391
(d) FUNDING.—Section 4401(b)(2) of OBRA–1990
is amended by striking ‘‘75 percent,’’ and all that follows
and inserting ‘‘75 percent.’’.
(e) 
DEMONSTRATION
PROJECTS.—Section
4401(c)(1) of OBRA–1990 is amended—
(A) in subparagraph (A), by striking ‘‘10’’ and
inserting ‘‘5’’; and
(B) in subparagraph (C), by striking ‘‘regi-
ment’’ and inserting ‘‘regimen’’.
(f) STUDIES.—Section 4401(d) of OBRA–1990 is
amended—
(1) in paragraph (1)(A), by striking ‘‘other in-
stitutional facilities, and managed care plans’’ and
inserting ‘‘nursing facilities, intermediate care facili-
ties for the mentally retarded, and health mainte-
nance organizations’’;
(2) in paragraph (1)(B), by striking ‘‘under
this subsection’’ and inserting ‘‘under this para-
graph’’;
(3) in paragraph (1)(B)(i), by striking ‘‘under
this section’’ and inserting ‘‘under section 1927 of
the Social Security Act’’;
(4) in paragraph (1)(B)(ii)—
392
(A) by striking ‘‘drug use review’’ the sec-
ond place it appears and inserting ‘‘the type of
drug use review that is’’, and
(B) by striking ‘‘under this section’’ and
inserting ‘‘under such section’’;
(5) in paragraph (1)(B)(iii), by striking ‘‘under
this title’’ and inserting ‘‘under title XIX of the So-
cial Security Act’’;
(6) in paragraph (1)(C)—
(A) by striking ‘‘May 1, 1991’’ and insert-
ing ‘‘May 1, 1992’’, and
(B) by striking ‘‘hereafter’’;
(7) in paragraph (2), by striking ‘‘the Commit-
tees on Aging of the Senate and House of Rep-
resentatives an annual report’’ and inserting ‘‘the
Committee on Aging of the Senate a report’’;
(8) in paragraph (3)—
(A) in subparagraph (A), by striking ‘‘,
acting in consultation with the Comptroller
General,’’, and
(B) in subparagraph (B)—
(i) by striking ‘‘December 31, 1991,
the Secretary and the Comptroller Gen-
eral’’ and inserting ‘‘June 1, 1993, the
Secretary’’, and
393
(ii) by striking ‘‘the Committees on
Aging of the Senate and the House of Rep-
resentatives’’ and inserting ‘‘the Commit-
tee on Aging of the Senate’’;
(9) in paragraph (4)(A), by striking ‘‘each’’ and
by striking the semicolon and inserting a comma;
and
(10) by striking paragraphs (5) and (6).
PART III—RESTRICTIONS ON DIVESTITURE OF
ASSETS AND ESTATE RECOVERY
SEC. 5111. TRANSFER OF ASSETS.
(a) PERIOD OF INELIGIBILITY.—
(1) EXTENDING
LOOK-BACK
PERIOD
TO
MONTHS.—Section 
1917(c)(1) 
(42 
U.S.C.
1396p(c)(1)) is amended by striking ‘‘30-month pe-
riod’’ and inserting ‘‘36-month period’’.
(2) ELIMINATING 30-MONTH LIMIT ON PERIOD
OF
INELIGIBILITY.—The second sentence of such
section is amended by striking ‘‘equal to’’ and all
that follows and inserting the following: ‘‘equal to—
‘‘(A) the total uncompensated value of the re-
sources so transferred; divided by
‘‘(B) the average monthly cost, to a private pa-
tient at the time of the application, of nursing facil-
ity services in the State or, at State option, in the
394
community in which the individual is institutional-
ized.’’.
(3) CUMULATIVE PERIODS OF INELIGIBILITY IN
THE
CASE
OF
MULTIPLE
TRANSFERS.—Such sen-
tence is further amended by inserting ‘‘(or, in the
case of a transfer which occurs during a period of
ineligibility attributable to a previous transfer, the
first month after the end of all periods of ineligibil-
ity attributable to any previous transfer)’’ after
‘‘shall begin with the month in which such resources
were transferred’’.
(b) CRITERIA FOR UNDUE HARDSHIP EXCEPTION.—
Section 1917(c)(2)(D) (42 U.S.C. 1396p(c)(2)(D)) is
amended to read as follows:
‘‘(D) the State agency determines, under proce-
dures established by the State (in accordance with
standards specified by the Secretary) that the denial
of eligibility would work an undue hardship (in ac-
cordance with criteria established by the Sec-
retary).’’.
(c) TREATMENT OF JOINTLY HELD ASSETS.—Sec-
tion 1917(c) (42 U.S.C. 1936p(c)) is further amended by
adding at the end the following new paragraph:
‘‘(6) For purposes of this subsection, in the case of
an asset held by an individual in common with another
395
person or persons in a joint tenancy or a similar arrange-
ment, the asset (or the affected portion thereof) shall be
considered to be transferred by such individual when any
action is taken, either by such individual or by any other
person, that reduces or eliminates such individual’s owner-
ship or control of such asset.’’.
(d) 
MEDICAID
QUALIFYING
TRUSTS.—Section
1902(k) (42 U.S.C. 1396a(k)) is amended to read as fol-
lows:
‘‘(k) TREATMENT OF TRUST AMOUNTS.—
‘‘(1) IN GENERAL.—For purposes of determin-
ing an individual’s eligibility for or amount of bene-
fits under a State plan under this title, subject to
paragraph (4), the following rules shall apply to a
trust (which term includes, for purposes of this sub-
section, any similar legal instrument or device, such
as an annuity) established by such individual:
‘‘(A) REVOCABLE TRUSTS.—In the case of
a revocable trust—
‘‘(i) the corpus of the trust shall be
considered resources available to the indi-
vidual,
‘‘(ii) payments from the trust to or
for the benefit of the individual shall be
considered income of the individual, and
396
‘‘(iii) any other payments from the
trust shall be considered a transfer of as-
sets by the individual subject to section
1917(c).
‘‘(B) IRREVOCABLE
TRUSTS
WHICH
MAY
BENEFIT GRANTOR.—In the case of an irrev-
ocable trust, if there are any circumstances
under which payment from the trust could be
made to or for the benefit of the individual—
‘‘(i) the corpus of the trust (or that
portion of the corpus from which, or from
the increase whereof, payment to the indi-
vidual could be made) shall be considered
resources available to the individual, and
payments from that portion of the corpus
(or increase)—
‘‘(I) to or for the benefit of the
individual, shall be considered income
of the individual, and
‘‘(II) for any other purpose, shall
be considered a transfer of assets by
the individual subject to the provisions
of section 1917(c); and
‘‘(ii) any portion of the trust from
which (or from the income whereof) no
397
payment could under any circumstances be
made to the individual shall be considered,
as of the date of establishment of the trust
(or, if later, the date on which payment to
the individual was foreclosed), a transfer of
assets by the individual subject to section
1917(c), and payments from such portion
of the trust after such date shall be dis-
regarded.
‘‘(C) IRREVOCABLE TRUSTS WHICH CAN-
NOT BENEFIT GRANTOR.—In the case of an ir-
revocable trust, if no payment may be made
from the trust under any circumstances to or
for the benefit of the individual—
‘‘(i) the corpus of the trust shall be
considered, as of the date of establishment
of the trust (or, if later, the date on which
payment to the individual was foreclosed),
a transfer of assets subject to section
1917(c), and
‘‘(ii) payments from the trust after
the date specified in clause (i) shall be dis-
regarded.
‘‘(2) DETERMINATION OF GRANTOR.—
398
‘‘(A) TREATMENT OF ACTS BY INDIVIDUAL
AND OTHERS.—For purposes of this subsection,
an individual shall be considered to have estab-
lished a trust if—
‘‘(i) the individual (or the individual’s
spouse), or a person (including a court or
administrative body) with legal authority
to act in place of or on behalf of such indi-
vidual (or spouse), or any person (includ-
ing any court or administrative body) act-
ing at the direction or upon the request of
such individual (or spouse), established
(other than by will) such a trust, and
‘‘(ii) assets of the individual (as de-
fined in subparagraph (B)) were used to
form all or part of the corpus of such
trust.
‘‘(B) ASSETS.—For purposes of this para-
graph, assets of an individual include all income
and resources of the individual and of the indi-
vidual’s spouse, including any income or re-
sources which the individual (or spouse) is enti-
tled to but does not receive because of action by
the individual (or spouse), by a person (includ-
ing a court or administrative body) with legal
399
authority to act in place of or on behalf of such
individual (or spouse), or by any person (includ-
ing any court or administrative body) acting at
the direction or upon the request of such indi-
vidual (or spouse).
‘‘(C) TRUSTS
CONTAINING
ASSETS
OF
MORE THAN ONE INDIVIDUAL.—In the case of
a trust whose corpus includes assets of an indi-
vidual (as determined pursuant to subpara-
graph (A)) and assets of any other person or
persons, the provisions of this subsection shall
apply to the portion of the trust attributable to
the assets of the individual.
‘‘(3) APPLICATION; RELATION TO OTHER PRO-
VISIONS.—Subject to paragraph (4), this subsection
shall apply without regard to—
‘‘(A) the purposes for which the trust is es-
tablished,
‘‘(B) whether the trustees have or exercise
any discretion under the trust,
‘‘(C) any restrictions on when or whether
distributions may be made from the trust, or
‘‘(D) any restrictions on the use of dis-
tributions from the trust.
‘‘(4) EXCEPTIONS AND HARDSHIP WAIVER.—
400
‘‘(A) EXCEPTION FOR CERTAIN TRUSTS.—
This subsection shall not apply to any of the
following trusts:
‘‘(i) A trust established for the benefit
of a disabled individual (as determined
under section 1614(a)(3)) by a parent,
grandparent, or other representative payee
of the individual.
‘‘(ii) A trust established in a State for
the benefit of an individual if—
‘‘(I) the trust is composed only of
pension, Social Security, and other in-
come to the individual (and accumu-
lated income in the trust),
‘‘(II) the State will receive any
amounts remaining in the trust upon
the death of the individual, and
‘‘(III) the State makes medical
assistance available to individuals de-
scribed 
in 
section
1902(a)(10)(A)(ii)(V), but does not
make such assistance available to any
group of individuals under section
1902(a)(10)(C).
401
‘‘(B) SPECIAL
TREATMENT
OF
ANNU-
ITIES.—In this subsection, the term ‘trust’ in-
cludes an annuity only to such extent and in
such manner as the Secretary specifies.
‘‘(C) 
HARDSHIP
WAIVER.—The 
State
agency shall establish procedures (in accordance
with standards specified by the Secretary)
under which the agency waives the application
of this subsection with respect to an individual
if the individual establishes (under criteria es-
tablished by the Secretary) that such applica-
tion would work an undue hardship on the indi-
vidual.’’.
(e) EFFECTIVE DATE.—(1) The amendments made
by this section shall apply, except as provided in this sub-
section, to payments under title XIX of the Social Security
Act for calendar quarters beginning on or after October
1, 1993, without regard to whether or not final regulations
to carry out such amendments have been promulgated by
such date.
(2) The amendments made by this section shall not
apply—
(A) to medical assistance provided for services
furnished before October 1, 1993,
402
(B) with respect to resources disposed of before
May 11, 1993,
(C) with respect to trusts established before
May 11, 1993, or
(D) with respect to inter-spousal transfers.
SEC. 5112. MEDICAID ESTATE RECOVERIES.
(a) REQUIRING ESTABLISHMENT OF ESTATE RECOV-
ERY PROGRAMS.—
(1) IN
GENERAL.—Section 1902(a)(51) (42
U.S.C. 1396a(a)(51)) is amended by striking ‘‘and
(B)’’ and inserting ‘‘(B) provide for an estate recov-
ery program that meets the requirements of section
1917(b)(1), and (C)’’.
(2) REQUIREMENTS
FOR
ESTATE
RECOVERY
PROGRAMS.—Section 1917(b) (42 U.S.C. 1396p(b))
is amended—
(A) in paragraph (1)—
(i) by striking ‘‘(b)(1)’’ and inserting
‘‘(2)’’, and
(ii) by striking ‘‘(a)(1)(B)’’ and in-
serting ‘‘(a)(1)(B)(i)’’;
(B) in paragraph (2), by striking ‘‘(2) Any
adjustment or recovery under’’ and inserting
‘‘(3) Any adjustment or recovery under an es-
tate recovery program under’’; and
403
(C) by inserting before paragraph (2), as
designated by subparagraph (A), the following:
‘‘(b)(1) For purposes of section 1902(a)(51)(B), the
requirements for an estate recovery program of a State
are as follows:
‘‘(A) The program provides for identifying and
tracking (and, at the option of the State, preserving)
resources (whether excluded or not) of individuals
who are furnished any of the following long-term
care services for which medical assistance is pro-
vided under this title:
‘‘(i) Nursing facility services.
‘‘(ii) Home and community-based services
(as defined in section 1915(d)(5)(C)(i)).
‘‘(iii) 
Services 
described 
in 
section
1905(a)(14) (relating to services in an institu-
tion for mental diseases).
‘‘(iv) Home and community care provided
under section 1929.
‘‘(v) Community supported living arrange-
ments services provided under section 1930.
‘‘(B) The program provides for promptly
ascertaining—
‘‘(i) when such an individual dies;
404
‘‘(ii) in the case of such an individual who
was married at the time of death, when the sur-
viving spouse dies; and
‘‘(iii) at the option of the State, cases in
which adjustment or recovery may not be made
at the time of death because of the application
of paragraph (3)(A) or paragraph (3)(B).
‘‘(C)(i) The program provides for the collection
consistent with paragraph (3) of an amount (not to
exceed the amount described in clause (ii)) from—
‘‘(I) the estate of the individual;
‘‘(II) in the case of an individual described
in subparagraph (B)(ii), from the estate of the
surviving spouse; or
‘‘(III) at the option of the State, in a case
described in subparagraph (B)(iii), from the ap-
propriate person.
‘‘(ii) The amount described in this clause is the
amount of medical assistance correctly paid under
this title for long-term care services described in
subparagraph (A) furnished on behalf of the individ-
ual.’’.
(b) HARDSHIP WAIVER.—Section 1917(b) (42 U.S.C.
1396p(b)) is further amended by adding at the end the
following new paragraph:
405
‘‘(4) The State agency shall establish procedures (in
accordance with standards specified by the Secretary)
under which the agency waives the application of this sub-
section if such application would work an undue hardship
(in accordance with criteria established by the Sec-
retary).’’.
(c) DEFINITION OF ESTATE.—Section 1917(b) (42
U.S.C. 1396(b)) is further amended by adding at the end
the following new paragraph:
‘‘(5) For purposes of this section, the term ‘estate’,
with respect to a deceased individual, includes all real and
personal property and other assets in which the individual
had any legally cognizable title or interest at the time of
his death, including such assets conveyed to a survivor,
heir, or assign of the deceased individual through joint
tenancy, survivorship, life estate, living trust, or other ar-
rangement.’’.
(d) EFFECTIVE DATE.—
(1)(A) The amendments made by subsections
(a) and (b) apply (except as provided under subpara-
graph (B)) to payments under title XIX of the So-
cial Security Act for calendar quarters beginning on
or after October 1, 1993, without regard to whether
or not final regulations or standards to carry out
406
such amendments have been promulgated by such
date.
(B) In the case of a State plan for medical as-
sistance under title XIX of the Social Security Act
which the Secretary of Health and Human Services
determines requires State legislation (other than leg-
islation appropriating funds) in order for the plan to
meet the additional requirements imposed by the
amendments made by subsections (a) and (b), 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 these additional require-
ments before the first day of the first calendar quar-
ter beginning after the close of the first regular ses-
sion 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.
(2) The amendments made by this section shall
not apply to individuals who died before October 1,
1993.
407
SEC. 5113. CLOSING LOOPHOLE PERMITTING WEALTHY IN-
DIVIDUALS TO QUALIFY FOR MEDICAID.
(a) IN GENERAL.—Section 1902(r)(2) (42 U.S.C.
1396a(r)(2)) is amended by adding at the end the follow-
ing:
‘‘(C)(i) Notwithstanding subparagraph (A), except as
provided in clause (ii), a State plan may not provide pur-
suant to this paragraph for disregarding any assets—
‘‘(I) to the extent that payments are made
under a long-term care insurance policy; or
‘‘(II) because an individual has received (or is
entitled to receive) benefits for a specified period of
time under a long-term care insurance policy.
‘‘(ii) Clause (i) shall not apply to State plan provi-
sions that are approved as of May 14, 1993.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall take effect on the date of the enact-
ment of this Act.
PART IV—IMPROVEMENT IN IDENTIFICATION
AND COLLECTION OF THIRD PARTY PAYMENTS
SEC. 5116. LIABILITY OF THIRD PARTIES TO PAY FOR CARE
AND SERVICES.
(a) LIABILITY
OF
ERISA PLANS.—(1) Section
1902(a)(25)(A) (42 U.S.C. 1396a(a)(25)(A)) is amended
by striking ‘‘insurers)’’ and inserting ‘‘insurers and group
health plans (as defined in section 607(1) of the Employee
408
Retirement Income Security Act of 1974) and including
a service benefit plan and a health maintenance organiza-
tion)’’.
(2) Section 1903(o) of such Act (42 U.S.C. 1396b(o))
is amended by striking ‘‘regulation)’’ and inserting ‘‘regu-
lation and including a group health plan (as defined in
section 607(1) of the Employee Retirement Income Secu-
rity Act of 1974)), a service benefit plan, and a health
maintenance organization’’.
(b) REQUIRING
STATE
TO
PROHIBIT
INSURERS
FROM TAKING MEDICAID STATUS INTO ACCOUNT.—Sec-
tion 1902(a)(25) (42 U.S.C. 1396a(a)(25)) is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (F);
(2) by adding ‘‘and’’ at the end of subpara-
graph (G); and
(3) by adding after subparagraph (G) the fol-
lowing new subparagraph:
‘‘(H) that the State prohibits any health
insurer (including a group health plan, as de-
fined in section 607(1) of the Employee Retire-
ment Income Security Act of 1974, a service
benefit plan, and a health maintenance organi-
zation), in enrolling an individual or in making
any payments for benefits to the individual or
409
on the individual’s behalf, from taking into ac-
count that the individual is eligible for or is
provided medical assistance under a State
plan;’’.
(c) STATE
RIGHT
TO
SUBROGATION.—Section
1902(a)(25) (42 U.S.C. 1396a(a)(25)), as amended by
subsection (b), is further amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (G);
(2) by adding ‘‘and’’ at the end of subpara-
graph (H); and
(3) by adding after subparagraph (H) the fol-
lowing new subparagraph:
‘‘(I) that to the extent that payment has
been made under the State plan for medical as-
sistance in any case where a third party has a
legal liability to make payment for such assist-
ance, the State is subrogated to the right of any
other party to payment for such assistance;’’.
(d) EFFECTIVE DATE.—(1) Except as provided in
paragraph (2), the amendments made by subsections
(a)(1), (b), and (c) shall apply to calendar quarters begin-
ning on or after October 1, 1993, without regard to wheth-
er or not final regulations to carry out such amendments
have been promulgated by such date.
410
(2) In the case of a State plan for medical assistance
under title XIX of the Social Security Act which the Sec-
retary of Health and Human Services determines requires
State legislation (other than legislation appropriating
funds) in order for the plan to meet the additional require-
ments imposed by the amendments made by subsections
(a) and (b), 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 these additional requirements
before the first day of the first calendar quarter beginning
after the close of the first regular session of the State leg-
islature 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.
(3) The amendment made by subsection (a)(2) shall
apply to items and services furnished on or after October
1, 1993.
SEC. 5117. HEALTH COVERAGE CLEARINGHOUSE.
(a) IN GENERAL.—The Social Security Act is amend-
ed by adding at the end the following new title:
411
‘‘TITLE XXI—HEALTH COVERAGE
CLEARINGHOUSE
‘‘ESTABLISHMENT OF CLEARINGHOUSE
‘‘SEC. 2101. (a) IN GENERAL.—The Secretary shall
establish and operate a Health Coverage Clearinghouse (in
this title referred to as the ‘Clearinghouse’) for the pur-
pose of identifying, for beneficiaries of a covered health
program (as defined in subsection (c)), third parties
(which may include a covered health program) which may
be liable for payment for health care items and services
furnished to such beneficiaries under such program.
‘‘(b) DIRECTOR.—The Clearinghouse shall be headed
by a Director (in this title referred to as the ‘Director’)
appointed by the Secretary.
‘‘(c) COVERED HEALTH PROGRAM DEFINED.—In
this title, the term ‘covered health program’ means any
of the following under which payment is made for health
care items or services furnished to a beneficiary:
‘‘(1) The medicare program under title XVIII.
‘‘(2) A State plan for medical assistance under
title XIX (including a State plan operating under a
Statewide waiver under section 1115).
‘‘(3) The Indian Health Service and any pro-
gram under the Indian Health Care Improvement
Act.
412
‘‘(4) A State program under title V that pro-
vides payment for items or services.
‘‘(d) OTHER DEFINITIONS.—In this title:
‘‘(1) The term ‘administrator’ means, with re-
spect to the covered health program described in—
‘‘(A) subsection (c)(1), the Administrator
of the Health Care Financing Administration;
‘‘(B) subsection (c)(2), the single State
agency referred to in section 1902(a)(5);
‘‘(C) subsection (c)(3), the Director of the
Indian Health Service; and
‘‘(D) subsection (c)(4), the State agency
receiving funds under title V.
‘‘(2) The term ‘group health plan’ has the
meaning 
given 
such 
term 
in 
section
6103(l)(12)(E)(ii) of such Code.
‘‘(3) The term ‘qualified employer’ has the
meaning 
given 
such 
term 
in 
section
6103(l)(12)(E)(iii) of the Internal Revenue Code of
1986.
‘‘PROVISION OF INFORMATION
‘‘SEC. 2102. (a) REQUEST FOR INFORMATION.—An
administrator of a covered health program may request
from the Director information concerning the employment
and group health coverage of a program beneficiary, the
beneficiary’s spouse, and (if the beneficiary is a dependent
413
child) the beneficiary’s parents. The Director shall provide
such information if the request—
‘‘(1) is in such form and manner and at such
a time as the Director may require, and
‘‘(2) specifies the name and tax identification
number of the beneficiary.
‘‘(b) DATA MATCHING PROGRAM.—
‘‘(1) REQUEST
BY
DIRECTOR.—The Director
shall, at such intervals as the Director finds appro-
priate, transmit to the Secretary of the Treasury the
names and tax identification numbers of bene-
ficiaries with respect to whom a request has been
made pursuant to subsection (a), and request that
such Secretary disclose to the Commissioner of So-
cial Security the following information:
‘‘(A) Whether the beneficiary is married
and, if so, the name of the spouse and such
spouse’s tax identification number.
‘‘(B) If the beneficiary is a dependent
child, the name of and tax identification num-
bers of the beneficiary’s parents.
‘‘(2) INFORMATION
FROM
COMMISSIONER
OF
SOCIAL SECURITY.—The Secretary, acting through
the Commissioner of Social Security, shall, upon
414
written request from the Director, disclose to the Di-
rector, the following information:
‘‘(A) For each individual who is identified
as having received wages (as defined in section
3401(a) of the Internal Revenue Code of 1986)
from, and as having available coverage under a
group health plan of, an employer in a previous
year—
‘‘(i) the name and taxpayer identifica-
tion number of the individual;
‘‘(ii) the name, address, and taxpayer
identification number of the employer, and
whether such employer is a qualified em-
ployer; and
‘‘(iii) whether the employer has made
available a group health plan to the em-
ployee and the plan coverage provided (if
any) with respect to the employee and fam-
ily members of the employee under the
group health plan.
‘‘(B) For each individual who is identified
as married and whose spouse is identified as
having received wages (as defined in section
3401(a) of the Internal Revenue Code of 1986)
from, and as having available coverage under a
415
group health plan of, an employer in a previous
year—
‘‘(i) the name and taxpayer identifica-
tion number of the individual and of the
individual’s spouse;
‘‘(ii) the name, address, and taxpayer
identification number of the spouse’s em-
ployer, and whether such employer is a
qualified employer; and
‘‘(iii) whether the spouse’s employer
has made available a group health plan to
the spouse and the plan coverage provided
(if any) with respect to the spouse and
family members of the spouse under the
group health plan.
‘‘(C) For each individual who is identified
as a dependent child and whose parent is iden-
tified as having received wages (as defined in
section 3401(a) of the Internal Revenue Code
of 1986) from, and as having available coverage
under a group health plan of, an employer in a
previous year—
‘‘(i) the name and taxpayer identifica-
tion number of the individual and of the
individual’s parent;
416
‘‘(ii) the name, address, and taxpayer
identification number of the parent’s em-
ployer, and whether such employer is a
qualified employer; and
‘‘(iii) whether the parent’s employer
has made available a group health plan to
the parent and the plan coverage provided
(if any) with respect to the parent and de-
pendent children of the parent under the
group health plan.
‘‘(3) INFORMATION
FROM
EMPLOYERS.—The
Director shall—
‘‘(A) request, from the employer of each
individual (including each spouse) with respect
to whom information was received from the
Commissioner of Social Security pursuant to
paragraph (2), specific information concerning
coverage of such individual (and of the individ-
ual’s spouse and dependent children) under the
employer’s group health plan (including the pe-
riod and nature of the coverage, and the name,
address, and identifying number of the plan),
and
‘‘(B) furnish the information received in
response to such request with respect to an in-
417
dividual (or such individual’s spouse or depend-
ent children) to the administrator requesting
such information pursuant to subsection (a).
‘‘REQUIREMENT THAT EMPLOYERS FURNISH
INFORMATION
‘‘SEC. 2103. (a) IN GENERAL.—An employer shall
furnish to the Director the information requested pursu-
ant to section 2102(b)(3) within 30 days after receipt of
such a request.
‘‘(b) SUNSET
ON REQUIREMENT.—Subsection (a)
shall not apply to inquiries made after September 30,
1998.
‘‘(c) CIVIL MONEY PENALTY FOR FAILURE TO CO-
OPERATE.—
‘‘(1) IN GENERAL.—An employer (other than a
Federal or other governmental entity) who willfully
or repeatedly fails to provide timely and accurate re-
sponse to a request for information pursuant to sec-
tion 2102(b)(3) shall be subject, in addition to any
other penalties that may be prescribed by law, to a
civil money penalty of not to exceed $1,000 for each
individual with respect to whom such a request is
made.
‘‘(2) ENFORCEMENT AUTHORITY.—In cases of
failure to respond to the Director in accordance with
subsection (a) to inquiries relating to requests pur-
418
suant to section 2102, the provisions of section
1128A (other than subsections (a) and (b)) shall
apply to civil money penalties under paragraph (1)
in the same manner as such provisions apply to pen-
alties or proceedings under section 1128A(a).
‘‘DATA BANK
‘‘SEC. 2104. (a) MAINTENANCE OF INFORMATION.—
The Clearinghouse shall maintain a data bank, containing
information on individuals obtained pursuant to this title.
Individual information in the data bank shall be retained
for not less than one year after the date the information
was obtained.
‘‘(b) DISCLOSURE
OF
INFORMATION
IN
DATA
BANK.—
‘‘(1) IN GENERAL.—The Director is authorized
(subject to paragraph (2)) to disclose any informa-
tion in the data bank established pursuant to sub-
section (a) with respect to an individual (or an indi-
vidual’s spouse or parent)—
‘‘(A) to the Commissioner of Social Secu-
rity, the Secretary of the Treasury, administra-
tors, employers, and insurers, to the extent nec-
essary to assist such administrators;
‘‘(B) to Federal and State law enforcement
officials responsible for enforcement of civil or
criminal laws, in connection with investigations
419
or administrative or judicial law enforcement
proceedings relating to a covered health pro-
gram; and
‘‘(C) for research or statistical purposes.
‘‘(2) RESTRICTIONS ON DISCLOSURE.—Informa-
tion in the data bank may be disclosed under this
subsection only for purposes of, and to the extent
necessary in, determining the extent to which an in-
dividual is covered under any group health plan.
‘‘(c) USE OF CONTRACTORS.—The responsibilities of
the Clearinghouse under this section may be carried out
by contract.
‘‘(d) FEES.—The Clearinghouse shall—
‘‘(1) establish fees for services under this sec-
tion designed to cover the full costs to the Clearing-
house of providing such services, and
‘‘(2) require the payment of such fees to pro-
vide such services.’’.
(b) CONFORMING MEDICARE AMENDMENTS.—Sec-
tion 1862(b)(5) (42 U.S.C. 1395y(b)(5)) is amended—
(1) in subparagraph (A)(i)—
(A) by striking ‘‘Secretary of the Treas-
ury’’ and inserting ‘‘Director of the Health Cov-
erage Clearinghouse’’,
420
(B) by striking ‘‘(as defined in section
6103(l)(12) of the Internal Revenue Code of
1986)’’ and inserting ‘‘(as defined in clause
(iii))’’, and
(C) by striking ‘‘and request’’ and all that
follows and inserting a period;
(2) in subparagraph (A)(ii)—
(A) by striking ‘‘the Commissioner of the
Social Security Administration’’ and all that
follows and inserting ‘‘the Director of the
Health Coverage Clearinghouse to obtain and
disclose to the Administrator, pursuant to sec-
tion 2102(b) and to subparagraph (C) of sec-
tion 6103(l)(12) of the Internal Revenue Code
of 1986, the information described in section
2102(b) and subparagraph (B) of such section
6103(l)(12).’’, and
(B) by inserting ‘‘, pursuant to section
1144(c),’’ after ‘‘disclose to the Administrator’’;
and
(3) by striking subparagraph (C).
(c) MEDICAID USE OF CLEARINGHOUSE.—Section
1902(a)(25)(A) (42 U.S.C. 1396a(a)(25)(A)) is amended
by inserting ‘‘(including making appropriate requests to
421
the Director of the Health Coverage Clearinghouse under
section 2102)’’ after ‘‘all reasonable measures’’.
(d) COLLECTION
OF
THIRD
PARTY
PAYMENTS
UNDER MATERNAL AND CHILD HEALTH BLOCK GRANT
PROGRAM.—Section 505(a) (42 U.S.C. 705(a)) is amend-
ed—
(1) by striking ‘‘and’’ at the end of paragraph
(4),
(2) by striking the period at the end of para-
graph (5) and inserting ‘‘; and’’, and
(3) by inserting after paragraph (5) the follow-
ing new paragraph:
‘‘(6) provides for an entity providing health
services with assistance from the State under this
title taking all reasonable steps—
‘‘(A) to ascertain the legal liability of third
parties to pay for such services, and
‘‘(B) where such liability is found to exist,
to seek reimbursement for such services.’’.
(e) EFFECTIVE DATES.—
(1) The amendments made by subsections (a),
(b), and (d) shall take effect on April 1, 1995.
(2) The amendments made by subsection (c)
shall apply to allotments for years beginning with
fiscal year 1994.
422
SEC. 5118. MEDICAL CHILD SUPPORT.
(a) 
STATE
PLAN
REQUIREMENT.—Section
1902(a)(45) (42 U.S.C. 1396a(a)(45)) is amended by
striking ‘‘owed to recipients’’ and inserting ‘‘and have in
effect laws relating to medical child support’’.
(b) MEDICAL CHILD SUPPORT LAWS.—Section 1912
of such Act (42 U.S.C. 1396k) is amended—
(1) by adding at the end of the heading the fol-
lowing: ‘‘; REQUIRED LAWS RELATING TO MEDICAL
CHILD SUPPORT’’; and
(2) by adding at the end the following new sub-
section:
‘‘(c) The laws relating to medical child support, which
a State is required to have in effect under section
1902(a)(45), are as follows:
‘‘(1) A law that prohibits an insurer from deny-
ing enrollment of a child under the health coverage
of the child’s parent on the ground that the child
was born out of wedlock, on the ground that the
child may not be claimed as a dependent on the par-
ent’s Federal income tax return, or on the ground
that the child does not reside with the parent or in
the insurer’s service area. In this subsection, the
term ‘insurer’ includes a group health plan, as de-
fined in section 607(1) of the Employee Retirement
Income Security Act of 1974, a health maintenance
423
organization, and an entity offering a service benefit
plan.
‘‘(2) A law that requires an insurer, in any case
in which a parent is required by court or administra-
tive order to provide health coverage for a child and
the parent is eligible for family health coverage
through the insurer—
‘‘(A) to permit such parent, upon applica-
tion and without regard to any enrollment sea-
son restrictions, to enroll the parent and such
child under such family coverage;
‘‘(B) if such a parent is enrolled but fails
to make application to obtain coverage of such
child, to enroll such child under such family
coverage upon application by the child’s other
parent or by the State agency administering the
program under this title or part D of title IV;
and
‘‘(C) not to disenroll (or eliminate coverage
of) such a child unless the insurer is provided
satisfactory written evidence that—
‘‘(i) such court or administrative
order is no longer in effect, or
‘‘(ii) the child is or will be enrolled in
comparable health coverage through an-
424
other insurer which will take effect not
later than the effective date of such
disenrollment.
‘‘(3) A law that requires an employer doing
business in the State, in the case of health coverage
offered through employment with the employer and
providing coverage of a child of an employee pursu-
ant to a court or administrative order, to withhold
from such employee’s compensation the employee’s
share (if any) of premiums for health coverage (to
the maximum amount permitted under section
303(b) of the Consumer Credit Protection Act) and
to pay such share of premiums to the insurer.
‘‘(4) A law that prohibits an insurer from im-
posing requirements upon a State agency, which is
acting as an agent or subrogee of an individual eligi-
ble for medical assistance under this title and cov-
ered for health benefits from the insurer, that are
different from requirements applicable to an agent
or subrogee of any other individual so covered.
‘‘(5) A law that requires an insurer, in any case
in which a child has health coverage through the in-
surer of a noncustodial parent—
425
‘‘(A) to provide such information to the
custodial parent as may be necessary for the
child to obtain benefits through such coverage;
‘‘(B) to permit the custodial parent (or
provider, with the custodial parent’s approval)
to submit claims for covered services without
the approval of the noncustodial parent; and
‘‘(C) to make payment on claims submitted
in accordance with subparagraph (B) directly to
the custodial parent or the provider.
‘‘(6) A law that requires the State agency under
this title to garnish the wages, salary, or other em-
ployment income of, and to withhold amounts from
State tax refunds to, any person who—
‘‘(A) is required by court or administrative
order to provide coverage of the costs of health
services to a child who is eligible for medical as-
sistance under this title,
‘‘(B) has received payment from a third
party for the costs of such services to such
child, but
‘‘(C) has not used such payments to reim-
burse, as appropriate, either the other parent or
guardian of such child or the provider of such
services,
426
to the extent necessary to reimburse the State agen-
cy for expenditures for such costs under its plan
under this title, but any claims for current or past-
due child support shall take priority over any such
claims for the costs of such services.’’.
(c) EFFECTIVE DATE.—(1) Except as provided in
paragraph (2), the amendments made by this section
apply to calendar quarters beginning on or after April 1,
1994, without regard to whether or not final regulations
to carry out such amendments have been promulgated by
such date.
(2) In the case of a State plan under title XIX of
the Social Security Act which the Secretary of Health and
Human Services determines requires State legislation in
order for the plan to meet the additional requirements im-
posed 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 these additional requirements before the first day
of the first calendar quarter beginning after the close of
the first regular session of the State legislature that be-
gins after the date of 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
427
be deemed to be a separate regular session of the State
legislature.
PART V—ASSURING PROPER PAYMENTS TO
DISPROPORTIONATE SHARE HOSPITALS
SEC. 5121. ASSURING PROPER PAYMENTS TO DISPROPOR-
TIONATE SHARE HOSPITALS.
(a) DISPROPORTIONATE
SHARE
HOSPITALS
RE-
QUIRED TO PROVIDE MINIMUM LEVEL OF SERVICES TO
MEDICAID PATIENTS.—Section 1923 (42 U.S.C. 1396r–
4) is amended—
(1) in subsection (a)(1)(A), by striking ‘‘re-
quirement’’ and inserting ‘‘requirements’’;
(2) in subsection (b)(1), by striking ‘‘require-
ment’’ and inserting ‘‘requirements’’;
(3) in the heading to subsection (d), by striking
‘‘REQUIREMENT’’ and inserting ‘‘REQUIREMENTS’’;
(4) by adding at the end of subsection (d) the
following new paragraph:
‘‘(3) No hospital may be defined or deemed as
a disproportionate share hospital under a State plan
under this title or under subsection (b) or (e) of this
section unless the hospital has a medicaid inpatient
utilization rate (as defined in subsection (b)(2)) of
not less than 1 percent.’’;
(5) in subsection (e)(1)—
428
(A) by striking ‘‘and’’ before ‘‘(B)’’, and
(B) by inserting before the period at the
end the following: ‘‘, and (C) the plan meets the
requirement of subsection (d)(3) and such pay-
ment adjustments are made consistent with the
fourth sentence of subsection (c)’’; and
(6) in subsection (e)(2)—
(A) in subparagraph (A), by inserting
‘‘(other than the fourth sentence of subsection
(c))’’ after ‘‘(c)’’,
(B) by striking ‘‘and’’ at the end of sub-
paragraph (A),
(C) by striking the period at the end of
subparagraph (B) and inserting ‘‘, and’’, and
(D) by adding at the end the following new
subparagraph:
‘‘(C) subsection (d)(3) shall apply.’’.
(b) LIMITING AMOUNT OF PAYMENT ADJUSTMENTS
FOR STATE
OR COUNTY HOSPITALS
TO UNCOVERED
COSTS.—Subsection (c) of such section is amended by
adding at the end the following: ‘‘A payment adjustment
during a year is not considered to be consistent with this
subsection with respect to a hospital owned or operated
by a State (or by an instrumentality of or a unit of govern-
ment within a State) if the payment adjustment exceeds
429
the costs of furnishing hospital services (as determined by
the Secretary and net of payments under this title, other
than under this section, and by uninsured patients) by the
hospital to individuals who either are eligible for medical
assistance under the State plan or have no health insur-
ance (or other source of third party payment) for such
services during the year. For purposes of the preceding
sentence, payments made to a hospital for services pro-
vided to indigent patients made by a State or a unit of
local government within a State shall not be considered
to be a source of third party payment.’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to payments to States under sec-
tion 1903(a) of the Social Security Act for payments to
hospitals made under State plans after—
(1) the end of the State fiscal year that ends
during 1994, or
(2) in the case of a State with a State legisla-
ture which is not scheduled to have a regular legisla-
tive session in 1994, the end of the State fiscal year
that ends during 1995;
without regard to whether or not final regulations to carry
out such amendments have been promulgated by either
such date.
430
Subchapter B—Miscellaneous Provisions
PART I—ANTI-FRAUD AND ABUSE PROVISIONS
SEC. 5131. APPLICATION OF MEDICARE RULES LIMITING
CERTAIN PHYSICIAN REFERRALS.
(a) IN
GENERAL.—Section 1903(i) (42 U.S.C.
1396b(i)), as amended by section 5174(b), is amended—
(A) in paragraph (12), by striking or at
the end,
(B) in paragraph (13), by striking the pe-
riod at the end and inserting ‘‘; or’’, and
(C) by inserting after paragraph (13) the
following new paragraph:
‘‘(14) with respect to any amount expended for
an item or service for which payment would be de-
nied under section 1877(g)(1) if the item or service
were furnished to an individual entitled to benefits
under title XVIII.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to items and services furnished
on or after October 1, 1993.
SEC. 5132. INTERMEDIATE SANCTIONS FOR KICKBACK VIO-
LATIONS.
(a) PENALTY FOR KICKBACKS.—Section 1128A(a)
(42 U.S.C. 1320a–7a(a)) is amended—
431
(1) by striking ‘‘or’’ at the end of paragraphs
(1) and (2);
(2) by adding ‘‘or’’ at the end of paragraph (3);
(3) by inserting after paragraph (3) the follow-
ing new paragraph:
‘‘(4) carries out any activity in violation of
paragraph (1) or (2) of section 1128B(b);’’;
(4) by striking ‘‘given).’’ at the end of the first
sentence and inserting ‘‘given or, in cases under
paragraph (4), $50,000 for each such violation).’’;
(5) in the second sentence, by inserting ‘‘in
cases under paragraphs (1), (2), and (3),’’ after ‘‘In
addition,’’; and
(6) by inserting after the second sentence, the
following new sentence: ‘‘In cases under paragraph
(4), such a person shall be subject to an assessment
of not more than twice the total amount of the re-
muneration offered, paid, solicited, or received in
violation of section 1128B(b), determined without
regard to whether a portion of such remuneration
was offered, paid, solicited, or received for a lawful
purpose.’’.
(b) AUTHORIZATION TO ACT.—The first sentence of
section 1128A(c)(1) (42 U.S.C. 1320a–7a(c)(1)) is
amended by striking all that follows ‘‘(b)’’ and inserting
432
the following: ‘‘unless, within one year after the date the
Secretary presents a case to the Attorney General for con-
sideration, the Attorney General brings an action in a dis-
trict court of the United States.’’.
(c) EFFECTIVE DATES.—
(1) The amendments made by subsection (a)
shall apply to remuneration offered, paid, solicited,
or received before, on, or after the date of the enact-
ment of this Act.
(2) The amendment made by subsection (b)
shall apply to cases presented by the Secretary of
Health and Human Services for consideration on or
after the date of the enactment of this Act.
SEC. 5133. REQUIRING MAINTENANCE OF EFFORT FOR
STATE MEDICAID FRAUD CONTROL UNITS.
(a) IN GENERAL.—Section 1902(a)(49) (42 U.S.C.
1396a(a)(49)) is amended—
(1) by inserting ‘‘(A)’’ after ‘‘(49)’’, and
(2) by adding at the end the following new sub-
paragraph:
‘‘(B) provide that the State will expend for its
medicaid fraud and abuse control unit (as defined in
section 1903(q)), for each State fiscal year, an
amount that is not less than the amount expended
for such unit in the State fiscal year that ended in
433
1992 adjusted to reflect the percentage increase in
total expenditures under the State plan between
such State fiscal year and the State fiscal year in-
volved;’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to State fiscal years ending after
1993.
PART II—MANAGED CARE PROVISIONS
SEC. 5135. MEDICAID MANAGED CARE ANTI-FRAUD PROVI-
SIONS.
(a) PROHIBITING AFFILIATIONS WITH INDIVIDUALS
DEBARRED BY FEDERAL AGENCIES.—
(1) IN GENERAL.—Section 1903(m) (42 U.S.C.
1396b(m)) is amended—
(A) in paragraph (2)(A)—
(i) by striking ‘‘and’’ at the end of
clause (x),
(ii) by striking the period at the end
of clause (xi) and inserting ‘‘; and’’, and
(iii) by adding at the end the follow-
ing new clause:
‘‘(xii) the entity complies with the requirements
of paragraph (3) (relating to certain protections
against fraud and abuse).’’;
434
(B) in paragraph (2)(B), as amended by
section 5158(b), by striking ‘‘clause (ix)’’ and
inserting ‘‘clauses (ix) and (xii)’’; and
(C) by inserting after paragraph (2) the
following new paragraph:
‘‘(3)(A)(i) A health maintenance organization may
not have a person described in clause (iv) as a director,
officer, partner, or person with beneficial ownership of
more than 5 percent of organization’s equity.
‘‘(ii) A health maintenance organization may not have
an employment, consulting, or other agreement with a per-
son described in clause (iv) for the provision of goods and
services that are significant and material to the organiza-
tion’s obligations under its contract with the State de-
scribed in paragraph (2)(A)(iii).
‘‘(iii) If a health maintenance organization is not in
compliance with clause (i) or clause (ii)—
‘‘(I) a State may continue an existing agree-
ment with the organization unless the Secretary (in
consultation with the Inspector General of the De-
partment of Health and Human Services) directs
otherwise; and
‘‘(II) a State may not renew or otherwise ex-
tend the duration of an existing agreement with the
organization unless the Secretary (in consultation
435
with the Inspector General of the Department of
Health and Human Services) provides a written
statement describing compelling reasons that exist
for renewing or extending the agreement.
‘‘(iv) A person described in this clause is a person
that—
‘‘(I) is debarred or suspended by the Federal
Government, pursuant to the Federal acquisition
regulation, from Government contracting and sub-
contracting, or
‘‘(II) is an affiliate (within the meaning of the
Federal acquisition regulation) of a person described
in subclause (I).’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall apply to agreements between
a State and an entity under section 1903(m) of the
Social Security Act entered into or renewed on or
after October 1, 1993, without regard to whether
regulations to carry out such amendments are pro-
mulgated by such date.
(b) REQUIREMENT FOR STATE CONFLICT-OF-INTER-
EST SAFEGUARDS IN MEDICAID RISK CONTRACTING.—
(1) IN GENERAL.—Section 1903(m)(2)(A) (42
U.S.C. 1396b(m)(2)(A)), as amended by subsection
(a)(1)(C), is amended—
436
(A) by striking ‘‘and’’ at the end of clause
(xi),
(B) by striking the period at the end of
clause (xii) and inserting ‘‘; and’’, and
(C) by adding at the end the following new
clause:
‘‘(xiii) the State certifies to the Secretary that
it has in effect conflict-of-interest safeguards with
respect to officers and employees of the State with
responsibility with respect to contracts with organi-
zations under this subsection that are at least as ef-
fective as the Federal safeguards, provided under
section 27 of the Office of Federal Procurement Pol-
icy Act (41 U.S.C. 423), against conflicts of interest
that apply with respect to Federal procurement offi-
cials with comparable responsibilities with respect to
such contracts.’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall apply as of July 1, 1994,
without regard to whether regulations to carry out
such amendments are promulgated by such date.
(c) REQUIRING DISCLOSURE OF FINANCIAL INFOR-
MATION.—
437
(1) IN GENERAL.—Section 1903(m)(3), as in-
serted by subsection (a)(1)(C), is amended by add-
ing at the end the following new subparagraph:
‘‘(B) The contract between the State and an entity
referred to in paragraph (2)(A)(iii) shall provide that—
‘‘(i) the entity agrees to report to the State
such financial information as the Secretary or the
State may require to demonstrate that the entity has
a fiscally sound operation; and
‘‘(ii) the entity agrees to make available to its
enrollees upon reasonable request—
‘‘(I) the information reported under para-
graph (1),
‘‘(II) the information required to be dis-
closed under sections 1124 and 1126, and
‘‘(III) a description of each transaction,
described in subparagraphs (A) through (C) of
section 1318(a)(3) of the Public Health Service
Act, between the entity and a party in interest
(as defined in section 1318(b) of such Act).’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to contract years begin-
ning on or after October 1, 1993, without regard to
whether regulations to carry out such amendments
are promulgated by such date, with respect to infor-
438
mation reported or required to be disclosed, or
transactions occurring, before, on, or after such
date.
(d) PROHIBITING MARKETING FRAUD.—
(1) IN GENERAL.—Section 1903(m)(3), as in-
serted by subsection (a)(1) and as amended by sub-
section (c)(1), is amended by adding at the end the
following new subparagraph:
‘‘(C) The contract between the State and an entity
referred to in paragraph (2)(A)(iii) shall provide that the
entity agrees to comply with such procedures and condi-
tions as the Secretary prescribes in order to ensure that,
before an individual is enrolled with the entity, the individ-
ual is provided accurate and sufficient information to
make an informed decision whether or not to enroll.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to contract years that
begin on or after October 1, 1993, without regard
to whether regulations to carry out such amendment
are promulgated by such date.
(e) REQUIRING ADEQUATE EQUITY FOR FOR-PROFIT
ENTITIES.—
(1) IN GENERAL.—Section 1903(m)(3), as pre-
viously amended by this section, is further amended
439
by adding at the end the following new subpara-
graph:
‘‘(D)(i) The contract between the State and an entity
referred to in paragraph (2)(A)(iii) shall require, in the
case of a for-profit entity, that the entity shall maintain
an average ratio of—
‘‘(I) equity capital to
‘‘(II) payments made by the State to the entity
under the contract on a capitation basis or any other
risk basis,
of not less than such minimum ratio as the Secretary shall
specify.
‘‘(ii) The contract between the State and a non-profit
entity referred to in paragraph (2)(A)(iii) shall require
that no payment shall be made directly or indirectly under
an agreement between the non-profit entity and a related
for-profit entity (as defined by the Secretary) unless the
for-profit entity maintains an average ratio of equity cap-
ital to payments under such agreement of not less than
such ratio as the Secretary shall specify.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to contract years begin-
ning on or after July 1, 1994, without regard to
whether regulations to carry out such amendment
are promulgated by such date.
440
(f) REQUIRING ADEQUATE PROVISION AGAINST RISK
OF INSOLVENCY.—
(1) IN
GENERAL.—Section 1903(m)(1)(A)(ii)
(42 U.S.C. 1396b(m)(1)(A)(ii)) is amended by in-
serting ‘‘, which meets such standards as the Sec-
retary shall prescribe’’ after ‘‘satisfactory to the
State’’.
(2) EFFECTIVE DATE AND TRANSITION.—(A)
The amendment made by paragraph (1) shall apply
to contract years beginning on or after July 1, 1994,
without regard to whether regulations to carry out
such amendments are promulgated by such date.
(B) If the Secretary of Health and Human
Services has not promulgated standards to carry out
the amendment made by paragraph (1) by July 1,
1994, until such standards have been promulgated a
provision of a health maintenance organization
against the risk of insolvency shall not be considered
to meet standards prescribed by the Secretary, for
purposes of section 1903(m)(1)(A)(ii) of the Social
Security Act, unless such provision has been found
satisfactory 
by 
the 
Secretary 
under 
section
1876(b)(2)(E) of such Act.
(g) REQUIRING REPORT ON NET EARNINGS AND AD-
DITIONAL BENEFITS.—
441
(1) IN GENERAL.—Section 1903(m)(3), as pre-
viously amended by this section, is amended by add-
ing at the end the following new subparagraph:
‘‘(E) The contract between the State and an entity
referred to in paragraph (2)(A)(iii) shall provide that the
entity shall submit a report to the State and the Secretary
not later than 12 months after the close of a contract year
containing—
‘‘(i) a financial statement of the entity’s net
earnings under the contract during the contract
year, which statement has been audited using audit-
ing standards established by the Secretary in con-
sultation with the States; and
‘‘(ii) a description of any benefits that are in
addition to the benefits required to be provided
under the contract that were provided during the
contract year to members enrolled with the entity
and entitled to medical assistance under the plan.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to contract years begin-
ning on or after October 1, 1993, without regard to
whether regulations to carry out such amendments
are promulgated by such date.
(h) REPORT ON NET EARNINGS OF CONTRACTORS.—
Not later than 6 months after the date of the enactment
442
of this Act, the Secretary of Health and Human Services
shall submit a report to Congress on the earnings of orga-
nizations with contracts to receive payment for providing
medical assistance under title XIX of the Social Security
Act on a prepaid capitation or any other risk basis. The
report shall include the Secretary’s recommendations on
options for requiring such organizations, as a condition
of participation under such title, to dedicate a portion of
such earnings to the provision of additional benefits to in-
dividuals enrolled with the organization.
SEC. 5136. CLARIFICATION OF TREATMENT OF HMO EN-
ROLLEES IN COMPUTING THE MEDICAID IN-
PATIENT UTILIZATION RATE IN QUALIFYING
HOSPITALS AS DISPROPORTIONATE SHARE
HOSPITALS.
(a) IN GENERAL.—Section 1923(b)(2) (42 U.S.C.
1396r–4(b)(2)) is amended by inserting before the period
at the end the following: ‘‘and whether or not the individ-
ual is enrolled with an entity contracting with the State
on a prepaid capitation basis or other risk basis under sec-
tion 1903(m)’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to payments to States under sec-
tion 1903(a) of the Social Security Act for payments to
hospitals made under State plans on and after the first
443
day of the first calendar quarter beginning after the date
of the enactment of this Act.
SEC. 5137. EXTENSION OF PERIOD OF APPLICABILITY OF
ENROLLMENT MIX REQUIREMENT TO CER-
TAIN 
HEALTH 
MAINTENANCE 
ORGANIZA-
TIONS PROVIDING SERVICES UNDER DAYTON
AREA HEALTH PLAN.
Section 2 of Public Law 102–276 is amended by
striking ‘‘January 31, 1994’’ and inserting ‘‘December 31,
1995’’.
SEC. 5138. EXTENSION OF MEDICAID WAIVER FOR TEN-
NESSEE PRIMARY CARE NETWORK.
Section 6411(f) of the Omnibus Budget Reconcili-
ation Act of 1989, as amended by section 1 of Public Law
102–317, is amended by striking ‘‘January 31, 1994’’ and
inserting ‘‘December 31, 1995’’.
SEC. 5139. WAIVER OF APPLICATION OF MEDICAID EN-
ROLLMENT MIX REQUIREMENT TO DISTRICT
OF COLUMBIA CHARTERED HEALTH PLAN,
INC.
(a) IN GENERAL.—The Secretary of Health and
Human Services shall waive the application of the require-
ment described in section 1903(m)(2)(A)(ii) of the Social
Security Act to the entity known as the District of Colum-
bia Chartered Health Plan, Inc., for the period described
444
in subsection (b), if the Secretary determines that the en-
tity is making continuous efforts and progress toward
achieving compliance with such requirement.
(b) PERIOD OF APPLICABILITY.—The period referred
to in subsection (a) is the period that begins on October
1, 1992, and ends on December 31, 1995.
SEC. 5140. EXTENSION OF MINNESOTA PREPAID MEDICAID
DEMONSTRATION PROJECT.
(a) IN GENERAL.—Section 507 of the Family Sup-
port Act of 1988, as amended by section 6411(j) of
OBRA–1989 and by section 4733 of OBRA–1990, is
amended by striking ‘‘1996’’ and inserting ‘‘1998’’.
(b) AUTHORITY TO IMPOSE PREMIUM.—
(1) IN
GENERAL.—Notwithstanding section
1916 of the Social Security Act and subject to para-
graph (2), the State of Minnesota may impose a pre-
mium on individuals receiving medical assistance
under the Minnesota Prepaid Demonstration Project
operated under a waiver granted by the Secretary of
Health and Human Services under section 1115(a)
of the Social Security Act and other individuals eligi-
ble under the State’s plan for medical assistance
under title XIX of such Act.
(2) LIMITATION ON AMOUNT OF PREMIUM.—In
no case may the amount of any premium imposed on
445
an individual receiving medical assistance under the
State plan or under the Demonstration Project de-
scribed in paragraph (1) exceed 10 percent of the
amount by which the family income (less expenses
for the care of a dependent child) of the individual
exceeds 110 percent of the income official poverty
line (as defined by the Office of Management and
Budget), and revised annually in accordance with
section 673(2) of the Omnibus Budget Reconcili-
ation Act of 1981) applicable to a family of the size
involved.
PART III—EMERGENCY SERVICES TO
UNDOCUMENTED ALIENS
SEC. 5141. INCREASE IN FEDERAL FINANCIAL PARTICIPA-
TION FOR EMERGENCY MEDICAL ASSIST-
ANCE TO UNDOCUMENTED ALIENS.
(a) IN
GENERAL.—Section 1905(b) (42 U.S.C.
1396d(b)) is amended by adding at the end the following:
‘‘Notwithstanding the first sentence of this section, sub-
ject to 1903(v)(4), the Federal medical assistance percent-
age shall be 100 per centum with respect to amounts ex-
pended by an eligible State in a covered fiscal year (as
defined in section 1903(v)(4)(C)) as medical assistance for
care and services described in section 1903(v)(2) to aliens
described in section 1903(v)(1).’’.
446
(b) LIMITATION.—Section 1903(v) (42 U.S.C.
1396b(v)) is amended by adding at the end the following
new paragraphs:
‘‘(4)(A) With respect to any eligible State (as defined
in subparagraph (C)(i)), the amount of the increase in
payments to a State under subsection (a) in a covered fis-
cal year (as defined in subparagraph (C)(ii)), resulting
from the increase in the Federal medical assistance per-
centage under the fourth sentence of section 1905(b), shall
not exceed the State’s allotment determined under sub-
paragraph (B).
‘‘(B)(i) The total of the allotments to all States for
a covered fiscal year under this paragraph shall be
$300,000,000.
‘‘(ii) From the total allotment under clause (i) for
a covered fiscal year, the Secretary shall determine the
amount of the allotment for each eligible State. Subject
to clause (iii), the amount of such allotment for such a
fiscal year shall bear the same ratio to the total amount
specified in clause (i) for the fiscal year as the ratio of—
‘‘(I) the allotment to the State for fiscal year
1993 under section 204 of the Immigration Reform
and Control Act of 1986, to
‘‘(II) the total of such allotments for all such el-
igible States for fiscal year 1993.
447
‘‘(iii) In the case of an eligible State which notifies
the Secretary that an amount of its allotment will not be
used by the State under this paragraph, the State’s allot-
ment shall be reduced by such amount and such amount
shall be redistributed among the other eligible States in
proportion to the amount otherwise allotted to such State
under clause (ii).
‘‘(C) For purposes of this paragraph and the fourth
sentence of section 1905(b):
‘‘(i) The term ‘eligible State’ means a State—
‘‘(I) with a plan approved under this title
(including a State which is providing medical
assistance to its residents under a statewide
waiver granted under section 1115), and
‘‘(II) for which its allotment for fiscal year
1993 under section 204 of the Immigration Re-
form and Control Act of 1986 is at least 1 per-
cent of the total of such allotments for all the
States for fiscal year 1993.
‘‘(ii) The term ‘covered fiscal year’ means only
fiscal year 1994.
‘‘(D) Nothing in this paragraph or the fourth sen-
tence of section 1905(b) shall be construed as establishing
entitlement authority (within the meaning of section 3(9)
448
of the Congressional Budget Act of 1974) for any fiscal
year other than a covered fiscal year.’’.
SEC. 5142. LIMITING FEDERAL MEDICAID MATCHING PAY-
MENT TO BONA FIDE EMERGENCY SERVICES
FOR UNDOCUMENTED ALIENS.
(a) IN GENERAL.—Section 1903(v)(2) (42 U.S.C.
1396b(v)(2)) is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (A),
(2) by striking the period at the end of sub-
paragraph (B) and inserting ‘‘, and’’, and
(3) by adding at the end the following new sub-
paragraph:
‘‘(C) such care and services are not related to
an organ transplant procedure.’’.
(b) EFFECTIVE DATE.—(1) Subject to paragraph
(2), the amendments made by subsection (a) shall apply
as if included in the enactment of OBRA–1986.
(2) The Secretary of Health and Human Services
shall not disallow expenditures made for the care and serv-
ices described in section 1903(v)(2)(C) of the Social Secu-
rity Act, as added by subsection (a), furnished before the
date of the enactment of this Act.
449
PART IV—MISCELLANEOUS PROVISIONS
SEC. 5144. INCREASE IN LIMIT ON FEDERAL MEDICAID
MATCHING PAYMENTS TO PUERTO RICO AND
OTHER TERRITORIES.
(a) IN GENERAL.—Paragraphs (1) through (5) of
section 1108(c) (42 U.S.C. 1308(c)) are amended to read
as follows:
‘‘(1) 
Puerto 
Rico 
shall 
not 
exceed 
(A)
$104,000,000 for fiscal year 1994 and (B) for each
succeeding fiscal year the amount provided in this
paragraph for the preceding fiscal year increased by
the percentage increase in the medical care compo-
nent of the consumer price index for all urban con-
sumers (as published by the Bureau of Labor Statis-
tics) for the twelve-month period ending in March
preceding the beginning of the fiscal year, rounded
to the nearest $100,000;
‘‘(2) the Virgin Islands shall not exceed (A)
$3,425,000 for fiscal year 1994, and (B) for each
succeeding fiscal year the amount provided in this
paragraph for the preceding fiscal year increased by
the percentage increase referred to in paragraph
(1)(B), rounded to the nearest $10,000;
‘‘(3) Guam shall not exceed (A) $3,290,000 for
fiscal year 1994, and (B) for each succeeding fiscal
year the amount provided in this paragraph for the
452
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to disallowances made after the
date of the enactment of this Act and shall take effect
without regard to the promulgation of implementing regu-
lations.
SEC. 5146. RENEWAL OF UNFUNDED DEMONSTRATION
PROJECT 
FOR 
LOW-INCOME 
PREGNANT
WOMEN AND CHILDREN.
(a) IN GENERAL.—Section 6407 of OBRA–89 is
amended—
(1) in subsection (d), by striking ‘‘3 years’’ and
inserting ‘‘5 years’’;
(2) in subsection (f), by striking ‘‘$10,000,000
in each of fiscal years 1990, 1991, and 1992’’ and
inserting ‘‘$30,000,000’’; and
(3) in subsection (g)(2), by striking ‘‘January
1, 1994’’ and inserting ‘‘one year after the termi-
nation of the demonstration projects’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall take effect as if included in the enact-
ment of OBRA–89.
453
SEC. 5147. OPTIONAL MEDICAID COVERAGE OF TB-RELAT-
ED SERVICES FOR CERTAIN TB-INFECTED IN-
DIVIDUALS.
(a) COVERAGE
AS
OPTIONAL, CATEGORICALLY
NEEDY GROUP.—Section 1902(a)(10)(A)(ii) (42 U.S.C.
1396a(a)(10)(A)(ii)) is amended—
(1) by striking ‘‘or’’ at the end of subclause
(X),
(2) by adding ‘‘or’’ at the end of subclause
(XI), and
(3) by adding at the end the following new
subclause:
‘‘(XII) who are described in sub-
section (z)(1) (relating to certain TB-
infected individuals);’’.
(b) GROUP
AND
BENEFIT
DESCRIBED.—Section
1902 is amended by adding at the end the following new
subsection:
‘‘(z)(1) Individuals described in this paragraph are
individuals not described in subsection (a)(10)(A)(i)—
‘‘(A) who have tested positively to be infected
with tuberculosis;
‘‘(B) whose income (as determined under the
State plan under this title with respect to disabled
individuals) does not exceed the maximum amount
of income a disabled individual described in sub-
454
section (a)(10)(A)(i) may have and obtain medical
assistance under the plan; and
‘‘(C) whose resources (as determined under the
State plan under this title with respect to disabled
individuals) do not exceed the maximum amount of
resources a disabled individual described in sub-
section (a)(10)(A)(i) may have and obtain medical
assistance under the plan.
‘‘(2) For purposes of subsection (a)(10), the term
‘TB-related services’ means each of the following services
relating to treatment of infection with tuberculosis:
‘‘(A) Prescribed drugs.
‘‘(B) Physicians’ services and services described
in section 1905(a)(2).
‘‘(C) Laboratory and X-ray services.
‘‘(D) Clinic services and Federally-qualified
health center services.
‘‘(E) Case management services (as defined in
section 1915(g)(2)).
‘‘(F) Services (other than room and board) de-
signed to encourage completion of regimens of pre-
scribed drugs by outpatients, including services to
observe directly the intake of prescribed drugs.’’.
455
(c) 
LIMITATION
ON
BENEFITS.—Section
1902(a)(10), as amended by section 5162(a), is amended,
in the matter following subparagraph (F)—
(1) by striking ‘‘, and (XII)’’ and inserting ‘‘,
(XII)’’, and
(2) by inserting before the semicolon at the end
the following: ‘‘, and (XIII) the medical assistance
made available to an individual described in sub-
section (z)(1) who is eligible for medical assistance
only because of subparagraph (A)(ii)(XII) shall be
limited to medical assistance for TB-related services
(as defined in subsection (z)(2))’’.
(d) CONFORMING EXPANSION
OF CASE MANAGE-
MENT SERVICES OPTION.—Section 1915(g)(1) (42 U.S.C.
1396n(g)(1)) is amended by inserting ‘‘or to individuals
described in section 1902(z)(1)(A),’’ after ‘‘or with ei-
ther,’’.
(e) CONFORMING AMENDMENT.—Section 1905(a)
(42 U.S.C. 1396d(a)) is amended—
(1) by striking ‘‘or’’ at the end of clause (ix),
(2) by adding ‘‘or’’ at the end of clause (x),
(3) by inserting after clause (x) the following
new clause:
‘‘(xi) 
individuals 
described 
in 
section
1902(z)(1),’’, and
456
(4) by amending paragraph (19) to read as fol-
lows:
‘‘(19) case management services (as defined in
section 1915(g)(2)) and TB-related services de-
scribed in section 1902(z)(2)(F);’’.
(f) EFFECTIVE DATE.—The amendments made by
this section shall apply to medical assistance furnished on
or after January 1, 1994, without regard to whether or
not final regulations to carry out such amendments have
been promulgated by such date.
SEC. 5148. APPLICATION OF MAMMOGRAPHY CERTIFI-
CATION REQUIREMENTS UNDER THE MEDIC-
AID PROGRAM.
(a) IN GENERAL.—Section 1902(a)(9) (42 U.S.C.
1396a(a)(9)) is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (B),
(2) by striking the semicolon at the end of sub-
paragraph (C) and inserting ‘‘, and’’, and
(3) by adding at the end the following new sub-
paragraph:
‘‘(D) that any mammography paid for
under such plan must be conducted by a facility
that has a certificate (or provisional certificate)
457
issued under section 354 of the Public Health
Service Act;’’.
(b) EFFECTIVE DATE.—(1) Except as provided in
paragraph (2), the amendments made by subsection (a)
shall apply to mammography furnished by a facility during
calendar quarters beginning on or after the first date that
the certificate requirements of section 354(b) of the Public
Health Service Act apply to such mammography con-
ducted by such facility, without regard to whether or not
final regulations to carry out such amendments have been
promulgated by such date.
(2) In the case of a State plan for medical assistance
under title XIX of the Social Security Act which the Sec-
retary of Health and Human Services determines requires
State legislation (other than legislation appropriating
funds) in order for the plan to meet the additional require-
ment imposed by the amendment made by subsection
(a)(3), 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 be-
fore the first day of the first calendar quarter beginning
after the close of the first regular session of the State leg-
islature 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
458
of such session shall be deemed to be a separate regular
session of the State legislature.
SEC. 5149. REMOVAL OF SUNSET ON EXTENSION OF ELIGI-
BILITY FOR WORKING FAMILIES.
Subsection (f) of section 1925 (42 U.S.C. 1396r–6)
is repealed.
SEC. 5150. EXTENSION OF MORATORIUM ON TREATMENT
OF CERTAIN FACILITIES AS INSTITUTIONS
FOR MENTAL DISEASES.
Effective as if included in the enactment of OBRA–
1989, section 6408(a)(3) of such Act is amended by strik-
ing ‘‘180 days’’ and all that follows and inserting ‘‘Decem-
ber 31, 1995.’’.
SEC. 5150A. TREATMENT OF CERTAIN CLINICS AS FEDER-
ALLY-QUALIFIED HEALTH CENTERS.
(a) IN GENERAL.—Section 1905(l)(2)(B) (42 U.S.C.
1396d(l)(2)(B)), as amended by section 5158(c), is
amended—
(1) by striking ‘‘or’’ at the end of clause
(ii)(II),
(2) by adding ‘‘or’’ at the end of clause (iii),
and
(3) by inserting after clause (iii) the following
new clause:
459
‘‘(iv) was treated by the Secretary, for purposes
of part B of title XVIII, as a comprehensive Feder-
ally funded health center as of January 1, 1990;’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to calendar quarters beginning
on or after July 1, 1993.
SEC. 5150B. NURSING HOME REFORM.
(a) SUSPENSION OF DECERTIFICATION OF NURSE
AIDE TRAINING AND COMPETENCY EVALUATION PRO-
GRAMS BASED ON EXTENDED SURVEYS.—
(1) 
IN
GENERAL.—Section
1919(f)(2)(B)(iii)(I)(b) 
(42 
U.S.C.
1396r(f)(2)(B)(iii)(I)(b)) is amended by striking the
semicolon and inserting the following: ‘‘, unless the
survey shows that the facility is in compliance with
the requirements of subsections (b), (c), and (d) of
this section;’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect as included in the
enactment of OBRA–1990.
(b) REQUIREMENTS FOR CONSULTANTS CONDUCT-
ING REVIEWS OF USE OF DRUGS.—
(1) IN GENERAL.—Section 1919(c)(1)(D) (42
U.S.C. 1396r(c)(1)(D)) is amended by adding at the
end the following sentence: ‘‘In determining whether
460
such a consultant is qualified to conduct reviews
under the previous sentence, the Secretary shall take
into account the needs of nursing facilities under
this title to have access to the services of such a con-
sultant on a timely basis.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect as included in the
enactment of OBRA–1987.
(c) INCREASE IN MINIMUM AMOUNT REQUIRED FOR
SEPARATE DEPOSIT OF PERSONAL FUNDS.—
(1) IN GENERAL.—Section 1919(c)(6)(B)(i) (42
U.S.C. 1396r(c)(6)(B)(i)) is amended by striking
‘‘$50’’ and inserting ‘‘$100’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect October 1, 1993.
(d) DUE
PROCESS
PROTECTIONS
FOR
NURSE
AIDES.—
(1) PROHIBITING STATE FROM INCLUDING UN-
DOCUMENTED ALLEGATIONS IN NURSE AIDE REG-
ISTRY.—Section 
1919(e)(2)(B) 
(42 
U.S.C.
1396r(e)(2)(B)) is amended by striking the period at
the end of the first sentence and inserting the fol-
lowing: ‘‘, but shall not include any allegations of
resident abuse or neglect or misappropriation of
461
resident property that are not specifically docu-
mented by the State under such subsection.’’.
(2) DUE PROCESS REQUIREMENTS FOR REBUT-
TING
ALLEGATIONS.—Section 1919(g)(1)(C) (42
U.S.C. 1396r(g)(1)(C)) is amended by striking the
second sentence and inserting the following: ‘‘The
State shall, after providing the individual involved
with a written notice of the allegations (including a
statement of the availability of a hearing for the in-
dividual to rebut the allegations) and the oppor-
tunity for a hearing on the record, make a written
finding as to the accuracy of the allegations.’’.
(3) EFFECTIVE DATE.—The amendments made
by this subsection shall take effect October 1, 1993.
Subchapter C—Miscellaneous and Technical
Corrections Relating to OBRA–1990
SEC. 5151. EFFECTIVE DATE.
Except as otherwise provided, the amendments made
by this subchapter shall take effect as if included in the
enactment of OBRA–1990.
SEC. 5152. CORRECTIONS RELATING TO SECTION 4402 (EN-
ROLLMENT UNDER GROUP HEALTH PLANS).
Section 4402(b) of OBRA–1990 is amended by strik-
ing ‘‘1903(u)(1)(C)(iv) (42 U.S.C. 1396b(u)(1)(C)(iv))’’
462
and 
inserting 
‘‘1903(u)(1)(D)(iv) 
(42 
U.S.C.
1396b(u)(1)(D)(iv))’’.
SEC. 5153. CORRECTIONS RELATING TO SECTION 4501
(LOW-INCOME MEDICARE BENEFICIARIES).
(a) Section 1902(a)(10)(E)(iii), as added by section
4501(b)(3) of OBRA–1990, is amended by striking ‘‘cost
sharing’’ and inserting ‘‘cost-sharing’’.
(b) Section 1905(p)(4)(B), as amended by section
4501(c)(1) of OBRA–1990, is amended by striking
‘‘1902(a)(10)(E)(iii)’’ 
and 
inserting 
‘‘section
1902(a)(10)(E)(iii)’’.
SEC. 5154. CORRECTIONS RELATING TO SECTION 4601
(CHILD HEALTH).
(a) Section 1902(a)(10)(A)(i)(VII), as added by sec-
tion 4601(a)(10)(A)(iii) of OBRA–1990, is amended by
striking ‘‘family;’’ and inserting ‘‘family; and’’.
(b) Section 1902(l), as amended by section
4601(a)(1)(C) of OBRA–1990, is amended—
(1) in paragraph (1)(C), by striking ‘‘children’’
after ‘‘(C)’’;
(2) 
in 
paragraph 
(3), 
by 
striking
‘‘(a)(10)(A)(i)(VII),,’’ 
and 
inserting
‘‘(a)(10)(A)(i)(VII),’’; and
(3) in paragraph (4)(B), by inserting a comma
before ‘‘(a)(10)(A)(i)(VI),’’.
463
(c) Subsections (a)(3)(C) and (b)(3)(C)(i) of section
1925, as amended by section 4601(a) of OBRA–1990, are
each amended by striking ‘‘(i)(VI)’’ and inserting
‘‘(i)(VI),’’.
SEC. 5155. CORRECTIONS RELATING TO SECTION 4602 (OUT-
REACH LOCATIONS).
(a) Section 1902(a)(55), as added by section
4602(a)(3) of OBRA–1990, is amended—
(1) in the matter preceding subparagraph (A)—
(A) by striking ‘‘subsection’’ and inserting
‘‘paragraph’’, and
(B) by striking ‘‘(a)’’ each place it ap-
pears; and
(2) 
in 
subparagraph 
(A), 
by 
striking
‘‘1905(1)(2)(B)’’ and inserting ‘‘1905(l)(2)(B)’’.
(b) Section 1902(l)(1) is amended by striking ‘‘who
are not described in any of subclauses (I) through (III)
of subsection (a)(10)(A)(i) and’’.
SEC. 5156. CORRECTIONS RELATING TO SECTION 4604 (PAY-
MENT FOR HOSPITAL SERVICES FOR CHIL-
DREN UNDER 6 YEARS OF AGE).
(a) Section 1902(a)(10) is amended in clause (X) in
the matter following subparagraph (F) by striking ‘‘under
one year of age’’ and inserting ‘‘under 6 years of age’’.
464
(b) Section 1902(s), as added by section 4604(a) of
OBRA–1990, is amended to read as follows:
‘‘(s) In order to meet the requirements of subsection
(a)(56), the State plan must provide that payments to hos-
pitals under the plan for inpatient services furnished to
infants who have not attained the age of 1 year (or, in
the case of such an individual who is an inpatient on his
first birthday, until such individual is discharged) shall—
‘‘(1) if made on a prospective basis (whether
per diem, per case, or otherwise) provide for an
outlier adjustment in payment amounts for medi-
cally necessary inpatient hospital services involving
exceptionally high costs or exceptionally long lengths
of stay;
‘‘(2) not be limited by the imposition of day
limits; and
‘‘(3) not be limited by the imposition of dollar
limits (other than dollar limits resulting from pro-
spective payments as adjusted pursuant to para-
graph (1)).’’.
(c) Section 1923(a)(2)(C) is amended by striking
‘‘provided on or after July 1, 1989,’’ and all that follows
and inserting the following: ‘‘involving exceptionally high
costs or exceptionally long lengths of stay—
465
‘‘(i) for individuals under 1 year of age, in the
case of services provided on or after July 1, 1989,
and on or before June 30, 1991; and
‘‘(ii) for individuals under 6 years of age, in the
case of services provided on or after July 1, 1991.’’.
SEC. 5157. CORRECTIONS RELATING TO SECTION 4703 (PAY-
MENT ADJUSTMENTS FOR DISPROPORTION-
ATE SHARE HOSPITALS).
(a) Section 1923(c) is amended—
(1) in paragraph (2), by striking ‘‘paragraph
(b)(3)’’ and inserting ‘‘subsection (b)(3)’’;
(2) by striking the period at the end of para-
graph (3)(B) and inserting a comma; and
(3) in the third sentence, by striking ‘‘the pay-
ment adjustment described in paragraph (2)’’ and
inserting ‘‘a payment adjustment described in para-
graph (2) or (3)’’.
(b) 
Effective 
December 
22, 
1987, 
section
1923(d)(2)(A)(ii) is amended by striking ‘‘the date of the
enactment of this Act’’ and inserting ‘‘December 22,
1987’’.
(c) Section 4703(d) of OBRA–1990 is amended by
striking ‘‘412(a)(2)’’ and inserting ‘‘4112(a)(2)’’.
466
SEC. 5158. CORRECTIONS RELATING TO SECTION 4704 (FED-
ERALLY-QUALIFIED HEALTH CENTERS).
(a) Clause (ix) of section 1903(m)(2)(A), as added
by section 4704(b)(1)(C) of OBRA–1990, is amended—
(1) by striking ‘‘of such center’’ the first place
it appears;
(2) by striking ‘‘federally qualified’’ and insert-
ing ‘‘Federally-qualified’’;
(3) 
by 
inserting 
‘‘section’’ 
before
‘‘1905(a)(2)(C)’’; and
(4) by moving such clause 2 ems to the left.
(b) Section 1903(m)(2)(B), as amended by section
4704(b)(2) of OBRA–1990, is amended by striking ‘‘ex-
cept with respect to clause (ix) of subparagraph (A),’’ and
inserting ‘‘(except with respect to clause (ix) of such sub-
paragraph)’’.
(c) Section 1905(l)(2), as amended by section
4704(c) of OBRA–1990, is amended—
(1) in subparagraph (A)—
(A) by striking ‘‘Federally-qualififed’’ and
inserting ‘‘Federally-qualified’’, and
(B) by striking ‘‘an patient’’ and inserting
‘‘a patient’’; and
(2) in subparagraph (B)—
(A) in the matter preceding clause (i), by
striking ‘‘a entity’’ and inserting ‘‘an entity’’,
467
(B) by striking ‘‘or’’ at the end of clause
(i),
(C) by striking the semicolon at the end of
clause (ii)(II) and inserting ‘‘, or’’,
(D) by moving clause (ii) 4 ems to the left,
and
(E) in the last sentence, by striking
‘‘clause (ii)’’ and inserting ‘‘clause (iii)’’.
SEC. 5159. CORRECTIONS RELATING TO SECTION 4708 (SUB-
STITUTE PHYSICIANS).
Section 
1902(a)(32)(C), 
as 
added 
by 
section
4708(a)(3) of OBRA–1990, is amended to read as follows:
‘‘(C) payment may be made to a physician
for physicians’ services (and services furnished
incident to such services) furnished by a second
physician to patients of the first physician if (i)
the first physician is unavailable to provide the
services; (ii) the services are furnished pursuant
to an arrangement between the two physicians
that (I) is informal and reciprocal, or (II) in-
volves per diem or other fee-for-time compensa-
tion for such services; (iii) the services are not
provided by the second physician over a contin-
uous period of more than 60 days; and (iv) the
claim form submitted to the carrier for such
468
services includes the second physician’s unique
identifier (provided under the system estab-
lished under subsection (x)) and indicates that
the claim meets the requirements of this clause
for payment to the first physician.’’.
SEC. 5160. CORRECTIONS RELATING TO SECTION 4711
(HOME AND COMMUNITY CARE FOR FRAIL
ELDERLY).
(a) Section 1929, as added by section 4711(b) of
OBRA–1990, is amended—
(1) in subsection (c)(2)(F), by moving the sec-
ond sentence 2 ems to the right;
(2) in subsection (d)(2)(F)(ii), by striking ‘‘they
manage’’ and inserting ‘‘it manages’’;
(3) in subsection (d)(2)(F)(iii), by inserting
‘‘the agency or organization’’ after ‘‘(iii)’’;
(4) in subsection (e)(2)(B), by striking ‘‘fiscal
year 1989’’ and inserting ‘‘fiscal year 1990’’;
(5) in subsection (f)(1), by striking ‘‘Commu-
nity care’’ and inserting ‘‘community care’’;
(6) in subsection (g)(1)—
(A) by striking ‘‘SETTINGS’’ and inserting
‘‘SETTING’’, and
(B) in subparagraph (B), by striking ‘‘set-
ting.’’ and inserting ‘‘setting in which home and
469
community care under this section is pro-
vided.’’;
(7) in subsection (g)(2), by striking ‘‘commu-
nity care’’ the second, third, and fourth places it ap-
pears and inserting ‘‘home and community care’’;
(8) in subsection (h)(1)—
(A) by striking ‘‘more than 8’’ each place
it appears and inserting ‘‘8 or more’’, and
(B) in subparagraph (B), by inserting
‘‘(other than merely board)’’ after ‘‘personal
services’’;
(9) in subsection (h)(2), by striking ‘‘commu-
nity care’’ the second and third places it appears
and inserting ‘‘home and community care’’;
(10) in subsection (j)(1)—
(A) in subparagraph (B)(ii), by striking
‘‘1990’’ and inserting ‘‘1991’’, and
(B) by adding at the end the following new
subparagraph:
‘‘(C) APPLICABILITY TO COMMUNITY CARE
SETTINGS.—Subparagraphs (A) and (B) shall
apply to community care settings in the same
manner as such subparagraphs apply to provid-
ers of home or community care.’’;
470
(11) in subsection (j)(2), by adding at the end
the following new subparagraph:
‘‘(D) APPLICABILITY TO COMMUNITY CARE
SETTINGS.—Subparagraphs (A), (B), and (C)
shall apply to community care settings in the
same manner as such subparagraphs apply to
providers of home or community care.’’;
(12) in subsection (k)(1)(A)(i)—
(A) by striking ‘‘(d)(2)(E)’’ and inserting
‘‘(d)(2)’’, and
(B) by striking ‘‘settings,’’ and inserting
‘‘settings),’’;
(13) in subsection (l), by striking ‘‘State wide-
ness’’ and inserting ‘‘Statewideness’’;
(14) in subsection (m)—
(A) in paragraph (2), by striking ‘‘Individ-
ual Community Care Plan’’ and inserting ‘‘indi-
vidual community care plan’’,
(B) in paragraph (3), by striking ‘‘and
need for services’’ and inserting ‘‘need for serv-
ices, and income’’,
(C) in the second sentence in paragraph
(4), by striking ‘‘elderly individuals’’ and all
that follows and inserting ‘‘individuals receiving
home and community care under this section
471
who reside in such State in relation to the total
number of individuals receiving home and com-
munity care under this section.’’, and
(D) by adding at the end the following new
paragraph:
‘‘(5) NOTICE TO STATES OF AMOUNTS AVAIL-
ABLE FOR ASSISTANCE.—
‘‘(A) NOTICE TO SECRETARY.—In order to
receive Federal medical assistance for expendi-
tures for home and community care under this
section for a fiscal year (beginning with fiscal
year 1994), a State shall submit a notice to the
Secretary of its intention to provide such care
under this section not later than 3 months be-
fore the beginning of the fiscal year.
‘‘(B) NOTICE TO STATES.—Not later than
2 months before the beginning of each fiscal
year (beginning with fiscal year 1994), the Sec-
retary shall notify each State that has submit-
ted a notice to the Secretary under subpara-
graph (A) for the fiscal year of the amount of
Federal medical assistance that will be available
to the State for the fiscal year (as established
under paragraph (4)).’’; and
472
(15) by adding at the end the following new
subsection:
‘‘(n) COMMUNITY CARE SETTING DEFINED.—In this
section, the term ‘community care setting’ means a small
community care setting (as defined in subsection (g)(1))
or a large community care setting (as defined in sub-
section (h)(1)).’’.
(b) Section 1905(r)(5) is amended by striking
‘‘1905(a)’’ and inserting ‘‘subsection (a) (other than serv-
ices described in paragraph (22) or (23) of such sub-
section)’’.
(c) Section 4711(f) of OBRA–1990 is amended by
striking ‘‘Act’’ each place it appears and inserting ‘‘sec-
tion’’.
SEC. 5161. CORRECTIONS RELATING TO SECTION 4712
(COMMUNITY SUPPORTED LIVING ARRANGE-
MENTS SERVICES).
(a) Section 1930, as added by section 4712(b)(2) of
OBRA–1990, is amended—
(1) in subsection (b)—
(A) by striking ‘‘title the term,’’ and in-
serting ‘‘title, the term’’,
(B) by striking ‘‘guardian’’ and inserting
‘‘guardian or’’, and