,,ii  #aai? ,,congress  #b;d ,session   
,s4 #dhhf  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,june #bd1 #bjbf,ms4   
,blunt ,ro*e/] 7= h]self1 ,mr4 ,wyd51   
,mr4 ,s*um]1 ,mr4 ,m]kley1 ,mr4 ,lujn1  
,mr4 ,m>key1 ,ms4 ,w>r51 ,mr4 ,re$1 ,ms4
 ,duckwor?1 ,mr4 ,wel*1 ,mr4 ,book]1    
,mrs4 ,gillibr&1 ,mr4 ,padilla1 ,mr4    
,van ,holl51 & ,mrs4 ,murray7 introduc$ 
! foll[+ bill2 :i* 0 read twice & ref]r$
 to ! ,committee on ,f9ance  ,a ,,bill  
,to am5d title ,,xviii ( ! ,social      
,security ,act to protect aga9/ high    
out-(-pocket exp5ditures = ,m$ic>e      
fee-=-s]vice b5efits1 & to am5d titles  
,,xviii & ,,xix ( ! ,social ,security   
,act to enhance programs t protect      
l[-income ,m$ic>e b5efici>ies4  #a4     
,%ort title ,?is ,act may be cit$ z !   
,m$ic>e ,co/ ,cap ,act ( #bjbf4  #b4    
,protection aga9/ high out-(-pocket     
exp5ditures = ,m$ic>e fee-=-s]vice      
b5efits  7a7 ,9 g5]al ,title ,,xviii ( !
 ,social ,security ,act 7#db ,u4,s4,c4  
#acie et seq47 is am5d$ by add+ at ! end

 ! foll[+ new section3  #ahii;,d4       
,protection aga9/ high out-(-pocket     
exp5ditures  7a7 ,9 g5]al ,not)/&+ any  
o!r provision ( ?is title1 9 ! case ( an
 applicable individual 7z def9$ 9       
subsection 7c771 if ! am\nt ( !         
out-(-pocket co/-%>+ 7z def9$ 9         
subsection 7d77 incurr$ by su*          
individual = a ye> 7beg9n+ ) #bjbh7     
equals or exce$s ! annual out-(-pocket  
limit "u subsection 7b7 = t ye>1 !      
individual %all n be responsible =      
additional out-(-pocket co/-%>+ incurr$ 
dur+ t ye>4  7b7 ,annual out-(-,pocket  
limit  7#a7 ,9 g5]al ,! am\nt ( ! annual
 out-(-pocket limit "u ?is subsection   
%all be-- 7,a7 = #bjbh1 #e1jjj2 or  7,b7
 = a subsequ5t ye>1 ! am\nt specifi$ 9  
?is subsection = ! prec$+ ye> increas$  
by ! annual p]c5tage increase 9 av]age  
p] capita aggregate exp5ditures "u p>ts 
,a & ,b1 z det]m9$ by ! ,secret>y = !   
#ab-mon? p]iod end+ 9 ,july ( ! previ\s 
ye> us+ su* me?ods z ! ,secret>y %all   
specify4  7#b7 ,r\nd+ ,if any am\nt     

det]m9$ "u p>agraph 7#a77;,b7 is n a    
multiple ( #e1 su* am\nt %all be r\nd$  
to ! ne>e/ multiple ( #e4  7c7          
,applicable individual def9$ ,9 ?is     
section1 ! t]m applicable individual    
means an individual :o is entitl$ to1 or
 enroll$ =1 b5efits "u "p ,a or enroll$ 
9 "p ,b4  7d7 ,out-(-,pocket co/-,%>+   
def9$  7#a7 ,9 g5]al ,subject to        
p>agraphs 7#b7 & 7#c71 9 ?is section1 ! 
t]m out-(-pocket co/-%>+ means1 )       
respect to an applicable individual1 !  
am\nt ( ! exp5ses incurr$ by !          
individual t are attributable to        
co9surance1 d$uctible1 copaym5t1 or o!r 
co/-%>+ o!rwise applicable "u "p ,a or  
,b4  7#b7 ,c]ta9 co/s n includ$  7,a7   
,non-cov]$ items & s]vices ,exp5ses     
incurr$ = items & s]vices :i* are n     
cov]$ "u "p ,a or ,b %all n be consid]$ 
incurr$ exp5ses = purposes ( det]m9+    
out-(-pocket co/-%>+ "u p>agraph 7#a74  
7,b7 ,items & s]vices n furni%$ on an   
assignm5t-relat$ basis ,if an item or   
s]vice is furni%$ to an individual "u   

?is title & is n furni%$ on an          
assignm5t-relat$ basis1 any additional  
exp5ses ! individual incurs above !     
am\nt ! individual w\ld h incurr$ if !  
item or s]vice 0 furni%$ on an          
assignm5t-relat$ basis %all n be        
consid]$ incurr$ exp5ses = purposes (   
det]m9+ out-(-pocket co/-%>+ "u p>agraph
 7#a74  7#c7 ,application ,= purposes ( 
p>agraph 7#a71 ! ,secret>y %all consid] 
exp5ses to be incurr$ by ! individual   
reg>dless ( :e!r su* co/s are reimburs$ 
?r\gh insurance or o!rwise1 a gr\p heal?
 plan1 or o!r ?ird-p>ty paym5t          
arrangem5t4  7e7 ,ann\ncem5t ,n lat] ?an
 ! fir/ ,monday 9 ,april ( ea* ye>      
7beg9n+ ) #bjbg71 ! ,secret>y %all      
det]m9e1 & %all ann\nce 79 a mann]      
int5d$ to provide notice to int]e/$     
p>ties71 ! annual out-(-pocket limit "u 
?is section = ! succe$+ ye>4  7f7       
,implem5tation ,! ,secret>y %all e/abli%
 proc$ures to c>ry out ?is section1     
includ+ proc$ures-- 7#a7 to track !     
am\nt ( out-(-pocket co/-%>+ incurr$ by 

applicable individuals = items & s]vices
 cov]$ "u ?is title dur+ a ye>2 &  7#b7 
provide notice to ! applicable          
individual & provid]s ( s]vices &       
suppli]s :o furni% items & s]vices to ! 
applicable individual :5 ! applicable   
individual has incurr$ exp5ses t exce$ !
 annual out-(-pocket limit "u subsection
 7b7 = ! ye>4  7g7 ,paym5t ,= provisions
 relat+ to paym5t = items & s]vices     
furni%$ to an applicable individual once
 ! annual out-(-pocket limit has be5    
met1 see sections #ahac7;c7 &           
#ahcc7;ee74  4  7b7 ,con=m+ am5dm5ts    
7#a7 ,"p ,a ,section #ahac ( ! ,social  
,security ,act 7#db ,u4,s4,c4 #acie;e7  
is am5d$ by add+ at ! end ! foll[+ new  
subsection3  7c7 7#a7 ,not)/&+          
subsections 7a7 & 7b71 if ! am\nt ( !   
out-(-pocket co/-%>+ = an applicable    
individual = a ye> 7beg9n+ ) #bjbh7     
equals or exce$s ! annual out-(-pocket  
limit "u section #ahii;,d7b7 = t ye>1   
paym5t "u ?is "p ) respect to any       
additional incurr$ exp5ses = items or   

s]vices furni%$ to ! applicable         
individual 9 ! cal5d> ye> %all be made z
 if any r$uction 9 ! am\nt payable = su*
 items or s]vices "u subsection 7a7 due 
to any d$uctible or co9surance t w\ld 7b
 = ! application ( section #ahii;,d7    
o!rwise be applicable no long] appli$4  
7#b7 ,9 ?is subsection1 ! t]ms          
applicable individual & out-(-pocket co/
 %>+ h ! mean+ giv5 ^? t]ms 9 section   
#ahii;,d4  4  7#b7 ,"p ,b  7,a7 ,paym5t 
,section #ahcc ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciel7 is am5d$--  
7i7 by add+ at ! end ! foll[+ new       
subsection3  7ee7 7#a7 ,not)/&+         
subsections 7a7 & 7b71 if ! am\nt ( !   
out-(-pocket co/-%>+ = an applicable    
individual = a ye> 7beg9n+ ) #bjbh7     
equals or exce$s ! annual out-(-pocket  
limit "u section #ahii;,d7b7 = t ye>1   
paym5t "u ?is "p ) respect to any       
additional incurr$ exp5ses = items or   
s]vices furni%$ to ! applicable         
individual 9 ! cal5d> ye> %all be made z
 if-- 7,a7 ! d$uctible "u subsection 7b7

 no long] appli$2  7,b7 ! d$uction      
describ$ 9 ! second s5t5ce ( subsection 
7b7 7relat+ to blood7 no long] appli$2 &
  7,c7 #ajj p]c5t & #j p]c5t 7 sub/itut$
 = #hj p]c5t & #bj p]c5t1 respectively1 
ea* place ei!r appe>s 9 subsection 7a71 
9 subsection 7i77#b71 9 section         
#ahce7;b77#b71 & 9 subsections 7b77#b7 &
 7b77#c7 ( section #ahha4  7#b7 ,9 ?is  
subsection1 ! t]ms applicable individual
 & out-(-pocket co/ %>+ h ! mean+ giv5  
^? t]ms 9 section #ahii;,d4  2 &  7ii7 9
 subsections 7c7 & 7g71 by /rik+ 7a7 &  
7b7 ea* place x appe>s & ins]t+ 7a71    
7b71 & 7ee74  7,b7 ,limitation on *>ges 
:5 annual limit rea*$ ,section          
#ahff7;a77#b77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acie;cc7a77#b77;,a77 is am5d$ by add+  
at ! end ! foll[+ new s5t5ce3 ,a provid]
 ( s]vices may n impose a *>ge "u ! fir/
 s5t5ce ( ?is subp>agraph = s]vices =   
:i* paym5t is made to ! provid] pursuant
 to section #ahcc7;ee7 7relat+ to       
protection aga9/ high out-(-pocket      

exp5ses744  7,c7 ,b5efici>y protections 
,section #ahdb7;b77#c7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acieu7b77#c77 is am5d$-- 7i7 9         
subp>agraph 7,l71 by /rik+ ! p]iod at ! 
end & ins]t+ 2 &2 &  7ii7 by ins]t+ aft]
 subp>agraph 7,l7 ! foll[+ new          
subp>agraph3  7,m7 if x makes           
det]m9ations or paym5ts ) respect to    
items & s]vices furni%$ by a physician =
 :i* paym5t is made pursuant to section 
#ahcc7;ee7 b n on an assignm5t-relat$   
basis1 provide to ! physician a notice  
t-- 7i7 /ates t ! individual provid$ !  
s]vice has rea*$ ! annual out-(-pocket  
limit "u section #ahii;,d7b7 = ! ye>1 & 
7ii7 enc\rages ! physician n to *>ge !  
individual am\nts 9 excess ( !          
reasonable *>ge recogniz$ "u ?is section
 & to accept paym5t on an               
assignm5t-relat$ basis = physicians'    
s]vices furni%$ ! individual dur+ !     
rema9d] ( ! ye>4  4  #c4 ,enhancem5ts to
 programs t protect l[-income ,m$ic>e   
b5efici>ies  7a7 ,elim9ation ( res\rce  

/&>d = eligibility & enrollm5t          
det]m9ations  7#a7 ,,lis ,section       
#ahfj;,d-#ad7;a77#c77;,a77iii7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#aad7;a77#c77;,a77iii77 is am5d$ 
by /rik+ meets & ins]t+ ) respect to a  
plan ye> beg9n+ be=e ,janu>y #a1 #bjbh1 
meets4  7#b7 ,,msp ,section             
#aije7p77#a77;,c7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #acif;d7p77#a77;,c77
 is am5d$ by /rik+ ^: res\rces & ins]t+ 
prior to ,janu>y #a1 #bjbh1 ^: res\rces4
  7b7 ,align+ eligibility crit]ia across
 ,,msp & ,,lis  7#a7 ,,lis ,section     
#ahfj;,d-#ad7;a7 ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #aciew-#aad7;a77 is 
am5d$-- 7,a7 9 p>agraph 7#a71 9 ! matt] 
prec$+ subp>agraph 7,a71 by ins]t+ or1 )
 respect to a plan ye> beg9n+ on or aft]
 ,janu>y #a1 #bjbh1 #bjj p]c5t aft] #aej
 p]c5t2 &  7,b7 9 p>agraph              
7#c77;,a77ii71 by ins]t+ 7or1 ) respect 
to a plan ye> beg9n+ on or aft] ,janu>y 
#a1 #bjbh1 #bjj p]c5t aft] #aej p]c5t4  
7#b7 ,,msp  7,a7 ,9 g5]al ,section      

#aije7p7 ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #acif;d7p77 is am5d$-- 7i7 9 
p>agraph 7#a77;,b71 by ins]t+ 1 except  
t1 beg9n+ ) ,janu>y #a1 #bjbh1 !        
me?odology us$ 9 det]m9+ income         
eligibility "u ?is subsection %all be no
 m re/rictive ?an ! me?odology us$ by ! 
,social ,security ,adm9i/ration 9 mak+  
income det]m9ations "u section          
#ahfj;,d-#ad7;a77#c77;,c7 aft] income   
program2 &  7ii7 9 p>agraph 7#b7-- 7,i7 
9 subp>agraph 7,a7-- 7aa7 by /rik+ %all 
be at lea/ & ins]t+ 8%all be--  7i7     
prior to ,janu>y #a1 #bjbh1 at lea/  2  
7bb7 9 clause 7i71 z add$ by item 7aa71 
by /rik+ ! p]iod & ins]t+ 2 &2 &  7cc7  
by add+ at ! end ! foll[+ new clause3   
7ii7 on or aft] ,janu>y #a1 #bjbh1 #bjj 
p]c5t ( ! pov]ty l9e applicable to a    
family ( ! size involv$4  2 &  7,,ii7 by
 add+ at ! end ! foll[+ new subp>agraph3
  7,e7 ,) respect to eligibility =      
m$ical assi/ance on or aft] ,janu>y #a1 
#bjbh1 9 ?is p>agraph1 ! def9ition ( !  
t]m family ( ! size involv$ %all be no m

 re/rictive ?an ! def9ition ( t t]m =   
purposes ( section #ahfj;,d-#ad4  4     
7,b7 ,con=m+ am5dm5ts ,title ,,xix ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acif et seq47 is am5d$--  7i7 9 section
 #aijb7;a77#aj77;,e7-- 7,i7 9 clause    
7iii71 by /rik+ = mak+ & ins]t+ prior to
 ,janu>y #a1 #bjbh1 = mak+2 &  7,,ii7 9 
clause 7iv71 by /rik+ subject to &      
ins]t+ prior to ,janu>y #a1 #bjbh1      
subject to2 &  7ii7 9 section #aicc7;a71
 by /rik+ ,a ,/ate plan & ins]t+ ,prior 
to ,janu>y #a1 #bjbh1 a ,/ate plan4     
7#c7 ,bidirectional eligibility deem+   
betwe5 ,,msp & ,,lis  7,a7 ,,lis        
,section #ahfj;,d-#ad7;a77#c77;,b77v7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#aciew-#aad7;a77#c77;,b77v77 is am5d$ to
 read z foll[s3  7v7 ,treatm5t ( m$icaid
 b5efici>ies ,subject to subp>agraph    
7,f71 ! ,secret>y %all treat a "p ,d    
eligible individual z a subsidy eligible
 individual describ$ 9 p>agraph 7#a7 if 
!y are-- 7,i7 a full-b5efit dual        
eligible individual 7z def9$ 9 section  

#aice7;c77#f772  7,,ii7 a recipi5t (    
supplem5tal security income b5efits "u  
title ,,xvi2 or  7,,iii7 det]m9$ =      
purposes ( ! ,/ate plan "u title ,,xix  
to be eligible = m$ical assi/ance "u    
section #aijb7;a77#aj77;,e77i74  4  7,b7
 ,,msp ,section #aije7p7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acif;d7p77 is am5d$ by add+ at ! end ! 
foll[+ new p>agraph3  7#g7 ,beg9n+      
,janu>y #a1 #bjbh1 a ,/ate %all provide 
t an individual describ$ 9 p>agraph     
7#a77;,a7 :o is a subsidy eligible      
individual describ$ 9 section           
#ahfj;,d-#ad7;a77#c7 %all be treat$ z a 
qualifi$ m$ic>e b5efici>y describ$ 9    
p>agraph 7#a74  4  7,c7 ,treatm5t (     
leads data  7i7 ,transmittal ,section   
#aadd7;c77#c7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acbj;b-#ad7;c77#c77 is 
am5d$ by /rik+ :i* transmittal %all     
initiate an application ( ! individual =
 b5efits "u ! ,m$ic>e ,sav+s ,program ) 
! ,/ate ,m$icaid ag5cy & ins]t+ :i* !   
,/ate ,m$icaid ag5cy %all treat z an    

application ( ! individual = b5efits "u 
! ,m$ic>e ,sav+s ,program consi/5t )    
section #aice7;a77#d74  7ii7            
,consid]ation by ,/ates ,section        
#aice7;a77#d7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acifu-#e7;a77#d77 is   
am5d$ to read z foll[s3  7#d7           
,consid]ation ( data transmitt$ by !    
,social ,security adm9i/ration =        
purposes ( m$ic>e sav+s program  7,a7 ,9
 g5]al ,! ,/ate %all accept data        
transmitt$ "u section #aadd7;c77#c7 &-- 
7i7 9 ! case ( an individual :o is a    
subsidy eligible individual describ$ 9  
section #ahfj;,d-#ad7;a77#c71 promptly  
treat su* individual z a qualifi$ m$ic>e
 b5efici>y describ$ 9 #aije7p77#a72 &   
7ii7 9 ! case ( any o!r individual :o is
 likely to be a qualifi$ m$ic>e         
b5efici>y1 z det]m9$ by ! ,secret>y1 act
 on su* data 9 ! same mann] & 9         
accordance ) ! same deadl9es z if ! data
 con/itut$ an initiation ( an           
application = b5efits "u ! ,m$ic>e      
,sav+s ,program 7z def9$ = purposes (   

section #aadd7;c77#c77 t _h be5 submitt$
 directly by ! applicant4  7,b7 ,date ( 
application ,= purposes ( subp>agraph   
7,a77ii71 ! date ( ! individual's       
application = ! l[ income subsidy       
program f :i* ! data h be5 d]iv$ %all   
con/itute ! date ( fil+ ( su*           
application = b5efits "u ! ,m$ic>e      
,sav+s ,program4  4  7,d7 ,effective    
date ,! am5dm5ts made by ?is p>agraph   
%all take effect on ,janu>y #a1 #bjbh4