I 
111TH CONGRESS 
2D SESSION 
H. R. 5417 
To amend titles XIX and XVIII of the Social Security Act, as amended 
by the Patient Protection and Affordable Care Act and the Health 
Care and Education Reconciliation Act of 2010, with respect to payment 
of disproportionate share hospitals (DSH) under the Medicare and Med-
icaid programs. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 26, 2010 
Ms. EDDIE BERNICE JOHNSON of Texas introduced the following bill; which 
was referred to the Committee on Ways and Means, and in addition to 
the Committee on Energy and Commerce, for a period to be subsequently 
determined by the Speaker, in each case for consideration of such provi-
sions as fall within the jurisdiction of the committee concerned 
A BILL 
To amend titles XIX and XVIII of the Social Security Act, 
as amended by the Patient Protection and Affordable 
Care Act and the Health Care and Education Reconcili-
ation Act of 2010, with respect to payment of dispropor-
tionate share hospitals (DSH) under the Medicare and 
Medicaid programs. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. MEDICARE DSH REPORT AND PAYMENT AD-
JUSTMENTS IN RESPONSE TO COVERAGE EX-
PANSION INSTEAD OF PPACA AND HCERA RE-
VISIONS. 
(a) DSH REPORT.—Not later than January 1, 2016, 
the Secretary of Health and Human Services shall submit 
to Congress a report on Medicare DSH taking into ac-
count the impact of the health care reforms carried out 
under the Patient Protection and Affordable Care Act, as 
amended by the Health Care and Education Reconciliation 
Act of 2010, in reducing the number of uninsured individ-
uals. The report shall include recommendations relating 
to the following: 
(1) The appropriate amount, targeting, and dis-
tribution of Medicare DSH to compensate for higher 
Medicare costs, Medicaid reimbursement shortfalls, 
and uncompensated care associated with serving low- 
income beneficiaries (taking into account variations 
in the empirical justification for Medicare DSH at-
tributable to hospital characteristics, including bed 
size), consistent with the original intent of Medicare 
DSH. 
(2) The appropriate amount, targeting, and dis-
tribution of Medicare DSH to hospitals given their 
continued uncompensated care costs, to the extent 
such costs remain. 
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(b) PAYMENT ADJUSTMENTS IN RESPONSE TO COV-
ERAGE EXPANSION.— 
(1) IN GENERAL.—If there is a significant de-
crease in the national rate of uninsurance as a result 
of corrected PPACA (as determined under para-
graph (2)(A)), then the Secretary of Health and 
Human Services shall, beginning no earlier than fis-
cal year 2018, implement the following adjustments 
to Medicare DSH: 
(A) In lieu of the amount of Medicare 
DSH payment that would otherwise be made 
under section 1886(d)(5)(F) of the Social Secu-
rity Act, the amount of Medicare DSH payment 
shall be an amount based on the recommenda-
tions of the report under subsection (a)(1) and 
shall take into account variations in the empir-
ical justification for Medicare DSH attributable 
to hospital characteristics, including bed size. 
(B) Subject to paragraph (3), make an ad-
ditional payment to a hospital by an amount 
that is estimated based on the amount of un-
compensated care provided by the hospital 
based on criteria for uncompensated care as de-
termined by the Secretary, which shall exclude 
bad debt. 
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(2) SIGNIFICANT DECREASE IN NATIONAL RATE 
OF UNINSURANCE AS A RESULT OF THIS ACT.—For 
purposes of this subsection— 
(A) IN GENERAL.—There is a ‘‘significant 
decrease in the national rate of uninsurance as 
a result of corrected PPACA’’ if there is a de-
crease in the national rate of uninsurance (as 
defined in subparagraph (B)) from 2012 to 
2014 that exceeds 8 percentage points. 
(B) NATIONAL
RATE
OF
UNINSURANCE 
DEFINED.—The 
term 
‘‘national 
rate 
of 
uninsurance’’ means, for a year, such rate for 
the under-65 population for the year as deter-
mined and published by the Bureau of the Cen-
sus in its Current Population Survey in or 
about September of the succeeding year. 
(3) UNCOMPENSATED CARE INCREASE.— 
(A) COMPUTATION OF DSH SAVINGS.—For 
each fiscal year (beginning with fiscal year 
2018), the Secretary shall estimate the aggre-
gate reduction in the amount of Medicare DSH 
payment that would be expected to result from 
the adjustment under paragraph (1)(A). 
(B) 
STRUCTURE
OF
PAYMENT
IN-
CREASE.—The Secretary shall compute the ad-
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ditional payment to a hospital as described in 
paragraph (1)(B) for a fiscal year in accordance 
with a formula established by the Secretary 
that provides that— 
(i) the estimated aggregate amount of 
such increase for the fiscal year does not 
exceed 50 percent of the aggregate reduc-
tion in Medicare DSH estimated by the 
Secretary for such fiscal year; and 
(ii) hospitals with higher levels of un-
compensated care receive a greater in-
crease. 
(c) DEFINITIONS.—In this section: 
(1) The term ‘‘Medicare DSH’’ means adjust-
ments in payments under section 1886(d)(5)(F) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395ww(d)(5)(F)) for inpatient hospital services fur-
nished by disproportionate share hospitals. 
(2) The term ‘‘corrected PPACA’’ means the 
Patient Protection and Affordable Care Act, as 
amended by the Health Care and Education Rec-
onciliation Act of 2010. 
(d) ELIMINATION OF HCERA PROVISION.—Section 
1886 of the Social Security Act (42 U.S.C. 1395ww), as 
amended by sections 3133 and 10316 of the Patient Pro-
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tection and Affordable Care Act and section 1104 of the 
Health Care and Education Reconciliation Act of 2010, 
is amended— 
(1) in subsection (d)(5)(F)(i), by striking ‘‘Sub-
ject to subsection (r), for’’ and inserting ‘‘For’’; and 
(2) by striking subsection (r). 
SEC. 2. MEDICAID DSH REVISIONS. 
Section 1923(f)(7)(A) of the Social Security Act (42 
U.S.C. 1396r–4(f)(7)(A)), as amended by sections 
2551(a)(4) and 10201(e)(1) of the Patient Protection and 
Affordable Care Act and section 1203(a) of the Health 
Care and Education Reconciliation Act of 2010, is amend-
ed— 
(1) clause (i), by striking ‘‘2014 through 2020’’ 
and inserting ‘‘2018 through 2024’’; and 
(2) in subclauses (I) through (VII) of clause 
(ii), by striking ‘‘2014’’, ‘‘2015’’, ‘‘2016’’, ‘‘2017’’, 
‘‘2018’’, ‘‘2019’’, and ‘‘2020’’ and inserting ‘‘2018’’, 
‘‘2019’’, ‘‘2020’’, ‘‘2021’’, ‘‘2022’’, ‘‘2023’’, and 
‘‘2024’’, respectively. 
Æ 
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