293 
Federal agency, as applicable, shall issue guidance with 
respect to implementing the amendments made by this 
section. 
(k) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on the date of enactment of 
this Act and shall apply to services furnished on or after 
the date that is 180 days after the date on which any guid-
ance is issued pursuant to subsection (i). 
SEC. 4004. IMPROVE AFFORDABILITY AND REDUCE PRE-
MIUM COSTS OF HEALTH INSURANCE FOR 
CONSUMERS. 
(a) IN GENERAL.—Section 36B(b)(3)(A) of the In-
ternal Revenue Code of 1986 is amended to read as fol-
lows: 
‘‘(A) APPLICABLE PERCENTAGE.—The ap-
plicable percentage for any taxable year shall be 
the percentage such that the applicable percent-
age for any taxpayer whose household income is 
within an income tier specified in the following 
table shall increase, on a sliding scale in a lin-
ear manner, from the initial premium percent-
age to the final premium percentage specified in 
such table for such income tier: 
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‘‘In the case of household income (expressed as a 
percent of poverty line) within the following in-
come tier: 
The initial 
premium 
percentage 
is— 
The final 
premium 
percentage 
is— 
Up to 150 percent ..................................................
0.0 
0.0
150 percent up to 200 percent ...............................
0.0 
3.0
200 percent up to 250 percent ...............................
3.0 
4.0
250 percent up to 300 percent ...............................
4.0 
6.0
300 percent up to 400 percent ...............................
6.0 
8.5
400 percent and higher ..........................................
8.5 
8.5.’’. 
(b) 
CONFORMING
AMENDMENT.—Section 
36B(c)(1)(A) of the Internal Revenue Code of 1986 is 
amended by striking ‘‘but does not exceed 400 percent’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2021. 
SEC. 4005. REMOVING CITIZENSHIP AND IMMIGRATION 
BARRIERS 
TO 
ACCESS 
TO 
AFFORDABLE 
HEALTH CARE UNDER THE ACA. 
(a) IN GENERAL.— 
(1) PREMIUM TAX CREDITS.—Section 36B of 
the Internal Revenue Code of 1986 is amended— 
(A) in subsection (c)(1)(B)— 
(i) by amending the heading to read 
as follows: ‘‘SPECIAL RULE FOR CERTAIN 
INDIVIDUALS
INELIGIBLE
FOR
MEDICAID 
DUE TO STATUS’’; and 
(ii) in clause (ii), to read as follows: 
‘‘(ii) the taxpayer is a noncitizen who 
is not eligible for the Medicaid program 
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295 
under title XIX of the Social Security Act 
by reason of the individual’s immigration 
status,’’; and 
(B) by striking subsection (e). 
(2) COST-SHARING REDUCTIONS.—Section 1402 
of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18071) is amended— 
(A) by striking subsection (e); and 
(B) by redesignating subsection (f) as sub-
section (e). 
(3) BASIC
HEALTH
PROGRAM
ELIGIBILITY.— 
Section 1331(e)(1)(B) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18051(e)(1)(B)) is 
amended by striking ‘‘lawfully present in the United 
States,’’. 
(4) RESTRICTIONS ON FEDERAL PAYMENTS.— 
Section 1412 of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18082) is amended— 
(A) by striking subsection (d); and 
(B) by redesignating subsection (e) as sub-
section (d). 
(5) REQUIREMENT TO MAINTAIN MINIMUM ES-
SENTIAL COVERAGE.—Section 5000A(d) of the In-
ternal Revenue Code of 1986 is amended— 
(A) by striking paragraph (3); and 
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296 
(B) by redesignating paragraph (4) as 
paragraph (3). 
(b) CONFORMING AMENDMENTS.— 
(1) ESTABLISHMENT
OF
PROGRAM.—Section 
1411(a) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18081(a)) is amended— 
(A) by striking paragraph (1); and 
(B) by redesignating paragraphs (2), (3), 
and (4) as paragraphs (1), (2), and (3), respec-
tively. 
(2) QUALIFIED INDIVIDUALS.—Section 1312(f) 
of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18032(f)) is amended— 
(A) in the heading, by striking ‘‘; ACCESS 
LIMITED
TO CITIZENS
AND LAWFUL RESI-
DENTS’’; and 
(B) by striking paragraph (3). 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to years, plan years, and taxable 
years, as applicable, beginning after December 31, 2022. 
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297 
SEC. 4006. REMOVING BARRIERS TO ACCESS TO AFFORD-
ABLE HEALTH CARE FOR LAWFULLY RESID-
ING IMMIGRANTS UNDER MEDICAID AND 
CHIP. 
(a) MEDICAID.—Section 1903(v)(4) of the Social Se-
curity Act (42 U.S.C. 1396b(v)(4)) is amended— 
(1) by amending subparagraph (A) to read as 
follows: 
‘‘(A) Notwithstanding sections 401(a), 402(b), 
403, and 421 of the Personal Responsibility and 
Work Opportunity Reconciliation Act of 1996, a 
State shall provide medical assistance under this 
title to individuals who are lawfully residing in the 
United States (including individuals described in 
paragraph (1), battered individuals described in sec-
tion 431(c) of such Act, and individuals with an ap-
proved or pending application for deferred action or 
other federally authorized presence), if they other-
wise meet the eligibility requirements for medical as-
sistance under the State plan approved under this 
title (other than the requirement of the receipt of 
aid or assistance under title IV, supplemental secu-
rity income benefits under title XVI, or a State sup-
plementary payment).’’; 
(2) by amending subparagraph (B) to read as 
follows: 
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298 
‘‘(B) No debt shall accrue under an affidavit of 
support against any sponsor of an individual pro-
vided medical assistance under subparagraph (A) on 
the basis of provision of assistance to such individual 
and the cost of such assistance shall not be consid-
ered as an unreimbursed cost.’’; and 
(3) in subparagraph (C)— 
(A) by striking ‘‘an election by the State 
under subparagraph (A)’’ and inserting ‘‘the 
application of subparagraph (A)’’; 
(B) by inserting ‘‘or be lawfully present’’ 
after ‘‘lawfully reside’’; and 
(C) by inserting ‘‘or present’’ after ‘‘law-
fully residing’’ each place it appears. 
(b) CHIP.—Subparagraph (O) of section 2107(e)(1) 
of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is 
amended to read as follows: 
‘‘(O) Paragraph (4) of section 1903(v) (re-
lating to lawfully residing individuals).’’. 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
shall take effect on the date of enactment of this Act 
and shall apply to services furnished on or after the 
date that is 90 days after such date of enactment. 
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299 
(2) EXCEPTION
IF
STATE
LEGISLATION
RE-
QUIRED.—In the case of a State plan for medical as-
sistance under title XIX, or a State child health plan 
under title XXI, of the Social Security Act which the 
Secretary of Health and Human Services determines 
requires State legislation (other than legislation ap-
propriating funds) in order for the plan to meet the 
additional requirements imposed by the amendments 
made by this section, the respective State plan shall 
not be regarded as failing to comply with the re-
quirements of such title solely on the basis of its 
failure to meet these additional requirements before 
the first day of the first calendar quarter beginning 
after the close of the first regular session of the 
State legislature that begins after the date of enact-
ment of this Act. For purposes of the previous sen-
tence, in the case of a State that has a 2-year legis-
lative session, each year of such session shall be 
deemed to be a separate regular session of the State 
legislature. 
(d) PRESERVING COVERAGE.— 
(1) IN GENERAL.—Nothing in this section, in-
cluding the amendments made by this section, shall 
prevent lawfully present noncitizens who are ineli-
gible for full benefits under the Medicaid program 
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300 
under title XIX of the Social Security Act from se-
curing a credit for which such lawfully present non-
citizens would be eligible under section 36B(c)(1)(B) 
of the Internal Revenue Code of 1986 and under the 
Medicaid provisions for lawfully present noncitizens, 
as in effect on the date prior to the date of enact-
ment of this Act. 
(2) DEFINITION.—For purposes of paragraph 
(1), the term ‘‘full benefits’’ means, with respect to 
an individual and State, medical assistance for all 
services covered under the State plan under title 
XIX of the Social Security Act that is not less in 
amount, duration, or scope, or is determined by the 
Secretary of Health and Human Services to be sub-
stantially equivalent to the medical assistance avail-
able 
for 
an 
individual 
described 
in 
section 
1902(a)(10)(A)(i) of the Social Security Act (42 
U.S.C. 1396a(a)(10)(A)(i)). 
SEC. 4007. CONSISTENCY IN HEALTH INSURANCE COV-
ERAGE FOR INDIVIDUALS WITH FEDERALLY 
AUTHORIZED 
PRESENCE, 
INCLUDING 
DE-
FERRED ACTION. 
(a) IN GENERAL.—For purposes of eligibility under 
any of the provisions described in subsection (b), all indi-
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301 
viduals granted lawful presence in the United States shall 
be considered to be lawfully present in the United States. 
(b) PROVISIONS DESCRIBED.—The provisions de-
scribed in this subsection are the following: 
(1) EXCHANGE ELIGIBILITY.—Section 1411 of 
the Patient Protection and Affordable Care Act (42 
U.S.C. 18031). 
(2) REDUCED
COST-SHARING
ELIGIBILITY.— 
Section 1402 of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18071). 
(3) PREMIUM
SUBSIDY
ELIGIBILITY.—Section 
36B of the Internal Revenue Code of 1986 (26 
U.S.C. 36B). 
(4) MEDICAID AND CHIP ELIGIBILITY.—Titles 
XIX and XXI of the Social Security Act, including 
under section 1903(v) of such Act (42 U.S.C. 
1396b(v)). 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—Subsection (a) shall take ef-
fect on the date of enactment of this Act. 
(2) TRANSITION
THROUGH
SPECIAL
ENROLL-
MENT
PERIOD.—In the case of an individual de-
scribed in subsection (a) who, before the first day of 
the first annual open enrollment period under sub-
paragraph (B) of section 1311(c)(6) of the Patient 
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302 
Protection and Affordable Care Act (42 U.S.C. 
18031(c)(6)) beginning after the date of enactment 
of this Act, is granted lawful presence in the United 
States and who, as a result of such subsection, 
qualifies for a subsidy under a provision described in 
paragraph (2) or (3) of subsection (b), the Secretary 
of Health and Human Services shall establish a spe-
cial enrollment period under subparagraph (C) of 
such section 1311(c)(6) during which such individual 
may enroll in qualified health plans through Ex-
changes under title I of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18001 note et seq.) 
and qualify for such a subsidy. For such an indi-
vidual who has been granted federally authorized 
presence in the United States as of the date of en-
actment of this Act, such special enrollment period 
shall begin not later than 90 days after such date 
of enactment. Nothing in this paragraph shall be 
construed as affecting the authority of the Secretary 
to establish additional special enrollment periods 
under such subparagraph (C). 
SEC. 4008. STUDY ON THE UNINSURED. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’) shall— 
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303 
(1) conduct a study, in accordance with the 
standards under section 3101 of the Public Health 
Service Act (42 U.S.C. 300kk), on the demographic 
characteristics of the population of individuals who 
do not have health insurance coverage or oral health 
coverage; and 
(2) predict, based on such study, the demo-
graphic characteristics of the population of individ-
uals who would remain without health insurance cov-
erage after the end of any annual open enrollment 
or any special enrollment period or upon enactment 
and implementation of any legislative changes to the 
Patient Protection and Affordable Care Act (Public 
Law 111–148) that affect the number of persons eli-
gible for coverage. 
(b) REPORTING REQUIREMENTS.— 
(1) IN GENERAL.—Not later than 12 months 
after the date of the enactment of this Act, the Sec-
retary shall submit to the Congress the results of 
the study under subsection (a)(1) and the prediction 
made under subsection (a)(2). 
(2) REPORTING OF DEMOGRAPHIC CHARACTER-
ISTICS.—The Secretary shall— 
(A) report the demographic characteristics 
under paragraphs (1) and (2) of subsection (a) 
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304 
on the basis of racial and ethnic group (as de-
fined in section 1707(g)(1) of the Public Health 
Service Act, as amended by section 101 of this 
Act), and stratify the reporting on each racial 
and ethnic group by other demographic charac-
teristics that can impact access to health insur-
ance coverage, such as sexual orientation, gen-
der identity, primary language, disability status, 
sex, socioeconomic status, age group, citizen-
ship, and immigration status, in a manner con-
sistent with title I of this Act, including the 
amendments made by such title; and 
(B) not use such report, or any informa-
tion gathered in preparing such report— 
(i) to engage in or anticipate any de-
portation or immigration related enforce-
ment action by any entity, including the 
Department of Homeland Security; or 
(C) for the exploitation of, or discrimina-
tion against, communities of color or the 
LGBTQ+ population. 
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305 
SEC. 4009. MEDICAID FALLBACK COVERAGE PROGRAM FOR 
LOW-INCOME ADULTS IN NON-EXPANSION 
STATES. 
(a) IN GENERAL.—As soon as possible after the date 
of enactment of this Act the Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’) shall— 
(1) directly or by contract, establish a program 
that offers eligible individuals the opportunity to en-
roll in health benefits coverage that meets the re-
quirements described in subsection (c) and any re-
quirements applicable to such coverage pursuant to 
subsection (d); and 
(2) ensure that such program is administered 
consistent 
with 
the 
requirements 
of 
section 
431.10(c)(2) of title 42, Code of Federal Regula-
tions. 
(b) DEFINITION OF ELIGIBLE INDIVIDUAL.—In this 
section, the term ‘‘eligible individual’’ means an individual 
who— 
(1) 
is 
described 
in 
section 
1902(a)(10)(A)(i)(VIII) of the Social Security Act 
(42 U.S.C. 1396a(a)(10)(A)(i)(VIII)); 
(2) resides in a State that— 
(A) does not expend amounts for medical 
assistance under title XIX of the Social Secu-
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306 
rity Act (42 U.S.C. 1396 et seq.) for all individ-
uals described in such section; and 
(B) did not expend amounts for medical 
assistance under such title for all such individ-
uals as of the date of enactment of this Act; 
and 
(3) would not be eligible for medical assistance 
under such State’s plan for medical assistance under 
title XIX of the Social Security Act (42 U.S.C. 1396 
et seq.), or a waiver of such plan, as such plan or 
waiver was in effect on such date. 
(c) 
HEALTH
BENEFITS
COVERAGE
REQUIRE-
MENTS.—The requirements described in this subsection 
with respect to health benefits coverage are the following: 
(1) ESSENTIAL HEALTH BENEFITS.—At a min-
imum, the coverage meets the minimum standards 
required under paragraph (5) of section 1937(b) of 
the Social Security Act (42 U.S.C. 1396u–7(b)) for 
benchmark coverage described in paragraph (1) of 
such section or benchmark equivalent coverage de-
scribed in paragraph (2) of such section. 
(2) PREMIUMS
AND
COST-SHARING.—No pre-
miums are imposed for the coverage, and deduct-
ibles, cost sharing, or similar charges may only be 
imposed in accordance with the requirements im-
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307 
posed on State Medicaid plans under section 1916 of 
the Social Security Act (42 U.S.C. 1396o). 
(d) APPLICATION OF REQUIREMENTS AND PROVI-
SIONS OF TITLE XIX OF THE SOCIAL SECURITY ACT.— 
The Secretary shall specify that— 
(1) any requirement applicable to the furnishing 
of medical assistance under title XIX of the Social 
Security Act (42 U.S.C. 1396 et seq.) by States that 
have elected to make medical assistance available to 
individuals 
described 
in 
section 
1902(a)(10)(A)(i)(VIII) of such title (42 U.S.C. 
1396a(a)(10)(A)(i)(VIII)) that does not conflict with 
the requirements specified in subsection (c) applies 
to the program established under this section; and 
(2) other provisions of such title apply to such 
program. 
(e) NO STATE MANDATE.—Nothing in this section 
shall be construed as requiring a State to make expendi-
tures related to the program established under this section 
and the Secretary shall not impose any such requirement. 
(f) FUNDING.—There are appropriated to the Sec-
retary for each fiscal year beginning with fiscal year 2022 
from any funds in the Treasury not otherwise appro-
priated, such sums as are necessary to carry out this sec-
tion. 
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308 
SEC. 4010. INCREASE AND EXTENSION OF TEMPORARY EN-
HANCED FMAP FOR STATES WHICH BEGIN TO 
EXPEND AMOUNTS FOR CERTAIN MANDA-
TORY INDIVIDUALS. 
(a) IN GENERAL.—Section 1905(ii)(1) of the Social 
Security Act (42 U.S.C. 1396d(ii)(1)) is amended— 
(1) by striking ‘‘8-quarter period’’ and inserting 
‘‘40-quarter period’’; and 
(2) by striking ‘‘5 percentage points’’ and in-
serting ‘‘10 percentage points’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall take effect as if included in the enact-
ment of section 9814 of the American Rescue Plan Act 
of 2021 (Public Law 117–2). 
Subtitle B—Improvement of 
Coverage 
SEC. 4101. MEDICAID IN THE TERRITORIES. 
(a) ELIMINATION OF GENERAL MEDICAID FUNDING 
LIMITATIONS (‘‘CAP’’) FOR TERRITORIES.— 
(1) IN GENERAL.—Section 1108 of the Social 
Security Act (42 U.S.C. 1308) is amended— 
(A) in subsection (f), in the matter pre-
ceding paragraph (1), by striking ‘‘subsections 
(g) and (h)’’ and inserting ‘‘subsections (g), 
(h), and (i)’’; 
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309 
(B) in subsection (g)(2), in the matter pre-
ceding subparagraph (A), by inserting ‘‘sub-
section (i) and’’ after ‘‘subject to’’; and 
(C) by adding at the end the following new 
subsection: 
‘‘(i) SUNSET OF MEDICAID FUNDING LIMITATIONS 
FOR PUERTO RICO, THE VIRGIN ISLANDS, GUAM, THE 
NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA.— 
Subsections (f) and (g) shall not apply to Puerto Rico, 
the Virgin Islands, Guam, the Northern Mariana Islands, 
and American Samoa beginning with fiscal year 2024.’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1902(j) of the Social Security 
Act (42 U.S.C. 1396a(j)) is amended by strik-
ing ‘‘, the limitation in section 1108(f),,’’. 
(B) Section 1903(u) of the Social Security 
Act (42 U.S.C. 1396b(u)) is amended by strik-
ing paragraph (4). 
(3) EFFECTIVE DATE.—The amendments made 
by this section shall apply beginning with fiscal year 
2024. 
(b) ELIMINATION OF SPECIFIC FEDERAL MEDICAL 
ASSISTANCE PERCENTAGE (FMAP) LIMITATION
FOR 
TERRITORIES.—Section 1905(b) of the Social Security 
Act (42 U.S.C. 1396d(b)) is amended, in clause (2), by 
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inserting ‘‘for fiscal years before fiscal year 2024’’ after 
‘‘American Samoa’’. 
(c) PERMITTING MEDICAID DSH ALLOTMENTS FOR 
TERRITORIES.—Section 1923(f) of the Social Security Act 
(42 U.S.C. 1396r–4(f)) is amended— 
(1) in paragraph (6), by adding at the end the 
following new subparagraph: 
‘‘(C) TERRITORIES.— 
‘‘(i) FISCAL
YEAR
2023.—For fiscal 
year 2023, the DSH allotment for Puerto 
Rico, the Virgin Islands, Guam, the North-
ern Mariana Islands, and American Samoa 
shall bear the same ratio to $300,000,000 
as the ratio of the number of individuals 
who are low-income or uninsured and re-
siding in such respective territory (as esti-
mated from time to time by the Secretary) 
bears to the sums of the number of such 
individuals residing in all of the territories. 
‘‘(ii) SUBSEQUENT
FISCAL
YEAR.— 
For each subsequent fiscal year, the DSH 
allotment for each such territory is subject 
to an increase in accordance with para-
graph (3).’’; and 
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311 
(2) in paragraph (9), by inserting before the pe-
riod at the end the following: ‘‘, and includes, begin-
ning with fiscal year 2023, Puerto Rico, the Virgin 
Islands, Guam, the Northern Mariana Islands, and 
American Samoa’’. 
SEC. 4102. EXTENSION OF THE SUPPLEMENTAL SECURITY 
INCOME PROGRAM TO PUERTO RICO, THE 
UNITED STATES VIRGIN ISLANDS, GUAM, AND 
AMERICAN SAMOA. 
(a) IN GENERAL.—Section 303 of the Social Security 
Amendments of 1972 (86 Stat. 1484) is amended by strik-
ing subsection (b). 
(b) CONFORMING AMENDMENTS.— 
(1) 
DEFINITION
OF
STATE.—Section 
1101(a)(1) of the Social Security Act (42 U.S.C. 
1301(a)(1)) is amended by striking the 5th sentence 
and inserting the following: ‘‘Such term when used 
in title XVI includes Puerto Rico, the United States 
Virgin Islands, Guam, and American Samoa.’’. 
(2) ELIMINATION
OF
LIMIT
ON
TOTAL
PAY-
MENTS
TO
THE
TERRITORIES.—Section 1108 of 
such Act (42 U.S.C. 1308) is amended— 
(A) in the section heading, by striking ‘‘; 
LIMITATION ON TOTAL PAYMENTS’’; 
(B) by striking subsection (a); and 
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312 
(C) in subsection (c), by striking para-
graphs (2) and (4) and redesignating para-
graphs (3) and (5) as paragraphs (2) and (4), 
respectively. 
(3) UNITED STATES NATIONALS TREATED THE 
SAME AS CITIZENS.—Section 1614(a)(1)(B) of such 
Act (42 U.S.C. 1382c(a)(1)(B)) is amended— 
(A) in clause (i)(I), by inserting ‘‘or na-
tional,’’ after ‘‘citizen’’; 
(B) in clause (i)(II), by adding ‘‘; or’’ at 
the end; and 
(C) in clause (ii), by inserting ‘‘or na-
tional’’ after ‘‘citizen’’. 
(4) TERRITORIES
INCLUDED
IN
GEOGRAPHIC 
MEANING OF UNITED STATES.—Section 1614(e) of 
such Act (42 U.S.C. 1382c(e)) is amended by strik-
ing ‘‘and the District of Columbia’’ and inserting ‘‘, 
the District of Columbia, Puerto Rico, the United 
States 
Virgin 
Islands, 
Guam, 
and 
American 
Samoa’’. 
(c) WAIVER AUTHORITY.—The Commissioner of So-
cial Security may waive or modify any statutory require-
ment relating to the provision of benefits under the Sup-
plemental Security Income Program under title XVI of the 
Social Security Act in Puerto Rico, the United States Vir-
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313 
gin Islands, Guam, or American Samoa, to the extent that 
the Commissioner deems it necessary in order to adapt 
the program to the needs of the territory involved. 
(d) EFFECTIVE DATE.—This section and the amend-
ments made by this section shall take effect on the 1st 
day of the 1st Federal fiscal year that begins 1 year or 
more after the date of the enactment of this Act. 
SEC. 4103. EXTENSION OF MEDICARE SECONDARY PAYER. 
(a) IN GENERAL.—Section 1862(b)(1)(C) of the So-
cial Security Act (42 U.S.C. 1395y(b)(1)(C)) is amend-
ed— 
(1) in the last sentence, by inserting ‘‘, and be-
fore January 1, 2023’’ after ‘‘prior to such date)’’; 
and 
(2) by adding at the end the following new sen-
tence: ‘‘Effective for items and services furnished on 
or after January 1, 2023 (with respect to periods 
beginning on or after the date that is 42 months 
prior to such date), clauses (i) and (ii) shall be ap-
plied by substituting ‘42-month’ for ‘12-month’ each 
place it appears.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on the date of enactment of 
this Act. For purposes of determining an individual’s sta-
tus under section 1862(b)(1)(C) of the Social Security Act 
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314 
(42 U.S.C. 1395y(b)(1)(C)), as amended by subsection 
(a), an individual who is within the coordinating period 
as of the date of enactment of this Act shall have that 
period extended to the full 42 months described in the last 
sentence of such section, as added by the amendment 
made by subsection (a)(2). 
SEC. 4104. INDIAN DEFINED IN TITLE I OF THE PATIENT 
PROTECTION AND AFFORDABLE CARE ACT. 
(a) DEFINITION OF INDIAN.—Section 1304 of the 
Patient Protection and Affordable Care Act (42 U.S.C. 
18024) is amended by adding at the end the following: 
‘‘(f) INDIAN.—In this title: 
‘‘(1) IN GENERAL.—The term ‘Indian’ means— 
‘‘(A) an Indian, California Indian, or 
Urban Indian, as such terms are defined in sec-
tion 4 of the Indian Health Care Improvement 
Act (25 U.S.C. 1603); or 
‘‘(B) an individual who is— 
‘‘(i) of Indian descent and a member 
of an Indian community served by a local 
facility or program of the Indian Health 
Service; or 
‘‘(ii) described in paragraph (2). 
‘‘(2) INCLUSIONS.—The term ‘Indian’ includes 
the following individuals: 
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1793 
success of the proposed interventions or ap-
proaches. 
(F) The identification of the funding 
sources that would be used to finance the pro-
posed interventions or approaches. 
(G) A description of any financial incen-
tives that may be provided, including outcome- 
focused contracting approaches to encourage 
service providers and other partners to improve 
outcomes of, cost-effectiveness of, and return on 
investment from, Federal, State, local, or Tribal 
government spending. 
(H) The identification of the applicable 
Federal, State, local, or Tribal statutory and 
regulatory authorities, including waiver authori-
ties, to be leveraged to implement the proposed 
interventions or approaches. 
(I) A description of potential consider-
ations 
that 
would 
enhance 
the 
impact, 
scalability, or sustainability of the proposed 
interventions or approaches and the actions the 
grant awardee would take to address such con-
siderations. 
(J) A proposed evaluation plan, to be car-
ried out by an independent evaluator, to meas-
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