,i #aai? ,,congress #b;d ,session ,h4 ,r4 #iedd ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,june #cj1 #bjbf,mr4 ,doggett 7= himself1 ,ms4 ,ans>i1 ,ms4 ,bal9t1 ,mr4 ,cas>1 ,ms4 ,*u1 ,ms4 ,cl>ke ( ,new ,york1 ,mr4 ,cleav]1 ,mr4 ,coh51 ,mr4 ,davis ( ,ill9ois1 ,ms4 ,de,lauro1 ,mr4 ,deluzio1 ,mrs4 ,d+ell1 ,mr4 ,g>am5di1 ,mr4 ,g>ca ( ,ill9ois1 ,mr4 ,g>cia ( ,cali=nia1 ,mrs4 ,grijalva1 ,mr4 ,huffman1 ,mr4 ,jackson ( ,ill9ois1 ,ms4 ,jayapal1 ,mr4 ,johnson ( ,georgia1 ,mr4 ,khanna1 ,mr4 ,mfume1 ,mr4 ,nadl]1 ,ms4 ,norton1 ,ms4 ,ocasio-,cortez1 ,ms4 ,om>1 ,ms4 ,p+ree1 ,mr4 ,pocan1 ,ms4 ,r&all1 ,ms4 ,s*ak[sky1 ,mr4 ,scott ( ,virg9ia1 ,mr4 ,smi? ( ,wa%+ton1 ,mr4 ,takano1 ,mr4 ,?an$>1 ,mr4 ,?ompson ( ,mississippi1 ,ms4 ,tlaib1 ,ms4 ,velzquez1 ,ms4 ,wat]s1 ,mrs4 ,watson ,coleman1 ,mr4 ,gre5 ( ,texas1 ,mr4 ,c>son1 ,mr4 ,mc,govern1 ,ms4 ,tokuda1 & ,mr4 ,de,saulnier7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,ways & ,means1 & 9 addition to ! ,committees on ,en]gy & ,comm]ce1 & ,vet]ans' ,affairs1 = a p]iod to be subsequ5tly det]m9$ by ! ,speak]1 9 ea* case = consid]ation ( su* provisions z fall )9 ! jurisdiction ( ! committee conc]n$ ,a ,,bill ,to am5d title ,,xviii ( ! ,social ,security ,act to ensure appropriate paym5ts "u ,m$ic>e ,advantage1 & = o!r purposes4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,sav+ ,m$ic>e ,enrollees f ,deceptive ,insur]s & ,creat+ ,ample ,res\rces = ,ev]yone ,act ( #bjbf or ! ,save ,,m$ic>e ,act ( #bjbf4 #b4 ,risk adju/m5t 7a7 ,rulemak+ ,z "p ( ! annual rulemak+ cycle = ,m$ic>e ,advantage = paym5ts applicable to #bjbh & subsequ5t ye>s1 ! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices-- 7#a7 %all include an analysis id5tify+ diagnosis codes ) a high rate ( diff]5tial cod+ betwe5 equival5t enrollees 9 ,m$ic>e ,advantage & ,m$ic>e b5efici>ies n enroll$ "u a ,m$ic>e ,advantage plan1 a high rate ( discretion>y cod+1 or limit$ treatm5t implications2 & 7#b7 %all exclude or adju/ diagnosis codes t ! ,secret>y det]m9es are mo/ likely to be subject to cod+ v>iation by ,m$ic>e ,advantage plans f diagnosis data submitt$ to ! ,secret>y = purposes ( det]m9+ appropriate paym5t adju/m5ts = heal? /atus4 7b7 ,exclusion ( diagnoses collect$ f *>t reviews & heal? risk assessm5ts 7#a7 ,m$ic>e advantage plans ,section #ahec7;a77#a77;,c7 ( su* ,act 7#db ,u4,s4,c4 #aciew-#bc7;a77#a77;,c77 is am5d$ by add+ at ! end ! foll[+ new clause3 7iv7 ,exclusion ( diagnoses collect$ f *>t reviews & heal? risk assessm5ts 7,i7 ,9 g5]al ,= #bjbh & ea* subsequ5t ye>1 = purposes ( e/abli%+ ! paym5t adju/m5t factors & adju/+ paym5t bas$ on heal? /atus "u clause 7i71 ! ,secret>y %all n take into acc\nt a diagnosis collect$ f a *>t review or a heal? risk assessm5t4 7,,ii7 ,id5tification ( diagnoses collect$ f *>t reviews & heal? risk assessm5ts ,! ,secret>y %all e/abli% proc$ures to provide = ! id5tification & v]ification ( diagnoses collect$ f *>t reviews & heal? risk assessm5ts4 4 7#b7 ,prescription drug plans ,section #ahfj;,d-#ae7;c77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aae7;c77#a77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,e7 ,exclusion ( diagnoses collect$ f *>t reviews & heal? risk assessm5ts 7i7 ,9 g5]al ,= #bjbh & ea* subsequ5t ye>1 = purposes ( e/abli%+ ! me?odology & adju/+ ! /&>diz$ bid am\nt bas$ on heal? /atus "u subp>agraph 7,a71 ! ,secret>y %all n take into acc\nt a diagnosis collect$ f a *>t review or a heal? risk assessm5t4 7ii7 ,id5tification ( diagnoses collect$ f *>t reviews & heal? risk assessm5ts ,! ,secret>y %all e/abli% proc$ures to provide = ! id5tification & v]ification ( diagnoses collect$ f *>t reviews & heal? risk assessm5ts4 4 7c7 ,m$pac /udy & report 7#a7 ,/udy ,! ,m$ic>e ,paym5t ,advisory ,commission %all conduct a /udy to det]m9e h[ results f a ,consum] ,assessm5t ( ,heal?c>e ,provid]s & ,sy/ems 7,,caphs7-siz$ survey c\ld be extrapolat$ across all enrollees "u a ,m$ic>e ,advantage contract = ! purposes ( calculat+ risk adju/$ paym5ts4 ,su* /udy %all include recomm5dations on me?odology1 modifications to ! ,,caphs survey que/ions1 & ,,cahps survey sample size4 7#b7 ,report ,n lat] ?an #c ye>s aft] ! date ( enactm5t ( ?is ,act1 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit to ,congress a report on ! /udy conduct$ "u p>agraph 7#a71 toge!r ) recomm5dations = su* legislation & adm9i/rative action z ! ,commission det]m9es appropriate4 #c4 ,quality bonus program ,section #ahec7o77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o77#a77 is am5d$1 9 ! matt] prec$+ subp>agraph 7,a71 by ins]t+ & end+ ) #bjbh1 aft] #bjab4 #d4 ,b5*m>k paym5ts 7a7 ,elim9at+ ! c\nty qu>tile sy/em ,section #ahec7n77#b77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7n77#b77;,a77 is am5d$-- 7#a7 by r$esignat+ clauses 7i7 & 7ii7 z subclauses 7,i7 & 7,,ii71 respectively1 & ind5t+ appropriately2 7#b7 by /rik+ is ! product ( & ins]t+ is-- 7i7 = ea* ( #bjab ?r\gh #bjbg1 ! product ( 2 & 7#c7 by add+ at ! end ! foll[+ new clause3 7ii7 = #bjbh & ea* subsequ5t ye>1 is ! base paym5t am\nt specifi$ 9 subp>agraph 7,e7 = ! area & ye> adju/$ to take into acc\nt ! phase-out 9 ! indirect co/s ( m$ical education f capitation rates describ$ 9 subsection 7k77#d7 &1 = #bjba & subsequ5t ye>s1 ! exclusion ( paym5ts = organ acquisitions = kidney transplants f ! capitation rate z describ$ 9 subsection 7k77#e74 4 7b7 ,modifications to base paym5t am\nt ,section #ahec7n77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7n77#b77 is am5d$-- 7#a7 9 subp>agraph 7,e71 by /rik+ subp>agraphs 7,f7 & 7,g7 & ins]t+ subp>agraphs 7,f71 7,g71 & 7,h72 & 7#b7 by add+ at ! end ! foll[+ new subp>agraph3 7,h7 ,adju/m5t = favorable selection ,= #bjbh & ea* subsequ5t ye>3 7i7 ,9 g5]al ,! base paym5t am\nt specifi$ 9 subp>agraph 7,e7 = a ye> %all be adju/$ to acc\nt = favorable selection betwe5 ,m$ic>e ,advantage & ! orig9al ,m$ic>e fee-=-s]vice program "u p>ts ,a & ,b 9 accordance ) ?is subp>agraph4 7ii7 ,analysis 7,i7 ,9 g5]al ,9 ord] to ensure ! accuracy ( ! adju/m5t "u clause 7i71 ! ,secret>y %all annually conduct an analysis ( any diff]5ces 9 selection betwe5 ,m$ic>e ,advantage & ! orig9al ,m$ic>e fee-=-s]vice program "u p>ts ,a & ,b describ$ 9 su* subclause & publi% ! results ( su* analysis on ! int]net website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices 9 pla9 language & 9 rese>*-d[nloadable files4 ,! ,secret>y %all conduct su* analysis among subgr\ps ( ! ,m$ic>e population1 includ+ by at a m9imum race1 g5d]1 zip code1 income level1 & heal? condition4 7,,ii7 ,tim+ ,! ,secret>y %all complete su* analysis by ! date necess>y to ensure t ! results ( su* analysis are incorporat$ on a timely basis into ! base paym5t am\nt = #bjbi & subsequ5t ye>s4 7,,iii7 ,data ,9 conduct+ su* analysis1 ! ,secret>y %all use data submitt$ ) respect to #bjbe & subsequ5t ye>s1 z available & updat$ z appropriate4 7iii7 ,me?odology ,9 calculat+ ! adju/m5t "u clause 7i7 = ea* ye>1 ! ,secret>y %all apply ! ,m$ic>e ,paym5t ,advisory ,commission's me?od = e/imat+ favorable selection into ,m$ic>e ,advantage z describ$ 9 its ,m>* #bjbf report to ,congress4 ,apply+ su* me?od1 ! ,secret>y %all calculate a selection p]c5tage to adju/ = favorable selection betwe5 ,m$ic>e ,advantage & ! orig9al ,m$ic>e fee-=-s]vice program "u p>ts ,a & ,b4 ,! selection p]c5tage %all be calculat$ be=e ! int]v5tion ( ,m$ic>e ,advantage plans z ! ratio ( expect$ sp5d+ = ! national av]age ,m$ic>e ,advantage b5efici>y relative to expect$ sp5d+ = ! national av]age fee-=-s]vice b5efici>y1 aft] /&>diz+ = measur$ risk ,a value ( #a indicates no diff]5ce 9 expect$ sp5d+ :ile values bel[ #a indicate l[] expect$ sp5d+ 9 ,m$ic>e ,advantage ?an 9 fee-=-s]vice ,m$ic>e = b5efici>ies ) ! same risk scores4 ,! base paym5t am\nt specifi$ 9 subp>agraph 7,e7 %all be multipli$ by ! selection p]c5tage to yield a selection-adju/$ base paym5t am\nt4 ,! selection-adju/$ base paym5t am\nt %all replace ! prior base paym5t am\nt 9 all calculations ( paym5t b5*m>ks = ,m$ic>e ,advantage4 7iv7 ,m$pac review ,! ,m$ic>e ,paym5t ,advisory ,commission %all conduct & publi% a review ( ! analysis conduct$ "u clause 7ii7 & any adju/m5ts made "u clause 7i7 bas$ on su* analysis n lat] ?an #b ye>s aft] implem5tation ( ?is subp>agraph & bi5nially !reaft]4 4 #e4 ,risk adju/m5t data validation 7a7 ,risk adju/m5t data validation re=ms ,section #ahec7;a77#a77;,c7 ( ! ,social ,security ,act is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#g7 ,improv+ timel9ess ( ,,radv audits & appeals ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh1 ! foll[+ requirem5ts %all apply ) respect to ! ,m$ic>e ,advantage ,risk ,adju/m5t ,data ,validation ,program3 7,a7 ,contract-level audits ,! ,secret>y %all complete contract-level audits )9 "o ye>4 7,b7 ,m$ical record reviews ,! ,secret>y %all complete ,,radv m$ical record reviews )9 #fj days4 7,c7 ,deadl9e = completion ( /ages #a & #b ( appeals 7i7 ,/age #a ,! reconsid]ation /age describ$ 9 section #dbb4caa7;c77#f7 ( title #db1 ,code ( ,f$]al ,regulations 7or a successor regulation71 %all be complet$ )9 #ij days4 7ii7 ,/age #b ,! he>+ /age describ$ 9 section #dbb4caa7;c77#g7 ( title #db1 ,code ( ,f$]al ,regulations 7or a successor regulation71 %all be complet$ )9 #ij days4 7,d7 ,us] fee ,! ,secret>y %all r$uce ! paym5ts to ,m$ic>e ,advantage organizations "u section #ahec by #j4jb p]c5t = ! purpose ( c>ry+ out ,risk ,adju/m5t ,data ,validation audits4 7,e7 ,limitation on review ,!re %all be no judicial review "u section #ahfi1 section #ahgh1 or o!rwise ( any det]m9ation ( ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e & ,m$icaid ,s]vices "u ! ,risk ,adju/m5t ,data ,validation audit program4 7,f7 ,au?ority to extrapolate ,! ,secret>y may extrapolate ! results ( audit$ samples to ! g5]al ,m$ic>e ,advantage population & retroactively1 z ! ,secret>y det]m9es appropriate4 4 7b7 ,enhanc+ audit process ,section #ahec7;a77#a77;,c7 ( ! ,social ,security ,act1 z am5d$ by subsection 7a71 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#h7 ,id5tification & rec\pm5t ( ov]paym5ts 7,a7 ,9 g5]al ,! ,secret>y %all ent] into contracts ) "o or m recov]y audit contractors "u section #ahic7;h7 = ! id5tification & rec\pm5t ( ov]paym5ts1 includ+ p5alties z def9$ "u subp>agraph 7,b71 ) respect to items & s]vices = :i* paym5t is made "u ?is "p4 7,b7 ,p5alty ,) respect to any ov]paym5t id5tifi$ "u subp>agraph 7,a71 ! ,secret>y %all provide = ! imposition a p5alty 9 an am\nt equal to ! total am\nt ( ov]paym5t & ! rate ( int]e/ z def9$ "u section #dje4cgh7;d7 ( title #db1 ,code ( ,f$]al ,regulations 7or a successor regulation74 7,c7 ,cont+5cy fees ,! ,secret>y may provide cont+5cy fees to recov]y audit contractors 9 an am\nt equal to no m ?an #bj p]c5t ( rec\p$ ov]paym5ts made by su* contractor4 4 #f4 ,gu>d ,vet]ans ,heal? ,c>e ,act 7a7 ,co/-,recov]y f ,m$ic>e ,advantage & ,m$ic>e prescription drug plans 7#a7 ,co/ recov]y 7,a7 ,9 g5]al ,sub*apt] ,,iii ( *apt] #ag ( title #ch1 ,unit$ ,/ates ,code1 is am5d$ by ins]t+ aft] section #agbi;,b ! foll[+ new section3 #agbi;,c4 ,co/-recov]y f ,m$ic>e ,advantage & ,m$ic>e prescription drug plans 7a7 ,9 g5]al ,not)/&+ sections #ahad7;c71 #ahce7;d71 & #ahfb7;a77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7c71 #acien7d71 & #aciey7a77#c771 if ! ,secret>y provides "u ?is *apt] any heal? c>e item or s]vice 7includ+ = a s]vice-connect$ disability or a non-s]vice-connect$ disability7 cov]$ "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq471 includ+ outpati5t & inpati5t c>e1 prescription drugs1 m$ical devices1 lab te/+1 & items or s]vices deliv]$ 9 po/-acute & long-t]m c>e sett+s1 to any individual :o is enroll$ 9 a ,m$ic>e ,advantage plan1 includ+ an ,,ma-,,pd plan1 (f]$ by a ,,ma organization "u "p ,c ( su* title or a prescription drug plan (f]$ by a ,,pdp sponsor "u "p ,d ( su* title1 su* organization or sponsor %all1 to ! ext5t su* item or s]vice is cov]$ "u su* ,m$ic>e ,advantage plan or prescription drug plan1 reimburse ! ,secret>y = su* item or s]vice reg>dless ( any additional docum5tation1 utilization managem5t1 or o!r adm9i/rative requirem5t ! plan may impose on ! item or s]vice4 7b7 ,recov]y ( am\nts 7#a7 ,9 g5]al ,! ,secret>y %all recov] am\nts requir$ to be reimburs$ "u subsection 7a7 ?r\gh ! use ( proc$ures "u section #agbi ( ?is title to ! same ext5t z ^? proc$ures are us$ to recov] am\nts au?oriz$ to be recov]$ "u t section4 7#b7 ,am\nt & process ,except z provid$ 9 p>agraph 7#a71 recov]y "u t p>agraph ( am\nts reimburs$ "u subsection 7a7 %all be 9 su* an am\nt1 & occur 9 accordance ) su* proc$ures1 z ! ,secret>y %all prescribe = purposes ( ?is section4 7c7 ,application ,! provisions ( subsection 7a7 %all apply to ,m$ic>e ,advantage & prescription drug plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh4 7d7 ,treatm5t ( am\nts ,am\nts reimburs$ to ! ,secret>y "u subsection 7a7 %all be deposit$ 9 ! ,dep>tm5t ( ,vet]ans ,affairs ,m$ical ,c>e ,collections ,fund "u section #agbi;,a ( ?is title4 4 7,b7 ,cl]ical am5dm5t ,! table ( sections at ! beg9n+ ( su* *apt] is am5d$ by ins]t+ aft] ! item relat+ to section #agbi;,b ! foll[+ new item3 #agbi;,c4 ,co/-recov]y f ,m$ic>e ,advantage & ,m$ic>e prescription drug plans4 4 7#b7 ,m$ic>e con=m+ am5dm5ts 7,a7 ,"p ,a ,section #ahad7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7c77 is am5d$ by ins]t+ & section #agbi;,c ( title #ch1 ,unit$ ,/ates ,code aft] section #ahhj4 7,b7 ,"p ,b ,section #ahce7;d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acien7d77 is am5d$ by ins]t+ & section #agbi;,c ( title #ch1 ,unit$ ,/ates ,code aft] section #ahhj4 7,c7 ,exclusions f cov]age ,section #ahfb7;a77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77#c77 is am5d$ by ins]t+ 9 ! case ( items & s]vices & prescription drugs = :i* reimbursem5t is made "u section #agbi;,c ( title #ch1 ,unit$ ,/ates ,code1 aft] section #ahhj7;e714 7b7 ,modification ( au?ority = recov]y by ,unit$ ,/ates ( reasonable *>ges = c]ta9 c>e or s]vices furni%$ to vet]ans = non-,s]vice-,connect$ disabilities ,section #agbi ( title #ch1 ,unit$ ,/ates ,code1 is am5d$-- 7#a7 9 subsection 7a7-- 7,a7 by am5d+ p>agraph 7#a7 to read z foll[s3 7#a7 7,a7 ,subject to ! provisions ( ?is section1 ! ,unit$ ,/ates has ! "r to recov] or collect ! reasonable *>ges = c>e or s]vices t ! ,unit$ ,/ates is requir$ by law to furni% or pay = "u ?is *apt] = a non-s]vice-connect$ disability4 7,b7 ,! ,unit$ ,/ates has ! "r to recov] or collect f a ?ird p>ty ! reasonable *>ges = c>e or s]vices furni%$ z describ$ 9 subp>agraph 7,a7 to ! ext5t t ! recipi5t or provid] ( ! c>e or s]vices w\ld be eligible to receive paym5t f a ?ird p>ty4 7,c7 ,! "r to recov] or collect reasonable *>ges = c>e or s]vices "u ?is section %all apply to any & all causes ( action or recov]y rights 9 tort or "u any policy1 plan1 or contract provid+ b5efits = heal? c>e or injury1 :i* accrue to ! individual to :om ! c>e or s]vices 7 furni%$1 or to ! legal repres5tatives ( ! individual1 z a result ( ! non-s]vice-connect$ disability t necessitat$ ! c>e or s]vices4 2 & 7,b7 9 p>agraph 7#b7-- 7i7 9 subp>agraph 7,d71 by /rik+ 2 or & ins]t+ a semicolon2 7ii7 9 subp>agraph 7,e77#b71 by /rik+ ! p]iod at ! end & ins]t+ 2 or2 & 7iii7 by add+ at ! end ! foll[+ new subp>agraph3 7,f7 t is incurr$ by an individual :o is entitl$ to c>e 7or paym5t ( exp5ses ( c>e7 "u circum/ances creat+ a tort liability ^u a ?ird p>ty4 2 7#b7 9 subsection 7b71 by am5d+ p>agraph 7#b7 to read z foll[s3 7#b7 7,a7 ,! ,unit$ ,/ates may take any action necess>y to en=ce ! subrogation int]e/s ( ! ,unit$ ,/ates "u ?is section1 includ+ by int]v5+ or jo9+ 9 an action or proce$+4 7,b7 ,a proce$+ "u ?is section may n be br\ght aft] ! end ( ! six-ye> p]iod beg9n+ on ! la/ day on :i* ! c>e or s]vices = :i* recov]y is s\ght are furni%$4 ,not)/&+ ! previ\s s5t5ce1 subject to section #bdae ( title #bh1 & except z o!rwise provid$ by law1 any action = money damages "u ?is section br\ght by ! ,unit$ ,/ates or an (fic] or ag5cy !re( t is f\nd$ ^u a tort %all be b>r$ unless ! compla9t is fil$ )9 ?ree ye>s aft] ! "r ( action fir/ accrues4 2 7#c7 9 subsection 7c77#a71 by ins]t+ or p5alty aft] claim2 7#d7 by r$esignat+ subsections 7h7 & 7i7 z subsections 7l7 & 7m71 respectively2 7#e7 by ins]t+ aft] subsection 7f7 ! foll[+ new subsections3 7g7 7#a7 ,n lat] ?an #de days aft] receipt ( a claim to recov] or collect ! reasonable *>ges = c>e or s]vices describ$ 9 subsection 7a71 or 9 ! case ( a tort1 n lat] ?an #de days aft] settlem5t1 judgm5t1 aw>d1 liability det]m9ation1 or resolution relat+ to ! cause ( action1 a ?ird p>ty %all-- 7,a7 pay a clean claim = reimbursem5t 9 accordance ) ?is section2 7,b7 pay ! am\nt agre$ to 9 writ+ by ! ,dep>tm5t2 or 7,c7 provide notice ( ! date ! ?ird p>ty receiv$ ! claim & include a /atem5t t-- 7i7 ! ?ird p>ty refuses to reimburse all or "p ( ! claim & specify ea* reason = ! refusal to pay2 or 7ii7 additional in=mation is necess>y to det]m9e if all or "p ( ! claim w be reimburs$ & :at specific additional in=mation is necess>y4 7#b7 ,p>agraph 7#a7 %all n apply to a claim if !re is a good fai? dispute ab\t ! legitimacy ( ! claim4 7#c7 7,a7 ,if any ?ird p>ty fails to comply ) p>agraph 7#a71 su* ?ird p>ty %all be requir$ to pay int]e/ to ! ,unit$ ,/ates at ! rate e/abli%$ by ! ,secret>y ( ! ,treasury "u section #cgag ( title #ca p] mon? on ! am\nt ( ! claim t rema9s unpaid at ! end ( ! #de-;day p]iod specifi$ 9 su* p>agraph4 7,b7 ,! int]e/ paid pursuant to subp>agraph 7,a7 %all be includ$ 9 any late reimbursem5t f a ?ird p>ty )\t requir+ ! ,secret>y to make any additional claim = su* int]e/4 7#d7 7,a7 ,^u receiv+ a reque/ = additional in=mation by a ?ird p>ty pursuant to p>agraph 7#a77;,c77ii71 ! ,secret>y %all provide ! additional in=mation1 if det]m9$ relevant by ! ,secret>y1 n lat] ?an #de days aft] receipt ( ! reque/ = additional in=mation4 7,b7 ,failure to furni% relevant in=mation )9 ! "t requir$ "u subp>agraph 7,a7 %all n invalidate or r$uce any claim 9 connection ) su* in=mation4 7,c7 7i7 ,n lat] ?an #ae days aft] receipt ( additional relevant in=mation "u subp>agraph 7,a71 a ?ird p>ty %all pay a clean claim 9 accordance ) ?is subsection or s5d a writt5 or electronic notice t-- 7,i7 su* ?ird p>ty refuses to reimburse all or "p ( ! claim2 & 7,,ii7 specifies ea* reason = refusal to pay4 7ii7 ,any ?ird p>ty t fails to comply ) clause 7i7 %all pay int]e/ to ! ,unit$ ,/ates on any am\nt ( ! claim t rema9s unpaid at ! rate e/abli%$ by ! ,secret>y ( ! ,treasury "u section #cgag ( title #ca4 7#e7 ,a ?ird p>ty %all n be entitl$ to reque/ a refund to correct a paym5t error to ! ,dep>tm5t if ! reque/ by ! ?ird p>ty = su* paym5t correction is submitt$ m ?an #ah mon?s aft] ! date t ! ,dep>tm5t receiv$ paym5t f ! ?ird p>ty4 7#f7 ,any claim by ! ,dep>tm5t "u ?is section %all n be subject to non-,dep>tm5t claims processes1 policies1 or =ms4 7h7 ,! recov]y rights ( ! ,unit$ ,/ates "u ?is section are n limit$ to ! am\nts paid to non-,dep>tm5t provid]s & are n subject to non-,dep>tm5t fee s*$ules or non-,dep>tm5t reimbursem5t rates1 includ+ ^? adm9i/]$ "u work]s' comp5sation plans or automobile accid5t rep>ations insurance4 7i7 7#a7 ,a ?ird p>ty %all-- 7,a7 det]m9e :e!r a recipi5t ( c>e or s]vices cov]$ by ?is section 7includ+ a recipi5t ^: claim is unresolv$7 has receiv$ b5efits "u ?is *apt]2 & 7,b7 submit ! in=mation describ$ 9 p>agraph 7#b7 ) respect to ! recipi5t to ! ,secret>y 9 a =m & mann] 7includ+ frequ5cy7 specifi$ by ! ,secret>y4 7#b7 ,! in=mation requir$ to be submitt$ "u ?is p>agraph ) respect to a recipi5t ( c>e or s]vices is-- 7,a7 ! id5tity ( ! recipi5t2 & 7,b7 su* o!r in=mation z ! ,secret>y %all specify 9 ord] to enable ! ,secret>y to make an appropriate det]m9ation conc]n+ coord9ation ( b5efits1 includ+ any applicable recov]y claim4 7#c7 ,a ?ird p>ty %all submit ! in=mation requir$ "u p>agraph 7#a77;,b7 ) respect to a recipi5t ( c>e or s]vices cov]$ by ?is section 7includ+ a recipi5t ^: claim is unresolv$7 n lat] ?an #cj days1 or su* o!r "t p]iod z prescrib$ by ! ,secret>y1 aft] ! date on :i* ! ?ird p>ty kn[s or has reason to "k t ! recipi5t has receiv$ b5efits "u ?is *apt]4 7#d7 ,a ?ird p>ty %all n di/ribute proce$s ( a settlem5t1 judgm5t1 aw>d1 or o!r paym5t 9 connection ) a recipi5t ( c>e or s]vices cov]$ by ?is section 7includ+ a recipi5t ^: claim is unresolv$71 reg>dless ( :e!r !re has be5 a det]m9ation or admission ( liability1 )\t satisfaction ( a claim by ! ,dep>tm5t4 7j7 7#a7 ,a ?ird p>ty t fails to comply ) ! requirem5ts "u ?is section1 includ+ any regulations prescrib$ to implem5t ?is section1 ) respect to any individual receiv+ c>e furni%$ or paid = by ! ,dep>tm5t z describ$ 9 ?is section1 %all be subject to a civil p5alty 9 an am\nt publi%$ on a website ( ! ,dep>tm5t = ea* day ( noncompliance ) respect to ea* claim violation4 ,a civil p5alty "u ?is p>agraph %all be 9 addition to any o!r p5alties prescrib$ by law4 7#b7 7,a7 ,a ?ird p>ty t willfully fails or refuses to pay a clean claim "u ?is section1 includ+ any regulations prescrib$ to implem5t ?is section1 ) respect to any individual receiv+ c>e furni%$ or paid = by ! ,dep>tm5t z describ$ 9 ?is section1 %all be subject to pay+ ! high] ( triple ! am\nt ( ! claim or an am\nt n to exce$ #ej1jjj1 :i* may be adju/$ = inflation1 = ea* claim violation4 7,b7 ,a p5alty "u subp>agraph 7,a7 is 9 addition to any o!r p5alty "u ?is subsection & any o!r p5alty prescrib$ by law4 7,c7 ,be=e en=c+ any p5alty "u ?is p>agraph ) respect to a ?ird p>ty1 ! ,secret>y %all provide to ! ?ird p>ty writt5 notice ( ! am\nt due & a #cj-;day opportunity to pay ! clean claim1 includ+ p5alties1 int]e/s1 & co/s4 7#c7 ,not)/&+ any o!r applicable civil or crim9al rem$ies1 ! ,unit$ ,/ates %all h a cause ( action = damages 7:i* %all be 9 an am\nt d\ble ! am\nt o!rwise provid$7 9 ! case ( a ?ird p>ty t fails to provide paym5t1 or appropriate reimbursem5t1 = ! reasonable value ( ! c>e or s]vices furni%$1 to be furni%$1 paid =1 or to be paid = 9 accordance ) a clean claim4 7k7 ,not)/&+ any o!r provision ( law1 ! ,secret>y may implem5t ?is p>agraph by prescrib+ regulations1 program in/ructions1 or o!rwise4 2 & 7#f7 9 subsection 7m71 z r$esignat$ by p>agraph 7#d7-- 7,a7 9 p>agraph 7#c7-- 7i7 9 subp>agraph 7,c71 by /rik+ 2 or & ins]t+ a semicolon2 7ii7 9 subp>agraph 7,d71 by /rik+ ! p]iod at ! end & ins]t+ a semicolon2 & 7iii7 by add+ at ! end ! foll[+ new subp>agraphs3 7,e7 a p]son or entity responsible 9 tort = damages incurr$ z a result ( neglig5ce2 or 7,f7 a p]son or entity responsible = paym5t ( m$ical exp5ses o!r ?an "u a heal?-plan contract1 includ+ m$ical exp5ses cov]age1 m$ical paym5ts cov]age1 or und]9sur$ motori/ cov]age4 2 & 7,b7 by add+ at ! end ! foll[+ new p>agraphs3 7#d7 ,! t]m clean claim means a claim to recov] or collect reasonable *>ges "u subsection 7a7 t c be process$ )\t obta9+ additional in=mation4 7#e7 ,! t]m non-s]vice-connect$ disability includes-- 7,a7 a non-s]vice-connect$ disability1 injury1 illness1 heal? c>e ne$1 or condition2 & 7,b7 an aggravation or exac]bation ( a s]vice-connect$ disability4 4 7c7 ,con=m+ am5dm5t ,section #ahec7;c77#a77;,d77iii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7;c77#a77;,d77iii77 is am5d$ by ins]t+ 7be=e #bjbh7 aft] = a ye>4 #g4 ,all[+ ,/ates to en=ce ,m$ic>e ,advantage plan requirem5ts ,section #ahef7;b77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bf7;b77#c77 is am5d$-- 7#a7 by /rik+ ,! /&>ds & ins]t+ ! foll[+3 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 ! /&>ds 2 & 7#b7 by add+ at ! end ! foll[+ new subp>agraphs3 7,b7 ,/ate en=cem5t ,ea* ,/ate may require t ,,ma organizations t issue1 sell1 r5ew1 or (f] ,,ma plans 9 ! ,/ate meet ! requirem5ts ( ?is "p ) respect to su* ,,ma plans4 7,c7 ,coord9ation ( en=cem5t ,! ,secret>y %all coord9ate en=cem5t ( ! /&>ds e/abli%$ "u ?is "p ) ! ,/ate 9 :i* an ,,ma organization is lic5s$ & any ,/ate 9 :i* ! ,,ma organization issues1 sells1 r5ews1 or (f]s ,,ma plans4 ,! ,secret>y may ent] into a collaborative en=cem5t agreem5t ) any ,/ate to fur!r coord9ate en=cem5t4 4 #h4 ,provid] inc5tive contracts ,section #aheg7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#g7 ,prohibit+ p]c5tage ( premium contracts or o!r f9ancial inc5tives = cod+ ,beg9n+ ) plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh1 a contract "u ?is section ) an ,,ma organization %all prohibit ! use ( p]c5tage ( premium contracts or o!r f9ancial inc5tives = provid]s relat$ to cod+ items & s]vices furni%$ to enrollees "u ?is "p4 4