,,ii ,calendar ,no4 #bhe #aaith         
,,congress  #ast ,session  ,s4 #cchf    
,,in ,,the ,,senate ,,of ,,the ,,united 
,,states  ,december #h 7legislative day1
 ,december #d71 #bjbe,mr4 ,crapo 7for   
himself and ,mr4 ,cassidy7 introduced   
the following bill2 which was read the  
first time  ,december #h1 #bjbe,read the
 second time and placed on the calendar 
,a ,,bill  ,to provide a health savings 
account contribution to certain         
enrollees1 to reduce health care costs1 
and for other purposes4  #a4 ,short     
title2 table of contents  7a7 ,short    
title ,this ,act may be cited as the    
,health ,care ,freedom for ,patients    
,act of #bjbe4  7b7 ,table of contents  
,the table of contents for this ,act is 
as follows3 ,sec4 #a4 ,short title2     
table of contents4,,title               
,i--,increasing choice and reducing     
premiums,sec4 #aja4 ,exchange plan      
,h,s,as4,sec4 #ajb4 ,exchange plan ,,hsa
 contribution program4,sec4 #ajc4       
,funding cost-sharing reduction         

payments4,sec4 #ajd4 ,allowing all      
individuals purchasing health insurance 
in the individual market the option to  
purchase a lower premium plan4,,title   
,,ii--,putting ,american patients       
first,sec4 #bja4 ,expansion ,,fmap for  
certain ,states providing payments for  
health care furnished to certain        
individuals4,sec4 #bjb4 ,prohibiting    
,federal financial participation under  
,medicaid and ,,chip for individuals    
without verified citizenship1           
nationality1 or satisfactory immigration
 status4,,title ,,iii--,preventing      
wasteful spending,sec4 #cja4            
,prohibiting coverage of gender         
transition procedures as an essential   
health benefit under plans offered by   
,exchanges4,sec4 #cjb4 ,prohibiting     
,federal ,medicaid and ,,chip funding   
for certain items and services4  ,i     
,increasing choice and reducing premiums
  #aja4 ,exchange plan ,h,s,as  7a7 ,in 
general ,section #bbc of the ,internal  
,revenue ,code of #aihf is amended by   

adding at the end the following new     
subsection3  7i7 ,exchange plan ,h,s,as 
,for purposes of this section-- 7#a7 ,in
 general ,in the case of an ,exchange   
plan ,,hsa1 this section shall be       
applied as provided in paragraphs 7#c7  
through 7#d74  7#b7 ,exchange plan ,,hsa
 ,the term ,exchange plan ,,hsa means a 
health savings account which is         
designated as an ,exchange plan ,,hsa   
upon the establishment of such account4 
7#c7 ,no rollovers permitted ,except in 
the case of a contribution from one     
,exchange plan ,,hsa to another         
,exchange plan ,,hsa1 subsection 7f77#e7
 shall not apply4  7#d7 ,restriction on 
use of amounts ,for purposes of         
subsection 7d77#b77;,a71 amounts paid   
for-- 7,a7 abortion1 other than-- 7i7 if
 the pregnancy is the result of an act  
of rape or incest1 or  7ii7 in the case 
where a woman suffers from a physical   
disorder1 physical injury1 or physical  
illness1 including a life-endangering   
physical condition caused by or arising 

from the pregnancy itself1 that would1  
as certified by a physician1 place the  
woman in danger of death unless an      
abortion is performed1 or  7,b7 any sex 
trait modification procedure or service 
7as defined in section #aef4djj of title
 #de1 ,code of ,federal ,regulations1 as
 in effect on the date of the enactment 
of this subsection71  shall not be      
treated as paid for medical care4  4    
7b7 ,treatment of governmental          
contributions ,paragraph 7#d7 of section
 #bbc7;b7 of the ,internal ,revenue     
,code of #aihf is amended by striking   
and at the end of subparagraph 7,b71 by 
striking the period at the end of       
subparagraph 7,c7 and inserting 1 and1  
and by inserting after subparagraph 7,c7
 the following new subparagraph3  7,d7  
the aggregate amount contributed to an  
,exchange plan ,,hsa pursuant to section
 #ajb7;a7 of the ,health ,care ,freedom 
for ,patients ,act of #bjbe which is    
excludable from the taxpayer's gross    
income for the taxable year under       

section #ajb7;f7 of such ,act 7and such 
amount shall not be allowed as a        
deduction under subsection 7a774  4  7c7
 ,effective date ,the amendments made by
 this section shall apply to taxable    
years beginning after ,december #ca1    
#bjbe4  #ajb4 ,exchange plan ,,hsa      
contribution program  7a7 ,in general   
,as soon as administratively feasible1  
the ,secretary of ,health and ,human    
,services shall make payments to the    
,exchange plan ,,hsa of each individual 
who is an eligible enrollee1 for each   
month which is an eligible month with   
respect to such individual1 in the      
amount described in subsection 7c74  7b7
 ,eligible month ,for purposes of this  
section1 the term eligible month with   
respect to an individual means a        
calendar month-- 7#a7 occurring in      
calendar year #bjbf or #bjbg1 and  7#b7 
for which the individual is enrolled in 
a bronze level qualified health plan or 
a catastrophic plan through an ,exchange
 established under subtitle ,d of title 

,i of the ,patient ,protection and      
,affordable ,care ,act 7#db ,u4,s4,c4   
#ahjba et seq474  7c7 ,payment amount   
,the amount of each payment under       
subsection 7a7 for any individual for an
 eligible month is #a_/ab of-- 7#a7     
#a1jjj1 in the case of an eligible      
enrollee who has attained age #ah1 and  
has not attained age #ej1 as of the     
first day of the calendar year which    
includes such month1 and  7#b7 #a1ejj1  
in the case of an eligible enrollee who 
has attained age #ej1 and has not       
attained age #fe1 as of the first day of
 such calendar year4  7d7 ,eligible     
enrollee ,for purposes of this section1 
with respect to months occurring during 
a calendar year1 the term eligible      
enrollee means an eligible individual   
7as defined in section #bbc7;c77#a7 of  
the ,internal ,revenue ,code of #aihf7--
 7#a7 who has attained age #ah1 and has 
not attained age #fe1 as of the first   
day of such calendar year1  7#b7 in the 
case of an alien1 who is an eligible    

alien1 as defined in section            
#cf;,b7e77#b77;,b7 of such ,code 7as in 
effect for taxable years beginning after
 ,december #ca1 #bjbf1 applied by       
substituting for which the payment under
 section #ajb7;a7 of the ,health ,care  
,freedom for ,patients ,act of #bjbe is 
made for for which the credit under this
 section is being claimed71 and  7#c7   
whose household income1 expressed as a  
percent of the poverty line for the     
family size involved1 does not exceed   
#gjj percent4  7e7 ,determination of    
eligibility  7#a7 ,in general ,upon     
election pursuant to paragraph 7#b7 by  
an individual enrolling in a plan       
described in subsection 7b77#b71 the    
,secretary of ,health and ,human        
,services shall make a determination of 
the individual's status as an eligible  
enrollee on the basis of the latest     
determination pursuant to section #adab 
of the ,patient ,protection and         
,affordable ,care ,act 7#db ,u4,s4,c4   
#ahjhb7 of the individual's eligibility 

for the advance payment of the premium  
tax credits under section #cf;,b of the 
,internal ,revenue ,code of #aihf and   
cost-sharing reductions under section   
#adjb of such ,act 7#db ,u4,s4,c4       
#ahjga74  7#b7 ,election ,at such time  
and in such manner as the ,secretary of 
,health and ,human ,services shall      
provide1 an eligible enrollee shall     
notify the ,secretary of such enrollee's
 election to receive the payments under 
subsection 7a7 and shall provide-- 7,a7 
the social security number of such      
eligible enrollee1  7,b7 in the case of 
an alien1 an attestation that the       
individual is an eligible alien1 and    
7,c7 sufficient information to allow for
 the identification of1 and deposit of  
the payments under subsection 7a7 into1 
the ,exchange plan ,,hsa of the eligible
 enrollee4  7#c7 ,reporting by ,exchange
 ,the ,exchange through which an        
individual is enrolling in a plan       
described in subsection 7b77#b7 shall   
provide to the ,secretary of ,health and

 ,human ,services the information       
provided by the individual which is     
necessary for the determination under   
paragraph 7#a74  7#d7 ,timing of        
payments ,the payments under subsection 
7a7 with respect to any eligible months 
occurring before the determination under
 paragraph 7#a7 is completed shall be   
made as early as possible after the     
completion of such determination4  7f7  
,tax treatment of contributions ,for    
purposes of the ,internal ,revenue ,code
 of #aihf1 payments under subsection 7a7
 shall not be included in gross income  
of an eligible enrollee4  7g7           
,definitions ,for purposes of this      
section-- 7#a7 ,exchange plan ,,hsa ,the
 term ,exchange plan ,,hsa has the      
meaning given such term in section      
#bbc7;i7 of the ,internal ,revenue ,code
 of #aihf4  7#b7 ,household income2     
poverty line ,the terms household       
income1 poverty line1 and family size   
have the same respective meanings and   
shall be determined in the same manner  

as for purposes of section #cf;,b of the
 ,internal ,revenue ,code of #aihf4     
7#c7 ,bronze level qualified health plan
 ,the term bronze level qualified health
 plan means a qualified health plan1 as 
defined in section #acja7;a7 of the     
,patient ,protection and ,affordable    
,care ,act 7#db ,u4,s4,c4 #ahjba7;a771  
in the bronze level1 as defined in      
section #acjb7;d77#a77;,a7 of such ,act 
7#db ,u4,s4,c4 #ahjbb7;d77#a77;,a774    
7#d7 ,catastrophic plan ,the term       
catastrophic plan means a plan described
 in section #acjb7;e7 of such ,act 7#db 
,u4,s4,c4 #ahjbb7;e774  7h7 ,regulatory 
authority ,the ,secretary of ,health and
 ,human ,services shall prescribe such  
regulations or other guidance as are    
necessary to carry out the purposes of  
this section4  7i7 ,funding ,in addition
 to amounts otherwise available1 there  
is appropriated to the ,secretary of    
,health and ,human ,services1 out of any
 money in the ,treasury not otherwise   
appropriated1 #aj1jjj1jjj1jjj for each  

of fiscal years #bjbf and #bjbg1 to     
remain available until ,september #cj1  
#bjbh1 to carry out the purposes of this
 section4  7j7 ,information sharing     
,paragraph 7#ba7 of section #fajc7l7 of 
the ,internal ,revenue ,code of #aihf is
 amended-- 7#a7 by striking or a basic  
health program under section #acca of   
,patient ,protection and ,affordable    
,care ,act in subparagraph 7,a7 and     
inserting a basic health program under  
section #acca of the ,patient           
,protection and ,affordable ,care ,act1 
or a payment under section #ajb7;a7 of  
the ,health ,care ,freedom for ,patients
 ,act of #bjbe1  7#b7 by inserting 1    
program1 or payment after 7and the      
amount thereof7 in subparagraph 7,a77v71
 and  7#c7 by striking ,state programs  
in subparagraph 7,c77ii7 and inserting  
,state programs or payment4  #ajc4      
,funding cost-sharing reduction payments
 ,section #adjb of the ,patient         
,protection and ,affordable ,care ,act  
7#db ,u4,s4,c4 #ahjga7 is amended by    

adding at the end the following3  7h7   
,funding  7#a7 ,in general ,there are   
appropriated1 out of any monies in the  
,treasury not otherwise appropriated1   
such sums as may be necessary for       
purposes of making payments under this  
section for plan years beginning on or  
after ,january #a1 #bjbg4  7#b7 ,use of 
funds  7,a7 ,in general ,the amounts    
appropriated under paragraph 7#a7 may   
not be used for purposes of making      
payments under this section for a       
qualified health plan that provides     
health benefit coverage that includes   
coverage of abortion4  7,b7 ,exception  
,subparagraph 7,a7 shall not apply to   
payments for a qualified health plan    
that provides coverage of abortion only 
if necessary to save the life of the    
mother or if the pregnancy is a result  
of an act of rape or incest4  4  #ajd4  
,allowing all individuals purchasing    
health insurance in the individual      
market the option to purchase a lower   
premium plan  7a7 ,in general ,section  

#acjb7;e7 of the ,patient ,protection   
and ,affordable ,care ,act 7#db         
,u4,s4,c4 #ahjbb7;e77 is amended-- 7#a7 
in paragraph 7#a7-- 7,a7 by             
redesignating clauses 7i7 and 7ii7 of   
subparagraph 7,b7 as subparagraphs 7,a7 
and 7,b71 respectively1 and adjusting   
the margins accordingly2  7,b7 by       
striking plan year if-- and all that    
follows through the plan provides-- and 
inserting plan year if the plan         
provides--2 and  7,c7 in subparagraph   
7,a71 as redesignated by paragraph 7#a71
 by striking clause 7ii7 and inserting  
subparagraph 7,b72  7#b7 by striking    
paragraph 7#b72 and  7#c7 by            
redesignating paragraph 7#c7 as         
paragraph 7#b74  7b7 ,risk pools        
,section #acab7;c77#a7 of the ,patient  
,protection and ,affordable ,care ,act  
7#db ,u4,s4,c4 #ahjcb7;c77#a77 is       
amended by inserting and including      
enrollees in catastrophic plans         
described in section #acjb7;e7 after    
,exchange4  7c7 ,conforming amendment   

,section #acab7;d77#c77;,c7 of the      
,patient ,protection and ,affordable    
,care ,act 7#db ,u4,s4,c4               
#ahjcb7;d77#c77;,c77 is amended by      
striking 1 except that in the case of a 
catastrophic plan described in section  
#acjb7;e71 a qualified individual may   
enroll in the plan only if the          
individual is eligible to enroll in the 
plan under section #acjb7;e77#b74  7d7  
,effective date ,the amendments made by 
subsections 7a71 7b71 and 7c7 shall     
apply with respect to plan years        
beginning on or after ,january #a1      
#bjbg4  ,,ii ,putting ,american patients
 first  #bja4 ,expansion ,,fmap for     
certain ,states providing payments for  
health care furnished to certain        
individuals ,section #aije of the       
,social ,security ,act 7#db ,u4,s4,c4   
#acif;d7 is amended-- 7#a7 in subsection
 7y7-- 7,a7 in paragraph 7#a77;,e71 by  
inserting 7or1 for calendar quarters    
beginning on or after ,october #a1      
#bjbg1 in the case such ,state is a     

specified ,state with respect to such   
calendar quarter1 #hj percent7 after    
thereafter2 and  7,b7 in paragraph 7#b71
 by adding at the end the following new 
subparagraph3  7,c7 ,specified ,state   
,the term specified ,state means1 with  
respect to a quarter1 a ,state that--   
7i7 provides any form of financial      
assistance from a ,state general fund   
during such quarter1 in whole or in     
part1 whether or not made under a ,state
 plan 7or waiver of such plan7 under    
this title or under another program     
established by the ,state1 to or on     
behalf of an alien who is not a         
qualified alien and is not a child or   
pregnant woman who is lawfully residing 
in the ,united ,states and eligible for 
medical assistance pursuant to section  
#aijc7v77#d7 or for child health        
assistance or pregnancy-related         
assistance pursuant to section          
#bajg7;e77#a77,q71 for the purchasing of
 health insurance coverage 7as defined  
in section #bgia7;b77#a7 of the ,public 

,health ,service ,act7 for an alien who 
is not a qualified alien and is not such
 a child or pregnant woman2 or  7ii7    
provides any form of comprehensive      
health benefits coverage1 except such   
coverage required by ,federal law1      
during such quarter1 whether or not     
under a ,state plan 7or waiver of such  
plan7 under this title or under another 
program established by the ,state1 and  
regardless of the source of funding for 
such coverage1 to an alien who is not a 
qualified alien and is not such a child 
or pregnant woman4  7,d7 ,immigration   
terms  7i7 ,alien ,the term alien has   
the meaning given such term in section  
#aja7;a7 of the ,immigration and        
,nationality ,act4  7ii7 ,qualified     
alien ,the term qualified alien has the 
meaning given such term in section #dca 
of the ,personal ,responsibility and    
,work ,opportunity ,reconciliation ,act 
of #aiif1 except that the references to 
7in the opinion of the agency providing 
such benefits7 in subsection 7c7 of such

 section #dca shall be treated as       
references to 7in the opinion of the    
,state in which such comprehensive      
health benefits coverage or such        
financial assistance is provided1 as    
applicable74  2 and  7#b7 in subsection 
7z77#b7-- 7,a7 in subparagraph 7,a71 by 
striking for such year and inserting for
 such quarter2 and  7,b7 in subparagraph
 7,b77i7-- 7i7 in the matter preceding  
subclause 7,i71 by striking for a year  
and inserting for a calendar quarter in 
a year2 and  7ii7 in subclause 7,,ii71  
by striking for the year and inserting  
for the quarter for the ,state4  #bjb4  
,prohibiting ,federal financial         
participation under ,medicaid and ,,chip
 for individuals without verified       
citizenship1 nationality1 or            
satisfactory immigration status  7a7 ,in
 general  7#a7 ,medicaid ,section       
#aijc7;i77#bb7 of the ,social ,security 
,act 7#db ,u4,s4,c4 #acif;b7i77#bb77 is 
amended-- 7,a7 by adding and at the end2
  7,b7 by striking to amounts and       

inserting to--  7,a7 amounts  2 and     
7,c7 by adding at the end the following 
new subparagraph3  7,b7 in the case that
 the ,state elects under section        
#aijb7;a77#df77;,c7 to provide for      
making medical assistance available to  
an individual during-- 7i7 the period in
 which the individual is provided the   
reasonable opportunity to present       
satisfactory documentary evidence of    
citizenship or nationality under section
 #aijb7;ee77#b77;,c7 or subsection      
7x77#d72  7ii7 the #ij-;day period      
described in section                    
#aijb7;ee77#a77;,b77ii77,,ii72 or  7iii7
 the period in which the individual is  
provided the reasonable opportunity to  
submit evidence indicating a            
satisfactory immigration status under   
section #aacg7;d77#d71  amounts expended
 for such medical assistance1 unless the
 citizenship or nationality of such     
individual or the satisfactory          
immigration status of such individual   
7as applicable7 is verified by the end  

of such period2  4  7#b7 ,,chip ,section
 #bajg7;e77#a77,o7 of the ,social       
,security ,act 7#db ,u4,s4,c4           
#acig;gg7e77#a77,o77 is amended by      
striking and 7#ag7 and inserting 7#ag71 
and 7#bb74  7b7 ,eliminating ,state     
requirement to provide medical          
assistance during reasonable opportunity
 period  7#a7 ,documentary evidence of  
citizenship or nationality ,section     
#aijc7x77#d7 of the ,social ,security   
,act 7#db ,u4,s4,c4 #acif;b7x77 is      
amended-- 7,a7 by striking under clauses
 7i7 and 7ii7 of section                
#aacg7;d77#d77;,a7 and inserting under  
section #aacg7;d77#d72 and  7,b7 by     
inserting 1 except that the ,state shall
 not be required to make medical        
assistance available to such individual 
during the period in which such         
individual is provided such reasonable  
opportunity if the ,state has not       
elected the option under section        
#aijb7;a77#df77;,c7 before the period at
 the end4  7#b7 ,social ,security data  

match ,section #aijb7;ee7 of the ,social
 ,security ,act 7#db ,u4,s4,c4          
#acif;a7ee77 is amended-- 7,a7 in       
paragraph 7#a77;,b77ii7-- 7i7 in        
subclause 7,,ii71 by striking 7and      
continues to provide the individual with
 medical assistance during such #ij-;day
 period7 and inserting and1 if the      
,state has elected the option under     
subsection 7a77#df77;,c71 continues to  
provide the individual with medical     
assistance during such #ij-;day period2 
and  7ii7 in subclause 7,,iii71 by      
inserting 1 or denies eligibility for   
medical assistance under this title for 
such individual1 as applicable after    
under this title2 and  7,b7 in paragraph
 7#b77;,c7-- 7i7 by striking under      
clauses 7i7 and 7ii7 of section         
#aacg7;d77#d77;,a7 and inserting under  
section #aacg7;d77#d72 and  7ii7 by     
inserting 1 except that the ,state shall
 not be required to make medical        
assistance available to such individual 
during the period in which such         

individual is provided such reasonable  
opportunity if the ,state has not       
elected the option under section        
#aijb7;a77#df77;,c7 before the period at
 the end4  7#c7 ,individuals with       
satisfactory immigration status ,section
 #aacg7;d77#d7 of the ,social ,security 
,act 7#db ,u4,s4,c4 #acbj;b-#g7;d77#d77 
is amended-- 7,a7 in subparagraph       
7,a77ii71 by inserting 7except that such
 prohibition on delay1 denial1          
reduction1 or termination of eligibility
 for benefits under the ,medicaid       
program under title ,,xix shall apply   
only if the ,state has elected the      
option under section                    
#aijb7;a77#df77;,c77 after has been     
provided2 and  7,b7 in subparagraph     
7,b77ii71 by inserting 7except that such
 prohibition on delay1 denial1          
reduction1 or termination of eligibility
 for benefits under the ,medicaid       
program under title ,,xix shall apply   
only if the ,state has elected the      
option under section                    

#aijb7;a77#df77;,c77 after status4  7c7 
,option to continue providing medical   
assistance during reasonable opportunity
 period  7#a7 ,medicaid ,section        
#aijb7;a77#df7 of the ,social ,security 
,act 7#db ,u4,s4,c4 #acif;a7a77#df77 is 
amended-- 7,a7 in subparagraph 7,a71 by 
striking and at the end2  7,b7 in       
subparagraph 7,b77ii71 by adding and at 
the end2 and  7,c7 by inserting after   
subparagraph 7,b77ii7 the following new 
subparagraph3  7,c7 provide1 at the     
option of the ,state1 for making medical
 assistance available-- 7i7 to an       
individual described in subparagraph    
7,b7 during the period in which such    
individual is provided the reasonable   
opportunity to present satisfactory     
documentary evidence of citizenship or  
nationality under subsection            
7ee77#b77;,c7 or section #aijc7x77#d71  
or during the #ij-;day period described 
in subsection 7ee77#a77;,b77ii77,,ii72  
or  7ii7 to an individual who is not a  
citizen or national of the ,united      

,states during the period in which such 
individual is provided the reasonable   
opportunity to submit evidence          
indicating a satisfactory immigration   
status under section #aacg7;d77#d72  4  
7#b7 ,,chip ,section #baje7;c77#i7 of   
the ,social ,security ,act 7#db         
,u4,s4,c4 #acig;ee7c77#i77 is amended by
 adding at the end the following new    
subparagraph3  7,c7 ,option to continue 
providing child health assistance during
 reasonable opportunity period ,section 
#aijb7;a77#df77;,c7 shall apply to      
,states under this title in the same    
manner as it applies to a ,state under  
title ,,xix4  4  7d7 ,effective date    
,the amendments made by this section    
shall apply beginning on ,october #a1   
#bjbf4  ,,iii ,preventing wasteful      
spending  #cja4 ,prohibiting coverage of
 gender transition procedures as an     
essential health benefit under plans    
offered by ,exchanges  7a7 ,in general  
,section #acjb7;b77#b7 of the ,patient  
,protection and ,affordable ,care ,act  

7#db ,u4,s4,c4 #ahjbb7;b77#b77 is       
amended by adding at the end the        
following new subparagraph3  7,c7       
,gender transition procedures ,for plan 
years beginning on or after ,january #a1
 #bjbg1 the essential health benefits   
defined pursuant to paragraph 7#a7 may  
not include items and services furnished
 for a gender transition procedure4  4  
7b7 ,gender transition procedure defined
 ,section #acjd of the ,patient         
,protection and ,affordable ,care ,act  
7#db ,u4,s4,c4 #ahjbd7 is amended by    
adding at the end the following new     
subsection3  7f7 ,gender transition     
procedure  7#a7 ,in general ,in this    
title1 except as provided in paragraph  
7#b71 the term gender transition        
procedure means1 with respect to an     
individual1 any of the following when   
performed for the purpose of            
intentionally changing the body of such 
individual 7including by disrupting the 
body's development1 inhibiting its      
natural functions1 or modifying its     

appearance7 to no longer correspond to  
the individual's sex3 7,a7 ,performing  
any surgery1 including-- 7i7 castration2
  7ii7 sterilization2  7iii7            
orchiectomy2  7iv7 scrotoplasty2  7v7   
vasectomy2  7vi7 tubal ligation2  7vii7 
hysterectomy2  7viii7 oophorectomy2     
7ix7 ovariectomy2  7x7 metoidioplasty2  
7xi7 clitoroplasty2  7xii7              
reconstruction of the fixed part of the 
urethra with or without a metoidioplasty
 or a phalloplasty2  7xiii7 penectomy2  
7xiv7 phalloplasty2  7xv7 vaginoplasty2 
7xvi7 vaginectomy2  7xvii7 vulvoplasty2 
7xviii7 reduction thyrochondroplasty2   
7xix7 chondrolaryngoplasty2  7xx7       
mastectomy2 and  7xxi7 any plastic1     
cosmetic1 or aesthetic surgery that     
feminizes or masculinizes the facial or 
other body features of an individual4   
7,b7 ,any placement of chest implants to
 create feminine breasts or any         
placement of erection or testicular     
prosthesis4  7,c7 ,any placement of fat 
or artificial implants in the gluteal   

region4  7,d7 ,administering1           
prescribing1 or dispensing to an        
individual medications1 including-- 7i7 
gonadotropin-releasing hormone 7,gn,r,h7
 analogues or other puberty-blocking    
drugs to stop or delay normal puberty2  
and  7ii7 testosterone1 estrogen1 or    
other androgens to an individual at     
doses that are supraphysiologic than    
would normally be produced endogenously 
in a healthy individual of the same age 
and sex4  7#b7 ,exception ,paragraph    
7#a7 shall not apply to the following3  
7,a7 ,puberty suppression or blocking   
prescription drugs for the purpose of   
normalizing puberty for an individual   
experiencing precocious puberty4  7,b7  
,medically necessary procedures or      
treatments to correct for-- 7i7 a       
medically verifiable disorder of sex    
development1 including-- 7,i7 #df1,,xx  
chromosomes with virilization2  7,,ii7  
#df1,,xy chromosomes with               
undervirilization2 and  7,,iii7 both    
ovarian and testicular tissue2  7ii7 sex

 chromosome structure1 sex steroid      
hormone production1 or sex hormone      
action1 if determined to be abnormal by 
a physician through genetic or          
biochemical testing2  7iii7 infection1  
disease1 injury1 or disorder caused or  
exacerbated by a previous procedure     
described in paragraph 7#a71 or a       
physical disorder1 physical injury1 or  
physical illness that would1 as         
certified by a physician1 place the     
individual in imminent danger of death  
or impairment of a major bodily function
 unless the procedure is performed1 not 
including procedures performed for the  
alleviation of mental distress2 or  7iv7
 procedures to restore or reconstruct   
the body of the individual in order to  
correspond to the individual's sex after
 one or more previous procedures        
described in paragraph 7#a71 which may  
include the removal of a pseudo phallus 
or breast augmentation4  7#c7 ,sex ,for 
purposes of this subsection1 the term   
sex means either male or female1 as     

biologically determined and defined by  
subparagraph 7,a7 and subparagraph 7,b74
 7,a7 ,female ,the term female means an 
individual who naturally has1 had1 will 
have1 or would have1 but for a          
developmental or genetic anomaly or     
historical accident1 the reproductive   
system that at some point produces1     
transports1 and utilizes eggs for       
fertilization4  7,b7 ,male ,the term    
male means an individual who naturally  
has1 had1 will have1 or would have1 but 
for a developmental or genetic anomaly  
or historical accident1 the reproductive
 system that at some point produces1    
transports1 and utilizes sperm for      
fertilization4  4  #cjb4 ,prohibiting   
,federal ,medicaid and ,,chip funding   
for certain items and services  7a7     
,medicaid ,section #aijc7;i7 of the     
,social ,security ,act 7#db ,u4,s4,c4   
#acif;b7i77 is amended-- 7#a7 in        
paragraph 7#bf71 by striking 2 or and   
inserting a semicolon2  7#b7 in         
paragraph 7#bg71 by striking the period 

at the end and inserting 2 or2  7#c7 by 
inserting after paragraph 7#bg7 the     
following new paragraph3  7#bh7 with    
respect to any amount expended for      
specified gender transition procedures  
7as defined in section #aije7ll77       
furnished to an individual enrolled in a
 ,state plan 7or waiver of such plan74  
2 and  7#d7 in the flush left matter at 
the end1 by striking and 7#ah71 and     
inserting 7#ah71 and 7#bh74  7b7 ,,chip 
,section #bajg7;e77#a77,o7 of the       
,social ,security ,act 7#db ,u4,s4,c4   
#acig;gg7e77#a77,o771 as amended by this
 ,act1 is further amended by striking   
and 7#bb7 and inserting 7#bb71 and      
7#bh74  7c7 ,specified gender transition
 procedures defined ,section #aije of   
the ,social ,security ,act 7#db         
,u4,s4,c4 #acif;d7 is amended by adding 
at the end the following new subsection3
  7ll7 ,specified gender transition     
procedures  7#a7 ,in general ,for       
purposes of section #aijc7;i77#bh71     
except as provided in paragraph 7#b7 1  

the term specified gender transition    
procedure means1 with respect to an     
individual1 any of the following when   
performed for the purpose of            
intentionally changing the body of such 
individual 7including by disrupting the 
body's development1 inhibiting its      
natural functions1 or modifying its     
appearance7 to no longer correspond to  
the individual's sex3 7,a7 ,performing  
any surgery1 including-- 7i7 castration2
  7ii7 sterilization2  7iii7            
orchiectomy2  7iv7 scrotoplasty2  7v7   
vasectomy2  7vi7 tubal ligation2  7vii7 
hysterectomy2  7viii7 oophorectomy2     
7ix7 ovariectomy2  7x7 metoidioplasty2  
7xi7 clitoroplasty2  7xii7              
reconstruction of the fixed part of the 
urethra with or without a metoidioplasty
 or a phalloplasty2  7xiii7 penectomy2  
7xiv7 phalloplasty2  7xv7 vaginoplasty2 
7xvi7 vaginectomy2  7xvii7 vulvoplasty2 
7xviii7 reduction thyrochondroplasty2   
7xix7 chondrolaryngoplasty2  7xx7       
mastectomy2 and  7xxi7 any plastic1     

cosmetic1 or aesthetic surgery that     
feminizes or masculinizes the facial or 
other body features of an individual4   
7,b7 ,any placement of chest implants to
 create feminine breasts or any         
placement of erection or testicular     
prosthesis4  7,c7 ,any placement of fat 
or artificial implants in the gluteal   
region4  7,d7 ,administering1           
prescribing1 or dispensing to an        
individual medications1 including-- 7i7 
gonadotropin-releasing hormone 7,gn,r,h7
 analogues or other puberty-blocking    
drugs to stop or delay normal puberty2  
and  7ii7 testosterone1 estrogen1 or    
other androgens to an individual at     
doses that are supraphysiologic than    
would normally be produced endogenously 
in a healthy individual of the same age 
and sex4  7#b7 ,exception ,paragraph    
7#a7 shall not apply to the following   
when furnished to an individual by a    
health care provider if the individual  
is a minor with the consent of such     
individual's parent or legal guardian3  

7,a7 ,puberty suppression or blocking   
prescription drugs for the purpose of   
normalizing puberty for an individual   
experiencing precocious puberty4  7,b7  
,medically necessary procedures or      
treatments to correct for-- 7i7 a       
medically verifiable disorder of sex    
development1 including-- 7,i7 #df1,,xx  
chromosomes with virilization2  7,,ii7  
#df1,,xy chromosomes with               
undervirilization2 and  7,,iii7 both    
ovarian and testicular tissue2  7ii7 sex
 chromosome structure1 sex steroid      
hormone production1 or sex hormone      
action1 if determined to be abnormal by 
a physician through genetic or          
biochemical testing2  7iii7 infection1  
disease1 injury1 or disorder caused or  
exacerbated by a previous procedure     
described in paragraph 7#a71 or a       
physical disorder1 physical injury1 or  
physical illness that would1 as         
certified by a physician1 place the     
individual in danger of death or        
impairment of a major bodily function   

unless the procedure is performed1 not  
including procedures performed for the  
alleviation of mental distress2 or  7iv7
 procedures to restore or reconstruct   
the body of the individual in order to  
correspond to the individual's sex after
 one or more previous procedures        
described in paragraph 7#a71 which may  
include the removal of a pseudo phallus 
or breast augmentation4  7#c7 ,sex ,for 
purposes of paragraph 7#a71 the term sex
 means either male or female1 as        
biologically determined and defined in  
paragraphs 7#d7 and 7#e71 respectively4 
7#d7 ,female ,for purposes of paragraph 
7#c71 the term female means an          
individual who naturally has1 had1 will 
have1 or would have1 but for a          
developmental or genetic anomaly or     
historical accident1 the reproductive   
system that at some point produces1     
transports1 and utilizes eggs for       
fertilization4  7#e7 ,male ,for purposes
 of paragraph 7#c71 the term male means 
an individual who naturally has1 had1   

will have1 or would have1 but for a     
developmental or genetic anomaly or     
historical accident1 the reproductive   
system that at some point produces1     
transports1 and utilizes sperm for      
fertilization4  4  ,december #h1        
#bjbe,read the second time and placed on
 the calendar