H. R. 3590—139 
‘‘(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 Secretary may 
require. 
‘‘(c) STATEMENTS TO BE FURNISHED
TO INDIVIDUALS WITH 
RESPECT TO WHOM INFORMATION IS REPORTED.— 
‘‘(1) IN GENERAL.—Every person required to make a return 
under subsection (a) shall furnish to 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 informa-
tion contact for such person, and 
‘‘(B) the information required to be shown on the return 
with respect to such individual. 
‘‘(2) TIME FOR FURNISHING STATEMENTS.—The written state-
ment 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 REQUIREMENTS.—To the max-
imum 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 insurance issuer, the 
employer may enter into an agreement with the issuer to 
include information required under this section with the return 
and statement required 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 instrumentality thereof, the person appro-
priately designated for purposes of this section shall make the 
returns and statements 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 definitions), 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 returns relating 
to large employers required to report on health insur-
ance coverage), and’’. 
(2) Paragraph (2) of section 6724(d) of such Code, as so 
amended, is amended by striking ‘‘or’’ at the end of subpara-
graph (FF), by striking the period at the end of subparagraph
H. R. 3590—140 
(GG) and inserting ‘‘, or’’ and by inserting after subparagraph 
(GG) the following new subparagraph: 
‘‘(HH) section 6056(c) (relating to statements relating 
to large employers required to report on health insurance 
coverage).’’. 
(c) CONFORMING AMENDMENT.—The table of sections 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 fol-
lowing 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 December 31, 2013. 
SEC. 1515. OFFERING OF EXCHANGE-PARTICIPATING QUALIFIED 
HEALTH PLANS THROUGH CAFETERIA 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.— 
‘‘(A) IN GENERAL.—The term ‘qualified benefit’ shall 
not include any qualified health plan (as defined in section 
1301(a) of the Patient Protection and Affordable Care Act) 
offered through an Exchange established under section 
1311 of such Act. 
‘‘(B) EXCEPTION FOR EXCHANGE-ELIGIBLE EMPLOYERS.— 
Subparagraph (A) shall not apply with respect to any 
employee if such employee’s employer is a qualified 
employer (as defined in section 1312(f)(2) of the Patient 
Protection 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 section— 
‘‘(1) IN GENERAL.—The term’’, and 
(2) by striking ‘‘Such term shall not include’’ and inserting 
the following: 
‘‘(2) LONG-TERM
CARE
INSURANCE
NOT
QUALIFIED.—The 
term ‘qualified benefit’ shall not include’’. 
(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 definitions con-
tained in section 2791 of the Public Health Service 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 authorities provided to the Secretary 
under this Act (and the amendments made by this Act).
H. R. 3590—141 
SEC. 1553. PROHIBITION AGAINST DISCRIMINATION ON ASSISTED SUI-
CIDE. 
(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 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 
furnished 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 hydra-
tion; 
(3) abortion; or 
(4) the use of an item, good, benefit, or service furnished 
for the purpose of alleviating pain or discomfort, even if such 
use may increase the risk of 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 Depart-
ment of Health and Human Services is designated to receive com-
plaints 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 promulgate 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 services; 
(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; 
(5) violates the principles of informed consent and the 
ethical standards of health care professionals; or 
(6) limits the availability of health care treatment for the 
full duration of a patient’s medical needs.
H. R. 3590—142 
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 cov-
erage shall be required to participate in any Federal health insur-
ance 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 participate 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 amended by striking ‘‘, 
except with respect to a claim filed under 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 individual 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 Amend-
ments 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 Rehabilita-
tion Act of 1973 (29 U.S.C. 794), be excluded from participation 
in, be denied the benefits of, or be subjected to discrimination 
under, any health program or activity, any part of which is receiving 
Federal financial assistance, including credits, subsidies, or con-
tracts 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, 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 invali-
date or limit the rights, remedies, procedures, 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 Discrimina-
tion 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.
H. R. 3590—143 
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 respect to his 
or her compensation, terms, conditions, or 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 employer, the Federal Govern-
ment, or the attorney general of a State information relating 
to any violation 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 proceeding concerning 
such violation; 
‘‘(4) assisted or participated, or is about to assist or partici-
pate, 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 believed to be in violation of any provi-
sion 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 discriminated 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 bargaining 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 adminis-
tration and implementation of this title as it relates to such Depart-
ment. 
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 section, the term ‘‘antitrust laws’’ has 
the meaning given such term in subsection (a) of the first section 
of the Clayton Act, except that such term includes section 5 of 
the Federal Trade Commission Act to the extent that such section 
5 applies to unfair methods of competition.
H. R. 3590—144 
(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 Hawaii’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 Education Act of 1965) from offering a 
student health insurance 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 construed to modify any existing 
Federal requirement concerning the State agency responsible for 
determining eligibility for programs identified in section 1413. 
SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STAND-
ARDS 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 ENROLLMENT 
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 Stand-
ards Committee, shall develop interoperable and secure stand-
ards and protocols that facilitate enrollment of individuals in 
Federal and State health and human services programs, as 
determined by the Secretary. 
‘‘(2) METHODS.—The Secretary shall facilitate enrollment 
in such programs through methods determined appropriate by 
the Secretary, which shall include providing individuals and 
third parties authorized by such individuals and their designees 
notification of eligibility and verification of eligibility required 
under such programs. 
‘‘(b) CONTENT.—The standards and protocols for electronic 
enrollment in the Federal and State programs described in sub-
section (a) shall allow for the following: 
‘‘(1) Electronic matching against existing Federal and State 
data, including vital records, employment 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 documenta-
tion, digitization of documents, and systems verification of eligi-
bility. 
‘‘(3) Reuse of stored eligibility information (including docu-
mentation) to assist with retention of eligible individuals.
H. R. 3590—145 
‘‘(4) Capability for individuals to apply, recertify and man-
age 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 streamlined verification and eligibility 
processes to other Federal and State programs, as appropriate. 
‘‘(6) Notification of eligibility, recertification, and other 
needed communication regarding eligibility, 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 APPROPRIATE ENROLL-
MENT 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 proto-
cols developed under subsection (a) (referred to in this sub-
section as ‘appropriate HIT technology’). 
‘‘(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 application at such 
time, in such manner, and containing— 
‘‘(i) a plan to adopt and implement appropriate 
enrollment technology that includes— 
‘‘(I) proposed reduction in maintenance 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 located in the same State, political sub-
division, or locality; 
‘‘(ii) an assurance that the entity will share such 
appropriate enrollment technology in accordance with 
paragraph (4); and 
‘‘(iii) such other information as the Secretary may 
require. 
‘‘(3) SHARING.— 
‘‘(A) IN
GENERAL.—The Secretary shall ensure that 
appropriate enrollment HIT adopted under grants under 
this subsection is made available to other qualified State, 
qualified political subdivisions of a State, or other appro-
priate qualified entities (as described in subparagraph (B)) 
at no cost.
H. R. 3590—146 
‘‘(B) QUALIFIED ENTITIES.—The Secretary shall deter-
mine what entities are qualified to receive enrollment HIT 
under subparagraph (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 redesignated 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)— 
(i) in subparagraph (A), by striking ‘‘subparagraph 
(D)’’ and inserting ‘‘subparagraph (D) or (E)’’; 
(ii) by striking ‘‘1 through 3’’ and inserting ‘‘1 
and 2’’; and 
(iii) by adding at the end the following: 
‘‘(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 inserting ‘‘1 and 2 shall not 
apply to any individual coverage or any group’’; 
(B) in paragraph (2)— 
(i) in the matter preceding subparagraph (A), 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 
(ii) in subparagraph (C), by inserting ‘‘or, with 
respect to individual coverage, under any health insur-
ance coverage maintained by the same health insur-
ance 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 established 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— 
(1) in section 2704 (42 U.S.C. 300gg), as so redesignated 
by section 1201(2)— 
(A) in subsection (c)—
H. R. 3590—147 
(i) in paragraph (2), by striking ‘‘group health plan’’ 
each place that such term appears and inserting ‘‘group 
or individual health plan’’; and 
(ii) in paragraph (3)— 
(I) by striking ‘‘group health insurance’’ each 
place that such term appears and inserting ‘‘group 
or individual health insurance’’; and 
(II) in subparagraph (D), by striking ‘‘small 
or large’’ and inserting ‘‘individual or group’’; 
(B) in subsection (d), by striking ‘‘group health insur-
ance’’ each place that such term appears 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 insur-
ance’’; 
(2) by striking the second heading for subpart 2 of part 
A (relating to other requirements); 
(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 insurance coverage’’ and 
inserting ‘‘health insurance issuer offering group or indi-
vidual health insurance coverage’’; 
(B) in subsection (b)— 
(i) by striking ‘‘health insurance issuer offering 
group health insurance coverage in connection with 
a group health plan’’ in the matter preceding para-
graph (1) and inserting ‘‘health insurance issuer 
offering group or individual health insurance 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 
(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 insurance coverage’’ and 
inserting ‘‘health insurance issuer offering group or indi-
vidual health insurance 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)—
H. R. 3590—148 
(i) in paragraph (1), by striking ‘‘(and group health 
insurance coverage offered in connection with a group 
health plan)’’ and inserting ‘‘and a health insurance 
issuer offering group or individual health insurance 
coverage’’; 
(ii) in paragraph (2), by striking ‘‘(or health insur-
ance 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 insurance coverage’’; 
(5) in section 2727 (42 U.S.C. 300gg–6), as so redesignated 
by section 1001(2), by striking ‘‘health insurance issuers pro-
viding health insurance coverage in connection with group 
health plans’’ and inserting ‘‘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 insurance coverage’’; 
(B) in subsection (b)— 
(i) in paragraph (1), by striking ‘‘or a health insur-
ance issuer that provides health insurance coverage 
in connection with a group health plan’’ and inserting 
‘‘or a health insurance issuer that offers group or indi-
vidual health insurance coverage’’; 
(ii) in paragraph (2), by striking ‘‘health insurance 
coverage offered in connection with the plan’’ and 
inserting ‘‘individual 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 coverage in connection 
with a group health plan’’ and inserting ‘‘health insurance 
issuer that offers group or individual health insurance 
coverage’’; and 
(D) in subsection (e)(1), by striking ‘‘health insurance 
coverage offered in connection with such a plan’’ and 
inserting ‘‘individual health insurance coverage’’; 
(7) by striking the heading for subpart 3; 
(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 subparagraph (A), 
by striking ‘‘small group’’ and inserting ‘‘group and 
individual’’; and 
(II) in subparagraph (B)— 
(aa) in the matter preceding clause (i), 
by 
inserting 
‘‘and 
individuals’’ 
after 
‘‘employers’’;
H. R. 3590—149 
(bb) in clause (i), by inserting ‘‘or any 
additional 
individuals’’ 
after 
‘‘additional 
groups’’; and 
(cc) in clause (ii), by striking ‘‘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 individ-
uals without regard to the claims experience 
of those individuals, employers 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 individual’’; 
(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 individuals’’; 
(II) 
by 
striking 
‘‘those 
employers’’ 
and 
inserting ‘‘those individuals, employers’’; and 
(III) 
by 
striking 
‘‘such 
employees’’ 
and 
inserting ‘‘such individuals, employees’’; 
(D) by striking subsection (e); 
(E) by striking subsection (f); and 
(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 inserting the 
following: 
‘‘(3) 
VIOLATION
OF
PARTICIPATION
OR
CONTRIBUTION 
RATES.—In the case of a group health plan, the plan sponsor 
has failed to comply with a material plan provision relating 
to employer contribution or group participation rules, pursuant 
to applicable State law.’’; 
(C) in subsection (c)— 
(i) in paragraph (1)— 
(I) in the matter preceding subparagraph (A), 
by striking ‘‘group health insurance coverage 
offered in the small or large group market’’ and 
inserting ‘‘group or individual health insurance 
coverage’’;
H. R. 3590—150 
(II) in subparagraph (A), by inserting ‘‘or indi-
vidual, as applicable,’’ after ‘‘plan sponsor’’; 
(III) in subparagraph (B)— 
(aa) by inserting ‘‘or individual, as 
applicable,’’ after ‘‘plan sponsor’’; and 
(bb) by inserting ‘‘or individual health 
insurance coverage’’; and 
(IV) in subparagraph (C), by inserting ‘‘or 
individuals, as applicable,’’ after ‘‘those sponsors’’; 
and 
(ii) in paragraph (2)(A)— 
(I) in the matter preceding clause (i), by 
striking ‘‘small group market or the large group 
market, or both markets,’’ and inserting ‘‘indi-
vidual 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 redesig-
nated by section 1001(4)— 
(A) in subsection (a)— 
(i) in the matter preceding paragraph (1), by 
striking 
‘‘small 
employer’’ 
and 
inserting 
‘‘small 
employer or an individual’’; 
(ii) in paragraph (1), by inserting ‘‘, or individual, 
as applicable,’’ after ‘‘employer’’ 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)— 
(i) in paragraph (1)— 
(I) in the matter preceding subparagraph (A), 
by 
striking 
‘‘small 
employer’’ 
and 
inserting 
‘‘employer, or individual, as applicable,’’; 
(II) in subparagraph (A), by adding ‘‘and’’ at 
the end; 
(III) by striking subparagraphs (B) and (C); 
and 
(IV) in subparagraph (D)— 
(aa) by inserting ‘‘, or individual, as 
applicable,’’ after ‘‘employer’’; 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 individuals, as applicable,’’; and 
(II) by striking ‘‘small employer’’ and inserting 
‘‘employer, or individual, as applicable,’’; and 
(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 redesig-
nated by section 1001(4)—
H. R. 3590—151 
(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), respectively; 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 redesig-
nated by section 1001(4)— 
(A) in subsection (a)— 
(i) in paragraph (1), by striking ‘‘small or large 
group markets’’ and inserting ‘‘individual or group 
market’’; and 
(ii) in paragraph (2), by inserting ‘‘or individual 
health insurance coverage’’ after ‘‘group health plans’’; 
(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 APPLICA-
TION’’ 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 providing health insurance coverage 
in the individual 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 provision 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 regulations that prohibit) a 
group health plan or health insurance issuer from carrying 
out utilization management 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.
H. R. 3590—152 
(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 Retirement 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 subsection (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 connection 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 connection with group health plans, the provisions 
of such part A shall apply. 
‘‘(b) EXCEPTION.—Notwithstanding subsection (a), the provi-
sions of sections 2716 and 2718 of title XXVII of the Public Health 
Service Act (as amended by the Patient Protection and Affordable 
Care Act) shall not apply 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 adding at the end the following: 
‘‘SEC. 9815. ADDITIONAL MARKET REFORMS. 
‘‘(a) GENERAL RULE.—Except as provided in subsection (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 connection 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 insurance issuers providing health 
insurance coverage in connection with group health plans, the 
provisions of such part A shall apply. 
‘‘(b) EXCEPTION.—Notwithstanding subsection (a), the provi-
sions of sections 2716 and 2718 of title XXVII of the Public Health 
Service Act (as amended by the Patient 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.’’. 
SEC. 1563. SENSE OF THE SENATE PROMOTING FISCAL RESPONSI-
BILITY. 
(a) FINDINGS.—The Senate makes the following findings: 
(1) Based on Congressional Budget Office (CBO) estimates, 
this Act will reduce the Federal deficit between 2010 and 2019. 
(2) CBO projects this Act will continue to reduce budget 
deficits after 2019.
H. R. 3590—153 
(3) Based on CBO estimates, this Act will extend the sol-
vency of the Medicare HI Trust Fund. 
(4) This Act will increase the surplus in the Social Security 
Trust Fund, which should be reserved to strengthen the 
finances of Social Security. 
(5) The initial net savings generated by the Community 
Living Assistance Services and Supports (CLASS) program are 
necessary to ensure the long-term solvency of that program. 
(b) SENSE OF THE SENATE.—It is the sense of the Senate that— 
(1) the additional surplus in the Social Security Trust 
Fund generated by this Act should be reserved for Social Secu-
rity and not spent in this Act for other purposes; and 
(2) the net savings generated by the CLASS program should 
be reserved for the CLASS program and not spent in this 
Act for other purposes. 
TITLE II—ROLE OF PUBLIC PROGRAMS 
Subtitle A—Improved Access to Medicaid 
SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME POPU-
LATIONS. 
(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 subclause (VI); 
(B) by adding ‘‘or’’ at the end of subclause (VII); and 
(C) by inserting after subclause (VII) the following: 
‘‘(VIII) beginning January 1, 2014, who are 
under 65 years of age, not pregnant, not entitled 
to, or enrolled 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
ESSENTIAL
COV-
ERAGE.— 
(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 individual 
described in subclause (VIII) of subsection (a)(10)(A)(i) shall consist 
of benchmark coverage described in section 1937(b)(1) or benchmark 
equivalent coverage described in section 1937(b)(2). Such medical 
assistance shall be provided subject to the requirements of 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 
enrollment in benchmark coverage described in subsection (b)(1)
H. R. 3590—154 
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 following: 
‘‘(26) with respect to any amounts expended for medical 
assistance for individuals described in subclause (VIII) of sub-
section (a)(10)(A)(i) other than medical assistance provided 
through benchmark coverage described in section 1937(b)(1) 
or benchmark equivalent coverage described in section 
1937(b)(2).’’. 
(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 ‘‘section 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 period that begins 
on January 1, 2014, and ends on December 31, 2016, not-
withstanding subsection (b), the Federal medical assistance 
percentage 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 individ-
uals 
described 
in 
subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i) shall be equal to 100 percent. 
‘‘(B) 2017 AND 2018.— 
‘‘(i) IN GENERAL.—During the period that begins 
on January 1, 2017, and ends on December 31, 2018, 
notwithstanding subsection (b) and subject to subpara-
graph (D), the Federal medical assistance percentage 
determined for a State that is one of the 50 States 
or the District of Columbia for each fiscal year occur-
ring during that period with respect to amounts 
expended for medical assistance for newly eligible 
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 following:
H. R. 3590—155 
‘‘For any fiscal year quar-
ter occurring in the cal-
endar year: 
If the State is an expan-
sion State, the applicable 
percentage point increase 
is: 
If the State is not an ex-
pansion State, the appli-
cable percentage point in-
crease is: 
2017 
30.3 
34.3 
2018 
31.3 
33.3 
‘‘(II) EXPANSION STATE DEFINED.—For purposes 
of the table in subclause (I), a State is an expan-
sion State if, on the date of the enactment of 
the Patient Protection and Affordable 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 dependent on access to employer cov-
erage, employer contribution, or employment and 
is not limited to premium assistance, hospital-only 
benefits, a high deductible health plan, or alter-
native benefits under a demonstration program 
authorized under section 1938. A State that offers 
health benefits coverage to only parents or only 
nonpregnant childless adults described in the pre-
ceding sentence shall not be considered to be an 
expansion State. 
‘‘(C) 2019 AND SUCCEEDING YEARS.—Beginning January 
1, 2019, notwithstanding subsection (b) but subject to 
subparagraph (D), the Federal medical assistance percent-
age determined for a State that is one of the 50 States 
or the District of Columbia for each fiscal year quarter 
occurring during that period with respect to amounts 
expended for medical assistance for newly eligible individ-
uals 
described 
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 described 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 1937(b)(1) or 
benchmark equivalent coverage described in section 
1937(b)(2) that has an aggregate actuarial value that is 
at least actuarially 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.
H. R. 3590—156 
‘‘(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 individual described 
in section 1902(a)(10)(A)(i).’’. 
(4) STATE
OPTIONS
TO
OFFER
COVERAGE
EARLIER
AND 
PRESUMPTIVE ELIGIBILITY; CHILDREN REQUIRED TO HAVE COV-
ERAGE FOR PARENTS TO BE ELIGIBLE.— 
(A) IN
GENERAL.—Subsection (k) of section 1902 of 
the Social Security Act (as added by paragraph (2)), is 
amended by inserting after paragraph (1) the following: 
‘‘(2) Beginning with the first day of any fiscal year quarter 
that begins on or after January 1, 2011, and before January 1, 
2014, a State may elect through a State plan amendment to provide 
medical assistance to individuals who would be described in sub-
clause (VIII) of subsection (a)(10)(A)(i) if that subclause were effec-
tive before January 1, 2014. A State may elect to phase-in the 
extension 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 assistance. 
‘‘(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 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 
sentence, the term ‘parent’ includes 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 section 1920A, the State 
may elect to provide a presumptive eligibility period (as defined 
in subsection (b)(1)) for individuals 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 period 
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 subpara-
graph (G), by striking ‘‘and (XIV)’’ and inserting ‘‘(XIV)’’ 
and by inserting ‘‘and (XV) the medical assistance made 
available to an individual described in subparagraph 
(A)(i)(VIII) shall be limited to medical assistance described 
in subsection (k)(1)’’ before the semicolon. 
(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’’.
H. R. 3590—157 
(C) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) 
is amended in the matter preceding 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 inserting ‘‘subclause (VIII) of 
section 1902(a)(10)(A)(i) or under’’ after ‘‘eligible under’’. 
(b) MAINTENANCE OF MEDICAID INCOME ELIGIBILITY.—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 paragraph (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 sub-
section (gg).’’; and 
(2) by adding at the end the following new subsection: 
‘‘(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 
Protection and Affordable Care Act and ends on the date on 
which the Secretary determines that an Exchange established 
by the State under section 1311 of the Patient Protection and 
Affordable Care Act is 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, methodologies, or proce-
dures 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 procedures, 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 STANDARDS FOR CHIL-
DREN UNTIL OCTOBER 1, 2019.—The requirement under para-
graph (1) shall continue to apply to a State through September 
30, 2019, with respect to the eligibility standards, methodolo-
gies, and procedures under the State plan under this title 
or under any waiver of such plan that are applicable to deter-
mining 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 December 31, 2013, the require-
ment under paragraph (1) shall not apply to a State with 
respect to nonpregnant, nondisabled adults who are eligible
H. R. 3590—158 
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 certifi-
cation is made, the State has a budget deficit, 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 Secretary, the requirement under paragraph (1) shall 
not apply to the State with respect to any remaining portion 
of the period described in the preceding sentence. 
‘‘(4) DETERMINATION OF COMPLIANCE.— 
‘‘(A) STATES SHALL APPLY MODIFIED GROSS INCOME.— 
A State’s determination of income in accordance with sub-
section (e)(14) shall not be considered to be eligibility stand-
ards, methodologies, or procedures that are more restrictive 
than the standards, methodologies, 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 Afford-
able 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 para-
graph (1), (2), or (3), a State that applies eligibility stand-
ards, 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, meth-
odologies, or procedures, applied under the State plan or 
under a waiver of the plan on the date of enactment of 
the Patient Protection and Affordable Care Act, or that 
makes individuals who, on such date of enactment, 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 income 
eligibility level that is not less than the income eligibility 
level that applied under the waiver, or as a result of 
the 
application 
of 
subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i), shall not be considered to have in effect 
eligibility standards, methodologies, or procedures that are 
more restrictive than the standards, methodologies, or 
procedures in effect under the State plan or under a waiver 
of the plan on the date of enactment of the Patient Protec-
tion and Affordable Care Act for purposes of determining 
compliance with the requirements of paragraph (1), (2), 
or (3).’’. 
(c) MEDICAID BENCHMARK BENEFITS MUST CONSIST 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 paragraphs (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 ‘‘sub-
section (a)(1),’’;
H. R. 3590—159 
(B) in subparagraph (A)— 
(i) by redesignating clauses (iv) and (v) as clauses 
(vi) and (vii), respectively; and 
(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 paragraph (1) or benchmark 
equivalent coverage under paragraph (2) must provide at least 
essential health benefits as described in section 1302(b) of 
the Patient Protection and Affordable Care Act. 
‘‘(6) MENTAL HEALTH SERVICES PARITY.— 
‘‘(A) IN GENERAL.—In the case of any benchmark ben-
efit 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 disorder benefits, the entity shall 
ensure that the financial requirements and treatment 
limitations applicable to such mental health or substance 
use disorder benefits comply with the requirements of sec-
tion 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) (relating to early and periodic screening, diag-
nostic, and treatment services defined in section 1905(r)) 
and provided in accordance with section 1902(a)(43), shall 
be deemed to satisfy the requirements of subparagraph 
(A).’’. 
(d) ANNUAL REPORTS ON MEDICAID ENROLLMENT.— 
(1) STATE REPORTS.—Section 1902(a) of the Social Security 
Act (42 U.S.C. 1396a(a)), as amended by subsection (b), is 
amended— 
(A) by striking ‘‘and’’ at the end of paragraph (73); 
(B) by striking the period at the end of paragraph 
(74) and inserting ‘‘; and’’; and 
(C) by inserting after paragraph (74) the following 
new paragraph: 
‘‘(75) provide that, beginning January 2015, and annually 
thereafter, the State shall submit a report 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 calendar year, disaggregated by population, 
including children, parents, nonpregnant childless adults, 
disabled individuals, elderly individuals, and such other
H. R. 3590—160 
categories or sub-categories of individuals eligible for med-
ical 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 popu-
lation, 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 enrollment and retention of 
individuals eligible for medical assistance under the State 
plan or under a waiver of the plan.’’. 
(2) REPORTS
TO
CONGRESS.—Beginning April 2015, and 
annually thereafter, the Secretary of Health and Human Serv-
ices shall submit a report to the appropriate committees of 
Congress on the total enrollment and new enrollment in Med-
icaid 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 recommendations for adminis-
trative or legislative changes to improve enrollment in the 
Medicaid program 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 following new sub-
clause: 
‘‘(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 determined under 
subsection (e)(14)) exceeds 133 percent of the pov-
erty line (as defined in section 2110(c)(5)) 
applicable to a family of the size involved but 
does not exceed the highest income eligibility level 
established under the State plan or under a waiver 
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 assistance. 
‘‘(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 sentence,
H. R. 3590—161 
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),’’. 
(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 DETERMINED 
USING MODIFIED GROSS INCOME. 
(a) IN GENERAL.—Section 1902(e) of the Social Security 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 subsection (r) or 
any other provision of this title, except as provided in 
subparagraph (D), for purposes of determining income eligi-
bility 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 determina-
tion of income is required, including with respect to the 
imposition of premiums and cost-sharing, a State shall 
use the modified gross income of an individual and, in 
the case of an individual in a family greater than 1, the 
household income of such family. A State shall establish 
income eligibility thresholds for populations to be eligible 
for medical assistance under the State plan or a waiver 
of the plan using modified gross income 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 Afford-
able Care Act. For purposes of complying with the mainte-
nance of effort requirements under subsection (gg) during 
the transition to modified gross income and household 
income, a State shall, working with the Secretary, establish 
an equivalent income test that ensures individuals 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 that States establish income 
and eligibility determination systems that protect bene-
ficiaries. 
‘‘(B) NO
INCOME
OR
EXPENSE
DISREGARDS.—No type 
of expense, block, or other income disregard shall be applied
H. R. 3590—162 
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 determination of income is required. 
‘‘(C) NO ASSETS TEST.—A State shall not apply any 
assets or resources test for purposes of determining eligi-
bility 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
INDIVIDUALS, AND
INDIVIDUALS
ELIGIBLE
FOR 
MEDICARE COST-SHARING.—Subparagraphs (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: 
‘‘(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 
determination of income by the State agency 
administering the State plan or waiver, including 
as a result of eligibility for, or receipt of, other 
Federal or State aid or assistance, individuals who 
are eligible on the basis of receiving (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 attained 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 the individual 
is eligible for supplemental security income bene-
fits under title XVI on the basis of being blind 
or disabled and including an individual who is 
eligible for medical assistance on the basis of sec-
tion 1902(e)(3). 
‘‘(IV) Individuals described in subsection 
(a)(10)(C). 
‘‘(V) Individuals described in any clause of sub-
section (a)(10)(E). 
‘‘(ii) EXPRESS LANE AGENCY FINDINGS.—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 finding 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.—Subparagraphs (A), (B), and (C) 
shall not apply to any determinations of eligibility 
for premium and cost-sharing subsidies under and in
H. R. 3590—163 
accordance with section 1860D–14 made by the State 
pursuant to section 1935(a)(2). 
‘‘(iv) LONG-TERM CARE.—Subparagraphs (A), (B), 
and (C) shall not apply to any determinations of eligi-
bility of individuals for purposes of medical assistance 
for nursing facility services, a level of care in any 
institution equivalent to that of nursing facility serv-
ices, home or community-based services furnished 
under a waiver or State plan amendment under section 
1915 or a waiver under section 1115, and services 
described in section 1917(c)(1)(C)(ii). 
‘‘(v) GRANDFATHER OF CURRENT ENROLLEES UNTIL 
DATE OF NEXT REGULAR REDETERMINATION.—An indi-
vidual 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 application of the modified gross 
income or household income standard described in 
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 individual on that date) through March 31, 
2014, or the date on which the individual’s next regu-
larly scheduled redetermination of eligibility is to 
occur, whichever is later. 
‘‘(E) TRANSITION
PLANNING
AND
OVERSIGHT.—Each 
State shall submit to the Secretary for the Secretary’s 
approval the income eligibility thresholds proposed to be 
established using modified gross income and household 
income, the methodologies and procedures to be used to 
determine income eligibility using modified 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 prac-
ticable, the State shall use the same methodologies and 
procedures for purposes of making such determinations 
as the State used on the date of enactment of the Patient 
Protection and Affordable Care Act. The Secretary shall 
ensure that the income eligibility thresholds proposed to 
be 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 income 
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 AUTHORITY.—The Sec-
retary shall not waive compliance 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 provided in a hospital, a nursing facility, or an 
intermediate care facility for the mentally retarded.
H. R. 3590—164 
‘‘(G) DEFINITIONS
OF
MODIFIED
GROSS
INCOME
AND 
HOUSEHOLD INCOME.—In this paragraph, the terms ‘modi-
fied 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
MEDICAID
RULES 
REGARDING
POINT-IN-TIME
INCOME
AND
SOURCES
OF 
INCOME.—The requirement under this paragraph for States 
to use modified gross income and household income to 
determine 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 shall not 
be construed 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 income 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 the plan regarding sources 
of countable income.’’. 
(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 ASSISTANCE FOR 
EMPLOYER-SPONSORED INSURANCE. 
(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 inserting ‘‘shall’’; 
(B) by striking ‘‘under age 19’’; and 
(C) by inserting ‘‘, in the case of an individual 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 
(ii) by striking the third sentence and inserting 
‘‘A State may not require, as a condition of an indi-
vidual (or the individual’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 parent of an 
individual under age 19’’ and inserting ‘‘an individual (or 
the parent of an individual)’’; and 
(4) in subsection (e), by striking ‘‘under age 19’’ each place 
it appears.
H. R. 3590—165 
(b) CONFORMING AMENDMENT.—The heading for section 1906A 
of such Act (42 U.S.C. 1396e–1) is amended 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 CHIL-
DREN. 
(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— 
(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 following: 
‘‘(IX) who were in foster care under the respon-
sibility 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 ELIGIBILITY.—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),’’. 
(2) Section 1937(a)(2)(B)(viii) of such Act (42 U.S.C. 1396u– 
7(a)(2)(B)(viii)) is amended by inserting ‘‘, or the individual 
qualifies for medical assistance 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 paragraph: 
‘‘(5) FISCAL
YEAR
2011
AND
THEREAFTER.—The amounts 
otherwise determined under this subsection 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 preceding 
paragraphs of this subsection), shall be increased by 30 per-
cent.’’. 
(b) DISREGARD
OF
PAYMENTS
FOR
MANDATORY
EXPANDED 
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’’;
H. R. 3590—166 
(2) by striking the period at the end and inserting ‘‘; and’’; 
and 
(3) by adding at the end the following: 
‘‘(B) fiscal years beginning with fiscal year 2014, pay-
ments made to Puerto Rico, the Virgin Islands, Guam, 
the Northern Mariana Islands, or American Samoa with 
respect to amounts expended for medical assistance for 
newly eligible (as defined in section 1905(y)(2)) nonpreg-
nant childless adults who are eligible under subclause 
(VIII) of section 1902(a)(10)(A)(i) and whose income (as 
determined under section 1902(e)(14)) does not exceed (in 
the case of each such commonwealth and territory respec-
tively) the income eligibility level in effect for that popu-
lation under title XIX or under a waiver on the date of 
enactment of the Patient Protection and Affordable Care 
Act, shall not be taken into account in applying subsection 
(f) (as increased in accordance with paragraphs (1), (2), 
(3), and (5) of this subsection) to such commonwealth or 
territory 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 DETERMINATION FOR CER-
TAIN 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 subsection: 
‘‘(aa)(1) Notwithstanding subsection (b), beginning January 1, 
2011, the Federal medical assistance percentage for a fiscal year 
for a disaster-recovery FMAP adjustment 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 percent of the number of percentage points by which 
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 determined 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 preceding fiscal year) 
and without regard to this subsection, subsection (y), and sub-
sections (b) and (c) of section 5001 of Public Law 111–5. 
‘‘(B) In the case of the second or any succeeding fiscal 
year for which this subsection applies to the State, the Federal 
medical assistance percentage determined for the preceding 
fiscal year under this subsection for the State, increased by 
25 percent of the number of percentage points by which the 
Federal medical assistance percentage determined for the State
H. R. 3590—167 
for the fiscal year without regard to this subsection and sub-
section (y), is less than the Federal medical assistance percent-
age determined 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 Assistance 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 Govern-
ment 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 
determined 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 preceding fiscal year) and 
without regard to this subsection, subsection (y), and sub-
sections (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 succeeding 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 
determined for the State for the preceding fiscal year under 
this subsection by at least 3 percentage points. 
‘‘(3) The Federal medical assistance percentage determined 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.’’. 
SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION. 
(a) RESCISSION.—Any amounts available to the Medicaid 
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’’.
H. R. 3590—168 
Subtitle B—Enhanced Support for the 
Children’s Health Insurance Program 
SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR 
CHIP. 
(a) IN GENERAL.—Section 2105(b) of the Social Security 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) shall 
be increased by 23 percentage points, but in no case shall exceed 
100 percent. The increase in the enhanced FMAP under the pre-
ceding sentence shall not apply with respect to determining the 
payment to a State under subsection (a)(1) for expenditures 
described in subparagraph (D)(iv), paragraphs (8), (9), (11) of sub-
section (c), or clause (4) of the first sentence of section 1905(b).’’. 
(b) MAINTENANCE OF EFFORT.— 
(1) IN GENERAL.—Section 2105(d) of the Social Security 
Act (42 U.S.C. 1397ee(d)) is amended by adding at the end 
the following: 
‘‘(3) CONTINUATION OF ELIGIBILITY STANDARDS FOR CHIL-
DREN UNTIL OCTOBER 1, 2019.— 
‘‘(A) IN GENERAL.—During the period that begins on 
the date of enactment of the Patient Protection and Afford-
able Care Act and ends on September 30, 2019, a State 
shall not have in effect eligibility standards, methodologies, 
or procedures under its State child health plan (including 
any waiver under such plan) for children (including chil-
dren 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 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 
period 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 
restrictive than the eligibility standards, methodolo-
gies, 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 expendi-
tures under the State child health plan to those for 
which Federal financial participation is available under 
this section for the fiscal year. 
‘‘(B) ASSURANCE
OF
EXCHANGE
COVERAGE
FOR
TAR-
GETED
LOW-INCOME
CHILDREN
UNABLE
TO
BE
PROVIDED 
CHILD HEALTH ASSISTANCE AS A RESULT OF FUNDING SHORT-
FALLS.—In the event that allotments provided under section 
2104 are insufficient to provide 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
H. R. 3590—169 
establish procedures to ensure that such children are pro-
vided coverage through an Exchange 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 period ‘‘, except as required under section 
1902(e)(14)’’. 
(c) 
NO
ENROLLMENT
BONUS
PAYMENTS
FOR
CHILDREN 
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 children enrolled on or after October 1, 2013’’ 
before the period. 
(d) INCOME ELIGIBILITY DETERMINED USING MODIFIED 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— 
(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 sec-
tion 36B(d)(2) of the Internal Revenue Code of 1986) 
to determine eligibility for child health assistance 
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: 
‘‘(E) Section 1902(e)(14) (relating to income determined 
using modified gross income and household income).’’. 
(e) APPLICATION OF STREAMLINED ENROLLMENT SYSTEM.—Sec-
tion 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)), 
as amended by subsection (d)(2), is amended by adding at the 
end the following: 
‘‘(N) Section 1943(b) (relating to coordination with 
State Exchanges and the State Medicaid agency).’’. 
(f) CHIP ELIGIBILITY FOR CHILDREN INELIGIBLE FOR MEDICAID 
AS A RESULT OF ELIMINATION OF DISREGARDS.—Notwithstanding 
any other provision of law, a State shall treat any child who 
is determined to be ineligible for medical assistance under the 
State Medicaid plan or under a waiver of the plan as a result 
of the elimination of the application of an income disregard based 
on expense or type of income, as required under section 1902(e)(14) 
of the Social Security Act (as added by this Act), as a targeted 
low-income child under section 2110(b) (unless the child is excluded 
under paragraph (2) of that section) and shall provide child health 
assistance to the child under the State child health plan (whether
H. R. 3590—170 
implemented under title XIX or XXI, or both, of the Social Security 
Act). 
SEC. 2102. TECHNICAL CORRECTIONS. 
(a) CHIPRA.—Effective as if included in the enactment of the 
Children’s Health Insurance Program Reauthorization Act of 2009 
(Public Law 111–3) (in this section referred to as ‘‘CHIPRA’’): 
(1) Section 2104(m) of the Social Security Act, as added 
by section 102 of CHIPRA, is amended— 
(A) by redesignating paragraph (7) as paragraph (8); 
and 
(B) by inserting after paragraph (6), the following: 
‘‘(7) ADJUSTMENT
OF
FISCAL
YEAR
2010
ALLOTMENTS
TO 
ACCOUNT FOR CHANGES IN PROJECTED SPENDING FOR CERTAIN 
PREVIOUSLY APPROVED EXPANSION PROGRAMS.—For purposes of 
recalculating the fiscal year 2010 allotment, in the case of 
one of the 50 States or the District of Columbia that has 
an approved State plan amendment effective January 1, 2006, 
to provide child health assistance through the provision of 
benefits under the State plan under title XIX for children 
from birth through age 5 whose family income does not exceed 
200 percent of the poverty line, the Secretary shall increase 
the allotment by an amount that would be equal to the Federal 
share of expenditures that would have been claimed at the 
enhanced FMAP rate rather than the Federal medical assist-
ance percentage matching rate for such population.’’. 
(2) Section 605 of CHIPRA is amended by striking ‘‘legal 
residents’’ and insert ‘‘lawfully residing in the United States’’. 
(3) Subclauses (I) and (II) of paragraph (3)(C)(i) of section 
2105(a) of the Social Security Act (42 U.S.C. 1397ee(a)(3)(ii)), 
as added by section 104 of CHIPRA, are each amended by 
striking ‘‘, respectively’’. 
(4) Section 2105(a)(3)(E)(ii) of the Social Security Act (42 
U.S.C. 1397ee(a)(3)(E)(ii)), as added by section 104 of CHIPRA, 
is amended by striking subclause (IV). 
(5) Section 2105(c)(9)(B) of the Social Security Act (42 
U.S.C. 1397e(c)(9)(B)), as added by section 211(c)(1) of CHIPRA, 
is amended by striking ‘‘section 1903(a)(3)(F)’’ and inserting 
‘‘section 1903(a)(3)(G)’’. 
(6) Section 2109(b)(2)(B) of the Social Security Act (42 
U.S.C. 1397ii(b)(2)(B)), as added by section 602 of CHIPRA, 
is amended by striking ‘‘the child population growth factor 
under section 2104(m)(5)(B)’’ and inserting ‘‘a high-performing 
State under section 2111(b)(3)(B)’’. 
(7) Section 2110(c)(9)(B)(v) of the Social Security Act (42 
U.S.C. 1397jj(c)(9)(B)(v)), as added by section 505(b) of CHIPRA, 
is amended by striking ‘‘school or school system’’ and inserting 
‘‘local educational agency (as defined under section 9101 of 
the Elementary and Secondary Education Act of 1965’’. 
(8) Section 211(a)(1)(B) of CHIPRA is amended— 
(A) by striking ‘‘is amended’’ and all that follows 
through ‘‘adding’’ and inserting ‘‘is amended by adding’’; 
and 
(B) by redesignating the new subparagraph to be added 
by such section to section 1903(a)(3) of the Social Security 
Act as a new subparagraph (H).
H. R. 3590—171 
(b) ARRA.—Effective as if included in the enactment of section 
5006(a) of division B of the American Recovery and Reinvestment 
Act of 2009 (Public Law 111–5), the second sentence of section 
1916A(a)(1) of the Social Security Act (42 U.S.C. 1396o–1(a)(1)) 
is amended by striking ‘‘or (i)’’ and inserting ‘‘, (i), or (j)’’. 
Subtitle C—Medicaid and CHIP 
Enrollment Simplification 
SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH 
STATE HEALTH INSURANCE EXCHANGES. 
Title XIX of the Social Security Act (42 U.S.C. 1397aa et seq.) 
is amended by adding at the end the following: 
‘‘SEC. 1943. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH 
STATE HEALTH INSURANCE EXCHANGES. 
‘‘(a) CONDITION FOR PARTICIPATION IN MEDICAID.—As a condi-
tion of the State plan under this title and receipt of any Federal 
financial assistance under section 1903(a) for calendar quarters 
beginning after January 1, 2014, a State shall ensure that the 
requirements of subsection (b) is met. 
‘‘(b) ENROLLMENT SIMPLIFICATION
AND COORDINATION WITH 
STATE HEALTH INSURANCE EXCHANGES AND CHIP.— 
‘‘(1) IN GENERAL.—A State shall establish procedures for— 
‘‘(A) enabling individuals, through an Internet website 
that meets the requirements of paragraph (4), to apply 
for medical assistance under the State plan or under a 
waiver of the plan, to be enrolled in the State plan or 
waiver, to renew their enrollment in the plan or waiver, 
and to consent to enrollment or reenrollment in the State 
plan through electronic signature; 
‘‘(B) enrolling, without any further determination by 
the State and through such website, individuals who are 
identified by an Exchange established by the State under 
section 1311 of the Patient Protection and Affordable Care 
Act as being eligible for— 
‘‘(i) medical assistance under the State plan or 
under a waiver of the plan; or 
‘‘(ii) child health assistance under the State child 
health plan under title XXI; 
‘‘(C) ensuring that individuals who apply for but are 
determined to be ineligible for medical assistance under 
the State plan or a waiver or ineligible for child health 
assistance under the State child health plan under title 
XXI, are screened for eligibility for enrollment in qualified 
health plans offered through such an Exchange and, if 
applicable, premium assistance for the purchase of a quali-
fied health plan under section 36B of the Internal Revenue 
Code of 1986 (and, if applicable, advance payment 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 separate 
application, and that such individuals receive information 
regarding reduced cost-sharing for eligible individuals 
under section 1402 of the Patient Protection and Affordable
H. R. 3590—172 
Care Act, and any other assistance or subsidies available 
for coverage obtained through the Exchange; 
‘‘(D) ensuring that the State agency responsible 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 referred to as the ‘State 
CHIP agency’) and an Exchange established by the State 
under section 1311 of the Patient Protection and Affordable 
Care Act utilize a secure electronic interface sufficient to 
allow for a determination of an individual’s eligibility for 
such medical assistance, child health assistance, or pre-
mium assistance, and enrollment in the State plan under 
this title, title XXI, or a qualified health plan, as appro-
priate; 
‘‘(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 qualified health plan offered through 
such an Exchange, 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 services 
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 requirements 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, including children, unaccompanied homeless 
youth, children and youth with special health care needs, 
pregnant women, racial and ethnic minorities, rural popu-
lations, victims of abuse or trauma, individuals with mental 
health or substance-related disorders, and individuals with 
HIV/AIDS. 
‘‘(2) 
AGREEMENTS
WITH
STATE
HEALTH
INSURANCE 
EXCHANGES.—The State Medicaid agency and the State CHIP 
agency may enter into an agreement with an Exchange estab-
lished by the State under section 1311 of the Patient Protection 
and Affordable Care Act under which the State Medicaid agency 
or State CHIP agency may determine whether a State resident 
is eligible for premium assistance for the purchase of a qualified 
health plan under section 36B of the Internal Revenue Code 
of 1986 (and, if applicable, advance payment of such assistance 
under section 1412 of the Patient Protection and Affordable 
Care Act), so long as the agreement meets such conditions 
and requirements as the Secretary of the Treasury may pre-
scribe to reduce administrative costs and the likelihood of eligi-
bility errors and disruptions in coverage. 
‘‘(3) STREAMLINED ENROLLMENT SYSTEM.—The State Med-
icaid agency and State CHIP agency shall participate in and 
comply with the requirements for the system established under 
section 1413 of the Patient Protection and Affordable Care 
Act (relating to streamlined procedures for enrollment through 
an Exchange, Medicaid, and CHIP).
H. R. 3590—173 
‘‘(4) ENROLLMENT
WEBSITE
REQUIREMENTS.—The proce-
dures established by State under paragraph (1) shall include 
establishing and having in operation, not later than January 
1, 2014, an Internet website that is linked to any website 
of an Exchange established by the State under section 1311 
of the Patient Protection and Affordable Care Act and to the 
State CHIP agency (if different from the State Medicaid agency) 
and allows an individual who is eligible for medical assistance 
under the State plan or under a waiver of the plan and who 
is eligible to receive premium credit assistance for the purchase 
of a qualified health plan under section 36B of the Internal 
Revenue Code of 1986 to compare the benefits, premiums, 
and cost-sharing applicable to the individual under the State 
plan or waiver with the benefits, premiums, and cost-sharing 
available to the individual under a qualified health plan offered 
through such an Exchange, including, in the case of a child, 
the coverage that would be provided for the child through 
the State plan or waiver with the coverage that would be 
provided to the child through enrollment in family coverage 
under that plan and as supplemental coverage by the State 
under the State plan or waiver. 
‘‘(5) CONTINUED
NEED
FOR
ASSESSMENT
FOR
HOME
AND 
COMMUNITY-BASED SERVICES.—Nothing in paragraph (1) shall 
limit or modify the requirement that the State assess an indi-
vidual for purposes of providing home and community-based 
services under the State plan or under any waiver of such 
plan for individuals described in subsection (a)(10)(A)(ii)(VI).’’. 
SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMPTIVE ELIGI-
BILITY DETERMINATIONS FOR ALL MEDICAID ELIGIBLE 
POPULATIONS. 
(a) IN GENERAL.—Section 1902(a)(47) of the Social Security 
Act (42 U.S.C. 1396a(a)(47)) is amended— 
(1) by striking ‘‘at the option of the State, provide’’ and 
inserting ‘‘provide— 
‘‘(A) at the option of the State,’’; 
(2) by inserting ‘‘and’’ after the semicolon; and 
(3) by adding at the end the following: 
‘‘(B) that any hospital that is a participating provider 
under the State plan may elect to be a qualified entity 
for purposes of determining, on the basis of preliminary 
information, whether any individual is eligible for medical 
assistance under the State plan or under a waiver of the 
plan for purposes of providing the individual with medical 
assistance during a presumptive eligibility period, in the 
same manner, and subject to the same requirements, as 
apply to the State options with respect to populations 
described in section 1920, 1920A, or 1920B (but without 
regard to whether the State has elected to provide for 
a presumptive eligibility period under any such sections), 
subject to such guidance as the Secretary shall establish;’’. 
(b) CONFORMING AMENDMENT.—Section 1903(u)(1)(D)(v) of such 
Act (42 U.S.C. 1396b(u)(1)(D)v)) is amended— 
(1) by striking ‘‘or for’’ and inserting ‘‘for’’; and 
(2) by inserting before the period at the end the following: 
‘‘, or for medical assistance provided to an individual during 
a presumptive eligibility period resulting from a determination
H. R. 3590—174 
of presumptive eligibility made by a hospital that elects under 
section 1902(a)(47)(B) to be a qualified entity for such purpose’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
take effect on January 1, 2014, and apply to services furnished 
on or after that date. 
Subtitle D—Improvements to Medicaid 
Services 
SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES. 
(a) IN GENERAL.—Section 1905 of the Social Security Act (42 
U.S.C. 1396d), is amended— 
(1) in subsection (a)— 
(A) in paragraph (27), by striking ‘‘and’’ at the end; 
(B) by redesignating paragraph (28) as paragraph (29); 
and 
(C) by inserting after paragraph (27) the following 
new paragraph: 
‘‘(28) freestanding birth center services (as defined in sub-
section (l)(3)(A)) and other ambulatory services that are offered 
by a freestanding birth center (as defined in subsection (l)(3)(B)) 
and that are otherwise included in the plan; and’’; and 
(2) in subsection (l), by adding at the end the following 
new paragraph: 
‘‘(3)(A) The term ‘freestanding birth center services’ means serv-
ices furnished to an individual at a freestanding birth center (as 
defined in subparagraph (B)) at such center. 
‘‘(B) The term ‘freestanding birth center’ means a health 
facility— 
‘‘(i) that is not a hospital; 
‘‘(ii) where childbirth is planned to occur away from the 
pregnant woman’s residence; 
‘‘(iii) that is licensed or otherwise approved by the State 
to provide prenatal labor and delivery or postpartum care and 
other ambulatory services that are included in the plan; and 
‘‘(iv) that complies with such other requirements relating 
to the health and safety of individuals furnished services by 
the facility as the State shall establish. 
‘‘(C) A State shall provide separate payments to providers 
administering prenatal labor and delivery or postpartum care in 
a freestanding birth center (as defined in subparagraph (B)), such 
as nurse midwives and other providers of services such as birth 
attendants recognized under State law, as determined appropriate 
by the Secretary. For purposes of the preceding sentence, the term 
‘birth attendant’ means an individual who is recognized or reg-
istered by the State involved to provide health care at childbirth 
and who provides such care within the scope of practice under 
which the individual is legally authorized to perform such care 
under State law (or the State regulatory mechanism provided by 
State law), regardless of whether the individual is under the super-
vision of, or associated with, a physician or other health care 
provider. Nothing in this subparagraph shall be construed as 
changing State law requirements applicable to a birth attendant.’’. 
(b) CONFORMING AMENDMENT.—Section 1902(a)(10)(A) of the 
Social Security Act (42 U.S.C. 1396a(a)(10)(A)), is amended in the
H. R. 3590—175 
matter preceding clause (i) by striking ‘‘and (21)’’ and inserting 
‘‘, (21), and (28)’’. 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in paragraph (2), the 
amendments made by this section shall take effect on the 
date of the enactment of this Act and shall apply to services 
furnished on or after such date. 
(2) EXCEPTION IF STATE LEGISLATION REQUIRED.—In the 
case of a State plan for medical assistance under title XIX 
of the Social Security Act which the Secretary of Health and 
Human Services determines requires State legislation (other 
than legislation appropriating funds) in order for the plan to 
meet the additional requirement imposed by the amendments 
made by this section, the State plan shall not be regarded 
as failing to comply with the requirements of such title solely 
on the basis of its failure to meet this additional requirement 
before the first day of the first calendar quarter beginning 
after the close of the first regular session of the State legislature 
that begins after the date of the enactment of this Act. For 
purposes of the previous sentence, in the case of a State that 
has a 2-year legislative session, each year of such session 
shall be deemed to be a separate regular session of the State 
legislature. 
SEC. 2302. CONCURRENT CARE FOR CHILDREN. 
(a) IN GENERAL.—Section 1905(o)(1) of the Social Security Act 
(42 U.S.C. 1396d(o)(1)) is amended— 
(1) in subparagraph (A), by striking ‘‘subparagraph (B)’’ 
and inserting ‘‘subparagraphs (B) and (C)’’; and 
(2) by adding at the end the following new subparagraph: 
‘‘(C) A voluntary election to have payment made for hospice 
care for a child (as defined by the State) shall not constitute 
a waiver of any rights of the child to be provided with, or to 
have payment made under this title for, services that are related 
to the treatment of the child’s condition for which a diagnosis 
of terminal illness has been made.’’. 
(b) APPLICATION TO CHIP.—Section 2110(a)(23) of the Social 
Security Act (42 U.S.C. 1397jj(a)(23)) is amended by inserting 
‘‘(concurrent, in the case of an individual who is a child, with 
care related to the treatment of the child’s condition with respect 
to which a diagnosis of terminal illness has been made’’ after 
‘‘hospice care’’. 
SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING SERV-
ICES. 
(a) COVERAGE AS OPTIONAL CATEGORICALLY NEEDY GROUP.— 
(1) IN GENERAL.—Section 1902(a)(10)(A)(ii) of the Social 
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by 
section 2001(e), is amended— 
(A) in subclause (XIX), by striking ‘‘or’’ at the end; 
(B) in subclause (XX), by adding ‘‘or’’ at the end; and 
(C) by adding at the end the following new subclause: 
‘‘(XXI) who are described in subsection (ii) 
(relating to individuals who meet certain income 
standards);’’. 
(2) GROUP DESCRIBED.—Section 1902 of such Act (42 U.S.C. 
1396a), as amended by section 2001(d), is amended by adding 
at the end the following new subsection:
H. R. 3590—176 
‘‘(ii)(1) Individuals described in this subsection are individuals— 
‘‘(A) whose income does not exceed an income eligibility 
level established by the State that does not exceed the 
highest income eligibility level established under the State 
plan under this title (or under its State child health plan 
under title XXI) for pregnant women; and 
‘‘(B) who are not pregnant. 
‘‘(2) At the option of a State, individuals described in this 
subsection may include individuals who, had individuals 
applied on or before January 1, 2007, would have been made 
eligible pursuant to the standards and processes imposed by 
that State for benefits described in clause (XV) of the matter 
following subparagraph (G) of section subsection (a)(10) pursu-
ant to a waiver granted under section 1115. 
‘‘(3) At the option of a State, for purposes of subsection 
(a)(17)(B), in determining eligibility for services under this sub-
section, the State may consider only the income of the applicant 
or recipient.’’. 
(3) LIMITATION ON BENEFITS.—Section 1902(a)(10) of the 
Social Security Act (42 U.S.C. 1396a(a)(10)), as amended by 
section 2001(a)(5)(A), is amended in the matter following 
subparagraph (G)— 
(A) by striking ‘‘and (XV)’’ and inserting ‘‘(XV)’’; and 
(B) by inserting ‘‘, and (XVI) the medical assistance 
made available to an individual described in subsection 
(ii) shall be limited to family planning services and supplies 
described in section 1905(a)(4)(C) including medical diag-
nosis and treatment services that are provided pursuant 
to a family planning service in a family planning setting’’ 
before the semicolon. 
(4) CONFORMING AMENDMENTS.— 
(A) Section 1905(a) of the Social Security Act (42 U.S.C. 
1396d(a)), as amended by section 2001(e)(2)(A), is amended 
in the matter preceding paragraph (1)— 
(i) in clause (xiv), by striking ‘‘or’’ at the end; 
(ii) in clause (xv), by adding ‘‘or’’ at the end; and 
(iii) by inserting after clause (xv) the following: 
‘‘(xvi) individuals described in section 1902(ii),’’. 
(B) 
Section 
1903(f)(4) 
of 
such 
Act 
(42 
U.S.C. 
1396b(f)(4)), as amended by section 2001(e)(2)(B), is 
amended 
by 
inserting 
‘‘1902(a)(10)(A)(ii)(XXI),’’ 
after 
‘‘1902(a)(10)(A)(ii)(XX),’’. 
(b) PRESUMPTIVE ELIGIBILITY.— 
(1) IN GENERAL.—Title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.) is amended by inserting after section 
1920B the following: 
‘‘PRESUMPTIVE ELIGIBILITY FOR FAMILY PLANNING SERVICES 
‘‘SEC. 1920C. (a) STATE OPTION.—State plan approved under 
section 1902 may provide for making medical assistance available 
to an individual described in section 1902(ii) (relating to individuals 
who meet certain income eligibility standard) during a presumptive 
eligibility period. In the case of an individual described in section 
1902(ii), such medical assistance shall be limited to family planning 
services and supplies described in 1905(a)(4)(C) and, at the State’s 
option, medical diagnosis and treatment services that are provided
H. R. 3590—177 
in conjunction with a family planning service in a family planning 
setting. 
‘‘(b) DEFINITIONS.—For purposes of this section: 
‘‘(1) PRESUMPTIVE ELIGIBILITY PERIOD.—The term ‘presump-
tive eligibility period’ means, with respect to an individual 
described in subsection (a), the period that— 
‘‘(A) begins with the date on which a qualified entity 
determines, on the basis of preliminary information, that 
the individual is described in section 1902(ii); and 
‘‘(B) ends with (and includes) the earlier of— 
‘‘(i) the day on which a determination is made 
with respect to the eligibility of such individual for 
services under the State plan; or 
‘‘(ii) in the case of such an individual who does 
not file an application by the last day of the month 
following the month during which the entity makes 
the determination referred to in subparagraph (A), 
such last day. 
‘‘(2) QUALIFIED ENTITY.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 
term ‘qualified entity’ means any entity that— 
‘‘(i) is eligible for payments under a State plan 
approved under this title; and 
‘‘(ii) is determined by the State agency to be 
capable of making determinations of the type described 
in paragraph (1)(A). 
‘‘(B) RULE OF CONSTRUCTION.—Nothing in this para-
graph shall be construed as preventing a State from lim-
iting the classes of entities that may become qualified 
entities in order to prevent fraud and abuse. 
‘‘(c) ADMINISTRATION.— 
‘‘(1) IN GENERAL.—The State agency shall provide qualified 
entities with— 
‘‘(A) such forms as are necessary for an application 
to be made by an individual described in subsection (a) 
for medical assistance under the State plan; and 
‘‘(B) information on how to assist such individuals in 
completing and filing such forms. 
‘‘(2) NOTIFICATION REQUIREMENTS.—A qualified entity that 
determines under subsection (b)(1)(A) that an individual 
described in subsection (a) is presumptively eligible for medical 
assistance under a State plan shall— 
‘‘(A) notify the State agency of the determination within 
5 working days after the date on which determination 
is made; and 
‘‘(B) inform such individual at the time the determina-
tion is made that an application for medical assistance 
is required to be made by not later than the last day 
of the month following the month during which the deter-
mination is made. 
‘‘(3) APPLICATION FOR MEDICAL ASSISTANCE.—In the case 
of an individual described in subsection (a) who is determined 
by a qualified entity to be presumptively eligible for medical 
assistance under a State plan, the individual shall apply for 
medical assistance by not later than the last day of the month 
following the month during which the determination is made.
H. R. 3590—178 
‘‘(d) PAYMENT.—Notwithstanding any other provision of law, 
medical assistance that— 
‘‘(1) is furnished to an individual described in subsection 
(a)— 
‘‘(A) during a presumptive eligibility period; and 
‘‘(B) by a entity that is eligible for payments under 
the State plan; and 
‘‘(2) is included in the care and services covered by the 
State plan, 
shall be treated as medical assistance provided by such plan for 
purposes of clause (4) of the first sentence of section 1905(b).’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1902(a)(47) of the Social Security Act (42 
U.S.C. 1396a(a)(47)), as amended by section 2202(a), is 
amended— 
(i) in subparagraph (A), by inserting before the 
semicolon at the end the following: ‘‘and provide for 
making medical assistance available to individuals 
described in subsection (a) of section 1920C during 
a presumptive eligibility period in accordance with 
such section’’; and 
(ii) in subparagraph (B), by striking ‘‘or 1920B’’ 
and inserting ‘‘1920B, or 1920C’’. 
(B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C. 
1396b(u)(1)(D)(v)), as amended by section 2202(b), is 
amended by inserting ‘‘or for medical assistance provided 
to an individual described in subsection (a) of section 1920C 
during a presumptive eligibility period under such section,’’ 
after ‘‘1920B during a presumptive eligibility period under 
such section,’’. 
(c) CLARIFICATION OF COVERAGE OF FAMILY PLANNING SERVICES 
AND SUPPLIES.—Section 1937(b) of the Social Security Act (42 U.S.C. 
1396u–7(b)), as amended by section 2001(c), is amended by adding 
at the end the following: 
‘‘(7) COVERAGE OF FAMILY PLANNING SERVICES AND SUP-
PLIES.—Notwithstanding the previous provisions of this section, 
a State may not provide for medical assistance through enroll-
ment of an individual with benchmark coverage or benchmark- 
equivalent coverage under this section unless such coverage 
includes for any individual described in section 1905(a)(4)(C), 
medical assistance for family planning services and supplies 
in accordance with such section.’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
take effect on the date of the enactment of this Act and shall 
apply to items and services furnished on or after such date. 
SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL ASSISTANCE. 
Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) 
is amended by inserting ‘‘or the care and services themselves, 
or both’’ before ‘‘(if provided in or after’’.
H. R. 3590—179 
Subtitle E—New Options for States to 
Provide Long-Term Services and Supports 
SEC. 2401. COMMUNITY FIRST CHOICE OPTION. 
Section 1915 of the Social Security Act (42 U.S.C. 1396n) is 
amended by adding at the end the following: 
‘‘(k) STATE PLAN OPTION TO PROVIDE HOME AND COMMUNITY- 
BASED ATTENDANT SERVICES AND SUPPORTS.— 
‘‘(1) IN GENERAL.—Subject to the succeeding provisions of 
this subsection, beginning October 1, 2010, a State may provide 
through a State plan amendment for the provision of medical 
assistance for home and community-based attendant services 
and supports for individuals who are eligible for medical assist-
ance under the State plan whose income does not exceed 150 
percent of the poverty line (as defined in section 2110(c)(5)) 
or, if greater, the income level applicable for an individual 
who has been determined to require an institutional level of 
care to be eligible for nursing facility services under the State 
plan and with respect to whom there has been a determination 
that, but for the provision of such services, the individuals 
would require the level of care provided in a hospital, a nursing 
facility, an intermediate care facility for the mentally retarded, 
or an institution for mental diseases, the cost of which could 
be reimbursed under the State plan, but only if the individual 
chooses to receive such home and community-based attendant 
services and supports, and only if the State meets the following 
requirements: 
‘‘(A) AVAILABILITY.—The State shall make available 
home and community-based attendant services and sup-
ports to eligible individuals, as needed, to assist in accom-
plishing activities of daily living, instrumental activities 
of daily living, and health-related tasks through hands- 
on assistance, supervision, or cueing— 
‘‘(i) under a person-centered plan of services and 
supports that is based on an assessment of functional 
need and that is agreed to in writing by the individual 
or, as appropriate, the individual’s representative; 
‘‘(ii) in a home or community setting, which does 
not include a nursing facility, institution for mental 
diseases, or an intermediate care facility for the men-
tally retarded; 
‘‘(iii) under an agency-provider model or other 
model (as defined in paragraph (6)(C )); and 
‘‘(iv) the furnishing of which— 
‘‘(I) is selected, managed, and dismissed by 
the individual, or, as appropriate, with assistance 
from the individual’s representative; 
‘‘(II) is controlled, to the maximum extent pos-
sible, by the individual or where appropriate, the 
individual’s representative, regardless of who may 
act as the employer of record; and 
‘‘(III) provided by an individual who is quali-
fied to provide such services, including family 
members (as defined by the Secretary). 
‘‘(B) INCLUDED SERVICES AND SUPPORTS.—In addition 
to assistance in accomplishing activities of daily living,
H. R. 3590—180 
instrumental activities of daily living, and health related 
tasks, the home and community-based attendant services 
and supports made available include— 
‘‘(i) the acquisition, maintenance, and enhance-
ment of skills necessary for the individual to accom-
plish activities of daily living, instrumental activities 
of daily living, and health related tasks; 
‘‘(ii) back-up systems or mechanisms (such as the 
use of beepers or other electronic devices) to ensure 
continuity of services and supports; and 
‘‘(iii) voluntary training on how to select, manage, 
and dismiss attendants. 
‘‘(C) EXCLUDED SERVICES AND SUPPORTS.—Subject to 
subparagraph (D), the home and community-based attend-
ant services and supports made available do not include— 
‘‘(i) room and board costs for the individual; 
‘‘(ii) special education and related services provided 
under the Individuals with Disabilities Education Act 
and vocational rehabilitation services provided under 
the Rehabilitation Act of 1973; 
‘‘(iii) assistive technology devices and assistive 
technology services other than those under (1)(B)(ii); 
‘‘(iv) medical supplies and equipment; or 
‘‘(v) home modifications. 
‘‘(D) PERMISSIBLE SERVICES AND SUPPORTS.—The home 
and community-based attendant services and supports may 
include— 
‘‘(i) expenditures for transition costs such as rent 
and utility deposits, first month’s rent and utilities, 
bedding, basic kitchen supplies, and other necessities 
required for an individual to make the transition from 
a nursing facility, institution for mental diseases, or 
intermediate care facility for the mentally retarded 
to a community-based home setting where the indi-
vidual resides; and 
‘‘(ii) expenditures relating to a need identified in 
an individual’s person-centered plan of services that 
increase independence or substitute for human assist-
ance, to the extent that expenditures would otherwise 
be made for the human assistance. 
‘‘(2) INCREASED
FEDERAL
FINANCIAL
PARTICIPATION.—For 
purposes of payments to a State under section 1903(a)(1), with 
respect to amounts expended by the State to provide medical 
assistance under the State plan for home and community- 
based attendant services and supports to eligible individuals 
in accordance with this subsection during a fiscal year quarter 
occurring during the period described in paragraph (1), the 
Federal medical assistance percentage applicable to the State 
(as determined under section 1905(b)) shall be increased by 
6 percentage points. 
‘‘(3) STATE
REQUIREMENTS.—In order for a State plan 
amendment to be approved under this subsection, the State 
shall— 
‘‘(A) develop and implement such amendment in 
collaboration with a Development and Implementation 
Council established by the State that includes a majority 
of members with disabilities, elderly individuals, and their
H. R. 3590—181 
representatives and consults and collaborates with such 
individuals; 
‘‘(B) provide consumer controlled home and community- 
based attendant services and supports to individuals on 
a statewide basis, in a manner that provides such services 
and supports in the most integrated setting appropriate 
to the individual’s needs, and without regard to the individ-
ual’s age, type or nature of disability, severity of disability, 
or the form of home and community-based attendant serv-
ices and supports that the individual requires in order 
to lead an independent life; 
‘‘(C) with respect to expenditures during the first full 
fiscal year in which the State plan amendment is imple-
mented, maintain or exceed the level of State expenditures 
for medical assistance that is provided under section 
1905(a), section 1915, section 1115, or otherwise to individ-
uals with disabilities or elderly individuals attributable 
to the preceding fiscal year; 
‘‘(D) establish and maintain a comprehensive, contin-
uous quality assurance system with respect to community- 
based attendant services and supports that— 
‘‘(i) includes standards for agency-based and other 
delivery models with respect to training, appeals for 
denials and reconsideration procedures of an individual 
plan, and other factors as determined by the Secretary; 
‘‘(ii) incorporates feedback from consumers and 
their representatives, disability organizations, pro-
viders, families of disabled or elderly individuals, mem-
bers of the community, and others and maximizes con-
sumer independence and consumer control; 
‘‘(iii) monitors the health and well-being of each 
individual who receives home and community-based 
attendant services and supports, including a process 
for the mandatory reporting, investigation, and resolu-
tion of allegations of neglect, abuse, or exploitation 
in connection with the provision of such services and 
supports; and 
‘‘(iv) provides information about the provisions of 
the quality assurance required under clauses (i) 
through (iii) to each individual receiving such services; 
and 
‘‘(E) collect and report information, as determined nec-
essary by the Secretary, for the purposes of approving 
the State plan amendment, providing Federal oversight, 
and conducting an evaluation under paragraph (5)(A), 
including data regarding how the State provides home 
and community-based attendant services and supports and 
other home and community-based services, the cost of such 
services and supports, and how the State provides individ-
uals with disabilities who otherwise qualify for institutional 
care under the State plan or under a waiver the choice 
to instead receive home and community-based services in 
lieu of institutional care. 
‘‘(4) COMPLIANCE
WITH
CERTAIN
LAWS.—A State shall 
ensure that, regardless of whether the State uses an agency- 
provider model or other models to provide home and commu-
nity-based attendant services and supports under a State plan
H. R. 3590—182 
amendment under this subsection, such services and supports 
are provided in accordance with the requirements of the Fair 
Labor Standards Act of 1938 and applicable Federal and State 
laws regarding— 
‘‘(A) withholding and payment of Federal and State 
income and payroll taxes; 
‘‘(B) the provision of unemployment and workers com-
pensation insurance; 
‘‘(C) maintenance of general liability insurance; and 
‘‘(D) occupational health and safety. 
‘‘(5) EVALUATION, DATA COLLECTION, AND REPORT TO CON-
GRESS.— 
‘‘(A) EVALUATION.—The Secretary shall conduct an 
evaluation of the provision of home and community-based 
attendant services and supports under this subsection in 
order to determine the effectiveness of the provision of 
such services and supports in allowing the individuals 
receiving such services and supports to lead an independent 
life to the maximum extent possible; the impact on the 
physical and emotional health of the individuals who 
receive such services; and an comparative analysis of the 
costs of services provided under the State plan amendment 
under this subsection and those provided under institu-
tional care in a nursing facility, institution for mental 
diseases, or an intermediate care facility for the mentally 
retarded. 
‘‘(B) DATA COLLECTION.—The State shall provide the 
Secretary with the following information regarding the 
provision of home and community-based attendant services 
and supports under this subsection for each fiscal year 
for which such services and supports are provided: 
‘‘(i) The number of individuals who are estimated 
to receive home and community-based attendant serv-
ices and supports under this subsection during the 
fiscal year. 
‘‘(ii) The number of individuals that received such 
services and supports during the preceding fiscal year. 
‘‘(iii) The specific number of individuals served by 
type of disability, age, gender, education level, and 
employment status. 
‘‘(iv) Whether the specific individuals have been 
previously served under any other home and commu-
nity based services program under the State plan or 
under a waiver. 
‘‘(C) REPORTS.—Not later than— 
‘‘(i) December 31, 2013, the Secretary shall submit 
to Congress and make available to the public an 
interim report on the findings of the evaluation under 
subparagraph (A); and 
‘‘(ii) December 31, 2015, the Secretary shall submit 
to Congress and make available to the public a final 
report on the findings of the evaluation under subpara-
graph (A). 
‘‘(6) DEFINITIONS.—In this subsection: 
‘‘(A) ACTIVITIES OF DAILY LIVING.—The term ‘activities 
of daily living’ includes tasks such as eating, toileting, 
grooming, dressing, bathing, and transferring.
H. R. 3590—183 
‘‘(B) CONSUMER
CONTROLLED.—The term ‘consumer 
controlled’ means a method of selecting and providing serv-
ices and supports that allow the individual, or where appro-
priate, the individual’s representative, maximum control 
of the home and community-based attendant services and 
supports, regardless of who acts as the employer of record. 
‘‘(C) DELIVERY MODELS.— 
‘‘(i) AGENCY-PROVIDER MODEL.—The term ‘agency- 
provider model’ means, with respect to the provision 
of home and community-based attendant services and 
supports for an individual, subject to paragraph (4), 
a method of providing consumer controlled services 
and supports under which entities contract for the 
provision of such services and supports. 
‘‘(ii) OTHER
MODELS.—The term ‘other models’ 
means, subject to paragraph (4), methods, other than 
an agency-provider model, for the provision of con-
sumer controlled services and supports. Such models 
may include the provision of vouchers, direct cash pay-
ments, or use of a fiscal agent to assist in obtaining 
services. 
‘‘(D) 
HEALTH-RELATED
TASKS.—The 
term 
‘health- 
related tasks’ means specific tasks related to the needs 
of an individual, which can be delegated or assigned by 
licensed health-care professionals under State law to be 
performed by an attendant. 
‘‘(E) INDIVIDUAL’S REPRESENTATIVE.—The term ‘individ-
ual’s representative’ means a parent, family member, 
guardian, advocate, or other authorized representative of 
an individual 
‘‘(F) INSTRUMENTAL ACTIVITIES OF DAILY LIVING.—The 
term ‘instrumental activities of daily living’ includes (but 
is not limited to) meal planning and preparation, managing 
finances, shopping for food, clothing, and other essential 
items, performing essential household chores, commu-
nicating by phone or other media, and traveling around 
and participating in the community.’’. 
SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME AND COMMU-
NITY-BASED SERVICES. 
(a) OVERSIGHT AND ASSESSMENT OF THE ADMINISTRATION OF 
HOME AND COMMUNITY-BASED SERVICES.—The Secretary of Health 
and Human Services shall promulgate regulations to ensure that 
all States develop service systems that are designed to— 
(1) allocate resources for services in a manner that is 
responsive to the changing needs and choices of beneficiaries 
receiving non-institutionally-based long-term services and sup-
ports (including such services and supports that are provided 
under programs other the State Medicaid program), and that 
provides strategies for beneficiaries receiving such services to 
maximize their independence, including through the use of 
client-employed providers; 
(2) provide the support and coordination needed for a bene-
ficiary in need of such services (and their family caregivers 
or representative, if applicable) to design an individualized, 
self-directed, community-supported life; and
H. R. 3590—184 
(3) improve coordination among, and the regulation of, 
all providers of such services under federally and State-funded 
programs in order to— 
(A) achieve a more consistent administration of policies 
and procedures across programs in relation to the provision 
of such services; and 
(B) oversee and monitor all service system functions 
to assure— 
(i) coordination of, and effectiveness of, eligibility 
determinations and individual assessments; 
(ii) development and service monitoring of a com-
plaint system, a management system, a system to 
qualify and monitor providers, and systems for role- 
setting and individual budget determinations; and 
(iii) an adequate number of qualified direct care 
workers to provide self-directed personal assistance 
services. 
(b) ADDITIONAL STATE OPTIONS.—Section 1915(i) of the Social 
Security Act (42 U.S.C. 1396n(i)) is amended by adding at the 
end the following new paragraphs: 
‘‘(6) STATE OPTION TO PROVIDE HOME AND COMMUNITY-BASED 
SERVICES
TO
INDIVIDUALS
ELIGIBLE
FOR
SERVICES
UNDER
A 
WAIVER.— 
‘‘(A) IN GENERAL.—A State that provides home and 
community-based services in accordance with this sub-
section to individuals who satisfy the needs-based criteria 
for the receipt of such services established under paragraph 
(1)(A) may, in addition to continuing to provide such serv-
ices to such individuals, elect to provide home and commu-
nity-based services in accordance with the requirements 
of this paragraph to individuals who are eligible for home 
and community-based services under a waiver approved 
for the State under subsection (c), (d), or (e) or under 
section 1115 to provide such services, but only for those 
individuals whose income does not exceed 300 percent of 
the supplemental security income benefit rate established 
by section 1611(b)(1). 
‘‘(B) APPLICATION OF SAME REQUIREMENTS FOR INDIVID-
UALS
SATISFYING
NEEDS-BASED
CRITERIA.—Subject 
to 
subparagraph (C), a State shall provide home and commu-
nity-based services to individuals under this paragraph 
in the same manner and subject to the same requirements 
as apply under the other paragraphs of this subsection 
to the provision of home and community-based services 
to individuals who satisfy the needs-based criteria estab-
lished under paragraph (1)(A). 
‘‘(C) AUTHORITY TO OFFER DIFFERENT TYPE, AMOUNT, 
DURATION, OR SCOPE OF HOME AND COMMUNITY-BASED SERV-
ICES.—A State may offer home and community-based serv-
ices to individuals under this paragraph that differ in 
type, amount, duration, or scope from the home and 
community-based services offered for individuals who sat-
isfy the needs-based criteria established under paragraph 
(1)(A), so long as such services are within the scope of 
services described in paragraph (4)(B) of subsection (c) 
for which the Secretary has the authority to approve a 
waiver and do not include room or board.
H. R. 3590—185 
‘‘(7) STATE OPTION TO OFFER HOME AND COMMUNITY-BASED 
SERVICES TO SPECIFIC, TARGETED POPULATIONS.— 
‘‘(A) IN GENERAL.—A State may elect in a State plan 
amendment under this subsection to target the provision 
of home and community-based services under this sub-
section to specific populations and to differ the type, 
amount, duration, or scope of such services to such specific 
populations. 
‘‘(B) 5-YEAR TERM.— 
‘‘(i) IN GENERAL.—An election by a State under 
this paragraph shall be for a period of 5 years. 
‘‘(ii) PHASE-IN OF SERVICES AND ELIGIBILITY PER-
MITTED
DURING
INITIAL
5-YEAR
PERIOD.—A State 
making an election under this paragraph may, during 
the first 5-year period for which the election is made, 
phase-in the enrollment of eligible individuals, or the 
provision of services to such individuals, or both, so 
long as all eligible individuals in the State for such 
services are enrolled, and all such services are pro-
vided, before the end of the initial 5-year period. 
‘‘(C) RENEWAL.—An election by a State under this para-
graph may be renewed for additional 5-year terms if the 
Secretary determines, prior to beginning of each such 
renewal period, that the State has— 
‘‘(i) adhered to the requirements of this subsection 
and paragraph in providing services under such an 
election; and 
‘‘(ii) met the State’s objectives with respect to 
quality improvement and beneficiary outcomes.’’. 
(c) REMOVAL OF LIMITATION ON SCOPE OF SERVICES.—Para-
graph (1) of section 1915(i) of the Social Security Act (42 U.S.C. 
1396n(i)), as amended by subsection (a), is amended by striking 
‘‘or such other services requested by the State as the Secretary 
may approve’’. 
(d) OPTIONAL ELIGIBILITY CATEGORY TO PROVIDE FULL MED-
ICAID BENEFITS TO INDIVIDUALS RECEIVING HOME AND COMMUNITY- 
BASED SERVICES UNDER A STATE PLAN AMENDMENT.— 
(1) IN GENERAL.—Section 1902(a)(10)(A)(ii) of the Social 
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by 
section 2304(a)(1), is amended— 
(A) in subclause (XX), by striking ‘‘or’’ at the end; 
(B) in subclause (XXI), by adding ‘‘or’’ at the end; 
and 
(C) by inserting after subclause (XXI), the following 
new subclause: 
‘‘(XXII) who are eligible for home and commu-
nity-based services under needs-based criteria 
established under paragraph (1)(A) of section 
1915(i), or who are eligible for home and commu-
nity-based services under paragraph (6) of such 
section, and who will receive home and community- 
based services pursuant to a State plan amend-
ment under such subsection;’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1903(f)(4) of the Social Security Act (42 
U.S.C. 1396b(f)(4)), as amended by section 2304(a)(4)(B), 
is amended in the matter preceding subparagraph (A),
H. R. 3590—186 
by 
inserting 
‘‘1902(a)(10)(A)(ii)(XXII),’’ 
after 
‘‘1902(a)(10)(A)(ii)(XXI),’’. 
(B) Section 1905(a) of the Social Security Act (42 U.S.C. 
1396d(a)), as so amended, is amended in the matter pre-
ceding paragraph (1)— 
(i) in clause (xv), by striking ‘‘or’’ at the end; 
(ii) in clause (xvi), by adding ‘‘or’’ at the end; 
and 
(iii) by inserting after clause (xvi) the following 
new clause: 
‘‘(xvii) individuals who are eligible for home and commu-
nity-based services under needs-based criteria established 
under paragraph (1)(A) of section 1915(i), or who are eligible 
for home and community-based services under paragraph (6) 
of such section, and who will receive home and community- 
based services pursuant to a State plan amendment under 
such subsection,’’. 
(e) ELIMINATION OF OPTION TO LIMIT NUMBER OF ELIGIBLE 
INDIVIDUALS OR LENGTH OF PERIOD FOR GRANDFATHERED INDIVID-
UALS IF ELIGIBILITY CRITERIA IS MODIFIED.—Paragraph (1) of sec-
tion 1915(i) of such Act (42 U.S.C. 1396n(i)) is amended— 
(1) by striking subparagraph (C) and inserting the fol-
lowing: 
‘‘(C) PROJECTION OF NUMBER OF INDIVIDUALS TO BE 
PROVIDED
HOME
AND
COMMUNITY-BASED
SERVICES.—The 
State submits to the Secretary, in such form and manner, 
and upon such frequency as the Secretary shall specify, 
the projected number of individuals to be provided home 
and community-based services.’’; and 
(2) in subclause (II) of subparagraph (D)(ii), by striking 
‘‘to be eligible for such services for a period of at least 12 
months beginning on the date the individual first received 
medical assistance for such services’’ and inserting ‘‘to continue 
to be eligible for such services after the effective date of the 
modification and until such time as the individual no longer 
meets the standard for receipt of such services under such 
pre-modified criteria’’. 
(f) ELIMINATION OF OPTION TO WAIVE STATEWIDENESS; ADDI-
TION OF OPTION TO WAIVE COMPARABILITY.—Paragraph (3) of sec-
tion 1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by striking 
‘‘1902(a)(1) (relating to statewideness)’’ and inserting ‘‘1902(a)(10)(B) 
(relating to comparability)’’. 
(g) EFFECTIVE DATE.—The amendments made by subsections 
(b) through (f) take effect on the first day of the first fiscal year 
quarter that begins after the date of enactment of this Act. 
SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING DEMONSTRA-
TION. 
(a) EXTENSION OF DEMONSTRATION.— 
(1) IN GENERAL.—Section 6071(h) of the Deficit Reduction 
Act of 2005 (42 U.S.C. 1396a note) is amended— 
(A) in paragraph (1)(E), by striking ‘‘fiscal year 2011’’ 
and inserting ‘‘each of fiscal years 2011 through 2016’’; 
and 
(B) in paragraph (2), by striking ‘‘2011’’ and inserting 
‘‘2016’’.
H. R. 3590—187 
(2) EVALUATION.—Paragraphs (2) and (3) of section 6071(g) 
of such Act is amended are each amended by striking ‘‘2011’’ 
and inserting ‘‘2016’’. 
(b) REDUCTION OF INSTITUTIONAL RESIDENCY PERIOD.— 
(1) IN GENERAL.—Section 6071(b)(2) of the Deficit Reduction 
Act of 2005 (42 U.S.C. 1396a note) is amended— 
(A) in subparagraph (A)(i), by striking ‘‘, for a period 
of not less than 6 months or for such longer minimum 
period, not to exceed 2 years, as may be specified by the 
State’’ and inserting ‘‘for a period of not less than 90 
consecutive days’’; and 
(B) by adding at the end the following: 
‘‘Any days that an individual resides in an institution on the 
basis of having been admitted solely for purposes of receiving 
short-term rehabilitative services for a period for which pay-
ment for such services is limited under title XVIII shall not 
be taken into account for purposes of determining the 90- 
day period required under subparagraph (A)(i).’’. 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section take effect 30 days after the date of enactment of 
this Act. 
SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND COMMUNITY- 
BASED SERVICES AGAINST SPOUSAL IMPOVERISHMENT. 
During the 5-year period that begins on January 1, 2014, 
section 1924(h)(1)(A) of the Social Security Act (42 U.S.C. 1396r– 
5(h)(1)(A)) shall be applied as though ‘‘is eligible for medical assist-
ance for home and community-based services provided under sub-
section (c), (d), or (i) of section 1915, under a waiver approved 
under section 1115, or who is eligible for such medical assistance 
by reason of being determined eligible under section 1902(a)(10)(C) 
or by reason of section 1902(f) or otherwise on the basis of a 
reduction of income based on costs incurred for medical or other 
remedial care, or who is eligible for medical assistance for home 
and community-based attendant services and supports under section 
1915(k)’’ were substituted in such section for ‘‘(at the option of 
the State) is described in section 1902(a)(10)(A)(ii)(VI)’’. 
SEC. 2405. FUNDING TO EXPAND STATE AGING AND DISABILITY 
RESOURCE CENTERS. 
Out of any funds in the Treasury not otherwise appropriated, 
there is appropriated to the Secretary of Health and Human Serv-
ices, acting through the Assistant Secretary for Aging, $10,000,000 
for each of fiscal years 2010 through 2014, to carry out subsections 
(a)(20)(B)(iii) and (b)(8) of section 202 of the Older Americans Act 
of 1965 (42 U.S.C. 3012). 
SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM CARE. 
(a) FINDINGS.—The Senate makes the following findings: 
(1) Nearly 2 decades have passed since Congress seriously 
considered long-term care reform. The United States Bipartisan 
Commission on Comprehensive Health Care, also know as the 
‘‘Pepper Commission’’, released its ‘‘Call for Action’’ blueprint 
for health reform in September 1990. In the 20 years since 
those recommendations were made, Congress has never acted 
on the report. 
(2) In 1999, under the United States Supreme Court’s 
decision in Olmstead v. L.C., 527 U.S. 581 (1999), individuals
H. R. 3590—188 
with disabilities have the right to choose to receive their long- 
term services and supports in the community, rather than 
in an institutional setting. 
(3) Despite the Pepper Commission and Olmstead decision, 
the long-term care provided to our Nation’s elderly and disabled 
has not improved. In fact, for many, it has gotten far worse. 
(4) In 2007, 69 percent of Medicaid long-term care spending 
for elderly individuals and adults with physical disabilities 
paid for institutional services. Only 6 states spent 50 percent 
or more of their Medicaid long-term care dollars on home and 
community-based services for elderly individuals and adults 
with physical disabilities while 1⁄2 of the States spent less 
than 25 percent. This disparity continues even though, on aver-
age, it is estimated that Medicaid dollars can support nearly 
3 elderly individuals and adults with physical disabilities in 
home and community-based services for every individual in 
a nursing home. Although every State has chosen to provide 
certain services under home and community-based waivers, 
these services are unevenly available within and across States, 
and reach a small percentage of eligible individuals. 
(b) SENSE OF THE SENATE.—It is the sense of the Senate that— 
(1) during the 111th session of Congress, Congress should 
address long-term services and supports in a comprehensive 
way that guarantees elderly and disabled individuals the care 
they need; and 
(2) long term services and supports should be made avail-
able in the community in addition to in institutions. 
Subtitle F—Medicaid Prescription Drug 
Coverage 
SEC. 2501. PRESCRIPTION DRUG REBATES. 
(a) INCREASE IN MINIMUM REBATE PERCENTAGE FOR SINGLE 
SOURCE DRUGS AND INNOVATOR MULTIPLE SOURCE DRUGS.— 
(1) IN GENERAL.—Section 1927(c)(1)(B) of the Social Secu-
rity Act (42 U.S.C. 1396r–8(c)(1)(B)) is amended— 
(A) in clause (i)— 
(i) in subclause (IV), by striking ‘‘and’’ at the end; 
(ii) in subclause (V)— 
(I) by inserting ‘‘and before January 1, 2010’’ 
after ‘‘December 31, 1995,’’; and 
(II) by striking the period at the end and 
inserting ‘‘; and’’; and 
(iii) by adding at the end the following new sub-
clause: 
‘‘(VI) except as provided in clause (iii), after 
December 31, 2009, 23.1 percent.’’; and 
(B) by adding at the end the following new clause: 
‘‘(iii) MINIMUM REBATE PERCENTAGE FOR CERTAIN 
DRUGS.— 
‘‘(I) IN GENERAL.—In the case of a single source 
drug or an innovator multiple source drug 
described in subclause (II), the minimum rebate 
percentage for rebate periods specified in clause 
(i)(VI) is 17.1 percent.
H. R. 3590—189 
‘‘(II) DRUG DESCRIBED.—For purposes of sub-
clause (I), a single source drug or an innovator 
multiple source drug described in this subclause 
is any of the following drugs: 
‘‘(aa) A clotting factor for which a separate 
furnishing payment is made under section 
1842(o)(5) and which is included on a list of 
such factors specified and updated regularly 
by the Secretary. 
‘‘(bb) A drug approved by the Food and 
Drug Administration exclusively for pediatric 
indications.’’. 
(2) RECAPTURE OF TOTAL SAVINGS DUE TO INCREASE.—Sec-
tion 1927(b)(1) of such Act (42 U.S.C. 1396r–8(b)(1)) is amended 
by adding at the end the following new subparagraph: 
‘‘(C) SPECIAL RULE FOR INCREASED MINIMUM REBATE 
PERCENTAGE.— 
‘‘(i) IN
GENERAL.—In addition to the amounts 
applied as a reduction under subparagraph (B), for 
rebate periods beginning on or after January 1, 2010, 
during a fiscal year, the Secretary shall reduce pay-
ments to a State under section 1903(a) in the manner 
specified in clause (ii), in an amount equal to the 
product of— 
‘‘(I) 100 percent minus the Federal medical 
assistance percentage applicable to the rebate 
period for the State; and 
‘‘(II) the amounts received by the State under 
such subparagraph that are attributable (as esti-
mated by the Secretary based on utilization and 
other data) to the increase in the minimum rebate 
percentage effected by the amendments made by 
subsections (a)(1), (b), and (d) of section 2501 of 
the Patient Protection and Affordable Care Act, 
taking into account the additional drugs included 
under the amendments made by subsection (c) of 
section 2501 of such Act. 
The Secretary shall adjust such payment reduction 
for a calendar quarter to the extent the Secretary 
determines, based upon subsequent utilization and 
other data, that the reduction for such quarter was 
greater or less than the amount of payment reduction 
that should have been made. 
‘‘(ii) 
MANNER
OF
PAYMENT
REDUCTION.—The 
amount of the payment reduction under clause (i) for 
a State for a quarter shall be deemed an overpayment 
to the State under this title to be disallowed against 
the State’s regular quarterly draw for all Medicaid 
spending under section 1903(d)(2). Such a disallowance 
is not subject to a reconsideration under section 
1116(d).’’. 
(b) 
INCREASE
IN
REBATE
FOR
OTHER
DRUGS.—Section 
1927(c)(3)(B) of such Act (42 U.S.C. 1396r–8(c)(3)(B)) is amended— 
(1) in clause (i), by striking ‘‘and’’ at the end; 
(2) in clause (ii)— 
(A) by inserting ‘‘and before January 1, 2010,’’ after 
‘‘December 31, 1993,’’; and
H. R. 3590—190 
(B) by striking the period and inserting ‘‘; and’’; and 
(3) by adding at the end the following new clause: 
‘‘(iii) after December 31, 2009, is 13 percent.’’. 
(c) 
EXTENSION
OF
PRESCRIPTION
DRUG
DISCOUNTS
TO 
ENROLLEES OF MEDICAID MANAGED CARE ORGANIZATIONS.— 
(1) IN
GENERAL.—Section 1903(m)(2)(A) of such Act (42 
U.S.C. 1396b(m)(2)(A)) is amended— 
(A) in clause (xi), by striking ‘‘and’’ at the end; 
(B) in clause (xii), by striking the period at the end 
and inserting ‘‘; and’’; and 
(C) by adding at the end the following: 
‘‘(xiii) such contract provides that (I) covered out-
patient drugs dispensed to individuals eligible for med-
ical assistance who are enrolled with the entity shall 
be subject to the same rebate required by the agree-
ment entered into under section 1927 as the State 
is subject to and that the State shall collect such 
rebates from manufacturers, (II) capitation rates paid 
to the entity shall be based on actual cost experience 
related to rebates and subject to the Federal regula-
tions requiring actuarially sound rates, and (III) the 
entity shall report to the State, on such timely and 
periodic basis as specified by the Secretary in order 
to include in the information submitted by the State 
to a manufacturer and the Secretary under section 
1927(b)(2)(A), information on the total number of units 
of each dosage form and strength and package size 
by National Drug Code of each covered outpatient drug 
dispensed to individuals eligible for medical assistance 
who are enrolled with the entity and for which the 
entity is responsible for coverage of such drug under 
this subsection (other than covered outpatient drugs 
that under subsection (j)(1) of section 1927 are not 
subject to the requirements of that section) and such 
other data as the Secretary determines necessary to 
carry out this subsection.’’. 
(2) CONFORMING AMENDMENTS.—Section 1927 (42 U.S.C. 
1396r–8) is amended— 
(A) in subsection (b)— 
(i) in paragraph (1)(A), in the first sentence, by 
inserting ‘‘, including such drugs dispensed to individ-
uals enrolled with a medicaid managed care organiza-
tion if the organization is responsible for coverage of 
such drugs’’ before the period; and 
(ii) in paragraph (2)(A), by inserting ‘‘including 
such information reported by each medicaid managed 
care organization,’’ after ‘‘for which payment was made 
under the plan during the period,’’; and 
(B) in subsection (j), by striking paragraph (1) and 
inserting the following: 
‘‘(1) Covered outpatient drugs are not subject to the require-
ments of this section if such drugs are— 
‘‘(A) dispensed by health maintenance organizations, 
including Medicaid managed care organizations that con-
tract under section 1903(m); and 
‘‘(B) subject to discounts under section 340B of the 
Public Health Service Act.’’.
H. R. 3590—191 
(d) ADDITIONAL REBATE FOR NEW FORMULATIONS OF EXISTING 
DRUGS.— 
(1) IN GENERAL.—Section 1927(c)(2) of the Social Security 
Act (42 U.S.C. 1396r–8(c)(2)) is amended by adding at the 
end the following new subparagraph: 
‘‘(C) TREATMENT OF NEW FORMULATIONS.— 
‘‘(i) IN
GENERAL.—Except as provided in clause 
(ii), in the case of a drug that is a new formulation, 
such as an extended-release formulation, of a single 
source drug or an innovator multiple source drug, the 
rebate obligation with respect to the drug under this 
section shall be the amount computed under this sec-
tion for the new formulation of the drug or, if greater, 
the product of— 
‘‘(I) the average manufacturer price for each 
dosage form and strength of the new formulation 
of the single source drug or innovator multiple 
source drug; 
‘‘(II) the highest additional rebate (calculated 
as a percentage of average manufacturer price) 
under this section for any strength of the original 
single source drug or innovator multiple source 
drug; and 
‘‘(III) the total number of units of each dosage 
form and strength of the new formulation paid 
for under the State plan in the rebate period (as 
reported by the State). 
‘‘(ii) NO APPLICATION TO NEW FORMULATIONS OF 
ORPHAN DRUGS.—Clause (i) shall not apply to a new 
formulation of a covered outpatient drug that is or 
has been designated under section 526 of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 360bb) for 
a rare disease or condition, without regard to whether 
the period of market exclusivity for the drug under 
section 527 of such Act has expired or the specific 
indication for use of the drug.’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) shall apply to drugs that are paid for by a State after 
December 31, 2009. 
(e) MAXIMUM REBATE AMOUNT.—Section 1927(c)(2) of such Act 
(42 U.S.C. 1396r–8(c)(2)), as amended by subsection (d), is amended 
by adding at the end the following new subparagraph: 
‘‘(D) MAXIMUM REBATE AMOUNT.—In no case shall the 
sum of the amounts applied under paragraph (1)(A)(ii) 
and this paragraph with respect to each dosage form and 
strength of a single source drug or an innovator multiple 
source drug for a rebate period beginning after December 
31, 2009, exceed 100 percent of the average manufacturer 
price of the drug.’’. 
(f) CONFORMING AMENDMENTS.— 
(1) IN GENERAL.—Section 340B of the Public Health Service 
Act (42 U.S.C. 256b) is amended— 
(A) in subsection (a)(2)(B)(i), by striking ‘‘1927(c)(4)’’ 
and inserting ‘‘1927(c)(3)’’; and 
(B) by striking subsection (c); and 
(C) redesignating subsection (d) as subsection (c).
H. R. 3590—192 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section take effect on January 1, 2010. 
SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF CERTAIN 
DRUGS. 
(a) IN GENERAL.—Section 1927(d) of the Social Security Act 
(42 U.S.C. 1397r–8(d)) is amended— 
(1) in paragraph (2)— 
(A) by striking subparagraphs (E), (I), and (J), respec-
tively; and 
(B) by redesignating subparagraphs (F), (G), (H), and 
(K) as subparagraphs (E), (F), (G), and (H), respectively; 
and 
(2) by adding at the end the following new paragraph: 
‘‘(7) NON-EXCLUDABLE
DRUGS.—The following drugs or 
classes of drugs, or their medical uses, shall not be excluded 
from coverage: 
‘‘(A) Agents when used to promote smoking cessation, 
including agents approved by the Food and Drug Adminis-
tration under the over-the-counter monograph process for 
purposes of promoting, and when used to promote, tobacco 
cessation. 
‘‘(B) Barbiturates. 
‘‘(C) Benzodiazepines.’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to services furnished on or after January 1, 2014. 
SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSEMENT. 
(a) PHARMACY REIMBURSEMENT LIMITS.— 
(1) IN
GENERAL.—Section 1927(e) of the Social Security 
Act (42 U.S.C. 1396r–8(e)) is amended— 
(A) in paragraph (4), by striking ‘‘(or, effective January 
1, 2007, two or more)’’; and 
(B) by striking paragraph (5) and inserting the fol-
lowing: 
‘‘(5) USE OF AMP IN UPPER PAYMENT LIMITS.—The Secretary 
shall calculate the Federal upper reimbursement limit estab-
lished under paragraph (4) as no less than 175 percent of 
the weighted average (determined on the basis of utilization) 
of the most recently reported monthly average manufacturer 
prices for pharmaceutically and therapeutically equivalent mul-
tiple source drug products that are available for purchase by 
retail community pharmacies on a nationwide basis. The Sec-
retary shall implement a smoothing process for average manu-
facturer prices. Such process shall be similar to the smoothing 
process used in determining the average sales price of a drug 
or biological under section 1847A.’’. 
(2) DEFINITION OF AMP.—Section 1927(k)(1) of such Act 
(42 U.S.C. 1396r–8(k)(1)) is amended— 
(A) in subparagraph (A), by striking ‘‘by’’ and all that 
follows through the period and inserting ‘‘by— 
‘‘(i) wholesalers for drugs distributed to retail 
community pharmacies; and 
‘‘(ii) retail community pharmacies that purchase 
drugs directly from the manufacturer.’’; and 
(B) by striking subparagraph (B) and inserting the 
following:
H. R. 3590—193 
‘‘(B) EXCLUSION OF CUSTOMARY PROMPT PAY DISCOUNTS 
AND OTHER PAYMENTS.— 
‘‘(i) IN GENERAL.—The average manufacturer price 
for a covered outpatient drug shall exclude— 
‘‘(I) customary prompt pay discounts extended 
to wholesalers; 
‘‘(II) bona fide service fees paid by manufactur-
ers to wholesalers or retail community pharmacies, 
including (but not limited to) distribution service 
fees, inventory management fees, product stocking 
allowances, and fees associated with administra-
tive services agreements and patient care pro-
grams (such as medication compliance programs 
and patient education programs); 
‘‘(III) reimbursement by manufacturers for 
recalled, damaged, expired, or otherwise unsalable 
returned goods, including (but not limited to) 
reimbursement for the cost of the goods and any 
reimbursement of costs associated with return 
goods handling and processing, reverse logistics, 
and drug destruction; and 
‘‘(IV) payments received from, and rebates or 
discounts provided to, pharmacy benefit managers, 
managed care organizations, health maintenance 
organizations, insurers, hospitals, clinics, mail 
order pharmacies, long term care providers, manu-
facturers, or any other entity that does not conduct 
business as a wholesaler or a retail community 
pharmacy. 
‘‘(ii) INCLUSION
OF
OTHER
DISCOUNTS
AND
PAY-
MENTS.—Notwithstanding clause (i), any other dis-
counts, rebates, payments, or other financial trans-
actions that are received by, paid by, or passed through 
to, retail community pharmacies shall be included in 
the average manufacturer price for a covered out-
patient drug.’’; and 
(C) in subparagraph (C), by striking ‘‘the retail phar-
macy class of trade’’ and inserting ‘‘retail community phar-
macies’’. 
(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 striking ‘‘the State’’ 
and inserting ‘‘the United States’’; and 
(B) in subparagraph (C)— 
(i) in clause (i), by inserting ‘‘and’’ after the semi-
colon; 
(ii) in clause (ii), by striking ‘‘; and’’ and inserting 
a period; and 
(iii) by striking clause (iii). 
(4) DEFINITIONS OF RETAIL COMMUNITY PHARMACY; WHOLE-
SALER.—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 independent pharmacy, a 
chain pharmacy, a supermarket pharmacy, or a mass merchan-
diser pharmacy that is licensed as a pharmacy by the State 
and that dispenses medications to the general public at retail
H. R. 3590—194 
prices. Such term does not include a pharmacy that dispenses 
prescription medications to patients primarily through the mail, 
nursing home pharmacies, long-term care facility pharmacies, 
hospital pharmacies, clinics, charitable or not-for-profit phar-
macies, government pharmacies, or pharmacy benefit man-
agers. 
‘‘(11) WHOLESALER.—The term ‘wholesaler’ means a drug 
wholesaler that is engaged in wholesale distribution of prescrip-
tion drugs to retail community pharmacies, including (but not 
limited to) manufacturers, repackers, distributors, own-label 
distributors, private-label distributors, jobbers, brokers, ware-
houses (including manufacturer’s and distributor’s warehouses, 
chain drug warehouses, and wholesale drug warehouses) inde-
pendent wholesale drug traders, and retail community phar-
macies that conduct wholesale distributions.’’. 
(b) DISCLOSURE OF PRICE INFORMATION TO THE PUBLIC.—Sec-
tion 1927(b)(3) of such Act (42 U.S.C. 1396r–8(b)(3)) is amended— 
(1) in subparagraph (A)— 
(A) in the first sentence, by inserting after clause (iii) 
the following: 
‘‘(iv) not later than 30 days after the last day 
of each month of a rebate period under the agreement, 
on the manufacturer’s total number of units that are 
used to calculate the monthly average manufacturer 
price for each covered outpatient drug;’’; and 
(B) in the second sentence, by inserting ‘‘(relating to 
the weighted average of the most recently reported monthly 
average manufacturer prices)’’ after ‘‘(D)(v)’’; and 
(2) in subparagraph (D)(v), by striking ‘‘average manufac-
turer prices’’ and inserting ‘‘the weighted average of the most 
recently reported monthly average manufacturer prices and 
the average retail survey price determined for each multiple 
source drug in accordance with subsection (f)’’. 
(c) CLARIFICATION
OF APPLICATION
OF SURVEY
OF RETAIL 
PRICES.—Section 1927(f)(1) of such Act (42 U.S.C. 1396r–8(b)(1)) 
is amended— 
(1) in subparagraph (A)(i), by inserting ‘‘with respect to 
a retail community pharmacy,’’ before ‘‘the determination’’; and 
(2) in subparagraph (C)(ii), by striking ‘‘retail pharmacies’’ 
and inserting ‘‘retail community pharmacies’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall take effect on the first day of the first calendar year quarter 
that begins at least 180 days after the date of enactment of this 
Act, without regard to whether or not final regulations to carry 
out such amendments have been promulgated by such date. 
Subtitle G—Medicaid Disproportionate 
Share Hospital (DSH) Payments 
SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS. 
(a) IN GENERAL.—Section 1923(f) of the Social Security Act 
(42 U.S.C. 1396r–4(f)) is amended— 
(1) in paragraph (1), by striking ‘‘and (3)’’ and inserting 
‘‘, (3), and (7)’’; 
(2) in paragraph (3)(A), by striking ‘‘paragraph (6)’’ and 
inserting ‘‘paragraphs (6) and (7)’’;
H. R. 3590—195 
(3) by redesignating paragraph (7) as paragraph (8); and 
(4) by inserting after paragraph (6) the following new para-
graph: 
‘‘(7) REDUCTION OF STATE DSH ALLOTMENTS ONCE REDUC-
TION IN UNINSURED THRESHOLD REACHED.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (E), the 
DSH allotment for a State for fiscal years beginning with 
the fiscal year described in subparagraph (C) (with respect 
to the State), is equal to— 
‘‘(i) in the case of the first fiscal year described 
in subparagraph (C) with respect to a State, the DSH 
allotment that would be determined under this sub-
section for the State for the fiscal year without applica-
tion of this paragraph (but after the application of 
subparagraph (D)), reduced by the applicable percent-
age determined for the State for the fiscal year under 
subparagraph (B)(i); and 
‘‘(ii) in the case of any subsequent fiscal year with 
respect to the State, the DSH allotment determined 
under this paragraph for the State for the preceding 
fiscal year, reduced by the applicable percentage deter-
mined for the State for the fiscal year under subpara-
graph (B)(ii). 
‘‘(B) 
APPLICABLE
PERCENTAGE.—For 
purposes 
of 
subparagraph (A), the applicable percentage for a State 
for a fiscal year is the following: 
‘‘(i) UNINSURED
REDUCTION
THRESHOLD
FISCAL 
YEAR.—In the case of the first fiscal year described 
in subparagraph (C) with respect to the State— 
‘‘(I) if the State is a low DSH State described 
in paragraph (5)(B), the applicable percentage is 
equal to 25 percent; and 
‘‘(II) if the State is any other State, the 
applicable percentage is 50 percent. 
‘‘(ii) SUBSEQUENT
FISCAL
YEARS
IN
WHICH
THE 
PERCENTAGE OF UNINSURED DECREASES.—In the case 
of any fiscal year after the first fiscal year described 
in subparagraph (C) with respect to a State, if the 
Secretary determines on the basis of the most recent 
American Community Survey of the Bureau of the 
Census, that the percentage of uncovered individuals 
residing in the State is less than the percentage of 
such individuals determined for the State for the pre-
ceding fiscal year— 
‘‘(I) if the State is a low DSH State described 
in paragraph (5)(B), the applicable percentage is 
equal to the product of the percentage reduction 
in uncovered individuals for the fiscal year from 
the preceding fiscal year and 25 percent; and 
‘‘(II) if the State is any other State, the 
applicable percentage is equal to the product of 
the percentage reduction in uncovered individuals 
for the fiscal year from the preceding fiscal year 
and 50 percent. 
‘‘(C) 
FISCAL
YEAR
DESCRIBED.—For 
purposes 
of 
subparagraph (A), the fiscal year described in this subpara-
graph with respect to a State is the first fiscal year that
H. R. 3590—196 
occurs after fiscal year 2012 for which the Secretary deter-
mines, on the basis of the most recent American Commu-
nity Survey of the Bureau of the Census, that the percent-
age of uncovered individuals residing in the State is at 
least 45 percent less than the percentage of such individ-
uals determined for the State for fiscal year 2009. 
‘‘(D) EXCLUSION OF PORTIONS DIVERTED FOR COVERAGE 
EXPANSIONS.—For purposes of applying the applicable 
percentage reduction under subparagraph (A) to the DSH 
allotment for a State for a fiscal year, the DSH allotment 
for a State that would be determined under this subsection 
for the State for the fiscal year without the application 
of this paragraph (and prior to any such reduction) shall 
not include any portion of the allotment for which the 
Secretary has approved the State’s diversion to the costs 
of providing medical assistance or other health benefits 
coverage under a waiver that is in effect on July 2009. 
‘‘(E) MINIMUM ALLOTMENT.—In no event shall the DSH 
allotment determined for a State in accordance with this 
paragraph for fiscal year 2013 or any succeeding fiscal 
year be less than the amount equal to 35 percent of the 
DSH allotment determined for the State for fiscal year 
2012 under this subsection (and after the application of 
this paragraph, if applicable), increased by the percentage 
change in the consumer price index for all urban consumers 
(all items, U.S. city average) for each previous fiscal year 
occurring before the fiscal year. 
‘‘(F) UNCOVERED INDIVIDUALS.—In this paragraph, the 
term ‘uncovered individuals’ means individuals with no 
health insurance coverage at any time during a year (as 
determined by the Secretary based on the most recent 
data available).’’. 
(b) EFFECTIVE DATE.—The amendments made by subsection 
(a) take effect on October 1, 2011. 
Subtitle H—Improved Coordination for 
Dual Eligible Beneficiaries 
SEC. 2601. 5-YEAR PERIOD FOR DEMONSTRATION PROJECTS. 
(a) IN GENERAL.—Section 1915(h) of the Social Security Act 
(42 U.S.C. 1396n(h)) is amended— 
(1) by inserting ‘‘(1)’’ after ‘‘(h)’’; 
(2) by inserting ‘‘, or a waiver described in paragraph 
(2)’’ after ‘‘(e)’’; and 
(3) by adding at the end the following new paragraph: 
‘‘(2)(A) Notwithstanding subsections (c)(3) and (d) (3), any 
waiver under subsection (b), (c), or (d), or a waiver under section 
1115, that provides medical assistance for dual eligible individuals 
(including any such waivers under which non dual eligible individ-
uals may be enrolled in addition to dual eligible individuals) may 
be conducted for a period of 5 years and, upon the request of 
the State, may be extended for additional 5-year periods unless 
the Secretary determines that for the previous waiver period the 
conditions for the waiver have not been met or it would no longer 
be cost-effective and efficient, or consistent with the purposes of 
this title, to extend the waiver.
H. R. 3590—197 
‘‘(B) In this paragraph, the term ‘dual eligible individual’ means 
an individual who is entitled to, or enrolled for, benefits under 
part A of title XVIII, or enrolled for benefits under part B of 
title XVIII, and is eligible for medical assistance under the State 
plan under this title or under a waiver of such plan.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 1915 of such Act (42 U.S.C. 1396n) is amended— 
(A) in subsection (b), by adding at the end the following 
new sentence: ‘‘Subsection (h)(2) shall apply to a waiver 
under this subsection.’’; 
(B) in subsection (c)(3), in the second sentence, by 
inserting ‘‘(other than a waiver described in subsection 
(h)(2))’’ after ‘‘A waiver under this subsection’’; 
(C) in subsection (d)(3), in the second sentence, by 
inserting ‘‘(other than a waiver described in subsection 
(h)(2))’’ after ‘‘A waiver under this subsection’’. 
(2) Section 1115 of such Act (42 U.S.C. 1315) is amended— 
(A) in subsection (e)(2), by inserting ‘‘(5 years, in the 
case of a waiver described in section 1915(h)(2))’’ after 
‘‘3 years’’; and 
(B) in subsection (f)(6), by inserting ‘‘(5 years, in the 
case of a waiver described in section 1915(h)(2))’’ after 
‘‘3 years’’. 
SEC. 2602. PROVIDING FEDERAL COVERAGE AND PAYMENT COORDINA-
TION FOR DUAL ELIGIBLE BENEFICIARIES. 
(a) ESTABLISHMENT OF FEDERAL COORDINATED HEALTH CARE 
OFFICE.— 
(1) IN GENERAL.—Not later than March 1, 2010, the Sec-
retary of Health and Human Services (in this section referred 
to as the ‘‘Secretary’’) shall establish a Federal Coordinated 
Health Care Office. 
(2) ESTABLISHMENT
AND
REPORTING
TO
CMS
ADMINIS-
TRATOR.—The Federal Coordinated Health Care Office— 
(A) shall be established within the Centers for Medi-
care & Medicaid Services; and 
(B) have as the Office a Director who shall be appointed 
by, and be in direct line of authority to, the Administrator 
of the Centers for Medicare & Medicaid Services. 
(b) PURPOSE.—The purpose of the Federal Coordinated Health 
Care Office is to bring together officers and employees of the Medi-
care and Medicaid programs at the Centers for Medicare & Medicaid 
Services in order to— 
(1) more effectively integrate benefits under the Medicare 
program under title XVIII of the Social Security Act and the 
Medicaid program under title XIX of such Act; and 
(2) improve the coordination between the Federal Govern-
ment and States for individuals eligible for benefits under 
both such programs in order to ensure that such individuals 
get full access to the items and services to which they are 
entitled under titles XVIII and XIX of the Social Security 
Act. 
(c) GOALS.—The goals of the Federal Coordinated Health Care 
Office are as follows: 
(1) Providing dual eligible individuals full access to the 
benefits to which such individuals are entitled under the Medi-
care and Medicaid programs.
H. R. 3590—198 
(2) Simplifying the processes for dual eligible individuals 
to access the items and services they are entitled to under 
the Medicare and Medicaid programs. 
(3) Improving the quality of health care and long-term 
services for dual eligible individuals. 
(4) Increasing dual eligible individuals’ understanding of 
and satisfaction with coverage under the Medicare and Med-
icaid programs. 
(5) Eliminating regulatory conflicts between rules under 
the Medicare and Medicaid programs. 
(6) Improving care continuity and ensuring safe and effec-
tive care transitions for dual eligible individuals. 
(7) Eliminating cost-shifting between the Medicare and 
Medicaid program and among related health care providers. 
(8) Improving the quality of performance of providers of 
services and suppliers under the Medicare and Medicaid pro-
grams. 
(d) SPECIFIC RESPONSIBILITIES.—The specific responsibilities of 
the Federal Coordinated Health Care Office are as follows: 
(1) Providing States, specialized MA plans for special needs 
individuals (as defined in section 1859(b)(6) of the Social Secu-
rity Act (42 U.S.C. 1395w–28(b)(6))), physicians and other rel-
evant entities or individuals with the education and tools nec-
essary for developing programs that align benefits under the 
Medicare and Medicaid programs for dual eligible individuals. 
(2) Supporting State efforts to coordinate and align acute 
care and long-term care services for dual eligible individuals 
with other items and services furnished under the Medicare 
program. 
(3) Providing support for coordination of contracting and 
oversight by States and the Centers for Medicare & Medicaid 
Services with respect to the integration of the Medicare and 
Medicaid programs in a manner that is supportive of the goals 
described in paragraph (3). 
(4) To consult and coordinate with the Medicare Payment 
Advisory Commission established under section 1805 of the 
Social Security Act (42 U.S.C. 1395b–6) and the Medicaid and 
CHIP Payment and Access Commission established under sec-
tion 1900 of such Act (42 U.S.C. 1396) with respect to policies 
relating to the enrollment in, and provision of, benefits to 
dual eligible individuals under the Medicare program under 
title XVIII of the Social Security Act and the Medicaid program 
under title XIX of such Act. 
(5) To study the provision of drug coverage for new full- 
benefit dual eligible individuals (as defined in section 1935(c)(6) 
of the Social Security Act (42 U.S.C. 1396u–5(c)(6)), as well 
as to monitor and report annual total expenditures, health 
outcomes, and access to benefits for all dual eligible individuals. 
(e) REPORT.—The Secretary shall, as part of the budget trans-
mitted under section 1105(a) of title 31, United States Code, submit 
to Congress an annual report containing recommendations for legis-
lation that would improve care coordination and benefits for dual 
eligible individuals. 
(f) DUAL ELIGIBLE DEFINED.—In this section, the term ‘‘dual 
eligible individual’’ means an individual who is entitled to, or 
enrolled for, benefits under part A of title XVIII of the Social 
Security Act, or enrolled for benefits under part B of title XVIII
H. R. 3590—199 
of such Act, and is eligible for medical assistance under a State 
plan under title XIX of such Act or under a waiver of such plan. 
Subtitle I—Improving the Quality of 
Medicaid for Patients and Providers 
SEC. 2701. ADULT HEALTH QUALITY MEASURES. 
Title XI of the Social Security Act (42 U.S.C. 1301 et seq.), 
as amended by section 401 of the Children’s Health Insurance 
Program Reauthorization Act of 2009 (Public Law 111–3), is 
amended by inserting after section 1139A the following new section: 
‘‘SEC. 1139B. ADULT HEALTH QUALITY MEASURES. 
‘‘(a) DEVELOPMENT OF CORE SET OF HEALTH CARE QUALITY 
MEASURES FOR ADULTS ELIGIBLE FOR BENEFITS UNDER MEDICAID.— 
The Secretary shall identify and publish a recommended core set 
of adult health quality measures for Medicaid eligible adults in 
the same manner as the Secretary identifies and publishes a core 
set of child health quality measures under section 1139A, including 
with respect to identifying and publishing existing adult health 
quality measures that are in use under public and privately spon-
sored health care coverage arrangements, or that are part of 
reporting systems that measure both the presence and duration 
of health insurance coverage over time, that may be applicable 
to Medicaid eligible adults. 
‘‘(b) DEADLINES.— 
‘‘(1) RECOMMENDED
MEASURES.—Not later than January 
1, 2011, the Secretary shall identify and publish for comment 
a recommended core set of adult health quality measures for 
Medicaid eligible adults. 
‘‘(2) DISSEMINATION.—Not later than January 1, 2012, the 
Secretary shall publish an initial core set of adult health quality 
measures that are applicable to Medicaid eligible adults. 
‘‘(3) STANDARDIZED REPORTING.—Not later than January 
1, 2013, the Secretary, in consultation with States, shall develop 
a standardized format for reporting information based on the 
initial core set of adult health quality measures and create 
procedures to encourage States to use such measures to volun-
tarily report information regarding the quality of health care 
for Medicaid eligible adults. 
‘‘(4) REPORTS TO CONGRESS.—Not later than January 1, 
2014, and every 3 years thereafter, the Secretary shall include 
in the report to Congress required under section 1139A(a)(6) 
information similar to the information required under that 
section with respect to the measures established under this 
section. 
‘‘(5) ESTABLISHMENT OF MEDICAID QUALITY MEASUREMENT 
PROGRAM.— 
‘‘(A) IN GENERAL.—Not later than 12 months after the 
release of the recommended core set of adult health quality 
measures under paragraph (1)), the Secretary shall estab-
lish a Medicaid Quality Measurement Program in the same 
manner as the Secretary establishes the pediatric quality 
measures program under section 1139A(b). The aggregate 
amount awarded by the Secretary for grants and contracts 
for the development, testing, and validation of emerging
H. R. 3590—200 
and innovative evidence-based measures under such pro-
gram shall equal the aggregate amount awarded by the 
Secretary for grants under section 1139A(b)(4)(A) 
‘‘(B) REVISING, STRENGTHENING, AND IMPROVING INITIAL 
CORE MEASURES.—Beginning not later than 24 months after 
the establishment of the Medicaid Quality Measurement 
Program, and annually thereafter, the Secretary shall pub-
lish recommended changes to the initial core set of adult 
health quality measures that shall reflect the results of 
the testing, validation, and consensus process for the 
development of adult health quality measures. 
‘‘(c) CONSTRUCTION.—Nothing in this section shall be construed 
as supporting the restriction of coverage, under title XIX or XXI 
or otherwise, to only those services that are evidence-based, or 
in anyway limiting available services. 
‘‘(d) ANNUAL
STATE
REPORTS
REGARDING
STATE-SPECIFIC 
QUALITY OF CARE MEASURES APPLIED UNDER MEDICAID.— 
‘‘(1) ANNUAL
STATE
REPORTS.—Each State with a State 
plan or waiver approved under title XIX shall annually report 
(separately or as part of the annual report required under 
section 1139A(c)), to the Secretary on the— 
‘‘(A) State-specific adult health quality measures 
applied by the State under the such plan, including meas-
ures described in subsection (a)(5); and 
‘‘(B) State-specific information on the quality of health 
care furnished to Medicaid eligible adults under such plan, 
including information collected through external quality 
reviews of managed care organizations under section 1932 
and benchmark plans under section 1937. 
‘‘(2) PUBLICATION.—Not later than September 30, 2014, 
and annually thereafter, the Secretary shall collect, analyze, 
and make publicly available the information reported by States 
under paragraph (1). 
‘‘(e) APPROPRIATION.—Out of any funds in the Treasury not 
otherwise appropriated, there is appropriated for each of fiscal 
years 2010 through 2014, $60,000,000 for the purpose of carrying 
out this section. Funds appropriated under this subsection shall 
remain available until expended.’’. 
SEC. 2702. PAYMENT ADJUSTMENT FOR HEALTH CARE-ACQUIRED 
CONDITIONS. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(in this subsection referred to as the ‘‘Secretary’’) shall identify 
current State practices that prohibit payment for health care- 
acquired conditions and shall incorporate the practices identified, 
or elements of such practices, which the Secretary determines 
appropriate for application to the Medicaid program in regulations. 
Such regulations shall be effective as of July 1, 2011, and shall 
prohibit payments to States under section 1903 of the Social Secu-
rity Act for any amounts expended for providing medical assistance 
for health care-acquired conditions specified in the regulations. 
The regulations shall ensure that the prohibition on payment for 
health care-acquired conditions shall not result in a loss of access 
to care or services for Medicaid beneficiaries. 
(b) HEALTH CARE-ACQUIRED CONDITION.—In this section. the 
term ‘‘health care-acquired condition’’ means a medical condition 
for which an individual was diagnosed that could be identified
H. R. 3590—201 
by a secondary diagnostic code described in section 1886(d)(4)(D)(iv) 
of the Social Security Act (42 U.S.C. 1395ww(d)(4)(D)(iv)). 
(c) MEDICARE PROVISIONS.—In carrying out this section, the 
Secretary shall apply to State plans (or waivers) under title XIX 
of the Social Security Act the regulations promulgated pursuant 
to section 1886(d)(4)(D) of such Act (42 U.S.C. 1395ww(d)(4)(D)) 
relating to the prohibition of payments based on the presence of 
a secondary diagnosis code specified by the Secretary in such regula-
tions, as appropriate for the Medicaid program. The Secretary may 
exclude certain conditions identified under title XVIII of the Social 
Security Act for non-payment under title XIX of such Act when 
the Secretary finds the inclusion of such conditions to be inappli-
cable to beneficiaries under title XIX. 
SEC. 
2703. 
STATE 
OPTION 
TO 
PROVIDE 
HEALTH 
HOMES 
FOR 
ENROLLEES WITH CHRONIC CONDITIONS. 
(a) STATE PLAN AMENDMENT.—Title XIX of the Social Security 
Act (42 U.S.C. 1396a et seq.), as amended by sections 2201 and 
2305, is amended by adding at the end the following new section: 
‘‘SEC. 1945. STATE OPTION TO PROVIDE COORDINATED CARE 
THROUGH A HEALTH HOME FOR INDIVIDUALS WITH CHRONIC CONDI-
TIONS.— 
‘‘(a) IN GENERAL.—Notwithstanding section 1902(a)(1) (relating 
to statewideness), section 1902(a)(10)(B) (relating to comparability), 
and any other provision of this title for which the Secretary deter-
mines it is necessary to waive in order to implement this section, 
beginning January 1, 2011, a State, at its option as a State plan 
amendment, may provide for medical assistance under this title 
to eligible individuals with chronic conditions who select a des-
ignated provider (as described under subsection (h)(5)), a team 
of health care professionals (as described under subsection (h)(6)) 
operating with such a provider, or a health team (as described 
under subsection (h)(7)) as the individual’s health home for purposes 
of providing the individual with health home services. 
‘‘(b) HEALTH HOME QUALIFICATION STANDARDS.—The Secretary 
shall establish standards for qualification as a designated provider 
for the purpose of being eligible to be a health home for purposes 
of this section. 
‘‘(c) PAYMENTS.— 
‘‘(1) IN GENERAL.—A State shall provide a designated pro-
vider, a team of health care professionals operating with such 
a provider, or a health team with payments for the provision 
of health home services to each eligible individual with chronic 
conditions that selects such provider, team of health care profes-
sionals, or health team as the individual’s health home. Pay-
ments made to a designated provider, a team of health care 
professionals operating with such a provider, or a health team 
for such services shall be treated as medical assistance for 
purposes of section 1903(a), except that, during the first 8 
fiscal year quarters that the State plan amendment is in effect, 
the Federal medical assistance percentage applicable to such 
payments shall be equal to 90 percent. 
‘‘(2) METHODOLOGY.— 
‘‘(A) IN GENERAL.—The State shall specify in the State 
plan amendment the methodology the State will use for 
determining payment for the provision of health home serv-
ices. Such methodology for determining payment—
H. R. 3590—202 
‘‘(i) may be tiered to reflect, with respect to each 
eligible individual with chronic conditions provided 
such services by a designated provider, a team of health 
care professionals operating with such a provider, or 
a health team, as well as the severity or number of 
each such individual’s chronic conditions or the specific 
capabilities of the provider, team of health care profes-
sionals, or health team; and 
‘‘(ii) shall be established consistent with section 
1902(a)(30)(A). 
‘‘(B) ALTERNATE MODELS OF PAYMENT.—The method-
ology for determining payment for provision of health home 
services under this section shall not be limited to a per- 
member per-month basis and may provide (as proposed 
by the State and subject to approval by the Secretary) 
for alternate models of payment. 
‘‘(3) PLANNING GRANTS.— 
‘‘(A) IN GENERAL.—Beginning January 1, 2011, the Sec-
retary may award planning grants to States for purposes 
of developing a State plan amendment under this section. 
A planning grant awarded to a State under this paragraph 
shall remain available until expended. 
‘‘(B) STATE CONTRIBUTION.—A State awarded a plan-
ning grant shall contribute an amount equal to the State 
percentage determined under section 1905(b) (without 
regard to section 5001 of Public Law 111–5) for each fiscal 
year for which the grant is awarded. 
‘‘(C) LIMITATION.—The total amount of payments made 
to 
States 
under 
this 
paragraph 
shall 
not 
exceed 
$25,000,000. 
‘‘(d) HOSPITAL REFERRALS.—A State shall include in the State 
plan amendment a requirement for hospitals that are participating 
providers under the State plan or a waiver of such plan to establish 
procedures for referring any eligible individuals with chronic condi-
tions who seek or need treatment in a hospital emergency depart-
ment to designated providers. 
‘‘(e) COORDINATION.—A State shall consult and coordinate, as 
appropriate, with the Substance Abuse and Mental Health Services 
Administration in addressing issues regarding the prevention and 
treatment of mental illness and substance abuse among eligible 
individuals with chronic conditions. 
‘‘(f) MONITORING.—A State shall include in the State plan 
amendment— 
‘‘(1) a methodology for tracking avoidable hospital readmis-
sions and calculating savings that result from improved chronic 
care coordination and management under this section; and 
‘‘(2) a proposal for use of health information technology 
in providing health home services under this section and 
improving service delivery and coordination across the care 
continuum (including the use of wireless patient technology 
to improve coordination and management of care and patient 
adherence to recommendations made by their provider). 
‘‘(g) REPORT
ON
QUALITY
MEASURES.—As a condition for 
receiving payment for health home services provided to an eligible 
individual with chronic conditions, a designated provider shall 
report to the State, in accordance with such requirements as the 
Secretary shall specify, on all applicable measures for determining
H. R. 3590—203 
the quality of such services. When appropriate and feasible, a 
designated provider shall use health information technology in pro-
viding the State with such information. 
‘‘(h) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE INDIVIDUAL WITH CHRONIC CONDITIONS.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 
term ‘eligible individual with chronic conditions’ means 
an individual who— 
‘‘(i) is eligible for medical assistance under the 
State plan or under a waiver of such plan; and 
‘‘(ii) has at least— 
‘‘(I) 2 chronic conditions; 
‘‘(II) 1 chronic condition and is at risk of 
having a second chronic condition; or 
‘‘(III) 1 serious and persistent mental health 
condition. 
‘‘(B) RULE OF CONSTRUCTION.—Nothing in this para-
graph shall prevent the Secretary from establishing higher 
levels as to the number or severity of chronic or mental 
health conditions for purposes of determining eligibility 
for receipt of health home services under this section. 
‘‘(2) CHRONIC CONDITION.—The term ‘chronic condition’ has 
the meaning given that term by the Secretary and shall include, 
but is not limited to, the following: 
‘‘(A) A mental health condition. 
‘‘(B) Substance use disorder. 
‘‘(C) Asthma. 
‘‘(D) Diabetes. 
‘‘(E) Heart disease. 
‘‘(F) Being overweight, as evidenced by having a Body 
Mass Index (BMI) over 25. 
‘‘(3) HEALTH HOME.—The term ‘health home’ means a des-
ignated provider (including a provider that operates in coordina-
tion with a team of health care professionals) or a health 
team selected by an eligible individual with chronic conditions 
to provide health home services. 
‘‘(4) HEALTH HOME SERVICES.— 
‘‘(A) IN
GENERAL.—The term ‘health home services’ 
means comprehensive and timely high-quality services 
described in subparagraph (B) that are provided by a des-
ignated provider, a team of health care professionals oper-
ating with such a provider, or a health team. 
‘‘(B) SERVICES DESCRIBED.—The services described in 
this subparagraph are— 
‘‘(i) comprehensive care management; 
‘‘(ii) care coordination and health promotion; 
‘‘(iii) comprehensive transitional care, including 
appropriate follow-up, from inpatient to other settings; 
‘‘(iv) patient and family support (including author-
ized representatives); 
‘‘(v) referral to community and social support serv-
ices, if relevant; and 
‘‘(vi) use of health information technology to link 
services, as feasible and appropriate. 
‘‘(5) DESIGNATED PROVIDER.—The term ‘designated provider’ 
means a physician, clinical practice or clinical group practice, 
rural clinic, community health center, community mental health
H. R. 3590—204 
center, home health agency, or any other entity or provider 
(including pediatricians, gynecologists, and obstetricians) that 
is determined by the State and approved by the Secretary 
to be qualified to be a health home for eligible individuals 
with chronic conditions on the basis of documentation 
evidencing that the physician, practice, or clinic— 
‘‘(A) has the systems and infrastructure in place to 
provide health home services; and 
‘‘(B) satisfies the qualification standards established 
by the Secretary under subsection (b). 
‘‘(6) TEAM
OF
HEALTH
CARE
PROFESSIONALS.—The term 
‘team of health care professionals’ means a team of health 
professionals (as described in the State plan amendment) that 
may— 
‘‘(A) include physicians and other professionals, such 
as a nurse care coordinator, nutritionist, social worker, 
behavioral health professional, or any professionals deemed 
appropriate by the State; and 
‘‘(B) be free standing, virtual, or based at a hospital, 
community health center, community mental health center, 
rural clinic, clinical practice or clinical group practice, aca-
demic health center, or any entity deemed appropriate 
by the State and approved by the Secretary. 
‘‘(7) HEALTH
TEAM.—The term ‘health team’ has the 
meaning given such term for purposes of section 3502 of the 
Patient Protection and Affordable Care Act.’’. 
(b) EVALUATION.— 
(1) INDEPENDENT EVALUATION.— 
(A) IN GENERAL.—The Secretary shall enter into a con-
tract with an independent entity or organization to conduct 
an evaluation and assessment of the States that have 
elected the option to provide coordinated care through a 
health home for Medicaid beneficiaries with chronic condi-
tions under section 1945 of the Social Security Act (as 
added by subsection (a)) for the purpose of determining 
the effect of such option on reducing hospital admissions, 
emergency room visits, and admissions to skilled nursing 
facilities. 
(B) EVALUATION REPORT.—Not later than January 1, 
2017, the Secretary shall report to Congress on the evalua-
tion and assessment conducted under subparagraph (A). 
(2) SURVEY AND INTERIM REPORT.— 
(A) IN GENERAL.—Not later than January 1, 2014, the 
Secretary of Health and Human Services shall survey 
States that have elected the option under section 1945 
of the Social Security Act (as added by subsection (a)) 
and report to Congress on the nature, extent, and use 
of such option, particularly as it pertains to— 
(i) hospital admission rates; 
(ii) chronic disease management; 
(iii) coordination of care for individuals with 
chronic conditions; 
(iv) assessment of program implementation; 
(v) processes and lessons learned (as described in 
subparagraph (B)); 
(vi) assessment of quality improvements and clin-
ical outcomes under such option; and
H. R. 3590—205 
(vii) estimates of cost savings. 
(B) IMPLEMENTATION
REPORTING.—A State that has 
elected the option under section 1945 of the Social Security 
Act (as added by subsection (a)) shall report to the Sec-
retary, as necessary, on processes that have been developed 
and lessons learned regarding provision of coordinated care 
through a health home for Medicaid beneficiaries with 
chronic conditions under such option. 
SEC. 2704. DEMONSTRATION PROJECT TO EVALUATE INTEGRATED 
CARE AROUND A HOSPITALIZATION. 
(a) AUTHORITY TO CONDUCT PROJECT.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall 
establish a demonstration project under title XIX of the Social 
Security Act to evaluate the use of bundled payments for the 
provision of integrated care for a Medicaid beneficiary— 
(A) with respect to an episode of care that includes 
a hospitalization; and 
(B) for concurrent physicians services provided during 
a hospitalization. 
(2) DURATION.—The demonstration project shall begin on 
January 1, 2012, and shall end on December 31, 2016. 
(b) REQUIREMENTS.—The demonstration project shall be con-
ducted in accordance with the following: 
(1) The demonstration project shall be conducted in up 
to 8 States, determined by the Secretary based on consideration 
of the potential to lower costs under the Medicaid program 
while improving care for Medicaid beneficiaries. A State 
selected to participate in the demonstration project may target 
the demonstration project to particular categories of bene-
ficiaries, beneficiaries with particular diagnoses, or particular 
geographic regions of the State, but the Secretary shall insure 
that, as a whole, the demonstration project is, to the greatest 
extent possible, representative of the demographic and 
geographic composition of Medicaid beneficiaries nationally. 
(2) The demonstration project shall focus on conditions 
where there is evidence of an opportunity for providers of 
services and suppliers to improve the quality of care furnished 
to Medicaid beneficiaries while reducing total expenditures 
under the State Medicaid programs selected to participate, 
as determined by the Secretary. 
(3) A State selected to participate in the demonstration 
project shall specify the 1 or more episodes of care the State 
proposes to address in the project, the services to be included 
in the bundled payments, and the rationale for the selection 
of such episodes of care and services. The Secretary may modify 
the episodes of care as well as the services to be included 
in the bundled payments prior to or after approving the project. 
The Secretary may also vary such factors among the different 
States participating in the demonstration project. 
(4) The Secretary shall ensure that payments made under 
the demonstration project are adjusted for severity of illness 
and other characteristics of Medicaid beneficiaries within a 
category or having a diagnosis targeted as part of the dem-
onstration project. States shall ensure that Medicaid bene-
ficiaries are not liable for any additional cost sharing than
H. R. 3590—206 
if their care had not been subject to payment under the dem-
onstration project. 
(5) Hospitals participating in the demonstration project 
shall have or establish robust discharge planning programs 
to ensure that Medicaid beneficiaries requiring post-acute care 
are appropriately placed in, or have ready access to, post- 
acute care settings. 
(6) The Secretary and each State selected to participate 
in the demonstration project shall ensure that the demonstra-
tion project does not result in the Medicaid beneficiaries whose 
care is subject to payment under the demonstration project 
being provided with less items and services for which medical 
assistance is provided under the State Medicaid program than 
the items and services for which medical assistance would 
have been provided to such beneficiaries under the State Med-
icaid program in the absence of the demonstration project. 
(c) WAIVER OF PROVISIONS.—Notwithstanding section 1115(a) 
of the Social Security Act (42 U.S.C. 1315(a)), the Secretary may 
waive such provisions of titles XIX, XVIII, and XI of that Act 
as may be necessary to accomplish the goals of the demonstration, 
ensure beneficiary access to acute and post-acute care, and maintain 
quality of care. 
(d) EVALUATION AND REPORT.— 
(1) DATA.—Each State selected to participate in the dem-
onstration project under this section shall provide to the Sec-
retary, in such form and manner as the Secretary shall specify, 
relevant data necessary to monitor outcomes, costs, and quality, 
and evaluate the rationales for selection of the episodes of 
care and services specified by States under subsection (b)(3). 
(2) REPORT.—Not later than 1 year after the conclusion 
of the demonstration project, the Secretary shall submit a report 
to Congress on the results of the demonstration project. 
SEC. 2705. MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION 
PROJECT. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(referred to in this section as the ‘‘Secretary’’) shall, in coordination 
with the Center for Medicare and Medicaid Innovation (as estab-
lished under section 1115A of the Social Security Act, as added 
by section 3021 of this Act), establish the Medicaid Global Payment 
System Demonstration Project under which a participating State 
shall adjust the payments made to an eligible safety net hospital 
system or network from a fee-for-service payment structure to a 
global capitated payment model. 
(b) DURATION
AND SCOPE.—The demonstration project con-
ducted under this section shall operate during a period of fiscal 
years 2010 through 2012. The Secretary shall select not more than 
5 States to participate in the demonstration project. 
(c) ELIGIBLE SAFETY NET HOSPITAL SYSTEM OR NETWORK.— 
For purposes of this section, the term ‘‘eligible safety net hospital 
system or network’’ means a large, safety net hospital system or 
network (as defined by the Secretary) that operates within a State 
selected by the Secretary under subsection (b). 
(d) EVALUATION.— 
(1) TESTING.—The Innovation Center shall test and 
evaluate the demonstration project conducted under this section
H. R. 3590—207 
to examine any changes in health care quality outcomes and 
spending by the eligible safety net hospital systems or networks. 
(2) BUDGET NEUTRALITY.—During the testing period under 
paragraph (1), any budget neutrality requirements under sec-
tion 1115A(b)(3) of the Social Security Act (as so added) shall 
not be applicable. 
(3) MODIFICATION.—During the testing period under para-
graph (1), the Secretary may, in the Secretary’s discretion, 
modify or terminate the demonstration project conducted under 
this section. 
(e) REPORT.—Not later than 12 months after the date of comple-
tion of the demonstration project under this section, the Secretary 
shall submit to Congress a report containing the results of the 
evaluation and testing conducted under subsection (d), together 
with recommendations for such legislation and administrative 
action as the Secretary determines appropriate. 
(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as are necessary to carry out this 
section. 
SEC. 2706. PEDIATRIC ACCOUNTABLE CARE ORGANIZATION DEM-
ONSTRATION PROJECT. 
(a) AUTHORITY TO CONDUCT DEMONSTRATION.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (referred to in this section as the ‘‘Secretary’’) shall 
establish the Pediatric Accountable Care Organization Dem-
onstration Project to authorize a participating State to allow 
pediatric medical providers that meet specified requirements 
to be recognized as an accountable care organization for pur-
poses of receiving incentive payments (as described under sub-
section (d)), in the same manner as an accountable care 
organization is recognized and provided with incentive pay-
ments under section 1899 of the Social Security Act (as added 
by section 3022). 
(2) DURATION.—The demonstration project shall begin on 
January 1, 2012, and shall end on December 31, 2016. 
(b) APPLICATION.—A State that desires to participate in the 
demonstration project under this section shall submit to the Sec-
retary an application at such time, in such manner, and containing 
such information as the Secretary may require. 
(c) REQUIREMENTS.— 
(1) PERFORMANCE GUIDELINES.—The Secretary, in consulta-
tion with the States and pediatric providers, shall establish 
guidelines to ensure that the quality of care delivered to individ-
uals by a provider recognized as an accountable care organiza-
tion under this section is not less than the quality of care 
that would have otherwise been provided to such individuals. 
(2) SAVINGS REQUIREMENT.—A participating State, in con-
sultation with the Secretary, shall establish an annual minimal 
level of savings in expenditures for items and services covered 
under the Medicaid program under title XIX of the Social 
Security Act and the CHIP program under title XXI of such 
Act that must be reached by an accountable care organization 
in order for such organization to receive an incentive payment 
under subsection (d). 
(3) MINIMUM PARTICIPATION PERIOD.—A provider desiring 
to be recognized as an accountable care organization under