,,ii #aahth ,,congress #ast ,session ,s4 #bhdf ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,september #ai1 #bjbc,mr4 ,durbin 7for himself and ,mr4 ,van ,hollen7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to improve ,federal efforts with respect to the prevention of maternal mortality1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,community ,access1 ,resources1 and ,empowerment for ,moms ,act or the ,,care for ,moms ,act4 #b4 ,findings ,congress finds the following3 7#a7 ,every year1 across the ,united ,states1 nearly #d1jjj1jjj women give birth1 more than #a1jjj women suffer fatal complications during pregnancy1 while giving birth or during the postpartum period1 and about #gj1jjj women suffer near-fatal1 partum-related complications4 7#b7 ,the maternal mortality rate is often used as a proxy to measure the overall health of a population4 ,while the infant mortality rate in the ,united ,states has reached its lowest point1 the risk of death for women in the ,united ,states during pregnancy1 childbirth1 or the postpartum period is higher than such risk in many other high-income countries4 ,the estimated maternal mortality rate 7deaths per #ajj1jjj live births7 for the #dh contiguous ,states and ,washington1 ,,dc1 increased from #ad4e percent in #bjjj to #cb4j in #bjba4 ,the ,united ,states is the only industrialized nation with a rising maternal mortality rate4 7#c7 ,the ,national ,vital ,statistics ,system of the ,centers for ,disease ,control and ,prevention has found that in #bjba1 there were #cb4i maternal deaths for every #ajj1jjj live births in the ,united ,states4 ,that ratio continues to exceed the rate in other high-income countries4 7#d7 ,it is estimated that more than #hj percent of maternal deaths in the ,united ,states are preventable4 7#e7 ,according to the ,centers for ,disease ,control and ,prevention1 the maternal mortality rate varies drastically for women by race and ethnicity4 ,there are about #bf4f deaths per #ajj1jjj live births for ,white women1 #fi4i deaths per #ajj1jjj live births for non-,hispanic ,black women1 and #cb4j deaths per #ajj1jjj live births for ,american ,indian_/,alaska ,native women4 ,while maternal mortality disparately impacts ,black women1 this urgent public health crisis traverses race1 ethnicity1 socioeconomic status1 educational background1 and geography4 7#f7 ,in the ,united ,states1 non-,hispanic ,black women are about #c times more likely to die from causes related to pregnancy and childbirth compared to non-,hispanic ,white women1 which is one of the most disconcerting racial disparities in public health4 ,this disparity widens in certain cities and ,states across the country4 7#g7 ,according to the ,national ,center for ,health ,statistics of the ,centers for ,disease ,control and ,prevention1 the maternal mortality rate heightens with age1 as women #dj and older die at a rate of #ach4e per #ajj1jjj births compared to #bj4d per #ajj1jjj for women under #be4 ,this translates to women over #dj being #f4h times more likely to die compared to their counterparts under #be years of age4 7#h7 ,the ,,covid-#ai pandemic has exacerbated the maternal health crisis4 ,a study of the ,centers for ,disease ,control and ,prevention suggested that pregnant women are at a significantly higher risk for severe outcomes1 including death1 from ,,covid-#ai as compared to non-pregnant women4 ,the ,,covid-#ai pandemic also decreased access to prenatal and postpartum care4 ,a study by the ,government ,accountability ,office found that ,,covid-#ai contributed to #be percent of maternal deaths in #bjbj and #bjba4 7#i7 ,the findings described in paragraphs 7#a7 through 7#h7 are of major concern to researchers1 academics1 members of the business community1 and providers across the obstetric continuum represented by organizations such as-- 7,a7 the ,american ,college of ,nurse-,midwives2 7,b7 the ,american ,college of ,obstetricians and ,gynecologists2 7,c7 the ,american ,medical ,association2 7,d7 the ,association of ,women's ,health1 ,obstetric and ,neonatal ,nurses2 7,e7 the ,black ,mamas ,matter ,alliance2 7,f7 the ,black ,women's ,health ,imperative2 7,g7 the ,california ,maternal ,quality ,care ,collaborative2 7,h7 ,ever,thrive ,illinois2 7,i7 the ,illinois ,perinatal ,quality ,collaborative2 7,j7 the ,march of ,dimes2 7,k7 the ,national ,association of ,certified ,professional ,midwives2 7,l7 ,,rh ,impact3 ,the ,collaborative for ,equity ,justice2 7,m7 the ,national ,partnership for ,women ,families2 7,n7 the ,national ,polycystic ,ovary ,syndrome ,association2 7,o7 the ,preeclampsia ,foundation2 7,p7 the ,society for ,maternal-,fetal ,medicine2 7,q7 the ,what ,to ,expect ,project2 7,r7 ,tufts ,university ,school of ,medicine ,center for ,black ,maternal ,health and ,reproductive ,justice2 7,s7 the ,shades of ,blue ,project2 7,t7 the ,maternal ,mental ,health ,leadership ,alliance2 7,u7 ,tulane ,university ,mary ,amelia ,center for ,women's ,health ,equity ,research2 7,v7 ,in ,our ,own ,voice3 ,national ,black ,women's ,reproductive ,justice ,agenda2 and 7,w7 ,physicians for ,reproductive ,health4 7#aj7 ,hemorrhage1 cardiovascular and coronary conditions1 cardiomyopathy1 infection or sepsis1 embolism1 mental health conditions 7including substance use disorder71 hypertensive disorders1 stroke and cerebrovascular accidents1 and anesthesia complications are the predominant medical causes of maternal-related deaths and complications4 ,most of these conditions are largely preventable or manageable4 ,even when these conditions are not preventable1 mortality and morbidity may be prevented when conditions are diagnosed and treated in a timely manner4 7#aa7 ,according to a study published by the ,journal of ,perinatal ,education1 doula-assisted mothers are #d times less likely to have a low-birthweight baby1 #b times less likely to experience a birth complication involving themselves or their baby1 and significantly more likely to initiate breastfeeding and human lactation4 ,doula care has also been shown to produce cost savings resulting in part from reduced rates of cesarean and pre-term births4 7#ab7 ,intimate partner violence is one of the leading causes of maternal death1 and women are more likely to experience intimate partner violence during pregnancy than at any other time in their lives4 ,it is also more dangerous than pregnancy4 ,intimate partner violence during pregnancy and postpartum crosses every demographic and has been exacerbated by the ,,covid-#ai pandemic4 7#ac7 ,oral health is an important part of perinatal health4 ,reducing bacteria in a woman's mouth during pregnancy can significantly reduce her risk of developing oral diseases and spreading decay-causing bacteria to her baby4 ,moreover1 some evidence suggests that women with periodontal disease during pregnancy could be at greater risk for poor birth outcomes1 such as preeclampsia1 pre-term birth1 and low-birth weight4 ,furthermore1 a woman's oral health during pregnancy is a good predictor of her newborn's oral health1 and since mothers can unintentionally spread oral bacteria to their babies1 putting their children at higher risk for tooth decay1 prevention efforts should happen even before children are born1 as a matter of pre-pregnancy health and prenatal care during pregnancy4 7#ad7 ,in the ,united ,states1 death reporting and analysis is a ,state function rather than a ,federal process4 ,states report all deaths--including maternal deaths--on a semi-voluntary basis1 without standardization across ,states4 ,while the ,centers for ,disease ,control and ,prevention has the capacity and system for collecting death-related data based on death certificates1 these data are not sufficiently reported by ,states in an organized and standard format across ,states such that the ,centers for ,disease ,control and ,prevention is able to identify causes of maternal death and best practices for the prevention of such death4 7#ae7 ,vital statistics systems often underestimate maternal mortality and are insufficient data sources from which to derive a full scope of medical and social determinant factors contributing to maternal deaths1 such as intimate partner violence4 ,while the addition of pregnancy checkboxes on death certificates since #bjjc have likely improved ,states' abilities to identify pregnancy-related deaths1 they are not generally completed by obstetric providers or persons trained to recognize pregnancy-related mortality4 ,thus1 these vital forms may be missing information or may capture inconsistent data4 ,due to varying maternal mortality-related analyses1 lack of reliability1 and granularity in data1 current maternal mortality informatics do not fully encapsulate the myriad medical and socially determinant factors that contribute to such high maternal mortality rates within the ,united ,states compared to other developed nations4 ,lack of standardization of data and data sharing across ,states and between ,federal entities1 health networks1 and research institutions keep the ,nation in the dark about ways to prevent maternal deaths4 7#af7 ,having reliable and valid ,state data aggregated at the ,federal level are critical to the ,nation's ability to quell surges in maternal death and imperative for researchers to identify long-lasting interventions4 7#ag7 ,leaders in maternal wellness highly recommend that maternal deaths and cases of maternal morbidity1 including complications that result in chronic illness and future increased risk of death1 be investigated at the ,state level first1 and that standardized1 streamlined1 de-identified data regarding maternal deaths be sent annually to the ,centers for ,disease ,control and ,prevention4 ,such data standardization and collection would be similar in operation and effect to the ,national ,program of ,cancer ,registries of the ,centers for ,disease ,control and ,prevention and akin to the ,confidential ,enquiry in ,maternal ,deaths ,programme in the ,united ,kingdom4 ,such a maternal mortalities and morbidities registry and surveillance system would help providers1 academicians1 lawmakers1 and the public to address questions concerning the types of1 causes of1 and best practices to thwart1 maternal mortality and morbidity4 7#ah7 ,the ,united ,nations' ,millennium ,development ,goal #e;a aimed to reduce by #ge percent1 between #aiij and #bjae1 the maternal mortality rate1 yet this metric has not been achieved4 ,in fact1 the maternal mortality rate in the ,united ,states has been estimated to have more than doubled between #bjjj and #bjad4 7#ai7 ,the ,united ,states has no comparable1 coordinated ,federal process by which to review cases of maternal mortality1 systems failures1 or best practices4 ,the majority of ,states have active ,maternal ,mortality ,review ,committees 7referred to in this section as ,,mmrc71 which help leverage work to impact maternal wellness4 ,for example1 the ,state of ,california has worked extensively with their ,state health departments1 health and hospital systems1 and research collaborative organizations1 including the ,california ,maternal ,quality ,care ,collaborative and the ,alliance for ,innovation on ,maternal ,health1 to establish ,m,m,r,cs1 wherein such ,state has determined the most prevalent causes of maternal mortality and recorded and shared data with providers and researchers1 who have developed and implemented safety bundles and care protocols related to preeclampsia1 maternal hemorrhage1 peripartum cardiomyopathy1 and the like4 ,in this way1 the ,state of ,california has been able to leverage its maternal mortality review board system1 generate data1 and apply those data to effect changes in maternal care-related protocol4 7#bj7 ,hospitals and health systems across the ,united ,states lack standardization of emergency obstetric protocols before1 during1 and after delivery4 ,consequently1 many providers are delayed in recognizing critical signs indicating maternal distress that quickly escalate into fatal or near-fatal incidences4 ,moreover1 any attempt to address an obstetric emergency that does not consider both clinical and public health approaches falls woefully under the mark of excellent care delivery4 ,state-based perinatal quality collaboratives1 or entities participating in the ,alliance for ,innovation on ,maternal ,health 7,,aim71 have formed obstetric protocols1 tool kits1 and other resources to improve system care and response as they relate to maternal complications and warning signs for such conditions as maternal hemorrhage1 hypertension1 and preeclampsia4 ,these perinatal quality collaboratives serve an important role in providing infrastructure that supports quality improvement efforts addressing obstetric care and outcomes4 ,state-based perinatal quality collaboratives partner with hospitals1 physicians1 nurses1 midwives1 patients1 public health1 and other stakeholders to provide opportunities for collaborative learning1 rapid response data1 and quality improvement science support to achieve systems-level change4 7#ba7 ,the ,centers for ,disease ,control and ,prevention reports that #bb percent of deaths occurred during pregnancy1 #be percent occurred on the day of delivery or within #g days after the day of delivery1 and #ec percent occurred between #g days and #a year after the day of delivery4 ,yet1 for women eligible for the ,medicaid program on the basis of pregnancy in ,states without ,medicaid postpartum extension1 such ,medicaid coverage lapses at the end of the month on which the #fjth postpartum day lands4 7#bb7 ,the experience of serious traumatic events1 such as being exposed to domestic violence1 substance use disorder1 or pervasive and systematic racism1 can over-activate the body's stress-response system4 ,known as toxic stress1 the repetition of high-doses of cortisol to the brain1 can harm healthy neurological development and other body systems1 which can have cascading physical and mental health consequences1 as documented in the ,adverse ,childhood ,experiences study of the ,centers for ,disease ,control and ,prevention4 7#bc7 ,a growing body of evidence-based research has shown the correlation between the stress associated with systematic racism and one's birthing outcomes4 ,the undue stress of sex and race discrimination paired with institutional racism has been demonstrated to contribute to a higher risk of maternal mortality1 irrespective of one's gestational age1 maternal age1 socioeconomic status1 educational level1 geographic region1 or individual-level health risk factors1 including poverty1 limited access to prenatal care1 and poor physical and mental health 7although these are not nominal factors74 ,black women remain the most at risk for pregnancy-associated or pregnancy-related causes of death4 ,when it comes to preeclampsia1 for example1 for which obesity is a risk factor1 ,black women of normal weight remain at a higher at risk of dying during the perinatal period compared to non-,black obese women4 7#bd7 ,the rising maternal mortality rate in the ,united ,states is driven predominantly by the disproportionately high rates of ,black maternal mortality4 7#be7 ,compared to women from other racial and ethnic demographics1 ,black women across the socioeconomic spectrum experience prolonged1 unrelenting stress related to systematic racial and gender discrimination1 contributing to higher rates of maternal mortality1 giving birth to low-weight babies1 and experiencing pre-term birth4 ,racism is a risk-factor for these aforementioned experiences4 ,this cumulative stress1 called weathering1 often extends across the life course and is situated in everyday spaces where ,black women establish livelihood4 ,systematic racism1 structural barriers1 lack of access to quality maternal health care1 lack of access to nutritious food1 and social determinants of health exacerbate ,black women's likelihood to experience poor or fatal birthing outcomes1 but do not fully account for the great disparity4 7#bf7 ,black women are twice as likely to experience postpartum depression1 and disproportionately higher rates of preeclampsia compared to ,white women4 7#bg7 ,racism is deeply ingrained in ,united ,states systems1 including in health care delivery systems between patients and providers1 often resulting in disparate treatment for pain1 irreverence for cultural norms with respect to health1 and dismissiveness4 ,however1 the provider pool is not primed with many people of color1 nor are providers 7whether maternity care clinicians or maternity care support personnel7 consistently required to undergo implicit bias1 cultural competency1 respectful care practices1 or empathy training on a consistent1 on-going basis4 7#bh7 ,women are not the only people who can become pregnant or give birth4 ,nonbinary1 transgender1 and gender-expansive people can also become pregnant4 ,the terms birthing people or birthing persons are also used to describe pregnant or postpartum people in a way that is inclusive of individuals who experience gender beyond the binary4 7#bi7 ,substance misuse among pregnant women1 including the use of substances that are illegal or criminalized1 misuse of prescribed medications1 and binge drinking1 has increased year after year for the past decade4 ,pregnant people with substance use disorder1 particularly those with opioids1 amphetamines1 and cocaine use disorders1 are at greater risk of severe maternal morbidity1 including conditions such as eclampsia1 heart attack or failure1 and sepsis4 #c4 ,improving ,federal efforts with respect to prevention of maternal mortality 7a7 ,funding for ,state-,based perinatal quality collaboratives development and sustainability 7#a7 ,in general ,not later than one year after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services 7referred to in this subsection as the ,secretary71 acting through the ,division of ,reproductive ,health of the ,centers for ,disease ,control and ,prevention1 shall establish a grant program to be known as the ,state-,based ,perinatal ,quality ,collaborative grant program under which the ,secretary awards grants to eligible entities for the purpose of development and sustainability of perinatal quality collaboratives in every ,state1 the ,district of ,columbia1 and eligible territories1 in order to measurably improve perinatal care and perinatal health outcomes for pregnant and postpartum women and their infants4 7#b7 ,grant amounts ,grants awarded under this subsection shall be in amounts not to exceed #bej1jjj per year1 for the duration of the grant period4 7#c7 ,state-based perinatal quality collaborative defined ,for purposes of this subsection1 the term ,state-based perinatal quality collaborative means a network of teams that-- 7,a7 is multidisciplinary in nature and includes the full range of perinatal and maternity care providers2 7,b7 works to improve measurable outcomes for maternal and infant health by advancing evidence-informed clinical practices using quality improvement principles2 7,c7 works with hospital-based or outpatient facility-based clinical teams1 experts1 and stakeholders1 including patients and families1 to spread best practices and optimize resources to improve perinatal care and outcomes2 7,d7 employs strategies that include the use of the collaborative learning model to provide opportunities for hospitals and clinical teams to collaborate on improvement strategies1 rapid-response data to provide timely feedback to hospital and other clinical teams to track progress1 and quality improvement science to provide support and coaching to hospital and clinical teams2 7,e7 has the goal of improving population-level outcomes in maternal and infant health2 and 7,f7 has the goal of improving outcomes of all birthing people1 through the coordination1 integration1 and collaboration across birth settings4 7#d7 ,authorization of appropriations ,for purposes of carrying out this subsection1 there is authorized to be appropriated #ce1jjj1jjj for each of fiscal years #bjbd through #bjbh4 7b7 ,expansion of ,medicaid and ,,chip coverage for pregnant and postpartum women 7#a7 ,requiring coverage of oral health services for pregnant and postpartum women 7,a7 ,medicaid ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7 is amended-- 7i7 in subsection 7a77#d7-- 7,i7 by striking 2 and 7,d7 and inserting 2 7,d72 7,,ii7 by striking 2 and 7,e7 and inserting 2 7,e72 7,,iii7 by striking 2 and 7,f7 and inserting 2 7,f72 and 7,,iv7 by striking the semicolon at the end and inserting 2 and 7,g7 oral health services for pregnant and postpartum women 7as defined in subsection 7jj7722 and 7ii7 by adding at the end the following new subsection3 7jj7 ,oral health services for pregnant and postpartum women 7#a7 ,in general ,for purposes of this title1 the term oral health services for pregnant and postpartum women means dental services necessary to prevent disease and promote oral health1 restore oral structures to health and function1 and treat emergency conditions that are furnished to a woman during pregnancy 7or during the #a-year period beginning on the last day of the pregnancy74 7#b7 ,coverage requirements ,to satisfy the requirement to provide oral health services for pregnant and postpartum women1 a ,state shall1 at a minimum1 provide coverage for preventive1 diagnostic1 periodontal1 and restorative care consistent with recommendations for perinatal oral health care and dental care during pregnancy from the ,american ,academy of ,pediatric ,dentistry and the ,american ,college of ,obstetricians and ,gynecologists4 4 7,b7 ,,chip ,section #bajc7;c77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;cc7c77#f77 is amended-- 7i7 in subparagraph 7,a7-- 7,i7 by inserting or a targeted low-income pregnant woman after targeted low-income child2 and 7,,ii7 by inserting 1 and1 in the case of a targeted low-income child who is pregnant or a targeted low-income pregnant woman1 satisfy the coverage requirements specified in section #aije7;jj7 after emergency conditions2 and 7ii7 in subparagraph 7,b71 by inserting 7but only if1 in the case of a targeted low-income child who is pregnant or a targeted low-income pregnant woman1 the benchmark dental benefit package satisfies the coverage requirements specified in section #aije7;jj77 after subparagraph 7,c74 7#b7 ,requiring #ab-month continuous coverage of full benefits for pregnant and postpartum individuals under ,medicaid and ,,chip 7,a7 ,medicaid ,section #aijb of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7 is amended-- 7i7 in subsection 7a7-- 7ii7 in paragraph 7#hf71 by striking and at the end2 7iii7 in paragraph 7#hg71 by striking the period at the end and inserting 2 and2 and 7iv7 by inserting after paragraph 7#hg7 the following new paragraph3 7#hh7 provide that the ,state plan is in compliance with subsection 7e77#af74 2 and 7v7 in subsection 7e77#af7-- 7,i7 in subparagraph 7,a71 by striking ,at the option of the ,state1 the ,state plan 7or waiver of such ,state plan7 may provide and inserting ,a ,state plan 7or waiver of such ,state plan7 shall provide2 7,,ii7 in subparagraph 7,b71 in the matter preceding clause 7i71 by striking by a ,state making an election under this paragraph and inserting under a ,state plan 7or a waiver of such ,state plan72 and 7,,iii7 by striking subparagraph 7,c74 7,b7 ,,chip 7i7 ,in general ,section #bajg7;e77#a77;,j7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;gg7e77#a77;,j771 as inserted by section #ihbb of the ,american ,rescue ,plan ,act of #bjba 7,public ,law #aag-b71 is amended to read as follows3 7,j7 ,paragraphs 7#e7 and 7#af7 of section #aijb7;e7 7relating to the requirement to provide medical assistance under the ,state plan or waiver consisting of full benefits during pregnancy and throughout the #ab-month postpartum period under title ,,xix74 4 7ii7 ,conforming ,section #baab7;d77#b77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acigll7d77#b77;,a77 is amended by striking the month in which the #fj-;day period and all that follows through pursuant to section #bajg7;e77#a714 7#c7 ,maintenance of effort 7,a7 ,medicaid ,section #aijb7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7l77 is amended by adding at the end the following new paragraph3 7#e7 ,during the period that begins on the date of enactment of this paragraph and ends on the date that is #e years after such date of enactment1 as a condition for receiving any ,federal payments under section #aijc7;a7 for calendar quarters occurring during such period1 a ,state shall not have in effect1 with respect to women who are eligible for medical assistance under the ,state plan or under a waiver of such plan on the basis of being pregnant or having been pregnant1 eligibility standards1 methodologies1 or procedures under the ,state plan or waiver that are more restrictive than the eligibility standards1 methodologies1 or procedures1 respectively1 under such plan or waiver that are in effect on the date of enactment of this paragraph4 4 7,b7 ,,chip ,section #baje7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;ee7d77 is amended by adding at the end the following new paragraph3 7#d7 ,in eligibility standards for targeted low-income pregnant women ,during the period that begins on the date of enactment of this paragraph and ends on the date that is #e years after such date of enactment1 as a condition of receiving payments under subsection 7a7 and section #aijc7;a71 a ,state that elects to provide assistance to women on the basis of being pregnant 7including pregnancy-related assistance provided to targeted low-income pregnant women 7as defined in section #baab7;d771 pregnancy-related assistance provided to women who are eligible for such assistance through application of section #aijb7v77#d77;,a77i7 under section #bajg7;e77#a71 or any other assistance under the ,state child health plan 7or a waiver of such plan7 which is provided to women on the basis of being pregnant7 shall not have in effect1 with respect to such women1 eligibility standards1 methodologies1 or procedures under such plan 7or waiver7 that are more restrictive than the eligibility standards1 methodologies1 or procedures1 respectively1 under such plan 7or waiver7 that are in effect on the date of enactment of this paragraph4 4 7#d7 ,information on benefits ,the ,secretary of ,health and ,human ,services shall make publicly available on the internet website of the ,department of ,health and ,human ,services1 information regarding benefits available to pregnant and postpartum women and under the ,medicaid program and the ,children's ,health ,insurance ,program1 including information on-- 7,a7 benefits that ,states are required to provide to pregnant and postpartum women under such programs2 7,b7 optional benefits that ,states may provide to pregnant and postpartum women under such programs2 and 7,c7 the availability of different kinds of benefits for pregnant and postpartum women1 including oral health and mental health benefits and breastfeeding services and supplies1 under such programs4 7#e7 ,federal funding for cost of extended ,medicaid and ,,chip coverage for postpartum women 7,a7 ,medicaid ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d71 as amended by paragraph 7#a71 is further amended by adding at the end the following3 7kk7 ,increased ,,fmap for extended medical assistance for postpartum individuals 7#a7 ,in general ,notwithstanding subsection 7b71 the ,federal medical assistance percentage for a ,state1 with respect to amounts expended by such ,state for medical assistance for an individual who is eligible for such assistance on the basis of being pregnant or having been pregnant that is provided during the #cje-;day period that begins on the #fjth day after the last day of the individual's pregnancy 7including any such assistance provided during the month in which such period ends71 shall be equal to-- 7,a7 during the first #bj-quarter period for which this subsection is in effect with respect to a ,state1 #ajj percent2 and 7,b7 with respect to a ,state1 during each quarter thereafter1 #ij percent4 7#b7 ,exclusion from territorial caps ,any payment made to a territory for expenditures for medical assistance for an individual described in paragraph 7#a7 that is subject to the ,federal medical assistance percentage specified under paragraph 7#a7 shall not be taken into account for purposes of applying payment limits under subsections 7f7 and 7g7 of section #aajh4 4 7,b7 ,,chip ,section #baje7;c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;ee7c77 is amended by adding at the end the following new paragraph3 7#ac7 ,enhanced payment for extended assistance provided to pregnant women ,notwithstanding subsection 7b71 the enhanced ,,fmap1 with respect to payments under subsection 7a7 for expenditures under the ,state child health plan 7or a waiver of such plan7 for assistance provided under the plan 7or waiver7 to a woman who is eligible for such assistance on the basis of being pregnant 7including pregnancy-related assistance provided to a targeted low-income pregnant woman 7as defined in section #baab7;d771 pregnancy-related assistance provided to a woman who is eligible for such assistance through application of section #aijb7v77#d77;,a77i7 under section #bajg7;e77#a71 or any other assistance under the plan 7or waiver7 provided to a woman who is eligible for such assistance on the basis of being pregnant7 during the #cje-;day period that begins on the #fjth day after the last day of her pregnancy 7including any such assistance provided during the month in which such period ends71 shall be equal to-- 7,a7 during the first #bj-quarter period for which this subsection is in effect with respect to a ,state1 #ajj percent2 and 7,b7 with respect to a ,state1 during each quarter thereafter1 #ij percent4 4 7#f7 ,guidance on ,state options for ,medicaid coverage of doula services ,not later than #a year after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall issue guidance for the ,states concerning options for ,medicaid coverage and payment for support services provided by doulas4 7#g7 ,enhanced ,,fmap for rural obstetric and gynecological services ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d71 as amended by paragraphs 7#a7 and 7#e71 is further amended-- 7,a7 in subsection 7b71 by striking and 7ii7 and inserting 7ii71 7jj71 7kk71 and 7ll72 and 7,b7 by adding at the end the following new subsection3 7ll7 ,increased ,,fmap for medical assistance for obstetric and gynecological services furnished at rural hospitals 7#a7 ,in general ,notwithstanding subsection 7b71 the ,federal medical assistance percentage for a ,state1 with respect to amounts expended by such ,state for medical assistance for obstetric or gynecological services that are furnished in a hospital that is located in a rural area 7as defined for purposes of section #ahhf7 shall be equal to #ij percent for each calendar quarter beginning with the first calendar quarter during which this subsection is in effect4 7#b7 ,exclusion from territorial caps ,any payment made to a territory for expenditures for medical assistance described in paragraph 7#a7 that is subject to the ,federal medical assistance percentage specified under paragraph 7#a7 shall not be taken into account for purposes of applying payment limits under subsections 7f7 and 7g7 of section #aajh4 4 7#h7 ,effective dates 7,a7 ,in general ,subject to subparagraphs 7,b7 and 7,c7-- 7i7 the amendments made by paragraphs 7#a71 7#b71 and 7#e7 shall take effect on the first day of the first calendar quarter that begins on or after the date that is #a year after the date of enactment of this ,act2 7ii7 the amendments made by paragraph 7#c7 shall take effect on the date of enactment of this ,act2 and 7iii7 the amendments made by paragraph 7#g7 shall take effect on the first day of the first calendar quarter that begins on or after the date of enactment of this ,act4 7,b7 ,exception for ,state legislation ,in the case of a ,state plan under title ,,xix of the ,social ,security ,act or a ,state child health plan under title ,,xxi of such ,act that the ,secretary of ,health and ,human ,services determines requires ,state legislation in order for the respective plan to meet any requirement imposed by amendments made by this subsection1 the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the ,state legislature that begins after the date of enactment of this ,act4 ,for purposes of the previous sentence1 in the case of a ,state that has a #b-year legislative session1 each year of the session shall be considered to be a separate regular session of the ,state legislature4 7,c7 ,state option for earlier effective date ,a ,state may elect to have subsection 7e77#af7 of section #aijb of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7 and subparagraph 7,j7 of section #bajg7;e77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;gg7e77#a771 as amended by paragraph 7#b71 and subsection 7kk7 of section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7 and paragraph 7#ac7 of section #baje7;c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;ee7c771 as added by paragraph 7#e71 take effect with respect to the ,state on the first day of any fiscal quarter that begins before the date described in subparagraph 7,a7 and apply to amounts payable to the ,state for expenditures for medical assistance1 child health assistance1 or pregnancy-related assistance to pregnant or postpartum individuals furnished on or after such day4 7c7 ,regional centers of excellence ,part ,p of title ,,iii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bhj;g et seq47 is amended by adding at the end the following3 #cii,v-#h4 ,regional centers of excellence addressing implicit bias and cultural competency in patient-provider interactions education 7a7 ,in general ,not later than one year after the date of enactment of this section1 the ,secretary1 in consultation with such other agency heads as the ,secretary determines appropriate1 shall award cooperative agreements for the establishment or support of regional centers of excellence addressing implicit bias1 cultural competency1 and respectful care practices in patient-provider interactions education for the purpose of enhancing and improving how health care professionals are educated in implicit bias and delivering culturally competent health care4 7b7 ,eligibility ,to be eligible to receive a cooperative agreement under subsection 7a71 an entity shall-- 7#a7 be a public or other nonprofit entity specified by the ,secretary that provides educational and training opportunities for students and health care professionals1 which may be a health system1 teaching hospital1 community health center1 medical school1 school of public health1 school of nursing1 dental school1 social work school1 school of professional psychology1 or any other health professional school or program at an institution of higher education 7as defined in section #aja of the ,higher ,education ,act of #aife7 focused on the prevention1 treatment1 or recovery of health conditions that contribute to maternal mortality and the prevention of maternal mortality and severe maternal morbidity2 7#b7 demonstrate community engagement and participation1 such as through partnerships with home visiting and case management programs and community-based organizations serving minority populations2 7#c7 demonstrate engagement with groups engaged in the implementation of health care professional training in implicit bias and delivering culturally competent care1 such as departments of public health1 perinatal quality collaboratives1 hospital systems1 and health care professional groups1 in order to obtain input on resources needed for effective implementation strategies2 and 7#d7 provide to the ,secretary such information1 at such time and in such manner1 as the ,secretary may require4 7c7 ,diversity ,in awarding a cooperative agreement under subsection 7a71 the ,secretary shall take into account any regional differences among eligible entities and make an effort to ensure geographic diversity among award recipients4 7d7 ,dissemination of information 7#a7 ,public availability ,the ,secretary shall make publicly available on the internet website of the ,department of ,health and ,human ,services information submitted to the ,secretary under subsection 7b77#c74 7#b7 ,evaluation ,the ,secretary shall evaluate each regional center of excellence established or supported pursuant to subsection 7a7 and disseminate the findings resulting from each such evaluation to the appropriate public and private entities4 7#c7 ,distribution ,the ,secretary shall share evaluations and overall findings with ,state departments of health and other relevant ,state level offices to inform ,state and local best practices4 7e7 ,maternal mortality defined ,in this section1 the term maternal mortality means death of a woman that occurs during pregnancy or within the one-year period following the end of such pregnancy4 7f7 ,authorization of appropriations ,for purposes of carrying out this section1 there is authorized to be appropriated #e1jjj1jjj for each of fiscal years #bjbd through #bjbh4 4 7d7 ,special supplemental nutrition program for women1 infants1 and children ,section #ag7;d77#c77;,a77ii7 of the ,child ,nutrition ,act of #aiff 7#db ,u4,s4,c4 #aghf7;d77#c77;,a77ii77 is amended-- 7#a7 by striking the clause designation and heading and all that follows through ,a ,state and inserting the following3 7ii7 ,women 7,i7 ,breastfeeding women ,a ,state 2 7#b7 in subclause 7,i7 7as so designated71 by striking #a year and all that follows through earlier and inserting #b years postpartum2 and 7#c7 by adding at the end the following3 7,,ii7 ,postpartum women ,a ,state may elect to certify a postpartum woman for a period of #b years4 4 7e7 ,definition of maternal mortality ,in this section1 the term maternal mortality means death of a woman that occurs during pregnancy or within the one-year period following the end of such pregnancy4 #d4 ,full spectrum doula workforce 7a7 ,in general ,the ,secretary of ,health and ,human ,services shall establish and implement a program to award grants or contracts to health professions schools1 schools of public health1 academic health centers1 ,state or local governments1 territories1 ,indian ,tribes and ,tribal organizations1 ,urban ,indian organizations1 ,native ,hawaiian organizations1 or other appropriate public or private nonprofit entities or community-based organizations 7or consortia of any such entities1 including entities promoting multidisciplinary approaches71 to establish or expand programs to grow and diversify the doula workforce1 including through improving the capacity and supply of health care providers4 7b7 ,use of funds ,amounts made available by subsection 7a7 shall be used for the following activities3 7#a7 ,establishing programs that provide education and training to individuals seeking appropriate training or certification as full spectrum doulas4 7#b7 ,expanding the capacity of existing programs described in paragraph 7#a71 for the purpose of increasing the number of students enrolled in such programs1 including by awarding scholarships for students who agree to work in underserved communities after receiving such education and training4 7#c7 ,developing and implementing strategies to recruit and retain students from underserved communities1 particularly from demographic groups experiencing high rates of maternal mortality and severe maternal morbidity1 including racial and ethnic minority groups1 into programs described in paragraphs 7#a7 and 7#b74 7c7 ,funding ,in addition to amounts otherwise available1 there is appropriated to the ,secretary of ,health and ,human ,services for fiscal year #bjbd1 out of any money in the ,treasury not otherwise appropriated1 #ej1jjj1jjj1 to remain available until expended1 for carrying out this section4 #e4 ,grants for rural obstetric mobile health units ,part ,b of title ,,iii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bdc et seq47 is amended by adding at the end the following3 #cbj;,c4 ,grants for rural obstetric mobile health units 7a7 ,in general ,the ,secretary1 acting through the ,administrator of the ,health ,resources and ,services ,administration 7referred to in this section as the ,secretary71 shall establish a pilot program under which the ,secretary shall make grants to ,states-- 7#a7 to purchase and equip rural mobile health units for the purpose of providing pre-conception1 pregnancy1 postpartum1 and obstetric emergency services in rural and underserved communities2 7#b7 to train providers including obstetrician-gynecologists1 certified nurse-midwives1 nurse practitioners1 nurses1 and midwives to operate and provide obstetric services1 including training and planning for obstetric emergencies1 in such mobile health units2 and 7#c7 to address access issues1 including social determinants of health and wrap-around clinical and community services including nutrition1 housing1 lactation services1 and transportation support and referrals4 7b7 ,no sharing of data with law enforcement ,as a condition of receiving a grant under this section1 a ,state shall submit to the ,secretary an assurance that the ,state will not make available to ,federal or ,state law enforcement any personally identifiable information regarding any pregnant or postpartum individual collected pursuant to such grant4 7c7 ,grant duration ,the period of a grant under this section shall not exceed #e years4 7d7 ,implementing and reporting 7#a7 ,in general ,states that receive pilot grants under this section shall-- 7,a7 implement the program funded by the pilot grants2 and 7,b7 not later than #c years after the date of enactment of this section1 and not later than #f years after such date of enactment1 submit to the ,secretary a report that describes the results of such program1 including-- 7i7 relevant information and relevant quantitative indicators of the programs' success in improving the standard of care and maternal health outcomes for individuals in rural and underserved communities seen for pre-conception1 pregnancy1 or postpartum visits in the rural mobile health units1 stratified by the categories of data specified in paragraph 7#b72 7ii7 relevant qualitative evaluations from individuals receiving pre-conception1 pregnant1 or postpartum care from rural mobile health units1 including measures of patient-reported experience of care and measures of patient-reported issues with access to care without the rural mobile health unit pilot2 and 7iii7 strategies to sustain such programs beyond the duration of the grant and expand such programs to other rural and underserved communities4 7#b7 ,categories of data ,the categories of data specified in this paragraph are the following3 7,a7 ,race1 ethnicity1 sex1 gender1 gender identity1 primary language1 age1 geography1 insurance status1 disability status4 7,b7 ,number of visits provided for preconception1 prenatal1 or postpartum care4 7,c7 ,number of repeat visits provided for preconception1 prenatal1 or postpartum care4 7,d7 ,number of screenings or tests provided for smoking1 substance use1 hypertension1 sexually-transmitted diseases1 diabetes1 ,,hiv1 depression1 intimate partner violence1 pap smears1 and pregnancy4 7#c7 ,data privacy protection ,the reports referred to in paragraph 7#a77;,b7 shall not contain any personally identifiable information regarding any pregnant or postpartum individual4 7e7 ,evaluation ,the ,secretary shall conduct an evaluation of the pilot program under this section to determine the impact of the pilot program with respect to-- 7#a7 the effectiveness of the grants awarded under this section to improve maternal health outcomes in rural and underserved communities1 with data stratified by race1 ethnicity1 primary language1 socioeconomic status1 geography1 insurance type1 and other factors as the ,secretary determines appropriate2 7#b7 spending on maternity care by ,states participating in the pilot program2 7#c7 to the extent practicable1 qualitative and quantitative measures of patient experience2 and 7#d7 any other areas of assessment that the ,secretary determines relevant4 7f7 ,report ,not later than one year after the completion of the pilot program under this section1 the ,secretary shall submit to ,congress1 and make publicly available1 a report that describes-- 7#a7 the results of the evaluation conducted under subsection 7e72 and 7#b7 a recommendation regarding whether the pilot program should be continued after fiscal year #bjbh and expanded on a national basis4 7g7 ,authorization of appropriations ,there is authorized to be appropriated to the ,secretary to carry out this section #aj1jjj1jjj for each of fiscal years #bjbd through #bjbh4 4 #f4 ,requiring notification of impending hospital obstetric unit closure ,section #ahff7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#a77 is amended-- 7#a7 in subparagraph 7,x71 by striking and at the end2 7#b7 in subparagraph 7,y77ii77,v71 by striking the period and inserting 1 and2 and 7#c7 by inserting after subparagraph 7,y7 the following new subparagraph3 7,z7 beginning #ahj days after the date of the enactment of this subparagraph1 in the case of a hospital1 not less than #ij days prior to the closure of any obstetric unit of the hospital1 to submit to the ,secretary a notification which shall include-- 7i7 a report analyzing the impact the closure will have on the community2 7ii7 steps the hospital will take to identify other health care providers that can alleviate any service gaps as a result of the closure2 and 7iii7 any additional information as may be required by the ,secretary4 4 #g4 ,evaluation and report on maternal health needs 7a7 ,in general ,not later than #b years after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services shall conduct1 and submit to ,congress a report that describes the results of1 an evaluation of-- 7#a7 where the maternal health needs are greatest in the ,united ,states2 and 7#b7 the ,federal expenditures made to address such needs4 7b7 ,period covered ,the evaluation under subsection 7a7 shall cover the period of calendar years #bjjj through #bjbb4 7c7 ,analysis ,the evaluation under subsection 7a7 shall include analysis of the following3 7#a7 ,how ,federal funds provided to ,states for maternal health were distributed across regions1 ,states1 and localities or counties4 7#b7 ,barriers to applying for and receiving ,federal funds for maternal health1 including1 with respect to initial applications-- 7,a7 requirements for submission in partnership with other entities2 and 7,b7 stringent network requirements4 7#c7 ,why applicants did not receive funding1 including limited availability of funds1 the strength of the respective applications1 and failure to adhere to requirements4 7d7 ,disaggregation of data ,the report under subsection 7a7 shall disaggregate data on mothers served by race1 ethnicity1 insurance status1 and language spoken4 #h4 ,increasing excise taxes on cigarettes and establishing excise tax equity among all tobacco product tax rates 7a7 ,tax parity for ,roll-,your-,own tobacco ,section #egja7;g7 of the ,internal ,revenue ,code of #aihf is amended by striking #bd4gh and inserting #di4ef4 7b7 ,tax parity for pipe tobacco ,section #egja7;f7 of the ,internal ,revenue ,code of #aihf is amended by striking #b4hcaa cents and inserting #di4ef4 7c7 ,tax parity for smokeless tobacco 7#a7 ,section #egja7;e7 of the ,internal ,revenue ,code of #aihf is amended-- 7,a7 in paragraph 7#a71 by striking #a4ea and inserting #bf4hd2 7,b7 in paragraph 7#b71 by striking #ej4cc cents and inserting #aj4gd2 and 7,c7 by adding at the end the following3 7#c7 ,smokeless tobacco sold in discrete single-use units ,on discrete single-use units1 #ajj4ff per thousand4 4 7#b7 ,section #egjb7m7 of such ,code is amended-- 7,a7 in paragraph 7#a71 by striking or chewing tobacco and inserting 1 chewing tobacco1 or discrete single-use unit2 7,b7 in paragraphs 7#b7 and 7#c71 by inserting that is not a discrete single-use unit before the period in each such paragraph2 and 7,c7 by adding at the end the following3 7#d7 ,discrete single-use unit ,the term discrete single-use unit means any product containing1 made from1 or derived from tobacco or nicotine that-- 7,a7 is not intended to be smoked2 and 7,b7 is in the form of a lozenge1 tablet1 pill1 pouch1 dissolvable strip1 or other discrete single-use or single-dose unit4 4 7d7 ,tax parity for small cigars ,paragraph 7#a7 of section #egja7;a7 of the ,internal ,revenue ,code of #aihf is amended by striking #ej4cc and inserting #ajj4ff4 7e7 ,tax parity for large cigars 7#a7 ,in general ,paragraph 7#b7 of section #egja7;a7 of the ,internal ,revenue ,code of #aihf is amended by striking #eb4ge percent and all that follows through the period and inserting the following3 #di4ef per pound and a proportionate tax at the like rate on all fractional parts of a pound but not less than #aj4jff cents per cigar44 7#b7 ,guidance ,the ,secretary of the ,treasury1 or the ,secretary's delegate1 may issue guidance regarding the appropriate method for determining the weight of large cigars for purposes of calculating the applicable tax under section #egja7;a77#b7 of the ,internal ,revenue ,code of #aihf4 7#c7 ,conforming amendment ,section #egjb of such ,code is amended by striking subsection 7l74 7f7 ,tax parity for ,roll-,your-,own tobacco and certain processed tobacco ,subsection 7o7 of section #egjb of the ,internal ,revenue ,code of #aihf is amended by inserting 1 and includes processed tobacco that is removed for delivery or delivered to a person other than a person with a permit provided under section #egac1 but does not include removals of processed tobacco for exportation after wrappers thereof4 7g7 ,clarifying tax rate for other tobacco products 7#a7 ,in general ,section #egja of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7i7 ,other tobacco products ,any product not otherwise described under this section that has been determined to be a tobacco product by the ,food and ,drug ,administration through its authorities under the ,family ,smoking ,prevention and ,tobacco ,control ,act shall be taxed at a level of tax equivalent to the tax rate for cigarettes on an estimated per use basis as determined by the ,secretary4 4 7#b7 ,establishing per use basis ,for purposes of section #egja7;i7 of the ,internal ,revenue ,code of #aihf1 not later than #ab months after the later of the date of the enactment of this ,act or the date that a product has been determined to be a tobacco product by the ,food and ,drug ,administration1 the ,secretary of the ,treasury 7or the ,secretary of the ,treasury's delegate7 shall issue final regulations establishing the level of tax for such product that is equivalent to the tax rate for cigarettes on an estimated per use basis4 7h7 ,clarifying definition of tobacco products 7#a7 ,in general ,subsection 7c7 of section #egjb of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7c7 ,tobacco products ,the term tobacco products means-- 7#a7 cigars1 cigarettes1 smokeless tobacco1 pipe tobacco1 and roll-your-own tobacco1 and 7#b7 any other product subject to tax pursuant to section #egja7;i74 4 7#b7 ,conforming amendments ,subsection 7d7 of section #egjb of such ,code is amended by striking cigars1 cigarettes1 smokeless tobacco1 pipe tobacco1 or roll-your-own tobacco each place it appears and inserting tobacco products4 7i7 ,increasing tax on cigarettes 7#a7 ,small cigarettes ,section #egja7;b77#a7 of such ,code is amended by striking #ej4cc and inserting #ajj4ff4 7#b7 ,large cigarettes ,section #egja7;b77#b7 of such ,code is amended by striking #aje4fi and inserting #baa4ch4 7j7 ,tax rates adjusted for inflation ,section #egja of such ,code1 as amended by subsection 7g71 is amended by adding at the end the following new subsection3 7j7 ,inflation adjustment 7#a7 ,in general ,in the case of any calendar year beginning after #bjbc1 the dollar amounts provided under this chapter shall each be increased by an amount equal to-- 7,a7 such dollar amount1 multiplied by 7,b7 the cost-of-living adjustment determined under section #a7;f77#c7 for the calendar year1 determined by substituting #8calendar year #bjbb' for #8calendar year #bjaf' in subparagraph 7,a77ii7 thereof4 7#b7 ,rounding ,if any amount as adjusted under paragraph 7#a7 is not a multiple of #j4ja1 such amount shall be rounded to the next highest multiple of #j4ja4 4 7k7 ,floor ,stocks ,taxes 7#a7 ,imposition of tax ,on tobacco products manufactured in or imported into the ,united ,states which are removed before any tax increase date and held on such date for sale by any person1 there is hereby imposed a tax in an amount equal to the excess of-- 7,a7 the tax which would be imposed under section #egja of the ,internal ,revenue ,code of #aihf on the article if the article had been removed on such date1 over 7,b7 the prior tax 7if any7 imposed under section #egja of such ,code on such article4 7#b7 ,credit against tax ,each person shall be allowed as a credit against the taxes imposed by paragraph 7#a7 an amount equal to the lesser of #a1jjj or the amount of such taxes4 ,for purposes of the preceding sentence1 all persons treated as a single employer under subsection 7b71 7c71 7m71 or 7o7 of section #dad of the ,internal ,revenue ,code of #aihf shall be treated as #a person for purposes of this paragraph4 7#c7 ,liability for tax and method of payment 7,a7 ,liability for tax ,a person holding tobacco products on any tax increase date to which any tax imposed by paragraph 7#a7 applies shall be liable for such tax4 7,b7 ,method of payment ,the tax imposed by paragraph 7#a7 shall be paid in such manner as the ,secretary shall prescribe by regulations4 7,c7 ,time for payment ,the tax imposed by paragraph 7#a7 shall be paid on or before the date that is #abj days after the effective date of the tax rate increase4 7#d7 ,articles in foreign trade zones ,notwithstanding the ,act of ,june #ah1 #aicd 7commonly known as the ,foreign ,trade ,zone ,act1 #dh ,stat4 #iih1 #ai ,u4,s4,c4 #ha;a et seq471 or any other provision of law1 any article which is located in a foreign trade zone on any tax increase date shall be subject to the tax imposed by paragraph 7#a7 if-- 7,a7 internal revenue taxes have been determined1 or customs duties liquidated1 with respect to such article before such date pursuant to a request made under the first proviso of section #c7;a7 of such ,act1 or 7,b7 such article is held on such date under the supervision of an officer of the ,united ,states ,customs and ,border ,protection of the ,department of ,homeland ,security pursuant to the second proviso of such section #c7;a74 7#e7 ,definitions ,for purposes of this subsection-- 7,a7 ,in general ,any term used in this subsection which is also used in section #egjb of such ,code shall have the same meaning as such term has in such section4 7,b7 ,tax increase date ,the term tax increase date means the effective date of any increase in any tobacco product excise tax rate pursuant to the amendments made by this section 7other than subsection 7j7 thereof74 7,c7 ,secretary ,the term ,secretary means the ,secretary of the ,treasury or the ,secretary's delegate4 7#f7 ,controlled groups ,rules similar to the rules of section #ejfa7;e77#c7 of such ,code shall apply for purposes of this subsection4 7#g7 ,other laws applicable ,all provisions of law1 including penalties1 applicable with respect to the taxes imposed by section #egja of such ,code shall1 insofar as applicable and not inconsistent with the provisions of this subsection1 apply to the floor stocks taxes imposed by paragraph 7#a71 to the same extent as if such taxes were imposed by such section #egja4 ,the ,secretary may treat any person who bore the ultimate burden of the tax imposed by paragraph 7#a7 as the person to whom a credit or refund under such provisions may be allowed or made4 7l7 ,effective dates 7#a7 ,in general ,except as provided in paragraphs 7#b7 and 7#c71 the amendments made by this section shall apply to articles removed 7as defined in section #egjb7;j7 of the ,internal ,revenue ,code of #aihf7 after the last day of the month which includes the date of the enactment of this ,act4 7#b7 ,discrete single-use units1 large cigars1 and processed tobacco ,the amendments made by subsections 7c77#a77;,c71 7c77#b71 7e71 and 7f7 shall apply to articles removed 7as defined in section #egjb7;j7 of the ,internal ,revenue ,code of #aihf7 after the date that is #f months after the date of the enactment of this ,act4 7#c7 ,other tobacco products ,the amendments made by subsection 7g77#a7 shall apply to products removed after the last day of the month which includes the date that the ,secretary of the ,treasury 7or the ,secretary of the ,treasury's delegate7 issues final regulations establishing the level of tax for such product4