(1) the annual premium for the HAPI plan 
under which the individual is a covered individual; or 
(2) the weighted average of the premium for 
HAPI plans of the same class of coverage (as de-
scribed in section 111(d)(1)) as the individual’s in 
the applicable coverage area. 
(d) CHANGE IN STATUS NOTIFICATION.— 
(1) IN GENERAL.—If an individual’s modified 
adjusted income changes such that the individual be-
comes eligible or ineligible for a subsidy under this 
section, the individual shall report that change to 
the HHA of the individual’s State of residence not 
more than 60 days after the change takes effect. If 
an individual reports the change within 60 days 
under the preceding sentence, the individual’s HAPI 
plan coverage shall be deemed credible coverage for 
the purposes of maintaining coverage for preexisting 
conditions. 
(2) ADJUSTMENT.—The HHA shall adjust the 
premium subsidy of such individual to take effect on 
the first month after the date of the notification 
under paragraph (1) for which the next premium 
payment would be due from the individual. 
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(e) CATASTROPHIC EVENT.—A State may develop 
mechanisms to ensure that covered individuals do not have 
a break in coverage due to a catastrophic financial event. 
SEC. 122. ELIGIBILITY FOR PERSONAL RESPONSIBILITY 
CONTRIBUTION SUBSIDIES. 
(a) FULL SUBSIDY.—To meet the eligibility require-
ments under subtitle B for an HHA, for any taxable year, 
in the case of a covered individual who is determined to 
have a modified adjusted gross income that is below 100 
percent of the poverty line as applicable to a family of 
the size involved, an HHA shall provide to such an indi-
vidual a subsidy equal to the full amount of any personal 
responsibility contributions applicable to such individual. 
(b) PARTIAL SUBSIDY.—To meet the eligibility re-
quirements under subtitle B for an HHA, for any taxable 
year, in the case of a covered individual who is determined 
to have a modified adjusted gross income that is at or 
above 100 percent of the poverty line as applicable to a 
family of the size involved, an HHA may provide to such 
an individual a subsidy equal to the part of the amount 
of any personal responsibility contributions applicable to 
such individual. 
SEC. 123. DEFINITIONS AND SPECIAL RULES. 
(a) DETERMINATION
OF
MODIFIED
ADJUSTED 
GROSS INCOME.— 
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(1) IN GENERAL.—In this subtitle, the term 
‘‘modified adjusted gross income’’ means adjusted 
gross income (as defined in section 62 of the Inter-
nal Revenue Code of 1986)— 
(A) determined without regard to sections 
86, 135, 137, 199, 221, 222, 911, 931, and 
933 of such Code; and 
(B) increased by— 
(i) the amount of interest received or 
accrued during the taxable year which is 
exempt from tax under such Code; and 
(ii) the amount of any social security 
benefits (as defined in section 86(d) of 
such Code) received or accrued during the 
taxable year. 
(2) TAXABLE YEAR TO BE USED TO DETER-
MINE MODIFIED ADJUSTED GROSS INCOME.—In ap-
plying this subtitle to determine an individual’s an-
nual premiums, the covered individual’s modified ad-
justed gross income shall be such income determined 
using the individual’s most recent income tax return 
or other information furnished to the Secretary by 
such individual, as the Secretary may require. 
(b) POVERTY LINE.—In this subtitle, the term ‘‘pov-
erty line’’ has the meaning given such term in section 
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673(2) of the Community Health Services Block Grant 
Act (42 U.S.C. 9902(2)), including any revision required 
by such section. 
(c) OTHER PROCEDURES TO DETERMINE SUB-
SIDIES.—The Secretary shall promulgate regulations to be 
used by HHAs to calculate the premium subsidies under 
section 121 and personal responsibility subsidies under 
section 122 for individuals whose modified adjusted gross 
income described in subsection (a)(2) is significantly lower 
than the modified adjusted gross income of the year in-
volved. 
(d) SPECIAL RULE
FOR UNLAWFULLY PRESENT 
ALIENS.—A health insurance issuer shall remit to the 
Federal Government any funding, including any subsidy 
payments, received by such issuer from the Federal Gov-
ernment on behalf of any adult alien who is unlawfully 
present in the United States. 
(e) SPECIAL RULE FOR ALIENS.—The Secretary of 
Homeland Security may not extend or renew an alien’s 
eligibility for status in the United States or adjust the sta-
tus of an alien in the United States if the alien owes— 
(1) a premium payment for a HAPI plan that 
is past due; or 
(2) a penalty incurred for failing to pay such a 
premium. 
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(f) NO DISCHARGE IN BANKRUPTCY.—In the case of 
any bankruptcy filed by or on behalf of any person after 
the date that is 4 years after the date of enactment of 
this Act, under title 11, United States Code, any penalty 
imposed with respect to such person for failure to pay a 
HAPI plan premium shall not be subject to discharge 
under such title. 
Subtitle D—Wellness Programs 
SEC. 131. REQUIREMENTS FOR WELLNESS PROGRAMS. 
(a) DEFINITION.—In this Act, the term ‘‘wellness 
program’’ means a program that consists of a combination 
of activities that are designed to increase awareness, as-
sess risks, educate, and promote voluntary behavior 
change to improve the health of an individual, modify his 
or her consumer health behavior, enhance his or her per-
sonal well-being and productivity, and prevent illness and 
injury. 
(b) DISCOUNTS.— 
(1) ELIGIBILITY.—With respect to a HAPI 
plan that is offered in a State that permits premium 
discounts for enrollees who participate in a wellness 
program, to be eligible to receive such a discount, 
the administrator of the wellness program, on behalf 
of the enrollee, shall certify in writing to the plan 
that— 
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(A)(i) the enrollee is participating in an 
approved wellness program; or 
(ii) the dependent child of the enrollee is 
participating in an approved wellness program; 
and 
(B) the wellness program meets the re-
quirements of this subsection. 
(2) 
REQUIREMENTS.—A 
wellness 
program 
meets the requirements of this paragraph if such 
program— 
(A) is reasonably designed (as determined 
by the HAPI plan) to promote good health and 
prevent disease for program participants; 
(B) has been approved by the HAPI plan 
for purposes of applying participation discounts; 
(C) is offered to all enrollees in a HAPI 
plan regardless of health status; 
(D) permits any enrollee for whom it is un-
reasonably difficult to meet the initial program 
standard for participation due to a medical con-
dition (or for whom it is medically inadvisable 
to attempt) an opportunity to meet a reason-
able alternative participation standard— 
(i)(I) that is developed prior to enroll-
ment of the enrollee; or 
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(II) that is developed in consultation 
with the enrollee after enrollment of the 
enrollee, after a determination has been 
made that the enrollee cannot safely meet 
the program participation standard; and 
(ii) the availability of which is dis-
closed in the original documents relating to 
participation in the program; 
(E) applies procedures for determining 
whether an enrollee is participating in a mean-
ingful manner in the program, including proce-
dures to determine if such participation is re-
sulting in lifestyle changes that are indicative of 
an improved health outcome or outcomes; and 
(F) meets any other requirements imposed 
by the HAPI plan. 
(3) RELATION TO HEALTH STATUS.—Participa-
tion in a wellness program may not be used by a 
HAPI plan to make rate or discount determinations 
with respect to the health status of an enrollee. 
(4) AVAILABILITY OF DISCOUNTS.— 
(A) 
OFFERING
OF
ENROLLMENT.—A 
HAPI plan shall provide enrollees with the op-
portunity to participate in a wellness program 
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(for purposes of qualifying for premium dis-
counts) at least once each year. 
(B) 
DETERMINATIONS.—Determinations 
with respect to the successful participation by 
an enrollee in a wellness program for purposes 
of qualifying for discounts shall be made by the 
HAPI plan based on a retrospective review of 
the scope of activities of the enrollee under the 
program. The HAPI plan may require a min-
imum level of successful participation in such a 
program prior to applying any premium dis-
count. 
(C) PARTICIPATION
IN
MULTIPLE
PRO-
GRAMS.—An enrollee may participate in mul-
tiple wellness programs to reach the maximum 
premium discount permitted by the HAPI plan 
under applicable State law. 
(5) PERSONAL RESPONSIBILITY CONTRIBUTION 
DISCOUNT.—A HAPI plan may elect to provide dis-
counts in the amount of the personal responsibility 
contribution that is required of an enrollee if the en-
rollee participates in an approved wellness program. 
(c) EMPLOYER INCENTIVE
FOR WELLNESS PRO-
GRAMS.—For provisions relating to employers deducting 
the costs of offering wellness programs or worksite health 
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centers see section 162(l) of the Internal Revenue Code 
of 1986. 
TITLE II—HEALTHY START FOR 
CHILDREN 
Subtitle A—Benefits and Eligibility 
SEC. 201. GENERAL GOAL AND AUTHORIZATION OF APPRO-
PRIATIONS FOR HAPI PLAN COVERAGE FOR 
CHILDREN. 
(a) GENERAL GOAL.—It is the general goal of this 
Act to provide essential, good quality, affordable, and pre-
vention-oriented health care coverage for all children in 
the United States. 
(b) AUTHORIZATION OF APPROPRIATIONS.—There is 
authorized to be appropriated, such sums as may be nec-
essary for each fiscal year to enable the Secretary to pro-
vide assistance to States to enable such States to ensure 
that each child who is a member of a family with a modi-
fied adjusted gross income that is below 300 percent of 
the poverty line as applicable to a family of the size in-
volved, who is not otherwise eligible for coverage as a de-
pendent under a HAPI plan maintained by his or her par-
ents, is covered under a HAPI plan provided through the 
State HHA. 
(c) POLICIES
AND PROCEDURES.—The Secretary 
shall develop policies and procedures to be applied by the 
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States to identify children described in subsection (a) and 
to provide such children with coverage under a HAPI plan. 
States shall determine, in consultation with health insur-
ance issuers, a separate class of coverage to assure afford-
able child coverage. 
(d) DEFINITION.—In this title, the term ‘‘child’’ 
means an individual who is under the age of 19 years or, 
in the case of an individual in foster care, under the age 
of 21 years. 
SEC. 202. COORDINATION OF SUPPLEMENTAL COVERAGE 
UNDER THE MEDICAID PROGRAM TO HAPI 
PLAN COVERAGE FOR CHILDREN. 
(a) ASSURANCE OF SUPPLEMENTAL COVERAGE.— 
The Secretary shall provide guidance to States and health 
insurance issuers that ensures that, after December 31 of 
the last calendar year ending before the first calendar year 
in which coverage under a HAPI plan begins, any child 
covered under a HAPI plan provided through the State 
HHA continues to receive medical assistance under State 
Medicaid plans in a manner that— 
(1) is provided in coordination with, and as a 
supplement to, the coverage provided the child under 
the HAPI plan in which the child is enrolled; 
(2) does not supplant the child’s coverage under 
a HAPI plan; and 
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