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•AMDT. NO. 2786 
ployee of the employer to whom the extended waiting 
period applies. 
‘‘(2) AMOUNT.—For purposes of paragraph (1), 
the amount specified in this paragraph for a full- 
time employee is— 
‘‘(A) in the case of an extended waiting pe-
riod which exceeds 30 days but does not exceed 
60 days, $400, and 
‘‘(B) in the case of an extended waiting pe-
riod which exceeds 60 days, $600. 
‘‘(3) EXTENDED WAITING PERIOD.—The term 
‘extended waiting period’ means any waiting period 
(as defined in section 2701(b)(4) of the Public 
Health Service Act) which exceeds 30 days. 
‘‘(c) LARGE
EMPLOYERS
OFFERING
COVERAGE 
WITH EMPLOYEES WHO QUALIFY FOR PREMIUM TAX 
CREDITS OR COST-SHARING REDUCTIONS.— 
‘‘(1) IN GENERAL.—If— 
‘‘(A) an applicable large employer offers to 
its full-time employees (and their dependents) 
the opportunity to enroll in minimum essential 
coverage under an eligible employer-sponsored 
plan (as defined in section 5000A(f)(2)) for any 
month, and 
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•AMDT. NO. 2786 
‘‘(B) 1 or more full-time employees of the 
applicable large employer has been certified to 
the employer under section 1411 of the Patient 
Protection and Affordable Care Act as having 
enrolled for such month in a qualified health 
plan with respect to which an applicable pre-
mium tax credit or cost-sharing reduction is al-
lowed or paid with respect to the employee, 
then there is hereby imposed on the employer an as-
sessable payment equal to the product of the number 
of full-time employees of the applicable large em-
ployer described in subparagraph (B) for such 
month and 400 percent of the applicable payment 
amount. 
‘‘(2) OVERALL
LIMITATION.—The aggregate 
amount of tax determined under paragraph (1) with 
respect to all employees of an applicable large em-
ployer for any month shall not exceed the product of 
the applicable payment amount and the number of 
individuals employed by the employer as full-time 
employees during such month. 
‘‘(d) DEFINITIONS AND SPECIAL RULES.—For pur-
poses of this section— 
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•AMDT. NO. 2786 
‘‘(1) APPLICABLE
PAYMENT
AMOUNT.—The 
term ‘applicable payment amount’ means, with re-
spect to any month, 1⁄12 of $750. 
‘‘(2) APPLICABLE LARGE EMPLOYER.— 
‘‘(A) IN GENERAL.—The term ‘applicable 
large employer’ means, with respect to a cal-
endar year, an employer who employed an aver-
age of at least 50 full-time employees on busi-
ness days during the preceding calendar year. 
‘‘(B) EXEMPTION FOR CERTAIN EMPLOY-
ERS.— 
‘‘(i) IN GENERAL.—An employer shall 
not be considered to employ more than 50 
full-time employees if— 
‘‘(I) the employer’s workforce ex-
ceeds 50 full-time employees for 120 
days or fewer during the calendar 
year, and 
‘‘(II) the employees in excess of 
50 employed during such 120-day pe-
riod were seasonal workers. 
‘‘(ii) 
DEFINITION
OF
SEASONAL 
WORKERS.—The term ‘seasonal worker’ 
means a worker who performs labor or 
services on a seasonal basis as defined by 
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353 
•AMDT. NO. 2786 
the Secretary of Labor, including workers 
covered by section 500.20(s)(1) of title 29, 
Code of Federal Regulations and retail 
workers employed exclusively during holi-
day seasons. 
‘‘(C) RULES FOR DETERMINING EMPLOYER 
SIZE.—For purposes of this paragraph— 
‘‘(i) APPLICATION
OF
AGGREGATION 
RULE FOR EMPLOYERS.—All persons treat-
ed as a single employer under subsection 
(b), (c), (m), or (o) of section 414 of the 
Internal Revenue Code of 1986 shall be 
treated as 1 employer. 
‘‘(ii) EMPLOYERS NOT IN EXISTENCE 
IN PRECEDING YEAR.—In the case of an 
employer which was not in existence 
throughout the preceding calendar year, 
the determination of whether such em-
ployer is an applicable large employer shall 
be based on the average number of employ-
ees that it is reasonably expected such em-
ployer will employ on business days in the 
current calendar year. 
‘‘(iii) PREDECESSORS.—Any reference 
in this subsection to an employer shall in-
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354 
•AMDT. NO. 2786 
clude a reference to any predecessor of 
such employer. 
‘‘(3) APPLICABLE PREMIUM TAX CREDIT AND 
COST-SHARING
REDUCTION.—The term ‘applicable 
premium tax credit and cost-sharing reduction’ 
means— 
‘‘(A) any premium tax credit allowed under 
section 36B, 
‘‘(B) any cost-sharing reduction under sec-
tion 1402 of the Patient Protection and Afford-
able Care Act, and 
‘‘(C) any advance payment of such credit 
or reduction under section 1412 of such Act. 
‘‘(4) FULL-TIME EMPLOYEE.— 
‘‘(A) IN
GENERAL.—The term ‘full-time 
employee’ means an employee who is employed 
on average at least 30 hours of service per 
week. 
‘‘(B) HOURS OF SERVICE.—The Secretary, 
in consultation with the Secretary of Labor, 
shall prescribe such regulations, rules, and 
guidance as may be necessary to determine the 
hours of service of an employee, including rules 
for the application of this paragraph to employ-
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•AMDT. NO. 2786 
ees who are not compensated on an hourly 
basis. 
‘‘(5) INFLATION ADJUSTMENT.— 
‘‘(A) IN GENERAL.—In the case of any cal-
endar year after 2014, each of the dollar 
amounts in subsection (b)(2) and (d)(1) shall 
be increased by an amount equal to the product 
of— 
‘‘(i) such dollar amount, and 
‘‘(ii) the premium adjustment percent-
age (as defined in section 1302(c)(4) of 
the Patient Protection and Affordable Care 
Act) for the calendar year. 
‘‘(B) ROUNDING.—If the amount of any 
increase under subparagraph (A) is not a mul-
tiple of $10, such increase shall be rounded to 
the next lowest multiple of $10. 
‘‘(6) OTHER DEFINITIONS.—Any term used in 
this section which is also used in the Patient Protec-
tion and Affordable Care Act shall have the same 
meaning as when used in such Act. 
‘‘(7) TAX NONDEDUCTIBLE.—For denial of de-
duction for the tax imposed by this section, see sec-
tion 275(a)(6). 
‘‘(e) ADMINISTRATION AND PROCEDURE.— 
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•AMDT. NO. 2786 
‘‘(1) IN
GENERAL.—Any assessable payment 
provided by this section shall be paid upon notice 
and demand by the Secretary, and shall be assessed 
and collected in the same manner as an assessable 
penalty under subchapter B of chapter 68. 
‘‘(2) TIME FOR PAYMENT.—The Secretary may 
provide for the payment of any assessable payment 
provided by this section on an annual, monthly, or 
other periodic basis as the Secretary may prescribe. 
‘‘(3) COORDINATION
WITH
CREDITS, ETC..— 
The Secretary shall prescribe rules, regulations, or 
guidance for the repayment of any assessable pay-
ment (including interest) if such payment is based 
on the allowance or payment of an applicable pre-
mium tax credit or cost-sharing reduction with re-
spect to an employee, such allowance or payment is 
subsequently disallowed, and the assessable payment 
would not have been required to be made but for 
such allowance or payment.’’. 
(b) CLERICAL AMENDMENT.—The table of sections 
for chapter 43 of such Code is amended by adding at the 
end the following new item: 
‘‘Sec. 4980H. Shared responsibility for employers regarding health coverage.’’. 
(c) STUDY AND REPORT OF EFFECT OF TAX ON 
WORKERS’ WAGES.— 
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357 
•AMDT. NO. 2786 
(1) IN GENERAL.—The Secretary of Labor shall 
conduct a study to determine whether employees’ 
wages are reduced by reason of the application of 
the assessable payments under section 4980H of the 
Internal Revenue Code of 1986 (as added by the 
amendments made by this section). The Secretary 
shall make such determination on the basis of the 
National Compensation Survey published by the Bu-
reau of Labor Statistics. 
(2) REPORT.—The Secretary shall report the 
results of the study under paragraph (1) to the 
Committee on Ways and Means of the House of 
Representatives and to the Committee on Finance of 
the Senate. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply to months beginning after Decem-
ber 31, 2013. 
SEC. 1514. REPORTING OF EMPLOYER HEALTH INSURANCE 
COVERAGE. 
(a) IN GENERAL.—Subpart D of part III of sub-
chapter A of chapter 61 of the Internal Revenue Code of 
1986, as added by section 1502, is amended by inserting 
after section 6055 the following new section: 
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•AMDT. NO. 2786 
‘‘SEC. 6056. LARGE EMPLOYERS REQUIRED TO REPORT ON 
HEALTH INSURANCE COVERAGE. 
‘‘(a) IN GENERAL.—Every applicable large employer 
required to meet the requirements of section 4980H with 
respect to its full-time employees during a calendar year 
shall, at such time as the Secretary may prescribe, make 
a return described in subsection (b). 
‘‘(b) FORM AND MANNER OF RETURN.—A return is 
described in this subsection if such return— 
‘‘(1) is in such form as the Secretary may pre-
scribe, and 
‘‘(2) contains— 
‘‘(A) the name, date, and employer identi-
fication number of the employer, 
‘‘(B) a certification as to whether the em-
ployer offers to its full-time employees (and 
their dependents) the opportunity to enroll in 
minimum essential coverage under an eligible 
employer-sponsored plan (as defined in section 
5000A(f)(2)), 
‘‘(C) if the employer certifies that the em-
ployer did offer to its full-time employees (and 
their dependents) the opportunity to so enroll— 
‘‘(i) the length of any waiting period 
(as defined in section 2701(b)(4) of the 
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359 
•AMDT. NO. 2786 
Public Health Service Act) with respect to 
such coverage, 
‘‘(ii) the months during the calendar 
year for which coverage under the plan was 
available, 
‘‘(iii) the monthly premium for the 
lowest cost option in each of the enroll-
ment categories under the plan, and 
‘‘(iv) the applicable large employer’s 
share of the total allowed costs of benefits 
provided under the plan, 
‘‘(D) the number of full-time employees for 
each month during the calendar year, 
‘‘(E) the name, address, and TIN of each 
full-time employee during the calendar year and 
the months (if any) during which such employee 
(and any dependents) were covered under any 
such health benefits plans, and 
‘‘(F) such other information as the Sec-
retary may require. 
‘‘(c) STATEMENTS TO BE FURNISHED TO INDIVID-
UALS WITH RESPECT TO WHOM INFORMATION IS RE-
PORTED.— 
‘‘(1) IN GENERAL.—Every person required to 
make a return under subsection (a) shall furnish to 
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•AMDT. NO. 2786 
each full-time employee whose name is required to 
be set forth in such return under subsection 
(b)(2)(E) a written statement showing— 
‘‘(A) the name and address of the person 
required to make such return and the phone 
number of the information contact for such per-
son, and 
‘‘(B) the information required to be shown 
on the return with respect to such individual. 
‘‘(2) TIME
FOR
FURNISHING
STATEMENTS.— 
The written statement required under paragraph (1) 
shall be furnished on or before January 31 of the 
year following the calendar year for which the return 
under subsection (a) was required to be made. 
‘‘(d) 
COORDINATION
WITH
OTHER
REQUIRE-
MENTS.—To the maximum extent feasible, the Secretary 
may provide that— 
‘‘(1) any return or statement required to be 
provided under this section may be provided as part 
of any return or statement required under section 
6051 or 6055, and 
‘‘(2) in the case of an applicable large employer 
offering health insurance coverage of a health insur-
ance issuer, the employer may enter into an agree-
ment with the issuer to include information required 
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•AMDT. NO. 2786 
under this section with the return and statement re-
quired to be provided by the issuer under section 
6055. 
‘‘(e) COVERAGE
PROVIDED
BY
GOVERNMENTAL 
UNITS.—In the case of any applicable large employer 
which is a governmental unit or any agency or instrumen-
tality thereof, the person appropriately designated for pur-
poses of this section shall make the returns and state-
ments required by this section. 
‘‘(f) DEFINITIONS.—For purposes of this section, any 
term used in this section which is also used in section 
4980H shall have the meaning given such term by section 
4980H.’’. 
(b) ASSESSABLE PENALTIES.— 
(1) Subparagraph (B) of section 6724(d)(1) of 
the Internal Revenue Code of 1986 (relating to defi-
nitions), as amended by section 1502, is amended by 
striking ‘‘or’’ at the end of clause (xxiii), by striking 
‘‘and’’ at the end of clause (xxiv) and inserting ‘‘or’’, 
and by inserting after clause (xxiv) the following 
new clause: 
‘‘(xxv) section 6056 (relating to re-
turns relating to large employers required 
to report on health insurance coverage), 
and’’. 
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•AMDT. NO. 2786 
(2) Paragraph (2) of section 6724(d) of such 
Code, as so amended, is amended by striking ‘‘or’’ 
at the end of subparagraph (FF), by striking the pe-
riod at the end of subparagraph (GG) and inserting 
‘‘, or’’ and by inserting after subparagraph (GG) the 
following new subparagraph: 
‘‘(HH) section 6056(c) (relating to state-
ments relating to large employers required to 
report on health insurance coverage).’’. 
(c) CONFORMING AMENDMENT.—The table of sec-
tions for subpart D of part III of subchapter A of chapter 
61 of such Code, as added by section 1502, is amended 
by adding at the end the following new item: 
‘‘Sec. 6056. Large employers required to report on health insurance coverage.’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply to periods beginning after Decem-
ber 31, 2013. 
SEC. 
1515. 
OFFERING 
OF 
EXCHANGE-PARTICIPATING 
QUALIFIED HEALTH PLANS THROUGH CAFE-
TERIA PLANS. 
(a) IN GENERAL.—Subsection (f) of section 125 of 
the Internal Revenue Code of 1986 is amended by adding 
at the end the following new paragraph: 
‘‘(3) 
CERTAIN
EXCHANGE-PARTICIPATING 
QUALIFIED HEALTH PLANS NOT QUALIFIED.— 
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•AMDT. NO. 2786 
‘‘(A) IN
GENERAL.—The term ‘qualified 
benefit’ shall not include any qualified health 
plan (as defined in section 1301(a) of the Pa-
tient Protection and Affordable Care Act) of-
fered through an Exchange established under 
section 1311 of such Act. 
‘‘(B) EXCEPTION
FOR
EXCHANGE-ELIGI-
BLE EMPLOYERS.—Subparagraph (A) shall not 
apply with respect to any employee if such em-
ployee’s employer is a qualified employer (as de-
fined in section 1312(f)(2) of the Patient Pro-
tection and Affordable Care Act) offering the 
employee the opportunity to enroll through such 
an Exchange in a qualified health plan in a 
group market.’’. 
(b) CONFORMING AMENDMENTS.—Subsection (f) of 
section 125 of such Code is amended— 
(1) by striking ‘‘For purposes of this section, 
the term’’ and inserting ‘‘For purposes of this sec-
tion— 
‘‘(1) IN GENERAL.—The term’’, and 
(2) by striking ‘‘Such term shall not include’’ 
and inserting the following: 
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•AMDT. NO. 2786 
‘‘(2) LONG-TERM CARE INSURANCE NOT QUALI-
FIED.—The term ‘qualified benefit’ shall not in-
clude’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2013. 
Subtitle G—Miscellaneous 
Provisions 
SEC. 1551. DEFINITIONS. 
Unless specifically provided for otherwise, the defini-
tions contained in section 2791 of the Public Health Serv-
ice Act (42 U.S.C. 300gg-91) shall apply with respect to 
this title. 
SEC. 1552. TRANSPARENCY IN GOVERNMENT. 
Not later than 30 days after the date of enactment 
of this Act, the Secretary of Health and Human Services 
shall publish on the Internet website of the Department 
of Health and Human Services, a list of all of the authori-
ties provided to the Secretary under this Act (and the 
amendments made by this Act). 
SEC. 1553. PROHIBITION AGAINST DISCRIMINATION ON AS-
SISTED SUICIDE. 
(a) IN GENERAL.—The Federal Government, and 
any State or local government or health care provider that 
receives Federal financial assistance under this Act (or 
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•AMDT. NO. 2786 
under an amendment made by this Act) or any health plan 
created under this Act (or under an amendment made by 
this Act), may not subject an individual or institutional 
health care entity to discrimination on the basis that the 
entity does not provide any health care item or service fur-
nished for the purpose of causing, or for the purpose of 
assisting in causing, the death of any individual, such as 
by assisted suicide, euthanasia, or mercy killing. 
(b) DEFINITION.—In this section, the term ‘‘health 
care entity’’ includes an individual physician or other 
health care professional, a hospital, a provider-sponsored 
organization, a health maintenance organization, a health 
insurance plan, or any other kind of health care facility, 
organization, or plan. 
(c) CONSTRUCTION AND TREATMENT OF CERTAIN 
SERVICES.—Nothing in subsection (a) shall be construed 
to apply to, or to affect, any limitation relating to— 
(1) the withholding or withdrawing of medical 
treatment or medical care; 
(2) the withholding or withdrawing of nutrition 
or hydration; 
(3) abortion; or 
(4) the use of an item, good, benefit, or service 
furnished for the purpose of alleviating pain or dis-
comfort, even if such use may increase the risk of 
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•AMDT. NO. 2786 
death, so long as such item, good, benefit, or service 
is not also furnished for the purpose of causing, or 
the purpose of assisting in causing, death, for any 
reason. 
(d) ADMINISTRATION.—The Office for Civil Rights of 
the Department of Health and Human Services is des-
ignated to receive complaints of discrimination based on 
this section. 
SEC. 1554. ACCESS TO THERAPIES. 
Notwithstanding any other provision of this Act, the 
Secretary of Health and Human Services shall not pro-
mulgate any regulation that— 
(1) creates any unreasonable barriers to the 
ability of individuals to obtain appropriate medical 
care; 
(2) impedes timely access to health care serv-
ices; 
(3) interferes with communications regarding a 
full range of treatment options between the patient 
and the provider; 
(4) restricts the ability of health care providers 
to provide full disclosure of all relevant information 
to patients making health care decisions; 
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•AMDT. NO. 2786 
(5) violates the principles of informed consent 
and the ethical standards of health care profes-
sionals; or 
(6) limits the availability of health care treat-
ment for the full duration of a patient’s medical 
needs. 
SEC. 1555. FREEDOM NOT TO PARTICIPATE IN FEDERAL 
HEALTH INSURANCE PROGRAMS. 
No individual, company, business, nonprofit entity, or 
health insurance issuer offering group or individual health 
insurance coverage shall be required to participate in any 
Federal health insurance program created under this Act 
(or any amendments made by this Act), or in any Federal 
health insurance program expanded by this Act (or any 
such amendments), and there shall be no penalty or fine 
imposed upon any such issuer for choosing not to partici-
pate in such programs. 
SEC. 1556. EQUITY FOR CERTAIN ELIGIBLE SURVIVORS. 
(a) REBUTTABLE PRESUMPTION.—Section 411(c)(4) 
of the Black Lung Benefits Act (30 U.S.C. 921(c)(4)) is 
amended by striking the last sentence. 
(b) CONTINUATION OF BENEFITS.—Section 422(l) of 
the Black Lung Benefits Act (30 U.S.C. 932(l)) is amend-
ed by striking ‘‘, except with respect to a claim filed under 
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•AMDT. NO. 2786 
this part on or after the effective date of the Black Lung 
Benefits Amendments of 1981’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to claims filed under 
part B or part C of the Black Lung Benefits Act (30 
U.S.C. 921 et seq., 931 et seq.) after January 1, 2005, 
that are pending on or after the date of enactment of this 
Act. 
SEC. 1557. NONDISCRIMINATION. 
(a) IN GENERAL.—Except as otherwise provided for 
in this title (or an amendment made by this title), an indi-
vidual shall not, on the ground prohibited under title VI 
of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), 
title IX of the Education Amendments of 1972 (20 U.S.C. 
1681 et seq.), the Age Discrimination Act of 1975 (42 
U.S.C. 6101 et seq.), or section 504 of the Rehabilitation 
Act of 1973 (29 U.S.C. 794), be excluded from participa-
tion in, be denied the benefits of, or be subjected to dis-
crimination under, any health program or activity, any 
part of which is receiving Federal financial assistance, in-
cluding credits, subsidies, or contracts of insurance, or 
under any program or activity that is administered by an 
Executive Agency or any entity established under this title 
(or amendments). The enforcement mechanisms provided 
for and available under such title VI, title IX, section 504, 
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•AMDT. NO. 2786 
or such Age Discrimination Act shall apply for purposes 
of violations of this subsection. 
(b) CONTINUED APPLICATION OF LAWS.—Nothing in 
this title (or an amendment made by this title) shall be 
construed to invalidate or limit the rights, remedies, proce-
dures, or legal standards available to individuals aggrieved 
under title VI of the Civil Rights Act of 1964 (42 U.S.C. 
2000d et seq.), title VII of the Civil Rights Act of 1964 
(42 U.S.C. 2000e et seq.), title IX of the Education 
Amendments of 1972 (20 U.S.C. 1681 et seq.), section 
504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), 
or the Age Discrimination Act of 1975 (42 U.S.C. 611 
et seq.), or to supersede State laws that provide additional 
protections against discrimination on any basis described 
in subsection (a). 
(c) REGULATIONS.—The Secretary may promulgate 
regulations to implement this section. 
SEC. 1558. PROTECTIONS FOR EMPLOYEES. 
The Fair Labor Standards Act of 1938 is amended 
by inserting after section 18B (as added by section 1512) 
the following: 
‘‘SEC. 18C. PROTECTIONS FOR EMPLOYEES. 
‘‘(a) PROHIBITION.—No employer shall discharge or 
in any manner discriminate against any employee with re-
spect to his or her compensation, terms, conditions, or 
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•AMDT. NO. 2786 
other privileges of employment because the employee (or 
an individual acting at the request of the employee) has— 
‘‘(1) received a credit under section 36B of the 
Internal Revenue Code of 1986 or a subsidy under 
section 1402 of this Act; 
‘‘(2) provided, caused to be provided, or is 
about to provide or cause to be provided to the em-
ployer, the Federal Government, or the attorney 
general of a State information relating to any viola-
tion of, or any act or omission the employee reason-
ably believes to be a violation of, any provision of 
this title (or an amendment made by this title); 
‘‘(3) testified or is about to testify in a pro-
ceeding concerning such violation; 
‘‘(4) assisted or participated, or is about to as-
sist or participate, in such a proceeding; or 
‘‘(5) objected to, or refused to participate in, 
any activity, policy, practice, or assigned task that 
the employee (or other such person) reasonably be-
lieved to be in violation of any provision of this title 
(or amendment), or any order, rule, regulation, 
standard, or ban under this title (or amendment). 
‘‘(b) COMPLAINT PROCEDURE.— 
‘‘(1) IN GENERAL.—An employee who believes 
that he or she has been discharged or otherwise dis-
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371 
•AMDT. NO. 2786 
criminated against by any employer in violation of 
this section may seek relief in accordance with the 
procedures, notifications, burdens of proof, remedies, 
and statutes of limitation set forth in section 
2087(b) of title 15, United States Code. 
‘‘(2) NO LIMITATION ON RIGHTS.—Nothing in 
this section shall be deemed to diminish the rights, 
privileges, or remedies of any employee under any 
Federal or State law or under any collective bar-
gaining agreement. The rights and remedies in this 
section may not be waived by any agreement, policy, 
form, or condition of employment.’’. 
SEC. 1559. OVERSIGHT. 
The Inspector General of the Department of Health 
and Human Services shall have oversight authority with 
respect to the administration and implementation of this 
title as it relates to such Department. 
SEC. 1560. RULES OF CONSTRUCTION. 
(a) NO EFFECT ON ANTITRUST LAWS.—Nothing in 
this title (or an amendment made by this title) shall be 
construed to modify, impair, or supersede the operation 
of any of the antitrust laws. For the purposes of this sec-
tion, the term ‘‘antitrust laws’’ has the meaning given 
such term in subsection (a) of the first section of the Clay-
ton Act, except that such term includes section 5 of the 
VerDate Nov 24 2008 
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372 
•AMDT. NO. 2786 
Federal Trade Commission Act to the extent that such 
section 5 applies to unfair methods of competition. 
(b) RULE OF CONSTRUCTION REGARDING HAWAII’S 
PREPAID HEALTH CARE ACT.—Nothing in this title (or 
an amendment made by this title) shall be construed to 
modify or limit the application of the exemption for Ha-
waii’s Prepaid Health Care Act (Haw. Rev. Stat. §§ 393- 
1 et seq.) as provided for under section 514(b)(5) of the 
Employee Retirement Income Security Act of 1974 (29 
U.S.C. 1144(b)(5)). 
(c) STUDENT HEALTH INSURANCE PLANS.—Nothing 
in this title (or an amendment made by this title) shall 
be construed to prohibit an institution of higher education 
(as such term is defined for purposes of the Higher Edu-
cation Act of 1965) from offering a student health insur-
ance plan, to the extent that such requirement is otherwise 
permitted under applicable Federal, State or local law. 
(d) NO EFFECT ON EXISTING REQUIREMENTS.— 
Nothing in this title (or an amendment made by this title, 
unless specified by direct statutory reference) shall be con-
strued to modify any existing Federal requirement con-
cerning the State agency responsible for determining eligi-
bility for programs identified in section 1413. 
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373 
•AMDT. NO. 2786 
SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLL-
MENT STANDARDS AND PROTOCOLS. 
Title XXX of the Public Health Service Act (42 
U.S.C. 300jj et seq.) is amended by adding at the end 
the following: 
‘‘Subtitle C—Other Provisions 
‘‘SEC. 3021. HEALTH INFORMATION TECHNOLOGY ENROLL-
MENT STANDARDS AND PROTOCOLS. 
‘‘(a) IN GENERAL.— 
‘‘(1) STANDARDS AND PROTOCOLS.—Not later 
than 180 days after the date of enactment of this 
title, the Secretary, in consultation with the HIT 
Policy Committee and the HIT Standards Com-
mittee, shall develop interoperable and secure stand-
ards and protocols that facilitate enrollment of indi-
viduals in Federal and State health and human serv-
ices programs, as determined by the Secretary. 
‘‘(2) METHODS.—The Secretary shall facilitate 
enrollment in such programs through methods deter-
mined appropriate by the Secretary, which shall in-
clude providing individuals and third parties author-
ized by such individuals and their designees notifica-
tion of eligibility and verification of eligibility re-
quired under such programs. 
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374 
•AMDT. NO. 2786 
‘‘(b) CONTENT.—The standards and protocols for 
electronic enrollment in the Federal and State programs 
described in subsection (a) shall allow for the following: 
‘‘(1) Electronic matching against existing Fed-
eral and State data, including vital records, employ-
ment history, enrollment systems, tax records, and 
other data determined appropriate by the Secretary 
to serve as evidence of eligibility and in lieu of 
paper-based documentation. 
‘‘(2) Simplification and submission of electronic 
documentation, digitization of documents, and sys-
tems verification of eligibility. 
‘‘(3) Reuse of stored eligibility information (in-
cluding documentation) to assist with retention of el-
igible individuals. 
‘‘(4) Capability for individuals to apply, recer-
tify and manage their eligibility information online, 
including at home, at points of service, and other 
community-based locations. 
‘‘(5) Ability to expand the enrollment system to 
integrate new programs, rules, and functionalities, to 
operate at increased volume, and to apply stream-
lined verification and eligibility processes to other 
Federal and State programs, as appropriate. 
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375 
•AMDT. NO. 2786 
‘‘(6) Notification of eligibility, recertification, 
and other needed communication regarding eligi-
bility, which may include communication via email 
and cellular phones. 
‘‘(7) Other functionalities necessary to provide 
eligibles with streamlined enrollment process. 
‘‘(c) APPROVAL AND NOTIFICATION.—With respect 
to any standard or protocol developed under subsection (a) 
that has been approved by the HIT Policy Committee and 
the HIT Standards Committee, the Secretary— 
‘‘(1) shall notify States of such standards or 
protocols; and 
‘‘(2) may require, as a condition of receiving 
Federal funds for the health information technology 
investments, that States or other entities incorporate 
such standards and protocols into such investments. 
‘‘(d) GRANTS
FOR IMPLEMENTATION
OF APPRO-
PRIATE ENROLLMENT HIT.— 
‘‘(1) IN GENERAL.—The Secretary shall award 
grant to eligible entities to develop new, and adapt 
existing, technology systems to implement the HIT 
enrollment standards and protocols developed under 
subsection (a) (referred to in this subsection as ‘ap-
propriate HIT technology’). 
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376 
•AMDT. NO. 2786 
‘‘(2) ELIGIBLE ENTITIES.—To be eligible for a 
grant under this subsection, an entity shall— 
‘‘(A) be a State, political subdivision of a 
State, or a local governmental entity; and 
‘‘(B) submit to the Secretary an applica-
tion at such time, in such manner, and con-
taining— 
‘‘(i) a plan to adopt and implement 
appropriate enrollment technology that in-
cludes— 
‘‘(I) proposed reduction in main-
tenance costs of technology systems; 
‘‘(II) elimination or updating of 
legacy systems; and 
‘‘(III) demonstrated collaboration 
with other entities that may receive a 
grant under this section that are lo-
cated in the same State, political sub-
division, or locality; 
‘‘(ii) an assurance that the entity will 
share such appropriate enrollment tech-
nology in accordance with paragraph (4); 
and 
‘‘(iii) such other information as the 
Secretary may require. 
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377 
•AMDT. NO. 2786 
‘‘(3) SHARING.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
ensure that appropriate enrollment HIT adopt-
ed under grants under this subsection is made 
available to other qualified State, qualified po-
litical subdivisions of a State, or other appro-
priate qualified entities (as described in sub-
paragraph (B)) at no cost. 
‘‘(B) QUALIFIED
ENTITIES.—The Sec-
retary shall determine what entities are quali-
fied to receive enrollment HIT under subpara-
graph (A), taking into consideration the rec-
ommendations of the HIT Policy Committee 
and the HIT Standards Committee.’’. 
SEC. 1562. CONFORMING AMENDMENTS. 
(a) APPLICABILITY.—Section 2735 of the Public 
Health Service Act (42 U.S.C. 300gg-21), as so redesig-
nated by section 1001(4), is amended— 
(1) by striking subsection (a); 
(2) in subsection (b)— 
(A) in paragraph (1), by striking ‘‘1 
through 3’’ and inserting ‘‘1 and 2’’; and 
(B) in paragraph (2)— 
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378 
•AMDT. NO. 2786 
(i) in subparagraph (A), by striking 
‘‘subparagraph (D)’’ and inserting ‘‘sub-
paragraph (D) or (E)’’; 
(ii) by striking ‘‘1 through 3’’ and in-
serting ‘‘1 and 2’’; and 
(iii) by adding at the end the fol-
lowing: 
‘‘(E) ELECTION
NOT
APPLICABLE.—The 
election described in subparagraph (A) shall not 
be available with respect to the provisions of 
subpart 1.’’; 
(3) in subsection (c), by striking ‘‘1 through 3 
shall not apply to any group’’ and inserting ‘‘1 and 
2 shall not apply to any individual coverage or any 
group’’; and 
(4) in subsection (d)— 
(A) in paragraph (1), by striking ‘‘1 
through 3 shall not apply to any group’’ and in-
serting ‘‘1 and 2 shall not apply to any indi-
vidual coverage or any group’’; 
(B) in paragraph (2)— 
(i) in the matter preceding subpara-
graph (A), by striking ‘‘1 through 3 shall 
not apply to any group’’ and inserting ‘‘1 
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379 
•AMDT. NO. 2786 
and 2 shall not apply to any individual cov-
erage or any group’’; and 
(ii) in subparagraph (C), by inserting 
‘‘or, with respect to individual coverage, 
under any health insurance coverage main-
tained by the same health insurance 
issuer’’; and 
(C) in paragraph (3), by striking ‘‘any 
group’’ and inserting ‘‘any individual coverage 
or any group’’. 
(b) DEFINITIONS.—Section 2791(d) of the Public 
Health Service Act (42 U.S.C. 300gg-91(d)) is amended 
by adding at the end the following: 
‘‘(20) QUALIFIED
HEALTH
PLAN.—The term 
‘qualified health plan’ has the meaning given such 
term in section 1301(a) of the Patient Protection 
and Affordable Care Act. 
‘‘(21) 
EXCHANGE.—The 
term 
‘Exchange’ 
means an American Health Benefit Exchange estab-
lished under section 1311 of the Patient Protection 
and Affordable Care Act.’’. 
(c) TECHNICAL AND CONFORMING AMENDMENTS.— 
Title XXVII of the Public Health Service Act (42 U.S.C. 
300gg et seq.) is amended— 
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380 
•AMDT. NO. 2786 
(1) in section 2704 (42 U.S.C. 300gg), as so 
redesignated by section 1201(2)— 
(A) in subsection (c)— 
(i) in paragraph (2), by striking 
‘‘group health plan’’ each place that such 
term appears and inserting ‘‘group or indi-
vidual health plan’’; and 
(ii) in paragraph (3)— 
(I) by striking ‘‘group health in-
surance’’ each place that such term 
appears and inserting ‘‘group or indi-
vidual health insurance’’; and 
(II) in subparagraph (D), by 
striking ‘‘small or large’’ and insert-
ing ‘‘individual or group’’; 
(B) in subsection (d), by striking ‘‘group 
health insurance’’ each place that such term ap-
pears and inserting ‘‘group or individual health 
insurance’’; and 
(C) in subsection (e)(1)(A), by striking 
‘‘group health insurance’’ and inserting ‘‘group 
or individual health insurance’’; 
(2) by striking the second heading for subpart 
2 of part A (relating to other requirements); 
VerDate Nov 24 2008 
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381 
•AMDT. NO. 2786 
(3) in section 2725 (42 U.S.C. 300gg-4), as so 
redesignated by section 1001(2)— 
(A) in subsection (a), by striking ‘‘health 
insurance issuer offering group health insur-
ance coverage’’ and inserting ‘‘health insurance 
issuer offering group or individual health insur-
ance coverage’’; 
(B) in subsection (b)— 
(i) by striking ‘‘health insurance 
issuer offering group health insurance cov-
erage in connection with a group health 
plan’’ in the matter preceding paragraph 
(1) and inserting ‘‘health insurance issuer 
offering group or individual health insur-
ance coverage’’; and 
(ii) in paragraph (1), by striking 
‘‘plan’’ and inserting ‘‘plan or coverage’’; 
(C) in subsection (c)— 
(i) in paragraph (2), by striking 
‘‘group health insurance coverage offered 
by a health insurance issuer’’ and inserting 
‘‘health insurance issuer offering group or 
individual health insurance coverage’’; and 
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382 
•AMDT. NO. 2786 
(ii) in paragraph (3), by striking 
‘‘issuer’’ and inserting ‘‘health insurance 
issuer’’; and 
(D) in subsection (e), by striking ‘‘health 
insurance issuer offering group health insur-
ance coverage’’ and inserting ‘‘health insurance 
issuer offering group or individual health insur-
ance coverage’’; 
(4) in section 2726 (42 U.S.C. 300gg-5), as so 
redesignated by section 1001(2)— 
(A) in subsection (a), by striking ‘‘(or 
health insurance coverage offered in connection 
with such a plan)’’ each place that such term 
appears and inserting ‘‘or a health insurance 
issuer offering group or individual health insur-
ance coverage’’; 
(B) in subsection (b), by striking ‘‘(or 
health insurance coverage offered in connection 
with such a plan)’’ each place that such term 
appears and inserting ‘‘or a health insurance 
issuer offering group or individual health insur-
ance coverage’’; and 
(C) in subsection (c)— 
(i) in paragraph (1), by striking ‘‘(and 
group health insurance coverage offered in 
VerDate Nov 24 2008 
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383 
•AMDT. NO. 2786 
connection with a group health plan)’’ and 
inserting ‘‘and a health insurance issuer 
offering group or individual health insur-
ance coverage’’; 
(ii) in paragraph (2), by striking ‘‘(or 
health insurance coverage offered in con-
nection with such a plan)’’ each place that 
such term appears and inserting ‘‘or a 
health insurance issuer offering group or 
individual health insurance coverage’’; 
(5) in section 2727 (42 U.S.C. 300gg-6), as so 
redesignated by section 1001(2), by striking ‘‘health 
insurance issuers providing health insurance cov-
erage in connection with group health plans’’ and in-
serting ‘‘and health insurance issuers offering group 
or individual health insurance coverage’’; 
(6) in section 2728 (42 U.S.C. 300gg-7), as so 
redesignated by section 1001(2)— 
(A) in subsection (a), by striking ‘‘health 
insurance coverage offered in connection with 
such plan’’ and inserting ‘‘individual health in-
surance coverage’’; 
(B) in subsection (b)— 
(i) in paragraph (1), by striking ‘‘or a 
health insurance issuer that provides 
VerDate Nov 24 2008 
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384 
•AMDT. NO. 2786 
health insurance coverage in connection 
with a group health plan’’ and inserting 
‘‘or a health insurance issuer that offers 
group or individual health insurance cov-
erage’’; 
(ii) in paragraph (2), by striking 
‘‘health insurance coverage offered in con-
nection with the plan’’ and inserting ‘‘indi-
vidual health insurance coverage’’; and 
(iii) in paragraph (3), by striking 
‘‘health insurance coverage offered by an 
issuer in connection with such plan’’ and 
inserting ‘‘individual health insurance cov-
erage’’; 
(C) in subsection (c), by striking ‘‘health 
insurance issuer providing health insurance cov-
erage in connection with a group health plan’’ 
and inserting ‘‘health insurance issuer that of-
fers group or individual health insurance cov-
erage’’; and 
(D) in subsection (e)(1), by striking 
‘‘health insurance coverage offered in connec-
tion with such a plan’’ and inserting ‘‘individual 
health insurance coverage’’; 
(7) by striking the heading for subpart 3; 
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385 
•AMDT. NO. 2786 
(8) in section 2731 (42 U.S.C. 300gg-11), as so 
redesignated by section 1001(3)— 
(A) by striking the section heading and all 
that follows through subsection (b); 
(B) in subsection (c)— 
(i) in paragraph (1)— 
(I) in the matter preceding sub-
paragraph (A), by striking ‘‘small 
group’’ and inserting ‘‘group and indi-
vidual’’; and 
(II) in subparagraph (B)— 
(aa) in the matter preceding 
clause (i), by inserting ‘‘and indi-
viduals’’ after ‘‘employers’’; 
(bb) in clause (i), by insert-
ing ‘‘or any additional individ-
uals’’ after ‘‘additional groups’’; 
and 
(cc) in clause (ii), by strik-
ing ‘‘without regard to the claims 
experience of those employers 
and their employees (and their 
dependents) or any health status- 
related factor relating to such’’ 
and inserting ‘‘and individuals 
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386 
•AMDT. NO. 2786 
without regard to the claims ex-
perience of those individuals, em-
ployers and their employees (and 
their dependents) or any health 
status-related factor relating to 
such individuals’’; and 
(ii) in paragraph (2), by striking 
‘‘small group’’ and inserting ‘‘group or in-
dividual’’; 
(C) in subsection (d)— 
(i) by striking ‘‘small group’’ each 
place that such appears and inserting 
‘‘group or individual’’; and 
(ii) in paragraph (1)(B)— 
(I) by striking ‘‘all employers’’ 
and inserting ‘‘all employers and indi-
viduals’’; 
(II) by striking ‘‘those employ-
ers’’ and inserting ‘‘those individuals, 
employers’’; and 
(III) by striking ‘‘such employ-
ees’’ and inserting ‘‘such individuals, 
employees’’; 
(D) by striking subsection (e); 
(E) by striking subsection (f); and 
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387 
•AMDT. NO. 2786 
(F) by transferring such section (as 
amended by this paragraph) to appear at the 
end of section 2702 (as added by section 
1001(4)); 
(9) in section 2732 (42 U.S.C. 300gg-12), as so 
redesignated by section 1001(3)— 
(A) by striking the section heading and all 
that follows through subsection (a); 
(B) in subsection (b)— 
(i) in the matter preceding paragraph 
(1), by striking ‘‘group health plan in the 
small or large group market’’ and inserting 
‘‘health insurance coverage offered in the 
group or individual market’’; 
(ii) in paragraph (1), by inserting ‘‘, 
or individual, as applicable,’’ after ‘‘plan 
sponsor’’; 
(iii) in paragraph (2), by inserting ‘‘, 
or individual, as applicable,’’ after ‘‘plan 
sponsor’’; and 
(iv) by striking paragraph (3) and in-
serting the following: 
‘‘(3) VIOLATION
OF
PARTICIPATION
OR
CON-
TRIBUTION RATES.—In the case of a group health 
plan, the plan sponsor has failed to comply with a 
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388 
•AMDT. NO. 2786 
material plan provision relating to employer con-
tribution or group participation rules, pursuant to 
applicable State law.’’; 
(C) in subsection (c)— 
(i) in paragraph (1)— 
(I) in the matter preceding sub-
paragraph (A), by striking ‘‘group 
health insurance coverage offered in 
the small or large group market’’ and 
inserting ‘‘group or individual health 
insurance coverage’’; 
(II) in subparagraph (A), by in-
serting ‘‘or individual, as applicable,’’ 
after ‘‘plan sponsor’’; 
(III) in subparagraph (B)— 
(aa) by inserting ‘‘or indi-
vidual, as applicable,’’ after ‘‘plan 
sponsor’’; and 
(bb) by inserting ‘‘or indi-
vidual 
health 
insurance 
cov-
erage’’; and 
(IV) in subparagraph (C), by in-
serting ‘‘or individuals, as applicable,’’ 
after ‘‘those sponsors’’; and 
(ii) in paragraph (2)(A)— 
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389 
•AMDT. NO. 2786 
(I) in the matter preceding clause 
(i), by striking ‘‘small group market 
or the large group market, or both 
markets,’’ and inserting ‘‘individual or 
group market, or all markets,’’; and 
(II) in clause (i), by inserting ‘‘or 
individual, as applicable,’’ after ‘‘plan 
sponsor’’; and 
(D) by transferring such section (as 
amended by this paragraph) to appear at the 
end of section 2703 (as added by section 
1001(4)); 
(10) in section 2733 (42 U.S.C. 300gg-13), as 
so redesignated by section 1001(4)— 
(A) in subsection (a)— 
(i) in the matter preceding paragraph 
(1), by striking ‘‘small employer’’ and in-
serting ‘‘small employer or an individual’’; 
(ii) in paragraph (1), by inserting ‘‘, 
or individual, as applicable,’’ after ‘‘em-
ployer’’ each place that such appears; and 
(iii) in paragraph (2), by striking 
‘‘small employer’’ and inserting ‘‘employer, 
or individual, as applicable,’’; 
(B) in subsection (b)— 
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390 
•AMDT. NO. 2786 
(i) in paragraph (1)— 
(I) in the matter preceding sub-
paragraph (A), by striking ‘‘small em-
ployer’’ and inserting ‘‘employer, or 
individual, as applicable,’’; 
(II) in subparagraph (A), by add-
ing ‘‘and’’ at the end; 
(III) by striking subparagraphs 
(B) and (C); and 
(IV) in subparagraph (D)— 
(aa) by inserting ‘‘, or indi-
vidual, as applicable,’’ after ‘‘em-
ployer’’; and 
(bb) by redesignating such 
subparagraph as subparagraph 
(B); 
(ii) in paragraph (2)— 
(I) by striking ‘‘small employers’’ 
each place that such term appears 
and inserting ‘‘employers, or individ-
uals, as applicable,’’; and 
(II) by striking ‘‘small employer’’ 
and inserting ‘‘employer, or indi-
vidual, as applicable,’’; and 
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391 
•AMDT. NO. 2786 
(C) by redesignating such section (as 
amended by this paragraph) as section 2709 
and transferring such section to appear after 
section 2708 (as added by section 1001(5)); 
(11) by redesignating subpart 4 as subpart 2; 
(12) in section 2735 (42 U.S.C. 300gg-21), as 
so redesignated by section 1001(4)— 
(A) by striking subsection (a); 
(B) by striking ‘‘subparts 1 through 3’’ 
each place that such appears and inserting 
‘‘subpart 1’’; 
(C) 
by 
redesignating 
subsections 
(b) 
through (e) as subsections (a) through (d), re-
spectively; and 
(D) by redesignating such section (as 
amended by this paragraph) as section 2722; 
(13) in section 2736 (42 U.S.C. 300gg-22), as 
so redesignated by section 1001(4)— 
(A) in subsection (a)— 
(i) in paragraph (1), by striking 
‘‘small or large group markets’’ and insert-
ing ‘‘individual or group market’’; and 
(ii) in paragraph (2), by inserting ‘‘or 
individual health insurance coverage’’ after 
‘‘group health plans’’; 
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392 
•AMDT. NO. 2786 
(B) in subsection (b)(1)(B), by inserting 
‘‘individual health insurance coverage or’’ after 
‘‘respect to’’; and 
(C) by redesignating such section (as 
amended by this paragraph) as section 2723; 
(14) in section 2737(a)(1) (42 U.S.C. 300gg- 
23), as so redesignated by section 1001(4)— 
(A) by inserting ‘‘individual or’’ before 
‘‘group health insurance’’; and 
(B) by redesignating such section(as 
amended by this paragraph) as section 2724; 
(15) in section 2762 (42 U.S.C. 300gg-62)— 
(A) in the section heading by inserting 
‘‘AND APPLICATION’’ before the period; and 
(B) by adding at the end the following: 
‘‘(c) APPLICATION OF PART A PROVISIONS.— 
‘‘(1) IN GENERAL.—The provisions of part A 
shall apply to health insurance issuers providing 
health insurance coverage in the individual market 
in a State as provided for in such part. 
‘‘(2) CLARIFICATION.—To the extent that any 
provision of this part conflicts with a provision of 
part A with respect to health insurance issuers pro-
viding health insurance coverage in the individual 
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393 
•AMDT. NO. 2786 
market in a State, the provisions of such part A 
shall apply.’’; and 
(16) in section 2791(e) (42 U.S.C. 300gg- 
91(e))— 
(A) in paragraph (2), by striking ‘‘51’’ and 
inserting ‘‘101’’; and 
(B) in paragraph (4)— 
(i) by striking ‘‘at least 2’’ each place 
that such appears and inserting ‘‘at least 
1’’; and 
(ii) by striking ‘‘50’’ and inserting 
‘‘100’’. 
(d) APPLICATION.—Notwithstanding any other provi-
sion of the Patient Protection and Affordable Care Act, 
nothing in such Act (or an amendment made by such Act) 
shall be construed to— 
(1) prohibit (or authorize the Secretary of 
Health and Human Services to promulgate regula-
tions that prohibit) a group health plan or health in-
surance issuer from carrying out utilization manage-
ment techniques that are commonly used as of the 
date of enactment of this Act; or 
(2) restrict the application of the amendments 
made by this subtitle. 
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394 
•AMDT. NO. 2786 
(e) TECHNICAL AMENDMENT
TO
THE EMPLOYEE 
RETIREMENT INCOME SECURITY ACT OF 1974.—Subpart 
B of part 7 of subtitle A of title I of the Employee Retire-
ment Income Security Act of 1974 (29 U.S.C. 1181 et. 
seq.) is amended, by adding at the end the following: 
‘‘SEC. 715. ADDITIONAL MARKET REFORMS. 
‘‘(a) GENERAL RULE.—Except as provided in sub-
section (b)— 
‘‘(1) the provisions of part A of title XXVII of 
the Public Health Service Act (as amended by the 
Patient Protection and Affordable Care Act) shall 
apply to group health plans, and health insurance 
issuers providing health insurance coverage in con-
nection with group health plans, as if included in 
this subpart; and 
‘‘(2) to the extent that any provision of this 
part conflicts with a provision of such part A with 
respect to group health plans, or health insurance 
issuers providing health insurance coverage in con-
nection with group health plans, the provisions of 
such part A shall apply. 
‘‘(b) EXCEPTION.—Notwithstanding subsection (a), 
the provisions of sections 2716 and 2718 of title XXVII 
of the Public Health Service Act (as amended by the Pa-
tient Protection and Affordable Care Act) shall not apply 
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395 
•AMDT. NO. 2786 
with respect to self-insured group health plans, and the 
provisions of this part shall continue to apply to such 
plans as if such sections of the Public Health Service Act 
(as so amended) had not been enacted.’’. 
(f) TECHNICAL AMENDMENT
TO
THE INTERNAL 
REVENUE CODE OF 1986.—Subchapter B of chapter 100 
of the Internal Revenue Code of 1986 is amended by add-
ing at the end the following: 
‘‘SEC. 9815. ADDITIONAL MARKET REFORMS. 
‘‘(a) GENERAL RULE.—Except as provided in sub-
section (b)— 
‘‘(1) the provisions of part A of title XXVII of 
the Public Health Service Act (as amended by the 
Patient Protection and Affordable Care Act) shall 
apply to group health plans, and health insurance 
issuers providing health insurance coverage in con-
nection with group health plans, as if included in 
this subchapter; and 
‘‘(2) to the extent that any provision of this 
subchapter conflicts with a provision of such part A 
with respect to group health plans, or health insur-
ance issuers providing health insurance coverage in 
connection with group health plans, the provisions of 
such part A shall apply. 
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396 
•AMDT. NO. 2786 
‘‘(b) EXCEPTION.—Notwithstanding subsection (a), 
the provisions of sections 2716 and 2718 of title XXVII 
of the Public Health Service Act (as amended by the Pa-
tient Protection and Affordable Care Act) shall not apply 
with respect to self-insured group health plans, and the 
provisions of this subchapter shall continue to apply to 
such plans as if such sections of the Public Health Service 
Act (as so amended) had not been enacted.’’. 
TITLE II—ROLE OF PUBLIC 
PROGRAMS 
Subtitle A—Improved Access to 
Medicaid 
SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME 
POPULATIONS. 
(a) COVERAGE FOR INDIVIDUALS WITH INCOME AT 
OR BELOW 133 PERCENT OF THE POVERTY LINE.— 
(1) 
BEGINNING
2014.—Section 
1902(a)(10)(A)(i) of the Social Security Act (42 
U.S.C. 1396a) is amended— 
(A) by striking ‘‘or’’ at the end of sub-
clause (VI); 
(B) by adding ‘‘or’’ at the end of subclause 
(VII); and 
(C) by inserting after subclause (VII) the 
following: 
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397 
•AMDT. NO. 2786 
‘‘(VIII) beginning January 1, 
2014, who are under 65 years of age, 
not pregnant, not entitled to, or en-
rolled for, benefits under part A of 
title XVIII, or enrolled for benefits 
under part B of title XVIII, and are 
not described in a previous subclause 
of this clause, and whose income (as 
determined under subsection (e)(14)) 
does not exceed 133 percent of the 
poverty line (as defined in section 
2110(c)(5)) applicable to a family of 
the size involved, subject to subsection 
(k);’’. 
(2) PROVISION OF AT LEAST MINIMUM ESSEN-
TIAL COVERAGE.— 
(A) IN GENERAL.—Section 1902 of such 
Act (42 U.S.C. 1396a) is amended by inserting 
after subsection (j) the following: 
‘‘(k)(1) The medical assistance provided to an indi-
vidual described in subclause (VIII) of subsection 
(a)(10)(A)(i) shall consist of benchmark coverage de-
scribed in section 1937(b)(1) or benchmark equivalent 
coverage described in section 1937(b)(2). Such medical as-
sistance shall be provided subject to the requirements of 
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398 
•AMDT. NO. 2786 
section 1937, without regard to whether a State otherwise 
has elected the option to provide medical assistance 
through coverage under that section, unless an individual 
described in subclause (VIII) of subsection (a)(10)(A)(i) 
is also an individual for whom, under subparagraph (B) 
of section 1937(a)(2), the State may not require enroll-
ment in benchmark coverage described in subsection 
(b)(1) of section 1937 or benchmark equivalent coverage 
described in subsection (b)(2) of that section.’’. 
(B) CONFORMING
AMENDMENT.—Section 
1903(i) of the Social Security Act, as amended 
by section 6402(c), is amended— 
(i) in paragraph (24), by striking ‘‘or’’ 
at the end; 
(ii) in paragraph (25), by striking the 
period and inserting ‘‘; or’’; and 
(iii) by adding at the end the fol-
lowing: 
‘‘(26) with respect to any amounts expended for 
medical assistance for individuals described in sub-
clause (VIII) of subsection (a)(10)(A)(i) other than 
medical assistance provided through benchmark cov-
erage described in section 1937(b)(1) or benchmark 
equivalent 
coverage 
described 
in 
section 
1937(b)(2).’’. 
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399 
•AMDT. NO. 2786 
(3) FEDERAL FUNDING FOR COST OF COVERING 
NEWLY
ELIGIBLE
INDIVIDUALS.—Section 1905 of 
the Social Security Act (42 U.S.C. 1396d), is 
amended— 
(A) in subsection (b), in the first sentence, 
by inserting ‘‘subsection (y) and’’ before ‘‘sec-
tion 1933(d)’’; and 
(B) by adding at the end the following new 
subsection: 
‘‘(y) INCREASED FMAP FOR MEDICAL ASSISTANCE 
FOR NEWLY ELIGIBLE MANDATORY INDIVIDUALS.— 
‘‘(1) AMOUNT OF INCREASE.— 
‘‘(A) 100 PERCENT FMAP.—During the pe-
riod that begins on January 1, 2014, and ends 
on December 31, 2016, notwithstanding sub-
section (b), the Federal medical assistance per-
centage determined for a State that is one of 
the 50 States or the District of Columbia for 
each fiscal year occurring during that period 
with respect to amounts expended for medical 
assistance for newly eligible individuals de-
scribed 
in 
subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i) shall be equal to 100 percent. 
‘‘(B) 2017 AND 2018.— 
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400 
•AMDT. NO. 2786 
‘‘(i) IN GENERAL.—During the period 
that begins on January 1, 2017, and ends 
on December 31, 2018, notwithstanding 
subsection (b) and subject to subparagraph 
(D), the Federal medical assistance per-
centage determined for a State that is one 
of the 50 States or the District of Colum-
bia for each fiscal year occurring during 
that period with respect to amounts ex-
pended for medical assistance for newly eli-
gible individuals described in subclause 
(VIII) of section 1902(a)(10)(A)(i), shall 
be increased by the applicable percentage 
point increase specified in clause (ii) for 
the quarter and the State. 
‘‘(ii) APPLICABLE PERCENTAGE POINT 
INCREASE.— 
‘‘(I) IN GENERAL.—For purposes 
of clause (i), the applicable percentage 
point increase for a quarter is the fol-
lowing: 
‘‘For any fiscal year 
quarter occurring in 
the calendar year: 
If the State is an ex-
pansion State, the 
applicable percent-
age point increase 
is: 
If the State is not an 
expansion State, the 
applicable percent-
age point increase is: 
2017 
30.3 
34.3 
2018 
31.3 
33.3 
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401 
•AMDT. NO. 2786 
‘‘(II) EXPANSION
STATE
DE-
FINED.—For purposes of the table in 
subclause (I), a State is an expansion 
State if, on the date of the enactment 
of the Patient Protection and Afford-
able Care Act, the State offers health 
benefits coverage statewide to parents 
and nonpregnant, childless adults 
whose income is at least 100 percent 
of the poverty line, that is not depend-
ent on access to employer coverage, 
employer contribution, or employment 
and is not limited to premium assist-
ance, hospital-only benefits, a high de-
ductible health plan, or alternative 
benefits under a demonstration pro-
gram authorized under section 1938. 
A State that offers health benefits 
coverage to only parents or only non-
pregnant childless adults described in 
the preceding sentence shall not be 
considered to be an expansion State. 
‘‘(C) 2019 AND SUCCEEDING YEARS.—Be-
ginning January 1, 2019, notwithstanding sub-
section (b) but subject to subparagraph (D), 
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402 
•AMDT. NO. 2786 
the Federal medical assistance percentage de-
termined for a State that is one of the 50 
States or the District of Columbia for each fis-
cal year quarter occurring during that period 
with respect to amounts expended for medical 
assistance for newly eligible individuals de-
scribed 
in 
subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i), shall be increased by 32.3 
percentage points. 
‘‘(D) LIMITATION.—The Federal medical 
assistance percentage determined for a State 
under subparagraph (B) or (C) shall in no case 
be more than 95 percent. 
‘‘(2) DEFINITIONS.—In this subsection: 
‘‘(A) NEWLY ELIGIBLE.—The term ‘newly 
eligible’ means, with respect to an individual de-
scribed 
in 
subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i), an individual who is not 
under 19 years of age (or such higher age as 
the State may have elected) and who, on the 
date of enactment of the Patient Protection and 
Affordable Care Act, is not eligible under the 
State plan or under a waiver of the plan for full 
benefits or for benchmark coverage described in 
subparagraph (A), (B), or (C) of section 
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403 
•AMDT. NO. 2786 
1937(b)(1) or benchmark equivalent coverage 
described in section 1937(b)(2) that has an ag-
gregate actuarial value that is at least actuari-
ally equivalent to benchmark coverage described 
in subparagraph (A), (B), or (C) of section 
1937(b)(1), or is eligible but not enrolled (or is 
on a waiting list) for such benefits or coverage 
through a waiver under the plan that has a 
capped or limited enrollment that is full. 
‘‘(B) FULL
BENEFITS.—The term ‘full 
benefits’ means, with respect to an individual, 
medical assistance for all services covered under 
the State plan under this title that is not less 
in amount, duration, or scope, or is determined 
by the Secretary to be substantially equivalent, 
to the medical assistance available for an indi-
vidual described in section 1902(a)(10)(A)(i).’’. 
(4) STATE OPTIONS TO OFFER COVERAGE EAR-
LIER
AND
PRESUMPTIVE
ELIGIBILITY; CHILDREN 
REQUIRED TO HAVE COVERAGE FOR PARENTS TO BE 
ELIGIBLE.— 
(A) IN GENERAL.—Subsection (k) of sec-
tion 1902 of the Social Security Act (as added 
by paragraph (2)), is amended by inserting 
after paragraph (1) the following: 
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404 
•AMDT. NO. 2786 
‘‘(2) Beginning with the first day of any fiscal year 
quarter that begins on or after January 1, 2011, and be-
fore January 1, 2014, a State may elect through a State 
plan amendment to provide medical assistance to individ-
uals who would be described in subclause (VIII) of sub-
section (a)(10)(A)(i) if that subclause were effective before 
January 1, 2014. A State may elect to phase-in the exten-
sion of eligibility for medical assistance to such individuals 
based on income, so long as the State does not extend 
such eligibility to individuals described in such subclause 
with higher income before making individuals described in 
such subclause with lower income eligible for medical as-
sistance. 
‘‘(3) If an individual described in subclause (VIII) of 
subsection (a)(10)(A)(i) is the parent of a child who is 
under 19 years of age (or such higher age as the State 
may have elected) who is eligible for medical assistance 
under the State plan or under a waiver of such plan 
(under that subclause or under a State plan amendment 
under paragraph (2), the individual may not be enrolled 
under the State plan unless the individual’s child is en-
rolled under the State plan or under a waiver of the plan 
or is enrolled in other health insurance coverage. For pur-
poses of the preceding sentence, the term ‘parent’ includes 
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405 
•AMDT. NO. 2786 
an individual treated as a caretaker relative for purposes 
of carrying out section 1931.’’. 
(B) PRESUMPTIVE
ELIGIBILITY.—Section 
1920 of the Social Security Act (42 U.S.C. 
1396r–1) is amended by adding at the end the 
following: 
‘‘(e) If the State has elected the option to provide 
a presumptive eligibility period under this section or sec-
tion 1920A, the State may elect to provide a presumptive 
eligibility period (as defined in subsection (b)(1)) for indi-
viduals who are eligible for medical assistance under 
clause (i)(VIII) of subsection (a)(10)(A) or section 1931 
in the same manner as the State provides for such a pe-
riod under this section or section 1920A, subject to such 
guidance as the Secretary shall establish.’’. 
(5) CONFORMING AMENDMENTS.— 
(A) Section 1902(a)(10) of such Act (42 
U.S.C. 1396a(a)(10)) is amended in the matter 
following subparagraph (G), by striking ‘‘and 
(XIV)’’ and inserting ‘‘(XIV)’’ and by inserting 
‘‘and (XV) the medical assistance made avail-
able to an individual described in subparagraph 
(A)(i)(VIII) shall be limited to medical assist-
ance described in subsection (k)(1)’’ before the 
semicolon. 
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406 
•AMDT. NO. 2786 
(B) Section 1902(l)(2)(C) of such Act (42 
U.S.C. 1396a(l)(2)(C)) is amended by striking 
‘‘100’’ and inserting ‘‘133’’. 
(C) Section 1905(a) of such Act (42 
U.S.C. 1396d(a)) is amended in the matter pre-
ceding paragraph (1)— 
(i) by striking ‘‘or’’ at the end of 
clause (xii); 
(ii) by inserting ‘‘or’’ at the end of 
clause (xiii); and 
(iii) by inserting after clause (xiii) the 
following: 
‘‘(xiv) 
individuals 
described 
in 
section 
1902(a)(10)(A)(i)(VIII),’’. 
(D) Section 1903(f)(4) of such Act (42 
U.S.C. 1396b(f)(4)) is amended by inserting 
‘‘1902(a)(10)(A)(i)(VIII),’’ 
after 
‘‘1902(a)(10)(A)(i)(VII),’’. 
(E) Section 1937(a)(1)(B) of such Act (42 
U.S.C. 1396u–7(a)(1)(B)) is amended by in-
serting 
‘‘subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i) or under’’ after ‘‘eligible 
under’’. 
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407 
•AMDT. NO. 2786 
(b) MAINTENANCE
OF MEDICAID INCOME ELIGI-
BILITY.—Section 1902 of the Social Security Act (42 
U.S.C. 1396a) is amended— 
(1) in subsection (a)— 
(A) by striking ‘‘and’’ at the end of para-
graph (72); 
(B) by striking the period at the end of 
paragraph (73) and inserting ‘‘; and’’; and 
(C) by inserting after paragraph (73) the 
following new paragraph: 
‘‘(74) provide for maintenance of effort under 
the State plan or under any waiver of the plan in 
accordance with subsection (gg).’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(gg) MAINTENANCE OF EFFORT.— 
‘‘(1) GENERAL
REQUIREMENT
TO
MAINTAIN 
ELIGIBILITY STANDARDS UNTIL STATE EXCHANGE IS 
FULLY
OPERATIONAL.—Subject to the succeeding 
paragraphs of this subsection, during the period that 
begins on the date of enactment of the Patient Pro-
tection and Affordable Care Act and ends on the 
date on which the Secretary determines that an Ex-
change established by the State under section 1311 
of the Patient Protection and Affordable Care Act is 
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408 
•AMDT. NO. 2786 
fully operational, as a condition for receiving any 
Federal payments under section 1903(a) for cal-
endar quarters occurring during such period, a State 
shall not have in effect eligibility standards, meth-
odologies, or procedures under the State plan under 
this title or under any waiver of such plan that is 
in effect during that period, that are more restrictive 
than the eligibility standards, methodologies, or pro-
cedures, respectively, under the plan or waiver that 
are in effect on the date of enactment of the Patient 
Protection and Affordable Care Act. 
‘‘(2) CONTINUATION
OF
ELIGIBILITY
STAND-
ARDS FOR CHILDREN UNTIL OCTOBER 1, 2019.—The 
requirement under paragraph (1) shall continue to 
apply to a State through September 30, 2019, with 
respect to the eligibility standards, methodologies, 
and procedures under the State plan under this title 
or under any waiver of such plan that are applicable 
to determining the eligibility for medical assistance 
of any child who is under 19 years of age (or such 
higher age as the State may have elected). 
‘‘(3) NONAPPLICATION.—During the period 
that begins on January 1, 2011, and ends on De-
cember 31, 2013, the requirement under paragraph 
(1) shall not apply to a State with respect to non-
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409 
•AMDT. NO. 2786 
pregnant, nondisabled adults who are eligible for 
medical assistance under the State plan or under a 
waiver of the plan at the option of the State and 
whose income exceeds 133 percent of the poverty 
line (as defined in section 2110(c)(5)) applicable to 
a family of the size involved if, on or after December 
31, 2010, the State certifies to the Secretary that, 
with respect to the State fiscal year during which 
the certification is made, the State has a budget def-
icit, or with respect to the succeeding State fiscal 
year, the State is projected to have a budget deficit. 
Upon submission of such a certification to the Sec-
retary, the requirement under paragraph (1) shall 
not apply to the State with respect to any remaining 
portion of the period described in the preceding sen-
tence. 
‘‘(4) DETERMINATION OF COMPLIANCE.— 
‘‘(A) STATES
SHALL
APPLY
MODIFIED 
GROSS INCOME.—A State’s determination of in-
come in accordance with subsection (e)(14) 
shall not be considered to be eligibility stand-
ards, methodologies, or procedures that are 
more restrictive than the standards, methodolo-
gies, or procedures in effect under the State 
plan or under a waiver of the plan on the date 
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•AMDT. NO. 2786 
of enactment of the Patient Protection and Af-
fordable Care Act for purposes of determining 
compliance with the requirements of paragraph 
(1), (2), or (3). 
‘‘(B) STATES MAY EXPAND ELIGIBILITY OR 
MOVE WAIVERED POPULATIONS INTO COVERAGE 
UNDER THE STATE PLAN.—With respect to any 
period applicable under paragraph (1), (2), or 
(3), a State that applies eligibility standards, 
methodologies, or procedures under the State 
plan under this title or under any waiver of the 
plan that are less restrictive than the eligibility 
standards, methodologies, or procedures, ap-
plied under the State plan or under a waiver of 
the plan on the date of enactment of the Pa-
tient Protection and Affordable Care Act, or 
that makes individuals who, on such date of en-
actment, are eligible for medical assistance 
under a waiver of the State plan, after such 
date of enactment eligible for medical assistance 
through a State plan amendment with an in-
come eligibility level that is not less than the in-
come eligibility level that applied under the 
waiver, or as a result of the application of sub-
clause (VIII) of section 1902(a)(10)(A)(i), shall 
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411 
•AMDT. NO. 2786 
not be considered to have in effect eligibility 
standards, methodologies, or procedures that 
are more restrictive than the standards, meth-
odologies, or procedures in effect under the 
State plan or under a waiver of the plan on the 
date of enactment of the Patient Protection and 
Affordable Care Act for purposes of deter-
mining compliance with the requirements of 
paragraph (1), (2), or (3).’’. 
(c) MEDICAID BENCHMARK BENEFITS MUST CON-
SIST OF AT LEAST MINIMUM ESSENTIAL COVERAGE.— 
Section 1937(b) of such Act (42 U.S.C. 1396u–7(b)) is 
amended— 
(1) in paragraph (1), in the matter preceding 
subparagraph (A), by inserting ‘‘subject to para-
graphs (5) and (6),’’ before ‘‘each’’; 
(2) in paragraph (2)— 
(A) in the matter preceding subparagraph 
(A), by inserting ‘‘subject to paragraphs (5) 
and (6)’’ after ‘‘subsection (a)(1),’’; 
(B) in subparagraph (A)— 
(i) by redesignating clauses (iv) and 
(v) as clauses (vi) and (vii), respectively; 
and 
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412 
•AMDT. NO. 2786 
(ii) by inserting after clause (iii), the 
following: 
‘‘(iv) Coverage of prescription drugs. 
‘‘(v) Mental health services.’’; and 
(C) in subparagraph (C)— 
(i) by striking clauses (i) and (ii); and 
(ii) by redesignating clauses (iii) and 
(iv) as clauses (i) and (ii), respectively; and 
(3) by adding at the end the following new 
paragraphs: 
‘‘(5) MINIMUM STANDARDS.—Effective January 
1, 2014, any benchmark benefit package under para-
graph (1) or benchmark equivalent coverage under 
paragraph (2) must provide at least essential health 
benefits as described in section 1302(b) of the Pa-
tient Protection and Affordable Care Act. 
‘‘(6) MENTAL HEALTH SERVICES PARITY.— 
‘‘(A) IN
GENERAL.—In the case of any 
benchmark benefit package under paragraph 
(1) or benchmark equivalent coverage under 
paragraph (2) that is offered by an entity that 
is not a medicaid managed care organization 
and that provides both medical and surgical 
benefits and mental health or substance use dis-
order benefits, the entity shall ensure that the 
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•AMDT. NO. 2786 
financial requirements and treatment limita-
tions applicable to such mental health or sub-
stance use disorder benefits comply with the re-
quirements of section 2705(a) of the Public 
Health Service Act in the same manner as such 
requirements apply to a group health plan. 
‘‘(B) 
DEEMED
COMPLIANCE.—Coverage 
provided with respect to an individual described 
in section 1905(a)(4)(B) and covered under the 
State plan under section 1902(a)(10)(A) of the 
services described in section 1905(a)(4)(B) (re-
lating to early and periodic screening, diag-
nostic, and treatment services defined in section 
1905(r)) and provided in accordance with sec-
tion 1902(a)(43), shall be deemed to satisfy the 
requirements of subparagraph (A).’’. 
(d) ANNUAL
REPORTS
ON
MEDICAID
ENROLL-
MENT.— 
(1) STATE REPORTS.—Section 1902(a) of the 
Social Security Act (42 U.S.C. 1396a(a)), as amend-
ed by subsection (b), is amended— 
(A) by striking ‘‘and’’ at the end of para-
graph (73); 
(B) by striking the period at the end of 
paragraph (74) and inserting ‘‘; and’’; and 
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414 
•AMDT. NO. 2786 
(C) by inserting after paragraph (74) the 
following new paragraph: 
‘‘(75) provide that, beginning January 2015, 
and annually thereafter, the State shall submit a re-
port to the Secretary that contains— 
‘‘(A) the total number of enrolled and 
newly enrolled individuals in the State plan or 
under a waiver of the plan for the fiscal year 
ending on September 30 of the preceding cal-
endar year, disaggregated by population, includ-
ing children, parents, nonpregnant childless 
adults, disabled individuals, elderly individuals, 
and such other categories or sub-categories of 
individuals eligible for medical assistance under 
the State plan or under a waiver of the plan as 
the Secretary may require; 
‘‘(B) a description, which may be specified 
by population, of the outreach and enrollment 
processes used by the State during such fiscal 
year; and 
‘‘(C) any other data reporting determined 
necessary by the Secretary to monitor enroll-
ment and retention of individuals eligible for 
medical assistance under the State plan or 
under a waiver of the plan.’’. 
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415 
•AMDT. NO. 2786 
(2) REPORTS TO CONGRESS.—Beginning April 
2015, and annually thereafter, the Secretary of 
Health and Human Services shall submit a report to 
the appropriate committees of Congress on the total 
enrollment and new enrollment in Medicaid for the 
fiscal year ending on September 30 of the preceding 
calendar year on a national and State-by-State 
basis, and shall include in each such report such rec-
ommendations for administrative or legislative 
changes to improve enrollment in the Medicaid pro-
gram as the Secretary determines appropriate. 
(e) STATE OPTION FOR COVERAGE FOR INDIVIDUALS 
WITH INCOME THAT EXCEEDS 133 PERCENT OF THE 
POVERTY LINE.— 
(1) COVERAGE
AS
OPTIONAL
CATEGORICALLY 
NEEDY GROUP.—Section 1902 of the Social Security 
Act (42 U.S.C. 1396a) is amended— 
(A) in subsection (a)(10)(A)(ii)— 
(i) in subclause (XVIII), by striking 
‘‘or’’ at the end; 
(ii) in subclause (XIX), by adding 
‘‘or’’ at the end; and 
(iii) by adding at the end the fol-
lowing new subclause: 
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•AMDT. NO. 2786 
‘‘(XX) 
beginning 
January 
1, 
2014, who are under 65 years of age 
and are not described in or enrolled 
under a previous subclause of this 
clause, and whose income (as deter-
mined under subsection (e)(14)) ex-
ceeds 133 percent of the poverty line 
(as defined in section 2110(c)(5)) ap-
plicable to a family of the size in-
volved but does not exceed the highest 
income eligibility level established 
under the State plan or under a waiv-
er of the plan, subject to subsection 
(hh);’’ and 
(B) by adding at the end the following new 
subsection: 
‘‘(hh)(1) A State may elect to phase-in the extension 
of eligibility for medical assistance to individuals described 
in subclause (XX) of subsection (a)(10)(A)(ii) based on 
the categorical group (including nonpregnant childless 
adults) or income, so long as the State does not extend 
such eligibility to individuals described in such subclause 
with higher income before making individuals described in 
such subclause with lower income eligible for medical as-
sistance. 
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•AMDT. NO. 2786 
‘‘(2) If an individual described in subclause (XX) of 
subsection (a)(10)(A)(ii) is the parent of a child who is 
under 19 years of age (or such higher age as the State 
may have elected) who is eligible for medical assistance 
under the State plan or under a waiver of such plan, the 
individual may not be enrolled under the State plan unless 
the individual’s child is enrolled under the State plan or 
under a waiver of the plan or is enrolled in other health 
insurance coverage. For purposes of the preceding sen-
tence, the term ‘parent’ includes an individual treated as 
a caretaker relative for purposes of carrying out section 
1931.’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1905(a) of such Act (42 
U.S.C. 1396d(a)), as amended by subsection 
(a)(5)(C), is amended in the matter preceding 
paragraph (1)— 
(i) by striking ‘‘or’’ at the end of 
clause (xiii); 
(ii) by inserting ‘‘or’’ at the end of 
clause (xiv); and 
(iii) by inserting after clause (xiv) the 
following: 
‘‘(xv) 
individuals 
described 
in 
section 
1902(a)(10)(A)(ii)(XX),’’. 
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418 
•AMDT. NO. 2786 
(B) Section 1903(f)(4) of such Act (42 
U.S.C. 1396b(f)(4)) is amended by inserting 
‘‘1902(a)(10)(A)(ii)(XX),’’ 
after 
‘‘1902(a)(10)(A)(ii)(XIX),’’. 
(C) Section 1920(e) of such Act (42 
U.S.C. 1396r–1(e)), as added by subsection 
(a)(4)(B), is amended by inserting ‘‘or clause 
(ii)(XX)’’ after ‘‘clause (i)(VIII)’’. 
SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETER-
MINED USING MODIFIED GROSS INCOME. 
(a) IN GENERAL.—Section 1902(e) of the Social Se-
curity Act (42 U.S.C. 1396a(e)) is amended by adding at 
the end the following: 
‘‘(14) INCOME DETERMINED USING MODIFIED 
GROSS INCOME.— 
‘‘(A) IN GENERAL.—Notwithstanding sub-
section (r) or any other provision of this title, 
except as provided in subparagraph (D), for 
purposes of determining income eligibility for 
medical assistance under the State plan or 
under any waiver of such plan and for any 
other purpose applicable under the plan or 
waiver for which a determination of income is 
required, including with respect to the imposi-
tion of premiums and cost-sharing, a State 
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419 
•AMDT. NO. 2786 
shall use the modified gross income of an indi-
vidual and, in the case of an individual in a 
family greater than 1, the household income of 
such family. A State shall establish income eli-
gibility thresholds for populations to be eligible 
for medical assistance under the State plan or 
a waiver of the plan using modified gross in-
come and household income that are not less 
than the effective income eligibility levels that 
applied under the State plan or waiver on the 
date of enactment of the Patient Protection and 
Affordable Care Act. For purposes of complying 
with the maintenance of effort requirements 
under subsection (gg) during the transition to 
modified gross income and household income, a 
State shall, working with the Secretary, estab-
lish an equivalent income test that ensures indi-
viduals eligible for medical assistance under the 
State plan or under a waiver of the plan on the 
date of enactment of the Patient Protection and 
Affordable Care Act, do not lose coverage under 
the State plan or under a waiver of the plan. 
The Secretary may waive such provisions of this 
title and title XXI as are necessary to ensure 
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420 
•AMDT. NO. 2786 
that States establish income and eligibility de-
termination systems that protect beneficiaries. 
‘‘(B) NO
INCOME
OR
EXPENSE
DIS-
REGARDS.—No type of expense, block, or other 
income disregard shall be applied by a State to 
determine income eligibility for medical assist-
ance under the State plan or under any waiver 
of such plan or for any other purpose applicable 
under the plan or waiver for which a determina-
tion of income is required. 
‘‘(C) NO ASSETS TEST.—A State shall not 
apply any assets or resources test for purposes 
of determining eligibility for medical assistance 
under the State plan or under a waiver of the 
plan. 
‘‘(D) EXCEPTIONS.— 
‘‘(i) INDIVIDUALS ELIGIBLE BECAUSE 
OF OTHER AID OR ASSISTANCE, ELDERLY 
INDIVIDUALS, MEDICALLY NEEDY INDIVID-
UALS, AND
INDIVIDUALS
ELIGIBLE
FOR 
MEDICARE
COST-SHARING.—Subpara-
graphs (A), (B), and (C) shall not apply to 
the determination of eligibility under the 
State plan or under a waiver for medical 
assistance for the following: 
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421 
•AMDT. NO. 2786 
‘‘(I) Individuals who are eligible 
for medical assistance under the State 
plan or under a waiver of the plan on 
a basis that does not require a deter-
mination of income by the State agen-
cy administering the State plan or 
waiver, including as a result of eligi-
bility for, or receipt of, other Federal 
or State aid or assistance, individuals 
who are eligible on the basis of receiv-
ing (or being treated as if receiving) 
supplemental security income benefits 
under title XVI, and individuals who 
are eligible as a result of being or 
being deemed to be a child in foster 
care under the responsibility of the 
State. 
‘‘(II) Individuals who have at-
tained age 65. 
‘‘(III) Individuals who qualify for 
medical assistance under the State 
plan or under any waiver of such plan 
on the basis of being blind or disabled 
(or being treated as being blind or 
disabled) without regard to whether 
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•AMDT. NO. 2786 
the individual is eligible for supple-
mental security income benefits under 
title XVI on the basis of being blind 
or disabled and including an indi-
vidual who is eligible for medical as-
sistance on the basis of section 
1902(e)(3). 
‘‘(IV) Individuals described in 
subsection (a)(10)(C). 
‘‘(V) Individuals described in any 
clause of subsection (a)(10)(E). 
‘‘(ii) EXPRESS
LANE
AGENCY
FIND-
INGS.—In the case of a State that elects 
the Express Lane option under paragraph 
(13), notwithstanding subparagraphs (A), 
(B), and (C), the State may rely on a find-
ing made by an Express Lane agency in 
accordance with that paragraph relating to 
the income of an individual for purposes of 
determining the individual’s eligibility for 
medical assistance under the State plan or 
under a waiver of the plan. 
‘‘(iii) MEDICARE PRESCRIPTION DRUG 
SUBSIDIES
DETERMINATIONS.—Subpara-
graphs (A), (B), and (C) shall not apply to 
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423 
•AMDT. NO. 2786 
any determinations of eligibility for pre-
mium and cost-sharing subsidies under 
and in accordance with section 1860D–14 
made by the State pursuant to section 
1935(a)(2). 
‘‘(iv) LONG-TERM
CARE.—Subpara-
graphs (A), (B), and (C) shall not apply to 
any determinations of eligibility of individ-
uals for purposes of medical assistance for 
nursing facility services, a level of care in 
any institution equivalent to that of nurs-
ing facility services, home or community- 
based services furnished under a waiver or 
State plan amendment under section 1915 
or a waiver under section 1115, and serv-
ices described in section 1917(c)(1)(C)(ii). 
‘‘(v) GRANDFATHER OF CURRENT EN-
ROLLEES UNTIL DATE OF NEXT REGULAR 
REDETERMINATION.—An individual who, 
on January 1, 2014, is enrolled in the 
State plan or under a waiver of the plan 
and who would be determined ineligible for 
medical assistance solely because of the ap-
plication of the modified gross income or 
household income standard described in 
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424 
•AMDT. NO. 2786 
subparagraph (A), shall remain eligible for 
medical assistance under the State plan or 
waiver (and subject to the same premiums 
and cost-sharing as applied to the indi-
vidual on that date) through March 31, 
2014, or the date on which the individual’s 
next regularly scheduled redetermination of 
eligibility is to occur, whichever is later. 
‘‘(E) TRANSITION
PLANNING
AND
OVER-
SIGHT.—Each State shall submit to the Sec-
retary for the Secretary’s approval the income 
eligibility thresholds proposed to be established 
using modified gross income and household in-
come, the methodologies and procedures to be 
used to determine income eligibility using modi-
fied gross income and household income and, if 
applicable, a State plan amendment establishing 
an optional eligibility category under subsection 
(a)(10)(A)(ii)(XX). To the extent practicable, 
the State shall use the same methodologies and 
procedures for purposes of making such deter-
minations as the State used on the date of en-
actment of the Patient Protection and Afford-
able Care Act. The Secretary shall ensure that 
the income eligibility thresholds proposed to be 
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425 
•AMDT. NO. 2786 
established using modified gross income and 
household income, including under the eligibility 
category 
established 
under 
subsection 
(a)(10)(A)(ii)(XX), and the methodologies and 
procedures proposed to be used to determine in-
come eligibility, will not result in children who 
would have been eligible for medical assistance 
under the State plan or under a waiver of the 
plan on the date of enactment of the Patient 
Protection and Affordable Care Act no longer 
being eligible for such assistance. 
‘‘(F) LIMITATION
ON
SECRETARIAL
AU-
THORITY.—The Secretary shall not waive com-
pliance with the requirements of this paragraph 
except to the extent necessary to permit a State 
to coordinate eligibility requirements for dual 
eligible individuals (as defined in section 
1915(h)(2)(B)) under the State plan or under 
a waiver of the plan and under title XVIII and 
individuals who require the level of care pro-
vided in a hospital, a nursing facility, or an in-
termediate care facility for the mentally re-
tarded. 
‘‘(G) DEFINITIONS
OF
MODIFIED
GROSS 
INCOME
AND
HOUSEHOLD
INCOME.—In this 
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426 
•AMDT. NO. 2786 
paragraph, the terms ‘modified gross income’ 
and ‘household income’ have the meanings 
given such terms in section 36B(d)(2) of the 
Internal Revenue Code of 1986. 
‘‘(H) CONTINUED APPLICATION OF MED-
ICAID
RULES
REGARDING
POINT-IN-TIME
IN-
COME AND SOURCES OF INCOME.—The require-
ment under this paragraph for States to use 
modified gross income and household income to 
determine income eligibility for medical assist-
ance under the State plan or under any waiver 
of such plan and for any other purpose applica-
ble under the plan or waiver for which a deter-
mination of income is required shall not be con-
strued as affecting or limiting the application 
of— 
‘‘(i) the requirement under this title 
and under the State plan or a waiver of 
the plan to determine an individual’s in-
come as of the point in time at which an 
application for medical assistance under 
the State plan or a waiver of the plan is 
processed; or 
‘‘(ii) any rules established under this 
title or under the State plan or a waiver of 
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•AMDT. NO. 2786 
the plan regarding sources of countable in-
come.’’. 
(b) 
CONFORMING
AMENDMENT.—Section 
1902(a)(17) of such Act (42 U.S.C. 1396a(a)(17)) is 
amended by inserting ‘‘(e)(14),’’ before ‘‘(l)(3)’’. 
(c) EFFECTIVE DATE.—The amendments made by 
subsections (a) and (b) take effect on January 1, 2014. 
SEC. 2003. REQUIREMENT TO OFFER PREMIUM ASSIST-
ANCE FOR EMPLOYER-SPONSORED INSUR-
ANCE. 
(a) IN GENERAL.—Section 1906A of such Act (42 
U.S.C. 1396e–1) is amended— 
(1) in subsection (a)— 
(A) by striking ‘‘may elect to’’ and insert-
ing ‘‘shall’’; 
(B) by striking ‘‘under age 19’’; and 
(C) by inserting ‘‘, in the case of an indi-
vidual under age 19,’’ after ‘‘(and’’; 
(2) in subsection (c), in the first sentence, by 
striking ‘‘under age 19’’; and 
(3) in subsection (d)— 
(A) in paragraph (2)— 
(i) in the first sentence, by striking 
‘‘under age 19’’; and 
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428 
•AMDT. NO. 2786 
(ii) by striking the third sentence and 
inserting ‘‘A State may not require, as a 
condition of an individual (or the individ-
ual’s parent) being or remaining eligible 
for medical assistance under this title, that 
the individual (or the individual’s parent) 
apply for enrollment in qualified employer- 
sponsored coverage under this section.’’; 
and 
(B) in paragraph (3), by striking ‘‘the par-
ent of an individual under age 19’’ and insert-
ing ‘‘an individual (or the parent of an indi-
vidual)’’; and 
(4) in subsection (e), by striking ‘‘under age 
19’’ each place it appears. 
(b) CONFORMING AMENDMENT.—The heading for 
section 1906A of such Act (42 U.S.C. 1396e–1) is amend-
ed by striking ‘‘OPTION FOR CHILDREN’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on January 1, 2014. 
SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER 
CARE CHILDREN. 
(a) IN GENERAL.—Section 1902(a)(10)(A)(i) of the 
Social Security Act (42 U.S.C. 1396a), as amended by 
section 2001(a)(1), is amended— 
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429 
•AMDT. NO. 2786 
(1) by striking ‘‘or’’ at the end of subclause 
(VII); 
(2) by adding ‘‘or’’ at the end of subclause 
(VIII); and 
(3) by inserting after subclause (VIII) the fol-
lowing: 
‘‘(IX) who were in foster care 
under the responsibility of a State for 
more than 6 months (whether or not 
consecutive) but are no longer in such 
care, who are not described in any of 
subclauses (I) through (VII) of this 
clause, and who are under 25 years of 
age;’’. 
(b) OPTION
TO
PROVIDE
PRESUMPTIVE
ELIGI-
BILITY.—Section 1920(e) of such Act (42 U.S.C. 1396r– 
1(e)), as added by section 2001(a)(4)(B) and amended by 
section 2001(e)(2)(C), is amended by inserting ‘‘, clause 
(i)(IX),’’ after ‘‘clause (i)(VIII)’’. 
(c) CONFORMING AMENDMENTS.— 
(1) Section 1903(f)(4) of such Act (42 U.S.C. 
1396b(f)(4)), as amended by section 2001(a)(5)(D), 
is amended by inserting ‘‘1902(a)(10)(A)(i)(IX),’’ 
after ‘‘1902(a)(10)(A)(i)(VIII),’’. 
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•AMDT. NO. 2786 
(2) Section 1937(a)(2)(B)(viii) of such Act (42 
U.S.C. 1396u–7(a)(2)(B)(viii)) is amended by in-
serting ‘‘, or the individual qualifies for medical as-
sistance 
on 
the 
basis 
of 
section 
1902(a)(10)(A)(i)(IX)’’ before the period. 
(d) EFFECTIVE DATE.—The amendments made by 
this section take effect on January 1, 2019. 
SEC. 2005. PAYMENTS TO TERRITORIES. 
(a) INCREASE
IN LIMIT
ON PAYMENTS.—Section 
1108(g) of the Social Security Act (42 U.S.C. 1308(g)) 
is amended— 
(1) in paragraph (2), in the matter preceding 
subparagraph (A), by striking ‘‘paragraph (3)’’ and 
inserting ‘‘paragraphs (3) and (5)’’; 
(2) in paragraph (4), by striking ‘‘and (3)’’ and 
inserting ‘‘(3), and (4)’’; and 
(3) by adding at the end the following para-
graph: 
‘‘(5) FISCAL YEAR 2011 AND THEREAFTER.— 
The amounts otherwise determined under this sub-
section for Puerto Rico, the Virgin Islands, Guam, 
the Northern Mariana Islands, and American Samoa 
for the second, third, and fourth quarters of fiscal 
year 2011, and for each fiscal year after fiscal year 
2011 (after the application of subsection (f) and the 
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431 
•AMDT. NO. 2786 
preceding paragraphs of this subsection), shall be in-
creased by 30 percent.’’. 
(b) DISREGARD OF PAYMENTS FOR MANDATORY EX-
PANDED ENROLLMENT.—Section 1108(g)(4) of such Act 
(42 U.S.C. 1308(g)(4)) is amended— 
(1) by striking ‘‘to fiscal years beginning’’ and 
inserting ‘‘to— 
‘‘(A) fiscal years beginning’’; 
(2) by striking the period at the end and insert-
ing ‘‘; and’’; and 
(3) by adding at the end the following: 
‘‘(B) fiscal years beginning with fiscal year 
2014, payments made to Puerto Rico, the Vir-
gin Islands, Guam, the Northern Mariana Is-
lands, or American Samoa with respect to 
amounts expended for medical assistance for 
newly eligible (as defined in section 1905(y)(2)) 
nonpregnant childless adults who are eligible 
under 
subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i) and whose income (as deter-
mined under section 1902(e)(14)) does not ex-
ceed (in the case of each such commonwealth 
and territory respectively) the income eligibility 
level in effect for that population under title 
XIX or under a waiver on the date of enact-
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•AMDT. NO. 2786 
ment of the Patient Protection and Affordable 
Care Act, shall not be taken into account in ap-
plying subsection (f) (as increased in accord-
ance with paragraphs (1), (2), (3), and (5) of 
this subsection) to such commonwealth or terri-
tory for such fiscal year.’’. 
(c) INCREASED FMAP.— 
(1) IN GENERAL.—The first sentence of section 
1905(b) of the Social Security Act (42 U.S.C. 
1396d(b)) is amended by striking ‘‘shall be 50 per 
centum’’ and inserting ‘‘shall be 55 percent’’. 
(2) EFFECTIVE DATE.—The amendment made 
by paragraph (1) takes effect on January 1, 2011. 
SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINA-
TION FOR CERTAIN STATES RECOVERING 
FROM A MAJOR DISASTER. 
Section 1905 of the Social Security Act (42 U.S.C. 
1396d), as amended by sections 2001(a)(3) and 
2001(b)(2), is amended— 
(1) in subsection (b), in the first sentence, by 
striking ‘‘subsection (y)’’ and inserting ‘‘subsections 
(y) and (aa)’’; and 
(2) by adding at the end the following new sub-
section: 
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•AMDT. NO. 2786 
‘‘(aa)(1) Notwithstanding subsection (b), beginning 
January 1, 2011, the Federal medical assistance percent-
age for a fiscal year for a disaster-recovery FMAP adjust-
ment State shall be equal to the following: 
‘‘(A) In the case of the first fiscal year (or part 
of a fiscal year) for which this subsection applies to 
the State, the Federal medical assistance percentage 
determined for the fiscal year without regard to this 
subsection and subsection (y), increased by 50 per-
cent of the number of percentage points by which 
the Federal medical assistance percentage deter-
mined for the State for the fiscal year without re-
gard to this subsection and subsection (y), is less 
than the Federal medical assistance percentage de-
termined for the State for the preceding fiscal year 
after the application of only subsection (a) of section 
5001 of Public Law 111–5 (if applicable to the pre-
ceding fiscal year) and without regard to this sub-
section, subsection (y), and subsections (b) and (c) 
of section 5001 of Public Law 111–5. 
‘‘(B) In the case of the second or any suc-
ceeding fiscal year for which this subsection applies 
to the State, the Federal medical assistance percent-
age determined for the preceding fiscal year under 
this subsection for the State, increased by 25 per-
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434 
•AMDT. NO. 2786 
cent of the number of percentage points by which 
the Federal medical assistance percentage deter-
mined for the State for the fiscal year without re-
gard to this subsection and subsection (y), is less 
than the Federal medical assistance percentage de-
termined for the State for the preceding fiscal year 
under this subsection. 
‘‘(2) In this subsection, the term ‘disaster-recovery 
FMAP adjustment State’ means a State that is one of 
the 50 States or the District of Columbia, for which, at 
any time during the preceding 7 fiscal years, the President 
has declared a major disaster under section 401 of the 
Robert T. Stafford Disaster Relief and Emergency Assist-
ance Act and determined as a result of such disaster that 
every county or parish in the State warrant individual and 
public assistance or public assistance from the Federal 
Government under such Act and for which— 
‘‘(A) in the case of the first fiscal year (or part 
of a fiscal year) for which this subsection applies to 
the State, the Federal medical assistance percentage 
determined for the State for the fiscal year without 
regard to this subsection and subsection (y), is less 
than the Federal medical assistance percentage de-
termined for the State for the preceding fiscal year 
after the application of only subsection (a) of section 
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435 
•AMDT. NO. 2786 
5001 of Public Law 111–5 (if applicable to the pre-
ceding fiscal year) and without regard to this sub-
section, subsection (y), and subsections (b) and (c) 
of section 5001 of Public Law 111–5, by at least 3 
percentage points; and 
‘‘(B) in the case of the second or any suc-
ceeding fiscal year for which this subsection applies 
to the State, the Federal medical assistance percent-
age determined for the State for the fiscal year with-
out regard to this subsection and subsection (y), is 
less than the Federal medical assistance percentage 
determined for the State for the preceding fiscal 
year under this subsection by at least 3 percentage 
points. 
‘‘(3) The Federal medical assistance percentage de-
termined for a disaster-recovery FMAP adjustment State 
under paragraph (1) shall apply for purposes of this title 
(other than with respect to disproportionate share hospital 
payments described in section 1923 and payments under 
this title that are based on the enhanced FMAP described 
in 2105(b)) and shall not apply with respect to payments 
under title IV (other than under part E of title IV) or 
payments under title XXI.’’. 
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436 
•AMDT. NO. 2786 
SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION. 
(a) RESCISSION.—Any amounts available to the Med-
icaid Improvement Fund established under section 1941 
of the Social Security Act (42 U.S.C. 1396w–1) for any 
of fiscal years 2014 through 2018 that are available for 
expenditure from the Fund and that are not so obligated 
as of the date of the enactment of this Act are rescinded. 
(b) 
CONFORMING
AMENDMENTS.—Section 
1941(b)(1) of the Social Security Act (42 U.S.C. 1396w– 
1(b)(1)) is amended— 
(1) 
in 
subparagraph 
(A), 
by 
striking 
‘‘$100,000,000’’ and inserting ‘‘$0’’; and 
(2) 
in 
subparagraph 
(B), 
by 
striking 
‘‘$150,000,000’’ and inserting ‘‘$0’’. 
Subtitle B—Enhanced Support for 
the Children’s Health Insurance 
Program 
SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPA-
TION FOR CHIP. 
(a) IN GENERAL.—Section 2105(b) of the Social Se-
curity Act (42 U.S.C. 1397ee(b)) is amended by adding 
at the end the following: ‘‘Notwithstanding the preceding 
sentence, during the period that begins on October 1, 
2013, and ends on September 30, 2019, the enhanced 
FMAP determined for a State for a fiscal year (or for 
any portion of a fiscal year occurring during such period) 
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437 
•AMDT. NO. 2786 
shall be increased by 23 percentage points, but in no case 
shall exceed 100 percent. The increase in the enhanced 
FMAP under the preceding sentence shall not apply with 
respect to determining the payment to a State under sub-
section (a)(1) for expenditures described in subparagraph 
(D)(iv), paragraphs (8), (9), (11) of subsection (c), or 
clause (4) of the first sentence of section 1905(b).’’. 
(b) MAINTENANCE OF EFFORT.— 
(1) IN GENERAL.—Section 2105(d) of the So-
cial Security Act (42 U.S.C. 1397ee(d)) is amended 
by adding at the end the following: 
‘‘(3) CONTINUATION
OF
ELIGIBILITY
STAND-
ARDS FOR CHILDREN UNTIL OCTOBER 1, 2019.— 
‘‘(A) IN
GENERAL.—During the period 
that begins on the date of enactment of the Pa-
tient Protection and Affordable Care Act and 
ends on September 30, 2019, a State shall not 
have in effect eligibility standards, methodolo-
gies, or procedures under its State child health 
plan (including any waiver under such plan) for 
children (including children provided medical 
assistance for which payment is made under 
section 2105(a)(1)(A)) that are more restrictive 
than the eligibility standards, methodologies, or 
procedures, respectively, under such plan (or 
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438 
•AMDT. NO. 2786 
waiver) as in effect on the date of enactment of 
that Act. The preceding sentence shall not be 
construed as preventing a State during such pe-
riod from— 
‘‘(i) applying eligibility standards, 
methodologies, or procedures for children 
under the State child health plan or under 
any waiver of the plan that are less restric-
tive than the eligibility standards, meth-
odologies, or procedures, respectively, for 
children under the plan or waiver that are 
in effect on the date of enactment of such 
Act; or 
‘‘(ii) imposing a limitation described 
in section 2112(b)(7) for a fiscal year in 
order to limit expenditures under the State 
child health plan to those for which Fed-
eral financial participation is available 
under this section for the fiscal year. 
‘‘(B) ASSURANCE
OF
EXCHANGE
COV-
ERAGE FOR TARGETED LOW-INCOME CHILDREN 
UNABLE TO BE PROVIDED CHILD HEALTH AS-
SISTANCE AS A RESULT OF FUNDING SHORT-
FALLS.—In the event that allotments provided 
under section 2104 are insufficient to provide 
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439 
•AMDT. NO. 2786 
coverage to all children who are eligible to be 
targeted low-income children under the State 
child health plan under this title, a State shall 
establish procedures to ensure that such chil-
dren are provided coverage through an Ex-
change established by the State under section 
1311 of the Patient Protection and Affordable 
Care Act.’’. 
(2) CONFORMING AMENDMENT TO TITLE XXI 
MEDICAID
MAINTENANCE
OF
EFFORT.—Section 
2105(d)(1) of the Social Security Act (42 U.S.C. 
1397ee(d)(1)) is amended by adding before the pe-
riod 
‘‘, 
except 
as 
required 
under 
section 
1902(e)(14)’’. 
(c) NO ENROLLMENT BONUS PAYMENTS FOR CHIL-
DREN ENROLLED AFTER FISCAL YEAR 2013.—Section 
2105(a)(3)(F)(iii) of the Social Security Act (42 U.S.C. 
1397ee(a)(3)(F)(iii)) is amended by inserting ‘‘or any chil-
dren enrolled on or after October 1, 2013’’ before the pe-
riod. 
(d) INCOME ELIGIBILITY DETERMINED USING MODI-
FIED GROSS INCOME.— 
(1) 
STATE
PLAN
REQUIREMENT.—Section 
2102(b)(1)(B) of the Social Security Act (42 U.S.C. 
1397bb(b)(1)(B)) is amended— 
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440 
•AMDT. NO. 2786 
(A) in clause (iii), by striking ‘‘and’’ after 
the semicolon; 
(B) in clause (iv), by striking the period 
and inserting ‘‘; and’’; and 
(C) by adding at the end the following: 
‘‘(v) shall, beginning January 1, 2014, 
use modified gross income and household 
income (as defined in section 36B(d)(2) of 
the Internal Revenue Code of 1986) to de-
termine eligibility for child health assist-
ance under the State child health plan or 
under any waiver of such plan and for any 
other purpose applicable under the plan or 
waiver for which a determination of income 
is required, including with respect to the 
imposition of premiums and cost-sharing, 
consistent with section 1902(e)(14).’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
2107(e)(1) of the Social Security Act (42 U.S.C. 
1397gg(e)(1)) is amended— 
(A) by redesignating subparagraphs (E) 
through (L) as subparagraphs (F) through (M), 
respectively; and 
(B) by inserting after subparagraph (D), 
the following: 
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•AMDT. NO. 2786 
under section 36B of the Internal Revenue 
Code of 1986 (and, if applicable, advance pay-
ment of such assistance under section 1412 of 
the Patient Protection and Affordable Care 
Act), and, if eligible, enrolled in such a plan 
without having to submit an additional or sepa-
rate application, and that such individuals re-
ceive information regarding reduced cost-shar-
ing for eligible individuals under section 1402 
of the Patient Protection and Affordable Care 
Act, and any other assistance or subsidies avail-
able for coverage obtained through the Ex-
change; 
‘‘(D) ensuring that the State agency re-
sponsible for administering the State plan 
under this title (in this section referred to as 
the ‘State Medicaid agency’), the State agency 
responsible for administering the State child 
health plan under title XXI (in this section re-
ferred to as the ‘State CHIP agency’) and an 
Exchange established by the State under sec-
tion 1311 of the Patient Protection and Afford-
able Care Act utilize a secure electronic inter-
face sufficient to allow for a determination of 
an individual’s eligibility for such medical as-
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448 
•AMDT. NO. 2786 
sistance, child health assistance, or premium 
assistance, and enrollment in the State plan 
under this title, title XXI, or a qualified health 
plan, as appropriate; 
‘‘(E) coordinating, for individuals who are 
enrolled in the State plan or under a waiver of 
the plan and who are also enrolled in a quali-
fied health plan offered through such an Ex-
change, and for individuals who are enrolled in 
the State child health plan under title XXI and 
who are also enrolled in a qualified health plan, 
the provision of medical assistance or child 
health assistance to such individuals with the 
coverage provided under the qualified health 
plan in which they are enrolled, including serv-
ices described in section 1905(a)(4)(B) (relating 
to early and periodic screening, diagnostic, and 
treatment services defined in section 1905(r)) 
and provided in accordance with the require-
ments of section 1902(a)(43); and 
‘‘(F) conducting outreach to and enrolling 
vulnerable and underserved populations eligible 
for medical assistance under this title XIX or 
for child health assistance under title XXI, in-
cluding 
children, 
unaccompanied 
homeless 
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•AMDT. NO. 2786 
manufacturer price for a covered out-
patient drug.’’; and 
(C) in subparagraph (C), by striking ‘‘the 
retail pharmacy class of trade’’ and inserting 
‘‘retail community pharmacies’’. 
(3) 
DEFINITION
OF
MULTIPLE
SOURCE 
DRUG.—Section 1927(k)(7) of such Act (42 U.S.C. 
1396r–8(k)(7)) is amended— 
(A) in subparagraph (A)(i)(III), by strik-
ing ‘‘the State’’ and inserting ‘‘the United 
States’’; and 
(B) in subparagraph (C)— 
(i) in clause (i), by inserting ‘‘and’’ 
after the semicolon; 
(ii) in clause (ii), by striking ‘‘; and’’ 
and inserting a period; and 
(iii) by striking clause (iii). 
(4) DEFINITIONS OF RETAIL COMMUNITY PHAR-
MACY; WHOLESALER.—Section 1927(k) of such Act 
(42 U.S.C. 1396r–8(k)) is amended by adding at the 
end the following new paragraphs: 
‘‘(10) RETAIL
COMMUNITY
PHARMACY.—The 
term ‘retail community pharmacy’ means an inde-
pendent pharmacy, a chain pharmacy, a super-
market pharmacy, or a mass merchandiser phar-
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