,,ii  #aah? ,,congress  #a/ ,session    
,s4 #afee  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,may #ag1 #bjbc,mr4    
,s&]s 7= himself1 ,ms4 ,baldw91 ,mr4    
,blum5?al1 ,mr4 ,book]1 ,mrs4 ,gillibr&1
 ,mr4 ,he9ri*1 ,ms4 ,hirono1 ,mr4 ,lujn1
 ,mr4 ,m>key1 ,mr4 ,m]kley1 ,mr4        
,padilla1 ,mr4 ,s*atz1 ,ms4 ,w>r51 ,mr4 
,wel*1 & ,mr4 ,:iteh\se7 introduc$ !    
foll[+ bill2 :i* 0 read twice & ref]r$  
to ! ,committee on ,f9ance  ,a ,,bill   
,to e/abli% a ,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 ,entitlem5t to      
,b5efits2 ,enrollment,sec4 #aja4        
,e/abli%m5t ( ! ,m$ic>e = ,all          
,program4,sec4 #ajb4 ,univ]sal          
entitlem5t to b5efits4,sec4 #ajc4       
,fre$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+  
,b5efits = ,long-,t]m ,care,sec4 #bja4  
,compreh5sive b5efits4,sec4 #bjb4 ,no   
pati5t co/-%>+4,sec4 #bjc4 ,exclusions &
 limitations4,sec4 #bjd4 ,cont9u$       
cov]age ( in/itutional long-t]m c>e &   
o!r s]vices "u ,m$icaid4,sec4 #bje4     
,prohibit+ recov]y ( correctly paid     
,m$icaid b5efits4,sec4 #bjf4 ,additional
 ,/ate /&>ds4,,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 (         
,care,sec4 #eja4 ,quality /&>ds4,sec4   
#ejb4 ,address+ heal? c>e               
disp>ities4,,title ,,vi--,national      
,heal? ,budget2 ,provid] ,paym5ts2 ,co/ 
,conta9m5t ,measures,subtitle           
,a--,budgeting,sec4 #fja4 ,national     
heal? budget4,sec4 #fjb4 ,tempor>y work]
 assi/ance4,subtitle ,b--,paym5ts to    
,providers,sec4 #faa4 ,paym5ts to       
in/itutional provid]s bas$ on global    
budgets4,sec4 #fab4 ,paym5ts to         
individual provid]s ?r\gh               
fee-=-s]vice4,sec4 #fac4 ,accurate      
valuation ( s]vices "u ! ,m$ic>e        
physician fee s*$ule4,sec4 #fad4        
,paym5ts = prescription drugs & approv$ 
devices & equipm5t4,sec4 #fae4 ,paym5t  
prohibitions2 capital exp5ditures2      
special projects4,sec4 #faf4 ,(fice (   

,heal? ,equity4,sec4 #fag4 ,(fice (     
,prim>y ,heal? ,c>e4,,title             
,,vii--,m$ic>e = ,all ,tru/ ,fund,sec4  
#gja4 ,m$ic>e = ,all ,tru/ ,fund4,,title
 ,,viii--,con=m+ ,am5dm5ts to !         
,employee ,retirem5t ,income ,security  
,act ( #aigd,sec4 #hja4 ,prohibition (  
employee b5efits duplicative ( b5efits  
"u ! ,m$ic>e = ,all ,program2           
coord9ation 9 case ( work]s'            
comp5sation4,sec4 #hjb4 ,repeal (       
cont9uation cov]age requirem5ts "u      
,,erisa & c]ta9 o!r requirem5ts relat+  
to gr\p heal? plans4,sec4 #hjc4         
,effective date ( title4,,title         
,,ix--,additional ,con=m+               
,amendments,sec4 #ija4 ,relation%ip to  
exi/+ ,f$]al heal? programs4,sec4 #ijb4 
,sunset ( provisions relat$ to ! ,f$]al 
& ,/ate ,ex*anges4,,title               
,x--,transition to ,m$ic>e =            
,all,subtitle ,a--,improvem5ts to       
,medicare,sec4 #ajja4 ,protect+ ,m$ic>e 
fee-=-s]vice b5efici>ies f high         
out-(-pocket co/s4,sec4 #ajjb4 ,r$uc+   

,m$ic>e "p ,d annual out-(-pocket       
?re%old4,sec4 #ajjc4 ,exp&+ ,m$ic>e to  
cov] d5tal & vision s]vices & he>+ aids 
& exam9ations "u "p ,b4,sec4 #ajjd4     
,elim9at+ ! #bd-mon? wait+ p]iod =      
,m$ic>e cov]age = individuals )         
disabilities4,sec4 #ajje4 ,gu>ante$     
issue ( ,m$igap policies4,subtitle      
,b--,tempor>y ,m$ic>e ,buy-,9 ,option & 
,tempor>y ,public ,option,sec4 #ajaa4   
,l[]+ ! ,m$ic>e age4,sec4 #ajab4        
,e/abli%m5t ( ! ,m$ic>e transition      
plan4,subtitle ,c--,pati5t ,protections 
,dur+ ,m$ic>e = ,all ,transition        
,period,sec4 #ajba4 ,m9imiz+ disruptions
 to pati5t c>e4,sec4 #ajbb4 ,public     
consultation4,sec4 #ajbc4               
,def9itions4,,title                     
,,xi--,miscellaneous,sec4 #aaja4 ,updat+
 res\rce limits = ,supplem5tal ,security
 ,income eligibility 7,,ssi74,sec4      
#aajb4 ,def9itions4  ,i ,e/abli%m5t ( ! 
,m$ic>e = ,all ,program2 ,univ]sal      
,entitlem5t to ,b5efits2 ,enrollm5t     
#aja4 ,e/abli%m5t ( ! ,m$ic>e = ,all    

,program ,!re is h]eby e/abli%$ a       
national heal? insurance program 7ref]r$
 to 9 ?is ,act z ! ,m$ic>e = ,all       
,program7 to provide compreh5sive       
protection aga9/ ! co/s ( heal? c>e &   
heal?-relat$ items & s]vices1 9         
accordance ) ! /&>ds specifi$ 91 or     
e/abli%$ "u1 ?is ,act4  #ajb4 ,univ]sal 
entitlem5t to b5efits  7a7 ,9 g5]al ,e  
individual :o is a resid5t ( ! ,unit$   
,/ates is entitl$ to b5efits = heal? c>e
 items & 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-- 7#a7 may make eligible =    
b5efits = heal? c>e items & s]vices "u  
?is ,act o!r individuals n describ$ 9   
subsection 7a7 & regulate _! eligibility
 to ensure t e p]son 9 ! ,unit$ ,/ates  
has access to heal? c>e2 &  7#b7 %all   
promulgate a rule1 consi/5t ) ,f$]al    
immigration laws1 to prev5t an          
individual f travel+ to ! ,unit$ ,/ates 

= ! sole purpose ( obta9+ heal? c>e     
items & s]vices provid$ "u ?is ,act4    
#ajc4 ,fre$om ( *oice ,any individual   
entitl$ to b5efits "u ?is ,act may obta9
 heal? c>e items & 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$uction ( b5efits or o!r        
discrim9ation by any p>ticipat+ provid] 
7z describ$ 9 section #cja7;a771 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 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 ) 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 damages 7includ+ 
damages = emotional h>m71 decl>atory    
relief1 injunctive relief1 attorneys'   
fees & co/s1 or o!r relief z            
appropriate4  7c7 ,cont9u$ application (
 laws ,no?+ 9 ?is title %all be con/ru$ 
to invalidate or o!rwise limit any ( !  
rights1 rem$ies1 proc$ures1 or legal    

/&>ds available to individuals aggriev$ 
"u o!r ,f$]al laws1 includ+ section     
#aeeg ( ! ,pati5t ,protection &         
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahaaf71 title ,,vi ( ! ,civil ,rights  
,act ( #aifd 7#db ,u4,s4,c4 #bjjj;d et  
seq471 title ,,vii ( ! ,civil ,rights   
,act ( #aifd 7#db ,u4,s4,c4 #bjjj;e et  
seq471 title ,,ix ( ! ,education        
,am5dm5ts ( #aigb 7#bj ,u4,s4,c4 #afha  
et seq471 section #ejd ( !              
,rehabilitation ,act ( #aigc 7#bi       
,u4,s4,c4 #gid71 title ,,ii ( !         
,am]icans ) ,disabilities ,act ( #aiij  
7#db ,u4,s4,c4 #abaca et seq471 or !    
,age ,discrim9ation ,act ( #aige 7#db   
,u4,s4,c4 #faja et seq474 ,no?+ 9 ?is   
title %all be con/ru$ 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 !     
,m$ic>e = ,all ,program4 ,! 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 
( ! date describ$ 9 subsection 7a7 or   
7b71 z applicable1 ( section #ajf1 ( all
 individuals :o are eligible to be      
enroll$ z ( su* applicable date2 &  7#c7
 include a process = ! enrollm5t (      
individuals made eligible = heal? c>e   
items & s]vices "u section #ajb7;b74    
7b7 ,issuance ( ,m$ic>e = ,all c>ds ,9  
conjunction ) an individual's enrollm5t 
= b5efits "u ?is ,act1 ! ,secret>y %all 
provide = ! issuance ( a ,m$ic>e = ,all 
c>d t %all be us$ = purposes (          
id5tification & process+ ( claims =     
b5efits "u ! ,m$ic>e = ,all ,program4 ,!
 c>d %all n include an individual's     
,social ,security numb]4  #ajf4         
,effective date ( b5efits  7a7 ,9 g5]al 
,except z provid$ 9 subsection 7b71     
b5efits %all fir/ be available "u !     
,m$ic>e = ,all ,program = items &       

s]vices furni%$ on ,janu>y #a ( ! f\r?  
cal5d> ye> t beg9s aft] ! date (        
enactm5t ( ?is ,act4  7b7 ,imm$iate     
cov]age ( *ildr5  7#a7 ,9 g5]al ,= any  
eligible individual "u section #ajb :o  
has n yet atta9$ ! age ( #ai z ( ! date 
t is #a ye> aft] ! date ( enactm5t ( ?is
 ,act1 b5efits %all fir/ be available "u
 ! ,m$ic>e = ,all ,program = items &    
s]vices furni%$ on ,janu>y #a ( ! fir/  
cal5d> ye> t beg9s aft] ! date (        
enactm5t ( ?is ,act4  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 on :i* b5efits   
are fir/ available "u subsection 7a74   
#ajg4 ,prohibition aga9/ duplicat+      
cov]age  7a7 ,9 g5]al ,beg9n+ on ! date 
on :i* b5efits are fir/ available "u    

section #ajf7;a71 x %all be unlawful =--
 7#a7 a private heal? insur] to sell    
heal? insurance cov]age t duplicates !  
b5efits provid$ "u ! ,m$ic>e = ,all     
,program2 or  7#b7 an employ] to provide
 b5efits = an employee1 =m] employee1 or
 ! dep5d5ts ( an employee or =m]        
employee t duplicate ! b5efits provid$  
"u ! ,m$ic>e = ,all ,program4  7b7      
,con/ruction ,no?+ 9 ?is ,act %all be   
con/ru$ z prohibit+ ! sale ( heal?      
insurance cov]age = any additional      
b5efits n cov]$ by ! ,m$ic>e = ,all     
,program1 includ+ additional b5efits t  
an employ] may provide to employees or  
_! dep5d5ts1 or to =m] employees or _!  
dep5d5ts4  ,,ii ,compreh5sive ,b5efits1 
,includ+ ,b5efits = ,long-,t]m ,c>e     
#bja4 ,compreh5sive b5efits  7a7 ,9     
g5]al ,subject to ! o!r provisions ( ?is
 title & titles ,,iv ?r\gh ,,ix1        
individuals enroll$ = b5efits "u !      
,m$ic>e = ,all ,program are entitl$ to h
 paym5t made by ! ,secret>y to a        
p>ticipat+ 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   
biological products1 & m$ical devices1 &
 all contraceptive items approv$ by !   
,food & ,drug ,adm9i/ration4  7#e7      
,m5tal heal? & sub/ance use treatm5t    
s]vices1 includ+ inpati5t c>e & treatm5t
 = co-occurr+ m5tal illness & sub/ance  
use disord]s4  7#f7 ,laboratory &       
diagno/ic s]vices4  7#g7 ,compreh5sive  
reproductive c>e1 includ+ abortion1     
contraception1 & assi/ive reproductive  
te*nology4  7#h7 ,compreh5sive 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]vices1 
includ+ devices4  7#ab7 ,em]g5cy        
s]vices1 includ+ transportation4  7#ac7 
,p$iatrics1 includ+ e>ly & p]iodic      
scre5+1 diagno/ic1 & treatm5t s]vices 7z
 def9$ 9 section #aije7r7 ( ! ,social   
,security ,act 7#db ,u4,s4,c4           
#acif;d7r7774  7#ad7 ,necess>y          
transportation to receive heal? c>e     
items & s]vices = p]sons ) disabilities1
 old] individuals ) functional          
limitations1 & l[-income individuals 7z 
det]m9$ by ! ,secret>y74  7#ae7 ,s]vices
 provid$ by a lic5s$ m>riage & family   
!rapi/ or a lic5s$ m5tal heal? c\nselor4
  7#af7 ,home & community-bas$ long-t]m 
c>e s]vices & supports 7to be provid$ 9 
accordance ) ! requirem5ts = home &     
community-bas$ sett+s "u sections       
#dda4ecj & #dda4gaj ( title #db1 ,code (
 ,f$]al ,regulations 7z 9 effect on !   
date ( enactm5t ( ?is ,act71 includ+--  
7,a7 s]vices describ$ 9 p>agraphs 7#g71 
7#h71 7#ac71 7#ai71 & 7#bd7 ( section   

#aije7;a7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #acif;d7a772  7,b7 home &
 community-bas$ s]vices describ$ 9      
subsection 7c77#d77;,b7 ( section #aiae 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #acifn7 7includ+ habilitation 
s]vices def9$ 9 subsection 7c77#e7 ( su*
 section72  7,c7 self-direct$ home &    
community-bas$ s]vices describ$ 9       
subsection 7i7 ( section #aiae ( !      
,social ,security ,act2  7,d7           
self-direct$ p]sonal assi/ance s]vices  
7z def9$ 9 subsection 7j77#d77;,a7 (    
section #aiae ( ! ,social ,security     
,act72 &  7,e7 home & community-bas$    
att5dant s]vices & supports describ$ 9  
subsection 7k7 ( section #aiae ( !      
,social ,security ,act4  7#ag7 ,any item
 or s]vice describ$ 9 any ( p>agraphs   
7#a7 ?r\gh 7#af7 t is furni%$ us+       
teleheal?1 to ! ext5t practicable4  7b7 
,revision ,! ,secret>y %all1 at lea/ on 
an annual 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  7c7        
,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$ic9e practices t are      
appropriate to include 9 ! b5efits      
package2 &  7,b7 id5tify+ b>ri]s to !   
effective provision & integration ( su* 
practices into ! deliv]y ( heal? c>e1 & 
id5tify+ me*anisms = ov]com+ su* b>ri]s4
  7#b7 ,consultation ,9 accordance )    
p>agraph 7#a71 ! ,secret>y %all consult 
)-- 7,a7 ! ,director ( ! ,national ,c5t]
 = ,complem5t>y & ,integrative ,heal?2  
7,b7 ! ,commission] ( ,food & ,drugs2   
7,c7 in/itutions ( high] education1     
private rese>* in/itutes1 & individual  
rese>*]s ) ext5sive exp]i5ce 9          
complem5t>y & integrative m$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  7d7 ,/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 !   
,m$ic>e = ,all ,program at ! exp5se ( ! 
,/ate4  #bjb4 ,no pati5t co/-%>+  7a7 ,9
 g5]al ,! ,secret>y %all ensure t no    
co/-%>+1 includ+ d$uctibles1 co9surance1
 copaym5ts1 or simil> *>ges1 be impos$  
on an individual = any b5efits provid$  
"u ! ,m$ic>e = ,all ,program1 except z  
describ$ 9 subsection 7b74  7b7         
,exceptions ,! ,secret>y may set a      
co/-%>+ s*$ule = prescription drugs     
cov]$ "u ! ,m$ic>e = ,all ,program--    
7#a7 provid$ t-- 7,a7 su* s*$ule is     

evid5ce-bas$1 pati5t-c5t]$1 & enc\rages 
! use ( g5]ic drugs2  7,b7 su* co/-%>+  
does n apply to prev5tive drugs2  7,c7  
su* co/-%>+ does n exce$ #bjj annually  
p] individual1 adju/$ annually =        
inflation2 &  7,d7 su* co/-%>+ is n     
impos$ on individuals ) a h\sehold      
income equal to or bel[ #bej p]c5t ( !  
pov]ty l9e = a family ( ! size involv$2 
&  7#b7 "u :i* ! ,secret>y may-- 7,a7   
exempt br&-"n drugs f consid]ation 9    
det]m9+ :e!r an individual has rea*$ any
 out-(-pocket limit if a safe &         
appropriate g5]ic v]sion ( su* drug is  
available to su* individual2 &  7,b7    
waive co/-%>+ 9 response to a cov]age   
appeal "u section #bjc7;b77#b74  7c7 ,no
 balance bill+ ,not)/&+ contracts 9     
accordance ) section #cjc1 no provid]   
may impose a *>ge to an individual      
enroll$ = b5efits "u ! ,m$ic>e = ,all   
,program = items & s]vices = :i* b5efits
 are provid$ "u su* ,program4  #bjc4    
,exclusions & limitations  7a7 ,9 g5]al 
,b5efits = items & s]vices are n        

available "u ! ,m$ic>e = ,all ,program  
unless ! items & s]vices meet ! /&>ds   
develop$ by ! ,secret>y pursuant to     
section #bja7;a74  7b7 ,treatm5t (      
exp]im5tal items & s]vices  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  
are consid]$ to meet ! /&>ds specifi$ 9 
section #bja7;a7 if !y h be5 provid$ 9  
accordance ) su* guidel9e4  7#b7 ,c]ta9 
exceptions ,= purposes ( ?is subsection1
 an item or s]vice n provid$ 9          
accordance ) a national practice        
guidel9e %all be consid]$ to h be5      
provid$ 9 accordance ) su* guidel9e if !
 heal? c>e provid] provid+ ! item or    
s]vice-- 7,a7 ex]cis$ appropriate       
pr(essional discretion to deviate f !   
guidel9e 9 a mann] au?oriz$ or          
anticipat$ by ! guidel9e2  7,b7 act$ 9  
accordance ) ! laws & requirem5ts 9 :i* 
su* item or s]vice is furni%$2  7,c7    
act$ 9 ! be/ int]e/s ( ! individual     
receiv+ ! item or s]vice2 &  7,d7 act$ 9
 a mann] consi/5t ) ! individual's      
wi%es4  #bjd4 ,cont9u$ cov]age (        
in/itutional long-t]m c>e & o!r s]vices 
"u ,m$icaid ,title ,,xix ( ! ,social    
,security ,act 7#db ,u4,s4,c4 #acif et  
seq47 is am5d$ by ins]t+ ! foll[+       
section aft] section #aidg3  #aidh4     

,/ate ,plan = ,provid+ ,in/itutional    
,long-,t]m ,c>e ,s]vices  7a7 ,9 g5]al  
,= qu>t]s beg9n+ on or aft] ! date on   
:i* b5efits are fir/ available "u       
section #ajf7;a7 ( ! ,m$ic>e = ,all     
,act1 not)/&+ any o!r provision ( ?is   
title-- 7#a7 a ,/ate plan = m$ical      
assi/ance %all provide = mak+ m$ical    
assi/ance available = in/itutional      
long-t]m c>e s]vices 9 a mann] consi/5t 
) ?is section2 &  7#b7 no paym5t to a   
,/ate %all be made "u ?is title )       
respect to exp5ditures incurr$ by !     
,/ate 9 provid+ m$ical assi/ance on or  
aft] su* date = s]vices t are n-- 7,a7  
in/itutional long-t]m c>e s]vices2 or   
7,b7 o!r s]vices = :i* b5efits are n    
available "u ! ,m$ic>e = ,all ,act & :i*
 are furni%$ "u a ,/ate plan = m$ical   
assi/ance :i* provid$ = m$ical assi/ance
 = su* s]vices on ,septemb] #a1 #bjbb4  
7b7 ,in/itutional long-,t]m c>e s]vices 
def9$ ,9 ?is section1 ! t]m in/itutional
 long-t]m c>e s]vices means ! foll[+3   
7#a7 ,nurs+ facility s]vices =          

individuals #ba ye>s ( age or ov]       
describ$ 9 subp>agraph 7,a7 ( section   
#aije7;a77#d74  7#b7 ,inpati5t s]vices =
 individuals #fe ye>s ( age or ov]      
provid$ 9 an in/itution = m5tal disease 
describ$ 9 section #aije7;a77#ad74  7#c7
 ,int]m$iate c>e facility s]vices       
describ$ 9 section #aije7;a77#ae74  7#d7
 ,inpati5t psy*iatric hospital s]vices =
 individuals "u age #ba describ$ 9      
section #aije7;a77#af74  7#e7 ,nurs+    
facility s]vices describ$ 9 section     
#aije7;a77#ca74  7c7 ,/ate ma9t5ance (  
ef=t requirem5t  7#a7 ,eligibility /&>ds
  7,a7 ,9 g5]al ,beg9n+ on ! date       
describ$ 9 subsection 7a71 no paym5t may
 be made "u section #aijc ) respect to  
m$ical assi/ance provid$ "u a ,/ate plan
 = m$ical assi/ance if ! ,/ate adopts   
income1 res\rce1 or o!r /&>ds &         
me?odologies = purposes ( det]m9+ an    
individual's eligibility = m$ical       
assi/ance "u ! ,/ate plan t are m       
re/rictive ?an ^? appli$ z ( ,janu>y #a1
 #bjbc4  7,b7 ,index+ ( am\nts ( income 

& res\rce /&>ds ,9 det]m9+ :e!r a ,/ate 
has adopt$ income or res\rce /&>ds t are
 m re/rictive ?an ! /&>ds :i* appli$ z (
 ,janu>y #a1 #bjbc1 ! ,secret>y %all    
deem ! am\nt ( any su* /&>d t 0 appli$ z
 ( su* date to be increas$ by ! p]c5tage
 increase 9 ! m$ical c>e compon5t ( !   
consum] price index = all urban consum]s
 7,u4,s4 city av]age7 f ,septemb] (     
#bjbb to ,septemb] ( ! fiscal ye> = :i* 
! ,secret>y is mak+ su* det]m9ation4    
7#b7 ,exp5ditures  7,a7 ,9 g5]al ,= ea* 
fiscal ye> or portion ( a fiscal ye> t  
occurs dur+ ! p]iod t beg9s on ! fir/   
day ( ! fir/ fiscal qu>t] t beg9s on or 
aft] ! date on :i* b5efits are fir/     
available "u section #ajf7;a7 ( !       
,m$ic>e = ,all ,act1 z a condition (    
receiv+ paym5ts "u section #aijc7;a71 a 
,/ate %all make exp5ditures = m$ical    
assi/ance = in/itutional long-t]m c>e   
s]vices 9 an am\nt t is n less ?an !    
exp5diture floor det]m9$ = ! ,/ate &    
fiscal ye> 7or portion ( a fiscal ye>7  
"u subp>agraph 7,b74  7,b7 ,exp5diture  

floor  7i7 ,9 g5]al ,= ea* fiscal ye> or
 portion ( a fiscal ye> describ$ 9      
subp>agraph 7,a71 ! ,secret>y %all      
det]m9e = ea* ,/ate an exp5diture floor 
t %all be equal to-- 7,i7 ! am\nt ( !   
,/ate's exp5ditures = fiscal ye> #bjba  
on m$ical assi/ance = in/itutional      
long-t]m c>e s]vices2 increas$ by       
7,,ii7 ! gr[? factor det]m9$ "u         
subclause 7ii74  7ii7 ,gr[? factor ,=   
ea* fiscal ye> or portion ( a fiscal ye>
 describ$ 9 subp>agraph 7,a71 !         
,secret>y %all1 n lat] ?an ,septemb] #a 
( ! fiscal ye> prec$+ su* fiscal ye> or 
portion ( a fiscal ye>1 det]m9e a gr[?  
factor = ea* ,/ate t takes into acc\nt--
 7,i7 ! p]c5tage increase 9 heal? c>e   
co/s 9 ! ,/ate2  7,,ii7 ! total am\nt   
exp5d$ by ! ,/ate = ! previ\s fiscal ye>
 on m$ical assi/ance = in/itutional     
long-t]m c>e s]vices2  7,,iii7 !        
increase1 if any1 9 ! total population (
 ! ,/ate f ,july ( #bjbb to ,july ( !   
fiscal ye> prec$+ ! fiscal ye> involv$2 
7,,iv7 ! increase1 if any1 9 !          

population ( individuals ag$ #fe & old] 
( ! ,/ate f ,july ( #bjbb to ,july ( !  
fiscal ye> prec$+ ! fiscal ye> involv$2 
&  7,v7 ! decrease1 if any1 9 !         
population ( ! ,/ate t requires m$ical  
assi/ance = in/itutional long-t]m c>e   
s]vices t is attributable to !          
availability ( cov]age = ! s]vices      
describ$ 9 section #bja7;a77#af7 ( !    
,m$ic>e = ,all ,act4  7iii7 ,proration  
rule ,any am\nt det]m9$ "u ?is          
subp>agraph = a portion ( a fiscal ye>  
%all be prorat$ bas$ on ! l5g? ( su*    
portion ( a fiscal ye> relative to a    
complete fiscal ye>4  7d7               
,nonapplication ( c]ta9 requirem5ts     
,beg9n+ on ! date describ$ 9 subsection 
7a71 any provision ( ?is title requir+ a
 ,/ate plan = m$ical assi/ance to make  
available m$ical assi/ance = s]vices t  
are n in/itutional long-t]m c>e s]vices 
or items & s]vices describ$ 9 section   
#ija7;a77#c77;,a77ii7 ( ! ,m$ic>e = ,all
 ,act %all h no effect4  4  #bje4       
,prohibit+ recov]y ( correctly paid     

,m$icaid b5efits ,section #aiag ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#acifp7 is am5d$-- 7#a7 by am5d+        
subsection 7a7 to read z foll[s3  7a7   
,no li5 may be impos$ aga9/ ! prop]ty ( 
any individual prior to 8 dea? on acc\nt
 ( m$ical assi/ance paid or to be paid  
on 8 behalf "u ! ,/ate plan1 except     
pursuant to ! judgm5t ( a c\rt on acc\nt
 ( b5efits incorrectly paid on behalf ( 
su* individual4  2 &  7#b7 by am5d+     
subsection 7b7 to read z foll[s3  7b7   
,no adju/m5t or recov]y ( any m$ical    
assi/ance correctly paid on behalf ( an 
individual "u ! ,/ate plan may be made4 
4  #bjf4 ,additional ,/ate /&>ds  7a7 ,9
 g5]al ,no?+ 9 ?is ,act %all prohibit   
individual ,/ates f sett+ additional    
/&>ds relat$ to eligibility1 b5efits1 & 
m9imum provid] /&>ds1 consi/5t ) !      
purposes ( ?is ,act1 provid$ t su* /&>ds
 d n re/rict eligibility or r$uce access
 to b5efits = items & s]vices4  7b7     
,re/rictions on provid]s ,) respect to  
any individuals or entities c]tifi$ to  

provide items & s]vices cov]$ "u section
 #bja7;a77#g71 a ,/ate may n prohibit an
 individual or entity f p>ticipat+ 9 !  
,m$ic>e = ,all ,program = reasons o!r   
?an ! ability ( ! individual or entity  
to provide su* items & s]vices4  ,,iii  
,provid] ,p>ticipation  #cja4 ,provid]  
p>ticipation & /&>ds2 :i/lebl[]         
protections  7a7 ,9 g5]al ,an individual
 or entity furni%+ any item or s]vice   
cov]$ "u ! ,m$ic>e = ,all ,program is n 
a p>ticipat+ provid] "u su* ,program    
unless ! individual or entity-- 7#a7 is 
a qualifi$ 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 items or s]vices cov]$ "u !      
,m$ic>e = ,all ,program o!r ?an = paym5t
 au?oriz$ 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 review2  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? c>e items or 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 ! ,m$ic>e =  
,all ,program1 ! provid] agrees to      
submit bills & any requir$ support+     
docum5tation relat+ to ! provision (    
items or s]vices cov]$ "u su* ,program  
)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+ items & s]vices cov]$ "u !    
,m$ic>e = ,all ,program & 9 accordance )
 ! uni=m report+ /&>ds e/abli%$ "u      

section #dja7;b77#a71 includ+ in=mation 
on a qu>t]ly basis t-- 7i7 relates to ! 
provision ( items & s]vices cov]$ "u !  
,m$ic>e = ,all ,program2 &  7ii7        
describes su* items & s]vices furni%$ ) 
respect to specific individuals4  7,g7  
,9 ! case ( a provid] t receives paym5t 
= items & s]vices furni%$ "u ! ,m$ic>e =
 ,all ,program bas$ 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 p>ticipat+       
provid] describ$ 9 subsection 7a7 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  
#dj7;b7 ( ! ,consum] ,product ,safety   
,act 7#ae ,u4,s4,c4 #bjhg7;b774  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       
describ$ 9 section #cgcj7;h77#c7 ( title
 #ca1 ,unit$ ,/ates ,code1 & ! rules &  

proc$ures1 legal burd5s ( pro(1 &       
rem$ies applicable "u section #caaje (  
title #di1 ,unit$ ,/ates ,code4  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$ies  
aga9/ retaliatory action "u section     
#cgcj7;h7 ( title #ca1 ,unit$ ,/ates    
,code1 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     
section #cgcj7;h7 ( title #ca1 ,unit$   
,/ates ,code4  7#d7 ,def9itions ,9 ?is  
subsection3 7,a7 ,employ] ,! t]m employ]

 means any p]son engag$ 9 pr(it or a    
nonpr(it bus9ess or indu/ry1 includ+ "o 
or m individuals1 p>tn]%ips1            
associations1 corporations1 tru/s1      
pr(essional memb]%ip organizations      
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]$ a
 qualifi$ provid] to furni% items &     
s]vices "u ! ,m$ic>e = ,all ,program if 
! provid] is lic5s$ or c]tifi$ to furni%
 su* items & s]vices 9 ! ,/ate 9 :i* !  
individual receiv+ su* items & s]vices  
is locat$ & meets-- 7#a7 ! requirem5ts (
 su* ,/ate's laws to furni% su* items & 
s]vices2 &  7#b7 applicable requirem5ts 
( ,f$]al law to furni% su* items &      
s]vices4  7b7 ,f$]al provid]s ,any      

provid] qualifi$ to provide heal? c>e   
items & s]vices at a facility ( !       
,dep>tm5t ( ,vet]ans ,affairs1 ! ,indian
 ,heal? ,s]vice1 or ! uni=m$ s]vices 7z 
def9$ 9 section #ajgb7a7 ( title #aj1   
,unit$ ,/ates ,code7 7) respect to !    
direct c>e compon5t ( ! ,,tric>e        
program7 is a qualifi$ provid] "u ?is   
section ) respect to any individual :o  
qualifies = su* items & s]vices "u      
applicable ,f$]al law4  7c7 ,m9imum     
provid] /&>ds  7#a7 ,9 g5]al ,!         
,secret>y %all e/abli%1 evaluate1 &     
update national m9imum /&>ds to ensure !
 quality ( items & s]vices provid$ "u ! 
,m$ic>e = ,all ,program & to monitor    
ef=ts by ,/ates to ensure ! quality (   
su* items & s]vices4 ,a ,/ate may also  
e/abli% additional m9imum /&>ds :i*     
provid]s %all meet ) respect to items & 
s]vices provid$ 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 ( 
items or 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] ( items or s]vices 
%all meet /&>ds applicable to su* a     
provid] "u ! ,m$ic>e program "u title   
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #acie et seq474 ,su* /&>ds    
also may include1 :]e appropriate1      
elem5ts relat+ to-- 7,a7 adequacy &     
quality ( facilities2  7,b7 tra9+ &     
compet5ce ( p]sonnel 7includ+           
requirem5ts relat$ to ! numb] or type ( 
requir$ cont9u+ education h\rs72  7,c7  
compreh5siv5ess ( items & s]vices2  7,d7
 cont9uity ( items & s]vices2  7,e7     
pati5t wait+ times1 access to items &   
s]vices1 & ref]5ces2 &  7,f7 p]=mance   
/&>ds1 includ+ organization1 facilities1
 /ructure ( items & 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   
#cjc4 ,use ( private contracts  7a7 ,9  
g5]al ,?is section %all apply beg9n+ on 
! date on :i* b5efits are fir/ available
 "u section #ajf7;a74 ,subject to !     
provisions ( ?is section1 no?+ 9 ?is    
,act %all prohibit an in/itutional or   
individual provid] f ent]+ into a       
private contract ) an individual enroll$
 = b5efits "u ! ,m$ic>e = ,all ,program 
= any item or s]vice-- 7#a7 = :i* no    
claim = paym5t is to be submitt$ "u ?is 
,act2 &  7#b7 = :i* ! provid] receives--
 7,a7 no reimbursem5t "u ?is ,act       
directly or on a capitat$ basis2 &  7,b7
 receives no am\nt f an organization :i*
 receives reimbursem5t = su* item or    
s]vice "u ?is ,act directly or on a     
capitat$ basis4  7b7 ,contract          
requirem5ts  7#a7 ,9 g5]al ,any contract
 to provide an item or s]vice "u        

subsection 7a7 %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 be
 ent]$ into at a "t :5 ! individual is  
fac+ an em]g5cy heal? c>e situation2 &  
7,c7 conta9 ! items describ$ 9 p>agraph 
7#b74  7#b7 ,items requir$ to be includ$
 9 contract ,any contract to provide an 
item or s]vice to :i* subsection 7a7    
applies %all cle>ly indicate to !       
individual t by sign+ su* contract !    
individual-- 7,a7 agrees n to submit a  
claim 7or to reque/ t ! provid] submit a
 claim7 "u ?is ,act = su* item or s]vice
 ev5 if su* item or s]vice is o!rwise   
cov]$ by ! ,m$ic>e = ,all ,program2     
7,b7 agrees to be responsible1 :e!r     
?r\gh insurance (f]$ "u section #ajg7;b7
 or o!rwise1 = paym5t ( su* item or     
s]vice & und]/&s t no reimbursem5t w be 
provid$ "u ?is ,act = su* item or       
s]vice2  7,c7 ackn[l$ges t no limits "u 
?is ,act apply to am\nts t may be *>g$ =

 su* item or s]vice2  7,d7 if ! provid] 
is a nonp>ticipat+ provid]1 ackn[l$ges t
 ! b5efici>y has ! "r to h su* item or  
s]vice provid$ by o!r provid]s = :om    
paym5t w\ld be made "u ! ,m$ic>e = ,all 
,program2 &  7,e7 ackn[l$ges t ! provid]
 is provid+ an item or s]vice outside ! 
scope ( ! ,m$ic>e = ,all ,program4  7c7 
,provid] requirem5ts  7#a7 ,9 g5]al     
,subsection 7a7 %all n apply to any     
contract unless an affidavit describ$ 9 
p>agraph 7#b7 is 9 effect dur+ ! p]iod  
any item or s]vice is to be provid$     
pursuant to ! contract4  7#b7 ,affidavit
 ,an affidavit z describ$ 9 ?is         
subp>agraph %all-- 7,a7 id5tify !       
provid]1 & be sign$ by su* provid]2     
7,b7 provide t ! provid] w n submit any 
claim "u ?is title = any item or s]vice 
provid$ to any b5efici>y 7& w n receive 
any reimbursem5t or am\nt describ$ 9    
subsection 7a77#b7 = any su* item or    
s]vice7 dur+ ! #a-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#c7  
,en=cem5t ,if a provid] sign+ an        
affidavit describ$ 9 p>agraph 7#b7      
kn[+ly & willfully submits a claim "u   
?is title = any item or s]vice provid$  
dur+ ! #a-ye> p]iod describ$ 9 p>agraph 
7#b77;,b7 7or receives any reimbursem5t 
or am\nt describ$ 9 subsection 7a77#b7 =
 any su* item or s]vice7 ) respect to   
su* affidavit-- 7,a7 ?is subsection %all
 n apply ) respect to any item or s]vice
 provid$ by ! provid] pursuant to any   
contract on & aft] ! date ( su*         
submission & be=e ! end ( su* p]iod2 &  
7,b7 no paym5t %all be made "u ?is title
 = any item or s]vice furni%$ by !      
provid] dur+ ! p]iod describ$ 9         
subp>agraph 7,a7 7& no reimbursem5t or  
paym5t ( any am\nt describ$ 9 subsection
 7a77#b7 %all be made = any su* item or 
s]vice74  ,,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 = b5efits "u ! ,m$ic>e =    
,all ,program2  7,b7 enrollm5t "u su*   
,program2  7,c7 b5efits provid$ "u su*  
,program2  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 ( items & s]vices cov]$ "u !   
,m$ic>e = ,all ,program1 consi/5t )     
subtitle ,b2  7,g7 a process = appeal+  
or petition+ = a det]m9ation ( cov]age =
 items & s]vices "u ! ,m$ic>e = ,all    
,program2  7,h7 plann+ = capital        
exp5ditures & item & 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  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+ requirem5ts1 provid] report+    
requirem5ts1 & 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]vices cov]$ "u ! ,m$ic>e = ,all    
,program1 ! quality ( su* items &       
s]vices1 ! outcomes ( su* items &       
s]vices1 & ! equity ( heal? among       
population gr\ps4 ,su* database %all    
include1 to ! maximum ext5t feasible )\t
 compromis+ pati5t privacy1 heal?       
outcome measures us$ "u ?is ,act1 & to !
 maximum ext5t feasible )\t excessively 
burd5+ provid]s1 ! measures describ$ 9  
subp>agraphs 7,d7 ?r\gh 7,f7 (          
subsection 7a77#a74  7,b7 ,reports ,!   
,secret>y %all-- 7i7 regul>ly analyze   
in=mation report$ to ! ,secret>y2 &     
7ii7 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+ ,janu>y #a ( !   
second ye> beg9n+ aft] ! date on :i*    
b5efits are fir/ available "u section   
#ajf7;a71 ! ,secret>y %all annually     
report to ,congress on ! foll[+3 7,a7 ,!
 /atus ( implem5tation ( ?is ,act4  7,b7
 ,enrollm5t "u ! ,m$ic>e = ,all         
,program4  7,c7 ,b5efits "u ! ,m$ic>e = 
,all ,program4  7,d7 ,exp5ditures &     
f9anc+ "u ?is ,act4  7,e7 ,co/-conta9m5t
 measures & a*ievem5ts "u ! ,m$ic>e =   
,all ,program4  7,f7 ,quality assurance4
  7,g7 ,heal? c>e utilization patt]ns1  
includ+ any *anges attributable to !    
,m$ic>e = ,all ,program4  7,h7 ,*anges 9
 ! p] capita co/s ( heal? c>e4  7,i7    
,diff]5ces 9 ! heal? /atus ( !          
populations ( ! diff]5t ,/ates1 by      
demographic *>act]i/ics1 includ+ race1  
e?nicity1 national orig91 prim>y        
language use1 age1 disability1 sex      

7includ+ g5d] id5tity & sexual          
ori5tation71 geography1 or socioeconomic
 /atus4  7,j7 ,progress on implem5t+    
quality & outcome measures "u ?is ,act1 
& long-range plans & goals = a*ievem5ts 
9 su* measures4  7,k7 ,plans = improv+  
items & s]vices to m$ically und]s]v$    
populations 7z def9$ 9 section          
#ccj7;b77#c7 ( ! ,public ,heal? ,s]vice 
,act 7#db ,u4,s4,c4 #bed;b7b77#c7774    
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 =      
evid5ce-bas$ 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[+ ! date on :i*    
b5efits are fir/ available "u section   
#ajf7;a7 to det]m9e ! effectiv5ess ( !  
,m$ic>e = ,all ,program 9 c>ry+ out !   
duties "u subsection 7a74  7#b7 ,reports
 ,! ,comptroll] ,g5]al ( ! ,unit$ ,/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    
pati5t advocate gr\ps1 disability rights
 organizations1 & labor 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 )
 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 ,regional ,m$ic>e =   
,all (fices ,! ,secret>y %all e/abli% & 
ma9ta9 regional (fices = ! purpose (    
c>ry+ out ! duties specifi$ 9 subsection
 7c7 & promot+ adequate access to1 &    
effici5t use (1 t]ti>y c>e facilities1  
equipm5t1 items1 & s]vices by           
individuals enroll$ "u ! ,m$ic>e = ,all 
,program4  7b7 ,coord9ation ,:]ev]      
possible1 ! ,secret>y %all incorporate !
 regional (fices & ! adm9i/rative       
processes ( ! ,c5t]s = ,m$ic>e  ,m$icaid
 ,s]vices = ! purposes ( c>ry+ out      
subsection 7a74  7c7 ,appo9tm5t (       
regional directors ,9 ea* regional (fice
 e/abli%$ "u subsection 7a7 !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 director appo9t$ by ! regional   
director to ov]see home- &              
community-bas$ s]vices & supports4  7d7 
,duties ,ea* regional director %all--   
7#a7 submit an annual regional heal? c>e
 ne$s assessm5t report to ! ,secret>y1  
aft] a ?or\gh exam9ation ( heal? ne$s & 
consultation ) public heal? (ficials1   
cl9icians1 pati5ts1 & pati5t advocates2 
7#b7 recomm5d any *anges 9 provid]      
reimbursem5t or paym5t = deliv]y ( items
 & s]vices cov]$ "u ! ,m$ic>e = ,all    
,program det]m9$ appropriate by !       
regional director1 subject to !         
requirem5ts ( title ,,vi2 &  7#c7       
e/abli% a quality assurance me*anism 9  
ea* su* region 9 ord] to m9imize bo?    
"u-utilization & ov]-utilization ( heal?
 c>e items & s]vices cov]$ "u ! ,m$ic>e 
= ,all ,program & to ensure t all       

p>ticipat+ provid]s describ$ 9 section  
#cja7;a7 meet ! quality & o!r /&>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 & 9 
provid+ assi/ance to individuals entitl$
 to b5efits "u ! ,m$ic>e = ,all         
,program4  7b7 ,duties  7#a7 ,9 g5]al ,!
 ,b5efici>y ,ombudsman %all-- 7,a7      
receive compla9ts1 grievances1 & reque/s
 = in=mation submitt$ by individuals    
entitl$ to b5efits "u ! ,m$ic>e = ,all  
,program ) respect to any aspect ( su*  
,program2  7,b7 provide assi/ance )     
respect to compla9ts1 grievances1 &     
reque/s ref]r$ to 9 subp>agraph 7,a71   
includ+-- 7i7 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 &  7ii7 assi/ance to su*   
individuals 9 pres5t+ in=mation relat+  
to co/-%>+2 &  7,c7 submit annual       

reports to ,congress & ! ,secret>y t    
describe ! activities ( ! ,(fice & t    
include su* recomm5dations = improvem5t 
9 ! adm9i/ration ( ?is ,act z !         
,ombudsman det]m9es appropriate4  7#b7  
,au?orities ,! ,ombudsman %all n s]ve z 
an advocate = any increases 9 paym5ts or
 new cov]age ( items or 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 ! ,m$ic>e = ,all ,program 9 ! 

same mann] z !y apply to ,/ate m$ical   
assi/ance plans "u title ,,xix ( su*    
,act 7#db ,u4,s4,c4 #acif et seq473 7#a7
 ,section #aabh 7#db ,u4,s4,c4          
#acbj;a-#g7 7relat+ to exclusion (      
individuals & entities74  7#b7 ,section 
#aabh;,a 7#db ,u4,s4,c4 #acbj;a-#g;a7   
7civil monet>y p5alties74  7#c7 ,section
 #aabh;,b 7#db ,u4,s4,c4 #acbj;a-#g;b7  
7crim9al p5alties74  7#d7 ,section #aabd
 7#db ,u4,s4,c4 #acbj;a-#c7 7relat+ to  
disclosure ( own]%ip & relat$           
in=mation74  7#e7 ,section #aabf 7#db   
,u4,s4,c4 #acbj;a-#e7 7relat+ to        
disclosure ( c]ta9 own]s74  7#f7        
,section #ahgg 7#db ,u4,s4,c4 #acienn7  
7relat+ to physician ref]rals74  ,v     
,quality ( ,c>e  #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 ag5cies 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
 ,act 7#db ,u4,s4,c4 #bii;b et seq474 ,9
 s review+ & evaluat+1 ! ,c5t] %all     
det]m9e :e!r ! guidel9e %\ld be         
recogniz$ z a national practice guidel9e
 9 accordance ) & subject to 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;b 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 (     

items & s]vices "u section              
#dja7;a77#a77;,g74  #ejb4 ,address+     
heal? c>e disp>ities  7a7 ,evaluat+ data
 collection approa*es ,! ,c5t]1 9       
coord9ation ) ! ,(fice ( ,heal? ,equity 
e/abli%$ "u section #agab ( ! ,public   
,heal? ,s]vice ,act 7z add$ by section  
#faf7 & o!r ag5cies 9 ! ,dep>tm5t (     
,heal? & ,human ,s]vices det]m9$        
relevant by ! ,secret>y1 %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 items & 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 ! ,m$ic>e = ,all ,program4  
7#c7 ,improv+ data on race1 e?nicity1   
national orig91 prim>y language use1    
age1 disability1 sex 7includ+ g5d]      
id5tity & sexual ori5tation71 geography1
 & socioeconomic /atus4  7b7 ,reports to
 ,congress  7#a7 ,report on evaluation  
,n lat] ?an #ah mon?s aft] ! date on :i*
 b5efits are fir/ available "u section  
#ajf7;a71 ! ,c5t] %all submit to        
,congress & ! ,secret>y a report on !   
evaluation conduct$ "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 p>agraph 7#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 are fir/     
available "u 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 ,national ,heal? ,budget2 
,provid] ,paym5ts2 ,co/ ,conta9m5t      
,measures  ,a ,budget+  #fja4 ,national 
heal? budget  7a7 ,national heal? budget
  7#a7 ,9 g5]al ,n lat] ?an ,septemb] #a
 ( ea* ye>1 beg9n+ ) ! ye> prior to !   
date on :i* b5efits are fir/ available  
"u section #ajf7;a71 ! ,secret>y %all   
e/abli% a national heal? budget1 :i*    
specifies a budget = ! total exp5ditures
 to be made = items & s]vices cov]$ "u !
 ,m$ic>e = ,all ,program4  7#b7         
,division ( budget into compon5ts ,!    
national heal? budget %all consi/ ( at  
lea/ ! foll[+ compon5ts3 7,a7 ,an op]at+
 budget4  7,b7 ,a capital exp5ditures   
budget4  7,c7 ,a special projects       
budget4  7,d7 ,quality assessm5t        
activities "u title ,v4  7,e7 ,heal?    
pr(essional education exp5ditures4  7,f7
 ,adm9i/rative co/s1 includ+ co/s relat$
 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#g7 ?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 describ$ 9 p>agraph 7#b77;,e7  
is suffici5t to provide = ! am\nt (     
heal? pr(essional education exp5ditures 
suffici5t to meet ! ne$ = items &       
s]vices cov]$ "u ! ,m$ic>e = ,all       
,program4  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
 areas or areas describ$ 9 section      
#ccj7;b77#c7 ( ! ,public ,heal? ,s]vice 
,act 7#db ,u4,s4,c4 #bed;b7b77#c771     
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 ,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#i7 ,con/ruction compliance   
,exp5ditures f ea* compon5t ( ! national
 heal? budget1 includ+ con/ruction1 %all
 exp& accessibility = p]sons )          
disabilities to a*ieve full compliance )

 ! ,am]icans ) ,disabilities ,act (     
#aiij 7#db ,u4,s4,c4 #abaja et seq474   
,any project fund$ ?r\gh ! national     
budget %all at lea/ meet ! new          
con/ruction /&>ds "u su* ,act4  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 recruitm5t1 ret5tion1 & div]sity
 on pati5t outcomes4  #fjb4 ,tempor>y   
work] assi/ance  7a7 ,9 g5]al ,= up to  
#e ye>s foll[+ ! date on :i* b5efits are
 fir/ available "u section #ajf7;a71 at 
lea/ #a p]c5t ( ! national heal? 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 organizations1 :o may    
exp]i5ce economic dislocation z a result
 ( ! implem5tation ( ?is ,act4  7b7     
,cl>ification ,assi/ance describ$ 9     
subsection 7a7 %all include wage        
replacem5t1 retirem5t b5efits1 job tra9+
 & placem5t1 pref]5tial hir+1 &         
education b5efits4  ,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 &   
indep5d5t dialysis facilities7 is to    
furni% items & s]vices "u ! ,m$ic>e =   
,all ,program1 ! ,secret>y %all pay to  
su* in/itutional provid] a lump sum 9   
accordance ) ! succe$+ 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 !  
,m$ic>e = ,all ,program1 :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   
volume1 & 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  
7,a7 ,9 g5]al ,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 #fab4  7,b7 
,sal>ies ,any 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 "u 
?is p>agraph %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]4  7,c7 ,report+ &  
disclosure requirem5ts ,any gr\p        
practice or o!r heal? c>e provid] t     
receives paym5t ?r\gh an in/itutional   
provid]'s 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 public   
heal? em]g5cies includ+ 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+ wages1 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* cal5d> 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 (  
items & s]vices provid$ = ea* item &    
s]vice 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 7#db 
,u4,s4,c4 #acie et seq47 = 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%$2  7,d7   
wages = employees1 includ+ any necess>y 
increases to ensure m&atory m9imum safe 
regi/]$ 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 areas or areas   
describ$ 9 section #ccj7;b77#c7 ( !     
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #bed;b7b77#c771 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;e7a7772  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 ! ,m$ic>e = ,all         
,program2 or  7,d7 be us$ 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#b74  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 n exce$ ! comp5sation cap  
e/abli%$ 9 section #dcjd7;a77#af7 (     
title #da1 ,unit$ ,/ates ,code1 z add$  
by section #gjb ( ! ,bip>tisan ,budget  
,act ( #bjac1 & 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 7#db 
,u4,s4,c4 #acie et seq47 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 = items & s]vices cov]$ "u ! 
,m$ic>e = ,all ,program furni%$ ! prec$+
 ye> ) applicable adju/m5ts1 includ+    
adju/m5ts due to any public heal?       
em]g5cies 9 ! prec$+ ye>1 & 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 items or 
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 items & 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 items & 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 ,paym5ts to individual  
provid]s ?r\gh fee-=-s]vice  7a7 ,m$ic>e
 = all fee s*$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% & annually update a       
national fee s*$ule t e/abli%es am\nts =
 items & s]vices payable "u ! ,m$ic>e = 
,all ,program1 furni%$ by-- 7,a7        
individual provid]s2  7,b7 provid]s 9   
gr\p practices :o are n receiv+ paym5ts 
on a sal>i$ basis describ$ 9 section    
#faa7;a77#c72  7,c7 provid]s ( home- &  
community-bas$ s]vices2 &  7,d7 any o!r 
provid] n describ$ 9 section #faa4  7#b7
 ,am\nts ,9 e/abli%+ ! fee s*$ule "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 ,act & o!r ,f$]al    
heal? programs2 &  7,b7 ! exp]tise (    
provid]s & ! value ( items & s]vices    
furni%$ by su* provid]s4  7b7 ,lev]ag+  
exi/+ m$ic>e paym5t processes  7#a7     
,application ( paym5t processes "u title
 ,,xviii ,except z o!rwise provid$ 9 ?is
 section1 ! ,secret>y %all e/abli%1 &   
%all annually update by regulation1 !   
fee s*$ule "u subsection 7a7 9 a mann] t
 is docum5t$1 is transp>5t1 all[s =     
public comm5t1 &1 to ! greate/ ext5t    
practicable1 is consi/5t ) processes =  
det]m9+1 revis+1 & mak+ paym5ts = items 
& s]vices "u title ,,xviii ( ! ,social  
,security ,act 7#db ,u4,s4,c4 #acie et  
seq471 includ+ ! application ( !        
provisions (1 & am5dm5ts made by1       
section #fac4  7#b7 ,electronic bill+ ,!
 ,secret>y %all e/abli% a uni=m national
 sy/em = electronic bill+ = purposes (  
mak+ paym5ts "u ?is section4  7c7       
,application ( curr5t & plann$ paym5t   
re=ms ,to ! ext5t ! ,secret>y det]m9es  
su* application is necess>y to ensure a 

smoo? & fair transition1 ! ,secret>y may
 apply paym5t re=m activities plann$ or 
implem5t$ ) respect to su* title ,,xviii
 z ( ! date ( ! enactm5t ( ?is ,act1    
includ+ demon/rations1 waiv]s1 or any   
o!r provid] paym5t agreem5ts1 to b5efits
 "u ! ,m$ic>e = ,all ,program1 provid$ t
 ! ,secret>y sets =? a process = review+
 su* applications & mak+ su*            
det]m9ations t is reasonable1 transp>5t1
 & docum5t$1 & all[s = public comm5t4   
7d7 ,physician practice review bo>d ,ea*
 director ( a regional (fice1 9         
consultation ) repres5tatives (         
physicians practic+ 9 t region1 %all    
e/abli% & appo9t a physician practice   
review bo>d to assure quality1 co/      
effectiv5ess1 & fair reimbursem5ts =    
physician-deliv]$ items & s]vices4 ,!   
use ( me*anisms t discrim9ate aga9/ p ) 
disabilities is prohibit$ = use 9 any   
value or co/-effectiv5ess assessm5ts4   
#fac4 ,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                     
#acjew-#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 "o   
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 :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         
subp>agraph 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 ,paym5ts =            
prescription drugs & approv$ devices &  
equipm5t  7a7 ,negotiat$ prices ,!      
prices to be paid = ph>maceutical       
products1 m$ical supplies1 & m$ically   
necess>y assi/ive equipm5t cov]$ "u !   
,m$ic>e = ,all ,program %all be         
negotiat$ annually by ! ,secret>y4  7b7 
,prescription drug =mul>y  7#a7 ,9 g5]al
 ,! ,secret>y %all e/abli% a            
prescription drug =mul>y sy/em1 pursuant
 to ! requirem5ts ( section #bjb1 :i*   
%all enc\rage be/-practices 9 prescrib+ 
& disc\rage ! use ( ineffective1        
dang]\s1 or excessively co/ly m$ications
 :5 bett] alt]natives are available4    
7#b7 ,promotion ( use ( g5]ics ,! =mul>y
 "u ?is subsection %all promote ! use ( 
g5]ic m$ications to ! greate/ ext5t     
possible4  7#c7 ,=mul>y updates &       

petition rights ,! =mul>y "u ?is        
subsection %all be updat$ frequ5tly &   
cl9icians & pati5ts may petition !      
,secret>y to add new ph>maceuticals or  
to remove ineffective or dang]\s        
m$ications f ! =mul>y4  7#d7 ,use (     
(f-=mul>y m$ications ,! ,secret>y %all  
promulgate rules reg>d+ ! use (         
(f-=mul>y m$ications :i* all[ = pati5t  
access b d n compromise ! =mul>y4  #fae4
 ,paym5t prohibitions2 capital          
exp5ditures2 special projects  7a7      
,prohibitions ,paym5ts to p>ticipat+    
provid]s describ$ 9 section #cja7;a7 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 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#d7      
political or o!r contributions prohibit$

 "u section #cag7;a77#a7 ( ! ,f$]al     
,elections ,campaign ,act ( #aiga 7#eb  
,u4,s4,c4 #cjaai7;a77#a774  7b7 ,paym5ts
 = capital exp5ditures  7#a7 ,9 g5]al ,!
 ,secret>y %all pay1 f am\nts made      
available = capital exp5ditures pursuant
 to section #fja7;a77#b77;,b71 su* sums 
det]m9$ 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 items & s]vices = m$ically      
und]s]v$ populations & areas describ$ 9 
section #ccj7;b77#c7 ( ! ,public ,heal? 
,s]vice ,act 7#db ,u4,s4,c4             
#bed;b7b77#c77 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$4  7c7           
,prohibition aga9/ co-,m+l+ op]at+ &    
capital funds ,provid]s t receive paym5t
 "u ?is title %all be prohibit$ 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  7d7 ,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 facilities 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  7e7 ,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  #faf4 ,(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$ ,/ates1    
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+
 pollutants1 population d5sity1 &       
accessibility72  7,c7 b>ri]s to heal?   
c>e access1 includ+-- 7i7 lack ( tru/ & 
aw>5ess2  7ii7 lack ( transportation2   
7iii7 lack ( accessibility2  7iv7       

geography2  7v7 hospital & s]vice       
closures2  7vi7 lack ( heal? c>e        
infra/ructure & facilities2 &  7vii7    
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$ ,/ates1 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     
#fag4 ,(fice ( ,prim>y ,heal? ,c>e      
,title ,,xvii ( ! ,public ,heal? ,s]vice
 ,act 7#db ,u4,s4,c4 #cjju et seq471 z  
am5d$ by section #faf1 is fur!r am5d$ by
 add+ at ! end ! foll[+3  #agac4 ,(fice 
( ,prim>y ,heal? ,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]s includ+ prim>y m$ical1     
d5tal1 & behavioral heal? c>e provid]s1 
regi/]$ nurses1 & o!r advanc$ practice  
cl9icians2  7#d7 recomm5d appropriate   
work=ce tra9+1 te*nical assi/ance1 &    
pati5t protection enhancem5ts = prim>y  
heal? c>e practition]s1 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 community heal? c5t]s1 rural     
heal? c5t]s1 behavioral heal? cl9ics1 & 
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  ,,vii ,m$ic>e =   
,all ,tru/ ,fund  #gja4 ,m$ic>e = ,all  
,tru/ ,fund  7a7 ,9 g5]al ,!re is h]eby 

creat$ on ! books ( ! ,treasury ( !     
,unit$ ,/ates a tru/ fund to be kn[n z !
 ,m$ic>e = ,all ,tru/ ,fund 79 ?is      
section ref]r$ 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 
are fir/ available "u section #ajf7;a71 
out ( any moneys 9 ! ,treasury n o!rwise
 appropriat$1 am\nts equival5t to #ajj  
p]c5t ( ! net increase 9 rev5ues to !   
,treasury :i* is attributable to !      
am5dm5ts made by section #hja & section 
#ijb4 ,! am\nts appropriat$ 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$4  7#b7 ,curr5t program        
receipts  7,a7 ,initial ye> ,not)/&+ any
 o!r provision ( law1 !re is h]eby      
appropriat$ to ! ,tru/ ,fund = ! fir/   
fiscal ye> beg9n+ at lea/ "o ye> aft] ! 
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 7#db        
,u4,s4,c4 #acie et seq47 7o!r ?an am\nts
 attributable to any premiums "u su*    
title74  7ii7 ,! ,m$icaid program "u    
,/ate plans approv$ "u title ,,xix ( su*
 ,act 7#db ,u4,s4,c4 #acif et seq474    
7iii7 ,! ,f$]al ,employees ,heal?       
,b5efits program1 "u *apt] #hi ( title  
#e1 ,unit$ ,/ates ,code4  7iv7 ,!       
mat]nal & *ild heal? program 7"u title  

,v ( ! ,social ,security ,act 7#db      
,u4,s4,c4 #gja et seq4771 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? c>e 
items & s]vices ! paym5t ( :i* may be   
made "u ?is ,act4  7,b7 ,subsequ5t ye>s 
,not)/&+ any o!r provision ( law1 !re is
 appropriat$ to ! ,tru/ ,fund = ea*     
fiscal ye> foll[+ ! fiscal ye> 9 :i* !  
appropriation is made "u subp>agraph    
7,a71 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$]al funds = any reproductive
 heal? item or s]vice %all n apply to   
monies 9 ! ,tru/ ,fund4  7c7            
,incorporation ( provisions ,!          
provisions ( subsections 7b7 ?r\gh 7i7 (
 section #ahag ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acie;i7 %all apply 
to ! ,tru/ ,fund "u ?is section 9 ! same
 mann] z su* provisions appli$ to !     
,f$]al ,hospital ,insurance ,tru/ ,fund 
"u su* section #ahag1 except t1 =       
purposes ( apply+ su* subsections to ?is
 section1 ! ,bo>d ( ,tru/ees ( ! ,tru/  
,fund or ! ,bo>d ( ,tru/ees %all mean ! 
,secret>y4  7d7 ,transf] ( funds ,any   
am\nts rema9+ 9 ! ,f$]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 ! ,m$ic>e = ,all ,tru/
 ,fund "u ?is section4  ,,viii ,con=m+  
,am5dm5ts to ! ,employee ,retirem5t     
,income ,security ,act ( #aigd  #hja4   
,prohibition ( employee b5efits         
duplicative ( b5efits "u ! ,m$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  #ebc4 ,prohibition ( employee 
b5efits duplicative ( ,m$ic>e = ,all    
,program b5efits2 coord9ation 9 case (  
work]s' comp5sation  7a7 ,9 g5]al       
,subject to subsection 7b71 no employee 
b5efit plan may provide b5efits t       
duplicate paym5t = any items or s]vices 
= :i* paym5t may be made "u ! ,m$ic>e = 
,all ,program e/abli%$ "u section #aja (
 ! ,m$ic>e = ,all ,act 7ref]r$ to 9 ?is 
section z ! ,m$ic>e = ,all ,program74   
7b7 ,reimbursem5t ,ea* work]s           
comp5sation c>ri] t is liable = paym5t =

 work]s comp5sation s]vices furni%$ 9 a 
,/ate %all reimburse ! ,m$ic>e = ,all   
,program = ! co/ ( su* s]vices4  7c7    
,def9itions ,9 ?is subsection-- 7#a7 !  
t]m work]s comp5sation c>ri] means an   
insurance company t und]writes work]s   
comp5sation m$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$ical b5efits & includes   
items & s]vices 7includ+ rehabilitation 
items & s]vices & long-t]m c>e items &  
s]vices7 commonly us$ = 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 #ebc7;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 #ebb ! foll[+ new
 item3  ,sec4 #ebc4 ,prohibition (      
employee b5efits duplicative ( ,m$ic>e =
 ,all ,program b5efits2 coord9ation 9   
case ( work]s' comp5sation4  4  #hjb4   
,repeal ( 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 is repeal$4    
7b7 ,con=m+ am5dm5ts  7#a7 ,section     
#ejb7;a7 ( su* ,act 7#bi ,u4,s4,c4      
#aacb7;a77 is am5d$-- 7,a7 by /rik+     
p>agraph 7#g72 &  7,b7 by r$esignat+    

p>agraphs 7#h71 7#i71 & 7#aj7 z         
p>agraphs 7#g71 7#h71 & 7#i71           
respectively4  7#b7 ,section            
#ejb7;c77#a7 ( su* ,act 7#bi ,u4,s4,c4  
#aacb7;c77#a77 is am5d$ by /rik+        
p>agraph 7#a7 or 7#d7 ( section #fjf14  
7#c7 ,section #ejb7;e7 ( su* ,act 7#bi  
,u4,s4,c4 #aacb7;e77 is am5d$ by /rik+  
p>agraphs 7#a77;,b7 & 7#g7 & ins]t+     
p>agraph 7#a77;,b74  7#d7 ,section      
#ejb7l77#c77;,b7 ( su* ,act 7#bi        
,u4,s4,c4 #aacb7l77#c77;,b77 is am5d$ by
 /rik+ subsection 7a77#i7 & ins]t+      
subsection 7a77#h74  7#e7 ,section      
#ead7;b7 ( su* ,act 7#bi ,u4,s4,c4      
#aadd7;b77 is am5d$-- 7,a7 9 p>agraph   
7#g71 by /rik+ section                  
#bjf7;d77#c77;,b77i7712 &  7,b7 by /rik+
 p>agraph 7#h74  7#f7 ,! table ( cont5ts
 9 section #a ( ! ,employee ,retirem5t  
,income ,security ,act ( #aigd is am5d$ 
by /rik+ ! items relat+ to "p #f (      
subtitle ,b ( title ,i ( su* ,act4      
#hjc4 ,effective date ( title ,!        
provisions ( & am5dm5ts made by ?is     

title %all take effect on ! date on :i* 
b5efits are fir/ available "u section   
#ajf7;a74  ,,ix ,additional ,con=m+     
,am5dm5ts  #ija4 ,relation%ip to exi/+  
,f$]al heal? programs  7a7 ,m$ic>e1     
,m$icaid1 & ,/ate ,*ildr5's ,heal?      
,insurance ,program 7,,s*ip7  7#a7 ,9   
g5]al ,not)/&+ any o!r provision ( law1 
subject to p>agraphs 7#b7 & 7#c7-- 7,a7 
no b5efits %all be available "u title   
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #acie et seq47 = any item or  
s]vice furni%$ beg9n+ on or aft] ! date 
on :i* b5efits are fir/ available "u    
section #ajf7;a72  7,b7 no individual is
 entitl$ to m$ical assi/ance "u a ,/ate 
plan approv$ "u title ,,xix ( su* ,act  
7#db ,u4,s4,c4 #acif et seq47 = any item
 or s]vice furni%$ on or aft] su* date2 
7,c7 no individual is entitl$ to m$ical 
assi/ance "u a ,/ate *ild heal? plan "u 
title ,,xxi ( su* ,act 7#db ,u4,s4,c4   
#acig;aa et seq47 = any item or s]vice  
furni%$ on or aft] su* date2 &  7,d7 no 
paym5t %all be made to a ,/ate "u       

section #aijc7;a7 or #baje7;a7 ( su*    
,act 7#db ,u4,s4,c4 #acif;b7a72 #db     
,u4,s4,c4 #acig;ee7 ) 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 ! date on :i* b5efits are    
fir/ available "u section #ajf7;a71 &   
: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 
,cont9u$ cov]age ( long-t]m c>e & o!r   
c]ta9 s]vices "u ,m$icaid  7,a7 ,9 g5]al
 ,?is subsection %all n apply to        
entitlem5t to m$ical assi/ance provid$  
"u title ,,xix ( ! ,social ,security    
,act =-- 7i7 in/itutional long-t]m c>e  
s]vices 7z def9$ 9 section #aidh7;b7 (  

su* ,act72 or  7ii7 any o!r s]vice = :i*
 b5efits are n available "u ! ,m$ic>e = 
,all ,program & :i* is furni%$ "u a     
,/ate plan "u title ,,xix ( ! ,social   
,security ,act :i* provid$ = m$ical     
assi/ance = su* s]vice on ,janu>y #a1   
#bjbc4  7,b7 ,coord9ation betwe5        
,secret>y & ,/ates ,! ,secret>y %all    
coord9ate ) ! directors ( ,/ate ag5cies 
responsible = adm9i/]+ ,/ate plans "u   
title ,,xix ( ! ,social ,security ,act  
to-- 7i7 id5tify items & s]vices        
describ$ 9 subp>agraph 7,a77ii7 )       
respect to ea* ,/ate plan2 &  7ii7      
ensure t su* items & s]vices cont9ue to 
be made available "u su* plan4  7,c7    
,/ate ma9t5ance ( ef=t requirem5t ,)    
respect to any s]vice describ$ 9        
subp>agraph 7,a77ii7 t is made available
 "u a ,/ate plan "u title ,,xix ( !     
,social ,security ,act1 ! ma9t5ance (   
ef=t requirem5ts describ$ 9 section     
#aidh7;c7 ( su* ,act 7relat$ to         
eligibility /&>ds & requir$ exp5ditures7
 %all apply to su* s]vice 9 ! same mann]

 t su* requirem5ts apply to in/itutional
 long-t]m c>e s]vices 7z def9$ 9 section
 #aidh7;b7 ( su* ,act74  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 !  
,m$ic>e = ,all ,program4  7c7 ,treatm5t 
( b5efits = vet]ans & native am]icans   
7#a7 ,9 g5]al ,no?+ 9 ?is ,act %all     
affect ! eligibility ( vet]ans = !      
m$ical b5efits & s]vices provid$ "u     
title #ch1 ,unit$ ,/ates ,code1 !       
eligibility ( individuals = ,,tric>e    
m$ical b5efits & s]vices provid$ "u     
sections #ajgi & #ajhf ( title #aj1     
,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 ! ,f$]al & ,/ate ,ex*anges    

,effective on ! date on :i* b5efits are 
fir/ available "u section #ajf7;a71 !   
,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  ,x           
,transition to ,m$ic>e = ,all  ,a       
,improvem5ts to ,m$ic>e  #ajja4         
,protect+ ,m$ic>e fee-=-s]vice          
b5efici>ies f high out-(-pocket co/s    
7a7 ,protection aga9/ high out-(-,pocket
 exp5ditures ,title ,,xviii ( ! ,social 
,security ,act 7#db ,u4,s4,c4 #acie et  
seq47 is am5d$ by add+ at ! end ! foll[+
 new section3  #ahii;,c4 ,protection    
,aga9/ ,high ,out-(-,pocket ,exp5ditures
  7a7 ,9 g5]al ,not)/&+ any o!r         
provision ( ?is title1 9 ! case ( an    
individual entitl$ to1 or enroll$ =1    
b5efits "u "p ,a or enroll$ 9 "p ,b1 if 

! am\nt ( ! out-(-pocket co/-%>+ ( su*  
individual = a ye> 7effective ! ye>     
beg9n+ ,janu>y #a ( ! ye> foll[+ ! date 
( enactm5t ( ! ,m$ic>e = ,all ,act7     
equals or exce$s #a1ejj1 ! individual   
%all n be responsible = additional      
out-(-pocket co/-%>+ t occurr$ dur+ t   
ye>4  7b7 ,out-(-,pocket co/-,%>+ def9$ 
7#a7 ,9 g5]al ,subject to p>agraphs 7#b7
 & 7#c71 9 ?is section1 ! t]m           
out-(-pocket co/-%>+ means1 ) respect to
 an individual1 ! am\nt ( ! exp5ses     
incurr$ by ! individual t are           
attributable to-- 7,a7 co9surance &     
copaym5ts applicable "u "p ,a or ,b2 or 
7,b7 = items & s]vices t w\ld h o!rwise 
be5 cov]$ "u "p ,a or ,b b = ! exhau/ion
 ( ^? b5efits4  7#b7 ,c]ta9 co/s n      
includ$  7,a7 ,non-cov]$ items & s]vices
 ,exp5ses incurr$ = items & s]vices :i* 
are n includ$ 7or treat$ z be+ includ$7 
"u "p ,a or ,b %all n be consid]$       
incurr$ exp5ses = purposes ( det]m9+    
out-(-pocket co/-%>+ "u p>agraph 7#a74  
7,b7 ,items & s]vices n furni%$ on an   

assignm5t-relat$ basis ,if an item or   
s]vice is furni%$ to an individual "u   
?is title & is n furni%$ on an          
assignm5t-relat$ basis1 any additional  
exp5ses ! individual incurs above !     
am\nt ! individual w\ld h incurr$ if !  
item or s]vice 0 furni%$ on an          
assignm5t-relat$ basis %all n be        
consid]$ incurr$ exp5ses = purposes (   
det]m9+ out-(-pocket co/-%>+ "u p>agraph
 7#a74  7#c7 ,s\rce ( paym5t ,= purposes
 ( p>agraph 7#a71 ! ,secret>y %all      
consid] exp5ses to be incurr$ by !      
individual )\t reg>d to :e!r !          
individual or ano!r p]son1 includ+ a    
,/ate program or o!r ?ird-p>ty cov]age1 
has paid = su* exp5ses4  4  7b7         
,elim9ation ( p>ts ,a & ,b d$uctibles   
7#a7 ,"p ,a ,section #ahac7;b7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#acie;e7b77 is am5d$ by add+ at ! end ! 
foll[+ new p>agraph3  7#d7 ,= ea* ye>   
7beg9n+ ,janu>y #a ( ! ye> foll[+ ! date
 ( enactm5t ( ! ,m$ic>e = ,all ,act71 ! 
inpati5t hospital d$uctible = ! ye> %all

 be #j4  4  7#b7 ,"p ,b ,section        
#ahcc7;b7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciel7b77 is am5d$1 9 ! 
fir/ s5t5ce-- 7,a7 by /rik+ & = a       
subsequ5t ye> & ins]t+ = ea* ( #bjjf    
?r\gh ! ye> t includes ! date ( enactm5t
 ( ! ,m$ic>e = ,all ,act2 &  7,b7 by    
ins]t+ 1 & #j = ea* ye> subsequ5t ye>   
aft] #a74  #ajjb4 ,r$uc+ ,m$ic>e "p ,d  
annual out-(-pocket ?re%old ,section    
#ahfj;,d-#b7;b77#d77;,b7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#aciew-#ajb7;b77#d77;,b77 is am5d$--    
7#a7 9 clause 7i71 by /rik+ ,= purposes 
& ins]t+ ,subject to clause 7iii71 =    
purposes2 &  7#b7 by add+ at ! end !    
foll[+ new clause3  7iii7 ,r$uction 9   
?re%old dur+ transition p]iod  7,i7 ,9  
g5]al ,subject to subclause 7,,ii71 =   
plan ye>s beg9n+ on or aft] ,janu>y #a  
foll[+ ! date ( enactm5t ( ! ,m$ic>e =  
,all ,act & be=e ,janu>y #a ( ! ye> t is
 #d ye>s foll[+ su* date ( enactm5t1    
not)/&+ clauses 7i7 & 7ii71 ! annual    
out-(-pocket ?re%old specifi$ 9 ?is     

subp>agraph is equal to #cjj4  7,,ii7   
,au?ority to exempt br&-"n drugs if     
g5]ic available ,9 apply+ subclause     
7,i71 ! ,secret>y may exempt co/s       
incurr$ = a cov]$ "p ,d drug t is an    
applicable drug "u section              
#ahfj;,d-#ad;,a7g77#b7 if ! ,secret>y   
det]m9es t a g5]ic v]sion ( t drug is   
available4  4  #ajjc4 ,exp&+ ,m$ic>e to 
cov] d5tal & vision s]vices & he>+ aids 
& exam9ations "u "p ,b  7a7 ,d5tal      
s]vices  7#a7 ,removal ( exclusion f    
cov]age ,section #ahfb7;a7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4 #aciey7a77
 is am5d$ by /rik+ p>agraph 7#ab74  7#b7
 ,cov]age  7,a7 ,9 g5]al ,section       
#ahfa7s77#b7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #aciex7s77#b77 is am5d$--
 7i7 9 subp>agraph 7,,ii71 by /rik+ & at
 ! end2  7ii7 9 subp>agraph 7,,jj71 by  
ins]t+ & at ! end2 &  7iii7 by add+ at !
 end ! foll[+ new subp>agraph3  7,,kk7  
d5tal s]vices2  4  7,b7 ,paym5t ,section
 #ahcc7;a77#a7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciel7a77#a77 is   

am5d$-- 7i7 by /rik+ & be=e 7,,hh72 &   
7ii7 by ins]t+ be=e ! semicolon at ! end
 ! foll[+3 & 7,,ii7 ) respect to d5tal  
s]vices describ$ 9 section              
#ahfa7s77#b77,,kk71 ! am\nt paid %all be
 an am\nt equal to #hj p]c5t ( ! less] (
 ! actual *>ge = ! s]vices or ! am\nt   
det]m9$ "u ! fee s*$ule e/abli%$ "u     
section #ahdh7;b744  7,c7 ,effective    
date ,! am5dm5ts made by ?is subsection 
%all apply to items & s]vices furni%$ on
 or aft] ,janu>y #a foll[+ ! date ( !   
enactm5t ( ?is ,act4  7b7 ,vision       
s]vices  7#a7 ,9 g5]al ,section         
#ahfa7s77#b7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #aciex7s77#b771 z am5d$  
by subsection 7a71 is am5d$-- 7,a7 9    
subp>agraph 7,,jj71 by /rik+ & at ! end2
  7,b7 9 subp>agraph 7,,kk71 by ins]t+ &
 at ! end2 &  7,c7 by add+ at ! end !   
foll[+ new subp>agraph3  7,,ll7 vision  
s]vices2  4  7#b7 ,paym5t ,section      
#ahcc7;a77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciel7a77#a771 z am5d$ 
by subsection 7a71 is am5d$-- 7,a7 by   

/rik+ & be=e 7,,ii72 &  7,b7 by ins]t+  
be=e ! semicolon at ! end ! foll[+3 1 & 
7,,jj7 ) respect to vision s]vices      
describ$ 9 section #ahfa7s77#b77,,ll71 !
 am\nt paid %all be an am\nt equal to   
#hj p]c5t ( ! less] ( ! actual *>ge = ! 
s]vices or ! am\nt det]m9$ "u ! fee     
s*$ule e/abli%$ "u section #ahdh7;b744  
7#c7 ,effective date ,! am5dm5ts made by
 ?is subsection %all apply to items &   
s]vices furni%$ on or aft] ,janu>y #a   
foll[+ ! date ( ! enactm5t ( ?is ,act4  
7c7 ,he>+ aids & exam9ations !re=  7#a7 
,9 g5]al ,section #ahfb7;a77#g7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#aciey7a77#g77 is am5d$ by /rik+ he>+   
aids or exam9ations !re=14  7#b7        
,effective date ,! am5dm5t made by ?is  
subsection %all apply to items & s]vices
 furni%$ on or aft] ,janu>y #a foll[+ ! 
date ( ! enactm5t ( ?is ,act4  #ajjd4   
,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$-- 7,a7 by /rik+
 subsections 7e77#a77;,b71 7f71 & 7h72 &

  7,b7 by 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 ,janu>y #a ( ! ye> t is #d ye>s    
aft] su* date ( enactm5t4  #ajje4       
,gu>ante$ issue ( ,m$igap policies      
,section #ahhb ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciess7 is am5d$ by
 add+ at ! end ! foll[+ new subsection3 
7aa7 ,gu>ante$ issue = all              
,m$igap-,eligible ,m$ic>e b5efici>ies   
,not)/&+ p>agraphs 7#b77;,a7 & 7#b77;,d7
 ( subsection 7s7 or any o!r provision (
 ?is section1 on or aft] ! date (       
enactm5t ( ?is subsection1 ! issu] ( a  
,m$ic>e supplem5tal policy may n d5y or 
condition ! issuance or effectiv5ess ( a
 ,m$ic>e supplem5tal policy1 or         
discrim9ate 9 ! pric+ ( ! policy1       
because ( heal? /atus1 claims exp]i5ce1 
receipt ( heal? c>e1 or m$ical condition
 9 ! case ( any individual entitl$ to1  
or enroll$ =1 b5efits "u "p ,a & enroll$
 = b5efits "u "p ,b4  4  ,b ,tempor>y   
,m$ic>e ,buy-,9 ,option & ,tempor>y     
,public ,option  #ajaa4 ,l[]+ ! ,m$ic>e 
age  7a7 ,9 g5]al ,title ,,xviii ( !    

,social ,security ,act 7#db ,u4,s4,c4   
#acie;c et seq471 z am5d$ by section    
#ajja1 is am5d$ by add+ at ! end !      
foll[+ new section3  #ahii;,e4 ,tempor>y
 ,m$ic>e ,buy-,9 ,option = ,c]ta9       
,individuals  7a7 ,no effect on o!r     
b5efits = individuals o!rwise eligible  
or on ,tru/ ,funds ,! ,secret>y %all    
implem5t ! provisions ( ?is section 9   
su* a mann] to ensure t su* provisions--
 7#a7 h no effect on ! b5efits "u ?is   
title = individuals :o are entitl$ to1  
or enroll$ =1 su* b5efits o!r ?an ?r\gh 
?is section2 &  7#b7 h no negative      
impact on ! ,f$]al ,hospital ,insurance 
,tru/ ,fund or ! ,f$]al ,supplem5t>y    
,m$ical ,insurance ,tru/ ,fund 7includ+ 
! ,m$ic>e ,prescription ,drug ,acc\nt )9
 su* ,tru/ ,fund74  7b7 ,option  7#a7 ,9
 g5]al ,e individual :o meets !         
requirem5ts describ$ 9 p>agraph 7#c7    
%all be eligible to enroll "u ?is       
section4  7#b7 ,"p ,a1 ,b1 & ,d b5efits 
,an individual enroll$ "u ?is section is
 entitl$ to ! same b5efits 7& %all      

receive ! same protections7 "u ?is title
 z an individual :o is entitl$ to       
b5efits "u "p ,a & enroll$ "u p>ts ,b & 
,d1 includ+ ! ability to enroll 9 a     
private plan t provides qualifi$        
prescription drug cov]age4  7#c7        
,requirem5ts = eligibility ,!           
requirem5ts describ$ 9 ?is p>agraph are 
! foll[+3 7,a7 ,! individual is a       
resid5t ( ! ,unit$ ,/ates4  7,b7 ,!     
individual is-- 7i7 a citiz5 or national
 ( ! ,unit$ ,/ates2 or  7ii7 an ali5    
lawfully admitt$ = p]man5t resid5ce4    
7,c7 ,! individual is n o!rwise entitl$ 
to b5efits "u "p ,a or eligible to      
enroll "u "p ,a or "p ,b4  7,d7 ,!      
individual has atta9$ ! applicable ye>s 
( age b has n atta9$ #fe ye>s ( age4    
7#d7 ,applicable ye>s ( age def9$ ,=    
purposes ( ?is section1 ! t]m applicable
 ye>s ( age means-- 7,a7 effective      
,janu>y #a ( ! fir/ ye> foll[+ ! date ( 
enactm5t ( ! ,m$ic>e = ,all ,act1 ! age 
( #ee2  7,b7 effective ,janu>y #a ( !   
second ye> foll[+ su* date ( enactm5t1 !

 age ( #de2 &  7,c7 effective ,janu>y #a
 ( ! ?ird ye> foll[+ su* date (         
enactm5t1 ! age ( #ce4  7c7 ,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  7d7 ,premium    
7#a7 ,am\nt ( mon?ly premiums ,!        
,secret>y %all1 dur+ ,septemb] ( ea* ye>
 7beg9n+ ) ! fir/ ,septemb] foll[+ !    
date ( enactm5t ( ! ,m$ic>e = ,all      
,act71 det]m9e a mon?ly premium = all   
individuals enroll$ "u ?is section4 ,su*
 mon?ly premium %all be equal to #a_/ab 
( ! annual premium comput$ "u p>agraph  
7#b77;,b71 :i* %all apply ) respect to  
cov]age provid$ "u ?is section = any    
mon? 9 ! succe$+ ye>4  7#b7 ,annual     
premium  7,a7 ,comb9$ p] capita av]age =

 all ,m$ic>e b5efits ,! ,secret>y %all  
e/imate ! av]age1 annual p] capita am\nt
 = b5efits & adm9i/rative exp5ses t w be
 payable "u p>ts ,a1 ,b1 & ,d 9 ! ye> = 
all individuals enroll$ "u ?is section4 
7,b7 ,annual premium ,! annual premium  
"u ?is subsection = mon?s 9 a ye> is    
equal to ! av]age1 annual p] capita     
am\nt e/imat$ "u subp>agraph 7,a7 = !   
ye>4  7#c7 ,increas$ premium =          
complem5t>y plans ,no?+ 9 ?is section   
%all preclude an individual f *oos+ a   
prescription drug plan or o!r           
complem5t>y plans :i* requires !        
individual to pay an additional am\nt   
7because ( supplem5tal b5efits or       
because x is a m exp5sive plan74 ,9 su* 
case ! individual w\ld be responsible = 
! increas$ mon?ly premium4  7e7 ,paym5t 
( premiums  7#a7 ,9 g5]al ,premiums =   
enrollm5t "u ?is section %all be paid to
 ! ,secret>y at su* times1 & 9 su*      
mann]1 z ! ,secret>y det]m9es           
appropriate4  7#b7 ,deposit ,am\nts     
collect$ by ! ,secret>y "u ?is section  

%all be deposit$ 9 ! ,f$]al ,hospital   
,insurance ,tru/ ,fund & ! ,f$]al       
,supplem5t>y ,m$ical ,insurance ,tru/   
,fund 7includ+ ! ,m$ic>e ,prescription  
,drug ,acc\nt )9 su* ,tru/ ,fund7 9 su* 
proportion z ! ,secret>y det]m9es       
appropriate4  7f7 ,n eligible = ,m$ic>e 
co/-,%>+ assi/ance ,an individual       
enroll$ "u ?is section %all n be treat$ 
z enroll$ "u any "p ( ?is title =       
purposes ( obta9+ m$ical assi/ance =    
,m$ic>e co/-%>+ or o!rwise "u title     
,,xix4  7g7 ,treatm5t 9 relation to !   
,af=dable ,c>e ,act  7#a7 ,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  7#b7 ,eligibility
 = premium assi/ance ,cov]age provid$ "u
 ?is section-- 7,a7 %all be treat$ z    
cov]age "u a qualifi$ heal? plan 9 !    
individual m>ket enroll$ 9 ?r\gh !      
,ex*ange :]e ! individual resides = all 

purposes ( section #cf;,b ( ! ,int]nal  
,rev5ue ,code ( #aihf o!r ?an subsection
 7c77#b77;,b7 !re(2 &  7,b7 %all n be   
treat$ z eligibility = o!r m9imum       
ess5tial cov]age = purposes ( subsection
 7c77#b77;,b7 ( su* section #cf;,b4  ,! 
,secret>y %all det]m9e ! applicable     
second l[e/ co/ silv] plan :i* %all     
apply to cov]age "u ?is section =       
purposes ( section #cf;,b ( su* ,code4  
7#c7 ,eligibility = co/-%>+ subsidies ,=
 purposes ( apply+ section #adjb ( !    
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjga7-- 7,a7      
cov]age provid$ "u ?is section %all be  
treat$ z cov]age "u a qualifi$ heal?    
plan 9 ! silv] level ( cov]age 9 !      
individual m>ket (f]$ ?r\gh an ,ex*ange2
 &  7,b7 ! ,secret>y %all be treat$ z ! 
issu] ( su* plan4  7h7 ,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     

#ajab4 ,e/abli%m5t ( ! ,m$ic>e          
transition plan  7a7 ,9 g5]al ,to c>ry  
out ! purpose ( ?is section1 = plan ye>s
 beg9n+ ) ! fir/ plan ye> t beg9s aft] !
 date ( enactm5t ( ?is ,act & end+ ) !  
date on :i* b5efits are fir/ available  
"u section #ajf7;a71 ! ,secret>y1 act+  
?r\gh ! ,adm9i/rator ( ! ,c5t]s =       
,m$ic>e  ,m$icaid 7ref]r$ to 9 ?is      
section z ! ,adm9i/rator71 %all e/abli%1
 & provide = ! (f]+ ?r\gh ! ,ex*anges1 (
 a public heal? plan 79 ?is ,act ref]r$ 
to z ! ,m$ic>e ,transition plan7 t      
provides af=dable1 high-quality heal?   
b5efits cov]age ?r\gh\t ! ,unit$ ,/ates4
  7b7 ,adm9i/rat+ ! ,m$ic>e transition  
7#a7 ,adm9i/rator ,! ,adm9i/rator %all  
adm9i/] ! ,m$ic>e ,transition plan 9    
accordance ) ?is section4  7#b7         
,application ( ,,aca requirem5ts        
,consi/5t ) ?is section1 ! ,m$ic>e      
,transition plan %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$ic>e        
,transition plan %all be made available 
only ?r\gh ! ,ex*anges1 & %all be       
available to individuals wi%+ to enroll 
& to qualifi$ employ]s 7z def9$ 9       
section #acab7;f77#b7 ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjcb7;f77#b777 :o wi% to    
make su* plan available to _! employees4
  7#d7 ,eligibility to pur*ase ,any     
,unit$ ,/ates resid5t may enroll 9 !    
,m$ic>e ,transition plan4  7c7 ,b5efits2
 actu>ial value ,9 c>ry+ out ?is        
section1 ! ,adm9i/rator %all ensure t ! 
,m$ic>e ,transition plan provides-- 7#a7
 cov]age = ! b5efits requir$ to be cov]$
 "u title ,,ii2 &  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$ic>e ,transition plan1 !
 ,adm9i/rator %all reimburse su*        
provid]s at rates det]m9$ = equival5t   
items & s]vices "u ! orig9al ,m$ic>e    
fee-=-s]vice program "u p>ts ,a & ,b (  
title ,,xviii ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;c et seq474 ,=    
items & s]vices cov]$ "u ! ,m$ic>e      
,transition plan b n cov]$ "u su* p>ts  
,a & ,b1 ! ,adm9i/rator %all reimburse  
provid]s at rates set by ! ,adm9i/rator 
9 a mann] consi/5t ) ! mann] 9 :i* rates
 = o!r items & s]vices 7 set "u !       
orig9al ,m$ic>e fee-=-s]vice program4   
7#b7 ,prescription drugs ,any paym5t    
rate "u ?is subsection = a prescription 
drug %all be at a rate negotiat$ by !   
,adm9i/rator ) ! manufactur] ( ! drug4  
,if ! ,adm9i/rator is unable to rea* a  
negotiat$ agreem5t on su* a reimbursem5t
 rate1 ! ,adm9i/rator %all e/abli% !    

rate at an am\nt equal to ! less] (--   
7,a7 ! price paid by ! ,secret>y (      
,vet]ans ,affairs to procure ! drug "u !
 laws adm9i/]$ by ! ,secret>y ( ,vet]ans
 ,affairs2  7,b7 ! price paid to procure
 ! drug "u section #habf ( title #ch1   
,unit$ ,/ates ,code2 or  7,c7 ! be/     
price det]m9$ "u section                
#aibg7;c77#a77;,c7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acifr-#h7;c77#a77;,c77 = ! drug4  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$ic>e ,transition plan4  
7,b7 ,additional provid]s ,!            
,adm9i/rator %all e/abli% a process to  
all[ heal? c>e provid]s n describ$ 9    
subp>agraph 7,a7 to become p>ticipat+   

provid]s 9 ! ,m$ic>e ,transition plan4  
,su* process %all be simil> to ! process
 appli$ 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 plan1 :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$ic>e ,transition plan by rat+ area1
 z describ$ 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$4  7f7 
,t]m9ation ,! provisions ( ?is section  
%all cease to h =ce or effect on ! date 
on :i* b5efits are fir/ available "u    
section #ajf7;a74  7g7 ,tax cr$its &    
co/-,%>+ subsidies  7#a7 ,premium       
assi/ance tax cr$its  7,a7 ,cr$its all[$
 to ,m$ic>e ,transition plan enrollees  
at or above #dd p]c5t ( pov]ty 9        
non-expansion ,/ates ,p>agraph 7#a7 (   
section #cf;,b7c7 ( ! ,int]nal ,rev5ue  
,code ( #aihf is am5d$ by r$esignat+    
subp>agraphs 7,c71 7,d71 & 7,e7 z       
subp>agraphs 7,d71 7,e71 & 7,f71        
respectively1 & by ins]t+ aft]          
subp>agraph 7,b7 ! foll[+ new           
subp>agraph3  7,c7 ,special rules =     
,m$ic>e ,transition plan 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 plan e/abli%$ "u section    
#ajab7;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 ,! prec$+ s5t5ce %all 
n apply to any taxable ye> to :i*       
subp>agraph 7,e7 applies4  7ii7         
,enrollees 9 ,m$icaid non-expansion     
,/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 plan    
e/abli%$ "u section #ajab7;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$ic>e ,transition plan  7i7 
,9 g5]al ,subp>agraph 7,a7 ( section    
#cf;,b7b77#c7 ( su* ,code is am5d$--    
7,i7 by r$esignat+ clauses 7ii7 & 7iii7 

z clauses 7iii7 & 7iv71 respectively2   
7,,ii7 by /rik+ clause 7ii7 9 clause 7i7
 & ins]t+ clauses 7ii7 & 7iii72 &       
7,,iii7 by ins]t+ aft] clause 7i7 !     
foll[+ new clause3  7ii7 ,special rules 
= taxpay]s enroll$ 9 ,m$ic>e ,transition
 plan ,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 plan e/abli%$ "u section    
#ajab7;a7 ( ! ,m$ic>e = ,all ,act = all 
mon?s 9 ! taxable ye> ! applicable      
p]c5tage = any taxable ye> %all be      
det]m9$ 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#bb #ajj p]c5t up to #ach          
p]c5t#b4jdb4jd #ach p]c5t up to #aej    
p]c5t#c4jfd4jh #aej p]c5t & above#d4jhe4
 ,! prec$+ s5t5ce %all n apply to any   
taxable ye> to :i* clause 7iv7 applies4 

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 plan e/abli%$
 "u section #ajab7;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$ic>e ,transition plan 
enrollees 9 ,m$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$ic>e 
,transition plan1 subp>agraph 7,a71     
p>agraph 7#a77;,b71 & p>agraphs         
7#a77;,a77i7 & 7#b77;,a7 ( subsection   
7c7 %all ea* be appli$ by sub/itut+ #j  
p]c5t = #ajj p]c5t ea* place x appe>s4  
7,c7 ,adju/$ co/-%>+ = ,m$ic>e          
,transition plan enrollees ,9 ! case (  
any individual :o enrolls 9 su* ,m$ic>e 
,transition plan1 9 lieu ( ! p]c5tages  
"u subsection 7c77#a77;,b77i7 & 7c77#b71

 ! ,secret>y %all prescribe a me?od (   
det]m9+ ! co/-%>+ r$uction = any su*    
individual su* t ! total ( ! co/-%>+ & !
 premiums paid by ! individual "u su*   
,m$ic>e ,transition plan does n exce$ ! 
p]c5tage ( ! total all[$ co/s ( b5efits 
provid$ "u ! plan equal to ! f9al       
premium p]c5tage applicable to su*      
individual "u section                   
#cf;,b7b77#c77;,a77ii7 ( ! ,int]nal     
,rev5ue ,code ( #aihf4  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$-- 7,a7 9 ! p>agraph head+1 by     
ins]t+ 1 ! ,m$ic>e ,transition plan1    
be=e &2 &  7,b7 by ins]t+ ! ,m$ic>e     
,transition plan "u section #ajab ( !   
,m$ic>e = ,all ,act1 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 plan "u section  

#ajab ( ! ,m$ic>e = ,all ,act1 be=e or a
 multi-,/ate qualifi$ heal? plan4  ,c   
,pati5t ,protections ,dur+ ,m$ic>e =    
,all ,transition ,p]iod  #ajba4 ,m9imiz+
 disruptions to pati5t c>e ,! ,secret>y 
%all ensure t all individuals enroll$ 91
 or :o seek to enroll 91 a gr\p heal?   
plan1 heal? insurance cov]age (f]$ by a 
heal? insurance issu]1 or ! plan        
e/abli%$ "u section #ajab dur+ !        
transition p]iod ( ?is ,act are protect$
 f disruptions 9 _! c>e dur+ !          
transition p]iod4  #ajbb4 ,public       
consultation ,! ,secret>y %all consult )
 communities & advocacy organizations ( 
individuals liv+ ) disabilities & o!r   
pati5t advocacy organizations to ensure 
! transition describ$ 9 section #ajba   
takes into acc\nt ! safety & cont9uity (
 c>e = individuals ) disabilities1      
complex m$ical ne$s1 or *ronic          
conditions4  #ajbc4 ,def9itions ,9 ?is  
subtitle1 ! t]ms heal? insurance        
cov]age1 heal? insurance issu]1 & gr\p  
heal? plan h ! mean+s giv5 su* t]ms 9   

section #bgia ( ! ,public ,heal? ,s]vice
 ,act 7#db ,u4,s4,c4 #cjj;gg-#ia74  ,,xi
 ,miscellane\s  #aaja4 ,updat+ res\rce  
limits = ,supplem5tal ,security ,income 
eligibility 7,,ssi7 ,section            
#afaa7;a77#c7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #achb7;a77#c77 is       
am5d$-- 7#a7 9 subp>agraph 7,a7-- 7,a7  
by /rik+ & aft] ,janu>y #a1 #aihh12 &   
7,b7 by ins]t+ 1 & to #f1bjj on ,janu>y 
#a1 #bjbc be=e ! p]iod2  7#b7 9         
subp>agraph 7,b7-- 7,a7 by /rik+ & aft] 
,janu>y #a1 #aihh12 &  7,b7 by ins]t+ 1 
& to #d1ajj on ,janu>y #a1 #bjbc be=e ! 
p]iod2 &  7#c7 by add+ at ! end ! foll[+
 new subp>agraph3  7,c7 ,beg9n+ )       
,decemb] ( #bjbc1 :5ev] ! doll> am\nts 9
 effect "u p>agraphs 7#a77;,a7 &        
7#b77;,a7 ( ?is subsection are increas$ 
= a mon? by a p]c5tage "u section       
#afag7;a77#b71 ea* ( ! doll> am\nts 9   
effect "u ?is p>agraph %all be increas$1
 effective ) su* mon?1 by ! same        
p]c5tage 7& r\nd$1 if n a multiple (    
#aj1 to ! close/ multiple ( #aj74 ,ea*  

increase "u ?is subp>agraph %all be bas$
 on ! unr\nd$ am\nt = ! prior #ab-mon?  
p]iod4  4  #aajb4 ,def9itions ,9 ?is    
,act-- 7#a7 ! t]m ,secret>y means !     
,secret>y ( ,heal? & ,human ,s]vices2   
7#b7 ! t]m ,/ate means any ( ! #ej      
,/ates1 ! ,di/rict ( ,columbia1 or a    
t]ritory ( ! ,unit$ ,/ates2 &  7#c7 !   
t]m ,unit$ ,/ates %all include ! #ej    
,/ates1 ! ,di/rict ( ,columbia1 & !     
t]ritories ( ! ,unit$ ,/ates4