,i  #aah? ,,congress  #a/ ,session  ,h4 
,r4 #cjjd  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,april #bh1 #bjbc     
,mrs4 ,flet*] introduc$ ! foll[+ bill2  
:i* 0 ref]r$ to ! ,committee on ,ways & 
,means1 & 9 addition to ! ,committee on 
,en]gy & ,comm]ce1 = a p]iod to be      
subsequ5tly det]m9$ by ! ,speak]1 9 ea* 
case = consid]ation ( su* provisions z  
fall )9 ! jurisdiction ( ! committee    
conc]n$  ,a ,,bill  ,to am5d ! ,int]nal 
,rev5ue ,code ( #aihf to provide = a    
tempor>y expansion ( heal? insurance    
premium tax cr$its = c]ta9 l[-income    
populations1 & to am5d title ,,xix ( !  
,social ,security ,act to e/abli% a     
,f$]al ,m$icaid program4  #a4 ,%ort     
title ,?is ,act may be cit$ z !         
,af=dable ,c>e ,cov]age ,expansion &    
,support = ,/ates ,act or ! ,,access    
,act4  #b4 ,tempor>y expansion ( heal?  
insurance premium tax cr$its = c]ta9    
l[-income populations  7a7 ,9 g5]al     
,section #cf;,b ( ! ,int]nal ,rev5ue    
,code ( #aihf is am5d$ by r$esignat+    

subsection 7h7 z subsection 7i7 & by    
ins]t+ aft] subsection 7g7 ! foll[+ new 
subsection3  7h7 ,c]ta9 tempor>y rules  
beg9n+ 9 #bjbd ,) respect to any taxable
 ye> beg9n+ aft] ,decemb] #ca1 #bjbc1 & 
be=e ,janu>y #a1 #bjbg-- 7#a7           
,eligibility = cr$it n limit$ bas$ on   
income ,subsection 7c77#a77;,a7 %all be 
disreg>d$ 9 det]m9+ :e!r a taxpay] is an
 applicable taxpay]4  7#b7 ,cr$it all[$ 
to c]ta9 l[-income employees (f]$       
employ]-provid$ cov]age ,subclause      
7,,ii7 ( subsection 7c77#b77;,c77i7 %all
 n apply if ! taxpay]'s h\sehold income 
does n exce$ #ach p]c5t ( ! pov]ty l9e =
 a family ( ! size involv$4 ,subclause  
7,,ii7 ( subsection 7c77#b77;,c77i7 %all
 also n apply to an individual describ$ 
9 ! la/ s5t5ce ( su* subsection if !    
taxpay]'s h\sehold income does n exce$  
#ach p]c5t ( ! pov]ty l9e = a family ( !
 size involv$4  7#c7 ,cr$it all[$ to    
c]ta9 l[-income employees (f]$ qualifi$ 
small employ] heal? reimbursem5t        
arrangem5ts ,a qualifi$ small employ]   

heal? reimbursem5t arrangem5t %all n be 
treat$ z con/itut+ af=dable cov]age = an
 employee 7or any sp\se or dep5d5t ( su*
 employee7 = any mon?s ( a taxable ye>  
if ! employee's h\sehold income = su*   
taxable ye> does n exce$ #ach p]c5t ( ! 
pov]ty l9e = a family ( ! size involv$4 
7#d7 ,limitations on recapture  7,a7 ,9 
g5]al ,9 ! case ( a taxpay] ^: h\sehold 
income is less ?an #bjj p]c5t ( ! pov]ty
 l9e = ! size ( ! family involv$ = !    
taxable ye>1 ! am\nt ( ! increase "u    
subsection 7f77#b77;,a7 %all 9 no ev5t  
exce$ #cjj 7"o-half ( su* am\nt 9 ! case
 ( a taxpay] ^: tax is det]m9$ "u       
section #a7;c7 = ! taxable ye>74  7,b7  
,limitation on increase = c]ta9         
non-fil]s ,9 ! case ( any taxpay] :o    
w\ld n be requir$ to file a return ( tax
 = ! taxable ye> b = any requirem5t to  
reconcile advance cr$it paym5ts "u      
subsection 7f71 if an ,ex*ange e/abli%$ 
"u title ,i ( ! ,pati5t ,protection &   
,af=dable ,c>e ,act has det]m9$ t--  7i7
 su* taxpay] is eligible = advance      

paym5ts "u section #adab ( su* ,act =   
any portion ( su* taxable ye>1 &  7ii7  
su* taxpay]'s h\sehold income = su*     
taxable ye> is project$ to n exce$ #ach 
p]c5t ( ! pov]ty l9e = a family ( ! size
 involv$1  subsection 7f77#b77;,a7 %all 
n apply to su* taxpay] = su* taxable ye>
 & su* taxpay] %all n be requir$ to file
 su* return ( tax4  7,c7 ,in=mation     
provid$ by ,ex*ange ,! in=mation requir$
 to be provid$ by an ,ex*ange to !      
,secret>y & to ! taxpay] "u subsection  
7f77#c7 %all include su* in=mation z is 
necess>y to det]m9e :e!r su* ,ex*ange   
has made ! det]m9ations describ$ 9      
clauses 7i7 & 7ii7 ( subp>agraph 7,b7 ) 
respect to su* taxpay]4  4  7b7 ,employ]
 %>$ responsibility provision n         
applicable ) respect to c]ta9 l[-,income
 taxpay]s receiv+ premium assi/ance     
,section #dihj;,h7c77#c7 is am5d$ to    
read z foll[s3  7#c7 ,applicable premium
 tax cr$it & co/-%>+ r$uction  7,a7 ,9  
g5]al ,! t]m applicable premium tax     
cr$it & co/-%>+ r$uction means-- 7i7 any

 premium tax cr$it all[$ "u section     
#cf;,b1  7ii7 any co/-%>+ r$uction "u   
section #adjb ( ! ,pati5t ,protection & 
,af=dable ,c>e ,act1 &  7iii7 any       
advance paym5t ( su* cr$it or r$uction  
"u section #adab ( su* ,act4  7,b7      
,exception ) respect to c]ta9 l[-income 
taxpay]s ,su* t]m %all n include any    
premium tax cr$it1 co/-%>+ r$uction1 or 
advance paym5t o!rwise describ$ 9       
subp>agraph 7,a7 if su* cr$it1 r$uction1
 or paym5t is all[$ or paid = a taxable 
ye> ( an employee 7beg9n+ aft] ,decemb] 
#ca1 #bjbc1 & be=e ,janu>y #a1 #bjbg7 ) 
respect to :i*-- 7i7 an ,ex*ange        
e/abli%$ "u title ,i ( ! ,pati5t        
,protection & ,af=dable ,c>e ,act has   
det]m9$ t su* employee's h\sehold income
 = su* taxable ye> is project$ to n     
exce$ #ach p]c5t ( ! pov]ty l9e = a     
family ( ! size involv$1 or  7ii7 su*   
employee's h\sehold income = su* taxable
 ye> does n exce$ #ach p]c5t ( ! pov]ty 
l9e = a family ( ! size involv$4  4  7c7
 ,effective date ,! am5dm5ts made by ?is

 section %all apply to taxable ye>s     
beg9n+ aft] ,decemb] #ca1 #bjbc4  #c4   
,clos+ ! ,m$icaid cov]age gap  7a7      
,f$]al ,m$icaid program ,to close       
cov]age gap 9 nonexpansion ,/ates ,title
 ,,xix ( ! ,social ,security ,act 7#db  
,u4,s4,c4 #acif et seq47 is am5d$ by    
add+ at ! end ! foll[+ new section3     
#aidh4 ,f$]al ,m$icaid program to close 
cov]age gap 9 nonexpansion ,/ates  7a7  
,e/abli%m5t ,9 ! case ( a ,/ate t !     
,secret>y det]m9es 7bas$ on ! ,/ate plan
 "u ?is title1 waiv] ( su* plan1 or o!r 
relevant in=mation7 is n expect$ to     
exp5d am\nts "u ! ,/ate plan 7or waiv] (
 su* plan7 = all individuals describ$ 9 
section #aijb7;a77#aj77;,a77i77,,viii7  
dur+ a ye> 7beg9n+ ) #bjbg7 79 ?is      
section def9$ z a cov]age gap ,/ate1 )  
respect to su* ye>71 ! ,secret>y %all   
7includ+ ?r\gh contract ) eligible      
entities 7z specifi$ by ! ,secret>y71   
consi/5t ) subsection 7b77 provide = !  
(f]+ to su* individuals resid+ 9 su*    
,/ate ( a heal? b5efits plan 79 ?is     

section ref]r$ to z ! ,f$]al ,m$icaid   
program or ! ,program71 = ea* qu>t] dur+
 ! p]iod beg9n+ on ,janu>y #a ( su* ye>1
 & end+ ) ! la/ day ( ! fir/ qu>t] dur+ 
:i* ! ,/ate provides m$ical assi/ance to
 all su* individuals "u ! ,/ate plan 7or
 waiv] ( su* plan74 ,"u ! ,f$]al        
,m$icaid program1 ! ,secret>y--  7#a7   
may use ! ,f$]ally ,facilitat$          
,m>ketplace to facilitate eligibility   
det]m9ations & enrollm5ts "u ! ,f$]al   
,m$icaid ,program & %all e/abli% a set (
 eligibility rules to be appli$ "u !    
,program 9 a mann] consi/5t ) section   
#aijb7;e77#ad72 &  7#b7 %all e/abli%    
b5efits1 b5efici>y protections1 & access
 to c>e /&>ds by1 at a m9imum--  7,a7   
e/abli%+ a m9imum set ( b5efits to be   
provid$ 7& provid+ su* b5efits7 "u !    
,f$]al ,m$icaid program1 :i* %all be 9  
compliance ) ! requirem5ts ( section    
#aicg & %all consi/ ( b5*m>k cov]age    
describ$ 9 section #aicg7;b77#a7 or     
b5*m>k equival5t cov]age describ$ 9     
section #aicg7;b77#b7 to ! same ext5t z 

m$ical assi/ance provid$ to su* an      
individual "u ?is title 7)\t application
 ( ?is section7 is requir$ "u section   
#aijb7k77#a7 to consi/ ( su* b5*m>k     
cov]age or b5*m>k equival5t cov]age2    
7,b7 apply+ ! provisions ( sections     
#aijb7;a77#h71 #aijb7;a77#cd7 7:i* may  
be appli$ 9 accordance ) su* phas$-9    
implem5tation z ! ,secret>y deems       
necess>y1 b beg9n+ z soon z             
practicable71 & #aidc ) respect to su*  
an individual1 b5efits "u ! ,f$]al      
,m$icaid program1 & mak+ application =  
su* b5efits 7:i* may be 9 accordance ) a
 phas$-9 implem5tation z ! ,secret>y    
deems necess>y1 b beg9n+ z soon z       
practicable7 9 ! same mann] z su*       
provisions w\ld apply to su* an         
individual1 m$ical assi/ance "u ?is     
title 7o!r ?an pursuant to ?is section71
 & mak+ application = su* m$ical        
assi/ance "u ?is title 7o!r ?an pursuant
 to ?is section72 & provid+ t           
r$et]m9ations & appeals ( eligibility & 
cov]age det]m9ations ( s]vices 7includ+ 

b5efit r$uctions1 t]m9ations1 &         
susp5sion7 %all be conduct$ "u ! ,f$]al 
,m$icaid program 9 accordance ) a ,f$]al
 fair he>+ process e/abli%$ by !        
,secret>y t is subject to ! same        
requirem5ts z appli$ ) respect to       
r$et]m9ations & appeals ( eligibility1 &
 ) respect to cov]age ( s]vices 7includ+
 b5efit r$uctions1 t]m9ations1 &        
susp5sion71 "u a ,/ate plan "u ?is title
 & t may provide = su* fair he>+s relat$
 to d5ials ( eligibility 7bas$ on       
modifi$ adju/$ gross income eligibility 
det]m9ations7 to be conduct$ ?r\gh !    
,f$]ally ,facilitat$ ,m>ketplace =      
,ex*anges2  7,c7 apply+1 9 accordance ) 
subsection 7d71 ! provisions ( section  
#aibg 7o!r ?an subp>agraphs 7,b7 & 7,c7 
( subsection 7b77#a7 ( su* section7 )   
respect to ! ,secret>y & paym5t "u !    
,f$]al ,m$icaid program = cov]$         
outpati5t drugs ) respect to a rebate   
p]iod 9 ! same mann] & to ! same ext5t z
 su* provisions apply ) respect to a    
,/ate & paym5t "u ! ,/ate plan = cov]$  

outpati5t drugs ) respect to ! rebate   
p]iod2 &  7,d7 apply+ ! provisions (    
sections #aijb7;a77#ad71 #aijb7;a77#bc71
 #aijb7;a77#dg71 & #aibj ?r\gh #aibj;,c 
7z applicable7 to ! ,f$]al ,m$icaid     
program & su* individuals enroll$ 9 su* 
program 9 ! same mann] & to ! same ext5t
 z su* provisions apply to a ,/ate plan 
& su* individuals eligible = m$ical     
assi/ance "u ! ,/ate plan1 & apply+ !   
provisions ( section #aijb7;a77#cj77;,a7
 ) respect to m$ical assi/ance available
 "u ! ,f$]al ,m$icaid program 9 ! same  
mann] & to ! same ext5t z su* provisions
 apply to m$ical assi/ance "u a ,/ate   
plan "u ?is title1 except t--  7i7 !    
,secret>y %all provide t no co/ %>+ %all
 be appli$ "u ! ,f$]al ,m$icaid program2
  7ii7 ! ,secret>y may waive !          
provisions ( subp>agraph 7,a7 ( section 
#aijb7;a77#bc7 to ! ext5t deem$         
appropriate to facilitate !             
implem5tation ( manag$ c>e2 &  7iii7 9  
apply+ ! provisions ( section           
#aijb7;a77#dg7 & sections #aibj ?r\gh   

#aibj;,c1 ! ,secret>y-- 7,i7 %all       
e/abli% a s+le presumptive eligibility  
process = individuals eligible "u !     
,f$]al ,m$icaid program1 "u :i* !       
,secret>y may contract ) entities to    
c>ry out su* process2 &  7,,ii7 may     
apply su* provisions & process 9        
accordance ) su* phas$-9 implem5tation z
 ! ,secret>y deems necess>y1 b beg9n+ z 
soon z practicable4  7b7 ,adm9i/ration (
 ,f$]al ,m$icaid program ?r\gh contracts
 ) ,m$icaid manag$ c>e organization &   
?ird p>ty plan adm9i/rator requirem5ts  
7#a7 ,9 g5]al ,= ! purpose ( adm9i/]+ ! 
b5efits "u ! ,program 7across all       
cov]age gap geographic areas 7z def9$ 9 
p>agraph 7#h777 to provide m$ical       
assi/ance to individuals describ$ 9     
section #aijb7;a77#aj77;,a77i77,,viii7  
enroll$ "u ! ,f$]al ,m$icaid program &  
resid+ 9 su* areas1 ! ,secret>y %all    
solicit bids describ$ 9 p>agraph 7#b7 & 
ent] into contracts ) a total ( at lea/ 
#b eligible entities 7z specifi$ by !   
,secret>y1 :i* may be a m$icaid manag$  

c>e organization 79 ?is section def9$ z 
includ+ a manag$ c>e organization       
describ$ 9 section                      
#aicb7;a77#a77;,b77i71 a prepaid        
inpati5t heal? plan1 & a prepaid        
ambulatory heal? plans 7z def9$ 9       
section #dch4b ( title #db1 ,code (     
,f$]al ,regulations771 a ?ird p>ty plan 
adm9i/rator1 or bo?74 ,an eligible      
entity ent]+ into a contract ) !        
,secret>y "u ?is p>agraph may adm9i/]   
su* b5efits z a ,m$icaid manag$ c>e     
organization 7z s def9$71 9 :i* case su*
 contract %all be 9 accordance )        
p>agraph 7#c7 ) respect to su*          
geographic area1 or z a ?ird-p>ty       
adm9i/rator1 9 :i* case su* contract    
%all be 9 accordance ) p>agraph 7#d7 )  
respect to su* geographic area4 ,!      
,secret>y may s contract ) a ,m$icaid   
manag$ c>e organization or ?ird p>ty    
plan adm9i/rator 9 ea* cov]age gap      
geographic area 7& may specify :i* type 
( eligible entity may bid ) respect to a
 cov]age gap geographic area or areas7 &

 may contract ) m ?an "o su* eligible   
entity 9 ! same cov]age gap geographic  
area4  7#b7 ,bids  7,a7 ,9 g5]al ,to be 
eligible to ent] into a contract "u ?is 
subsection1 = a ye>1 an entity %all     
submit 7at su* "t1 9 su* mann]1 &       
conta9+ su* in=mation z specifi$ by !   
,secret>y7 "o or m bids to adm9i/] !    
,program 9 "o or m cov]age gap          
geographic areas1 :i* reflects !        
project$ mon?ly co/ to ! entity (       
furni%+ b5efits "u ! ,program to an     
individual enroll$ "u ! ,program 9 su* a
 geographic area 7or areas7 = su* ye>4  
7,b7 ,selection ,9 select+ f bids       
submitt$ "u subp>agraph 7,a7 = purposes 
( ent]+ into contracts ) eligible       
entities "u ?is subsection1 ) respect to
 a cov]age gap geographic area1 !       
,secret>y %all take into acc\nt at lea/ 
ea* ( ! foll[+1 ) respect to ea* su*    
bid3  7i7 ,network adequacy 7z propos$ 9
 ! submitt$ bid74  7ii7 ,! am\nt1       
duration1 & scope ( b5efits 7su* z      
value-add$ s]vices (f]$ 9 ! submitt$    

bid71 z comp>$ to ! m9imum set ( b5efits
 e/abli%$ by ! ,secret>y "u subsection  
7a77#b77;,a74  7iii7 ,! am\nt ( ! bid1  
tak+ into acc\nt ! av]age p] memb] co/ (
 provid+ m$ical assi/ance "u ,/ate plans
 "u ?is title 7or waiv]s ( su* plans7 to
 individuals enroll$ 9 su* plans 7or    
waiv]s7 :o are at lea/ #ah ye>s ( age & 
resid+ 9 ! cov]age gap geographic area1 
z well z ! av]age co/ ( provid+ m$ical  
assi/ance "u ,/ate plans "u ?is title 7&
 waiv]s ( su* plans7 to individuals     
describ$ 9 section                      
#aijb7;a77#aj77;,a77i77,,viii74  7#c7   
,contract ) ,m$icaid manag$ c>e         
organization ,9 ! case ( a contract "u  
p>agraph 7#a7 betwe5 ! ,secret>y & an   
eligible entity adm9i/]+ b5efits "u !   
,program z a ,m$icaid manag$ c>e        
organization1 ) respect to "o or m      
cov]age gap geographic areas1 ! foll[+  
%all apply3  7,a7 ,! provisions (       
clauses 7i7 ?r\gh 7xi7 ( section        
#aijc7m77#b77;,a71 clause 7xii7 ( su*   
section 7to ! ext5t su* clause relates  

to subsections 7b7 & 7f7 ( section      
#aicb71 & clause 7xiii7 ( su* section   
#aijc7m77#b77;,a7 %all1 to ! greate/    
ext5t practicable1 apply to ! contract1 
to ! ,secret>y1 & to ! ,m$icaid manag$  
c>e organization1 ) respect to provid+  
m$ical assi/ance "u ! ,f$]al ,m$icaid   
program ) respect to su* area1 9 ! same 
mann] & to ! same ext5t z su* provisions
 apply to a contract "u section #aijc7m7
 betwe5 a ,/ate & an entity t is a      
,m$icaid manag$ c>e organization 7z     
def9$ 9 section #aijc7m77#a771 to !     
,/ate1 & to ! entity1 ) respect to      
provid+ m$ical assi/ance to individuals 
eligible = b5efits "u ?is title4  7,b7  
,! provisions ( section #aicb7;h7 %all  
apply to ! contract1 ,secret>y1 &       
,m$icaid manag$ c>e organization4  7,c7 
,! contract %all provide t ! entity pay 
claims 9 a timely mann] & 9 accordance )
 ! provisions ( section #aijb7;a77#cg74 
7,d7 ,! contract %all provide t !       
,secret>y %all make paym5ts "u ?is      
section to ! entity1 ) respect to       

cov]age ( ea* individual enroll$ "u !   
,program 9 su* a cov]age gap geographic 
area ) respect to :i* ! entity adm9i/]s 
! ,program 9 an am\nt specifi$ 9 !      
contract1 subject to subp>agraph        
7,d77ii7 & p>agraph 7#f74  7,e7 ,!      
contract %all require-- 7i7 !           
application ( a m9imum m$ical loss ratio
 7z calculat$ "u subsection 7d7 (       
section #dch4h ( title #db1 ,code (     
,f$]al ,regulations 7or any successor   
regulation77 = paym5t = m$ical assi/ance
 adm9i/]$ by ! manag$ c>e organization  
"u ! ,program1 ) respect to a ye>1 t is 
equal to or great] ?an #he p]c5t 7or su*
 high] p]c5t z specifi$ by ! ,secret>y72
 &  7ii7 9 ! case1 ) respect to a ye>1 !
 m9imum m$ical loss ratio 7z s          
calculat$7 = paym5t = s]vices "u !      
b5efits s adm9i/]$ is less ?an #he p]c5t
 7or su* high] p]c5t z specifi$ by !    
,secret>y "u clause 7i771 remittance by 
! organization to ! ,secret>y ( any     
paym5ts 7or portions ( paym5ts7 made to 
! organization "u ?is section 9 an am\nt

 equal to ! diff]5ce 9 paym5ts = m$ical 
assi/ance1 ) respect to ! ye>1 result+ f
 ! organization's failure to meet su*   
ratio = su* ye>4  7,f7 ,! contract %all 
require t ! eligible entity submit to ! 
,secret>y ! numb] ( individuals enroll$ 
9 ! ,program ) respect to ea* cov]age   
gap geographic area & mon? ) respect to 
:i* ! contract applies & su* additional 
in=mation z specifi$ by ! ,secret>y =   
purposes ( paym5t1 program integrity1   
ov]sight1 quality measurem5t1 or su* o!r
 purpose specifi$ by ! ,secret>y4  7,g7 
,! contract %all require t ! eligible   
entity p]=m any o!r activity id5tifi$ by
 ! ,secret>y4  7#d7 ,contract ) a ?ird  
p>ty plan adm9i/rator  7,a7 ,9 g5]al ,9 
! case ( a contract "u p>agraph 7#a7    
betwe5 ! ,secret>y & an eligible entity 
to adm9i/] ! ,program z a ?ird p>ty plan
 adm9i/rator1 ) respect to "o or m      
cov]age gap geographic areas1 su*       
contract %all provide t1 ) respect to   
m$ical assi/ance provid$ "u ! ,f$]al    
,m$icaid program to individuals :o are  

enroll$ 9 ! ,program ) respect to su*   
area 7or areas7--  7i7 ! ?ird p>ty plan 
adm9i/rator %all1 consi/5t ) su*        
requirem5ts z may be e/abli%$ by !      
,secret>y-- 7,i7 e/abli% provid]        
networks1 paym5t rates1 & utilization   
managem5t1 consi/5t ) ! provisions (    
section #aijb7;a77#cj77;,a71 z appli$ by
 subsection 7a77#d72  7,,ii7 pay claims 
9 a timely mann] & 9 accordance ) !     
provisions ( section #aijb7;a77#cg72    
7,,iii7 submit to ! ,secret>y ! numb] ( 
individuals enroll$ 9 ! ,program )      
respect to ea* cov]age gap geographic   
area & mon? ) respect to :i* ! contract 
applies & su* additional in=mation z    
specifi$ by ! ,secret>y = purposes (    
paym5t1 program integrity1 ov]sight1    
quality measurem5t1 or su* o!r purpose  
specifi$ by ! ,secret>y2 &  7,,iv7 p]=m 
any o!r activity id5tifi$ by !          
,secret>y2 &  7ii7 ! ,secret>y %all make
 paym5ts 7= ! claims submitt$ by ! ?ird 
p>ty plan adm9i/rator & = an economic & 
effici5t adm9i/rative fee7 "u ?is       

section to ! ?ird p>ty plan adm9i/rator1
 ) respect to cov]age ( ea* individual  
enroll$ "u ! ,program 9 a cov]age gap   
geographic area ) respect to :i* ! ?ird 
p>ty plan adm9i/rator adm9i/]s !        
,program 9 an am\nt det]m9$ "u !        
contract1 subject to subclause          
7,,vi77bb7 & p>agraph 7#g74  7,b7 ,?ird 
p>ty plan adm9i/rator def9$ ,= purposes 
( ?is section1 ! t]m ?ird p>ty plan     
adm9i/rator means an entity t satisfies 
su* requirem5ts z e/abli%$ by !         
,secret>y1 :i* %all include at lea/ t   
su* an entity adm9i/]s heal? plan       
b5efits1 pays claims "u ! plan1         
e/abli%es provid] networks1 sets paym5t 
rates1 & are n risk-be>+ entities4  7#e7
 ,adm9i/rative au?ority ,! ,secret>y may
 take su* actions z are necess>y to     
adm9i/] ?is subsection1 includ+ by sett+
 paym5t rates1 sett+ network adequacy   
/&>ds1 e/abli%+ quality requirem5ts1    
e/abli%+ report+ requirem5ts1 & specify+
 any o!r program requirem5ts or /&>ds   
necess>y 9 contract+ ) specifi$ entities

 "u ?is subsection1 & ov]see+ su*       
entities1 ) respect to ! adm9i/ration ( 
! ,f$]al ,m$icaid program4  7#f7        
,preemption ,9 c>ry+ out ! duties "u a  
contract ent]$ into "u p>agraph 7#a7    
betwe5 ! ,secret>y & a ,m$icaid manag$  
c>e organization or a ?ird p>ty plan    
adm9i/rator1 ) respect to a cov]age gap 
,/ate-- 7,a7 ! ,secret>y may e/abli%    
m9imum /&>ds & lic5sure requirem5ts =   
su* a ,m$icaid manag$ c>e organization  
or ?ird p>ty plan adm9i/rator = purposes
 ( c>ry+ out su* duties2 &  7,b7 any    
provisions ( law ( t ,/ate :i* relate to
 ! lic5s+ ( ! organization or           
adm9i/rator & :i* prohibit !            
organization or adm9i/rator f provid+   
cov]age pursuant to a contract "u ?is   
section %all be sup]s$$4  7#g7 ,p5alties
 ,9 ! case ( an eligible entity ) a     
contract "u ?is section t fails to      
comply ) ! requirem5ts ( su* entity     
pursuant to ?is section or su* contract1
 ! ,secret>y may )hold paym5t 7or any   
portion ( su* paym5t7 to su* entity "u  

?is section 9 accordance ) a process    
specifi$ by ! ,secret>y1 impose a       
corrective action plan on su* entity1 or
 impose a civil monet>y p5alty on su*   
entity 9 an am\nt n to exce$ #aj1jjj =  
ea* su* failure4 ,9 implem5t+ ?is       
p>agraph1 ! ,secret>y %all h !          
au?orities provid$ ! ,secret>y "u       
section #aicb7;e7 & subp>ts ,f & ,i ( "p
 #dch ( title #db1 ,code ( ,f$]al       
,regulations4  7#h7 ,cov]age gap        
geographic area ,= purposes ( ?is       
section1 ! t]m cov]age gap geographic   
area means an area ( "o or m cov]age gap
 ,/ates1 z specifi$ by ! ,secret>y1 or  
any area )9 su* a ,/ate1 z specifi$ by !
 ,secret>y4  7c7 ,p]iodic data mat*+ ,! 
,secret>y %all1 includ+ ?r\gh contract1 
p]iodically v]ify ! income ( an         
individual enroll$ 9 ! ,f$]al ,m$icaid  
program = a ye>1 be=e ! end ( su* ye>1  
to det]m9e if !re has be5 any *ange 9 ! 
individual's eligibility = b5efits "u ! 
program4 ,= purposes ( ! previ\s s5t5ce1
 ! ,secret>y may v]ify income ( an      

individual bas$ on ! prospective income 
( ! individual = su* ye> or bas$ on     
curr5t mon?ly income ( ! individual1 z  
specifi$ by ! ,secret>y4 ,9 ! case t1   
pursuant to su* v]ification1 an         
individual is det]m9$ to h _h a *ange 9 
income t results 9 su* individual no    
long] be includ$ z an individual        
describ$ 9 section                      
#aijb7;a77#aj77;,a77i77,,viii71 !       
,secret>y %all apply ! same processes & 
protections z ,/ates are requir$ "u ?is 
title to apply ) respect to an          
individual :o is det]m9$ to h _h a *ange
 9 income t results 9 su* individual no 
long] be+ includ$ z eligible = m$ical   
assi/ance "u ?is title 7o!r ?an pursuant
 to ?is section74  7d7 ,drug rebates ,= 
purposes ( subsection 7a77#b77;,b71 9   
apply+ section #aibg1 ! ,secret>y %all  
7ei!r directly or ?r\gh contracts7--    
7#a7 require an eligible entity ) a     
contract "u subsection 7b7 to report !  
data requir$ to be report$ "u section   
#aibg7;b77#b7 by a ,/ate ag5cy & require

 su* entity to submit to ! ,secret>y    
rebate data1 utilization data1 & any o!r
 in=mation t w\ld o!rwise be requir$ "u 
section #aibg to be submitt$ to !       
,secret>y by a ,/ate2  7#b7 %all take   
su* actions z are necess>y & develop or 
adapt su* processes & me*anisms z are   
necess>y to report & collect data z is  
necess>y & to bill & track rebates "u   
section #aibg1 z appli$ pursuant to     
subsection 7a77#b77;,b7 = drugs t are   
provid$ "u ! ,f$]al ,m$icaid program2   
7#c7 provide t ! cov]age requirem5ts (  
prescription drugs "u ! ,f$]al ,m$icaid 
program comply ) ! cov]age requirem5ts  
section #aibg2 &  7#d7 require t 9 ord] 
= paym5t to be available "u ! ,f$]al    
,m$icaid program or "u section #aijc7;a7
 = cov]$ outpati5t drugs ( a            
manufactur]1 ! manufactur] mu/ h ent]$  
into & h 9 effect a rebate agreem5t to  
provide rebates "u section #aibg to !   
,f$]al ,m$icaid program 9 ! same =m &   
mann] z ! manufactur] is requir$ to     
provide rebates "u an agreem5t describ$ 

9 section #aibg7;b7 to a ,/ate ,m$icaid 
program "u ?is title4  7e7 ,transitions 
7#a7 ,f ,ex*ange plans onto ,f$]al      
,m$icaid program ,! ,secret>y %all      
provide = a process "u :i*1 9 ! case (  
individuals describ$ 9 section          
#aijb7;a77#aj77;,a77i77,,viii7 :o are   
enroll$ 9 qualifi$ heal? plans ?r\gh an 
,ex*ange 9 a cov]age gap ,/ate1 !       
,secret>y takes su* /eps z are necess>y 
to transition su* individuals to cov]age
 "u ! ,f$]al ,m$icaid program4 ,su*     
process %all apply proc$ures describ$ 9 
section #aidc7;b77#a77;,c7 to scre5 =   
eligibility & enrollm5t "u ! ,f$]al     
,m$icaid program 9 ! same mann] z su*   
proc$ures scre5 = eligibility &         
enrollm5t "u qualifi$ heal? plans ?r\gh 
an ,ex*ange e/abli%$ "u title ,i ( !    
,pati5t ,protection & ,af=dable ,c>e    
,act4  7#b7 ,9 case cov]age gap ,/ate   
beg9s provid+ cov]age "u ,/ate plan ,!  
,secret>y %all provide = a process =1 9 
! case ( a cov]age gap ,/ate 9 :i* !    
,/ate beg9s to provide m$ical assi/ance 

to individuals describ$ 9 section       
#aijb7;a77#aj77;,a77i77,,viii7 "u !     
,/ate plan 7or waiv] ( su* plan7 & !    
,f$]al ,m$icaid program ceases to be    
(f]$1 transition+ individuals f su*     
program to ! ,/ate plan 7or waiv]71 z   
eligible1 includ+ a process =           
transition+ all eligibility             
r$et]m9ations4  7f7 ,coord9ation ) &    
enrollm5t ?r\gh ,ex*anges ,! ,secret>y  
%all take su* actions z are necess>y to 
provide1 9 ! case ( a cov]age gap ,/ate 
9 :i* ! ,f$]al ,m$icaid program is (f]$1
 = ! availability ( in=mation on1       
det]m9ations ( eligibility =1 &         
enrollm5t 9 su* program ?r\gh &         
coord9at$ ) ! ,ex*ange e/abli%$ )       
respect to su* ,/ate "u title ,i ( !    
,pati5t ,protection & ,af=dable ,c>e    
,act4  7g7 ,?ird p>ty liability ,!      
provisions ( section #aijb7;a77#be7 %all
 apply ) respect to ! ,f$]al ,m$icaid   
program1 ! ,secret>y1 & ! eligible      
entities ) a contract "u subsection 7b7 
9 ! same mann] z su* provisions apply ) 

respect to ,/ate plans "u ?is title 7or 
waiv] ( su* plans7 & ! ,/ate or local   
ag5cy adm9i/]+ su* plan 7or waiv]74 ,!  
,secret>y may specify a timel9e 7:i* may
 include a phase-97 = implem5t+ ?is     
subsection4  7h7 ,fraud ,& ,abuse       
,provisions ,provisions ( law 7o!r ?an  
crim9al law provisions7 id5tifi$ by !   
,secret>y by regulation1 9 consultation 
7z appropriate7 ) ! ,inspector ,g5]al ( 
! ,dep>tm5t ( ,heal? & ,human ,s]vices1 
t impose sanctions ) respect to wa/e1   
fraud1 & abuse "u ?is title or title    
,,xi1 su* z ! ,false ,claims ,act1 z    
well z provisions ( law 7o!r ?an crim9al
 law provisions7 id5tifi$ by ! ,secret>y
 t provide ov]sight au?ority1 %all also 
apply to ! ,f$]al ,m$icaid program4  7i7
 ,ma9t5ance ( ef=t  7#a7 ,paym5t  7,a7  
,9 g5]al ,9 ! case ( a ,/ate t1 z (     
,janu>y #a1 #bjbg1 is exp5d+ am\nts =   
all individuals describ$ 9 section      
#aijb7;a77#aj77;,a77i77,,viii7 "u !     
,/ate plan 7or waiv] ( su* plan7 & t    
/ops exp5d+ am\nts = all su* individuals

 "u ! ,/ate plan 7or waiv] ( su* plan71 
su* ,/ate %all = ea* qu>t] beg9n+ aft]  
,janu>y #a1 #bjbg1 dur+ :i* su* ,/ate   
does n exp5d am\nts = all su*           
individuals provide = paym5t "u ?is     
subsection to ! ,secret>y ( ! product   
(-- 7i7 #aj p]c5t (1 subject to         
subp>agraph 7,b71 ! av]age mon?ly p]    
capita co/s exp5d$ "u ! ,/ate plan 7or  
waiv] ( su* plan7 = su* individuals dur+
 ! mo/ rec5t previ\s qu>t] ) respect to 
:i* ! ,/ate exp5d$ am\nts = all su*     
individuals2 &  7ii7 ! sum1 = ea* mon?  
dur+ su* qu>t]1 ( ! numb] ( individuals 
enroll$ "u su* program 9 su* ,/ate4     
7,b7 ,annual increase ,= purposes (     
subp>agraph 7,a71 9 ! case ( a ,/ate )  
respect to :i* su* subp>agraph applies )
 respect to a p]iod ( consecutive qu>t]s
 occurr+ dur+ m ?an "o cal5d> ye>1 = su*
 consecutive qu>t]s occurr+ dur+ !      
second ( su* cal5d> ye>s or a subsequ5t 
cal5d> ye>1 ! av]age mon?ly p] capita   
co/s = ea* su* qu>t] = su* ,/ate det]m9$
 "u subp>agraph 7,a77i71 or ?is         

subp>agraph1 %all be annually increas$  
by ! ,secret>y by ! p]c5tage increase 9 
,m$icaid sp5d+ "u ?is title dur+ !      
prec$+ ye> 7z det]m9$ bas$ on ! mo/     
rec5t ,national ,heal? ,exp5diture data 
) respect to su* ye>74  7#b7 ,=m & mann]
 ( paym5t ,paym5t "u p>agraph 7#a7 %all 
be made 9 a =m & mann] specifi$ by !    
,secret>y4  7#c7 ,compliance ,if a ,/ate
 fails to pay to ! ,secret>y an am\nt   
requir$ "u p>agraph 7#a71 int]e/ %all   
accrue on su* am\nt at ! rate provid$ "u
 section #aijc7;d77#e74 ,! am\nt s ow$ &
 applicable int]e/ %all be imm$iately   
(fset aga9/ am\nts o!rwise payable to ! 
,/ate "u section #aijc7;a71 9 accordance
 ) ! ,f$]al ,claims ,collection ,act (  
#aiif & applicable regulations4  7#d7   
,data mat* ,! ,secret>y %all p]=m su*   
p]iodic data mat*es z may be necess>y to
 id5tify & compute ! numb] ( individuals
 enroll$ "u ! ,f$]al ,m$icaid program "u
 section #aidh 9 a cov]age gap ,/ate 7z 
ref]5c$ 9 subsection 7a7 ( su* section7 
= purposes ( comput+ ! am\nt "u p>agraph

 7#a74  7#e7 ,notice ,! ,secret>y %all  
notify ea* ,/ate describ$ 9 p>agraph    
7#a7 n lat] ?an a date specifi$ by !    
,secret>y t is be=e ! beg9n+ ( ea* qu>t]
 7beg9n+ ) #bjbg7 ( ! am\nt comput$ "u  
p>agraph 7#a7 = ! ,/ate = t ye>4  7j7   
,appropriations ,!re is appropriat$1 out
 ( any funds 9 ! ,treasury n o!rwise    
appropriat$1 = ea* fiscal ye> su* sums z
 are necess>y to c>ry out subsections   
7a7 ?r\gh 7i7 ( ?is section4  4  7b7    
,drug rebate con=m+ am5dm5t ,section    
#aibg7;a77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acifr-#h7;a77#a77 is   
am5d$ 9 ! fir/ s5t5ce--  7#a7 by /rik+  
or "u "p ,b ( title ,,xviii & ins]t+ 1  
"u ! ,f$]al ,m$icaid program "u section 
#aidh1 or "u "p ,b ( title ,,xviii2 &   
7#b7 by ins]t+ includ+ z su* subsection 
is appli$ pursuant to subsections       
7a77#b77;,c7 & 7d7 ( section #aidh )    
respect to ! ,f$]al ,m$icaid program1   
be=e & mu/ meet4