,,ii  #aag? ,,congress  #a/ ,session    
,s4 #aahj  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,april #ae1 #bjba,mr4  
,m]kley 7= himself1 ,mr4 ,murphy1 ,mrs4 
,fe9/e91 ,mr4 ,blum5?al1 ,mr4 ,s*atz1   
,ms4 ,baldw91 ,ms4 ,smi?1 ,mrs4 ,%ahe51 
,ms4 ,duckwor?1 ,mr4 ,van ,holl51 ,mr4  
,durb91 & ,mr4 ,re$7 introduc$ ! foll[+ 
bill2 :i* 0 read twice & ref]r$ to !    
,committee on ,f9ance  ,a ,,bill  ,to   
provide = ! e/abli%m5t ( ,m$ic>e "p ,e  
public heal? plans1 & = o!r purposes4   
#a4 ,%ort title ,?is ,act may be cit$ z 
! ,*oose ,m$ic>e ,act4  #b4 ,public     
heal? plan ,! ,social ,security ,act is 
am5d$ by add+ at ! end ! foll[+3  #bbja4
 ,title ,,xxii--,m$ic>e "p ,e public    
heal? plans ,public heal? plans4-- 7a7  
,e/abli%m5t ,! ,secret>y %all e/abli%   
public heal? plans 7to be kn[n z ,m$ic>e
 "p ,e plans7 t are available 9 !       
individual m>ket1 small gr\p m>ket1 &   
l>ge gr\p m>ket4  7b7 ,b5efits  7#a7 ,9 
g5]al ,ea* ,m$ic>e "p ,e plan1 reg>dless
 ( :e!r ! plan is (f]$ 9 ! individual   

m>ket1 small gr\p m>ket1 or l>ge gr\p   
m>ket1 %all be a qualifi$ heal? plan )9 
! mean+ ( section #acja7;a7 ( ! ,pati5t 
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjba7;a77 t-- 7,a7 meets all
 requirem5ts applicable to qualifi$     
heal? plans "u subtitle ,d ( title ,i ( 
! ,pati5t ,protection & ,af=dable ,c>e  
,act 7#db ,u4,s4,c4 #ahjba et seq47 7o!r
 ?an ! requirem5t "u section            
#acja7;a77#a77;,c77ii7 ( su* ,act7 &    
title ,,xxvii ( ! ,public ,heal? ,s]vice
 ,act 7#db ,u4,s4,c4 #cjj;gg et seq472  
7,b7 provides cov]age (-- 7i7 ! ess5tial
 heal? b5efits describ$ 9 section       
#acjb7;b7 ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjbb7;b772 &  7ii7 all items & s]vices
 = :i* b5efits are available "u title   
,,xviii2  7,c7 provides gold-level      
cov]age describ$ 9 section              
#acjb7;d77#a77;,c7 ( ! ,pati5t          
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjbb7;d77#a77;,c772 &  7,d7 
provides cov]age ( abortions & all o!r  

reproductive s]vices4  7#b7 ,preemption 
,not)/&+ section #acjc7;a77#a7 ( !      
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjbc7;a77#a77--   
7,a7 a ,/ate may n prohibit a ,m$ic>e "p
 ,e plan f (f]+ ! cov]age describ$ 9    
p>agraph 7#a77;,d72 &  7,b7 no ,/ate law
 t w\ld prohibit su* a plan f (f]+ su*  
cov]age %all apply to su* plan4  7c7    
,eligibility2 enrollm5t  7#a7           
,availability on ! ,ex*anges ,! ,m$ic>e 
"p ,e plans (f]$ 9 ! individual & small 
gr\p m>kets %all be (f]$ ?r\gh ! ,f$]al 
& ,/ate ,ex*anges1 includ+ ! ,small     
,bus9ess ,heal? ,options ,program       
,ex*anges 7commonly ref]r$ to z ! ,,%op 
,ex*anges74  7#b7 ,eligibility  7,a7 ,9 
g5]al ,any individual :o is a resid5t ( 
! ,unit$ ,/ates1 z det]m9$ by !         
,secret>y "u subp>agraph 7,c71 & :o is n
 an individual describ$ 9 subp>agraph   
7,b71 is eligible to enroll 9 a ,m$ic>e 
"p ,e plan4  7,b7 ,exclusions ,an       
individual describ$ 9 ?is subp>agraph is
 any individual :o is-- 7i7 entitl$ to1 

or enroll$ =1 b5efits "u title ,,xviii2 
7ii7 eligible = m$ical assi/ance "u a   
,/ate plan "u title ,,xix2 or  7iii7    
enroll$ = *ild heal? assi/ance or       
pregnancy-relat$ assi/ance "u a ,/ate   
plan "u title ,,xxi4  7,c7 ,regulations 
,! ,secret>y %all promulgate a rule =   
det]m9+ resid5cy = purposes (           
subp>agraph 7,a74  7#c7                 
,employ]-sponsor$ plans  7,a7 ,employ]  
enrollm5t ,effective ) respect to ! fir/
 plan ye> t beg9s #a ye> aft] ! date (  
enactm5t ( ! ,*oose ,m$ic>e ,act & ea*  
plan ye> !reaft]1 ! ,secret>y %all      
provide options = ,m$ic>e "p ,e plans 9 
! small gr\p m>ket & l>ge gr\p m>ket t  
are volunt>y1 & available to all        
employ]s4  7,b7 ,gr\p heal? plans ,!    
,secret>y1 act+ ?r\gh ! ,adm9i/rator = !
 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices1 at
 ! reque/ ( a plan sponsor1 %all s]ve z 
a ?ird p>ty adm9i/rator ( a gr\p heal?  
plan t is a ,m$ic>e "p ,e plan (f]$ by  
su* sponsor4  7,c7 ,portability =       
employ]-sponsor$ plans ,! ,secret>y %all

 develop a process = all[+ individuals  
enroll$ 9 a ,m$ic>e "p ,e plan (f]$ 9 ! 
small gr\p m>ket or l>ge gr\p m>ket to  
ma9ta9 heal? insurance cov]age ?r\gh a  
,m$ic>e "p ,e plan if ! individual      
subsequ5tly loses eligibility =         
enrollm5t 9 su* a plan bas$ on t]m9ation
 ( ! employm5t relation%ip4 ,! ability  
to ma9ta9 su* cov]age %all exi/         
reg>dless ( :e!r ! individual has !     
option to enroll 9 o!r heal? insurance  
cov]age1 includ+ cov]age (f]$ 9 !       
individual m>ket or ?r\gh a subsequ5t   
employ]4  7d7 ,premiums ,! ,secret>y    
%all e/abli% premium rates = ! ,m$ic>e  
"p ,e plans t-- 7#a7 are adju/$ bas$    
on-- 7,a7 :e!r ! plan is (f]$ 9 !       
individual m>ket1 small gr\p m>ket1 or  
l>ge gr\p m>ket2 &  7,b7 ! applicable   
rat+ area2  7#b7 are at a level         
suffici5t to fully f9ance-- 7,a7 ! co/s 
( heal? b5efits provid$ by su* plans2 & 
7,b7 adm9i/rative co/s relat$ to op]at+ 
! plans2 &  7#c7 comply ) ! requirem5ts 
"u section #bgja ( ! ,public ,heal?     

,s]vice ,act1 includ+ = su* plans t are 
(f]$ 9 ! l>ge gr\p m>ket4  7e7 ,provid]s
 & reimbursem5t rates  7#a7 ,9 g5]al ,! 
,secret>y %all e/abli% a rate s*$ule =  
reimburs+ types ( heal? c>e provid]s    
furni%+ items & s]vices "u ! ,m$ic>e "p 
,e plans at rates t are consi/5t ) !    
negotiations describ$ 9 p>agraph 7#b7 & 
are necess>y to ma9ta9 network adequacy4
  7#b7 ,mann] ( negotiation ,! ,secret>y
 %all negotiate ! rates describ$ 9      
p>agraph 7#a7 9 a mann] t results 9     
paym5t rates t are n l[]1 9 ! aggregate1
 ?an rates "u title ,,xviii1 & n high]1 
9 ! aggregate1 ?an ! av]age rates paid  
by o!r heal? insurance issu]s (f]+ heal?
 insurance cov]age ?r\gh an ,ex*ange4   
7#c7 ,p>ticipat+ provid]s  7,a7 ,9 g5]al
 ,a heal? c>e provid] t is a p>ticipat+ 
provid] ( s]vices or suppli] "u !       
,m$ic>e program "u title ,,xviii on !   
date ( enactm5t ( ,*oose ,m$ic>e ,act   
%all be a p>ticipat+ provid] = ,m$ic>e  
"p ,e plans4  7,b7 ,additional provid]s 
,! ,secret>y %all e/abli% a process to  

all[ heal? c>e provid]s n describ$ 9    
subp>agraph 7,a7 to become p>ticipat+   
provid]s = ,m$ic>e "p ,e plans4  7#d7   
,limitations on balance bill+ ,!        
limitations on balance bill+ pursuant to
 ! provisions ( section                 
#ahff7;a77#a77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acie;cc7a77#a77;,a77 %all apply to     
p>ticipat+ provid]s = ,m$ic>e "p ,e     
plans 9 ! same mann] z su* provisions   
apply to p>ticipat+ provid]s "u !       
,m$ic>e program4  7f7 ,enc\rag+ use (   
alt]native paym5t models ,! ,secret>y   
%all1 z applicable1 utilize alt]native  
paym5t models1 includ+ ^? describ$ 9    
section #ahcc7z77#c77;,c71 z add$ by    
section #aja7;e77#b7 ( ! ,m$ic>e ,access
 & ,,*ip ,reau?orization ,act ( #bjae   
7,public ,law #aad-aj71 9 mak+ paym5ts =
 items & s]vices 7includ+ prescription  
drugs7 furni%$ "u ,m$ic>e "p ,e plans4  
,! paym5t rates "u su* alt]native paym5t
 models %all comply ) ! requirem5t =    
negotiat$ rates "u subsection 7e77#b74  

7g7 ,prescription drugs ,! ,secret>y    
%all apply ! provisions ( section       
#ahfj;,d-#aa7;i7 to prescription drugs  
"u ,m$ic>e "p ,e plans 9 ! same mann] z 
su* provisions apply ) respect to       
applicable cov]$ "p ,d drugs "u su*     
section4  7h7 ,appropriations  7#a7 ,/>t
 up fund+ ,= purposes ( e/abli%+ !      
,m$ic>e "p ,e plans1 !re is appropriat$ 
to ! ,secret>y1 out ( any funds 9 !     
,treasury n o!rwise obligat$1           
#b1jjj1jjj1jjj1 = fiscal ye> #bjbb4     
7#b7 ,initial res]ves ,!re is           
appropriat$ to ! ,secret>y1 out ( any   
funds 9 ! ,treasury n o!rwise obligat$1 
su* sums z may be necess>y1 bas$ on     
project$ enrollm5t 9 ! ,m$ic>e "p ,e    
plans 9 ! fir/ plan ye> 9 :i* su* plans 
are (f]$1 to provide res]ves = ! purpose
 ( pay+ claims fil$ dur+ ! initial      
#ij-;day p]iod ( su* plan ye>4  7#c7    
,cl>ification ,any provision ( law      
re/rict+ ! use ( ,f$]al funds ) respect 
to any reproductive heal? s]vice %all n 
apply to funds appropriat$ "u p>agraph  

7#a7 or 7#b74  7i7 ,heal? insurance     
issu] ,) respect to any ,m$ic>e "p ,e   
plan1 ! ,secret>y %all be consid]$ a    
heal? insurance issu]1 )9 ! mean+ (     
section #bgia7;b7 ( ! ,public ,heal?    
,s]vice ,act4  4  #c4 ,notice &         
navigator ref]ral = employees "u ! ,fair
 ,labor ,/&>ds ,act ( #aich  7a7 ,9     
g5]al ,section #ah;,b ( ! ,fair ,labor  
,/&>ds ,act ( #aich 7#bi ,u4,s4,c4      
#bah;b7 is am5d$-- 7#a7 9 ! head+1 by   
/rik+ to & ins]t+ & navigator ref]ral =2
  7#b7 by r$esignat+ subsection 7b7 z   
subsection 7c72  7#c7 by ins]t+ aft]    
subsection 7a7 ! foll[+3  7b7 ,navigator
 ref]ral  7#a7 ,9 g5]al ,an employ]     
describ$ 9 p>agraph 7#c7 %all ref] ea*  
full-"t employee 7z def9$ 9 section     
#dihj;,h ( ! ,int]nal ,rev5ue ,code (   
#aihf7 to-- 7,a7 an entity t s]ves z a  
navigator "u section #acaa7;i7 ( !      
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjca7;i77 = !     
,ex*ange op]at+ 9 ! ,/ate ( ! employ]2  
or  7,b7 if ! ,ex*ange op]at+ 9 ! ,/ate 

( ! employ] does n h an entity s]v+ z   
su* a navigator1 ano!r entity t %all    
c>ry out equival5t activities z su* a   
navigator4  7#b7 ,ref]ral ,! ref]ral    
describ$ 9 p>agraph 7#a7 %all occur--   
7,a7 at ! "t ! employ] hires ! employee2
 or  7,b7 on ! effective date describ$ 9
 subsection 7c77#b7 ) respect to an     
employee :o is curr5tly employ$ by !    
employ] on su* date4  7#c7 ,employ] ,an 
employ] describ$ 9 ?is p>agraph is any  
employ] t-- 7,a7 does n provide an      
eligible employ]-sponsor$ plan z def9$ 9
 section #ejjj;,a7f77#b7 ( ! ,int]nal   
,rev5ue ,code ( #aihf2 or  7,b7 provides
 su* an eligible employ]-sponsor$ plan1 
b ! plan is det]m9$ "u section          
#cf;,b7c77#b77;,c7 ( su* ,code-- 7i7 to 
be unaf=dable to ! employee2 or  7ii7 to
 n provide ! requir$ m9imum actu>ial    
value4  2 &  7#d7 9 subsection 7c71 z s 
r$esignat$-- 7,a7 9 ! head+1 by /rik+   
,effective date & ins]t+ ,effective     
dates2  7,b7 by /rik+ ,subsection 7a7 & 
ins]t+ ! foll[+3  7#a7 ,notice          

,subsection 7a72  2 &  7,c7 by add+ at !
 end ! foll[+3  7#b7 ,navigator ref]ral 
,subsection 7b7 %all take effect )      
respect to employ]s 9 a ,/ate beg9n+ on 
! date t is #b ye>s aft] ! date (       
enactm5t ( ! ,*oose ,m$ic>e ,act4  4    
7b7 ,/udy ,n lat] ?an ,janu>y #a1 #bjbf1
 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates 
%all conduct a /udy on ! impact ( !     
requirem5ts "u section #ah;,b ( ! ,fair 
,labor ,/&>ds ,act ( #aich 7#bi         
,u4,s4,c4 #bah;b71 includ+ ! am5dm5ts   
made by subsection 7a71 on ! rate (     
individuals )\t m9imum ess5tial cov]age 
z def9$ 9 section #ejjj;,a ( ! ,int]nal 
,rev5ue ,code ( #aihf 9 ! ,unit$ ,/ates 
& 9 ea* ,/ate4  7c7 ,fund+ = navigator  
program ,section #acaa7;i77#f7 ( !      
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjca7;i77#f77 is  
am5d$-- 7#a7 by /rik+ ,grants & ins]t+ !
 foll[+3  7,a7 ,9 g5]al ,grants  2 &    
7#b7 by add+ at ! end ! foll[+3  7,b7   
,au?orization ( appropriations ,!re is  
au?oriz$ to be appropriat$ su* sums z   

may be necess>y to address capacity     
limitations ( entities s]v+ z navigators
 ?r\gh a grant "u ?is subsection4  4    
#d4 ,protect+ aga9/ high out-(-pocket   
exp5ditures = ,m$ic>e fee-=-s]vice      
b5efits ,title ,,xviii ( ! ,social      
,security ,act 7#db ,u4,s4,c4 #acie et  
seq47 is am5d$ by add+ at ! end ! foll[+
 new section3  #ahii;,c4 ,protection    
aga9/ high out-(-pocket exp5ditures  7a7
 ,9 g5]al ,not)/&+ any o!r provision (  
?is title1 9 ! case ( an individual     
entitl$ to1 or enroll$ =1 b5efits "u "p 
,a or enroll$ 9 "p ,b1 if ! am\nt ( !   
out-(-pocket co/-%>+ ( su* individual = 
a ye> 7beg9n+ ) #bjbc7 equals or exce$s 
! annual out-(-pocket limit "u          
subsection 7b7 = t ye>1 ! individual    
%all n be responsible = additional      
out-(-pocket co/-%>+ incurr$ dur+ t ye>4
  7b7 ,annual out-(-,pocket limit  7#a7 
,9 g5]al ,! am\nt ( ! annual            
out-(-pocket limit "u ?is subsection    
%all be-- 7,a7 = #bjbc1 #f1gjj2 or  7,b7
 = a subsequ5t ye>1 ! am\nt specifi$ 9  

?is subsection = ! prec$+ ye> increas$  
or decreas$ by ! p]c5tage *ange 9 !     
m$ical c>e compon5t ( ! ,consum] ,price 
,index = ,all ,urban ,consum]s = !      
#ab-mon? p]iod end+ ) ,june ( su* prec$+
 ye>4  7#b7 ,r\nd+ ,if any am\nt det]m9$
 "u p>agraph 7#a77;,b7 is n a multiple (
 #e1 su* am\nt %all be r\nd$ to ! ne>e/ 
multiple ( #e4  7c7 ,out-(-,pocket      
co/-,%>+ def9$  7#a7 ,9 g5]al ,subject  
to p>agraphs 7#b7 & 7#c71 9 ?is section1
 ! t]m out-(-pocket co/-%>+ means1 )    
respect to an individual1 ! am\nt ( !   
exp5ses incurr$ by ! individual t are   
attributable to-- 7,a7 d$uctibles1      
co9surance1 & copaym5ts applicable "u "p
 ,a or ,b2 or  7,b7 = items & s]vices t 
w\ld h o!rwise be5 cov]$ "u "p ,a or ,b 
b = ! exhau/ion ( ^? b5efits4  7#b7     
,c]ta9 co/s n includ$  7,a7 ,non-cov]$  
items & s]vices ,exp5ses incurr$ = items
 & s]vices :i* are n cov]$ "u "p ,a or  
,b %all n be consid]$ incurr$ exp5ses = 
purposes ( det]m9+ out-(-pocket co/-%>+ 
"u p>agraph 7#a74  7,b7 ,items & s]vices

 n furni%$ on an assignm5t-relat$ basis 
,if an item or s]vice is furni%$ to an  
individual "u ?is title & is n furni%$  
on an assignm5t-relat$ basis1 any       
additional exp5ses ! individual incurs  
above ! am\nt ! individual w\ld h       
incurr$ if ! item or s]vice 0 furni%$ on
 an assignm5t-relat$ basis %all n be    
consid]$ incurr$ exp5ses = purposes (   
det]m9+ out-(-pocket co/-%>+ "u p>agraph
 7#a74  7#c7 ,s\rce ( paym5t ,= purposes
 ( p>agraph 7#a71 ! ,secret>y %all      
consid] exp5ses to be incurr$ by !      
individual )\t reg>d to :e!r !          
individual or ano!r p]son1 includ+ a    
,/ate program1 an employ]1 a m$ic>e     
supplem5tal policy1 or o!r ?ird-p>ty    
cov]age1 has paid = su* exp5ses4  7d7   
,ann\ncem5t ( ! annual out-(-,pocket    
limit ,! ,secret>y %all 7beg9n+ 9 #bjbj7
 ann\nce 79 a mann] int5d$ to provide   
notice to all int]e/$ p>ties7 ! annual  
out-(-pocket limit "u ?is section t w be
 applicable = ! succe$+ ye>4  4  #e4    
,negotiat+ fair prices = ,m$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 7i7 7relat+ to non9t]f]5ce7 &
 by ins]t+ ! foll[+3  7i7 ,negotiat+    
fair prices ) drug manufactur]s  7#a7 ,9
 g5]al ,not)/&+ any o!r provision ( law1
 9 fur!rance ( ! goals ( provid+ quality
 c>e & conta9+ co/s "u ?is "p1 !        
,secret>y %all1 ) respect to applicable 
cov]$ "p ,d drugs1 & may1 ) respect to  
o!r cov]$ "p ,d drugs1 negotiate1 us+ ! 
negotiation te*nique or te*niques t !   
,secret>y det]m9es w maximize sav+s &   
value to ! gov]nm5t = prescription drug 
plans & ,,ma-,,pd plans & = plan        
enrollees 79 a mann] t may be simil> to 
,f$]al entities & t may include1 b is n 
limit$ to1 =mul>ies1 ref]5ce pric+1     
disc\nts1 rebates1 o!r price            
concessions1 & cov]age det]m9ations71 ) 
drug manufactur]s ! prices t may be *>g$
 to ,,pdp sponsors & ,,ma organizations 
= su* drugs = "p ,d eligible individuals

 :o are enroll$ 9 a prescription drug   
plan or 9 an ,,ma-,,pd plan4 ,9 conduct+
 su* negotiations1 ! ,secret>y %all     
consid] ! drug's curr5t price1 initial  
laun* price1 preval5ce ( disease &      
usage1 & approv$ indications1 ! numb] ( 
simil>ly effective alt]native treatm5ts 
= ea* approv$ use ( ! drug1 ! budget>y  
impact ( provid+ cov]age "u ?is "p = su*
 drug = all individuals :o w\ld likely  
b5efit f ! drug1 evid5ce on ! drug's    
effectiv5ess & safety comp>$ to simil>  
drugs1 & ! quality & quantity ( cl9ical 
data & rigor ( ! applicable process (   
approval ( a drug "u section #eje ( !   
,f$]al ,food1 ,drug1 & ,cosmetic ,act or
 a biological product "u section #cea ( 
! ,public ,heal? ,s]vice ,act4  7#b7    
,use ( l[] ( ,,va or big f\r price if   
negotiations fail ,if1 aft] attempt+ to 
negotiate = a price ) respect to a cov]$
 "p ,d drug "u p>agraph 7#a7 = a p]iod (
 #a ye>1 ! ,secret>y is n successful 9  
obta9+ an appropriate price = ! drug 7z 
det]m9$ by ! ,secret>y71 ! ,secret>y    

%all e/abli% ! price t may be *>g$ to   
,,pdp sponsors & ,,ma organizations =   
su* drug = "p ,d eligible individuals :o
 are enroll$ 9 a prescription drug plan 
or 9 an ,,ma-,,pd plan at an am\nt equal
 to ! less] (-- 7,a7 ! price paid by !  
,secret>y ( ,vet]ans ,affairs to procure
 ! drug "u ! laws adm9i/]$ by !         
,secret>y ( ,vet]ans ,affairs2 or  7,b7 
! price paid to procure ! drug "u       
section #habf ( title #ch1 ,unit$ ,/ates
 ,code4  7#c7 ,applicable cov]$ "p ,d   
drug def9$ ,= purposes ( ?is subsection1
 ! t]m applicable cov]$ "p ,d drug means
 a cov]$ "p ,d drug t ! ,secret>y       
det]m9es to be appropriate = negotiation
 "u p>agraph 7#a7 bas$ on "o or m ( !   
foll[+ factors z appli$ to su* drug3    
7,a7 ,sp5d+ on a p] b5efici>y basis4    
7,b7 ,! proportion ( total sp5d+ "u ?is 
title4  7,c7 ,unit price increases ov] !
 prec$+ #e ye>s4  7,d7 ,initial laun*   
price4  7,e7 ,availability ( less       
exp5sive1 simil>ly effective alt]native 
treatm5ts4  7,f7 ,/atus ( ! drug z a    

foll[-on to previ\sly approv$ drugs4    
7,g7 ,any o!r crit]ia det]m9$ by !      
,secret>y4  7#d7 ,,pdp sponsors & ,,ma  
organization may negotiate l[] prices   
,no?+ 9 ?is subsection %all be con/ru$ z
 prev5t+ ! sponsor ( a prescription drug
 plan1 or an organization (f]+ an       
,,ma-,,pd plan1 f obta9+ a disc\nt or   
r$uction ( ! price = a cov]$ "p ,d drug 
bel[ ! price negotiat$ "u p>agraph 7#a7 
or ! price e/abli%$ "u p>agraph 7#b74   
7#e7 ,no effect on exi/+ appeals process
 ,no?+ 9 ?is subsection %all be con/ru$ 
to affect ! appeals proc$ures "u        
subsections 7g7 & 7h7 ( section         
#ahfj;,d-#d4  4  7b7 ,effective date ,! 
am5dm5ts made by ?is section %all take  
effect on ! date ( ! enactm5t ( ?is ,act
 & %all fir/ apply to negotiations &    
prices = plan ye>s beg9n+ on ,janu>y #a1
 #bjbb4  #f4 ,enhancem5t ( premium      
assi/ance cr$it  7a7 ,use ( gold level  
plan = b5*m>k  7#a7 ,9 g5]al ,clause 7i7
 ( section #cf;,b7b77#b77;,b7 ( !       
,int]nal ,rev5ue ,code ( #aihf is am5d$ 

by /rik+ applicable second l[e/ co/     
silv] plan & ins]t+ applicable second   
l[e/ co/ gold plan4  7#b7 ,con=m+       
am5dm5t relat$ to af=dability ,section  
#cf;,b7c77#d77;,c77i77,i7 ( su* ,code is
 am5d$ by /rik+ second l[e/ co/ silv]   
plan & ins]t+ second l[e/ co/ gold plan4
  7#c7 ,o!r con=m+ am5dm5ts             
,subp>agraphs 7,b7 & 7,c7 ( section     
#cf;,b7b77#c7 ( su* ,code are ea* am5d$ 
by /rik+ silv] plan ea* place x appe>s 9
 ! text & ! head+ & ins]t+ gold plan4   
7b7 ,expansion ( eligibility =          
refundable cr$its = cov]age "u qualifi$ 
heal? plans  7#a7 ,9 g5]al ,section     
#cf;,b7c77#a77;,a7 ( ! ,int]nal ,rev5ue 
,code ( #aihf is am5d$ by /rik+ #djj    
p]c5t & ins]t+ #fjj p]c5t4  7#b7 ,con=m+
 am5dm5t ,! la/ l9e ( ! table conta9$ 9 
section #cf;,b7b77#c77;,a77i7 ( su*     
,code is am5d$ by /rik+ #djj & ins]t+   
#fjj4  7#c7 ,con=m+ am5dm5ts relat+ to  
recapture ( excess advanc$ paym5ts      
,clause 7i7 ( section #cf;,b7f77#b77;,b7
 ( su* ,code is am5d$-- 7,a7 by /rik+   

#djj p]c5t & ins]t+ #fjj p]c5t2 &  7,b7 
by /rik+ #djj 9 ! table !re9 & ins]t+   
#fjj4  7c7 ,elim9ation ( failsafe       
,section #cf;,b7b77#c77;,a77ii7 ( !     
,int]nal ,rev5ue ,code ( #aihf is am5d$ 
by /rik+ subclause 7,,iii74  7d7        
,effective date ,! am5dm5ts made by ?is 
section %all apply to taxable ye>s      
beg9n+ aft] ,decemb] #ca1 #bjbj4  #g4   
,enhancem5ts = r$uc$ co/ %>+  7a7       
,def9ition ( eligible individual        
,section #adjb7;b77#a7 ( ! ,pati5t      
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjga7;b77#a77 is am5d$ by   
/rik+ silv] level & ins]t+ gold level4  
7b7 ,modification ( am\nt  7#a7 ,9 g5]al
 ,section #adjb7;c77#b7 ( ! ,pati5t     
,protection & ,af=dable ,c>e ,act is    
am5d$ to read z foll[s3  7#b7           
,additional r$uction ,! ,secret>y %all  
e/abli% proc$ures "u :i* ! issu] ( a    
qualifi$ heal? plan to :i* ?is section  
applies %all fur!r r$uce co/-%>+ "u !   
plan 9 a mann] suffici5t to-- 7,a7 9 !  
case ( an eligible insur$ ^: h\sehold   

income is n less ?an #ajj p]c5t b n m   
?an #acc p]c5t ( ! pov]ty l9e = a family
 ( ! size involv$1 increase ! plan's %>e
 ( ! total all[$ co/s ( b5efits provid$ 
"u ! plan to #id p]c5t ( su* co/s2  7,b7
 9 ! case ( an eligible insur$ ^:       
h\sehold income is m ?an #acc p]c5t b n 
m ?an #aej p]c5t ( ! pov]ty l9e = a     
family ( ! size involv$1 increase !     
plan's %>e ( ! total all[$ co/s (       
b5efits provid$ "u ! plan to #ib p]c5t (
 su* co/s2  7,c7 9 ! case ( an eligible 
insur$ ^: h\sehold income is m ?an #aej 
p]c5t b n m ?an #bjj p]c5t ( ! pov]ty   
l9e = a family ( ! size involv$1        
increase ! plan's %>e ( ! total all[$   
co/s ( b5efits provid$ "u ! plan to #ij 
p]c5t ( su* co/s2  7,d7 9 ! case ( an   
eligible insur$ ^: h\sehold income is m 
?an #bjj p]c5t b n m ?an #cjj p]c5t ( ! 
pov]ty l9e = a family ( ! size involv$1 
increase ! plan's %>e ( ! total all[$   
co/s ( b5efits provid$ "u ! plan to #he 
p]c5t ( su* co/s2 &  7,e7 9 ! case ( an 
eligible insur$ ^: h\sehold income is m 

?an #cjj p]c5t b n m ?an #djj p]c5t ( ! 
pov]ty l9e = a family ( ! size involv$1 
increase ! plan's %>e ( ! total all[$   
co/s ( b5efits provid$ "u ! plan to #hj 
p]c5t ( su* co/s4  4  7#b7 ,con=m+      
am5dm5t ,clause 7i7 ( section           
#adjb7;c77#a77;,b7 ( su* ,act is am5d$  
to read z foll[s3  7i7 ,9 g5]al ,!      
,secret>y %all ensure ! r$uction "u ?is 
p>agraph %all n result 9 an increase 9 !
 plan's %>e ( ! total all[$ co/s (      
b5efits provid$ "u ! plan above-- 7,i7  
#id p]c5t 9 ! case ( an eligible insur$ 
describ$ 9 p>agraph 7#b77;,a72  7,,ii7  
#ib p]c5t 9 ! case ( an eligible insur$ 
describ$ 9 p>agraph 7#b77;,b72  7,,iii7 
#ij p]c5t 9 ! case ( an eligible insur$ 
describ$ 9 p>agraph 7#b77;,c72  7,,iv7  
#he p]c5t 9 ! case ( an eligible insur$ 
describ$ 9 p>agraph 7#b77;,d72 &  7,v7  
#hj p]c5t 9 ! case ( an eligible insur$ 
describ$ 9 p>agraph 7#b77;,e74  4  7c7  
,effective date ,! am5dm5ts made by ?is 
section %all apply to plan ye>s beg9n+  
aft] ,decemb] #ca1 #bjba4  #h4          

,re9surance & af=dability fund ,"p #e ( 
subtitle ,d ( title ,i ( ! ,pati5t      
,protection & ,af=dable ,c>e ,act is    
am5d$ by ins]t+ aft] section #acda 7#db 
,u4,s4,c4 #ahjfa7 ! foll[+3  #acda;,a4  
,re9surance & af=dability fund = !      
individual m>ket 9 ea* ,/ate  7a7 ,9    
g5]al ,! ,secret>y1 9 consultation ) !  
,national ,association ( ,insurance     
,commission]s1 %all e/abli% a program to
 enable ea* ,/ate1 = any plan ye> beg9n+
 9 ! #c-ye> p]iod beg9n+ ,janu>y #a1    
#bjbb1 to-- 7#a7 provide re9surance     
paym5ts to heal? insurance issu]s )     
respect to individuals enroll$ "u       
individual heal? insurance cov]age (f]$ 
by su* issu]s2 or  7#b7 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]$ 9 ! individual m>ket ?r\gh an
 ,ex*ange4  7b7 ,appropriations ,!re is 
appropriat$1 out ( any money 9 !        

,treasury n o!rwise appropriat$1        
#cj1jjj1jjj1jjj = ! p]iod ( fiscal ye>s 
#bjbb to #bjbd = purposes ( e/abli%+ &  
adm9i/]+ ! program e/abli%$ "u ?is      
section4 ,su* am\nt %all rema9 available
 until exp5d$4  4  #i4 ,exp&+ rat+ rules
 to l>ge gr\p m>ket  7a7 ,9 g5]al       
,section #bgja7;a7 ( ! ,public ,heal?   
,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg7a77 
is am5d$-- 7#a7 9 p>agraph 7#a71 by     
/rik+ small2 &  7#b7 by /rik+ p>agraph  
7#e74  7b7 ,effective date ,! am5dm5ts  
made by subsection 7a7 %all apply to    
plans (f]$ 9 ! fir/ plan ye> beg9n+ aft]
 ! date ( enactm5t ( ?is ,act & any plan
 ye> !reaft]4  #aj4 ,protection (       
consum]s f excessive1 unju/ifi$1 or     
unfairly discrim9atory rates  7a7       
,protection f excessive1 unju/ifi$1 or  
unfairly discrim9atory rates ,! fir/    
section #bgid ( ! ,public ,heal? ,s]vice
 ,act 7#db ,u4,s4,c4 #cjj;gg-#id71 z    
add$ by section #ajjc ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act       
7,public ,law #aaa-adh71 is am5d$ by    

add+ at ! end ! foll[+ new subsection3  
7e7 ,protection f excessive1 unju/ifi$1 
or unfairly discrim9atory rates  7#a7   
,au?ority ( ,/ates ,no?+ 9 ?is section  
%all be con/ru$ to prohibit a ,/ate f   
impos+ requirem5ts 7includ+ requirem5ts 
relat+ to rate review /&>ds & proc$ures 
& in=mation report+7 on heal? insurance 
issu]s ) respect to rates t are 9       
addition to ! requirem5ts ( ?is section 
& are m protective ( consum]s ?an su*   
requirem5ts4  7#b7 ,consultation 9 rate 
review process ,9 c>ry+ out ?is section1
 ! ,secret>y %all consult ) ! ,national 
,association ( ,insurance ,commission]s 
& consum] gr\ps4  7#c7 ,det]m9ation ( :o
 conducts reviews = ea* ,/ate ,!        
,secret>y %all det]m9e1 aft] ! date (   
enactm5t ( ?is subsection & p]iodically 
!reaft]1 ! foll[+3 7,a7 ,9 :i* m>kets 9 
ea* ,/ate ! ,/ate insurance commission] 
or relevant ,/ate regulator %all        
und]take ! corrective actions "u        
p>agraph 7#d71 bas$ on ! ,secret>y's    
det]m9ation t ! ,/ate insurance         

commission] or relevant ,/ate regulator 
is adequately und]tak+ & utiliz+ su*    
actions 9 t m>ket4  7,b7 ,9 :i* m>kets 9
 ea* ,/ate ! ,secret>y %all und]take !  
corrective actions "u p>agraph 7#d71 9  
coop]ation ) ! relevant ,/ate insurance 
commission] or ,/ate regulator1 bas$ on 
! ,secret>y's det]m9ation t ! ,/ate is n
 adequately und]tak+ & utiliz+ su*      
actions 9 t m>ket4  7#d7 ,corrective    
action = excessive1 unju/ifi$1 or       
unfairly discrim9atory rates ,9         
accordance ) ! process e/abli%$ "u ?is  
section1 ! ,secret>y or ! relevant ,/ate
 insurance commission] or ,/ate         
regulator %all take corrective actions  
to ensure t any excessive1 unju/ifi$1 or
 unfairly discrim9atory rates are       
correct$ prior to implem5tation1 or z   
soon z possible !reaft]1 ?r\gh me*anisms
 su* z-- 7,a7 d5y+ rates2  7,b7 modify+ 
rates2 or  7,c7 requir+ rebates to      
consum]s4  7#e7 ,noncompliance ,failure 
to comply ) any corrective action tak5  
by ! ,secret>y "u ?is subsection may    

result 9 ! application ( civil monet>y  
p5alties &1 if ! ,secret>y det]m9es     
appropriate1 make ! plan involv$        
ineligible = classification z a qualifi$
 heal? plan4  4  7b7 ,cl>ification (    
,regulatory ,au?ority ,su* section is   
fur!r am5d$-- 7#a7 9 subsection 7a7--   
7,a7 9 ! subsection head+1 by /rik+     
premium & ins]t+ rate2  7,b7 9 p>agraph 
7#a71 by /rik+ unreasonable increases 9 
premiums & ins]t+ pot5tially excessive1 
unju/ifi$1 or unfairly discrim9atory    
rates1 includ+ premiums12 &  7,c7 9     
p>agraph 7#b7-- 7i7 by /rik+ an         
unreasonable premium increase & ins]t+ a
 pot5tially excessive1 unju/ifi$1 or    
unfairly discrim9atory rate2  7ii7 by   
/rik+ ! increase & ins]t+ ! rate2 &     
7iii7 by /rik+ su* increases & ins]t+   
su* rates2 &  7#b7 9 subsection 7b7--   
7,a7 9 ! subsection head+1 by /rik+     
,premium & ins]t+ ,rate2  7,b7 by /rik+ 
premium increases ea* place x appe>s &  
ins]t+ rates2  7,c7 9 p>agraph 7#a71 9 !
 p>agraph head+1 by /rik+ ,premium      

,increase & ins]t+ ,rate2 &  7,d7 9     
p>agraph 7#b7-- 7i7 9 ! p>agraph head+1 
by /rik+ ,premium ,increases & ins]t+   
,rates2 &  7ii7 9 subp>agraph 7,b71 by  
/rik+ premium & ins]t+ rate4  7c7       
,con=m+ am5dm5ts  7#a7 ,public ,heal?   
,s]vice ,act ,title ,,xxvii ( ! ,public 
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg et seq47 is am5d$-- 7,a7 9      
section #bgbc 7#db ,u4,s4,c4            
#cjj;gg-#bb7-- 7i7 9 subsection 7a7--   
7,i7 9 p>agraph 7#a71 by ins]t+ 1       
section #bgid 7relat+ to ensur+ t       
consum]s get value = _! doll>s71 aft]   
?is "p2 &  7,,ii7 9 p>agraph 7#b71 by   
ins]t+ 1 su* section #bgid1 aft] ?is "p2
 &  7ii7 9 subsection 7b7-- 7,i7 9      
p>agraph 7#a71 by ins]t+ 1 section #bgid
 7relat+ to ensur+ t consum]s get value 
= _! doll>s71 aft] ?is "p2 &  7,,ii7 9  
p>agraph 7#b7-- 7aa7 9 subp>agraph 7,a71
 by ins]t+ 1 su* section #bgid1 aft] ?is
 "p2 &  7bb7 9 subp>agraph 7,c77ii71 by 
ins]t+ 1 su* section #bgid1 aft] ?is "p2
 &  7,b7 9 section #bgfa 7#db ,u4,s4,c4 

#cjj;gg-#fa7-- 7i7 9 subsection 7a7--   
7,i7 9 p>agraph 7#a71 by ins]t+ &       
section #bgid 7relat+ to ensur+ t       
consum]s get value = _! doll>s7 aft] ?is
 "p2 &  7,,ii7 9 p>agraph 7#b7-- 7aa7 by
 ins]t+ or su* section #bgid aft] set =?
 9 ?is "p2 &  7bb7 by ins]t+ & su*      
section #bgid aft] ! requirem5ts ( ?is  
"p2 &  7ii7 9 subsection 7b71 by ins]t+ 
& su* section #bgid aft] ?is "p4  7#b7  
,pati5t ,protection & ,af=dable ,c>e    
,act ,section #acaa7;e77#b7 ( ! ,pati5t 
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjca7;e77#b77 is am5d$ by   
/rik+ unju/ifi$ premium increases &     
ins]t+ unju/ifi$ rates4  7d7            
,applicability to gr&fa!r$ plans        
,section #abea7;a77#d77;,a7 ( ! ,pati5t 
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjaa7;a77#d77;,a77 is am5d$ 
by add+ at ! end ! foll[+3  7v7 ,section
 #bgid 7relat+ to ensur+ t consum]s get 
value = _! doll>s74  4  7e7 ,effective  
date ,! am5dm5ts made by ?is section    
%all take effect on ! date ( enactm5t ( 

?is ,act & %all be implem5t$ ) respect  
to heal? plans beg9n+ n lat] ?an ,janu>y
 #a1 #bjbb4  #aa4 ,s5se ( ,congress ,x  
is ! s5se ( ! ,congress t-- 7#a7 !      
,f$]al ,gov]nm5t1 act+ 9 its capacity z 
an insur]1 employ]1 or heal? c>e        
provid]1 %\ld s]ve z a model = ! ,nation
 to ensure cov]age ( all reproductive   
s]vices2 &  7#b7 all re/rictions on     
cov]age ( reproductive s]vices 9 !      
private insurance m>ket %\ld end4