,i #aah? ,,congress #a/ ,session ,h4 ,r4 #cdba ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,may #ag1 #bjbc,ms4 ,jayapal 7= h]self1 ,mrs4 ,d+ell1 ,ms4 ,adams1 ,ms4 ,bal9t1 ,ms4 ,b>ragn1 ,mr4 ,bey]1 ,mr4 ,blum5au]1 ,ms4 ,bonamici1 ,mr4 ,b[man1 ,mr4 ,boyle ( ,p5nsylvania1 ,ms4 ,br[n1 ,ms4 ,bu%1 ,mr4 ,c>bajal1 ,mr4 ,crd5as1 ,mr4 ,c>son1 ,mr4 ,c>t] ( ,l\isiana1 ,mr4 ,c>twright1 ,mr4 ,cas>1 ,mrs4 ,*]filus-,mc,cormick1 ,ms4 ,*u1 ,mr4 ,cicill9e1 ,ms4 ,cl>ke ( ,new ,york1 ,mr4 ,cleav]1 ,mr4 ,coh51 ,ms4 ,crockett1 ,mr4 ,davis ( ,ill9ois1 ,ms4 ,de,gette1 ,mr4 ,deluzio1 ,mr4 ,de,saulnier1 ,mr4 ,doggett1 ,ms4 ,escob>1 ,mr4 ,espaillat1 ,mrs4 ,f\%ee1 ,ms4 ,lois ,frankel ( ,florida1 ,mr4 ,fro/1 ,mr4 ,g>am5di1 ,mr4 ,rob]t ,g>cia ( ,cali=nia1 ,mr4 ,g>ca ( ,ill9ois1 ,mr4 ,goldman ( ,new ,york1 ,mr4 ,gomez1 ,mr4 ,gre5 ( ,texas1 ,mr4 ,grijalva1 ,mr4 ,h>d] ( ,cali=nia1 ,mrs4 ,hayes1 ,mr4 ,higg9s ( ,new ,york1 ,ms4 ,hoyle ( ,oregon1 ,mr4 ,huffman1 ,mr4 ,ivey1 ,mr4 ,jackson ( ,ill9ois1 ,ms4 ,jackson ,lee1 ,ms4 ,jacobs1 ,mr4 ,johnson ( ,georgia1 ,ms4 ,kamlag]-,dove1 ,mr4 ,keat+1 ,ms4 ,kelly ( ,ill9ois1 ,mr4 ,khanna1 ,ms4 ,lee ( ,cali=nia1 ,ms4 ,lee ( ,p5nsylvania1 ,ms4 ,leg] ,f]n&ez1 ,mr4 ,lev91 ,mr4 ,lieu1 ,ms4 ,mc,collum1 ,mr4 ,mc,garvey1 ,mr4 ,mc,govern1 ,mr4 ,meeks1 ,ms4 ,m5g1 ,mr4 ,mfume1 ,mr4 ,mull91 ,mr4 ,nadl]1 ,mrs4 ,napolitano1 ,mr4 ,neguse1 ,ms4 ,norton1 ,ms4 ,ocasio-,cortez1 ,ms4 ,om>1 ,mr4 ,pallone1 ,mr4 ,panetta1 ,mr4 ,payne1 ,ms4 ,p+ree1 ,mr4 ,pocan1 ,ms4 ,port]1 ,ms4 ,pressley1 ,mr4 ,quigley1 ,mrs4 ,ramirez1 ,mr4 ,rask91 ,mr4 ,sablan1 ,ms4 ,sal9as1 ,ms4 ,sn*ez1 ,mr4 ,s>banes1 ,ms4 ,s*ak[sky1 ,mr4 ,s*iff1 ,mr4 ,scott ( ,virg9ia1 ,mr4 ,%]man1 ,mr4 ,smi? ( ,wa%+ton1 ,ms4 ,/ansbury1 ,mr4 ,swalwell1 ,mr4 ,takano1 ,mr4 ,?an$>1 ,mr4 ,?ompson ( ,cali=nia1 ,mr4 ,?ompson ( ,mississippi1 ,ms4 ,titus1 ,ms4 ,tlaib1 ,ms4 ,tokuda1 ,mr4 ,tonko1 ,mr4 ,torres ( ,new ,york1 ,mrs4 ,trahan1 ,mr4 ,v>gas1 ,ms4 ,velzquez1 ,ms4 ,wat]s1 ,mrs4 ,watson ,coleman1 ,ms4 ,wild1 ,ms4 ,williams ( ,georgia1 ,ms4 ,wilson ( ,florida1 & ,ms4 ,l(gr57 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,ways & ,means1 ,education & ! ,work=ce1 ,rules1 ,ov]sight & ,acc\ntability1 ,arm$ ,s]vices1 & ! ,judici>y1 = 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 e/abli% an improv$ ,m$ic>e = ,all national heal? insurance program4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,m$ic>e = ,all ,act4 7b7 ,table ( cont5ts ,! table ( cont5ts ( ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4,title ,i--,e/abli%m5t ( ! ,m$ic>e = ,all ,program2 ,univ]sal ,cov]age2 ,enrollment,sec4 #aja4 ,e/abli%m5t ( ! ,m$ic>e = ,all ,program4,sec4 #ajb4 ,univ]sal cov]age4,sec4 #ajc4 ,fre$om ( *oice4,sec4 #ajd4 ,non-discrim9ation4,sec4 #aje4 ,enrollm5t4,sec4 #ajf4 ,effective date ( b5efits4,sec4 #ajg4 ,prohibition aga9/ duplicat+ cov]age4,title ,,ii--,compreh5sive ,b5efits1 ,includ+ ,prev5tive ,b5efits & ,b5efits = ,long-,t]m ,care,sec4 #bja4 ,compreh5sive b5efits4,sec4 #bjb4 ,no co/-%>+2 o!r limitations4,sec4 #bjc4 ,exclusions & limitations4,sec4 #bjd4 ,cov]age ( long-t]m c>e s]vices4,title ,,iii--,provid] ,participation,sec4 #cja4 ,provid] p>ticipation & /&>ds2 :i/lebl[] protections4,sec4 #cjb4 ,qualifications = provid]s4,sec4 #cjc4 ,use ( private contracts4,title ,,iv--,administration,subtitle ,a--,g5]al ,adm9i/ration ,provisions,sec4 #dja4 ,adm9i/ration4,sec4 #djb4 ,consultation4,sec4 #djc4 ,regional adm9i/ration4,sec4 #djd4 ,b5efici>y ombudsman4,sec4 #dje4 ,conduct ( relat$ heal? programs4,subtitle ,b--,control ,ov] ,fraud & ,abuse,sec4 #daa4 ,application ( ,f$]al sanctions to all fraud & abuse "u ! ,m$ic>e = ,all ,program4,title ,v--,quality ,assessment,sec4 #eja4 ,quality /&>ds4,sec4 #ejb4 ,address+ heal? c>e disp>ities4,title ,,vi--,heal? ,budget2 ,paym5ts2 ,co/ ,conta9m5t ,measures,subtitle ,a--,budgeting,sec4 #fja4 ,national heal? budget4,subtitle ,b--,paym5ts to ,providers,sec4 #faa4 ,paym5ts to in/itutional provid]s bas$ on global budgets4,sec4 #fab4 ,paym5t to individual provid]s ?r\gh fee-=-s]vice4,sec4 #fac4 ,ensur+ accurate valuation ( s]vices "u ! ,m$ic>e physician fee s*$ule4,sec4 #fad4 ,paym5t prohibitions2 capital exp5ditures2 special projects4,sec4 #fae4 ,(fice ( ,heal? ,equity4,sec4 #faf4 ,(fice ( ,prim>y ,c>e4,sec4 #fag4 ,paym5ts = prescription drugs & approv$ devices & equipm5t4,title ,,vii--,univ]sal ,m$ic>e ,tru/ ,fund,sec4 #gja4 ,univ]sal ,m$ic>e ,tru/ ,fund4,title ,,viii--,con=m+ ,am5dm5ts to ! ,employee ,retirem5t ,income ,security ,act ( #aigd,sec4 #hja4 ,prohibition ( employee b5efits duplicative ( b5efits "u ! ,m$ic>e = ,all ,program2 coord9ation 9 case ( work]s' comp5sation4,sec4 #hjb4 ,application ( cont9uation cov]age requirem5ts "u ,,erisa & c]ta9 o!r requirem5ts relat+ to gr\p heal? plans4,sec4 #hjc4 ,effective date ( title4,title ,,ix--,additional ,con=m+ ,amendments,sec4 #ija4 ,relation%ip to exi/+ ,f$]al heal? programs4,sec4 #ijb4 ,sunset ( provisions relat$ to ! ,/ate ,ex*anges4,sec4 #ijc4 ,sunset ( provisions relat$ to pay = p]=mance programs4,title ,x--,transition,subtitle ,a--,m$ic>e = ,all ,transition ov] #b ,ye>s & ,transitional ,buy-,9 ,option,sec4 #ajja4 ,m$ic>e = all transition ov] two ye>s4,sec4 #ajjb4 ,e/abli%m5t ( ! ,m$ic>e transition buy-94,subtitle ,b--,transitional ,m$ic>e ,reforms,sec4 #ajaa4 ,elim9at+ ! #bd-mon? wait+ p]iod = ,m$ic>e cov]age = individuals ) disabilities4,sec4 #ajab4 ,ensur+ cont9uity ( c>e4,title ,,xi--,miscellaneous,sec4 #aaja4 ,def9itions4,sec4 #aajb4 ,rules ( con/ruction4,sec4 #aajc4 ,no use ( res\rces = law en=cem5t ( c]ta9 regi/ration requirem5ts4 ,i ,e/abli%m5t ( ! ,m$ic>e = ,all ,program2 ,univ]sal ,cov]age2 ,enrollm5t #aja4 ,e/abli%m5t ( ! ,m$ic>e = ,all ,program ,!re is h]eby e/abli%$ a national heal? insurance program to provide compreh5sive protection aga9/ ! co/s ( heal? c>e & heal?-relat$ s]vices1 9 accordance ) ! /&>ds specifi$ 91 or e/abli%$ "u1 ?is ,act4 #ajb4 ,univ]sal cov]age 7a7 ,9 g5]al ,e individual :o is a resid5t ( ! ,unit$ ,/ates is entitl$ to b5efits = heal? c>e s]vices "u ?is ,act4 ,! ,secret>y %all promulgate a rule t provides crit]ia = det]m9+ resid5cy = eligibility purposes "u ?is ,act4 7b7 ,treatm5t ( o!r individuals ,! ,secret>y may make eligible = b5efits = heal? c>e s]vices "u ?is ,act o!r individuals n describ$ 9 subsection 7a71 & regulate ! eligibility ( su* individuals1 to ensure t e p]son 9 ! ,unit$ ,/ates has access to heal? c>e4 ,9 regulat+ su* eligibility1 ! ,secret>y %all ensure t individuals are n all[$ to travel to ! ,unit$ ,/ates = ! sole purpose ( obta9+ heal? c>e items & s]vices provid$ "u ! program e/abli%$ "u ?is ,act4 #ajc4 ,fre$om ( *oice ,any individual entitl$ to b5efits "u ?is ,act may obta9 heal? s]vices f any in/itution1 ag5cy1 or individual qualifi$ to p>ticipate "u ?is ,act4 #ajd4 ,non-discrim9ation 7a7 ,9 g5]al ,no p]son %all1 on ! basis ( race1 color1 national orig91 age1 disability1 m>ital /atus1 citiz5%ip /atus1 prim>y language use1 g5etic conditions1 previ\s or exi/+ m$ical conditions1 religion1 or sex1 includ+ sex /]eotyp+1 g5d] id5tity1 sexual ori5tation1 & pregnancy & relat$ m$ical conditions 7includ+ t]m9ation ( pregnancy71 be exclud$ f p>ticipation 9 or be d5i$ ! b5efits ( ! program e/abli%$ "u ?is ,act 7except z expressly au?oriz$ by ?is ,act = purposes ( en=c+ eligibility /&>ds describ$ 9 section #ajb71 or be subject to any r$uction ( b5efits or o!r discrim9ation by any p>ticipat+ provid] 7z def9$ 9 section #cja71 or any entity conduct+1 adm9i/]+1 or fund+ a heal? program or activity1 includ+ contracts ( insurance1 pursuant to ?is ,act4 7b7 ,claims ( discrim9ation 7#a7 ,9 g5]al ,! ,secret>y %all e/abli% a proc$ure = adjudication ( adm9i/rative compla9ts alleg+ a violation ( subsection 7a74 7#b7 ,jurisdiction ,any p]son aggriev$ by a violation ( subsection 7a7 by a cov]$ entity may file suit 9 any di/rict c\rt ( ! ,unit$ ,/ates hav+ jurisdiction ( ! p>ties4 ,a p]son may br+ an action "u ?is p>agraph concurr5tly z su* adm9i/rative rem$ies z e/abli%$ 9 p>agraph 7#a74 7#c7 ,damages ,if ! c\rt f9ds a violation ( subsection 7a71 ! c\rt may grant comp5satory & punitive damages1 decl>atory relief1 injunctive relief1 attorneys' fees & co/s1 or o!r relief z appropriate4 7c7 ,cont9u$ application ( laws ,no?+ 9 ?is title 7or an am5dm5t made by ?is title7 %all be con/ru$ to invalidate or o!rwise limit any ( ! rights1 rem$ies1 proc$ures1 or legal /&>ds available to individuals aggriev$ "u section #aeeg ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahaaf71 title ,,vi ( ! ,civil ,rights ,act ( #aifd 7#db ,u4,s4,c4 #bjjj;d et seq471 title ,,vii ( ! ,civil ,rights ,act ( #aifd 7#db ,u4,s4,c4 #bjjj;e et seq471 title ,,ix ( ! ,education ,am5dm5ts ( #aigb 7#bj ,u4,s4,c4 #afha et seq471 section #ejd ( ! ,rehabilitation ,act ( #aigc 7#bi ,u4,s4,c4 #gid71 or ! ,age ,discrim9ation ,act ( #aige 7#db ,u4,s4,c4 #faa et seq474 ,no?+ 9 ?is title 7or an am5dm5t to ?is title7 %all be con/ru$ to sup]s$e ,/ate laws t provide additional protections aga9/ discrim9ation on any basis describ$ 9 subsection 7a74 #aje4 ,enrollm5t 7a7 ,9 g5]al ,! ,secret>y %all provide a me*anism = ! enrollm5t ( individuals eligible = b5efits "u ?is ,act4 ,! me*anism %all-- 7#a7 include a process = ! automatic enrollm5t ( individuals at ! "t ( bir? 9 ! ,unit$ ,/ates 7or ^u e/abli%m5t ( resid5cy 9 ! ,unit$ ,/ates72 7#b7 provide = ! enrollm5t1 z ( ! dates describ$ 9 section #ajf1 ( all individuals :o are eligible to be enroll$ z ( su* dates1 z applicable2 & 7#c7 include a process = ! enrollm5t ( individuals made eligible = heal? c>e s]vices "u section #ajb7;b74 7b7 ,issuance ( ,univ]sal ,m$ic>e c>ds ,9 conjunction ) an individual's enrollm5t = b5efits "u ?is ,act1 ! ,secret>y %all provide = ! issuance ( a ,univ]sal ,m$ic>e c>d t %all be us$ = purposes ( id5tification & process+ ( claims = b5efits "u ?is program4 ,! c>d %all n include an individual's ,social ,security numb]4 #ajf4 ,effective date ( b5efits 7a7 ,9 g5]al ,except z provid$ 9 subsection 7b71 b5efits %all fir/ be available "u ?is ,act = items & s]vices furni%$ #b ye>s aft] ! date ( ! enactm5t ( ?is ,act4 7b7 ,cov]age = c]ta9 individuals 7#a7 ,9 g5]al ,= any eligible individual :o-- 7,a7 has n yet atta9$ ! age ( #ai z ( ! date t is #a ye> aft] ! date ( ! enactm5t ( ?is ,act2 or 7,b7 has atta9$ ! age ( #ee z ( ! date t is #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 b5efits %all fir/ be available "u ?is ,act = items & s]vices furni%$ z ( su* date4 7#b7 ,option to cont9ue 9 o!r cov]age dur+ transition p]iod ,any p]son :o is eligible to receive b5efits z describ$ 9 p>agraph 7#a7 may opt to ma9ta9 any cov]age describ$ 9 section #ija1 private heal? insurance cov]age1 or cov]age (f]$ pursuant to subtitle ,a ( title ,x 7includ+ ! am5dm5ts made by su* subtitle7 until ! date describ$ 9 subsection 7a74 #ajg4 ,prohibition aga9/ duplicat+ cov]age 7a7 ,9 g5]al ,beg9n+ on ! effective date describ$ 9 section #ajf7;a71 x %all be unlawful =-- 7#a7 a private heal? insur] to sell heal? insurance cov]age t duplicates ! b5efits provid$ "u ?is ,act2 or 7#b7 an employ] to provide b5efits = an employee1 =m] employee1 or ! dep5d5ts ( an employee or =m] employee t duplicate ! b5efits provid$ "u ?is ,act4 7b7 ,con/ruction ,no?+ 9 ?is ,act %all be con/ru$ z prohibit+ ! sale ( heal? insurance cov]age = any additional b5efits n cov]$ by ?is ,act1 includ+ additional b5efits t an employ] may provide to employees or _! dep5d5ts1 or to =m] employees or _! dep5d5ts4 ,,ii ,compreh5sive ,b5efits1 ,includ+ ,prev5tive ,b5efits & ,b5efits = ,long-,t]m ,c>e #bja4 ,compreh5sive b5efits 7a7 ,9 g5]al ,subject to ! o!r provisions ( ?is title & titles ,,iv ?r\gh ,,ix1 individuals enroll$ = b5efits "u ?is ,act are entitl$ to h paym5t made by ! ,secret>y to an eligible provid] = ! foll[+ items & s]vices if m$ically necess>y or appropriate = ! ma9t5ance ( heal? or = ! diagnosis1 treatm5t1 or rehabilitation ( a heal? condition3 7#a7 ,hospital s]vices1 includ+ inpati5t & outpati5t hospital c>e1 includ+ #bd-;h\r-a-day em]g5cy s]vices & inpati5t prescription drugs4 7#b7 ,ambulatory pati5t s]vices4 7#c7 ,prim>y & prev5tive s]vices1 includ+ *ronic disease managem5t4 7#d7 ,prescription drugs & m$ical devices1 includ+ outpati5t prescription drugs1 m$ical devices1 & biological products1 & all contraceptive items approv$ by ! ,food & ,drug ,adm9i/ration4 7#e7 ,m5tal heal? & sub/ance use treatm5t s]vices1 includ+ inpati5t c>e4 7#f7 ,laboratory & diagno/ic s]vices4 7#g7 ,compreh5sive reproductive c>e1 includ+ abortion1 contraception1 & assi/ive reproductive te*nology4 7#h7 ,mat]nity & newborn c>e4 7#i7 ,compreh5sive g5d] affirm+ heal? c>e4 7#aj7 ,oral heal?1 audiology1 & vision s]vices4 7#aa7 ,rehabilitative & habilitative s]vices & devices4 7#ab7 ,em]g5cy s]vices & transportation4 7#ac7 ,e>ly & p]iodic scre5+1 diagno/ic1 & treatm5t s]vices1 z describ$ 9 sections #aijb7;a77#aj77;,a71 #aijb7;a77#dc71 #aije7;a77#d77;,b71 & #aije7r7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#aj77;,a72 #acif;a7a77#dc72 #acif;d7a77#d77;,b72 #acif;d7r774 7#ad7 ,necess>y transportation to receive heal? c>e s]vices = p]sons ) disabilities1 old] individuals ) functional limitations1 or l[-income individuals 7z det]m9$ by ! ,secret>y74 7#ae7 ,long-t]m c>e s]vices & support 7z describ$ 9 section #bjd74 7#af7 ,hospice c>e4 7#ag7 ,s]vices provid$ by a lic5s$ m>riage & family !rapi/ or a lic5s$ m5tal heal? c\nselor4 7#ah7 ,any s]vice describ$ 9 a prec$+ p>agraph t is furni%$ via teleheal?1 to ! ext5t practical4 7b7 ,revision ,! ,secret>y %all1 at lea/ annually1 & on a regul> basis1 evaluate :e!r ! b5efits package %\ld be improv$ to promote ! heal? ( b5efici>ies1 acc\nt = *anges 9 m$ical practice or new in=mation f m$ical rese>*1 or respond to o!r relevant developm5ts 9 heal? sci5ce1 & %all make recomm5dations to ,congress reg>d+ any su* improvem5ts4 ,su* recomm5dations may n include a recomm5dation to elim9ate any b5efit4 7c7 ,he>+s 7#a7 ,9 g5]al ,! ,committee on ,en]gy & ,comm]ce & ! ,committee on ,ways & ,means ( ! ,h\se ( ,repres5tatives %all1 n less frequ5tly ?an annually1 hold a he>+ on ! recomm5dations submitt$ by ! ,secret>y "u subsection 7b74 7#b7 ,ex]cise ( rulemak+ au?ority ,p>agraph 7#a7 is enact$-- 7,a7 z an ex]cise ( rulemak+ p[] ( ! ,h\se ( ,repres5tatives1 &1 z su*1 %all be consid]$ z "p ( ! rules ( ! ,h\se1 & su* rules %all sup]s$e any o!r rule ( ! ,h\se only to ! ext5t t rule is inconsi/5t !re)2 & 7,b7 ) full recognition ( ! con/itutional "r ( ei!r ,h\se to *ange su* rules 7s f> z relat+ to ! proc$ure 9 su* ,h\se7 at any "t1 9 ! same mann]1 & to ! same ext5t z 9 ! case ( any o!r rule ( ! ,h\se4 7d7 ,complem5t>y & ,integrative ,m$ic9e 7#a7 ,9 g5]al ,9 c>ry+ out subsection 7b71 ! ,secret>y %all consult ) ! p]sons describ$ 9 p>agraph 7#b7 ) respect to-- 7,a7 id5tify+ specific complem5t>y & integrative m$ic9e practices t are appropriate to include 9 ! b5efits package2 & 7,b7 id5tify+ b>ri]s to ! effective provision & integration ( su* practices into ! deliv]y ( heal? c>e1 & id5tify+ me*anisms = ov]com+ su* b>ri]s4 7#b7 ,consultation ,9 accordance ) p>agraph 7#a71 ! ,secret>y %all consult )-- 7,a7 ! ,director ( ! ,national ,c5t] = ,complem5t>y & ,integrative ,heal?2 7,b7 ! ,commission] ( ,food & ,drugs2 7,c7 in/itutions ( high] education1 private rese>* in/itutes1 & individual rese>*]s ) ext5sive exp]i5ce 9 complem5t>y & alt]native m$ic9e & ! integration ( su* practices into ! deliv]y ( heal? c>e2 7,d7 nationally recogniz$ provid]s ( complem5t>y & integrative m$ic9e2 & 7,e7 su* o!r (ficials1 entities1 & individuals ) exp]tise on complem5t>y & integrative m$ic9e z ! ,secret>y det]m9es appropriate4 7e7 ,/ates may provide additional b5efits ,individual ,/ates may provide additional b5efits = ! resid5ts ( su* ,/ates1 z det]m9$ by su* ,/ate1 & may provide b5efits to individuals n eligible = b5efits "u ?is ,act1 at ! exp5se ( ! ,/ate1 subject to ! requirem5ts specifi$ 9 section #aajb4 #bjb4 ,no co/-%>+2 o!r limitations 7a7 ,9 g5]al ,! ,secret>y %all ensure t no co/-%>+1 includ+ d$uctibles1 co9surance1 copaym5ts1 or simil> *>ges1 is impos$ on an individual = any b5efits provid$ "u ?is ,act4 7b7 ,no balance bill+ ,no provid] may impose a *>ge to an enroll$ individual = cov]$ s]vices = :i* b5efits are provid$ "u ?is ,act4 7c7 ,no prior au?orization ,b5efits provid$ "u ?is ,act %all be cov]$ )\t any ne$ = any prior au?orization det]m9ation & )\t any limitation appli$ ?r\gh ! use ( /ep !rapy protocols4 #bjc4 ,exclusions & limitations 7a7 ,9 g5]al ,b5efits = items & s]vices are n available "u ?is ,act unless ! items & s]vices meet ! /&>ds develop$ by ! ,secret>y pursuant to section #bja7;a74 7b7 ,treatm5t ( exp]im5tal items & s]vices & drugs 7#a7 ,9 g5]al ,9 apply+ subsection 7a71 ! ,secret>y %all make national cov]age det]m9ations ) respect to items & s]vices t are exp]im5tal 9 nature4 ,su* det]m9ations %all be consi/5t ) ! national cov]age det]m9ation process z def9$ 9 section #ahfi7;f77#a77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7f77#a77;,b774 7#b7 ,appeals process ,! ,secret>y %all e/abli% a process by :i* individuals c appeal cov]age decisions4 ,! process %all1 z mu* z is feasible1 foll[ ! process = appeals "u ! ,m$ic>e program describ$ 9 section #ahfi ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff74 7c7 ,application ( practice guidel9es 7#a7 ,9 g5]al ,9 ! case ( items & s]vices = :i* ! ,dep>tm5t ( ,heal? & ,human ,s]vices has recogniz$ a national practice guidel9e1 su* items & s]vices %all be deem$ to meet ! /&>ds specifi$ 9 section #bja7;a7 if !y h be5 provid$ 9 accordance ) su* guidel9e4 ,= purposes ( ?is subsection1 an item or s]vice n provid$ 9 accordance ) a practice guidel9e %all be deem$ to h be5 provid$ 9 accordance ) ! guidel9e if ! heal? c>e provid] provid+ ! item or s]vice-- 7,a7 ex]cis$ appropriate pr(essional judgm5t 9 accordance ) ! laws & requirem5ts ( ! ,/ate 9 :i* su* item or s]vice is furni%$ 9 deviat+ f ! guidel9e2 7,b7 act$ 9 ! be/ int]e/ ( ! individual receiv+ ! item or s]vice2 & 7,c7 act$ 9 a mann] consi/5t ) ! individual's wi%es4 7#b7 ,ov]ride ( /&>ds 7,a7 ,9 g5]al ,an individual's treat+ physician or o!r heal? c>e pr(essional au?oriz$ to ex]cise indep5d5t pr(essional judgm5t 9 implem5t+ a pati5t's m$ical or nurs+ c>e plan 9 accordance ) ! scope ( practice1 lic5sure1 & o!r law ( ! ,/ate :]e items & s]vices are to be furni%$ may ov]ride practice /&>ds e/abli%$ pursuant to section #bja7;a7 or practice guidel9es describ$ 9 p>agraph 7#a71 includ+ su* /&>ds & guidel9es t are implem5t$ by a provid] ?r\gh ! use ( heal? in=mation te*nology1 su* z electronic heal? record te*nology1 cl9ical decision support te*nology1 & comput]iz$ ord] entry programs4 7,b7 ,limitation ,an ov]ride describ$ 9 subp>agraph 7,a7 %all1 9 ! pr(essional judgm5t ( su* physician1 nurse1 or heal? c>e pr(essional1 be-- 7i7 consi/5t ) su* physician's1 nurse's1 or heal? c>e pr(essional's det]m9ation ( m$ical necessity & appropriat5ess or nurs+ assessm5t2 7ii7 9 ! be/ int]e/s ( ! individual2 & 7iii7 consi/5t ) ! individual's wi%es4 #bjd4 ,cov]age ( long-t]m c>e s]vices 7a7 ,9 g5]al ,subject to ! o!r provisions ( ?is ,act1 individuals enroll$ = b5efits "u ?is ,act are entitl$ to ! foll[+ long-t]m s]vices & supports & to h paym5t made by ! ,secret>y to an eligible provid] = su* s]vices & supports if m$ically necess>y & appropriate & 9 accordance ) ! /&>ds e/abli%$ 9 ?is ,act1 = ma9t5ance ( heal? or = c>e1 s]vices1 diagnosis1 treatm5t1 or rehabilitation t is relat$ to a m$ically det]m9able condition1 :e!r physical or m5tal1 ( heal?1 injury1 or age t-- 7#a7 causes a functional limitation 9 p]=m+ "o or m activities ( daily liv+2 or 7#b7 requires a simil> ne$ ( assi/ance 9 p]=m+ in/rum5tal activities ( daily liv+4 7b7 ,eligibility ,an individual %all be eligible = s]vices & supports describ$ 9 ?is section if su* individual has "o or m m$ically det]m9able conditions describ$ 9 subsection 7a74 7c7 ,s]vices & supports ,long-t]m s]vices & supports "u ?is section %all be tailor$ to an individual's ne$s1 z det]m9$ ?r\gh assessm5t1 & %all be def9$ by ! ,secret>y to-- 7#a7 include any long-t]m nurs+ s]vices = ! enrollee1 :e!r provid$ 9 an in/itution or 9 a home & community-bas$ sett+2 7#b7 provide cov]age = a broad spectrum ( long-t]m s]vices & supports1 includ+ = home & community-bas$ s]vices & o!r c>e provid$ ?r\gh non-in/itutional sett+s2 7#c7 provide cov]age t meets ! physical1 m5tal1 & social ne$s ( recipi5ts :ile all[+ recipi5ts _! maximum possible autonomy & _! maximum possible civic1 social1 & economic p>ticipation2 7#d7 prioritize deliv]y ( long-t]m s]vices & supports ?r\gh home & community-bas$ s]vices ov] in/itutionalization2 7#e7 unless an individual elects o!rwise1 ensure t recipi5ts w receive home & community bas$ long-t]m s]vices & supports 7z def9$ 9 subsection 7f77#d771 reg>dless ( ! individuals's type or level ( disability1 s]vice ne$1 or age2 7#f7 be provid$ ) ! goal ( enabl+ p]sons ) disabilities to receive s]vices 9 ! lea/ re/rictive & mo/ integrat$ sett+ appropriate to ! individual's ne$s2 7#g7 be provid$ 9 su* a mann] t all[s p]sons ) disabilities to ma9ta9 _! indep5d5ce1 self-det]m9ation1 & dignity2 7#h7 provide long-t]m s]vices & supports t are ( equal quality & equally accessible across geographic regions2 & 7#i7 ensure t long-t]m s]vices & supports provide recipi5t's ! option ( self-direction ( s]vices f ei!r ! recipi5t or c>e coord9ators ( ! recipi5t's *oos+4 7d7 ,public consultation ,9 develop+ regulations to implem5t ?is section1 ! ,secret>y %all consult ) an advisory commission on long-t]m s]vices & supports t includes-- 7#a7 p ) disabilities :o use long-t]m s]vices & supports & old] adults :o use long-t]m s]vices & supports2 7#b7 repres5tatives ( p ) disabilities & repres5tatives ( old] adults2 7#c7 gr\ps t repres5t ! div]sity ( ! population ( p liv+ ) disabilities1 includ+ racial1 e?nic1 national orig91 prim>y language use1 age1 sex1 includ+ g5d] id5tity & sexual ori5tation1 geographical1 & socioeconomic div]sity2 7#d7 provid]s ( long-t]m s]vices & supports1 includ+ family att5dants & family c>egiv]s1 & memb]s ( organiz$ labor2 7#e7 disability rights organizations2 & 7#f7 relevant academic in/itutions & rese>*]s4 7e7 ,budget+ & paym5ts ,budget+ & paym5ts = long-t]m s]vices & supports provid$ "u ?is section %all be made 9 accordance ) ! provisions "u title ,,vi4 7f7 ,def9itions ,9 ?is section3 7#a7 ,! t]m long-t]m s]vices & supports means long-t]m c>e1 treatm5t1 ma9t5ance1 or s]vices ne$$ to support ! activities ( daily liv+ & in/rum5tal activities ( daily liv+1 includ+ home & community-bas$ s]vices & any additional s]vices & supports id5tifi$ by ! ,secret>y to support p ) disabilities to live1 "w1 & p>ticipate 9 _! communities4 7#b7 ,! t]m activities ( daily liv+ means basic p]sonal ev]yday activities1 includ+ tasks su* z eat+1 toilet+1 groom+1 dress+1 ba?+1 & transf]r+4 7#c7 ,! t]m in/rum5tal activities ( daily liv+ means activities relat$ to liv+ indep5d5tly 9 ! community1 includ+ meal plann+ & prep>ation1 manag+ f9ances1 %opp+ = food1 clo?+1 & o!r ess5tial items1 p]=m+ ess5tial h\sehold *ores1 communicat+ by phone or o!r m$ia1 & travel+ ar\nd & p>ticipat+ 9 ! community4 7#d7 ,! t]m home & community-bas$ s]vices means ! home & community-bas$ s]vices t are cov]able "u subsections 7c71 7d71 7i71 & 7k7 ( section #aiae ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifn71 & z def9$ by ! ,secret>y1 includ+ z def9$ 9 ! home & community-bas$ s]vices sett+s rule 9 sections #dda4ecj & #dda4gaj ( title #db1 ,code ( ,f$]al ,regulations 7or a successor regulation74 ,,iii ,provid] ,p>ticipation #cja4 ,provid] p>ticipation & /&>ds2 :i/lebl[] protections 7a7 ,9 g5]al ,an individual or o!r entity furni%+ any cov]$ item or s]vice "u ?is ,act is n a qualifi$ provid] unless ! individual or entity-- 7#a7 is a qualifi$ provid] ( ! items or s]vices "u section #cjb2 7#b7 has fil$ ) ! ,secret>y a p>ticipation agreem5t describ$ 9 subsection 7b72 & 7#c7 meets1 z applicable1 su* o!r qualifications & conditions ) respect to a provid] ( s]vices "u title ,,xviii ( ! ,social ,security ,act z describ$ 9 section #ahff ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc74 7b7 ,requirem5ts 9 p>ticipation agreem5t 7#a7 ,9 g5]al ,a p>ticipation agreem5t describ$ 9 ?is subsection betwe5 ! ,secret>y & a provid] %all provide at lea/ = ! foll[+3 7,a7 ,items & s]vices to eligible p]sons %all be furni%$ by ! provid] )\t discrim9ation1 9 accordance ) section #ajd7;a74 ,no?+ 9 ?is subp>agraph %all be con/ru$ z requir+ ! provision ( a type or class ( items or s]vices t are outside ! scope ( ! provid]'s normal practice4 7,b7 ,no *>ge w be made to any enroll$ individual = any cov]$ items or s]vices o!r ?an = paym5t au?oriz$ by ?is ,act4 7,c7 ,! provid] agrees to furni% su* in=mation z may be reasonably requir$ by ! ,secret>y1 9 accordance ) uni=m report+ /&>ds e/abli%$ "u section #dja7;b77#a71 =-- 7i7 quality review by designat$ entities2 7ii7 mak+ paym5ts "u ?is ,act1 includ+ ! exam9ation ( records z may be necess>y = ! v]ification ( in=mation on :i* su* paym5ts are bas$2 7iii7 /ati/ical or o!r /udies requir$ = ! implem5tation ( ?is ,act2 & 7iv7 su* o!r purposes z ! ,secret>y may specify4 7,d7 ,9 ! case ( a provid] t is n an individual1 ! provid] agrees n to employ or use = ! provision ( heal? s]vices any individual or o!r provid] t has _h a p>ticipation agreem5t "u ?is subsection t]m9at$ = cause4 ,! ,secret>y may au?orize su* employm5t or use on a case-by-case basis4 7,e7 ,9 ! case ( a provid] paid "u a fee-=-s]vice basis = items & s]vices furni%$ "u ?is ,act1 ! provid] agrees to submit bills & any requir$ support+ docum5tation relat+ to ! provision ( cov]$ items & s]vices )9 #cj days aft] ! date ( provid+ su* items & s]vices4 7,f7 ,9 ! case ( an in/itutional provid] paid pursuant to section #faa1 ! provid] agrees to submit in=mation & any o!r requir$ support+ docum5tation z may be reasonably requir$ by ! ,secret>y )9 #cj days aft] ! date ( provid+ su* items & s]vices & 9 accordance ) ! uni=m report+ /&>ds e/abli%$ "u section #dja7;b77#a71 includ+ in=mation on a qu>t]ly basis t-- 7i7 relates to ! provision ( cov]$ items & s]vices2 & 7ii7 describes items & s]vices furni%$ ) respect to specific individuals4 7,g7 ,9 ! case ( a provid] t receives paym5t = items & s]vices furni%$ "u ?is ,act bas$ on diagnosis-relat$ cod+1 proc$ure cod+1 or o!r cod+ sy/em or data1 ! provid] agrees-- 7i7 to disclose to ! ,secret>y any sy/em or index ( cod+ or classify+ pati5t symptoms1 diagnoses1 cl9ical int]v5tions1 episodes1 or proc$ures t su* provid] utilizes = global budget negotiations "u title ,,vi or = meet+ any o!r paym5t1 docum5tation1 or data collection requirem5ts "u ?is ,act2 & 7ii7 n to use any su* sy/em or index to e/abli% f9ancial inc5tives or dis9c5tives = heal? c>e pr(essionals1 or t is propriet>y1 int]f]es ) ! m$ical or nurs+ process1 or is design$ to increase ! am\nt or numb] ( paym5ts4 7,h7 ,! provid] complies ) ! duty ( provid] e?ics & report+ requirem5ts describ$ 9 p>agraph 7#b74 7,i7 ,9 ! case ( a provid] t is n an individual1 ! provid] agrees t no bo>d memb]1 executive1 or adm9i/rator ( su* provid] receives comp5sation f1 owns /ock or has o!r f9ancial inve/m5ts 91 or s]ves z a bo>d memb] ( any entity t contracts ) or provides items or s]vices1 includ+ ph>maceutical products & m$ical devices or equipm5t1 to su* provid]4 7#b7 ,provid] duty ( e?ics ,ea* heal? c>e provid]1 includ+ in/itutional provid]s1 has a duty to advocate = & to act 9 ! exclusive int]e/ ( ea* individual "u ! c>e ( su* provid] accord+ to ! applicable legal /&>d ( c>e1 su* t no f9ancial int]e/ or relation%ip impairs any heal? c>e provid]'s ability to furni% necess>y & appropriate c>e to su* individual4 ,to implem5t ! duty e/abli%$ 9 ?is p>agraph1 ! ,secret>y %all-- 7,a7 promulgate reasonable report+ rules to evaluate p>ticipat+ provid] compliance ) ?is p>agraph2 7,b7 prohibit p>ticipat+ provid]s1 sp\ses1 & imm$iate family memb]s ( p>ticipat+ provid]s1 f accept+ or ent]+ into any arrangem5t = any bonus1 inc5tive paym5t1 pr(it-%>+1 or comp5sation bas$ on pati5t utilization or bas$ on f9ancial outcomes ( any o!r provid] or entity2 & 7,c7 prohibit p>ticipat+ provid]s or any bo>d memb] or repres5tative ( su* provid] f s]v+ z bo>d memb]s = or receiv+ any comp5sation1 /ock1 or o!r f9ancial inve/m5t 9 an entity t contracts ) or provides items or s]vices 7includ+ ph>maceutical products & m$ical devices or equipm5t7 to su* provid]4 7#c7 ,t]m9ation ( p>ticipation agreem5t 7,a7 ,9 g5]al ,p>ticipation agreem5ts may be t]m9at$1 ) appropriate notice-- 7i7 by ! ,secret>y = failure to meet ! requirem5ts ( ?is ,act2 7ii7 9 accordance ) ! provisions describ$ 9 section #daa2 or 7iii7 by a provid]4 7,b7 ,t]m9ation process ,provid]s %all be provid$ notice & a reasonable opportunity to correct defici5cies be=e ! ,secret>y t]m9ates an agreem5t unless a m imm$iate t]m9ation is requir$ = public safety or simil> reasons4 7,c7 ,provid] protections 7i7 ,prohibition ,! ,secret>y may n t]m9ate a p>ticipation agreem5t or 9 any o!r way discrim9ate aga9/1 or cause to be discrim9at$ aga9/1 any cov]$ provid] or au?oriz$ repres5tative ( ! provid]1 on acc\nt ( su* provid] or repres5tative-- 7,i7 provid+1 caus+ to be provid$1 or be+ ab\t to provide or cause to be provid$ to ! provid]1 ! ,f$]al ,gov]nm5t1 or ! attorney g5]al ( a ,/ate in=mation relat+ to any violation (1 or any act or omission ! provid] or repres5tative reasonably believes to be a violation (1 any provision ( ?is title 7or an am5dm5t made by ?is title72 7,,ii7 te/ify+ or be+ ab\t to te/ify 9 a proce$+ conc]n+ su* violation2 7,,iii7 assi/+ or p>ticipat+1 or be+ ab\t to assi/ or p>ticipate1 9 su* a proce$+2 or 7,,iv7 object+ to1 or refus+ to p>ticipate 91 any activity1 policy1 practice1 or assign$ task t ! provid] or repres5tative reasonably believes to be 9 violation ( any provision ( ?is ,act 7includ+ any am5dm5t made by ?is ,act71 or any ord]1 rule1 regulation1 /&>d1 or ban "u ?is ,act 7includ+ any am5dm5t made by ?is ,act74 7ii7 ,compla9t proc$ure ,a provid] or repres5tative :o believes t he or %e has be5 discrim9at$ aga9/ 9 violation ( ?is section may seek relief 9 accordance ) ! proc$ures1 notifications1 burd5s ( pro(1 rem$ies1 & /atutes ( limitation set =? 9 section #bjhg7;b7 ( title #ae1 ,unit$ ,/ates ,code4 7c7 ,:i/lebl[] protections 7#a7 ,retaliation prohibit$ ,no p]son may dis*>ge or o!rwise discrim9ate aga9/ any employee because ! employee or any p]son act+ pursuant to a reque/ ( ! employee-- 7,a7 notifi$ ! ,secret>y or ! employee's employ] ( any alleg$ violation ( ?is title1 includ+ communications relat$ to c>ry+ out ! employee's job duties2 7,b7 refus$ to engage 9 any practice made unlawful by ?is title1 if ! employee has id5tifi$ ! alleg$ illegality to ! employ]2 7,c7 te/ifi$ be=e or o!rwise provid$ in=mation relevant = ,congress or = any ,f$]al or ,/ate proce$+ reg>d+ any provision 7or propos$ provision7 ( ?is title2 7,d7 comm5c$1 caus$ to be comm5c$1 or is ab\t to comm5ce or cause to be comm5c$ a proce$+ "u ?is title2 7,e7 te/ifi$ or is ab\t to te/ify 9 any su* proce$+2 or 7,f7 assi/$ or p>ticipat$ or is ab\t to assi/ or p>ticipate 9 any mann] 9 su* a proce$+ or 9 any o!r mann] 9 su* a proce$+ or 9 any o!r action to c>ry out ! purposes ( ?is title4 7#b7 ,en=cem5t action ,any employee cov]$ by ?is section :o alleges discrim9ation by an employ] 9 violation ( p>agraph 7#a7 may br+ an action1 subject to ! /atute ( limitations 9 ! anti-retaliation provisions ( ! ,false ,claims ,act & ! rules & proc$ures1 legal burd5s ( pro(1 & rem$ies applicable "u ! employee protections provisions ( ! ,surface ,transportation ,assi/ance ,act4 7#c7 ,application 7,a7 ,no?+ 9 ?is subsection %all be con/ru$ to dim9i% ! rights1 privileges1 or rem$ies ( any employee "u any ,f$]al or ,/ate law or regulation1 includ+ ! rights & rem$ies aga9/ retaliatory action "u ! ,false ,claims ,act 7#ca ,u4,s4,c4 #cgcj7;h771 or "u any collective b>ga9+ agreem5t4 ,! rights & rem$ies 9 ?is section may n be waiv$ by any agreem5t1 policy1 =m1 or condition ( employm5t4 7,b7 ,no?+ 9 ?is subsection %all be con/ru$ to preempt or dim9i% any o!r ,f$]al or ,/ate law or regulation aga9/ discrim9ation1 demotion1 dis*>ge1 susp5sion1 ?reats1 h>assm5t1 reprim&1 retaliation1 or any o!r mann] ( discrim9ation1 includ+ ! rights & rem$ies aga9/ retaliatory action "u ! ,false ,claims ,act 7#ca ,u4,s4,c4 #cgcj7;h774 7#d7 ,def9itions ,9 ?is subsection3 7,a7 ,employ] ,! t]m employ] means any p]son engag$ 9 pr(it or nonpr(it bus9ess or indu/ry1 includ+ "o or m individuals1 p>tn]%ips1 associations1 corporations1 tru/s1 pr(essional memb]%ip organization includ+ a c]tification1 discipl9>y1 or o!r pr(essional body1 un9corporat$ organizations1 nongov]nm5tal organizations1 or tru/ees1 & subject to liability = violat+ ! provisions ( ?is ,act4 7,b7 ,employee ,! t]m employee means any individual p]=m+ activities "u ?is ,act on behalf ( an employ]4 #cjb4 ,qualifications = provid]s 7a7 ,9 g5]al ,a heal? c>e provid] is consid]$ to be qualifi$ to furni% cov]$ items & s]vices "u ?is ,act if ! provid] is lic5s$ or c]tifi$ to furni% su* items & s]vices 9 ! ,/ate 9 :i* ! individual receiv+ su* items or s]vices is locat$ & meets-- 7#a7 ! requirem5ts ( su* ,/ate's law to furni% su* items & s]vices2 & 7#b7 applicable requirem5ts ( ,f$]al law to furni% su* items & s]vices4 7b7 ,limitation ,an entity or provid] %all n be qualifi$ to furni% cov]$ items & s]vices "u ?is ,act if ! entity or provid] provides no items & s]vices directly to individuals1 includ+-- 7#a7 entities or provid]s t contract ) o!r entities or provid]s to provide su* items & s]vices2 & 7#b7 entities t are curr5tly approv$ to coord9ate c>e plans "u ! ,m$ic>e ,advantage program e/abli%$ 9 "p ,c ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #ahea et seq47 b d n directly provide items & s]vices ( su* c>e plans4 7c7 ,m9imum provid] /&>ds 7#a7 ,9 g5]al ,! ,secret>y %all e/abli%1 evaluate1 & update national m9imum /&>ds to ensure ! quality ( items & s]vices provid$ "u ?is ,act & to monitor ef=ts by ,/ates to ensure ! quality ( su* items & s]vices4 ,a ,/ate may e/abli% additional m9imum /&>ds :i* provid]s %all meet ) respect to items & s]vices provid$ 9 su* ,/ate4 7#b7 ,national m9imum /&>ds ,! ,secret>y %all e/abli% national m9imum /&>ds "u p>agraph 7#a7 = in/itutional provid]s ( s]vices & individual heal? c>e practition]s4 ,except z ! ,secret>y may specify 9 ord] to c>ry out ?is ,act1 a hospital1 skill$ nurs+ facility1 or o!r in/itutional provid] ( s]vices %all meet /&>ds applicable to su* a provid] "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq474 ,su* /&>ds also may include1 :]e appropriate1 elem5ts relat+ to-- 7,a7 adequacy & quality ( facilities2 7,b7 m&atory m9imum safe regi/]$ nurse-to-pati5t /aff+ ratios & optimal /aff+ levels = physicians & o!r heal? c>e practition]s2 7,c7 tra9+ & compet5ce ( p]sonnel 7includ+ requirem5ts relat$ to ! numb] ( or type ( requir$ cont9u+ education h\rs72 7,d7 compreh5siv5ess ( s]vice2 7,e7 cont9uity ( s]vice2 7,f7 pati5t wait+ "t1 access to s]vices1 & pref]5ces2 & 7,g7 p]=mance /&>ds1 includ+ organization1 facilities1 /ructure ( s]vices1 effici5cy ( op]ation1 & outcome 9 palliation1 improvem5t ( heal?1 /abilization1 cure1 or rehabilitation4 7#c7 ,transition 9 application ,if ! ,secret>y provides = additional requirem5ts = provid]s "u ?is subsection1 any su* additional requirem5t %all be implem5t$ 9 a mann] t provides = a reasonable p]iod dur+ :i* a previ\sly qualifi$ provid] is p]mitt$ to meet su* an additional requirem5t4 7#d7 ,ability to provide s]vices ,) respect to any entity or provid] c]tifi$ to provide items & s]vices describ$ 9 section #bja7;a77#g71 ! ,secret>y may n prohibit su* entity or provid] f p>ticipat+ = reasons o!r ?an su* entity's or provid]'s ability to provide su* items & s]vices4 7d7 ,f$]al provid]s ,any provid] qualifi$ to provide heal? c>e items & s]vices ?r\gh ! ,dep>tm5t ( ,vet]ans ,affairs1 ! ,indian ,heal? ,s]vice1 or ! uni=m$ s]vices 7) respect to ! direct c>e compon5t ( ! ,,tric>e ,program7 is a qualify+ provid] "u ?is section ) respect to any individual :o qualifies = su* items & s]vices "u applicable ,f$]al law4 #cjc4 ,use ( private contracts 7a7 ,9 g5]al ,?is section %all apply beg9n+ #b ye>s aft] ! date ( ! enactm5t ( ?is ,act4 7b7 ,p>ticipat+ provid]s 7#a7 ,private contracts = cov]$ items & s]vices = eligible individuals ,an in/itutional or individual provid] ) an agreem5t 9 effect "u section #cja may n bill or ent] into any private contract ) any individual eligible = b5efits "u ! ,act = any item or s]vice t is a b5efit "u ?is ,act4 7#b7 ,private contracts = noncov]$ items & s]vices = eligible individuals ,an in/itutional or individual provid] ) an agreem5t 9 effect "u section #cja may bill or ent] into a private contract ) an individual eligible = b5efits "u ! ,act = any item or s]vice t is n a b5efit "u ?is ,act only if-- 7,a7 ! contract & provid] meet ! requirem5ts specifi$ 9 p>agraphs 7#c7 & 7#d71 respectively2 7,b7 su* item or s]vice is n payable or available "u ?is ,act2 & 7,c7 ! provid] receives-- 7i7 no reimbursem5t "u ?is ,act directly or indirectly = su* item or s]vice1 & 7ii7 receives no am\nt = su* item or s]vice f an organization :i* receives reimbursem5t = su* items or s]vice "u ?is ,act directly or indirectly4 7#c7 ,contract requirem5ts ,any contract to provide items & s]vices describ$ 9 p>agraph 7#b7 %all-- 7,a7 be 9 writ+ & sign$ by ! individual 7or au?oriz$ repres5tative ( ! individual7 receiv+ ! item or s]vice be=e ! item or s]vice is furni%$ pursuant to ! contract2 7,b7 n be ent]$ into at a "t :5 ! individual is fac+ an em]g5cy heal? c>e situation2 & 7,c7 cle>ly indicate to ! individual receiv+ su* items & s]vices t by sign+ su* a contract ! individual-- 7i7 agrees n to submit a claim 7or to reque/ t ! provid] submit a claim7 "u ?is ,act = su* items or s]vices2 7ii7 agrees to be responsible = paym5t ( su* items or s]vices & und]/&s t no reimbursem5t w be provid$ "u ?is ,act = su* items or s]vices2 7iii7 ackn[l$ges t no limits "u ?is ,act apply to am\nts t may be *>g$ = su* items or s]vices2 & 7iv7 ackn[l$ges t ! provid] is provid+ s]vices outside ! scope ( ! program "u ?is ,act4 7#d7 ,affidavit ,a p>ticipat+ provid] :o ent]s into a contract describ$ 9 p>agraph 7#b7 %all h 9 effect dur+ ! p]iod any item or s]vice is to be provid$ pursuant to ! contract an affidavit t %all-- 7,a7 id5tify ! provid] :o is to furni% su* noncov]$ item or s]vice1 & be sign$ by su* provid]2 7,b7 /ate t ! provid] w n submit any claim "u ?is ,act = any noncov]$ item or s]vice provid$ to any individual enroll$ "u ?is ,act2 & 7,c7 be fil$ ) ! ,secret>y no lat] ?an #aj days aft] ! fir/ contract to :i* su* affidavit applies is ent]$ into4 7#e7 ,en=cem5t ,if a provid] sign+ an affidavit describ$ 9 p>agraph 7#d7 kn[+ly & willfully submits a claim "u ?is title = any item or s]vice provid$ or receives any reimbursem5t or am\nt = any su* item or s]vice provid$ pursuant to a private contract describ$ 9 p>agraph 7#b7 ) respect to su* affidavit-- 7,a7 any contract describ$ 9 p>agraph 7#b7 %all be null & void2 7,b7 no paym5t %all be made "u ?is title = any item or s]vice furni%$ by ! provid] dur+ ! #b-ye> p]iod beg9n+ on ! date ! affidavit 0 sign$2 & 7,c7 any paym5t receiv$ "u ?is title = any item or s]vice furni%$ dur+ su* p]iod %all be remitt$4 7#f7 ,private contracts = ineligible individuals ,an in/itutional or individual provid] ) an agreem5t 9 effect "u section #cja may bill or ent] into a private contract ) any individual ineligible = b5efits "u ! ,act = any item or s]vice4 7c7 ,nonp>ticipat+ provid]s 7#a7 ,private contracts = cov]$ items & s]vices = eligible individuals ,an in/itutional or individual provid] ) no agreem5t 9 effect "u section #cja may bill or ent] into any private contract ) any individual eligible = b5efits "u ! ,act = any item or s]vice t is a b5efit "u ?is ,act describ$ 9 title ,,ii only if ! contract & provid] meet ! requirem5ts specifi$ 9 p>agraphs 7#b7 & 7#c71 respectively4 7#b7 ,items requir$ to be includ$ 9 contract ,any contract to provide items & s]vices describ$ 9 p>agraph 7#a7 %all-- 7,a7 be 9 writ+ & sign$ by ! individual 7or au?oriz$ repres5tative ( ! individual7 receiv+ ! item or s]vice be=e ! item or s]vice is furni%$ pursuant to ! contract2 7,b7 n be ent]$ into at a "t :5 ! individual is fac+ an em]g5cy heal? c>e situation2 & 7,c7 cle>ly indicate to ! individual receiv+ su* items & s]vices t by sign+ su* a contract ! individual-- 7i7 ackn[l$ges t ! individual has ! "r to h su* items or s]vices provid$ by o!r provid]s = :om paym5t w\ld be made "u ?is ,act2 7ii7 agrees n to submit a claim 7or to reque/ t ! provid] submit a claim7 "u ?is ,act = su* items or s]vices ev5 if su* items or s]vices are o!rwise cov]$ by ?is ,act2 7iii7 agrees to be responsible = paym5t ( su* items or s]vices & und]/&s t no reimbursem5t w be provid$ "u ?is ,act = su* items or s]vices2 7iv7 ackn[l$ges t no limits "u ?is ,act apply to am\nts t may be *>g$ = su* items or s]vices2 & 7v7 ackn[l$ges t ! provid] is provid+ s]vices outside ! scope ( ! program "u ?is ,act4 7#c7 ,affidavit ,a provid] :o ent]s into a contract describ$ 9 p>agraph 7#a7 %all h 9 effect dur+ ! p]iod any item or s]vice is to be provid$ pursuant to ! contract an affidavit t %all-- 7,a7 id5tify ! provid] :o is to furni% su* cov]$ item or s]vice1 & be sign$ by su* provid]2 7,b7 /ate t ! provid] w n submit any claim "u ?is ,act = any cov]$ item or s]vice provid$ to any individual enroll$ "u ?is ,act dur+ ! #b-ye> p]iod beg9n+ on ! date ! affidavit is sign$2 & 7,c7 be fil$ ) ! ,secret>y no lat] ?an #aj days aft] ! fir/ contract to :i* su* affidavit applies is ent]$ into4 7#d7 ,en=cem5t ,if a provid] sign+ an affidavit describ$ 9 p>agraph 7#c7 kn[+ly & willfully submits a claim "u ?is title = any item or s]vice provid$ or receives any reimbursem5t or am\nt = any su* item or s]vice provid$ pursuant to a private contract describ$ 9 p>agraph 7#a7 ) respect to su* affidavit-- 7,a7 any contract describ$ 9 p>agraph 7#a7 %all be null & void2 & 7,b7 no paym5t %all be made "u ?is title = any item or s]vice furni%$ by ! provid] dur+ ! #b-ye> p]iod beg9n+ on ! date ! affidavit 0 sign$4 7#e7 ,private contracts = noncov]$ items & s]vices = any individual ,an in/itutional or individual provid] ) no agreem5t 9 effect "u section #cja may bill or ent] into a private contract ) any individual = a item or s]vice t is n a b5efit "u ?is ,act4 ,,iv ,adm9i/ration ,a ,g5]al ,adm9i/ration ,provisions #dja4 ,adm9i/ration 7a7 ,g5]al duties ( ! ,secret>y 7#a7 ,9 g5]al ,! ,secret>y %all develop policies1 proc$ures1 guidel9es1 & requirem5ts to c>ry out ?is ,act1 includ+ relat$ to-- 7,a7 eligibility = b5efits2 7,b7 enrollm5t2 7,c7 b5efits provid$2 7,d7 provid] p>ticipation /&>ds & qualifications1 z describ$ 9 title ,,iii2 7,e7 levels ( fund+2 7,f7 me?ods = det]m9+ am\nts ( paym5ts to provid]s ( cov]$ items & s]vices1 consi/5t ) subtitle ,b2 7,g7 a process = appeal+ or petition+ = a det]m9ation ( cov]age or noncov]age ( items & s]vices "u ?is ,act2 7,h7 plann+ = capital exp5ditures & s]vice deliv]y2 7,i7 plann+ = heal? pr(essional education fund+2 7,j7 enc\rag+ ,/ates to develop regional plann+ me*anisms2 & 7,k7 any o!r regulations necess>y to c>ry out ! purposes ( ?is ,act4 7#b7 ,regulations ,regulations au?oriz$ by ?is ,act %all be issu$ by ! ,secret>y 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 7#c7 ,accessibility ,! ,secret>y %all h ! obligation to ensure ! timely & accessible provision ( items & s]vices t all eligible individuals are entitl$ to "u ?is ,act4 7b7 ,uni=m report+ /&>ds2 annual report2 /udies 7#a7 ,uni=m report+ /&>ds 7,a7 ,9 g5]al ,! ,secret>y %all e/abli% uni=m ,/ate report+ requirem5ts & national /&>ds to ensure an adequate national database conta9+ in=mation p]ta9+ to heal? s]vices practition]s1 approv$ provid]s1 ! co/s ( facilities & practition]s provid+ items & s]vices1 ! quality ( su* items & s]vices1 ! outcomes ( su* items & s]vices1 & ! equity ( heal? among population gr\ps4 ,su* database %all include1 to ! maximum ext5t feasible )\t compromis+ pati5t privacy1 heal? outcome measures us$ "u ?is ,act1 & to ! maximum ext5t feasible )\t excessively burd5+ provid]s1 a description ( ! /&>ds & qualifications1 levels ( f9d+1 & me?ods describ$ 9 subp>agraphs 7,d7 ?r\gh 7,f7 ( subsection 7a77#a74 7,b7 ,requir$ data disclosures ,9 e/abli%+ report+ requirem5ts & /&>ds "u subp>agraph 7,a71 ! ,secret>y %all require a provid] ) an agreem5t 9 effect "u section #cja to disclose to ! ,secret>y1 9 a "t & mann] specifi$ by ! ,secret>y1 ! foll[+ 7z applicable to ! type ( provid]73 7i7 ,any data ! provid] is requir$ to report or does report to any ,/ate or local ag5cy1 or1 z ( ,janu>y #a1 #bjai1 to ! ,secret>y or any entity t is "p ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 except data t are requir$ "u ! programs t]m9at$ 9 section #ijc4 7ii7 ,annual f9ancial data t includes in=mation on employees 7includ+ ! numb] ( employees1 h\rs work$1 & wage in=mation7 by job title & by ea* pati5t c>e unit or dep>tm5t )9 ea* facility 7includ+ outpati5t units or dep>tm5ts72 ! numb] ( regi/]$ nurses p] /aff$ b$ by ea* su* unit or dep>tm5t2 in=mation on ! doll> value & annual sp5d+ 7includ+ pur*ases1 upgrades1 & ma9t5ance7 = heal? in=mation te*nology2 & risk-adju/$ & raw pati5t outcome data 7includ+ data on m$ical1 surgical1 ob/etric1 & o!r proc$ures74 7,c7 ,reports ,! ,secret>y %all regul>ly analyze in=mation report$ to ! ,secret>y & %all def9e rules & proc$ures to all[ rese>*]s1 s*ol>s1 heal? c>e provid]s1 & o!rs to access & analyze data = purposes consi/5t ) quality & outcomes rese>*1 )\t compromis+ pati5t privacy4 7#b7 ,annual report ,beg9n+ #b ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all annually report to ,congress on ! foll[+3 7,a7 ,! /atus ( implem5tation ( ! ,act4 7,b7 ,enrollm5t "u ?is ,act4 7,c7 ,b5efits "u ?is ,act4 7,d7 ,exp5ditures & f9anc+ "u ?is ,act4 7,e7 ,co/-conta9m5t measures & a*ievem5ts "u ?is ,act4 7,f7 ,quality assurance4 7,g7 ,heal? c>e utilization patt]ns1 includ+ any *anges attributable to ! program4 7,h7 ,*anges 9 ! p]-capita co/s ( heal? c>e4 7,i7 ,diff]5ces 9 ! heal? /atus ( ! populations ( ! diff]5t ,/ates1 includ+ by racial1 e?nic1 national orig91 prim>y language use1 age1 disability1 sex1 includ+ g5d] id5tity & sexual ori5tation1 geographical1 & income *>act]i/ics2 7,j7 ,progress on quality & outcome measures1 & long-range plans & goals = a*ievem5ts 9 su* areas4 7,k7 ,plans = improv+ s]vice to m$ically und]s]v$ populations4 7,l7 ,transition problems z a result ( implem5tation ( ?is ,act4 7,m7 ,opportunities = improvem5ts "u ?is ,act4 7#c7 ,/ati/ical analyses & o!r /udies ,! ,secret>y may1 ei!r directly or by contract-- 7,a7 make /ati/ical & o!r /udies1 on a nationwide1 regional1 ,/ate1 or local basis1 ( any aspect ( ! op]ation ( ?is ,act2 7,b7 develop & te/ me?ods ( deliv]y ( items & s]vices z ! ,secret>y may consid] necess>y or promis+ = ! evaluation1 or = ! improvem5t1 ( ! op]ation ( ?is ,act2 & 7,c7 develop me?odological /&>ds = policymak+4 7c7 ,audits 7#a7 ,9 g5]al ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct an audit ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices e fif? fiscal ye> foll[+ ! effective date ( ?is ,act to det]m9e ! effectiv5ess ( ! program 9 c>ry+ out ! duties "u subsection 7a74 7#b7 ,reports ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit a report to ,congress conc]n+ ! results ( ea* audit conduct$ "u ?is subsection4 #djb4 ,consultation ,! ,secret>y %all consult ) ,f$]al ag5cies1 ,indian tribes & urban ,indian heal? organizations1 & private entities1 su* z labor organizations repres5t+ heal? c>e work]s1 pr(essional societies1 national associations1 nationally recogniz$ associations ( heal? c>e exp]ts1 m$ical s*ools & academic heal? c5t]s1 consum] gr\ps1 & bus9ess organizations 9 ! =mulation ( guidel9es1 regulations1 policy initiatives1 & in=mation ga!r+ to ensure ! broade/ & mo/ in=m$ input 9 ! adm9i/ration ( ?is ,act4 ,no?+ 9 ?is ,act %all prev5t ! ,secret>y f adopt+ guidel9es1 consi/5t ) ! provisions ( section #bjc7;c71 develop$ by su* a private entity if1 9 ! ,secret>y's judgm5t1 su* guidel9es are g5]ally accept$ z reasonable & prud5t & consi/5t ) ?is ,act4 #djc4 ,regional adm9i/ration 7a7 ,coord9ation ) regional (fices ,! ,secret>y %all e/abli% & ma9ta9 regional (fices = purposes ( c>ry+ out ! duties specifi$ 9 subsection 7c7 & promot+ adequate access to1 & effici5t use (1 t]ti>y c>e facilities1 equipm5t1 & s]vices by individuals enroll$ "u ?is ,act4 ,:]ev] possible1 ! ,secret>y %all incorporate regional (fices ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices = ?is purpose4 7b7 ,appo9tm5t ( regional directors ,9 ea* su* regional (fice !re %all be-- 7#a7 "o regional director appo9t$ by ! ,secret>y2 7#b7 "o deputy director appo9t$ by ! regional director to repres5t ! ,indian & ,alaska ,native tribes 9 ! region1 if any2 & 7#c7 "o deputy direction appo9t$ by ! regional director to ov]see long-t]m s]vices & supports4 7c7 ,regional (fice duties ,ea* regional director %all-- 7#a7 provide an annual heal? c>e ne$s assessm5t ) respect to ! region "u ! director's jurisdiction to ! ,secret>y aft] a ?or\gh exam9ation ( heal? ne$s & 9 consultation ) public heal? (ficials1 cl9icians1 pati5ts1 & pati5t advocates2 7#b7 recomm5d any *anges 9 provid] reimbursem5t or paym5t = deliv]y ( heal? s]vices det]m9$ appropriate by ! regional director1 subject to ! provisions ( title ,,vi2 & 7#c7 e/abli% a quality assurance me*anism 9 ea* su* region 9 ord] to m9imize bo? und]utilization & ov]utilization ( heal? c>e items & s]vices & to ensure t all provid]s meet quality /&>ds e/abli%$ pursuant to ?is ,act4 #djd4 ,b5efici>y ombudsman 7a7 ,9 g5]al ,! ,secret>y %all appo9t a ,b5efici>y ,ombudsman :o %all h exp]tise & exp]i5ce 9 ! fields ( heal? c>e & education (1 & assi/ance to1 individuals enroll$ "u ?is ,act4 7b7 ,duties ,! ,b5efici>y ,ombudsman %all-- 7#a7 receive compla9ts1 grievances1 & reque/s = in=mation submitt$ by individuals enroll$ "u ?is ,act or eligible to enroll "u ?is ,act ) respect to any aspect ( ! ,m$ic>e = ,all ,program2 7#b7 provide assi/ance ) respect to compla9ts1 grievances1 & reque/s ref]r$ to 9 p>agraph 7#a71 includ+ assi/ance 9 collect+ relevant in=mation = su* individuals1 to seek an appeal ( a decision or det]m9ation made by a regional (fice or ! ,secret>y2 & 7#c7 submit annual reports to ,congress & ! ,secret>y t describe ! activities ( ! ,ombudsman & t include su* recomm5dations = improvem5t 9 ! adm9i/ration ( ?is ,act z ! ,ombudsman det]m9es appropriate4 ,! ,ombudsman %all n s]ve z an advocate = any increases 9 paym5ts or new cov]age ( s]vices1 b may id5tify issues & problems 9 paym5t or cov]age policies4 #dje4 ,conduct ( relat$ heal? programs ,9 p]=m+ functions ) respect to heal? p]sonnel education & tra9+1 heal? rese>*1 environm5tal heal?1 disability insurance1 vocational rehabilitation1 ! regulation ( food & drugs1 & all o!r matt]s p]ta9+ to heal?1 ! ,secret>y %all direct ! activities ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices t[>d contributions to ! heal? ( ! p complem5t>y to ?is ,act4 ,b ,control ,ov] ,fraud & ,abuse #daa4 ,application ( ,f$]al sanctions to all fraud & abuse "u ! ,m$ic>e = ,all ,program ,! foll[+ sections ( ! ,social ,security ,act %all apply to ?is ,act 9 ! same mann] z !y apply to title ,,xviii or ,/ate plans "u title ,,xix ( ! ,social ,security ,act3 7#a7 ,section #aabh 7relat+ to exclusion ( individuals & entities74 7#b7 ,section #aabh;,a 7civil monet>y p5alties74 7#c7 ,section #aabh;,b 7crim9al p5alties74 7#d7 ,section #aabd 7relat+ to disclosure ( own]%ip & relat$ in=mation74 7#e7 ,section #aabf 7relat+ to disclosure ( c]ta9 own]s74 7#f7 ,section #ahgg 7relat+ to physician ref]rals74 ,v ,quality ,assessm5t #eja4 ,quality /&>ds 7a7 ,9 g5]al ,all /&>ds & quality measures "u ?is ,act %all be implem5t$ & evaluat$ by ! ,c5t] = ,cl9ical ,/&>ds & ,quality ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices 7ref]r$ to 9 ?is title z ! ,c5t]7 or su* o!r ag5cy det]m9$ appropriate by ! ,secret>y1 9 coord9ation ) ! ,ag5cy = ,heal?c>e ,rese>* & ,quality & o!r (fices ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 7b7 ,duties ( ! c5t] ,! ,c5t] %all p]=m ! foll[+ duties3 7#a7 ,review & evaluate ea* practice guidel9e develop$ "u "p ,b ( title ,,ix ( ! ,public ,heal? ,s]vice ,act4 ,9 s review+ & evaluat+1 ! ,c5t] %all det]m9e :e!r ! guidel9e %\ld be recogniz$ z a national practice guidel9e 9 accordance ) & subject to ! provisions ( section #bjc7;c74 7#b7 ,review & evaluate ea* /&>d ( quality1 p]=mance measure1 & m$ical review crit]ion develop$ "u "p ,b ( title ,,ix ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bii et seq474 ,9 s review+ & evaluat+1 ! ,c5t] %all det]m9e :e!r ! /&>d1 measure1 or crit]ion is appropriate = use 9 assess+ or review+ ! quality ( items & s]vices provid$ by heal? c>e in/itutions or heal? c>e pr(essionals4 ,! use ( me*anisms t discrim9ate aga9/ p ) disabilities is prohibit$ = use 9 any value or co/-effectiv5ess assessm5ts4 ,! ,c5t] %all consid] ! evid5ti>y basis = ! /&>d1 & ! validity1 reliability1 & feasibility ( measur+ ! /&>d4 7#c7 ,adoption ( me?odologies = pr(il+ ! patt]ns ( practice ( heal? c>e pr(essionals & = id5tify+ & notify+ outli]s4 7#d7 ,developm5t ( m9imum crit]ia = compet5ce = entities t c qualify to conduct ongo+ & cont9u\s ext]nal quality reviews 9 ! adm9i/rative regions4 ,su* crit]ia %all require su* an entity to be adm9i/ratively indep5d5t ( ! individual or bo>d t adm9i/]s ! region & %all ensure t su* entities d n provide f9ancial inc5tives to review]s to favor "o patt]n ( practice ov] ano!r4 ,! ,c5t] %all ensure coord9ation & report+ by su* entities to ensure national consi/5cy 9 quality /&>ds4 7#e7 ,submission ( a report to ! ,secret>y annually specifically on f9d+s f outcomes rese>* & developm5t ( practice guidel9es t may affect ! ,secret>y's det]m9ation ( cov]age ( s]vices "u section #dja7;a77#a77;,g74 #ejb4 ,address+ heal? c>e disp>ities 7a7 ,evaluat+ data collection approa*es ,! ,c5t] %all evaluate approa*es = ! collection ( data "u ?is ,act1 to be p]=m$ 9 conjunction ) exi/+ quality report+ requirem5ts & programs "u ?is ,act1 t all[ = ! ongo+1 accurate1 & timely collection ( data on disp>ities 9 heal? c>e s]vices & p]=mance on ! basis ( race1 e?nicity1 national orig91 prim>y language use1 age1 disability1 sex 7includ+ g5d] id5tity & sexual ori5tation71 geography1 or socioeconomic /atus4 ,9 conduct+ su* evaluation1 ! ,c5t] %all consid] ! foll[+ objectives3 7#a7 ,protect+ pati5t privacy4 7#b7 ,m9imiz+ ! adm9i/rative burd5s ( data collection & report+ on provid]s "u ?is ,act4 7#c7 ,improv+ data on race1 e?nicity1 national orig91 prim>y language use1 age1 disability1 sex 7includ+ g5d] id5tity & sexual ori5tation71 geography1 & socioeconomic /atus4 7b7 ,reports to congress 7#a7 ,report on evaluation ,n lat] ?an #ah mon?s aft] ! date on :i* b5efits fir/ become available z describ$ 9 section #ajf7;a71 ! ,c5t] %all submit to ,congress & ! ,secret>y a report on ! evaluation conduct$ "u subsection 7a74 ,su* report %all1 tak+ into consid]ation ! results ( su* evaluation-- 7,a7 id5tify approa*es 7includ+ def9+ me?odologies7 = id5tify+ & collect+ & evaluat+ data on heal? c>e disp>ities on ! basis ( race1 e?nicity1 national orig91 prim>y language use1 age1 disability1 sex 7includ+ g5d] id5tity & sexual ori5tation71 geography1 or socioeconomic /atus "u ! ,m$ic>e = ,all ,program2 & 7,b7 include recomm5dations on ! mo/ effective /rategies & approa*es to report+ quality measures1 z appropriate1 on ! basis ( race1 e?nicity1 national orig91 prim>y language use1 age1 disability1 sex 7includ+ g5d] id5tity & sexual ori5tation71 geography1 or socioeconomic /atus4 7#b7 ,report on data analyses ,n lat] ?an #d ye>s aft] ! submission ( ! report "u subsection 7b77#a71 & e #d ye>s !reaft]1 ! ,c5t] %all submit to ,congress & ! ,secret>y a report t includes recomm5dations = improv+ ! id5tification ( heal? c>e disp>ities bas$ on ! analyses ( data collect$ "u subsection 7c74 7c7 ,implem5t+ effective approa*es ,n lat] ?an #b ye>s aft] ! date on :i* b5efits fir/ become available z describ$ 9 section #ajf7;a71 ! ,secret>y %all implem5t ! approa*es id5tifi$ 9 ! report submitt$ "u subsection 7b77#a7 = ! ongo+1 accurate1 & timely collection & evaluation ( data on heal? c>e disp>ities on ! basis ( race1 e?nicity1 national orig91 prim>y language use1 age1 disability1 sex 7includ+ g5d] id5tity & sexual ori5tation71 geography1 or socioeconomic /atus4 ,,vi ,heal? ,budget2 ,paym5ts2 ,co/ ,conta9m5t ,measures ,a ,budget+ #fja4 ,national heal? budget 7a7 ,national heal? budget 7#a7 ,9 g5]al ,by n lat] ?an ,septemb] #a ( ea* ye>1 beg9n+ ) ! ye> prior to ! date on :i* b5efits fir/ become available z describ$ 9 section #ajf7;a71 ! ,secret>y %all e/abli% a national heal? budget1 :i* specifies a budget = ! total exp5ditures to be made = cov]$ heal? c>e items & s]vices "u ?is ,act4 7#b7 ,division ( budget into compon5ts ,! national heal? budget %all consi/ ( ! foll[+ compon5ts3 7,a7 ,an op]at+ budget4 7,b7 ,a capital exp5ditures budget4 7,c7 ,a special projects budget4 7,d7 ,quality assessm5t activities "u title ,v4 7,e7 ,heal? pr(essional education exp5ditures4 7,f7 ,adm9i/rative co/s1 includ+ co/s relat$ to ! op]ation ( regional (fices4 7,g7 ,a res]ve fund4 7,h7 ,prev5tion & public heal? activities4 7#c7 ,allocation among compon5ts ,! ,secret>y %all allocate ! funds receiv$ = purposes ( c>ry+ out ?is ,act among ! compon5ts describ$ 9 p>agraph 7#b7 9 a mann] t ensures-- 7,a7 t ! op]at+ budget all[s = e p>ticipat+ provid] 9 ! ,m$ic>e = ,all ,program to meet ! ne$s ( _! respective pati5t populations2 7,b7 t ! special projects budget is suffici5t to meet ! heal? c>e ne$s )9 areas describ$ 9 p>agraph 7#b77;,c7 ?r\gh ! con/ruction1 r5ovation1 & /aff+ ( heal? c>e facilities 9 a reasonable timeframe2 7,c7 a fair allocation = quality assessm5t activities2 & 7,d7 t ! heal? pr(essional education exp5diture compon5t is suffici5t to provide = ! am\nt ( heal? pr(essional education exp5ditures suffici5t to meet ! ne$ = cov]$ heal? c>e s]vices4 7#d7 ,regional allocation ,! ,secret>y %all annually provide ea* regional (fice ) an allotm5t ! ,secret>y det]m9es appropriate = purposes ( c>ry+ out ?is ,act 9 su* region1 includ+ paym5ts to provid]s 9 su* region1 capital exp5ditures 9 su* region1 special projects 9 su* region1 heal? pr(essional education 9 su* region1 adm9i/rative exp5ses 9 su* region1 & prev5tion & public heal? activities 9 su* region4 7#e7 ,op]at+ budget ,! op]at+ budget describ$ 9 p>agraph 7#b77;,a7 %all be us$ =-- 7,a7 paym5ts to in/itutional provid]s pursuant to section #faa2 & 7,b7 paym5ts to individual provid]s pursuant to section #fab4 7#f7 ,capital exp5ditures budget ,! capital exp5ditures budget describ$ 9 p>agraph 7#b77;,b7 %all be us$ =-- 7,a7 ! con/ruction or r5ovation ( heal? c>e facilities1 exclud+ congregate or segregat$ facilities = individuals ) disabilities :o receive long-t]m c>e s]vices & support2 & 7,b7 major equipm5t pur*ases4 7#g7 ,special projects budget ,! special projects budget describ$ 9 p>agraph 7#b77;,c7 %all be us$ = ! purposes ( allocat+ funds = ! con/ruction ( new facilities1 major equipm5t pur*ases1 & /aff+ 9 rural or m$ically und]s]v$ areas 7z def9$ 9 section #ccj7;b77#c7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bed;b7b77#c7771 includ+ areas designat$ z heal? pr(essional %ortage areas 7z def9$ 9 section #ccb7;a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bed;e7a7771 & to address heal? disp>ities1 includ+ racial1 e?nic1 national orig91 prim>y language use1 age1 disability1 sex 7includ+ g5d] id5tity & sexual ori5tation71 geography1 or socioeconomic heal? disp>ities4 7#h7 ,tempor>y work] assi/ance 7,a7 ,9 g5]al ,= up to #e ye>s foll[+ ! date on :i* b5efits fir/ become available z describ$ 9 section #ajf7;a71 at lea/ #a p]c5t ( ! budget %all be allocat$ to programs provid+ assi/ance to work]s :o p]=m functions 9 ! adm9i/ration ( ! heal? insurance sy/em1 or relat$ functions )9 heal? c>e in/itutions or organizations :o may be affect$ by ! implem5tation ( ?is ,act & :o may exp]i5ce economic dislocation z a result ( ! implem5tation ( ?is ,act4 7,b7 ,cl>ification ,assi/ance describ$ 9 subp>agraph 7,a7 %all include wage replacem5t1 retirem5t b5efits1 job tra9+ & placem5t1 pref]5tial hir+1 & education b5efits4 7#i7 ,res]ve fund ,! res]ve fund describ$ 9 p>agraph 7#b77;,g7 %all be us$ to respond to ! co/s ( an epidemic1 p&emic1 natural disa/]1 or o!r su* heal? em]g5cy1 or m>ket-%ift adju/m5ts relat$ to pati5t volume4 7#aj7 ,supplem5tal ,indian ,heal? ,s]vice allocation ,! ,secret>y %all annually det]m9e ! ne$ to provide an allotm5t ( supplem5tal funds to ,indian ,heal? ,s]vices1 includ+ paym5ts to provid]s1 capital exp5ditures1 special projects1 heal? pr(essional education1 adm9i/rative exp5ses1 & prev5tion & public heal? activities4 7b7 ,def9itions ,9 ?is section3 7#a7 ,capital exp5ditures ,! t]m capital exp5ditures means exp5ses = ! pur*ase1 lease1 con/ruction1 or r5ovation ( capital facilities & = major equipm5t4 7#b7 ,heal? pr(essional education exp5ditures ,! t]m heal? pr(essional education exp5ditures means exp5ditures 9 hospitals & o!r heal? c>e facilities to cov] co/s associat$ ) tea*+ & relat$ rese>* activities1 includ+ ! impact ( work=ce div]sity on pati5t outcomes4 ,b ,paym5ts to ,provid]s #faa4 ,paym5ts to in/itutional provid]s bas$ on global budgets 7a7 ,9 g5]al ,n lat] ?an ! beg9n+ ( ea* fiscal qu>t] dur+ :i* an in/itutional provid] ( c>e 7includ+ hospitals1 skill$ nurs+ facilities1 ,f$]ally qualifi$ heal? c5t]s1 & indep5d5t dialysis facilities7 is to furni% items & s]vices "u ?is ,act1 ! ,secret>y %all pay to su* in/itutional provid] a lump sum 9 accordance ) ! succe$+ provisions ( ?is subsection & consi/5t ) ! foll[+3 7#a7 ,paym5t 9 ,full ,su* paym5t %all be consid]$ z paym5t 9 full = all op]at+ exp5ses = items & s]vices furni%$ "u ?is ,act1 :e!r inpati5t or outpati5t1 by su* provid] = su* qu>t]1 includ+ outpati5t or any o!r c>e provid$ by ! in/itutional provid] or provid$ by any heal? c>e provid] :o provid$ items & s]vices pursuant to an agreem5t paid ?r\gh ! global budget z describ$ 9 p>agraph 7#c74 7#b7 ,qu>t]ly ,review ,! regional director1 on a qu>t]ly basis1 %all review :e!r requirem5ts ( ! in/itutional provid]'s p>ticipation agreem5t & negotiat$ global budget h be5 p]=m$ & %all det]m9e :e!r adju/m5ts to su* in/itutional provid]'s paym5t are w>rant$4 ,?is review %all include consid]ation = additional fund+ necess>y = unanticipat$ items & s]vices = individuals ) complex m$ical ne$s or m>ket-%ift adju/m5ts relat$ to pati5t volume4 ,! review %all also include an assessm5t ( any adju/m5ts made to ensure t accuracy & ne$ = adju/m5t 0 appropriate4 7#c7 ,agreem5ts = ,sal>i$ ,paym5ts = ,c]ta9 ,provid]s ,c]ta9 gr\p practices & o!r heal? c>e provid]s1 z det]m9$ by ! ,secret>y1 ) agreem5ts to provide items & s]vices at a specifi$ in/itutional provid] paid a global budget "u ?is subsection may elect to be paid ?r\gh su* in/itutional provid]'s global budget 9 lieu ( paym5t "u section #fab ( ?is title4 ,any-- 7,a7 individual heal? c>e pr(essional ( su* gr\p practice or o!r provid] receiv+ paym5t ?r\gh an in/itutional provid]'s global budget %all be paid on a sal>i$ basis t is equival5t to sal>ies or o!r comp5sation rates negotiat$ = individual heal? c>e pr(essionals ( su* in/itutional provid]2 & 7,b7 any gr\p practice or o!r heal? c>e provid] t receives paym5t ?r\gh an in/itutional provid] global budget "u ?is p>agraph %all be subject to ! same report+ & disclosure requirem5ts ( ! in/itutional provid]4 7#d7 ,int]im adju/m5ts ,! regional director %all consid] a petition = adju/m5t ( any paym5t "u ?is section fil$ by an in/itutional provid] at any "t bas$ on ! foll[+3 7,a7 ,factors t l$ to increas$ co/s = ! in/itutional provid] t c reasonably be consid]$ to be unanticipat$ & out ( ! control ( ! in/itutional provid]1 su* z-- 7i7 natural disa/]s2 7ii7 outbreaks ( epidemics or infecti\s diseases2 7iii7 unexpect$ facility or equipm5t repairs or pur*ases2 7iv7 significant & unexpect$ increases 9 ph>maceutical or m$ical device prices2 & 7v7 unanticipat$ increases 9 complex or high-co/ pati5ts or c>e ne$s4 7,b7 ,*anges 9 ,f$]al or ,/ate law t result 9 a *ange 9 co/s4 7,c7 ,reasonable increases 9 labor co/s1 includ+ sal>ies & b5efits1 & *anges 9 collective b>ga9+ agreem5ts1 prevail+ wage1 or local law4 7b7 ,paym5t am\nt 7#a7 ,9 g5]al ,! am\nt ( ea* paym5t to a provid] describ$ 9 subsection 7a7 %all be det]m9$ be=e ! />t ( ea* fiscal ye> ?r\gh negotiations betwe5 ! provid] & ! regional director ) jurisdiction ov] su* provid]4 ,su* am\nt %all be bas$ on factors specifi$ 9 p>agraph 7#b74 7#b7 ,paym5t factors ,paym5ts negotiat$ pursuant to p>agraph 7#a7 %all take into acc\nt1 ) respect to a provid]-- 7,a7 ! hi/orical volume ( s]vices provid$ = ea* item & s]vices 9 ! previ\s #c-ye> p]iod2 7,b7 ! actual exp5ditures ( su* provid] 9 su* provid]'s mo/ rec5t co/ report "u title ,,xviii ( ! ,social ,security ,act = ea* item & s]vice comp>$ to-- 7i7 su* exp5ditures = o!r in/itutional provid]s 9 ! director's jurisdiction2 & 7ii7 normative paym5t rates e/abli%$ "u comp>ative paym5t rate sy/ems1 includ+ any adju/m5ts1 = su* items & s]vices2 7,c7 project$ *anges 9 ! volume & type ( items & s]vices to be furni%$2 7,d7 wages = employees1 includ+ any necess>y increases = m&atory m9imum safe regi/]$ nurse-to-pati5t ratios & optimal /aff+ levels = physicians & o!r heal? c>e work]s2 7,e7 ! provid]'s maximum capacity to provide items & s]vices2 7,f7 education & prev5tion programs2 7,g7 p]missible adju/m5t to ! provid]'s op]at+ budget due to factors su* z-- 7i7 an increase 9 prim>y or specialty c>e access2 7ii7 ef=ts to decrease heal? c>e disp>ities 9 rural or m$ically und]s]v$ areas2 7iii7 a response to em]g5t epidemic conditions2 7iv7 an increase 9 complex or high-co/ pati5ts or c>e ne$s2 or 7v7 propos$ new & innovative pati5t c>e programs at ! in/itutional level2 7,h7 :e!r ! provid] is locat$ 9 a high social vuln]ability index community1 ,,zip ,code1 or c5sus track1 or is a m9ority-s]v+ provid]2 & 7,i7 any o!r factor det]m9$ appropriate by ! ,secret>y4 7#c7 ,limitation ,paym5t am\nts negotiat$ pursuant to p>agraph 7#a7 may n-- 7,a7 take into acc\nt capital exp5ditures ( ! provid] or any o!r exp5diture n directly associat$ ) ! provision ( items & s]vices by ! provid] to an individual2 7,b7 be us$ by a provid] = capital exp5ditures or su* o!r exp5ditures2 7,c7 exce$ ! provid]'s capacity to provide c>e "u ?is ,act2 or 7,d7 be us$ to pay or o!rwise comp5sate any bo>d memb]1 executive1 or adm9i/rator ( ! in/itutional provid] :o has any int]e/ or relation%ip prohibit$ "u section #cja7;b77#b7 ( ?is ,act or disclos$ "u section #cja ( ?is ,act4 7#d7 ,limitation on ,comp5sation ,comp5sation co/s = any employee or any contractor or any subcontractor employee ( an in/itutional provid] receiv+ global budgets "u ?is section %all meet ! comp5sation cap e/abli%$ 9 section #gjb ( ! ,bip>tisan ,budget ,act ( #bjac 7#da ,u4,s4,c4 #dcjd7;a77#af77 & implem5t+ regulations4 7#e7 ,regional negotiations p]mitt$ ,subject to section #fad1 a regional director may negotiate *anges to an in/itutional provid]'s global budget1 includ+ any adju/m5ts to address un=ese5 m>ket-%ifts relat$ to pati5t volume4 7c7 ,basel9e rates & adju/m5ts 7#a7 ,9 g5]al ,! ,secret>y %all use exi/+ prospective paym5t sy/ems "u title ,,xviii ( ! ,social ,security ,act to s]ve z ! comp>ative paym5t rate sy/em 9 global budget negotiations describ$ 9 subsection 7b74 ,! ,secret>y %all update su* comp>ative paym5t rate sy/ems annually4 7#b7 ,specifications ,9 develop+ ! comp>ative paym5t rate sy/em1 ! ,secret>y %all use only ! op]at+ base paym5t rates "u ea* su* prospective paym5t sy/ems ) applicable adju/m5ts4 7#c7 ,limitation ,! comp>ative rate sy/em e/abli%$ "u ?is subsection %all n include ! value-bas$ paym5t adju/m5ts & ! capital exp5ses base paym5t rates t may be includ$ 9 su* a prospective paym5t sy/em4 7#d7 ,initial ye> ,9 ! fir/ ye> t global budget paym5ts "u ?is ,act are available to in/itutional provid]s & = purposes ( select+ a comp>ative paym5t rate sy/em us$ dur+ initial global budget negotiations = ea* in/itutional provid]1 ! ,secret>y %all take into acc\nt ! appropriate prospective paym5t sy/em f ! mo/ rec5t ye> "u title ,,xviii ( ! ,social ,security ,act to det]m9e :at op]at+ base paym5t ! in/itutional provid] w\ld h be5 paid = cov]$ items & s]vices furni%$ ! prec$+ ye> ) applicable adju/m5ts1 exclud+ value-bas$ paym5t adju/m5ts1 bas$ on su* prospective paym5t sy/em4 7d7 ,op]at+ exp5ses ,= purposes ( ?is title1 op]at+ exp5ses ( a provid] include ! foll[+3 7#a7 ,! co/ ( all items & s]vices associat$ ) ! provision ( inpati5t c>e & outpati5t c>e1 includ+ ! foll[+3 7,a7 ,wages & sal>y co/s = physicians1 nurses1 & o!r heal? c>e practition]s employ$ by an in/itutional provid]1 includ+ m&atory m9imum safe regi/]$ nurse-to-pati5t /aff+ ratios & optimal /aff+ levels = physicians & o!r heal?c>e work]s4 7,b7 ,wages & sal>y co/s = all ancill>y /aff & s]vices4 7,c7 ,co/s ( all ph>maceutical products adm9i/]$ by heal? c>e cl9icians at ! in/itutional provid]'s facilities or ?r\gh s]vices provid$ 9 accordance ) ,/ate lic5s+ laws or regulations "u :i* ! in/itutional provid] op]ates4 7,d7 ,co/s = infecti\s disease response prep>$ness1 includ+ ma9t5ance ( a #a-ye> or #cfe-;day /ockpile ( p]sonal protective equipm5t1 occupational te/+ & surveillance1 m$ical s]vices = occupational infecti\s disease exposure1 & contact trac+4 7,e7 ,pur*as+ & ma9t5ance ( m$ical devices1 supplies1 & o!r heal? c>e te*nologies1 includ+ diagno/ic te/+ equipm5t4 7,f7 ,co/s ( all incid5tal s]vices necess>y = safe pati5t c>e & h&l+4 7,g7 ,co/s ( pati5t c>e1 education1 & prev5tion programs1 includ+ occupational heal? & safety programs1 public heal? programs1 & necess>y /aff to implem5t su* programs1 = ! cont9u$ education & heal? & safety ( cl9icians & o!r individuals employ$ by ! in/itutional provid]4 7#b7 ,adm9i/rative co/s = ! in/itutional provid]4 #fab4 ,paym5t to individual provid]s ?r\gh fee-=-s]vice 7a7 ,9 g5]al ,9 ! case ( a provid] n describ$ 9 section #faa7;a7 7includ+ ^? 9 gr\p practices :o are n receiv+ paym5t on a sal>i$ basis describ$ 9 section #faa7;a77#c7 & provid]s ( home & community-bas$ s]vices71 paym5t = items & s]vices furni%$ "u ?is ,act = :i* paym5t is n o!rwise made "u section #faa %all be made by ! ,secret>y 9 am\nts det]m9$ "u ! fee s*$ule e/abli%$ pursuant to subsection 7b74 ,su* paym5t %all be consid]$ to be paym5t 9 full = su* items & s]vices1 & a provid] receiv+ su* paym5t may n *>ge ! individual receiv+ su* item or s]vice 9 any am\nt4 7b7 ,fee s*$ule 7#a7 ,e/abli%m5t ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 & 9 consultation ) provid]s & regional (fice directors1 ! ,secret>y %all e/abli% a national fee s*$ule = items & s]vices payable "u ?is ,act4 ,! ,secret>y %all evaluate ! effectiv5ess ( ! fee-=-s]vice /ructure & update su* fee s*$ule annually4 7#b7 ,am\nts ,9 e/abli%+ paym5t am\nts = items & s]vices "u ! fee s*$ule e/abli%$ "u p>agraph 7#a71 ! ,secret>y %all take into acc\nt-- 7,a7 ! am\nts payable = su* items & s]vices "u title ,,xviii ( ! ,social ,security ,act2 & 7,b7 ! exp]tise ( provid]s & value ( items & s]vices furni%$ by su* provid]s4 7c7 ,electronic bill+ ,! ,secret>y %all e/abli% a uni=m national sy/em = electronic bill+ = purposes ( mak+ paym5ts "u ?is subsection4 7d7 ,physician practice review bo>d ,ea* director ( a regional (fice1 9 consultation ) repres5tatives ( physicians practic+ 9 t region1 %all e/abli% & appo9t a physician practice review bo>d to assure quality1 co/ effectiv5ess1 & fair reimbursem5ts = physician-deliv]$ items & s]vices4 ,! use ( me*anisms t discrim9ate aga9/ p ) disabilities is prohibit$ = use 9 any value or co/-effectiv5ess assessm5ts4 #fac4 ,ensur+ accurate valuation ( s]vices "u ! ,m$ic>e physician fee s*$ule 7a7 ,/&>diz$ & docum5t$ review process ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,p7 ,/&>diz$ & docum5t$ review process 7i7 ,9 g5]al ,n lat] ?an "o ye> aft] ! date ( enactm5t ( ?is subp>agraph1 ! ,secret>y %all e/abli%1 docum5t1 & make publicly available1 9 consultation ) ! ,(fice ( ,prim>y ,heal? ,c>e1 a /&>diz$ process = review+ ! relative values ( physicians' s]vices "u ?is p>agraph4 7ii7 ,m9imum requirem5ts ,! /&>diz$ process %all include1 at a m9imum1 me?ods & crit]ia = id5tify+ s]vices = review1 prioritiz+ ! review ( s]vices1 review+ /akehold] recomm5dations1 & id5tify+ additional res\rces to be consid]$ dur+ ! review process4 4 7b7 ,plann$ & docum5t$ use ( funds ,section #ahdh7;c77#b77,m7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77,m77 is am5d$ by add+ at ! end ! foll[+ new clause3 7x7 ,plann$ & docum5t$ use ( funds ,= ea* fiscal ye> 7beg9n+ ) ! fir/ fiscal ye> beg9n+ on or aft] ! date ( enactm5t ( ?is clause71 ! ,secret>y %all provide to ,congress a writt5 plan = us+ ! funds provid$ "u clause 7ix7 to collect & use in=mation on physicians' s]vices 9 ! det]m9ation ( relative values "u ?is subp>agraph4 4 7c7 ,int]nal track+ ( reviews 7#a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y %all submit to ,congress a propos$ plan = sy/ematically & int]nally track+ ! ,secret>y's review ( ! relative values ( physicians' s]vices1 su* z by e/abli%+ an int]nal database1 "u section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 z am5d$ by ?is section4 7#b7 ,m9imum requirem5ts ,! proposal %all include1 at a m9imum1 plans & a timel9e = a*iev+ ! ability to sy/ematically & int]nally track ! foll[+3 7,a7 ,:51 h[1 & by :om s]vices are id5tifi$ = review4 7,b7 ,:5 s]vices are review$ or review$ or :5 new s]vices are add$4 7,c7 ,! res\rces1 evid5ce1 data1 & recomm5dations us$ 9 reviews4 7,d7 ,:5 relative values are adju/$4 7,e7 ,! rationale = f9al relative value decisions4 7d7 ,frequ5cy ( review ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is am5d$-- 7#a7 9 subp>agraph 7,b77i71 by /rik+ #e & ins]t+ #d2 & 7#b7 9 subp>agraph 7,k77i77,i71 by /rik+ p]iodically & ins]t+ annually4 7e7 ,consultation ) ,m$ic>e ,paym5t ,advisory ,commission 7#a7 ,9 g5]al ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is am5d$-- 7,a7 9 subp>agraph 7,b77i71 by ins]t+ 9 consultation ) ! ,m$ic>e ,paym5t ,advisory ,commission1 aft] ,! ,secret>y12 & 7,b7 9 subp>agraph 7,k77i77,i71 z am5d$ by subsection 7d77#b71 by ins]t+ 1 9 coord9ation ) ! ,m$ic>e ,paym5t ,advisory ,commission1 aft] annually4 7#b7 ,con=m+ am5dm5ts ,section #ahje ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;b-#f7 is am5d$-- 7,a7 9 subsection 7b77#a77;,a71 by ins]t+ ! foll[+ be=e ! semicolon at ! end3 & includ+ coord9at+ ) ! ,secret>y 9 accordance ) section #ahdh7;c77#b7 to sy/ematically review ! relative values e/abli%$ = physicians' s]vices1 id5tify pot5tially misvalu$ s]vices1 & propose adju/m5ts to ! relative values = physicians' s]vices2 & 7,b7 9 subsection 7e77#a71 9 ! second s5t5ce1 by ins]t+ or ! ,rank+ ,m9ority ,memb] aft] ! ,*airman4 7f7 ,p]iodic audit by ! ,comptroll] ,g5]al ,section #ahdh7;c77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 z am5d$ by subsection 7a71 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,q7 ,p]iodic audit by ! ,comptroll] ,g5]al 7i7 ,9 g5]al ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates 79 ?is subsection ref]r$ to z ! ,comptroll] ,g5]al7 %all p]iodically audit ! review by ! ,secret>y ( relative values e/abli%$ "u ?is p>agraph = physicians' s]vices4 7ii7 ,access to in=mation ,! ,comptroll] ,g5]al %all h unre/rict$ access to all delib]ations1 records1 & data relat$ to ! activities c>ri$ out "u ?is p>agraph1 9 a timely mann]1 ^u reque/4 4 #fad4 ,paym5t prohibitions2 capital exp5ditures2 special projects 7a7 ,s5se ( ,congress ,x is ! s5se ( ,congress t t5s ( millions ( p 9 ! ,unit$ ,/ates d n receive heal?c>e s]vices :ile billions ( doll>s t c\ld be sp5t on provid+ heal? c>e are div]t$ to pr(it4 ,!re is a moral imp]ative to correct ! massive defici5cies 9 our curr5t heal? sy/em & to elim9ate pr(it f ! provision ( heal? c>e4 7b7 ,prohibitions ,paym5ts to provid]s "u ?is ,act may n take into acc\nt1 include any process = ! provision ( fund+ =1 or be us$ by a provid] =-- 7#a7 m>ket+ ( ! provid]2 7#b7 ! pr(it or net rev5ue ( ! provid]1 or increas+ ! pr(it or net rev5ue ( ! provid]2 7#c7 inc5tive paym5ts1 bonuses1 or o!r comp5sation bas$ on pati5t utilization ( items & s]vices or any f9ancial measure appli$ ) respect to ! provid] 7or any gr\p practice1 integrat$ heal? c>e deliv]y sy/em1 or o!r provid] ) :i* ! provid] contracts or has a pecuni>y int]e/71 includ+ any value-bas$ paym5t or employm5t-bas$ comp5sation2 7#d7 any agreem5t or arrangem5t describ$ 9 section #bjc7;a77#d7 ( ! ,labor-,managem5t ,report+ & ,disclosure ,act ( #aiei 7#bi ,u4,s4,c4 #dcc7;a77#d772 or 7#e7 political or contributions prohibit$ "u section #cag ( ! ,f$]al ,elections ,campaign ,act ( #aiga 7#eb ,u4,s4,c4 #cjaai7;a77#a774 7c7 ,paym5ts = capital exp5ditures 7#a7 ,9 g5]al ,! ,secret>y %all pay1 f am\nts made available = capital exp5ditures pursuant to section #fja7;a77#b77;,b71 su* sums det]m9$ appropriate by ! ,secret>y to provid]s :o h submitt$ an application to ! regional director ( ! region or regions 9 :i* ! provid] op]ates or seeks to op]ate 9 a "t & mann] specifi$ by ! ,secret>y = purposes ( fund+ capital exp5ditures ( su* provid]s4 7#b7 ,priority ,! ,secret>y %all prioritize allocation ( fund+ "u p>agraph 7#a7 to projects t propose to use su* funds to improve s]vice 9 a m$ically und]s]v$ area 7z def9$ 9 section #ccj7;b77#c7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bed;b7b77#c777 or to address heal? disp>ities1 includ+ racial1 e?nic1 national orig91 prim>y language use1 age1 disability1 sex 7includ+ g5d] id5tity & sexual ori5tation71 geography1 or socioeconomic heal? disp>ities4 7#c7 ,limitation ,! ,secret>y %all n grant fund+ = capital exp5ditures "u ?is subsection = capital projects t are f9anc$ directly or indirectly ?r\gh ! div]sion ( private or o!r non-,m$ic>e = ,all ,program fund+ t results 9 r$uctions 9 c>e to pati5ts1 includ+ r$uctions 9 regi/]$ nurs+ /aff+ patt]ns & *anges 9 em]g5cy room or prim>y c>e s]vices or availability4 7#d7 ,capital assets n fund$ by ! ,m$ic>e = ,all program ,op]at+ exp5ses & funds %all n be us$ by an in/itutional provid] receiv+ paym5t = capital exp5ditures "u ?is subsection = a capital asset t 0 n fund$ by ! ,m$ic>e = ,all program )\t ! approval ( ! regional director or directors ( ! region or regions :]e ! capital asset is locat$4 7d7 ,prohibition aga9/ co-,m+l+ op]at+ & capital funds ,provid]s t receive paym5t "u ?is title %all be prohibit$ f us+1 ) respect to funds made available "u ?is ,act-- 7#a7 funds designat$ = op]at+ exp5ditures = capital exp5ditures or = pr(it2 or 7#b7 funds designat$ = capital exp5ditures = op]at+ exp5ditures4 7e7 ,paym5ts = special projects 7#a7 ,9 g5]al ,! ,secret>y %all allocate to ea* regional director1 f am\nts made available = special projects pursuant to section #fja7;a77#b77;,c71 su* sums det]m9$ appropriate by ! ,secret>y = purposes ( fund+ projects describ$ 9 su* section1 includ+ ! con/ruction1 r5ovation1 or /aff+ ( heal? c>e facilities1 9 rural1 und]s]v$1 or heal? pr(essional or m$ical %ortage areas )9 su* region & to address heal? disp>ities1 includ+ racial1 e?nic1 national orig91 prim>y language use1 age1 disability1 sex1 includ+ g5d] id5tity & sexual ori5tation1 geography1 or socioeconomic heal? disp>ities4 ,ea* regional director %all1 prior to di/ribut+ su* funds 9 accordance ) p>agraph 7#b71 pres5t a budget describ+ h[ su* funds w be di/ribut$ to ! ,secret>y4 7#b7 ,di/ribution ,a regional director %all di/ribute funds to provid]s op]at+ 9 ! region ( su* director's jurisdiction 9 a mann] det]m9$ appropriate by ! director4 7f7 ,prohibition on f9ancial inc5tive metrics 9 paym5t det]m9ations ,! ,secret>y may n utilize any quality metrics or /&>ds = ! purposes ( e/abli%+ provid] paym5t me?odologies1 programs1 modifi]s1 or adju/m5ts = provid] paym5ts "u ?is title4 #fae4 ,(fice ( ,heal? ,equity ,title ,,xvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjju et seq47 is am5d$ by add+ at ! end ! foll[+3 #agab4 ,(fice ( ,heal? ,equity 7a7 ,9 g5]al ,!re is e/abli%$1 9 ! ,(fice ( ! ,secret>y ( ,heal? & ,human ,s]vices1 an ,(fice ( ,heal? ,equity1 to be head$ by a ,director1 to ensure coord9ation & collaboration across ! programs & activities ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices ) respect to ensur+ heal? equity4 7b7 ,monitor+1 track+1 & availability ( data 7#a7 ,9 g5]al ,9 c>ry+ out subsection 7a71 ! ,director ( ! ,(fice ( ,heal? ,equity %all monitor1 track1 & make publicly available data on-- 7,a7 ! disproportionate burd5 ( disease & dea? among p ( color1 disaggregat$ by race1 major e?nic gr\p1 ,tribal affiliation1 national orig91 prim>y language use1 ,engli% pr(ici5cy /atus1 immigration /atus1 l5g? ( /ay 9 ! ,unit$ ,/ates age1 disability1 sex 7includ+ g5d] id5tity & sexual ori5tation71 inc>c]ation1 homelessness1 geography1 & socioeconomic /atus2 7,b7 b>ri]s to heal?1 includ+ su* b>ri]s relat+ to income1 education1 h\s+1 food insecurity 7includ+ availability1 access1 utilization1 & /ability71 employm5t /atus1 work+ conditions1 & conditions relat$ to ! physical environm5t 7includ+ pollutants & population d5sity72 7,c7 b>ri]s to heal? c>e access1 includ+-- 7i7 lack ( tru/ & aw>5ess2 7ii7 lack ( transportation2 7iii7 geography2 7iv7 hospital & s]vice closures2 7v7 lack ( heal? c>e infra/ructure & facilities2 & 7vi7 lack ( heal? c>e pr(essional /aff+ & recruitm5t2 7,d7 disp>ities 9 quality ( c>e receiv$1 includ+ discrim9ation 9 heal? c>e sett+s & ! use ( racially-bias$ practice guidel9es & algori?ms2 & 7,e7 disp>ities 9 utilization ( c>e4 7#b7 ,analysis ( cross-sectional in=mation ,! ,director ( ! ,(fice ( ,heal? ,equity %all ensure t ! data collection & report+ process "u p>agraph 7#a7 all[s = ! analysis ( cross-sectional in=mation on p's id5tities4 7c7 ,policies ,9 c>ry+ out subsection 7a71 ! ,director ( ! ,(fice ( ,heal? ,equity %all develop1 coord9ate1 & promote policies t enhance heal? equity1 includ+ by-- 7#a7 provid+ recomm5dations on-- 7,a7 cultural compet5ce1 implicit bias1 & e?ics tra9+ ) respect to heal? c>e work]s2 7,b7 increas+ div]sity 9 ! heal? c>e work=ce2 & 7,c7 ensur+ suffici5t heal? c>e pr(essionals & facilities2 & 7#b7 ensur+ adequate public heal? fund+ at ! local & ,/ate levels to address heal? disp>ities4 7d7 ,consultation ,9 c>ry+ out subsection 7a71 ! ,director ( ! ,(fice ( ,heal? ,equity1 9 coord9ation ) ! ,director ( ! ,indian ,heal? ,s]vice1 %all consult ) ,indian ,tribes & ) ,urban ,indian organizations on data collection1 report+1 & implem5tation ( policies4 7e7 ,annual report ,9 c>ry+ out subsection 7a71 ! ,director ( ! ,(fice ( ,heal? ,equity %all develop & publi% an annual report on-- 7#a7 /ati/ics collect$ by ! ,(fice2 7#b7 propos$ evid5ce-bas$ solutions to mitigate heal? inequities2 & 7#c7 heal? c>e pr(essional /aff+ levels & access to facilities4 7f7 ,c5traliz$ electronic repository ,9 c>ry+ out subsection 7a71 ! ,director ( ! ,(fice ( ,heal? ,equity %all-- 7#a7 e/abli% & ma9ta9 a c5traliz$ electronic repository to incorporate data collect$ across ,f$]al dep>tm5ts & ag5cies on race1 e?nicity1 ,tribal affiliation1 national orig91 prim>y language use1 ,engli% pr(ici5cy /atus1 immigration /atus1 l5g? ( /ay 9 ! ,unit$ ,/ates age1 disability1 sex 7includ+ g5d] id5tity & sexual ori5tation71 inc>c]ation1 homelessness1 geography1 & socioeconomic /atus2 & 7#b7 make su* data available = public use & analysis4 7g7 ,privacy ,not)/&+ any o!r ,f$]al or ,/ate law1 no ,f$]al or ,/ate (ficial or employee or o!r entity %all disclose1 or use1 = any law en=cem5t or immigration purpose1 any p]sonally id5tifiable in=mation 7includ+ ) respect to an individual's religi\s beliefs1 practices1 or affiliation1 national orig91 e?nicity1 or immigration /atus7 t is collect$ or ma9ta9$ pursuant to ?is section4 4 #faf4 ,(fice ( ,prim>y ,c>e ,title ,,xvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjju et seq47 is am5d$ by add+ at ! end ! foll[+3 #agac4 ,(fice ( ,prim>y ,c>e 7a7 ,9 g5]al ,!re is e/abli%$1 9 ! ,(fice ( ,heal? ,equity e/abli%$ "u section #agab1 an ,(fice ( ,prim>y ,heal? ,c>e1 to be head$ by a ,director1 to ensure coord9ation & collaboration across ! programs & activities ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices ) respect to increas+ access to high-quality prim>y heal? c>e1 p>ticul>ly 9 und]s]v$ areas & = und]s]v$ populations4 7b7 ,national ,goals ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is section1 ! ,director ( ! ,(fice ( ,prim>y ,heal? ,c>e %all publi% national goals-- 7#a7 to increase access to high-quality prim>y heal? c>e1 p>ticul>ly 9 und]s]v$ areas & = und]s]v$ populations2 & 7#b7 to address heal? disp>ities1 includ+ ) respect to race1 e?nicity1 national orig9 7disaggregat$ by major e?nic gr\p & ,tribal affiliation71 prim>y language use1 ,engli% pr(ici5cy /atus1 immigration /atus1 l5g? ( /ay 9 ! ,unit$ ,/ates1 age1 disability1 sex 7includ+ g5d] id5tity & sexual ori5tation71 inc>c]ation1 homelessness1 geography1 & socioeconomic /atus4 7c7 ,o!r responsibilities ,9 c>ry+ out subsections 7a7 & 7b71 ! ,director ( ! ,(fice ( ,prim>y ,heal? ,c>e %all-- 7#a7 coord9ate1 9 consultation ) ! ,secret>y1 heal? pr(essional education policies & goals to a*ieve ! national goals publi%$ pursuant to subsection 7b72 7#b7 develop & ma9ta9 a sy/em to monitor ! numb] & specialties ( individuals pursu+ c>e]s 91 or practic+1 prim>y heal? c>e ?r\gh _! heal? pr(essional education1 any po/graduate tra9+1 & pr(essional practice2 7#c7 develop1 coord9ate1 & promote policies t exp& ! numb] ( prim>y heal? c>e practition]s1 regi/]$ nurses1 advance practice cl9icians1 & d5ti/s2 7#d7 recomm5d appropriate tra9+1 te*nical assi/ance1 & pati5t protection enhancem5ts = prim>y c>e heal? pr(essionals1 includ+ regi/]$ nurses1 to a*ieve uni=m high quality & pati5t safety2 7#e7 provide recomm5dations on t>get$ programs & res\rces = ,f$]ally qualifi$ heal? c5t]s1 rural heal? c5t]s1 community heal? c5t]s1 & o!r community-bas$ organizations2 7#f7 provide recomm5dations = broad] pati5t ref]ral to additional res\rces1 n limit$ to heal? c>e1 & collaboration ) o!r organizations & sectors t influ5ce heal? outcomes2 & 7#g7 consult ) ! ,secret>y on ! allocation ( ! special projects budget "u section #fja7;a77#b77;,c7 ( ! ,m$ic>e = ,all ,act4 7d7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$-- 7#a7 to preempt any provision ( ,/ate law e/abli%+ practice /&>ds or guidel9es = heal? c>e pr(essionals1 includ+ pr(essional lic5s+ or practice laws or regulations2 or 7#b7 to require t any ,/ate impose additional educational /&>ds or guidel9es = heal? c>e pr(essionals4 4 #fag4 ,paym5ts = prescription drugs & approv$ devices & equipm5t ,! prices to be paid = cov]$ ph>maceuticals1 m$ical supplies1 m$ical te*nologies1 & m$ically necess>y equipm5t cov]$ "u ?is ,act %all be negotiat$ annually by ! ,secret>y4 7#a7 ,9 g5]al ,not)/&+ any o!r provision ( law1 ! ,secret>y %all1 = fiscal ye>s beg9n+ on or aft] ! date ( ! enactm5t ( ?is subsection1 negotiate ) ph>maceutical manufactur]s ! prices 7includ+ disc\nts1 rebates1 & o!r price concessions7 t may be *>g$ to ! ,m$ic>e = ,all ,program dur+ a negotiat$ price p]iod 7z specifi$ by ! ,secret>y7 = cov]$ drugs = eligible individuals "u ! ,m$ic>e = ,all ,program4 ,9 negotiat+ su* prices "u ?is section1 ! ,secret>y %all take into acc\nt ! foll[+ factors3 7,a7 ,! comp>ative cl9ical effectiv5ess & co/ effectiv5ess1 :5 available f an imp>tial s\rce1 ( su* drug4 7,b7 ,! budget>y impact ( provid+ cov]age ( su* drug4 7,c7 ,! numb] ( simil>ly effective drugs or alt]native treatm5t regim5s = ea* approv$ use ( su* drug4 7,d7 ,! total rev5ues f global sales obta9$ by ! manufactur] = su* drug & ! associat$ inve/m5t 9 rese>* & developm5t ( su* drug by ! manufactur]4 7#b7 ,f9alization ( negotiat$ price ,! negotiat$ price ( ea* cov]$ drug = a negotiat$ price p]iod %all be f9aliz$ n lat] ?an #cj days be=e ! fir/ fiscal ye> 9 su* negotiat$ price p]iod4 7#c7 ,competitive lic5s+ au?ority 7,a7 ,9 g5]al ,not)/&+ any exclusivity "u clause 7iii7 or 7iv7 ( section #eje7;j77#e77;,f7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act1 clause 7iii7 or 7iv7 ( section #eje7;c77#c77;,e7 ( su* ,act1 section #cea7k77#g77;,a7 ( ! ,public ,heal? ,s]vice ,act1 or section #ebg7;a7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act1 or by an ext5sion ( su* exclusivity "u section #eje;,a ( su* ,act or section #eje;,e ( su* ,act1 & any o!r provision ( law t provides = m>ket exclusivity 7or ext5sion ( m>ket exclusivity7 ) respect to a drug1 9 ! case t ! ,secret>y is unable to success fully negotiate an appropriate price = a cov]$ drug = a negotiat$ price p]iod1 ! ,secret>y %all au?orize ! use ( any pat5t1 cl9ical trial data1 or o!r exclusivity grant$ by ! ,f$]al ,gov]nm5t ) respect to su* drug z ! ,secret>y det]m9es appropriate = purposes ( manufactur+ su* drug = sale "u ,m$ic>e = ,all ,program4 ,any entity mak+ use ( a competitive lic5se to use pat5t1 cl9ical trial data1 or o!r exclusivity "u ?is section %all provide to ! manufactur] hold+ su* exclusivity reasonable comp5sation1 z det]m9$ by ! ,secret>y bas$ on ! foll[+ factors3 7i7 ,! risk-adju/$ value ( any ,f$]al ,gov]nm5t subsidies & inve/m5ts 9 rese>* & developm5t us$ to support ! developm5t ( su* drug4 7ii7 ,! risk-adju/$ value ( any inve/m5t made by su* manufactur] 9 ! rese>* & developm5t ( su* drug4 7iii7 ,! impact ( ! price1 includ+ lic5se comp5sation paym5ts1 on meet+ ! m$ical ne$ ( all pati5ts at a reasonable co/4 7iv7 ,! relation%ip betwe5 ! price ( su* drug1 includ+ comp5sation paym5ts1 & ! heal? b5efits ( su* drug4 7v7 ,o!r relevant factors det]m9$ appropriate by ! ,secret>y to provide reasonable comp5sation4 7,b7 ,reasonable comp5sation ,! manufactur] describ$ 9 subp>agraph 7,a7 may seek recov]y aga9/ ! ,unit$ ,/ates 9 ! ,unit$ ,/ates ,c\rt ( ,f$]al ,claims4 7,c7 ,int]im p]iod ,until #a ye> aft] a drug describ$ 9 subp>agraph 7,a7 is approv$ "u section #eje7;j7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act or section #cea7k7 ( ! ,public ,heal? ,s]vice ,act & is provid$ "u lic5se issu$ by ! ,secret>y "u su* subp>agraph1 ! ,m$ic>e = ,all ,program %all n pay m = su* drug ?an ! av]age ( ! prices available1 dur+ ! mo/ rec5t #ab-mon? p]iod = :i* data is available prior to ! beg9n+ ( su* negotiat$ price p]iod1 f ! manufactur] to any :olesal]1 retail]1 provid]1 heal? ma9t5ance organization1 nonpr(it entity1 or gov]nm5tal entity 9 ! t5 ,,oecd 7,organization = ,economic ,coop]ation & ,developm5t7 c\ntries t h ! l>ge/ gross dome/ic product ) a p] capita income t is n less ?an half ! p] capita income ( ! ,unit$ ,/ates4 7,d7 ,au?orization = ,secret>y to procure drugs directly ,! ,secret>y may procure a drug manufactur$ pursuant to a competitive lic5se "u subp>agraph 7,a7 = purposes ( ?is ,act4 7#d7 ,,fda review ( lic5s$ drug applications ,! ,secret>y %all prioritize review ( applications "u section #eje7;j7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act = drugs lic5s$ "u p>agraph 7#c77;,a74 7#e7 ,prohibition ( anticompetitive behavior ,no drug manufactur] may engage 9 anticompetitive behavior ) ano!r manufactur] t may int]f]e ) ! issuance & implem5tation ( a competitive lic5se or run contr>y to public policy4 7#f7 ,requir$ report+ ,! ,secret>y may require ph>maceutical manufactur]s to disclose to ! ,secret>y su* in=mation t ! ,secret>y det]m9es necess>y = purposes ( c>ry+ out ?is subsection4 ,,vii ,univ]sal ,m$ic>e ,tru/ ,fund #gja4 ,univ]sal ,m$ic>e ,tru/ ,fund 7a7 ,9 g5]al ,!re is h]eby creat$ on ! books ( ! ,treasury ( ! ,unit$ ,/ates a tru/ fund to be kn[n z ! ,univ]sal ,m$ic>e ,tru/ ,fund 79 ?is section ref]r$ to z ! ,tru/ ,fund74 ,! ,tru/ ,fund %all consi/ ( su* gifts & beque/s z may be made & su* am\nts z may be deposit$ 91 or appropriat$ to1 su* ,tru/ ,fund z provid$ 9 ?is ,act4 7b7 ,appropriations into tru/ fund 7#a7 ,taxes ,!re are appropriat$ to ! ,tru/ ,fund = ea* fiscal ye> beg9n+ ) ! fiscal ye> :i* includes ! date on :i* b5efits fir/ become available z describ$ 9 section #ajf1 out ( any moneys 9 ! ,treasury n o!rwise appropriat$1 am\nts equival5t to #ajj p]c5t ( ! net increase 9 rev5ues to ! ,treasury :i* is attributable to ! am5dm5ts made by sections #hja & #ijb4 ,! am\nts appropriat$ by ! prec$+ s5t5ce %all be transf]r$ f "t to "t 7b n less frequ5tly ?an mon?ly7 f ! g5]al fund 9 ! ,treasury to ! ,tru/ ,fund1 su* am\nts to be det]m9$ on ! basis ( e/imates by ! ,secret>y ( ! ,treasury ( ! taxes paid to or deposit$ into ! ,treasury1 & prop] adju/m5ts %all be made 9 am\nts subsequ5tly transf]r$ to ! ext5t prior e/imates 7 9 excess ( or 7 less ?an ! am\nts t %\ld h be5 s transf]r$4 7#b7 ,curr5t program receipts 7,a7 ,initial ye> ,not)/&+ any o!r provision ( law1 !re is appropriat$ to ! ,tru/ ,fund = ! fiscal ye> conta9+ ,janu>y #a ( ! fir/ ye> foll[+ ! date ( ! enactm5t ( ?is ,act1 an am\nt equal to ! aggregate am\nt appropriat$ = ! prec$+ fiscal ye> = ! foll[+ 7increas$ by ! consum] price index = all urban consum]s = ! fiscal ye> involv$73 7i7 ,! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7o!r ?an am\nts attributable to any premiums "u su* title74 7ii7 ,! ,m$icaid program "u ,/ate plans approv$ "u title ,,xix ( su* ,act4 7iii7 ,! ,f$]al ,employees ,heal? ,b5efits program1 "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code4 7iv7 ,! pur*as$ c>e compon5t ( ! ,,tric>e program1 "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code 7o!r ?an am\nts appropriat$ = ! pur*as$ c>e compon5t ( ! ,,tric>e ,ov]seas ,program74 7v7 ,! mat]nal & *ild heal? program 7"u title ,v ( ! ,social ,security ,act71 vocational rehabilitation programs1 programs = drug abuse & m5tal heal? s]vices "u ! ,public ,heal? ,s]vice ,act1 programs provid+ g5]al hospital or m$ical assi/ance1 & any o!r ,f$]al program id5tifi$ by ! ,secret>y1 9 consultation ) ! ,secret>y ( ! ,treasury1 to ! ext5t ! programs provide = paym5t = heal? s]vices ! paym5t ( :i* may be made "u ?is ,act4 7,b7 ,subsequ5t ye>s ,n)/&+ any o!r provision ( law1 !re is appropriat$ to ! tru/ fund = ! fiscal ye> conta9+ ,janu>y #a ( ! second ye> foll[+ ! date ( ! enactm5t ( ?is ,act1 & = ea* fiscal ye> !reaft]1 an am\nt equal to ! am\nt appropriat$ to ! ,tru/ ,fund = ! previ\s ye>1 adju/$ = r$uctions 9 co/s result+ f ! implem5tation ( ?is ,act1 *anges 9 ! consum] price index = all urban consum]s = ! fiscal ye> involv$1 & o!r factors det]m9$ appropriate by ! ,secret>y4 7#c7 ,re/rictions %all n apply ,any o!r provision ( law 9 effect on ! date ( enactm5t ( ?is ,act re/rict+ ! use ( ,f$]al funds = any reproductive heal? s]vice %all n apply to monies 9 ! ,tru/ ,fund4 7c7 ,incorporation ( provisions ,! provisions ( subsections 7b7 ?r\gh 7i7 ( section #ahag ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 %all apply to ! ,tru/ ,fund "u ?is section 9 ! same mann] z su* provisions appli$ to ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u su* section #ahag1 except t1 = purposes ( apply+ su* subsections to ?is section1 ! ,bo>d ( ,tru/ees ( ! ,tru/ ,fund %all mean ! ,secret>y4 7d7 ,transf] ( funds ,any am\nts rema9+ 9 ! ,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 ( su* ,act 7#db ,u4,s4,c4 #aciet7 aft] ! paym5t ( claims = items & s]vices furni%$ "u title ,,xviii ( su* ,act h be5 complet$1 %all be transf]r$ into ! ,univ]sal ,m$ic>e ,tru/ ,fund "u ?is section4 ,,viii ,con=m+ ,am5dm5ts to ! ,employee ,retirem5t ,income ,security ,act ( #aigd #hja4 ,prohibition ( employee b5efits duplicative ( b5efits "u ! ,m$ic>e = ,all ,program2 coord9ation 9 case ( work]s' comp5sation 7a7 ,9 g5]al ,"p #e ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aaca et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #ebb4 ,prohibition ( employee b5efits duplicative ( ,univ]sal ,m$ic>e ,program b5efits2 coord9ation 9 case ( work]s' comp5sation 7a7 ,9 g5]al ,subject to subsection 7b71 no employee b5efit plan may provide b5efits t duplicate paym5t = any items or s]vices = :i* paym5t may be made "u ! ,m$ic>e = ,all ,act4 7b7 ,reimbursem5t ,ea* work]s comp5sation c>ri] t is liable = paym5t = work]s comp5sation s]vices furni%$ 9 a ,/ate %all reimburse ! ,m$ic>e = ,all ,program = ! co/ ( su* s]vices4 7c7 ,def9itions ,9 ?is subsection-- 7#a7 ! t]m work]s comp5sation c>ri] means an insurance company t und]write work]s comp5sation m$ical b5efits ) respect to "o or m employ]s & includes an employ] or fund t is f9ancially at risk = ! provision ( work]s comp5sation m$ical b5efits2 7#b7 ! t]m work]s comp5sation m$ical b5efits means1 ) respect to an enrollee :o is an employee subject to ! work]s comp5sation laws ( a ,/ate1 ! compreh5sive m$ical b5efits = "w-relat$ injuries & illnesses provid$ = "u su* laws ) respect to su* an employee2 & 7#c7 ! t]m work]s comp5sation s]vices means items & s]vices includ$ 9 work]s comp5sation m$ical b5efits & includes items & s]vices 7includ+ rehabilitation s]vices & long-t]m c>e s]vices7 commonly us$ = treatm5t ( "w-relat$ injuries & illnesses4 4 7b7 ,con=m+ am5dm5t ,section #d7;b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajjc7;b77 is am5d$ by add+ at ! end ! foll[+3 ,p>agraph 7#c7 %all apply subject to section #ebb7;b7 7relat+ to reimbursem5t ( ! ,m$ic>e = ,all ,program by work]s comp5sation c>ri]s744 7c7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( su* ,act is am5d$ by ins]t+ aft] ! item relat+ to section #eba ! foll[+ new item3 ,sec4 #ebb4 ,prohibition ( employee b5efits duplicative ( ,univ]sal ,m$ic>e ,program b5efits2 coord9ation 9 case ( work]s' comp5sation4 4 #hjb4 ,application ( cont9uation cov]age requirem5ts "u ,,erisa & c]ta9 o!r requirem5ts relat+ to gr\p heal? plans 7a7 ,9 g5]al ,"p #f ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aafa et seq47 %all apply only ) respect to any employee heal? b5efit plan t does n duplicate paym5ts = any items or s]vices = :i* paym5t may be made "u ! ?is ,act4 7b7 ,con=m+ am5dm5t ,section #fja ( "p #f ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#ai ,u4,s4,c4 #aafa7 is am5d$ by add+ ! foll[+ subsection at ! end3 7c7 ,subsection 7a7 %all apply to any gr\p heal? plan t does n duplicate paym5ts = any items or s]vices = :i* paym5t may be made "u ! ,m$ic>e = ,all ,act4 4 #hjc4 ,effective date ( title ,! provisions ( & am5dm5ts made by ?is title %all take effect on ! date describ$ 9 section #ajf7;a74 ,,ix ,additional ,con=m+ ,am5dm5ts #ija4 ,relation%ip to exi/+ ,f$]al heal? programs 7a7 ,m$ic>e1 ,m$icaid1 & ,/ate ,*ildr5's ,heal? ,insurance ,program 7,,s*ip7 7#a7 ,9 g5]al ,not)/&+ any o!r provision ( law & ) respect to an individual eligible to enroll "u ?is ,act1 subject to p>agraphs 7#b7 & 7#c7-- 7,a7 no b5efits %all be available "u title ,,xviii ( ! ,social ,security ,act = any item or s]vice furni%$ beg9n+ on ! date t is #b ye>s aft] ! date ( ! enactm5t ( ?is ,act2 7,b7 no individual is entitl$ to m$ical assi/ance "u a ,/ate plan approv$ "u title ,,xix ( su* ,act = any item or s]vice furni%$ on or aft] su* date2 7,c7 no individual is entitl$ to m$ical assi/ance "u a ,/ate *ild heal? plan "u title ,,xxi ( su* ,act = any item or s]vice furni%$ on or aft] su* date2 & 7,d7 no paym5t %all be made to a ,/ate "u section #aijc7;a7 or #baje7;a7 ( su* ,act ) respect to m$ical assi/ance or *ild heal? assi/ance = any item or s]vice furni%$ on or aft] su* date4 7#b7 ,transition ,9 ! case ( inpati5t hospital s]vices & ext5d$ c>e s]vices dur+ a cont9u\s p]iod ( /ay :i* began be=e ! effective date ( b5efits "u section #ajf1 & :i* _h n end$ z ( su* date1 = :i* b5efits are provid$ "u title ,,xviii ( ! ,social ,security ,act1 "u a ,/ate plan "u title ,,xix ( su* ,act1 or "u a ,/ate *ild heal? plan "u title ,,xxi ( su* ,act1 ! ,secret>y %all provide = cont9uation ( b5efits "u su* title or plan until ! end ( ! p]iod ( /ay4 7#c7 ,s*ool programs ,all s*ool relat$ heal? programs1 c5t]s1 initiatives1 s]vices1 or o!r activities or "w provid$ "u title ,,xix or title ,,xxi ( ! ,social ,security ,act z ( ,janu>y #a1 #bjai1 %all be cont9u$ & cov]$ by ! ,m$ic>e = ,all ,program4 7b7 ,f$]al employees heal? b5efits program ,no b5efits %all be made available "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 ) respect to items & s]vices furni%$ to any individual eligible to enroll "u ?is ,act4 7c7 ,,tric>e ,program 7#a7 ,direct c>e compon5t ,no?+ 9 ?is ,act %all affect ! eligibility ( b5efici>ies "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code1 :o are entitl$ to receive c>e furni%$ at facilities ( ! uni=m$ s]vices "u ! ,,tric>e program = su* c>e4 7#b7 ,pur*as$ c>e compon5t 7,a7 ,9 g5]al ,except z provid$ 9 subp>agraph 7,b71 no b5efits %all be made available "u ! pur*as$ c>e compon5t ( ! ,,tric>e program = items or s]vices furni%$ to any individual eligible to enroll "u ?is ,act4 7,b7 ,,tric>e ,ov]seas ,dur+ any p]iod 9 :i* an individual is eligible = b5efits "u ! ,,tric>e ,ov]seas ,program & is locat$ 9 a ,,tric>e ov]seas region1 ! individual may receive b5efits = items or s]vices furni%$ to ! individual "u ! pur*as$ c>e compon5t ( su* program dur+ su* p]iod4 7d7 ,treatm5t ( b5efits = vet]ans & ,native ,am]icans 7#a7 ,9 g5]al ,no?+ 9 ?is ,act %all affect ! eligibility ( vet]ans = ! m$ical b5efits & s]vices provid$ "u title #ch1 ,unit$ ,/ates ,code1 or ( ,indians = ! m$ical b5efits & s]vices provid$ by or ?r\gh ! ,indian ,heal? ,s]vice4 7#b7 ,reevaluation ,no reevaluation ( ! ,indian ,heal? ,s]vice %all be und]tak5 )\t consultation ) tribal lead]s & /akehold]s4 #ijb4 ,sunset ( provisions relat$ to ! ,/ate ,ex*anges ,effective on ! date t is #b ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,f$]al & ,/ate ,ex*anges e/abli%$ pursuant to title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh7 %all t]m9ate1 & any o!r provision ( law t relies ^u p>ticipation 9 or enrollm5t ?r\gh su* an ,ex*ange1 includ+ su* provisions ( ! ,int]nal ,rev5ue ,code ( #aihf1 %all cease to h =ce or effect4 #ijc4 ,sunset ( provisions relat$ to pay = p]=mance programs 7a7 ,effective on ! date describ$ 9 section #ajf7;a71 ! ,f$]al programs relat$ to pay = p]=mance programs & value-bas$ pur*as+ %all t]m9ate1 & any o!r provision ( law t relies ^u p>ticipation 9 or enrollm5t 9 su* program %all cease to h =ce or effect4 ,programs t %all t]m9ate include-- 7#a7 ! ,m]it-bas$ ,inc5tive ,paym5t ,sy/em e/abli%$ pursuant to subsection 7q7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q772 7#b7 ! inc5tives = mean+ful use ( c]tifi$ ,,ehr te*nology e/abli%$ pursuant to subsection 7a77#g7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;a77#g772 7#c7 ! inc5tives = adoption & mean+ful use ( c]tifi$ ,,ehr te*nology e/abli%$ pursuant to subsection 7o7 ( section #ahdh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o772 7#d7 alt]native paym5t models e/abli%$ "u section #ahcc7z7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie7z772 & 7#e7 ! foll[+ programs z e/abli%$ pursuant to ! foll[+ sections ( ! ,pati5t ,protection & ,af=dable ,c>e ,act3 7,a7 ,section #bgja 7adult heal? quality measures74 7,b7 ,section #bgjb 7paym5t adju/m5ts = heal? c>e acquir$ conditions74 7,c7 ,section #bgjf 7,p$iatric ,acc\ntable ,c>e ,organization ,demon/ration ,projects = ! purposes ( receiv+ inc5tive paym5ts74 7,d7 ,section #cjjb7;b7 7#db ,u4,s4,c4 #aciew-#d7;a77#h77 7inc5tive paym5ts = quality report+74 7,e7 ,section #cjja7;a7 7#db ,u4,s4,c4 #acieww7o77 7,hospital ,value-,bas$ ,pur*as+74 7,f7 ,section #cjjf 7value-bas$ pur*as+ program = skill$ nurs+ facilities & home heal? ag5cies74 7,g7 ,section #cjjg 7#db ,u4,s4,c4 #aciew-#d7p77 7value bas$ paym5t modifi] "u physician fee s*$ule74 7,h7 ,section #cjjh 7#db ,u4,s4,c4 #acieww7p77 7paym5t adju/m5ts = heal? c>e-acquir$ condition74 7,i7 ,section #cjbb 7#db ,u4,s4,c4 #acie;jjj7 7,m$ic>e %>$ sav+s programs74 7,j7 ,section #cjbc 7#db ,u4,s4,c4 #acie;cc-#d7 7,national ,pilot ,program on ,paym5t ,bundl+74 7,k7 ,section #cjbd 7#db ,u4,s4,c4 #acie;cc-#e7 7,indep5d5ce at home demon/ration program74 7,l7 ,section #cjbe 7#db ,u4,s4,c4 #acieww7q77 7hospital readmissions r$uction program74 7,m7 ,section #ajcja 7plans = value-bas$ pur*as+ program = ambulatory surgical c5t]s74 ,x ,transition ,a ,m$ic>e = ,all ,transition ov] #b ,ye>s & ,transitional ,buy-,9 ,option #ajja4 ,m$ic>e = all transition ov] two ye>s ,title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;c et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #ahii;,c4 ,m$ic>e = all transition ov] #b ye>s 7a7 ,transition 7#a7 ,9 g5]al ,e individual :o meets ! requirem5ts describ$ 9 p>agraph 7#c7 %all be eligible to enroll 9 ! ,m$ic>e = ,all ,program "u ?is section dur+ ! transition p]iod />t+ "o ye> aft] ! date ( enactm5t ( ! ,m$ic>e = ,all ,act4 7#b7 ,b5efits ,an individual enroll$ "u ?is section is entitl$ to ! b5efits e/abli%$ "u title ,,ii ( ! ,m$ic>e = ,all ,act4 7#c7 ,requirem5ts = eligibility ,! requirem5ts describ$ 9 ?is p>agraph are ! foll[+3 7,a7 ,! individual meets ! eligibility requirem5ts e/abli%$ by ! ,secret>y "u title ,i ( ! ,m$ic>e = ,all ,act4 7,b7 ,! individual has atta9$ ! applicable ye> ( age1 or is curr5tly enroll$ 9 ,m$ic>e at ! "t ( ! transition to ,m$ic>e = ,all4 7#d7 ,applicable ye> ( age def9$ ,= purposes ( ?is section1 ! t]m applicable ye> ( age means "o ye> aft] ! date ( enactm5t ( ! ,m$ic>e = ,all ,act1 ! age ( #ee or old]1 ! age #ah or y\ng]4 7b7 ,enrollm5t2 cov]age ,! ,secret>y %all e/abli% enrollm5t p]iods & cov]age "u ?is section consi/5t ) ! pr9ciples = e/abli%m5t ( enrollm5t p]iods & cov]age = individuals "u o!r provisions ( ?is title4 ,! ,secret>y %all e/abli% su* p]iods s t cov]age "u ?is section %all fir/ beg9 on ,janu>y #a ( ! ye> on :i* an individual fir/ becomes eligible to enroll "u ?is section4 7c7 ,satisfaction ( individual m&ate ,= purposes ( apply+ section #ejjj;,a ( ! ,int]nal ,rev5ue ,code ( #aihf1 ! cov]age provid$ "u ?is section con/itutes m9imum ess5tial cov]age "u subsection 7f77#a77;,a77i7 ( su* section #ejjj;,a4 7d7 ,consultation ,9 promulgat+ regulations to implem5t ?is section1 ! ,secret>y %all consult ) int]e/$ p>ties1 includ+ gr\ps repres5t+ b5efici>ies1 heal? c>e provid]s1 employ]s1 & insurance companies4 4 #ajjb4 ,e/abli%m5t ( ! ,m$ic>e transition buy-9 7a7 ,9 g5]al ,to c>ry out ! purpose ( ?is section1 = ! ye> beg9n+ "o ye> aft] ! date ( enactm5t ( ?is ,act & end+ ) ! effective date describ$ 9 section #ajf7;a71 ! ,secret>y1 act+ ?r\gh ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid 7ref]r$ to 9 ?is section z ! ,adm9i/rator71 %all e/abli%1 & provide = ! (f]+ ?r\gh ! ,ex*anges1 an option to buy 9 to ! ,m$ic>e = ,all ,program 79 ?is ,act ref]r$ to z ! ,m$ic>e ,transition buy-974 7b7 ,adm9i/]+ ! m$ic>e transition buy-,9 7#a7 ,adm9i/rator ,! ,adm9i/rator %all adm9i/] ! ,m$ic>e ,transition buy-9 9 accordance ) ?is section4 7#b7 ,application ( ,,aca requirem5ts ,consi/5t ) ?is section1 ! ,m$ic>e ,transition buy-9 %all comply ) requirem5ts "u title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7& ! am5dm5ts made by t title7 & title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 t are applicable to qualifi$ heal? plans (f]$ ?r\gh ! ,ex*anges1 subject to ! limitation "u subsection 7e77#b74 7#c7 ,(f]+ ?r\gh ex*anges ,! ,m$ic>e ,transition buy-9 %all be made available only ?r\gh ! ,ex*anges1 & %all be available to individuals wi%+ to enroll & to qualifi$ employ]s 7z def9$ 9 section #acab7;f77#b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjcb77 :o wi% to make su* plan available to _! employees4 7#d7 ,eligibility to pur*ase ,any ,unit$ ,/ates resid5t may enroll 9 ! ,m$ic>e ,transition buy-94 7c7 ,b5efits2 actu>ial value ,9 c>ry+ out ?is section1 ! ,adm9i/rator %all ensure t ! ,m$ic>e ,transition buy-9 provides-- 7#a7 cov]age = ! b5efits requir$ to be cov]$ "u title ,,ii ( ?is ,act2 & 7#b7 cov]age ( b5efits t are actu>ially equival5t to #ij p]c5t ( ! full actu>ial value ( ! b5efits provid$ "u ! plan4 7d7 ,provid]s & reimbursem5t rates 7#a7 ,9 g5]al ,) respect to ! reimbursem5t provid$ to heal? c>e provid]s = cov]$ b5efits1 z describ$ 9 section #bja1 provid$ "u ! ,m$ic>e ,transition buy-91 ! ,adm9i/rator %all reimburse su* provid]s at rates det]m9$ = equival5t items & s]vices "u ! ,m$ic>e = ,all fee-=-s]vice s*$ule e/abli%$ 9 section #fab7;b7 ( ?is ,act4 7#b7 ,prescription drugs ,any paym5t rate "u ?is subsection = a prescription drug %all be at ! prices negotiat$ "u section #faf ( ?is ,act4 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 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 or "u a ,/ate ,m$icaid plan "u title ,,xix ( su* ,act 7#db ,u4,s4,c4 #acif et seq47 on ! date ( enactm5t ( ?is ,act %all be a p>ticipat+ provid] 9 ! ,m$ic>e ,transition buy-94 7,b7 ,additional provid]s ,! ,adm9i/rator %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 9 ! ,m$ic>e ,transition buy-94 ,su* process %all be simil> to ! process appli$ to new provid]s "u ! ,m$ic>e program4 7e7 ,premiums 7#a7 ,det]m9ation ,! ,adm9i/rator %all det]m9e ! premium am\nt = enroll+ 9 ! ,m$ic>e ,transition buy-91 :i*-- 7,a7 may v>y accord+ to family or individual cov]age1 age1 & tobacco /atus 7consi/5t ) clauses 7i71 7iii71 & 7iv7 ( section #bgja7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg7a77#a77;,a7772 & 7,b7 %all take into acc\nt ! co/-%>+ r$uctions & premium tax cr$its :i* w be available ) respect to ! plan "u section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjga7 & section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by subsection 7g74 7#b7 ,limitation ,v>iation 9 premium rates ( ! ,m$ic>e ,transition buy-9 by rat+ area1 z describ$ 9 clause 7ii7 ( section #bgja7;a77#a77;,a77iii7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg7a77#a77;,a77 is n p]mitt$4 7f7 ,t]m9ation ,?is section %all cease to h =ce or effect on ! effective date describ$ 9 section #ajf7;a74 7g7 ,tax cr$its & co/-,%>+ subsidies 7#a7 ,premium assi/ance tax cr$its 7,a7 ,cr$its all[$ to m$ic>e transition buy-9 enrollees 9 non-expansion /ates ,p>agraph 7#a7 ( section #cf;,b7c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by r$esignat+ subp>agraphs 7,c7 & 7,d7 z subp>agraphs 7,d7 & 7,e71 respectively1 & by ins]t+ aft] subp>agraph 7,b7 ! foll[+ new subp>agraph3 7,c7 ,special rules = m$ic>e transition buy-9 enrollees 7i7 ,9 g5]al ,9 ! case ( a taxpay] :o is cov]$1 or ^: sp\se or dep5d5t 7z def9$ 9 section #aeb7 is cov]$1 by ! ,m$ic>e ,transition buy-9 e/abli%$ "u section #ajjb7;a7 ( ! ,m$ic>e = ,all ,act = all mon?s 9 ! taxable ye>1 subp>agraph 7,a7 %all be appli$ )\t reg>d to b does n exce$ #djj p]c5t4 7ii7 ,enrollees 9 m$icaid nonexpansion /ates ,9 ! case ( a taxpay] resid+ 9 a ,/ate :i* 7z ( ! date ( ! enactm5t ( ! ,m$ic>e = ,all ,act7 does n provide = eligibility "u clause 7i77,,viii7 or 7ii77,,xx7 ( section #aijb7;a77#aj77;,a7 ( ! ,social ,security ,act = m$ical assi/ance "u title ,,xix ( su* ,act 7or a waiv] ( ! ,/ate plan approv$ "u section #aaae7 :o is cov]$1 or ^: sp\se or dep5d5t 7z def9$ 9 section #aeb7 is cov]$1 by ! ,m$ic>e ,transition buy-9 e/abli%$ "u section #ajjb7;a7 ( ! ,m$ic>e = ,all ,act = all mon?s 9 ! taxable ye>1 subp>agraphs 7,a7 & 7,b7 %all be appli$ by sub/itut+ #j p]c5t = #ajj p]c5t ea* place x appe>s4 4 7,b7 ,premium assi/ance am\nts = taxpay]s enroll$ 9 m$ic>e transition buy-9 7i7 ,9 g5]al ,subp>agraph 7,a7 ( section #cf;,b7b77#c7 ( su* ,code is am5d$--7,i7 by r$esignat+ clause 7ii7 z clause 7iii71 7,,ii7 by /rik+ clause 7ii7 9 clause 7i7 & ins]t+ clauses 7ii7 & 7iii71 & 7,,iii7 by ins]t+ aft] clause 7i7 ! foll[+ new clause3 7ii7 ,special rules = taxpay]s enroll$ 9 m$ic>e transition buy-9 ,9 ! case ( a taxpay] :o is cov]$1 or ^: sp\se or dep5d5t 7z def9$ 9 section #aeb7 is cov]$1 by ! ,m$ic>e ,transition buy-9 e/abli%$ "u section #ajjb7;a7 ( ! ,m$ic>e = ,all ,act = all mon?s 9 ! taxable ye>1 ! applicable p]c5tage = any taxable ye> %all be det]m9$ 9 ! same mann] z "u clause 7i71 except t ! foll[+ table %all apply 9 lieu ( ! table conta9$ 9 su* clause3 ,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 #ajj p]c5t#b4jjb4jjajj p]c5t up to #ach p]c5t#b4jdb4jdach p]c5t up to #aej p]c5t#c4jfd4jhaej p]c5t & above#d4jhe4jj4 4 7ii7 ,con=m+ am5dm5t ,subclause 7,i7 ( clause 7iii7 ( section #cf;,b7b77#c7 ( su* ,code1 z r$esignat$ by subp>agraph 7,a77i71 is am5d$ by ins]t+ 1 & det]m9$ aft] ! application ( clause 7ii7 aft] aft] application ( ?is clause4 7#b7 ,co/-%>+ subsidies ,subsection 7b7 ( section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjga7;b77 is am5d$-- 7,a7 by ins]t+ 1 or 9 ! ,m$ic>e ,transition buy-9 e/abli%$ "u section #ajjb7;a7 ( ! ,m$ic>e = ,all ,act1 aft] cov]age 9 p>agraph 7#a72 7,b7 by r$esignat+ p>agraphs 7#a7 7z s am5d$7 & 7#b7 z subp>agraphs 7,a7 & 7,b71 respectively1 & by mov+ su* subp>agraphs #b ems to ! "r2 7,c7 by /rik+ insur$4--,9 ?is section & ins]t+ 8insur$4-- 7#a7 ,9 g5]al ,9 ?is section 2 7,d7 by /rik+ ! flu% language2 & 7,e7 by add+ at ! end ! foll[+ new p>agraph3 7#b7 ,special rules 7,a7 ,individuals lawfully pres5t ,9 ! case ( an individual describ$ 9 section #cf;,b7c77#a77;,b7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 ! individual %all be treat$ z hav+ h\sehold income equal to #ajj p]c5t ( ! pov]ty l9e = a family ( ! size involv$ = purposes ( apply+ ?is section4 7,b7 ,m$ic>e transition buy-9 enrollees 9 m$icaid non-expansion /ates ,9 ! case ( an individual resid+ 9 a ,/ate :i* 7z ( ! date ( ! enactm5t ( ! ,m$ic>e = ,all ,act7 does n provide = eligibility "u clause 7i77,,viii7 or 7ii77,,xx7 ( section #aijb7;a77#aj77;,a7 ( ! ,social ,security ,act = m$ical assi/ance "u title ,,xix ( su* ,act 7or a waiv] ( ! ,/ate plan approv$ "u section #aaae7 :o enrolls 9 su* ,m$ic>e ,transition buy-91 ! prec$+ s5t5ce1 p>agraph 7#a77;,b71 & p>agraphs 7#a77;,a77i7 & 7#b77;,a7 ( subsection 7c7 %all ea* be appli$ by sub/itut+ #j p]c5t = #ajj p]c5t ea* place x appe>s4 4 7h7 ,con=m+ am5dm5ts 7#a7 ,treatm5t z a qualifi$ heal? plan ,section #acja7;a77#b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjba7;a77#b77 is am5d$-- 7,a7 9 ! p>agraph head+1 by ins]t+ ,! ,m$ic>e transition buy-91 be=e &2 & 7,b7 by ins]t+ ,! ,m$ic>e ,transition buy-91 be=e & a multi-,/ate plan4 7#b7 ,level play+ field ,section #acbd7;a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjdd7;a77 is am5d$ by ins]t+ ! ,m$ic>e ,transition buy-91 be=e or a multi-,/ate qualifi$ heal? plan4 ,b ,transitional ,m$ic>e ,re=ms #ajaa4 ,elim9at+ ! #bd-mon? wait+ p]iod = ,m$ic>e cov]age = individuals ) disabilities 7a7 ,9 g5]al ,section #bbf7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #dbf7;b77 is am5d$-- 7#a7 9 p>agraph 7#b77;,a71 by /rik+ 1 & has = #bd cal5d> mon?s be5 entitl$ to12 7#b7 9 p>agraph 7#b77;,b71 by /rik+ 1 & has be5 = n less ?an #bd mon?s12 7#c7 9 p>agraph 7#b77;,c77ii71 by /rik+ 1 includ+ ! requirem5t t he has be5 entitl$ to ! specifi$ b5efits = #bd mon?s12 7#d7 9 ! fir/ s5t5ce1 by /rik+ = ea* mon? beg9n+ ) ! lat] ( 7,i7 ,july #aigc or 7,,ii7 ! tw5ty-fif? mon? ( 8 entitlem5t or /atus z a qualifi$ railroad retirem5t b5efici>y describ$ 9 p>agraph 7#b71 & & ins]t+ = ea* mon? = :i* ! individual meets ! requirem5ts ( p>agraph 7#b71 beg9n+ ) ! mon? foll[+ ! mon? 9 :i* ! individual meets ! requirem5ts ( su* p>agraph1 &2 & 7#e7 9 ! second s5t5ce1 by /rik+ ! tw5ty-fif? mon? ( 8 entitlem5t & all t foll[s ?r\gh p>agraph 7#b77;,c7 &4 7b7 ,con=m+ am5dm5ts 7#a7 ,section #bbf ,section #bbf ( ! ,social ,security ,act 7#db ,u4,s4,c4 #dbf7 is am5d$ by-- 7,a7 /rik+ subsections 7e77#a77;,b71 7f71 & 7h72 & 7,b7 r$esignat+ subsections 7g7 & 7i7 z subsections 7f7 & 7g71 respectively4 7#b7 ,m$ic>e description ,section #ahaa7b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;c7#b77 is am5d$ by /rik+ h be5 entitl$ = n less ?an #bd mon?s & ins]t+ are entitl$4 7#c7 ,m$ic>e cov]age ,section #ahcg7;g77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciep7g77#a77 is am5d$ by /rik+ #be? mon? ( & ins]t+ mon? foll[+ ! fir/ mon? (4 7#d7 ,railroad retirem5t sy/em ,section #g7;d77#b77;ii7 ( ! ,railroad ,retirem5t ,act ( #aigd 7#de ,u4,s4,c4 #bca;f7d77#b77;ii77 is am5d$-- 7,a7 by /rik+ has be5 entitl$ to an annuity & ins]t+ is entitl$ to an annuity2 7,b7 by /rik+ 1 = n less ?an #bd mon?s2 & 7,c7 by /rik+ c\ld h be5 entitl$ = #bd cal5d> mon?s1 &4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to insurance b5efits "u title ,,xviii ( ! ,social ,security ,act ) respect to items & s]vices furni%$ 9 mon?s beg9n+ aft] ,decemb] #a foll[+ ! date ( enactm5t ( ?is ,act1 & be=e ! date t is #b ye>s aft] ! date ( ! enactm5t ( su* ,act4 #ajab4 ,ensur+ cont9uity ( c>e 7a7 ,9 g5]al ,! ,secret>y %all ensure t all p]sons enroll$ or :o seeks to enroll 9 a heal? plan dur+ ! transition p]iod ( ! ,m$ic>e = ,all ,program are protect$ f disruptions 9 _! c>e dur+ ! transition p]iod1 includ+ cont9uity ( c>e ) su* p]sons curr5t heal? c>e provid] teams4 7b7 ,cont9uity ( cov]age & c>e 9 g5]al ,dur+ ! transition p]iod ( ! ,m$ic>e = ,all ,act1 gr\p heal? plans & heal? insurance issu]s (f]+ gr\p or individual heal? insurance cov]age %all n end cov]age = an enrollee dur+ ! transition p]iod describ$ 9 ! ,act until all ages are eligible to enroll 9 ! ,m$ic>e = ,all ,program except z expressly agre$ ^u "u ! t]ms ( ! plan4 7c7 ,cont9uity ( cov]age & c>e = p]sons ) complex m$ical ne$s 7#a7 ,! ,secret>y %all ensure t p]sons ) disabilities1 complex m$ical ne$s1 or *ronic conditions are protect$ f disruptions 9 _! c>e dur+ ! transition p]iod1 includ+ cont9uity ( c>e ) su* p]sons curr5t heal? c>e provid] teams4 7#b7 ,dur+ ! transition p]iod ( ! ,m$ic>e = ,all ,act gr\p heal? plans & heal? insurance issu]s (f]+ gr\p or individual heal? insurance cov]age %all n-- 7,a7 end cov]age = an enrollee :o has a disability1 complex m$ical ne$1 or *ronic condition dur+ ! transition p]iod describ$ 9 ! ,act until all ages are eligible to enroll 9 ! ,m$ic>e = ,all ,program2 or 7,b7 impose any exclusion ) respect to su* plan or cov]age on ! basis ( a p]son's disability1 complex m$ical ne$1 or *ronic condition dur+ ! transition p]iod describ$ "u ?is ,act until all ages are eligible to enroll 9 ! ,m$ic>e = ,all ,program4 7d7 ,public consultation dur+ transition ,! ,secret>y %all consult ) communities & advocacy organizations ( p]sons liv+ ) disabilities z well z o!r pati5t advocacy organizations to ensure t ! transition buy-9 takes into acc\nt ! cont9uity ( c>e = p]sons ) disabilities1 complex m$ical ne$s1 or *ronic conditions4 ,,xi ,miscellane\s #aaja4 ,def9itions ,9 ?is ,act-- 7#a7 ! t]m global budget means ! paym5t negotiat$ betwe5 an in/itutional provid] & z describ$ 9 section #faa7;b72 7#b7 ! t]m gr\p practice has ! mean+ giv5 su* t]m 9 section #ahgg7;h77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acienn7h77#d772 7#c7 ! t]m individual provid] means a suppli] 7z def9$ 9 section #ahfa7;d7 ( su* ,act 7#db ,u4,s4,c4 #aciex7d7772 7#d7 ! t]m in/itutional provid] means-- 7,a7 provid]s ( s]vices describ$ 9 section #ahfa7u7 ( su* ,act 7#db ,u4,s4,c4 #aciex7u772 7,b7 hospitals z def9$ 9 section #ahfa7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7e771 & any outpati5t sett+s or cl9ics op]at+ )9 a hospital lic5se or any sett+ or cl9ic t provides outpati5t hospital s]vices2 7,c7 psy*iatric hospitals 7z def9$ 9 section #ahfa7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7f7772 7,d7 rehabilitation hospitals 7z def9$ by ! ,secret>y ( ,heal? & ,human ,s]vices "u section #ahhf7;d77#a77;,b77ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#a77;,b77ii7772 7,e7 long-t]m c>e hospitals z def9$ 9 section #ahfa ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7ccc772 & 7,f7 indep5d5t dialysis facilities & indep5d5t end-/age r5al disease facilities z describ$ 9 #db ,,cfr #dac4agd7;b72 7#e7 ! t]m m$ically necess>y or appropriate means ! heal? c>e items & s]vices or supplies t are ne$$ or appropriate to prev5t1 diagnose1 or treat an illness1 injury1 condition1 disease1 or its symptoms = an individual & are det]m9$ to be necess>y or appropriate = su* individual by ! physician or o!r heal? c>e pr(essional treat+ su* individual1 aft] su* pr(essional p]=ms an assessm5t ( su* individual's condition1 9 a mann] t meets-- 7,a7 ! scope ( practice1 lic5s+1 & o!r law ( ! ,/ate 9 :i* ! individual receiv+ su* items & s]vices is locat$2 & 7,b7 appropriate /&>ds e/abli%$ by ! ,secret>y = purposes ( c>ry+ out ?is ,act2 7#f7 ! t]m provid] means an in/itutional provid] or a suppli] 7z def9$ 9 section #ahfa7;d7 ( su* ,act 7#db ,u4,s4,c4 #aciex7d77 if ! ref]5ce to ?is title 7 a ref]5ce to ! ,m$ic>e = ,all ,program72 7#g7 ! t]m ,secret>y means ! ,secret>y ( ,heal? & ,human ,s]vices2 7#h7 ! t]m ,/ate means a ,/ate1 ! ,di/rict ( ,columbia1 or a t]ritory ( ! ,unit$ ,/ates2 7#i7 ! t]m ,,tric>e ,ov]seas ,program means ! elem5t ( ! ,,tric>e program adm9i/]$ by ,int]national ,,sos 7or su* successor adm9i/rator7 "u :i* c>e & heal? b5efits are furni%$ to ,,tric>e b5efici>ies locat$ 9 a ,,tric>e ov]seas region2 7#aj7 ! t]m ,,tric>e program has ! mean+ giv5 su* t]m 9 section #ajgb ( title #aj1 ,unit$ ,/ates ,code2 7#aa7 ! t]m uni=m$ s]vices has ! mean+ giv5 su* t]m 9 section #aja ( title #aj1 ,unit$ ,/ates ,code2 & 7#ab7 ! t]m ,unit$ ,/ates %all include ! ,/ates1 ! ,di/rict ( ,columbia1 & ! t]ritories ( ! ,unit$ ,/ates4 #aajb4 ,rules ( con/ruction 7a7 ,9 g5]al ,a ,/ate or local gov]nm5t may set additional /&>ds or apply o!r ,/ate or local laws ) respect to eligibility1 b5efits1 & m9imum provid] /&>ds1 only if su* ,/ate or local /&>ds-- 7#a7 provide equal or great] eligibility ?an is available "u ?is ,act2 7#b7 provide equal or great] 9-p]son access to b5efits "u ?is ,act2 7#c7 d n r$uce access to b5efits "u ?is ,act2 7#d7 all[ = ! effective ex]cise ( ! pr(essional judgm5t ( physicians or o!r heal? c>e pr(essionals2 & 7#e7 are o!rwise consi/5t ) ?is ,act4 7b7 ,relation to /ate lic5s+ law ,no?+ 9 ?is ,act %all be con/ru$ to preempt ,/ate lic5s+1 practice1 or educational laws or regulations ) respect to heal? c>e pr(essionals & heal? c>e provid]s1 = su* pr(essionals & provid]s :o practice 9 t ,/ate4 7c7 ,application to /ate & f$]al law on workplace rights ,no?+ 9 ?is ,act %all be con/ru$ to dim9i% or alt] ! rights1 privileges1 rem$ies1 or obligations ( any employee or employ] "u any ,f$]al or ,/ate law or regulation or "u any collective b>ga9+ agreem5t4 7d7 ,re/rictions on provid]s ,) respect to any individuals or entities c]tifi$ to provide items & s]vices cov]$ "u section #bja7;a77#g71 a ,/ate may n prohibit an individual or entity f p>ticipat+ 9 ! program "u ?is ,act = reasons o!r ?an ! ability ( ! individual or entity to provide su* s]vices4 #aajc4 ,no use ( res\rces = law en=cem5t ( c]ta9 regi/ration requirem5ts ,not)/&+ any provision ( ,f$]al or ,/ate law1 no ,f$]al or ,/ate law en=cem5t (ficial or employee %all use any funds1 facilities1 prop]ty1 equipm5t1 or p]sonnel made available pursuant to ?is ,act 7or any am5dm5t made !reby7 to inve/igate1 en=ce1 or assi/ 9 ! inve/igation or en=cem5t ( any crim9al1 civil1 or adm9i/rative violation or w>rant = a violation ( any requirem5t t individuals regi/] ) ! ,f$]al ,gov]nm5t bas$ on religion1 national orig91 e?nicity1 immigration /atus1 or o!r protect$ category4