II 

109TH CONGRESS 

1ST SESSION S. 1563 

To amend title XIX of the Social Security Act to protect and strengthen 

the safety net of children’s public health coverage by extending the 

enhanced Federal matching rate under the State children’s health insurance program to children covered by medicaid at State option and by 

encouraging innovations in children’s enrollment and retention, to advance quality and performance in children’s public health insurance programs, to provide payments for children’s hospitals to reward quality 

and performance, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JULY 29, 2005 

Mr. DEWINE (for himself and Mrs. LINCOLN) introduced the following bill; 

which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XIX of the Social Security Act to protect 

and strengthen the safety net of children’s public health 

coverage by extending the enhanced Federal matching 

rate under the State children’s health insurance program 

to children covered by medicaid at State option and 

by encouraging innovations in children’s enrollment and 

retention, to advance quality and performance in children’s public health insurance programs, to provide payments for children’s hospitals to reward quality and performance, and for other purposes. 
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1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Advancing Better Cov5 erage and Care for Children’s Health Act of 2005’’ or the 

6 ‘‘ABCs for Children’s Health Act of 2005’’. 

7 SEC. 2. TABLE OF CONTENTS. 

8 The table of contents for this Act is as follows: 

Sec. 1. Short title. 

Sec. 2. Table of contents. 

TITLE I—COVERING CHILDREN 

Sec. 101. Phased-in application of enhanced FMAP for children whose eligibility is optional under medicaid. 

Sec. 102. Enhanced matching rate for the effective enrollment and retention of 

children under medicaid. 

Sec. 103. Preserving comprehensive benefits appropriate to children’s needs. 

TITLE II—ADVANCING QUALITY AND PERFORMANCE: 

INNOVATIONS IN CARE 

Sec. 201. Purpose. 

Sec. 202. National quality forum; advancing consensus-based pediatric quality 

and performance measures. 

Sec. 203. Research grant program; developing new pediatric quality and performance measures. 

Sec. 204. Medicaid demonstration program; evaluating evidence-based quality 

and performance measures for children’s health services. 

Sec. 205. Funding. 

TITLE III—ENSURING ACCESS TO CARE 

Sec. 301. Pay for performance for children’s critical access hospitals. 

Sec. 302. Inclusion of children’s hospitals as covered entities for purposes of 

limitation of purchased drug price. 
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1 TITLE I—COVERING CHILDREN 

2 SEC. 101. PHASED-IN APPLICATION OF ENHANCED FMAP 

3 FOR CHILDREN WHOSE ELIGIBILITY IS OP4 TIONAL UNDER MEDICAID. 

5 (a) IN GENERAL.—The first sentence of section 1905 

6 of the Social Security Act (42 U.S.C. 1396d) is amend7 ed— 

8 (1) in subsection (b)— 

9 (A) by striking ‘‘and (4)’’ and inserting 

10 ‘‘(4)’’; and 

11 (B) by inserting before the period the fol12 lowing: ‘‘, and (5) the Federal medical assist13 ance percentage shall be equal to the applicable 

14 percentage determined under subsection (y) 

15 with respect to medical assistance provided to 

16 children who are eligible for such assistance on 

17 the basis of subsection (a)(10)(A)(ii), 

18 (a)(10)(C), (e)(3), or (e)(9) of section 1902, or 

19 a waiver under subsection (c) or (e) of section 

20 1915, or who are eligible for such assistance 

21 during a presumptive eligibility period under 

22 section 1920A (but only if the child is not eligi23 ble for medical assistance on the basis of sec24 tion 1902(a)(10)(A)(i))’’; and 

25 (2) by adding at the end the following: 
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1 ‘‘(y) For purposes of the fifth clause of the first sen2 tence of subsection (b), the applicable percentage deter3 mined under this subsection is— 

4 ‘‘(1) in the case of fiscal year 2006, the en5 hanced FMAP determined under section 2105(b) by 

6 substituting ‘6 percent’ for ‘30 percent’ in such sec7 tion; 

8 ‘‘(2) in the case of fiscal year 2007, the en9 hanced FMAP determined under section 2105(b) by 

10 substituting ‘12 percent’ for ‘30 percent’ in such 

11 section; 

12 ‘‘(3) in the case of fiscal year 2008, the en13 hanced FMAP determined under section 2105(b) by 

14 substituting ‘18 percent’ for ‘30 percent’ in such 

15 section; 

16 ‘‘(4) in the case of fiscal year 2009, the en17 hanced FMAP determined under section 2105(b) by 

18 substituting ‘24 percent’ for ‘30 percent’ in such 

19 section; and 

20 ‘‘(5) in the case of fiscal year 2010 or any fiscal 

21 year thereafter, the enhanced FMAP determined 

22 under section 2105(b).’’. 

23 (b) EFFECTIVE DATE.—The amendments made by 

24 subsection (a) take effect on October 1, 2005. 
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1 SEC. 102. ENHANCED MATCHING RATE FOR THE EFFEC2 TIVE ENROLLMENT AND RETENTION OF 

3 CHILDREN UNDER MEDICAID. 

4 (a) IN GENERAL.—Section 1903(a)(3) of the Social 

5 Security Act (42 U.S.C. 1396b(a)(3)) is amended— 

6 (1) in subparagraph (E), by striking ‘‘plus’’ at 

7 the end and inserting ‘‘and’’; and 

8 (2) by adding at the end the following: 

9 ‘‘(F) 90 percent of the sums expended dur10 ing such quarter which are attributable to the 

11 design, development, implementation, and eval12 uation of such enrollment systems as the Sec13 retary determines are likely to provide more ef14 ficient and effective administration of the plan’s 

15 enrollment and retention of eligible children, in16 cluding— 

17 ‘‘(i) ‘express lane’ enrollment for chil18 dren through procedures to ensure that 

19 children’s eligibility for medical assistance 

20 is determined and expedited through the 

21 use of technology and shared information 

22 with other public benefit programs, such as 

23 the school lunch program under the Rich24 ard B. Russell National School Lunch Act 

25 and the food stamp program under the 

26 Food Stamp Act of 1977; 
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1 ‘‘(ii) a single, simplified application 

2 form for medical assistance under this title 

3 and for children’s health assistance under 

4 title XXI; 

5 ‘‘(iii) procedures which allow for the 

6 enrollment of children by mail or through 

7 the Internet; 

8 ‘‘(iv) the timely evaluation, assistance, 

9 and determination of presumptive eligi10 bility under section 1920A; 

11 ‘‘(v) procedures which allow for pas12 sive reenrollment of children to protect 

13 against the loss of coverage among eligible 

14 children; and 

15 ‘‘(vi) such other enrollment system 

16 changes as the Secretary determines are 

17 likely to provide more efficient and effec18 tive administration of the plan’s enrollment 

19 and retention of eligible children; plus’’. 

20 (b) EXCLUSION FROM ERRONEOUS EXCESS PAY21 MENT DETERMINATION.—Section 1903(u)(1)(D) of such 

22 Act (42 U.S.C. 1396a(u)(1)(D)) is amended by adding at 

23 the end the following: 

24 ‘‘(vi)(I) Notwithstanding clauses (ii) 

25 and (iii), and subject to subclause (II), in 
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1 determining the amount of erroneous ex2 cess payments, there shall not be included 

3 any erroneous payments made with respect 

4 to medical assistance provided to children 

5 who are erroneously enrolled or erro6 neously provided with continued enrollment 

7 under this title as a result of the applica8 tion of enrollment systems described in 

9 subsection (a)(3)(F). 

10 ‘‘(II) Subclause (I) shall only apply 

11 with respect to erroneous payments made 

12 during the first 5 fiscal years that begin on 

13 or after the date of enactment of this 

14 clause.’’. 

15 SEC. 103. PRESERVING COMPREHENSIVE BENEFITS APPRO16 PRIATE TO CHILDREN’S NEEDS. 

17 (a) IN GENERAL.—Title XIX of the Social Security 

18 Act is amended by inserting after section 1925 the fol19 lowing: 

20 ‘‘CLARIFICATION OF AUTHORITY UNDER SECTION 1115

21 ‘‘SEC. 1926. The Secretary may not impose or ap22 prove under the authority of section 1115 an elimination 

23 or modification of the amount, duration, or scope of the 

24 services described in section 1905(a)(4)(B) (relating to 

25 early and periodic screening, diagnostic, and treatment 

26 services (as defined in section 1905(r))) or of the require-
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1 ments of subparagraphs (A) through (C) of section 

2 1902(a)(43).’’. 

3 (b) EFFECTIVE DATE.— 

4 (1) IN GENERAL.—Except as provided in para5 graph (2), section 1926 of the Social Security Act, 

6 as added by subsection (a), shall apply to the ap7 proval on or after the date of enactment of this Act 

8 of— 

9 (A) a waiver, experimental, pilot, or dem10 onstration project under section 1115 of the So11 cial Security Act (42 U.S.C. 1315); and 

12 (B) an amendment or extension of such a 

13 project. 

14 (2) EXCEPTION.—Section 1926 of the Social 

15 Security Act, as so added, shall not apply with re16 spect to any extension of approval of a waiver, ex17 perimental, pilot, or demonstration project with re18 spect to title XIX of the Social Security Act that 

19 was first approved before 1994 and that provides a 

20 comprehensive and preventive child health program 

21 under such project that includes screening, diag22 nosis, and treatment of children who have not at23 tained age 21. 
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1 TITLE II—ADVANCING QUALITY 

2 AND PERFORMANCE: INNOVA3 TIONS IN CARE 

4 SEC. 201. PURPOSE. 

5 The purpose of this title is to increase the quality 

6 of the health care furnished to children under the health 

7 insurance programs under titles XIX and XXI of the So8 cial Security Act. 

9 SEC. 202. NATIONAL QUALITY FORUM; ADVANCING CON10 SENSUS-BASED PEDIATRIC QUALITY AND 

11 PERFORMANCE MEASURES. 

12 (a) IN GENERAL.—The Secretary of Health and 

13 Human Services (in this title referred to as the ‘‘Sec14 retary’’), acting through the Director of the Center for 

15 Medicaid and State Operations of the Centers for Medi16 care & Medicaid Services, shall enter into agreements with 

17 the National Quality Forum to facilitate the development 

18 of consensus-based pediatric quality and performance 

19 measures. 

20 (b) CONSULTATION.—In carrying out agreements 

21 under subsection (a), the Director of the Center for Med22 icaid and State Operations shall consult with— 

23 (1) the Agency for Healthcare Research and 

24 Quality; and 

25 (2) national pediatric provider groups. 
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1 SEC. 203. RESEARCH GRANT PROGRAM; DEVELOPING NEW 

2 PEDIATRIC QUALITY AND PERFORMANCE 

3 MEASURES. 

4 (a) IN GENERAL.—The Secretary, acting through the 

5 Administrator of the Agency for Healthcare Research and 

6 Quality, shall award grants to eligible entities for the de7 velopment and evaluation of pediatric quality and perform8 ance measures. 

9 (b) ELIGIBLE ENTITY DEFINED.—In this section, 

10 the term ‘‘eligible entity’’ means— 

11 (1) an institution or multiple institutions with 

12 demonstrated expertise and capacity to evaluate pe13 diatric quality and performance measures; 

14 (2) a National nonprofit association of pediatric 

15 academic medical centers with demonstrated experi16 ence in working with other pediatric provider and 

17 accrediting organizations in developing quality and 

18 performance measures for children’s inpatient and 

19 outpatient care; and 

20 (3) a collaboration of national pediatric organi21 zations working to improve quality and performance 

22 in pediatric critical care. 

23 (c) APPLICATION.—Each eligible entity desiring a 

24 grant under this section shall submit an application to the 

25 Secretary at such time, in such manner, and accompanied 

26 by such information as the Secretary may require. 
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1 SEC. 204. MEDICAID DEMONSTRATION PROGRAM; EVALU2 ATING EVIDENCE-BASED QUALITY AND PER3 FORMANCE MEASURES FOR CHILDREN’S 

4 HEALTH SERVICES. 

5 (a) IN GENERAL.—Not later than 1 year after the 

6 date of enactment of this Act, the Secretary, acting 

7 through the Director of the Center for Medicaid and State 

8 Operations of the Centers for Medicare & Medicaid Serv9 ices, shall establish demonstration projects in each of the 

10 3 categories described in subsection (c) to advance quality 

11 and performance in the delivery of medical assistance pro12 vided to children under the medicaid program established 

13 under title XIX of the Social Security Act (42 U.S.C. 

14 1396 et seq.). 

15 (b) AUTHORITY.— 

16 (1) IN GENERAL.—The Secretary is authorized 

17 to award grants to States or providers to conduct 

18 such projects. 

19 (2) USE OF FUNDS.—Funds provided under a 

20 grant awarded under this section may be used for 

21 administrative costs, including costs associated with 

22 the design, data collection, and evaluation of the 

23 demonstration project conducted with such funds, 

24 and other expenditures that are not otherwise eligi25 ble for reimbursement under the medicaid program. 
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1 (3) EVIDENCE OF ORGANIZATIONAL COMMIT2 MENT REQUIRED FOR AWARD OF GRANTS.—A State 

3 or provider shall not be eligible to receive a grant to 

4 conduct a demonstration project under this section 

5 unless the State or provider demonstrates a commit6 ment to the concept of change and transformation in 

7 the delivery of children’s health services. Dedication 

8 of financial resources of the State or provider to the 

9 project may be deemed to demonstrate evidence of 

10 such a commitment. 

11 (c) PROJECT CATEGORIES DESCRIBED.—The 3 dem12 onstration project categories described in this subsection 

13 are the following: 

14 (1) Projects that adopt and use health informa15 tion technology and evidenced-based outcome meas16 ures for pediatric inpatient and sub-specialty physi17 cian care and evaluate the impact of such technology 

18 and measures on the quality, safety, and costs of 

19 such care. 

20 (2) Projects that demonstrate and evaluate care 

21 management for children with chronic conditions to 

22 determine the extent to which such management 

23 promotes continuity of care, stabilization of medical 

24 conditions, and functional outcomes, prevents or 

25 minimizes acute exacerbations of chronic conditions, 
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1 and reduces adverse health outcomes and avoidable 

2 hospitalizations. 

3 (3) Projects that implement evidenced-based 

4 approaches to improving efficiency, safety, and effec5 tiveness in the delivery of hospital care for children 

6 across hospital services and evaluate the impact of 

7 such changes on the quality and costs of such care. 

8 (d) SITES.—To the extent practicable, the Secretary 

9 shall use multiple sites in different geographical locations 

10 in conducting each of the 3 demonstration project cat11 egories described in subsection (c). 

12 (e) UNIFORM MEASURES, DATA, PROJECT EVALUA13 TIONS.—Working in consultation with experts described in 

14 subsection (f) and with participating States or providers, 

15 the Secretary shall establish uniform measures (adjusted 

16 for patient acuity), collect data, and conduct evaluations 

17 with respect to the 3 demonstration project categories de18 scribed in subsection (c). 

19 (f) CONSULTATION.—In developing and imple20 menting demonstration projects under this section, the 

21 Secretary shall consult with national pediatric provider or22 ganizations, consumers, and such other entities or individ23 uals with relevant expertise as the Secretary deems nec24 essary. 
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1 (g) REPORT.—Not later than 6 months after the 

2 completion of all demonstration projects conducted under 

3 this section, the Secretary shall evaluate such projects and 

4 submit a report to Congress that includes the findings of 

5 the evaluation and recommendations with respect to— 

6 (1) expanding the projects to additional sites; 

7 and 

8 (2) the broad implementation of identified suc9 cessful approaches in advancing quality and per10 formance in the delivery of medical assistance pro11 vided to children under the medicaid program. 

12 SEC. 205. FUNDING. 

13 In order to carry out the provisions of this title, out 

14 of funds in the Treasury not otherwise appropriated, there 

15 are appropriated to the Secretary— 

16 (1) $25,000,000 for fiscal year 2006; 

17 (2) $30,000,000 for fiscal year 2007; and 

18 (3) $35,000,000 for each of the fiscal years 

19 2008, 2009, and 2010. 

20 TITLE III—ENSURING ACCESS 

21 TO CARE 

22 SEC. 301. PAY FOR PERFORMANCE FOR CHILDREN’S CRIT23 ICAL ACCESS HOSPITALS. 

24 (a) IN GENERAL.—The Secretary of Health and 

25 Human Services (in this section referred to as the ‘‘Sec-
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1 retary’’), acting through the Administrator of the Centers 

2 for Medicare & Medicaid Services (in this section referred 

3 to as the ‘‘Administrator’’), shall implement a 4-year pro4 gram to develop, implement, and evaluate a pay-for-per5 formance program for eligible children’s hospitals pro6 viding critical access to children eligible for medical assist7 ance under the medicaid program established under title 

8 XIX of the Social Security Act (42 U.S.C. 1396 et seq.). 

9 (b) CONSULTATION.—Measures of quality and per10 formance utilized in the program will be determined by 

11 the Administrator in collaboration with participating eligi12 ble children’s hospitals and in consultation with States, 

13 the National Association of Children’s Hospitals and Re14 lated Institutions, the Agency for Healthcare Research 

15 and Quality, the National Quality Forum, and such other 

16 entities or individuals with expertise in pediatric quality 

17 and performance measures as the Administrator deems 

18 appropriate. 

19 (c) ELIGIBLE CHILDREN’S HOSPITALS.—For pur20 poses of this section, an eligible children’s hospital is a 

21 children’s hospital that, not later than January 1, 2006, 

22 has submitted an application to the Secretary to partici23 pate in the program established under this section and has 

24 been certified by the Secretary as— 
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1 (1) meeting the criteria described in subsection 

2 (d); 

3 (2) agreeing to report data on quality and per4 formance measures; and 

5 (3) meeting or exceeding such measures as are 

6 established by the Secretary with respect to the pro7 vision of care by the hospital. 

8 (d) CRITERIA DESCRIBED.—In order to be certified 

9 as meeting the criteria described in this subsection, a hos10 pital shall be a general acute care children’s hospital or 

11 a specialty children’s hospital as defined under 

12 1886(d)(1)(B)(iii) of the Social Security Act (42 U.S.C. 

13 1395ww(d)(1)(B)(iii)), or a non-freestanding general 

14 acute care children’s hospital which shares a provider 

15 number with another hospital or hospital system that— 

16 (1) has 62 or more total pediatric beds; 

17 (2) has 38 or more total combined pediatric 

18 general medical or surgical and pediatric intensive 

19 care beds; 

20 (3) has at least 4 pediatric intensive care beds; 

21 (4) has a pediatric emergency room in the hos22 pital or access to an emergency room with pediatric 

23 services through the hospital system; and 
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1 (5) provides a minimum of 25 percent of its 

2 days of care to patients eligible for medical assist3 ance under the medicaid program. 

4 (e) PAYMENT METHODOLOGY.— 

5 (1) IN GENERAL.—An eligible children’s hos6 pital that participates in the program established 

7 under this section shall receive supplemental Federal 

8 payments for inpatient and outpatient care (which 

9 shall be in addition to any other payments the hos10 pitals receive for such care under the medicaid pro11 gram) for cost reporting periods or portions of such 

12 reporting periods occurring during fiscal years 2007 

13 through 2010 in accordance with the following: 

14 (A) FISCAL YEARS 2007 AND 2008.— 

15 (i) IN GENERAL.—For hospital cost 

16 reporting periods or portions of such re17 porting periods occurring during fiscal year 

18 2007 or 2008, hospitals reporting data for 

19 quality and performance measures estab20 lished under the program and participating 

21 in the development of pay-for-performance 

22 methodology under this section, subject to 

23 clause (ii), shall receive with respect to in24 patient or outpatient care that is deter25 mined to meet such measures, a Federal 
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1 supplemental payment increase equal to 

2 the amount received under the medicaid 

3 program for such care multiplied by the 

4 market basket percentage increase for the 

5 year (as defined under section 

6 1886(b)(3)(B)(iii) of the Social Security 

7 Act (42 U.S.C. 1395ww(b)(3)(B)(iii)). 

8 (ii) LIMITATION.—The total amount 

9 of all Federal supplemental payments 

10 made with respect to cost reporting periods 

11 or portions of such periods described in 

12 clause (i) shall not exceed the amounts ap13 propriated under this section for fiscal 

14 years 2007 and 2008. 

15 (B) FISCAL YEARS 2009 AND 2010.— 

16 (i) IN GENERAL.—For cost reporting 

17 periods or portions of such periods occur18 ring during fiscal year 2009 or 2010, hos19 pitals shall receive supplemental Federal 

20 payments reflecting measures of quality 

21 and performance and a pay-for-perform22 ance methodology developed by the Sec23 retary in consultation with the entities de24 scribed in subsection (b). Such method25 ology shall recognize clinical measures, pa-
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1 tient satisfaction and adoption of informa2 tion technology. 

3 (ii) LIMITATION.—The total amount 

4 of all Federal supplemental payments 

5 made for cost reporting periods or portions 

6 of such periods described in clause (i) shall 

7 not exceed the amounts appropriated 

8 under this section for fiscal years 2009 

9 and 2010. 

10 (2) STATE MAINTENANCE OF EFFORT.—With 

11 respect to the periods for payment of the Federal 

12 supplemental payments established under paragraph 

13 (1), in no case shall a State— 

14 (A) pay a participating hospital less for 

15 services for children eligible for medical assist16 ance under the medicaid program than the hos17 pital was paid with respect to the most recent 

18 cost reporting period ending before the date of 

19 enactment of this Act; or 

20 (B) not provide an eligible children’s hos21 pital participating in the program established 

22 under this section (determined on a facility-spe23 cific basis) with the same increase in payment 

24 that the State may provide to any other hos25 pital participating in the State medicaid pro-
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1 gram, including any State-owned or operated 

2 hospital or any hospital operated by a State 

3 university system. 

4 (f) APPROPRIATIONS.— 

5 (1) IN GENERAL.—Out of funds in the Treas6 ury not otherwise appropriated, there are appro7 priated for making payments under this section— 

8 (A) for fiscal year 2007, $80,000,000; 

9 (B) for fiscal year 2008, $100,000,000; 

10 and 

11 (C) for each of fiscal years 2009 and 2010, 

12 $120,000,000. 

13 (2) CARRYOVER.—Any amount appropriated 

14 under paragraph (1) with respect to a fiscal year 

15 that remains unobligated as of the end of that fiscal 

16 year, shall remain available for obligation during the 

17 succeeding fiscal year, in addition to the amount ap18 propriated under that paragraph for such succeeding 

19 fiscal year. 

20 (g) EVALUATION AND REPORT.—Not later than Sep21 tember 1, 2010, the Secretary shall report to Congress 

22 on the program established under this section. In pro23 viding such a report, the Secretary shall— 

24 (1) conduct an independent evaluation; 
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1 (2) consult with States, eligible children’s hos2 pitals participating in the program, the National As3 sociation of Children’s Hospitals and Related Insti4 tutions, and other national pediatric organizations 

5 and individuals with expertise in pediatric measures 

6 of quality and performance; 

7 (3) include a detailed description of the meas8 ures and payment enhancements used in deter9 mining and rewarding performance under the pro10 gram; 

11 (4) assess the impact of rewarding performance 

12 through the Federal supplemental payments pro13 vided under the program, including with respect to 

14 any improvements and innovations in the delivery of 

15 children’s hospital care and children’s access to ap16 propriate care; 

17 (5) assess how State hospital payment meth18 odologies under the medicaid program, including 

19 hospital and physician payments and coverage, affect 

20 the capacity of the medicaid program to reward per21 formance; and 

22 (6) include recommendations to the Committee 

23 on Finance of the Senate and the Committee on En24 ergy and Commerce of the House of Representatives 

25 regarding the implementation and design of the per-
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1 formance-based payments made under the program, 

2 whether to continue such program, and potential al3 ternative approaches to making performance-based 

4 payments to such hospitals. 

5 SEC. 302. INCLUSION OF CHILDREN’S HOSPITALS AS COV6 ERED ENTITIES FOR PURPOSES OF LIMITA7 TION OF PURCHASED DRUG PRICE. 

8 (a) IN GENERAL.—Section 340B(a)(4) of the Public 

9 Health Services Act (42 U.S.C. 256b(a)(4)) is amended 

10 by adding at the end the following new subparagraph: 

11 ‘‘(M) A children’s hospital described in sec12 tion 1886(d)(1)(B)(iii) of the Social Security 

13 Act which meets the requirements of clauses (i) 

14 and (iii) of subparagraph (L) and which would 

15 meet the requirements of clause (ii) of such 

16 subparagraph if that clause were applied by 

17 taking into account the percentage of care pro18 vided by the hospital to patients eligible for 

19 medical assistance under the medicaid pro20 gram.’’. 

21 (b) EFFECTIVE DATE.—The amendment made by 

22 subsection (a) shall apply to drugs purchased on or after 

23 the date of enactment of this Act. 

Æ