,,ii ,cal5d> ,no4 #bhe #aai? ,,congress #a/ ,session ,s4 #cchf ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,decemb] #h 7legislative day1 ,decemb] #d71 #bjbe,mr4 ,crapo 7= himself & ,mr4 ,cassidy7 introduc$ ! foll[+ bill2 :i* 0 read ! fir/ "t ,decemb] #h1 #bjbe,read ! second "t & plac$ on ! cal5d> ,a ,,bill ,to provide a heal? sav+s acc\nt contribution to c]ta9 enrollees1 to r$uce heal? c>e co/s1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,heal? ,c>e ,fre$om = ,pati5ts ,act ( #bjbe4 7b7 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4,,title ,i--,increas+ *oice & r$uc+ premiums,sec4 #aja4 ,ex*ange plan ,h,s,as4,sec4 #ajb4 ,ex*ange plan ,,hsa contribution program4,sec4 #ajc4 ,fund+ co/-%>+ r$uction paym5ts4,sec4 #ajd4 ,all[+ all individuals pur*as+ heal? insurance 9 ! individual m>ket ! option to pur*ase a l[] premium plan4,,title ,,ii--,putt+ ,am]ican pati5ts first,sec4 #bja4 ,expansion ,,fmap = c]ta9 ,/ates provid+ paym5ts = heal? c>e furni%$ to c]ta9 individuals4,sec4 #bjb4 ,prohibit+ ,f$]al f9ancial p>ticipation "u ,m$icaid & ,,*ip = individuals )\t v]ifi$ citiz5%ip1 nationality1 or satisfactory immigration /atus4,,title ,,iii--,prev5t+ wa/eful spending,sec4 #cja4 ,prohibit+ cov]age ( g5d] transition proc$ures z an ess5tial heal? b5efit "u plans (f]$ by ,ex*anges4,sec4 #cjb4 ,prohibit+ ,f$]al ,m$icaid & ,,*ip fund+ = c]ta9 items & s]vices4 ,i ,increas+ *oice & r$uc+ premiums #aja4 ,ex*ange plan ,h,s,as 7a7 ,9 g5]al ,section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subsection3 7i7 ,ex*ange plan ,h,s,as ,= purposes ( ?is section-- 7#a7 ,9 g5]al ,9 ! case ( an ,ex*ange plan ,,hsa1 ?is section %all be appli$ z provid$ 9 p>agraphs 7#c7 ?r\gh 7#d74 7#b7 ,ex*ange plan ,,hsa ,! t]m ,ex*ange plan ,,hsa means a heal? sav+s acc\nt :i* is designat$ z an ,ex*ange plan ,,hsa ^u ! e/abli%m5t ( su* acc\nt4 7#c7 ,no rollov]s p]mitt$ ,except 9 ! case ( a contribution f "o ,ex*ange plan ,,hsa to ano!r ,ex*ange plan ,,hsa1 subsection 7f77#e7 %all n apply4 7#d7 ,re/riction on use ( am\nts ,= purposes ( subsection 7d77#b77;,a71 am\nts paid =-- 7,a7 abortion1 o!r ?an-- 7i7 if ! pregnancy is ! result ( an act ( rape or ince/1 or 7ii7 9 ! case :]e a woman suff]s f a physical disord]1 physical injury1 or physical illness1 includ+ a life-endang]+ physical condition caus$ by or aris+ f ! pregnancy itself1 t w\ld1 z c]tifi$ by a physician1 place ! woman 9 dang] ( dea? unless an abortion is p]=m$1 or 7,b7 any sex trait modification proc$ure or s]vice 7z def9$ 9 section #aef4djj ( title #de1 ,code ( ,f$]al ,regulations1 z 9 effect on ! date ( ! enactm5t ( ?is subsection71 %all n be treat$ z paid = m$ical c>e4 4 7b7 ,treatm5t ( gov]nm5tal contributions ,p>agraph 7#d7 ( section #bbc7;b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ & at ! end ( subp>agraph 7,b71 by /rik+ ! p]iod at ! end ( subp>agraph 7,c7 & ins]t+ 1 &1 & by ins]t+ aft] subp>agraph 7,c7 ! foll[+ new subp>agraph3 7,d7 ! aggregate am\nt contribut$ to an ,ex*ange plan ,,hsa pursuant to section #ajb7;a7 ( ! ,heal? ,c>e ,fre$om = ,pati5ts ,act ( #bjbe :i* is excludable f ! taxpay]'s gross income = ! taxable ye> "u section #ajb7;f7 ( su* ,act 7& su* am\nt %all n be all[$ z a d$uction "u subsection 7a774 4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjbe4 #ajb4 ,ex*ange plan ,,hsa contribution program 7a7 ,9 g5]al ,z soon z adm9i/ratively feasible1 ! ,secret>y ( ,heal? & ,human ,s]vices %all make paym5ts to ! ,ex*ange plan ,,hsa ( ea* individual :o is an eligible enrollee1 = ea* mon? :i* is an eligible mon? ) respect to su* individual1 9 ! am\nt describ$ 9 subsection 7c74 7b7 ,eligible mon? ,= purposes ( ?is section1 ! t]m eligible mon? ) respect to an individual means a cal5d> mon?-- 7#a7 occurr+ 9 cal5d> ye> #bjbf or #bjbg1 & 7#b7 = :i* ! individual is enroll$ 9 a bronze level qualifi$ heal? plan or a cata/rophic plan ?r\gh an ,ex*ange e/abli%$ "u subtitle ,d ( title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjba et seq474 7c7 ,paym5t am\nt ,! am\nt ( ea* paym5t "u subsection 7a7 = any individual = an eligible mon? is #a_/ab (-- 7#a7 #a1jjj1 9 ! case ( an eligible enrollee :o has atta9$ age #ah1 & has n atta9$ age #ej1 z ( ! fir/ day ( ! cal5d> ye> :i* includes su* mon?1 & 7#b7 #a1ejj1 9 ! case ( an eligible enrollee :o has atta9$ age #ej1 & has n atta9$ age #fe1 z ( ! fir/ day ( su* cal5d> ye>4 7d7 ,eligible enrollee ,= purposes ( ?is section1 ) respect to mon?s occurr+ dur+ a cal5d> ye>1 ! t]m eligible enrollee means an eligible individual 7z def9$ 9 section #bbc7;c77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf7-- 7#a7 :o has atta9$ age #ah1 & has n atta9$ age #fe1 z ( ! fir/ day ( su* cal5d> ye>1 7#b7 9 ! case ( an ali51 :o is an eligible ali51 z def9$ 9 section #cf;,b7e77#b77;,b7 ( su* ,code 7z 9 effect = taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjbf1 appli$ by sub/itut+ = :i* ! paym5t "u section #ajb7;a7 ( ! ,heal? ,c>e ,fre$om = ,pati5ts ,act ( #bjbe is made = = :i* ! cr$it "u ?is section is be+ claim$71 & 7#c7 ^: h\sehold income1 express$ z a p]c5t ( ! pov]ty l9e = ! family size involv$1 does n exce$ #gjj p]c5t4 7e7 ,det]m9ation ( eligibility 7#a7 ,9 g5]al ,^u election pursuant to p>agraph 7#b7 by an individual enroll+ 9 a plan describ$ 9 subsection 7b77#b71 ! ,secret>y ( ,heal? & ,human ,s]vices %all make a det]m9ation ( ! individual's /atus z an eligible enrollee on ! basis ( ! late/ det]m9ation pursuant to section #adab ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjhb7 ( ! individual's eligibility = ! advance paym5t ( ! premium tax cr$its "u section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf & co/-%>+ r$uctions "u section #adjb ( su* ,act 7#db ,u4,s4,c4 #ahjga74 7#b7 ,election ,at su* "t & 9 su* mann] z ! ,secret>y ( ,heal? & ,human ,s]vices %all provide1 an eligible enrollee %all notify ! ,secret>y ( su* enrollee's election to receive ! paym5ts "u subsection 7a7 & %all provide-- 7,a7 ! social security numb] ( su* eligible enrollee1 7,b7 9 ! case ( an ali51 an atte/ation t ! individual is an eligible ali51 & 7,c7 suffici5t in=mation to all[ = ! id5tification (1 & deposit ( ! paym5ts "u subsection 7a7 into1 ! ,ex*ange plan ,,hsa ( ! eligible enrollee4 7#c7 ,report+ by ,ex*ange ,! ,ex*ange ?r\gh :i* an individual is enroll+ 9 a plan describ$ 9 subsection 7b77#b7 %all provide to ! ,secret>y ( ,heal? & ,human ,s]vices ! in=mation provid$ by ! individual :i* is necess>y = ! det]m9ation "u p>agraph 7#a74 7#d7 ,tim+ ( paym5ts ,! paym5ts "u subsection 7a7 ) respect to any eligible mon?s occurr+ be=e ! det]m9ation "u p>agraph 7#a7 is complet$ %all be made z e>ly z possible aft] ! completion ( su* det]m9ation4 7f7 ,tax treatm5t ( contributions ,= purposes ( ! ,int]nal ,rev5ue ,code ( #aihf1 paym5ts "u subsection 7a7 %all n be includ$ 9 gross income ( an eligible enrollee4 7g7 ,def9itions ,= purposes ( ?is section-- 7#a7 ,ex*ange plan ,,hsa ,! t]m ,ex*ange plan ,,hsa has ! mean+ giv5 su* t]m 9 section #bbc7;i7 ( ! ,int]nal ,rev5ue ,code ( #aihf4 7#b7 ,h\sehold income2 pov]ty l9e ,! t]ms h\sehold income1 pov]ty l9e1 & family size h ! same respective mean+s & %all be det]m9$ 9 ! same mann] z = purposes ( section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf4 7#c7 ,bronze level qualifi$ heal? plan ,! t]m bronze level qualifi$ heal? plan means a qualifi$ heal? plan1 z def9$ 9 section #acja7;a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjba7;a771 9 ! bronze level1 z def9$ 9 section #acjb7;d77#a77;,a7 ( su* ,act 7#db ,u4,s4,c4 #ahjbb7;d77#a77;,a774 7#d7 ,cata/rophic plan ,! t]m cata/rophic plan means a plan describ$ 9 section #acjb7;e7 ( su* ,act 7#db ,u4,s4,c4 #ahjbb7;e774 7h7 ,regulatory au?ority ,! ,secret>y ( ,heal? & ,human ,s]vices %all prescribe su* regulations or o!r guidance z are necess>y to c>ry out ! purposes ( ?is section4 7i7 ,fund+ ,9 addition to am\nts o!rwise available1 !re is appropriat$ to ! ,secret>y ( ,heal? & ,human ,s]vices1 out ( any money 9 ! ,treasury n o!rwise appropriat$1 #aj1jjj1jjj1jjj = ea* ( fiscal ye>s #bjbf & #bjbg1 to rema9 available until ,septemb] #cj1 #bjbh1 to c>ry out ! purposes ( ?is section4 7j7 ,in=mation %>+ ,p>agraph 7#ba7 ( section #fajc7l7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7#a7 by /rik+ or a basic heal? program "u section #acca ( ,pati5t ,protection & ,af=dable ,c>e ,act 9 subp>agraph 7,a7 & ins]t+ a basic heal? program "u section #acca ( ! ,pati5t ,protection & ,af=dable ,c>e ,act1 or a paym5t "u section #ajb7;a7 ( ! ,heal? ,c>e ,fre$om = ,pati5ts ,act ( #bjbe1 7#b7 by ins]t+ 1 program1 or paym5t aft] 7& ! am\nt !re(7 9 subp>agraph 7,a77v71 & 7#c7 by /rik+ ,/ate programs 9 subp>agraph 7,c77ii7 & ins]t+ ,/ate programs or paym5t4 #ajc4 ,fund+ co/-%>+ r$uction paym5ts ,section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjga7 is am5d$ by add+ at ! end ! foll[+3 7h7 ,fund+ 7#a7 ,9 g5]al ,!re are appropriat$1 out ( any monies 9 ! ,treasury n o!rwise appropriat$1 su* sums z may be necess>y = purposes ( mak+ paym5ts "u ?is section = plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbg4 7#b7 ,use ( funds 7,a7 ,9 g5]al ,! am\nts appropriat$ "u p>agraph 7#a7 may n be us$ = purposes ( mak+ paym5ts "u ?is section = a qualifi$ heal? plan t provides heal? b5efit cov]age t includes cov]age ( abortion4 7,b7 ,exception ,subp>agraph 7,a7 %all n apply to paym5ts = a qualifi$ heal? plan t provides cov]age ( abortion only if necess>y to save ! life ( ! "m or if ! pregnancy is a result ( an act ( rape or ince/4 4 #ajd4 ,all[+ all individuals pur*as+ heal? insurance 9 ! individual m>ket ! option to pur*ase a l[] premium plan 7a7 ,9 g5]al ,section #acjb7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjbb7;e77 is am5d$-- 7#a7 9 p>agraph 7#a7-- 7,a7 by r$esignat+ clauses 7i7 & 7ii7 ( subp>agraph 7,b7 z subp>agraphs 7,a7 & 7,b71 respectively1 & adju/+ ! m>g9s accord+ly2 7,b7 by /rik+ plan ye> if-- & all t foll[s ?r\gh ! plan provides-- & ins]t+ plan ye> if ! plan provides--2 & 7,c7 9 subp>agraph 7,a71 z r$esignat$ by p>agraph 7#a71 by /rik+ clause 7ii7 & ins]t+ subp>agraph 7,b72 7#b7 by /rik+ p>agraph 7#b72 & 7#c7 by r$esignat+ p>agraph 7#c7 z p>agraph 7#b74 7b7 ,risk pools ,section #acab7;c77#a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjcb7;c77#a77 is am5d$ by ins]t+ & includ+ enrollees 9 cata/rophic plans describ$ 9 section #acjb7;e7 aft] ,ex*ange4 7c7 ,con=m+ am5dm5t ,section #acab7;d77#c77;,c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjcb7;d77#c77;,c77 is am5d$ by /rik+ 1 except t 9 ! case ( a cata/rophic plan describ$ 9 section #acjb7;e71 a qualifi$ individual may enroll 9 ! plan only if ! individual is eligible to enroll 9 ! plan "u section #acjb7;e77#b74 7d7 ,effective date ,! am5dm5ts made by subsections 7a71 7b71 & 7c7 %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbg4 ,,ii ,putt+ ,am]ican pati5ts fir/ #bja4 ,expansion ,,fmap = c]ta9 ,/ates provid+ paym5ts = heal? c>e furni%$ to c]ta9 individuals ,section #aije ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7 is am5d$-- 7#a7 9 subsection 7y7-- 7,a7 9 p>agraph 7#a77;,e71 by ins]t+ 7or1 = cal5d> qu>t]s beg9n+ on or aft] ,octob] #a1 #bjbg1 9 ! case su* ,/ate is a specifi$ ,/ate ) respect to su* cal5d> qu>t]1 #hj p]c5t7 aft] !reaft]2 & 7,b7 9 p>agraph 7#b71 by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,specifi$ ,/ate ,! t]m specifi$ ,/ate means1 ) respect to a qu>t]1 a ,/ate t-- 7i7 provides any =m ( f9ancial assi/ance f a ,/ate g5]al fund dur+ su* qu>t]1 9 :ole or 9 "p1 :e!r or n made "u a ,/ate plan 7or waiv] ( su* plan7 "u ?is title or "u ano!r program e/abli%$ by ! ,/ate1 to or on behalf ( an ali5 :o is n a qualifi$ ali5 & is n a *ild or pregnant woman :o is lawfully resid+ 9 ! ,unit$ ,/ates & eligible = m$ical assi/ance pursuant to section #aijc7v77#d7 or = *ild heal? assi/ance or pregnancy-relat$ assi/ance pursuant to section #bajg7;e77#a77,q71 = ! pur*as+ ( heal? insurance cov]age 7z def9$ 9 section #bgia7;b77#a7 ( ! ,public ,heal? ,s]vice ,act7 = an ali5 :o is n a qualifi$ ali5 & is n su* a *ild or pregnant woman2 or 7ii7 provides any =m ( compreh5sive heal? b5efits cov]age1 except su* cov]age requir$ by ,f$]al law1 dur+ su* qu>t]1 :e!r or n "u a ,/ate plan 7or waiv] ( su* plan7 "u ?is title or "u ano!r program e/abli%$ by ! ,/ate1 & reg>dless ( ! s\rce ( fund+ = su* cov]age1 to an ali5 :o is n a qualifi$ ali5 & is n su* a *ild or pregnant woman4 7,d7 ,immigration t]ms 7i7 ,ali5 ,! t]m ali5 has ! mean+ giv5 su* t]m 9 section #aja7;a7 ( ! ,immigration & ,nationality ,act4 7ii7 ,qualifi$ ali5 ,! t]m qualifi$ ali5 has ! mean+ giv5 su* t]m 9 section #dca ( ! ,p]sonal ,responsibility & ,"w ,opportunity ,reconciliation ,act ( #aiif1 except t ! ref]5ces to 79 ! op9ion ( ! ag5cy provid+ su* b5efits7 9 subsection 7c7 ( su* section #dca %all be treat$ z ref]5ces to 79 ! op9ion ( ! ,/ate 9 :i* su* compreh5sive heal? b5efits cov]age or su* f9ancial assi/ance is provid$1 z applicable74 2 & 7#b7 9 subsection 7z77#b7-- 7,a7 9 subp>agraph 7,a71 by /rik+ = su* ye> & ins]t+ = su* qu>t]2 & 7,b7 9 subp>agraph 7,b77i7-- 7i7 9 ! matt] prec$+ subclause 7,i71 by /rik+ = a ye> & ins]t+ = a cal5d> qu>t] 9 a ye>2 & 7ii7 9 subclause 7,,ii71 by /rik+ = ! ye> & ins]t+ = ! qu>t] = ! ,/ate4 #bjb4 ,prohibit+ ,f$]al f9ancial p>ticipation "u ,m$icaid & ,,*ip = individuals )\t v]ifi$ citiz5%ip1 nationality1 or satisfactory immigration /atus 7a7 ,9 g5]al 7#a7 ,m$icaid ,section #aijc7;i77#bb7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7i77#bb77 is am5d$-- 7,a7 by add+ & at ! end2 7,b7 by /rik+ to am\nts & ins]t+ to-- 7,a7 am\nts 2 & 7,c7 by add+ at ! end ! foll[+ new subp>agraph3 7,b7 9 ! case t ! ,/ate elects "u section #aijb7;a77#df77;,c7 to provide = mak+ m$ical assi/ance available to an individual dur+-- 7i7 ! p]iod 9 :i* ! individual is provid$ ! reasonable opportunity to pres5t satisfactory docum5t>y evid5ce ( citiz5%ip or nationality "u section #aijb7;ee77#b77;,c7 or subsection 7x77#d72 7ii7 ! #ij-;day p]iod describ$ 9 section #aijb7;ee77#a77;,b77ii77,,ii72 or 7iii7 ! p]iod 9 :i* ! individual is provid$ ! reasonable opportunity to submit evid5ce indicat+ a satisfactory immigration /atus "u section #aacg7;d77#d71 am\nts exp5d$ = su* m$ical assi/ance1 unless ! citiz5%ip or nationality ( su* individual or ! satisfactory immigration /atus ( su* individual 7z applicable7 is v]ifi$ by ! end ( su* p]iod2 4 7#b7 ,,*ip ,section #bajg7;e77#a77,o7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acig;gg7e77#a77,o77 is am5d$ by /rik+ & 7#ag7 & ins]t+ 7#ag71 & 7#bb74 7b7 ,elim9at+ ,/ate requirem5t to provide m$ical assi/ance dur+ reasonable opportunity p]iod 7#a7 ,docum5t>y evid5ce ( citiz5%ip or nationality ,section #aijc7x77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7x77 is am5d$-- 7,a7 by /rik+ "u clauses 7i7 & 7ii7 ( section #aacg7;d77#d77;,a7 & ins]t+ "u section #aacg7;d77#d72 & 7,b7 by ins]t+ 1 except t ! ,/ate %all n be requir$ to make m$ical assi/ance available to su* individual dur+ ! p]iod 9 :i* su* individual is provid$ su* reasonable opportunity if ! ,/ate has n elect$ ! option "u section #aijb7;a77#df77;,c7 be=e ! p]iod at ! end4 7#b7 ,social ,security data mat* ,section #aijb7;ee7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7ee77 is am5d$-- 7,a7 9 p>agraph 7#a77;,b77ii7-- 7i7 9 subclause 7,,ii71 by /rik+ 7& cont9ues to provide ! individual ) m$ical assi/ance dur+ su* #ij-;day p]iod7 & ins]t+ &1 if ! ,/ate has elect$ ! option "u subsection 7a77#df77;,c71 cont9ues to provide ! individual ) m$ical assi/ance dur+ su* #ij-;day p]iod2 & 7ii7 9 subclause 7,,iii71 by ins]t+ 1 or d5ies eligibility = m$ical assi/ance "u ?is title = su* individual1 z applicable aft] "u ?is title2 & 7,b7 9 p>agraph 7#b77;,c7-- 7i7 by /rik+ "u clauses 7i7 & 7ii7 ( section #aacg7;d77#d77;,a7 & ins]t+ "u section #aacg7;d77#d72 & 7ii7 by ins]t+ 1 except t ! ,/ate %all n be requir$ to make m$ical assi/ance available to su* individual dur+ ! p]iod 9 :i* su* individual is provid$ su* reasonable opportunity if ! ,/ate has n elect$ ! option "u section #aijb7;a77#df77;,c7 be=e ! p]iod at ! end4 7#c7 ,individuals ) satisfactory immigration /atus ,section #aacg7;d77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;b-#g7;d77#d77 is am5d$-- 7,a7 9 subp>agraph 7,a77ii71 by ins]t+ 7except t su* prohibition on delay1 d5ial1 r$uction1 or t]m9ation ( eligibility = b5efits "u ! ,m$icaid program "u title ,,xix %all apply only if ! ,/ate has elect$ ! option "u section #aijb7;a77#df77;,c77 aft] has be5 provid$2 & 7,b7 9 subp>agraph 7,b77ii71 by ins]t+ 7except t su* prohibition on delay1 d5ial1 r$uction1 or t]m9ation ( eligibility = b5efits "u ! ,m$icaid program "u title ,,xix %all apply only if ! ,/ate has elect$ ! option "u section #aijb7;a77#df77;,c77 aft] /atus4 7c7 ,option to cont9ue provid+ m$ical assi/ance dur+ reasonable opportunity p]iod 7#a7 ,m$icaid ,section #aijb7;a77#df7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#df77 is am5d$-- 7,a7 9 subp>agraph 7,a71 by /rik+ & at ! end2 7,b7 9 subp>agraph 7,b77ii71 by add+ & at ! end2 & 7,c7 by ins]t+ aft] subp>agraph 7,b77ii7 ! foll[+ new subp>agraph3 7,c7 provide1 at ! option ( ! ,/ate1 = mak+ m$ical assi/ance available-- 7i7 to an individual describ$ 9 subp>agraph 7,b7 dur+ ! p]iod 9 :i* su* individual is provid$ ! reasonable opportunity to pres5t satisfactory docum5t>y evid5ce ( citiz5%ip or nationality "u subsection 7ee77#b77;,c7 or section #aijc7x77#d71 or dur+ ! #ij-;day p]iod describ$ 9 subsection 7ee77#a77;,b77ii77,,ii72 or 7ii7 to an individual :o is n a citiz5 or national ( ! ,unit$ ,/ates dur+ ! p]iod 9 :i* su* individual is provid$ ! reasonable opportunity to submit evid5ce indicat+ a satisfactory immigration /atus "u section #aacg7;d77#d72 4 7#b7 ,,*ip ,section #baje7;c77#i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acig;ee7c77#i77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,option to cont9ue provid+ *ild heal? assi/ance dur+ reasonable opportunity p]iod ,section #aijb7;a77#df77;,c7 %all apply to ,/ates "u ?is title 9 ! same mann] z x applies to a ,/ate "u title ,,xix4 4 7d7 ,effective date ,! am5dm5ts made by ?is section %all apply beg9n+ on ,octob] #a1 #bjbf4 ,,iii ,prev5t+ wa/eful sp5d+ #cja4 ,prohibit+ cov]age ( g5d] transition proc$ures z an ess5tial heal? b5efit "u plans (f]$ by ,ex*anges 7a7 ,9 g5]al ,section #acjb7;b77#b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjbb7;b77#b77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,g5d] transition proc$ures ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbg1 ! ess5tial heal? b5efits def9$ pursuant to p>agraph 7#a7 may n include items & s]vices furni%$ = a g5d] transition proc$ure4 4 7b7 ,g5d] transition proc$ure def9$ ,section #acjd ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjbd7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7f7 ,g5d] transition proc$ure 7#a7 ,9 g5]al ,9 ?is title1 except z provid$ 9 p>agraph 7#b71 ! t]m g5d] transition proc$ure means1 ) respect to an individual1 any ( ! foll[+ :5 p]=m$ = ! purpose ( int5tionally *ang+ ! body ( su* individual 7includ+ by disrupt+ ! body's developm5t1 inhibit+ its natural functions1 or modify+ its appe>ance7 to no long] correspond to ! individual's sex3 7,a7 ,p]=m+ any surg]y1 includ+-- 7i7 ca/ration2 7ii7 /]ilization2 7iii7 or*iectomy2 7iv7 scrotopla/y2 7v7 vasectomy2 7vi7 tubal ligation2 7vii7 hy/]ectomy2 7viii7 oophorectomy2 7ix7 ov>iectomy2 7x7 metoidiopla/y2 7xi7 clitoropla/y2 7xii7 recon/ruction ( ! fix$ "p ( ! ure?ra ) or )\t a metoidiopla/y or a phallopla/y2 7xiii7 p5ectomy2 7xiv7 phallopla/y2 7xv7 vag9opla/y2 7xvi7 vag9ectomy2 7xvii7 vulvopla/y2 7xviii7 r$uction ?yro*ondropla/y2 7xix7 *ondrol>yngopla/y2 7xx7 ma/ectomy2 & 7xxi7 any pla/ic1 cosmetic1 or ae/hetic surg]y t fem9izes or mascul9izes ! facial or o!r body features ( an individual4 7,b7 ,any placem5t ( *e/ implants to create fem99e brea/s or any placem5t ( erection or te/icul> pro/hesis4 7,c7 ,any placem5t ( fat or artificial implants 9 ! gluteal region4 7,d7 ,adm9i/]+1 prescrib+1 or disp5s+ to an individual m$ications1 includ+-- 7i7 gonadotrop9-releas+ hormone 7,gn,r,h7 analogues or o!r pub]ty-block+ drugs to /op or delay normal pub]ty2 & 7ii7 te/o/]one1 e/rog51 or o!r &rog5s to an individual at doses t are supraphysiologic ?an w\ld normally be produc$ endog5\sly 9 a heal?y individual ( ! same age & sex4 7#b7 ,exception ,p>agraph 7#a7 %all n apply to ! foll[+3 7,a7 ,pub]ty suppression or block+ prescription drugs = ! purpose ( normaliz+ pub]ty = an individual exp]i5c+ precoci\s pub]ty4 7,b7 ,m$ically necess>y proc$ures or treatm5ts to correct =-- 7i7 a m$ically v]ifiable disord] ( sex developm5t1 includ+-- 7,i7 #df1,,xx *romosomes ) virilization2 7,,ii7 #df1,,xy *romosomes ) und]virilization2 & 7,,iii7 bo? ov>ian & te/icul> tissue2 7ii7 sex *romosome /ructure1 sex /]oid hormone production1 or sex hormone action1 if det]m9$ to be abnormal by a physician ?r\gh g5etic or bio*emical te/+2 7iii7 infection1 disease1 injury1 or disord] caus$ or exac]bat$ by a previ\s proc$ure describ$ 9 p>agraph 7#a71 or a physical disord]1 physical injury1 or physical illness t w\ld1 z c]tifi$ by a physician1 place ! individual 9 imm95t dang] ( dea? or impairm5t ( a major bodily function unless ! proc$ure is p]=m$1 n includ+ proc$ures p]=m$ = ! alleviation ( m5tal di/ress2 or 7iv7 proc$ures to re/ore or recon/ruct ! body ( ! individual 9 ord] to correspond to ! individual's sex aft] "o or m previ\s proc$ures describ$ 9 p>agraph 7#a71 :i* may include ! removal ( a pseudo phallus or brea/ augm5tation4 7#c7 ,sex ,= purposes ( ?is subsection1 ! t]m sex means ei!r male or female1 z biologically det]m9$ & def9$ by subp>agraph 7,a7 & subp>agraph 7,b74 7,a7 ,female ,! t]m female means an individual :o naturally has1 _h1 w h1 or w\ld h1 b = a developm5tal or g5etic anomaly or hi/orical accid5t1 ! reproductive sy/em t at "s po9t produces1 transports1 & utilizes eggs = f]tilization4 7,b7 ,male ,! t]m male means an individual :o naturally has1 _h1 w h1 or w\ld h1 b = a developm5tal or g5etic anomaly or hi/orical accid5t1 ! reproductive sy/em t at "s po9t produces1 transports1 & utilizes sp]m = f]tilization4 4 #cjb4 ,prohibit+ ,f$]al ,m$icaid & ,,*ip fund+ = c]ta9 items & s]vices 7a7 ,m$icaid ,section #aijc7;i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7i77 is am5d$-- 7#a7 9 p>agraph 7#bf71 by /rik+ 2 or & ins]t+ a semicolon2 7#b7 9 p>agraph 7#bg71 by /rik+ ! p]iod at ! end & ins]t+ 2 or2 7#c7 by ins]t+ aft] p>agraph 7#bg7 ! foll[+ new p>agraph3 7#bh7 ) respect to any am\nt exp5d$ = specifi$ g5d] transition proc$ures 7z def9$ 9 section #aije7ll77 furni%$ to an individual enroll$ 9 a ,/ate plan 7or waiv] ( su* plan74 2 & 7#d7 9 ! flu% left matt] at ! end1 by /rik+ & 7#ah71 & ins]t+ 7#ah71 & 7#bh74 7b7 ,,*ip ,section #bajg7;e77#a77,o7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acig;gg7e77#a77,o771 z am5d$ by ?is ,act1 is fur!r am5d$ by /rik+ & 7#bb7 & ins]t+ 7#bb71 & 7#bh74 7c7 ,specifi$ g5d] transition proc$ures def9$ ,section #aije ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7ll7 ,specifi$ g5d] transition proc$ures 7#a7 ,9 g5]al ,= purposes ( section #aijc7;i77#bh71 except z provid$ 9 p>agraph 7#b7 1 ! t]m specifi$ g5d] transition proc$ure means1 ) respect to an individual1 any ( ! foll[+ :5 p]=m$ = ! purpose ( int5tionally *ang+ ! body ( su* individual 7includ+ by disrupt+ ! body's developm5t1 inhibit+ its natural functions1 or modify+ its appe>ance7 to no long] correspond to ! individual's sex3 7,a7 ,p]=m+ any surg]y1 includ+-- 7i7 ca/ration2 7ii7 /]ilization2 7iii7 or*iectomy2 7iv7 scrotopla/y2 7v7 vasectomy2 7vi7 tubal ligation2 7vii7 hy/]ectomy2 7viii7 oophorectomy2 7ix7 ov>iectomy2 7x7 metoidiopla/y2 7xi7 clitoropla/y2 7xii7 recon/ruction ( ! fix$ "p ( ! ure?ra ) or )\t a metoidiopla/y or a phallopla/y2 7xiii7 p5ectomy2 7xiv7 phallopla/y2 7xv7 vag9opla/y2 7xvi7 vag9ectomy2 7xvii7 vulvopla/y2 7xviii7 r$uction ?yro*ondropla/y2 7xix7 *ondrol>yngopla/y2 7xx7 ma/ectomy2 & 7xxi7 any pla/ic1 cosmetic1 or ae/hetic surg]y t fem9izes or mascul9izes ! facial or o!r body features ( an individual4 7,b7 ,any placem5t ( *e/ implants to create fem99e brea/s or any placem5t ( erection or te/icul> pro/hesis4 7,c7 ,any placem5t ( fat or artificial implants 9 ! gluteal region4 7,d7 ,adm9i/]+1 prescrib+1 or disp5s+ to an individual m$ications1 includ+-- 7i7 gonadotrop9-releas+ hormone 7,gn,r,h7 analogues or o!r pub]ty-block+ drugs to /op or delay normal pub]ty2 & 7ii7 te/o/]one1 e/rog51 or o!r &rog5s to an individual at doses t are supraphysiologic ?an w\ld normally be produc$ endog5\sly 9 a heal?y individual ( ! same age & sex4 7#b7 ,exception ,p>agraph 7#a7 %all n apply to ! foll[+ :5 furni%$ to an individual by a heal? c>e provid] if ! individual is a m9or ) ! cons5t ( su* individual's p>5t or legal gu>dian3 7,a7 ,pub]ty suppression or block+ prescription drugs = ! purpose ( normaliz+ pub]ty = an individual exp]i5c+ precoci\s pub]ty4 7,b7 ,m$ically necess>y proc$ures or treatm5ts to correct =-- 7i7 a m$ically v]ifiable disord] ( sex developm5t1 includ+-- 7,i7 #df1,,xx *romosomes ) virilization2 7,,ii7 #df1,,xy *romosomes ) und]virilization2 & 7,,iii7 bo? ov>ian & te/icul> tissue2 7ii7 sex *romosome /ructure1 sex /]oid hormone production1 or sex hormone action1 if det]m9$ to be abnormal by a physician ?r\gh g5etic or bio*emical te/+2 7iii7 infection1 disease1 injury1 or disord] caus$ or exac]bat$ by a previ\s proc$ure describ$ 9 p>agraph 7#a71 or a physical disord]1 physical injury1 or physical illness t w\ld1 z c]tifi$ by a physician1 place ! individual 9 dang] ( dea? or impairm5t ( a major bodily function unless ! proc$ure is p]=m$1 n includ+ proc$ures p]=m$ = ! alleviation ( m5tal di/ress2 or 7iv7 proc$ures to re/ore or recon/ruct ! body ( ! individual 9 ord] to correspond to ! individual's sex aft] "o or m previ\s proc$ures describ$ 9 p>agraph 7#a71 :i* may include ! removal ( a pseudo phallus or brea/ augm5tation4 7#c7 ,sex ,= purposes ( p>agraph 7#a71 ! t]m sex means ei!r male or female1 z biologically det]m9$ & def9$ 9 p>agraphs 7#d7 & 7#e71 respectively4 7#d7 ,female ,= purposes ( p>agraph 7#c71 ! t]m female means an individual :o naturally has1 _h1 w h1 or w\ld h1 b = a developm5tal or g5etic anomaly or hi/orical accid5t1 ! reproductive sy/em t at "s po9t produces1 transports1 & utilizes eggs = f]tilization4 7#e7 ,male ,= purposes ( p>agraph 7#c71 ! t]m male means an individual :o naturally has1 _h1 w h1 or w\ld h1 b = a developm5tal or g5etic anomaly or hi/orical accid5t1 ! reproductive sy/em t at "s po9t produces1 transports1 & utilizes sp]m = f]tilization4 4 ,decemb] #h1 #bjbe,read ! second "t & plac$ on ! cal5d>