H. R. 4994 

One Hundred Eleventh Congress 

of the 

United States of America 

AT THE SECOND SESSION 

Begun and held at the City of Washington on Tuesday, 

the fifth day of January, two thousand and ten 

An Act 

To extend certain expiring provisions of the Medicare and Medicaid programs, 

and for other purposes. 

Be it enacted by the Senate and House of Representatives of 

the United States of America in Congress assembled, 

SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

(a) SHORT TITLE.—This Act may be cited as the ‘‘Medicare 

and Medicaid Extenders Act of 2010’’. 

(b) TABLE OF CONTENTS.—The table of contents of this Act 

is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—EXTENSIONS 

Sec. 101. Physician payment update. 

Sec. 102. Extension of MMA section 508 reclassifications. 

Sec. 103. Extension of Medicare work geographic adjustment floor. 

Sec. 104. Extension of exceptions process for Medicare therapy caps. 

Sec. 105. Extension of payment for technical component of certain physician pathology services. Sec. 106. Extension of ambulance add-ons. 

Sec. 107. Extension of physician fee schedule mental health add-on payment. 

Sec. 108. Extension of outpatient hold harmless provision. 

Sec. 109. Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural 

areas. Sec. 110. Extension of the qualifying individual (QI) program. 

Sec. 111. Extension of Transitional Medical Assistance (TMA). 

Sec. 112. Special diabetes programs. 

TITLE II—OTHER PROVISIONS 

Sec. 201. Clarification of effective date of part B special enrollment period for disabled TRICARE beneficiaries. 

Sec. 202. Repeal of delay of RUG–IV. 

Sec. 203. Clarification for affiliated hospitals for distribution of additional residency 

positions. Sec. 204. Continued inclusion of orphan drugs in definition of covered outpatient 

drugs with respect to children’s hospitals under the 340B drug discount 

program. Sec. 205. Medicaid and CHIP technical corrections. 

Sec. 206. Funding for claims reprocessing. 

Sec. 207. Revision to the Medicare Improvement Fund. 

Sec. 208. Limitations on aggregate amount recovered on reconciliation of the health 

insurance tax credit and the advance of that credit. 

Sec. 209. Determination of budgetary effects. 

TITLE I—EXTENSIONS 

SEC. 101. PHYSICIAN PAYMENT UPDATE. 

Section 1848(d) of the Social Security Act (42 U.S.C. 1395w– 

4(d)) is amended by adding at the end the following new paragraph: 
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‘‘(12) UPDATE FOR 2011.— 

‘‘(A) IN GENERAL.—Subject to paragraphs (7)(B), (8)(B), 

(9)(B), (10)(B), and (11)(B), in lieu of the update to the 

single conversion factor established in paragraph (1)(C) 

that would otherwise apply for 2011, the update to the 

single conversion factor shall be 0 percent. 

‘‘(B) NO EFFECT ON COMPUTATION OF CONVERSION

FACTOR FOR 2012 AND SUBSEQUENT YEARS.—The conversion 

factor under this subsection shall be computed under paragraph (1)(A) for 2012 and subsequent years as if subparagraph (A) had never applied.’’. 

SEC. 102. EXTENSION OF MMA SECTION 508 RECLASSIFICATIONS. 

(a) EXTENSION.— (1) IN GENERAL.—Section 106(a) of division B of the Tax 

Relief and Health Care Act of 2006 (42 U.S.C. 1395 note), 

as amended by section 117 of the Medicare, Medicaid, and 

SCHIP Extension Act of 2007 (Public Law 110–173), section 

124 of the Medicare Improvements for Patients and Providers 

Act of 2008 (Public Law 110–275), and sections 3137(a) and 

10317 of the Patient Protection and Affordable Care Act (Public 

Law 111–148), is amended by striking ‘‘September 30, 2010’’ 

and inserting ‘‘September 30, 2011’’. 

(2) SPECIAL RULE FOR FISCAL YEAR 2011.— 

(A) IN GENERAL.—Subject to subparagraph (B), for purposes of implementation of the amendment made by paragraph (1), including (notwithstanding paragraph (3) of section 117(a) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110–173), as amended by 

section 124(b) of the Medicare Improvements for Patients 

and Providers Act of 2008 (Public Law 110–275)) for purposes of the implementation of paragraph (2) of such section 

117(a), during fiscal year 2011, the Secretary of Health 

and Human Services shall use the hospital wage index 

that was promulgated by the Secretary of Health and 

Human Services in the Federal Register on August 16, 

2010 (75 Fed. Reg. 50042), and any subsequent corrections. 

(B) EXCEPTION.—Beginning on April 1, 2011, in determining the wage index applicable to hospitals that qualify 

for wage index reclassification, the Secretary shall include 

the average hourly wage data of hospitals whose reclassification was extended pursuant to the amendment made 

by paragraph (1) only if including such data results in 

a higher applicable reclassified wage index. Any revision 

to hospital wage indexes made as a result of this subparagraph shall not be effected in a budget neutral manner. 

(3) ADJUSTMENT FOR CERTAIN HOSPITALS IN FISCAL YEAR

2011.— (A) IN GENERAL.—In the case of a subsection (d) hospital (as defined in subsection (d)(1)(B) of section 1886 

of the Social Security Act (42 U.S.C. 1395ww)) with respect 

to which— 

(i) a reclassification of its wage index for purposes 

of such section was extended pursuant to the amendment made by paragraph (1); and 

(ii) the wage index applicable for such hospital 

for the period beginning on October 1, 2010, and ending 
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on March 31, 2011, was lower than for the period 

beginning on April 1, 2011, and ending on September 

30, 2011, by reason of the application of paragraph 

(2)(B); 

the Secretary shall pay such hospital an additional payment that reflects the difference between the wage index 

for such periods. 

(B) TIMEFRAME FOR PAYMENTS.—The Secretary shall 

make payments required under subparagraph (A) by not 

later than December 31, 2011. 

(b) CONFORMING AMENDMENT.—Section 117(a)(3) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 

110–173) is amended by inserting ‘‘in fiscal years 2008 and 2009’’ 

after ‘‘For purposes of implementation of this subsection’’. 

SEC. 103. EXTENSION OF MEDICARE WORK GEOGRAPHIC ADJUSTMENT 

FLOOR. 

Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 

1395w–4(e)(1)(E)) is amended by striking ‘‘before January 1, 2011’’ 

and inserting ‘‘before January 1, 2012’’. 

SEC. 104. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE 

THERAPY CAPS. 

Section 1833(g)(5) of the Social Security Act (42 U.S.C. 

1395l(g)(5)) is amended by striking ‘‘and ending on’’ and all that 

follows through ‘‘2010’’ and inserting ‘‘and ending on December 

31, 2011’’. 

SEC. 105. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF 

CERTAIN PHYSICIAN PATHOLOGY SERVICES. 

Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits 

Improvement and Protection Act of 2000 (as enacted into law by 

section 1(a)(6) of Public Law 106–554), as amended by section 

732 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w–4 note), section 104 of 

division B of the Tax Relief and Health Care Act of 2006 (42 

U.S.C. 1395w–4 note), section 104 of the Medicare, Medicaid, and 

SCHIP Extension Act of 2007 (Public Law 110–173), section 136 

of the Medicare Improvements for Patients and Providers Act of 

2008 (Public Law 110–275), and section 3104 of the Patient Protection and Affordable Care Act (Public Law 111–148) is amended 

by striking ‘‘and 2010’’ and inserting ‘‘2010, and 2011’’. 

SEC. 106. EXTENSION OF AMBULANCE ADD-ONS. 

(a) GROUND AMBULANCE.—Section 1834(l)(13)(A) of the Social 

Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended— 

(1) in the matter preceding clause (i), by striking ‘‘2011’’ 

and inserting ‘‘2012,’’; and 

(2) in each of clauses (i) and (ii), by striking ‘‘January 

1, 2011’’ and inserting ‘‘January 1, 2012’’ each place it appears. 

(b) AIR AMBULANCE.—Section 146(b)(1) of the Medicare 

Improvements for Patients and Providers Act of 2008 (Public Law 

110–275), as amended by sections 3105(b) and 10311(b) of Public 

Law 111–148, is amended by striking ‘‘December 31, 2010’’ and 

inserting ‘‘December 31, 2011’’. 

(c) SUPER RURAL AMBULANCE.—Section 1834(l)(12)(A) of the 

Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended by 

striking ‘‘2011’’ and inserting ‘‘2012’’. 
H. R. 4994—4 

SEC. 107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH 

ADD-ON PAYMENT. 

Section 138(a)(1) of the Medicare Improvements for Patients 

and Providers Act of 2008 (Public Law 110–275), as amended by 

section 3107 of the Patient Protection and Affordable Care Act 

(Public Law 111–148), is amended by striking ‘‘December 31, 2010’’ 

and inserting ‘‘December 31, 2011’’. 

SEC. 108. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION. 

Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 

1395l(t)(7)(D)(i)), as amended by section 3121(a) of the Patient 

Protection and Affordable Care Act (Public Law 111–148), is 

amended— 

(1) in subclause (II)— 

(A) in the first sentence, by striking ‘‘2011’’ and 

inserting ‘‘2012’’; and 

(B) in the second sentence, by striking ‘‘or 2010’’ and 

inserting ‘‘2010, or 2011’’; and 

(2) in subclause (III), by striking ‘‘January 1, 2011’’ and 

inserting ‘‘January 1, 2012’’. 

SEC. 109. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS 

FOR CERTAIN CLINICAL DIAGNOSTIC LABORATORY TESTS 

FURNISHED TO HOSPITAL PATIENTS IN CERTAIN RURAL 

AREAS. 

Section 416(b) of the Medicare Prescription Drug, Improvement, 

and Modernization Act of 2003 (42 U.S.C. 1395l–4), as amended 

by section 105 of division B of the Tax Relief and Health Care 

Act of 2006 (42 U.S.C. 1395l note), section 107 of the Medicare, 

Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395l note), 

and section 3122 of the Patient Protection and Affordable Care 

Act (Public Law 111–148), is amended by striking ‘‘the 1-year 

period beginning on July 1, 2010’’ and inserting ‘‘the 2-year period 

beginning on July 1, 2010’’. 

SEC. 110. EXTENSION OF THE QUALIFYING INDIVIDUAL (QI) PROGRAM. 

(a) EXTENSION.—Section 1902(a)(10)(E)(iv) of the Social Security 

Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is amended by striking 

‘‘December 2010’’ and inserting ‘‘December 2011’’. 

(b) EXTENDING TOTAL AMOUNT AVAILABLE FOR ALLOCATION.— 

Section 1933(g) of such Act (42 U.S.C. 1396u-3(g)) is amended— 

(1) in paragraph (2)— 

(A) by striking ‘‘and’’ at the end of subparagraph (M); 

(B) in subparagraph (N), by striking the period at 

the end and inserting a semicolon; and 

(C) by adding at the end the following new subparagraphs: 

‘‘(O) for the period that begins on January 1, 2011, 

and ends on September 30, 2011, the total allocation 

amount is $720,000,000; and 

‘‘(P) for the period that begins on October 1, 2011, 

and ends on December 31, 2011, the total allocation amount 

is $280,000,000.’’; and 

(2) in paragraph (3), in the matter preceding subparagraph 

(A), by striking ‘‘or (N)’’ and inserting ‘‘(N), or (P)’’. 
H. R. 4994—5 

SEC. 111. EXTENSION OF TRANSITIONAL MEDICAL ASSISTANCE (TMA). 

Sections 1902(e)(1)(B) and 1925(f) of the Social Security Act 

(42 U.S.C. 1396a(e)(1)(B), 1396r–6(f)) are each amended by striking 

‘‘December 31, 2010’’ and inserting ‘‘December 31, 2011’’. 

SEC. 112. SPECIAL DIABETES PROGRAMS. 

(1) SPECIAL DIABETES PROGRAMS FOR TYPE I DIABETES.— 

Section 330B(b)(2)(C) of the Public Health Service Act (42 

U.S.C. 254c–2(b)(2)(C)) is amended by striking ‘‘2011’’ and 

inserting ‘‘2013’’. 

(2) SPECIAL DIABETES PROGRAMS FOR INDIANS.—Section 

330C(c)(2)(C) of the Public Health Service Act (42 U.S.C. 254c– 

3(c)(2)(C)) is amended by striking ‘‘2011’’ and inserting ‘‘2013’’. 

TITLE II—OTHER PROVISIONS 

SEC. 201. CLARIFICATION OF EFFECTIVE DATE OF PART B SPECIAL 

ENROLLMENT PERIOD FOR DISABLED TRICARE BENEFICIARIES. 

Effective as if included in the enactment of Public Law 111– 

148, section 3110(a)(2) of such Act is amended to read as follows: 

‘‘(2) EFFECTIVE DATE.—The amendment made by paragraph 

(1) shall apply to elections made on and after the date of 

the enactment of this Act.’’. 

SEC. 202. REPEAL OF DELAY OF RUG–IV. 

Effective as if included in the enactment of Public Law 111– 

148, section 10325 of such Act is repealed. 

SEC. 203. CLARIFICATION FOR AFFILIATED HOSPITALS FOR DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS. 

Effective as if included in the enactment of section 5503(a) 

of Public Law 111–148, section 1886(h)(8) of the Social Security 

Act (42 U.S.C. 1395ww(h)(8)), as added by such section 5503(a), 

is amended by adding at the end the following new subparagraph: 

‘‘(I) AFFILIATION.—The provisions of this paragraph 

shall be applied to hospitals which are members of the 

same affiliated group (as defined by the Secretary under 

paragraph (4)(H)(ii)) and the reference resident level for 

each such hospital shall be the reference resident level 

with respect to the cost reporting period that results in 

the smallest difference between the reference resident level 

and the otherwise applicable resident limit.’’. 

SEC. 204. CONTINUED INCLUSION OF ORPHAN DRUGS IN DEFINITION 

OF COVERED OUTPATIENT DRUGS WITH RESPECT TO 

CHILDREN’S HOSPITALS UNDER THE 340B DRUG DISCOUNT 

PROGRAM. 

(a) DEFINITION OF COVERED OUTPATIENT DRUG.— 

(1) AMENDMENT.—Subsection (e) of section 340B of the 

Public Health Service Act (42 U.S.C. 256b) is amended by 

striking ‘‘covered entities described in subparagraph (M)’’ and 

inserting ‘‘covered entities described in subparagraph (M) (other 

than a children’s hospital described in subparagraph (M))’’. 

(2) EFFECTIVE DATE.—The amendment made by paragraph 

(1) shall take effect as if included in the enactment of section 
H. R. 4994—6 

2302 of the Health Care and Education Reconciliation Act 

of 2010 (Public Law 111–152). 

(b) TECHNICAL AMENDMENT.—Subparagraph (B) of section 

1927(a)(5) of the Social Security Act (42 U.S.C. 1396r–8(a)(5)) is 

amended by striking ‘‘and a children’s hospital’’ and all that follows 

through the end of the subparagraph and inserting a period. 

SEC. 205. MEDICAID AND CHIP TECHNICAL CORRECTIONS. 

(a) REPEAL OF EXCLUSION OF CERTAIN INDIVIDUALS AND ENTITIES FROM MEDICAID.—Section 1902(a) of the Social Security Act 

(42 U.S.C. 1396a(a)) is amended by striking paragraph (78). 

(b) INCOME LEVEL FOR CERTAIN CHILDREN UNDER MEDICAID.— 

Section 1902(l)(2)(C) of the Social Security Act (42 U.S.C. 

1396a(l)(2)(C)) is amended by striking ‘‘133 percent’’ and inserting 

‘‘100 percent (or, beginning January 1, 2014, 133 percent)’’. 

(c) CALCULATION AND PUBLICATION OF PAYMENT ERROR RATE

MEASUREMENT FOR CERTAIN YEARS.—Section 601(b) of the Children’s Health Insurance Program Reauthorization Act of 2009 

(Public Law 111–3) is amended by adding at the end the following: 

‘‘The Secretary is not required under this subsection to calculate 

or publish a national or a State-specific error rate for fiscal year 

2009 or fiscal year 2010.’’. 

(d) CORRECTIONS TO EXCEPTIONS TO EXCLUSION OF CHILDREN

OF CERTAIN EMPLOYEES.—Section 2110(b)(6) of the Social Security 

Act (42 U.S.C. 1397jj(b)(6)) is amended— 

(1) in subparagraph (B)— 

(A) by striking ‘‘PER PERSON’’ in the heading; and 

(B) by striking ‘‘each employee’’ and inserting 

‘‘employees’’; and 

(2) in subparagraph (C), by striking ‘‘, on a case-by-case 

basis,’’. 

(e) ELECTRONIC HEALTH RECORDS.—Effective as if included in 

the enactment of section 4201(a)(2) of the American Recovery and 

Reinvestment Act of 2009 (Public Law 111–5), section 1903(t) of 

the Social Security Act (42 U.S.C. 1396b(t)) is amended— 

(1) in paragraph (3)(E), by striking ‘‘reduced by any payment that is made to such Medicaid provider from any other 

source (other than under this subsection or by a State or 

local government)’’ and inserting ‘‘reduced by the average payment the Secretary estimates will be made to such Medicaid 

providers (determined on a percentage or other basis for such 

classes or types of providers as the Secretary may specify) 

from other sources (other than under this subsection, or by 

the Federal government or a State or local government)’’; and 

(2) in paragraph (6)(B), by inserting before the period the 

following: ‘‘and shall be determined to have met such responsibility to the extent that the payment to the Medicaid provider 

is not in excess of 85 percent of the net average allowable 

cost’’. 

(f) CORRECTIONS OF DESIGNATIONS.— 

(1) Section 1902 of the Social Security Act (42 U.S.C. 1396a) 

is amended— 

(A) in subsection (a)(10), in the matter following 

subparagraph (G), by striking ‘‘and’’ before ‘‘(XVI) the medical’’ and by striking ‘‘(XVI) if’’ and inserting ‘‘(XVII) if’’; 

(B) in subsection (a)(23), by striking ‘‘(ii)’’ and inserting 

‘‘(kk)’’; 
H. R. 4994—7 

(C) in subsection (a)(77), by striking ‘‘(ii)’’ and inserting 

‘‘(kk)’’; 

(D) in subsection (ii)(2), as added by section 2303(a)(2) 

of Public Law 111–148, by striking ‘‘(XV)’’ and inserting 

‘‘(XVI)’’; and 

(E) by redesignating subsection (ii), as added by section 

6401(b)(1)(B) of Public Law 111–148, as subsection (kk) 

and transferring such subsection so as to appear after 

subsection (jj) of that section. 

(2) Section 2107(e)(1) of the Social Security Act (42 U.S.C. 

1397gg(e)(1)) is amended— 

(A) in subparagraph (D), as added by section 6401(c) 

of Public Law 111–148, by striking ‘‘(ii)’’ and inserting 

‘‘(kk)’’; and 

(B) by redesignating the subparagraph (N) of that section added by 2101(e) of Public Law 111–148 as subparagraph (O). 

SEC. 206. FUNDING FOR CLAIMS REPROCESSING. 

For purposes of carrying out the provisions of, and amendments 

made by, this Act that relate to title XVIII of the Social Security 

Act, and other provisions of, or relating to, such title that ensure 

appropriate payment of claims, there are appropriated to the Secretary of Health and Human Services for the Centers for Medicare 

& Medicaid Services Program Management Account, from amounts 

in the general fund of the Treasury not otherwise appropriated, 

$200,000,000. Amounts appropriated under the preceding sentence 

shall be in addition to any other funds available for such purposes, 

shall remain available until expended, and shall not be used to 

implement changes to title XVIII of the Social Security Act made 

by Public Laws 111-148 and 111-152. 

SEC. 207. REVISION TO THE MEDICARE IMPROVEMENT FUND. 

Section 1898(b)(1)(B) of the Social Security Act (42 U.S.C. 

1395iii(b)(1)(B)) is amended by striking ‘‘$550,000,000’’ and 

inserting ‘‘$275,000,000’’. 

SEC. 208. LIMITATIONS ON AGGREGATE AMOUNT RECOVERED ON RECONCILIATION OF THE HEALTH INSURANCE TAX CREDIT 

AND THE ADVANCE OF THAT CREDIT. 

(a) IN GENERAL.—So much of section 36B(f)(2)(B) of the Internal 

Revenue Code of 1986 as precedes clause (ii) thereof is amended 

to read as follows: 

‘‘(B) LIMITATION ON INCREASE.— 

‘‘(i) IN GENERAL.—In the case of a taxpayer whose 

household income is less than 500 percent of the poverty line for the size of the family involved for the 

taxable year, the amount of the increase under 

subparagraph (A) shall in no event exceed the 

applicable dollar amount determined in accordance 

with the following table (one-half of such amount in 

the case of a taxpayer whose tax is determined under 

section 1(c) for the taxable year): 
H. R. 4994—8 

‘‘If the household income (expressed as a 

percent of poverty line) is: 

The applicable dollar 

amount is: 

Less than 200% .............................................. $600 

At least 200% but less than 250% ............... $1,000 

At least 250% but less than 300% ............... $1,500 

At least 300% but less than 350% ............... $2,000 

At least 350% but less than 400% ............... $2,500 

At least 400% but less than 450% ............... $3,000 

At least 450% but less than 500% ............... $3,500’’. 

(b) CONFORMING AMENDMENT.—Section 36B(f)(2)(B)(ii) of such 

Code is amended by inserting ‘‘in the table contained’’ after ‘‘each 

of the dollar amounts’’. 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to taxable years beginning after December 31, 2013. 

SEC. 209. DETERMINATION OF BUDGETARY EFFECTS. 

(a) IN GENERAL.—The budgetary effects of this Act, for the 

purpose of complying with the Statutory Pay-As-You-Go Act of 

2010, shall be determined by reference to the latest statement 

titled ‘‘Budgetary Effects of PAYGO Legislation’’ for this Act, submitted for printing in the Congressional Record by the Chairman 

of the Senate Budget Committee, provided that such statement 

has been submitted prior to the vote on passage. 

(b) EMERGENCY DESIGNATION FOR CONGRESSIONAL ENFORCEMENT.—In the House of Representatives, this Act, with the exception of section 101, is designated as an emergency for purposes 

of pay-as-you-go principles. 

Speaker of the House of Representatives. 

Vice President of the United States and

President of the Senate.