>y ( ,heal? &    
,human ,s]vices %all e/abli% a me*anism 
to pool1 on a nationwide basis1 ! co/s (
 ! highe/-co/ pati5ts enroll$ 9         
individual heal? insurance cov]age 7z   
def9$ 9 section #bgia ( ! ,public ,heal?
 ,s]vice ,act 7#db ,u4,s4,c4            
#cjj;gg-#ia77 (f]$ on or (f ! ,ex*anges1
 to ! ext5t su* co/s are n already pool$
 pursuant to section #acdc ( ! ,pati5t  
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjfc71 = ! purpose ( r$uc+  
premiums = su* individual heal?         
insurance cov]age4  7b7 ,au?orization ( 
appropriations ,= purposes ( c>ry+ out  
p>agraph 7#a71 !re is au?oriz$ to be    
appropriat$ #aj1jjj1jjj1jjj = ea* (     
fiscal ye>s #bjba1 #bjbb1 & #bjbc4  #d4 
,expansion ( tax cr$it  7a7 ,9 g5]al    
,subp>agraph 7,a7 ( section             
#cf;,b7c77#a7 ( ! ,int]nal ,rev5ue ,code
 ( #aihf is am5d$ by /rik+ b does n     
exce$ #djj p]c5t4  7b7 ,applicable      
p]c5tages ,clause 7i7 ( section         
#cf;,b7b77#c77;,a7 ( ! ,int]nal ,rev5ue 

,code ( #aihf is am5d$ to read z foll[s3
  7i7 ,9 g5]al ,! applicable p]c5tage = 
any taxable ye> %all be ! p]c5tage su* t
 ! applicable p]c5tage = any taxpay] ^: 
h\sehold income is )9 an income ti]     
specifi$ 9 ! foll[+ table %all increase1
 on a slid+ scale 9 a l9e> mann]1 f !   
initial premium p]c5tage to ! f9al      
premium p]c5tage specifi$ 9 su* table = 
su* income ti]3  ,9 ! case ( h\sehold   
income 7express$ z a p]c5t ( pov]ty l9e7
 )9 ! foll[+ income ti]3,! initial      
premium p]c5tage is--,! f9al premium    
p]c5tage is--  ,up to #ach p]c5t#a4ea4e 
#ach p]c5t up to #aej p]c5t#b4ec4e #aej 
p]c5t up to #bjj p]c5t#c4ee4h #bjj p]c5t
 up to #bej p]c5t#e4hg4ee #bej p]c5t up 
to #cjj p]c5t#g4eei4j #cjj p]c5t up to  
#djj p]c5t#i4ji4j #djj p]c5t up to #fjj 
p]c5t#i4jac4j #fjj p]c5t & up#ac4jac4j4 
4  7c7 ,limitation on recapture ,clause 
7i7 ( section #cf;,b7f77#b77;,b7 ( !    
,int]nal ,rev5ue ,code ( #aihf is       
am5d$-- 7#a7 by /rik+ ,9 ! case ( a     
taxpay] & all t foll[s ?r\gh ! am\nt ( !

 increase & ins]t+ ,! am\nt ( !         
increase2  7#b7 by /rik+ ! p]iod at !   
end ( ! la/ r[ ( ! table2 &  7#c7 by    
add+ at ! end ( ! table ! foll[+ new r[3
  #djj p]c5t & up#e1jjj4 4  7d7         
,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ,decemb] #ca1 #bjai4  #e4   
,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