1362 
HR 1 PP 
‘‘(6) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) ELIGIBLE HOSPITAL.—The term ‘eligi-
ble hospital’ means— 
‘‘(i) a subsection (d) hospital; and 
‘‘(ii) a critical access hospital (as de-
fined in section 1861(mm)(1)). 
‘‘(B) REPORTING
PERIOD.—The term ‘re-
porting period’ means any period (or periods), 
with respect to a payment year, as specified by 
the Secretary.’’. 
(b) INCENTIVE MARKET BASKET ADJUSTMENT.— 
(1) IN GENERAL.—Section 1886(b)(3)(B) of the 
Social Security Act (42 U.S.C. 1395ww(b)(3)(B)) is 
amended— 
(A) in clause (viii)(I), by inserting ‘‘(or, be-
ginning with fiscal year 2016, by one-quarter)’’ 
after ‘‘2.0 percentage points’’; and 
(B) by adding at the end the following new 
clause: 
‘‘(ix)(I) For purposes of clause (i) for fiscal year 2015 
and each subsequent fiscal year, in the case of an eligible 
hospital (as defined in subsection (n)(6)(A)) that is not a 
meaningful EHR user (as defined in subsection (n)(3)) for 
the reporting period for such fiscal year, three-quarters of 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01362
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1363 
HR 1 PP 
the applicable percentage increase otherwise applicable 
under clause (i) for such fiscal year shall be reduced by 
331⁄3 percent for fiscal year 2015, 662⁄3 percent for fiscal 
year 2016, and 100 percent for fiscal year 2017 and each 
subsequent fiscal year. Such reduction shall apply only with 
respect to the fiscal year involved and the Secretary shall 
not take into account such reduction in computing the ap-
plicable percentage increase under clause (i) for a subse-
quent fiscal year. 
‘‘(II) The Secretary may, on a case-by-case basis, ex-
empt a subsection (d) hospital from the application of sub-
clause (I) with respect to a fiscal year if the Secretary deter-
mines, subject to annual renewal, that requiring such hos-
pital to be a meaningful EHR user during such fiscal year 
would result in a significant hardship, such as in the case 
of a hospital in a rural area without sufficient Internet ac-
cess. In no case may a hospital be granted an exemption 
under this subclause for more than 5 years. 
‘‘(III) For fiscal year 2015 and each subsequent fiscal 
year, a State in which hospitals are paid for services under 
section 1814(b)(3) shall adjust the payments to each sub-
section (d) hospital in the State that is not a meaningful 
EHR user (as defined in subsection (n)(3)) in a manner 
that is designed to result in an aggregate reduction in pay-
ments to hospitals in the State that is equivalent to the ag-
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01363
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1364 
HR 1 PP 
gregate reduction that would have occurred if payments had 
been reduced to each subsection (d) hospital in the State 
in a manner comparable to the reduction under the pre-
vious provisions of this clause. The State shall report to 
the Secretary the methodology it will use to make the pay-
ment adjustment under the previous sentence. 
‘‘(IV) For purposes of this clause, the term ‘reporting 
period’ means, with respect to a fiscal year, any period (or 
periods), with respect to the fiscal year, as specified by the 
Secretary.’’. 
(2) 
CRITICAL
ACCESS
HOSPITALS.—Section 
1814(l) of the Social Security Act (42 U.S.C. 
1395f(l)) is amended— 
(A) in subparagraph (1), by striking ‘‘para-
graph (2)’’ and inserting ‘‘paragraphs (2) and 
(3)’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(3)(A) Subject to subparagraph (B), for fiscal year 
2015 and each subsequent fiscal year, in the case of a crit-
ical access hospital that is not a meaningful EHR user (as 
defined in section 1886(n)(3)) for the reporting period for 
such fiscal year, paragraph (1) shall be applied by sub-
stituting the applicable percent under subparagraph (C) for 
the percent described in such paragraph (1). 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01364
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1365 
HR 1 PP 
‘‘(B) The Secretary may, on a case-by-case basis, ex-
empt a critical access hospital from the application of sub-
paragraph (A) with respect to a fiscal year if the Secretary 
determines, subject to annual renewal, that requiring such 
hospital to be a meaningful EHR user during such fiscal 
year would result in a significant hardship, such as in the 
case of a hospital in a rural area without sufficient Internet 
access. In no case may a hospital be granted an exemption 
under this subparagraph for more than 5 years. 
‘‘(C) The percent described in this subparagraph is— 
‘‘(i) for fiscal year 2015, 100.66 percent; 
‘‘(ii) for fiscal year 2016, 100.33 percent; and 
‘‘(iii) for fiscal year 2017 and each subsequent 
fiscal year, 100 percent.’’. 
(c) APPLICATION TO CERTAIN MA-AFFILIATED ELIGI-
BLE HOSPITALS.—Section 1853 of the Social Security Act 
(42 U.S.C. 1395w–23), as amended by section 4201(c), is 
further amended by adding at the end the following new 
subsection: 
‘‘(m) APPLICATION OF ELIGIBLE HOSPITAL INCEN-
TIVES FOR CERTAIN MA ORGANIZATIONS FOR ADOPTION 
AND
MEANINGFUL
USE
OF
CERTIFIED
EHR TECH-
NOLOGY.— 
‘‘(1) APPLICATION.—Subject to paragraphs (3) 
and (4), in the case of a qualifying MA organization, 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01365
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1366 
HR 1 PP 
the provisions of sections 1814(l)(3), 1886(n), and 
1886(b)(3)(B)(ix) shall apply with respect to eligible 
hospitals described in paragraph (2) of the organiza-
tion which the organization attests under subsection 
(l)(6) to be meaningful EHR users in a similar man-
ner as they apply to eligible hospitals under such sec-
tions. Incentive payments under paragraph (3) shall 
be made to and payment adjustments under para-
graph (4) shall apply to such qualifying organiza-
tions. 
‘‘(2) ELIGIBLE HOSPITAL DESCRIBED.—With re-
spect to a qualifying MA organization, an eligible 
hospital described in this paragraph is an eligible 
hospital (as defined in section 1886(n)(6)(A)) that is 
under common corporate governance with such orga-
nization and serves individuals enrolled under an MA 
plan offered by such organization. 
‘‘(3) 
ELIGIBLE
HOSPITAL
INCENTIVE
PAY-
MENTS.— 
‘‘(A) IN
GENERAL.—In applying section 
1886(n)(2) under paragraph (1), instead of the 
additional 
payment 
amount 
under 
section 
1886(n)(2), there shall be substituted an amount 
determined by the Secretary to be similar to the 
estimated amount in the aggregate that would be 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01366
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1367 
HR 1 PP 
payable if payment for services furnished by 
such hospitals was payable under part A instead 
of this part. In implementing the previous sen-
tence, the Secretary— 
‘‘(i) shall, insofar as data to determine 
the discharge related amount under section 
1886(n)(2)(C) for an eligible hospital are 
not available to the Secretary, use such al-
ternative data and methodology to estimate 
such discharge related amount as the Sec-
retary determines appropriate; and 
‘‘(ii) shall, insofar as data to deter-
mine the medicare share described in sec-
tion 1886(n)(2)(D) for an eligible hospital 
are not available to the Secretary, use such 
alternative data and methodology to esti-
mate such share, which data and method-
ology may include use of the inpatient bed 
days (or discharges) with respect to an eli-
gible hospital during the appropriate period 
which are attributable to both individuals 
for whom payment may be made under 
part A or individuals enrolled in an MA 
plan under a Medicare Advantage organiza-
tion under this part as a proportion of the 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01367
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1369 
HR 1 PP 
‘‘(II) to collect data from Medi-
care Advantage organizations to ensure 
against such duplicate payments. 
‘‘(4) PAYMENT ADJUSTMENT.— 
‘‘(A) Subject to paragraph (3), in the case 
of a qualifying MA organization (as defined in 
section 1853(l)(5)), if, according to the attesta-
tion of the organization submitted under sub-
section (l)(6) for an applicable period, one or 
more eligible hospitals (as defined in section 
1886(n)(6)(A)) that are under common corporate 
governance with such organization and that 
serve individuals enrolled under a plan offered 
by such organization are not meaningful EHR 
users (as defined in section 1886(n)(3)) with re-
spect to a period, the payment amount payable 
under this section for such organization for such 
period shall be the percent specified in subpara-
graph (B) for such period of the payment 
amount otherwise provided under this section for 
such period. 
‘‘(B) SPECIFIED
PERCENT.—The percent 
specified under this subparagraph for a year is 
100 percent minus a number of percentage 
points equal to the product of— 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01369
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1370 
HR 1 PP 
‘‘(i) the number of the percentage point 
reduction 
effected 
under 
section 
1886(b)(3)(B)(ix)(I) for the period; and 
‘‘(ii) the Medicare hospital expenditure 
proportion specified in subparagraph (C) 
for the year. 
‘‘(C) MEDICARE
HOSPITAL
EXPENDITURE 
PROPORTION.—The Medicare hospital expendi-
ture proportion under this subparagraph for a 
year is the Secretary’s estimate of the propor-
tion, of the expenditures under parts A and B 
that are not attributable to this part, that are 
attributable to expenditures for inpatient hos-
pital services. 
‘‘(D) APPLICATION
OF
PAYMENT
ADJUST-
MENT.—In the case that a qualifying MA orga-
nization attests that not all eligible hospitals are 
meaningful EHR users with respect to an appli-
cable period, the Secretary shall apply the pay-
ment adjustment under this paragraph based on 
a methodology specified by the Secretary, taking 
into account the proportion of such eligible hos-
pitals, or discharges from such hospitals, that are 
not meaningful EHR users for such period. 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01370
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1371 
HR 1 PP 
‘‘(5) POSTING ON WEBSITE.—The Secretary shall 
post on the Internet website of the Centers for Medi-
care & Medicaid Services, in an easily understand-
able format— 
‘‘(A) a list of the names, business addresses, 
and business phone numbers of each qualifying 
MA organization receiving an incentive payment 
under this subsection for eligible hospitals de-
scribed in paragraph (2); and 
‘‘(B) a list of the names of the eligible hos-
pitals for which such incentive payment is 
based.’’. 
(d) CONFORMING AMENDMENTS.— 
(1) Section 1814(b) of the Social Security Act 
(42 U.S.C. 1395f(b)) is amended— 
(A) in paragraph (3), in the matter pre-
ceding subparagraph (A), by inserting ‘‘, subject 
to section 1886(d)(3)(B)(ix)(III),’’ after ‘‘then’’; 
and 
(B) by adding at the end the following: 
‘‘For purposes of applying paragraph (3), there 
shall be taken into account incentive payments, 
and payment adjustments under subsection 
(b)(3)(B)(ix) or (n) of section 1886.’’. 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01371
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1372 
HR 1 PP 
(2) Section 1851(i)(1) of the Social Security Act 
(42 U.S.C. 1395w–21(i)(1)) is amended by striking 
‘‘and 1886(h)(3)(D)’’ and inserting ‘‘1886(h)(3)(D), 
and 1853(m)’’. 
(3) Section 1853 of the Social Security Act (42 
U.S.C. 1395w–23), as amended by section 4311(d)(1), 
is amended— 
(A) in subsection (c)— 
(i) in paragraph (1)(D)(i), by striking 
‘‘1848(o)’’ and inserting ‘‘, 1848(o), and 
1886(n)’’; and 
(ii) in paragraph (6)(A), by inserting 
‘‘and subsections (b)(3)(B)(ix) and (n) of 
section 1886’’ after ‘‘section 1848’’; and 
(B) in subsection (f), by inserting ‘‘and sub-
section (m)’’ after ‘‘under subsection (l)’’. 
SEC. 4203. PREMIUM HOLD HARMLESS AND IMPLEMENTA-
TION FUNDING. 
(a) PREMIUM HOLD HARMLESS.— 
(1) IN GENERAL.—Section 1839(a)(1) of the So-
cial Security Act (42 U.S.C. 1395r(a)(1)) is amended 
by adding at the end the following: ‘‘In applying this 
paragraph there shall not be taken into account addi-
tional payments under section 1848(o) and section 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01372
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1373 
HR 1 PP 
1853(l)(3) and the Government contribution under 
section 1844(a)(3).’’. 
(2) PAYMENT.—Section 1844(a) of such Act (42 
U.S.C. 1395w(a)) is amended— 
(A) in paragraph (2), by striking the period 
at the end and inserting ‘‘; plus’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(3) a Government contribution equal to the 
amount of payment incentives payable under sections 
1848(o) and 1853(l)(3).’’. 
(b) IMPLEMENTATION FUNDING.—In addition to funds 
otherwise available, out of any funds in the Treasury not 
otherwise appropriated, there are appropriated to the Sec-
retary of Health and Human Services for the Center for 
Medicare & Medicaid Services Program Management Ac-
count, $100,000,000 for each of fiscal years 2009 through 
2015 and $45,000,000 for each succeeding fiscal year 
through fiscal year 2018, which shall be available for pur-
poses of carrying out the provisions of (and amendments 
made by) this part. Amounts appropriated under this sub-
section for a fiscal year shall be available until expended. 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01373
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1374 
HR 1 PP 
SEC. 4204. NON-APPLICATION OF PHASED-OUT INDIRECT 
MEDICAL 
EDUCATION 
(IME) 
ADJUSTMENT 
FACTOR FOR FISCAL YEAR 2009. 
(a) IN GENERAL.—Section 412.322 of title 42, Code 
of Federal Regulations, shall be applied without regard to 
paragraph (c) of such section, and the Secretary of Health 
and Human Services shall recompute payments for dis-
charges occurring on or after October 1, 2008, as if such 
paragraph had never been in effect. 
(b) NO EFFECT ON SUBSEQUENT YEARS.—Nothing in 
subsection (a) shall be construed as having any effect on 
the application of paragraph (d) of section 412.322 of title 
42, Code of Federal Regulations. 
SEC. 4205. STUDY ON APPLICATION OF EHR PAYMENT IN-
CENTIVES FOR PROVIDERS NOT RECEIVING 
OTHER INCENTIVE PAYMENTS. 
(a) STUDY.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall conduct a study to determine 
the extent to which and manner in which payment 
incentives (such as under title XVIII or XIX of the 
Social Security Act) and other funding for purposes 
of implementing and using certified EHR technology 
(as defined in section 1848(o)(4) of the Social Secu-
rity Act, as added by section 4311(a)) should be made 
available to health care providers who are receiving 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01374
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1375 
HR 1 PP 
minimal or no payment incentives or other funding 
under this Act, under title XVIII or XIX of such Act, 
or otherwise, for such purposes. 
(2) DETAILS OF STUDY.—Such study shall in-
clude an examination of— 
(A) the adoption rates of certified EHR 
technology (as so defined) by such health care 
providers; 
(B) the clinical utility of such technology by 
such health care providers; 
(C) whether the services furnished by such 
health care providers are appropriate for or 
would benefit from the use of such technology; 
(D) the extent to which such health care 
providers work in settings that might otherwise 
receive an incentive payment or other funding 
under this Act, title XVIII or XIX of the Social 
Security Act, or otherwise; 
(E) the potential costs and the potential 
benefits of making payment incentives and other 
funding available to such health care providers; 
and 
(F) any other issues the Secretary deems to 
be appropriate. 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01375
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1376 
HR 1 PP 
(b) REPORT.—Not later than June 30, 2010, the Sec-
retary shall submit to Congress a report on the findings 
and conclusions of the study conducted under subsection (a). 
SEC. 4206. STUDY ON AVAILABILITY OF OPEN SOURCE 
HEALTH INFORMATION TECHNOLOGY SYS-
TEMS. 
(a) IN GENERAL.— 
(1) STUDY.—The Secretary of Health and 
Human Services shall, in consultation with the 
Under Secretary for Health of the Veterans Health 
Administration, the Director of the Indian Health 
Service, the Secretary of Defense, the Director of the 
Agency for Healthcare Research and Quality, the Ad-
ministrator of the Health Resources and Services Ad-
ministration, and the Chairman of the Federal Com-
munications Commission, conduct a study on— 
(A) the current availability of open source 
health information technology systems to Federal 
safety net providers (including small, rural pro-
viders); 
(B) the total cost of ownership of such sys-
tems in comparison to the cost of proprietary 
commercial products available; 
(C) the ability of such systems to respond to 
the needs of, and be applied to, various popu-
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01376
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1377 
HR 1 PP 
lations (including children and disabled individ-
uals); and 
(D) the capacity of such systems to facili-
tate interoperability. 
(2) CONSIDERATIONS.—In conducting the study 
under paragraph (1), the Secretary of Health and 
Human Services shall take into account the cir-
cumstances of smaller health care providers, health 
care providers located in rural or other medically un-
derserved areas, and safety net providers that deliver 
a significant level of health care to uninsured individ-
uals, Medicaid beneficiaries, SCHIP beneficiaries, 
and other vulnerable individuals. 
(b) REPORT.—Not later than October 1, 2010, the Sec-
retary of Health and Human Services shall submit to Con-
gress a report on the findings and the conclusions of the 
study conducted under subsection (a), together with rec-
ommendations for such legislation and administrative ac-
tion as the Secretary determines appropriate. 
Subtitle B—Medicaid Funding 
SEC. 4211. MEDICAID PROVIDER EHR ADOPTION AND OPER-
ATION PAYMENTS; IMPLEMENTATION FUND-
ING. 
(a) IN GENERAL.—Section 1903 of the Social Security 
Act (42 U.S.C. 1396b) is amended— 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01377
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1378 
HR 1 PP 
(1) in subsection (a)(3)— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (D); 
(B) by striking ‘‘plus’’ at the end of sub-
paragraph (E) and inserting ‘‘and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(F)(i) 100 percent of so much of the sums 
expended during such quarter as are attributable 
to payments for certified EHR technology (and 
support services including maintenance and 
training that is for, or is necessary for the adop-
tion and operation of, such technology) by Med-
icaid providers described in subsection (t)(1); 
and 
‘‘(ii) 90 percent of so much of the sums ex-
pended during such quarter as are attributable 
to payments for reasonable administrative ex-
penses related to the administration of payments 
described in clause (i) if the State meets the con-
dition described in subsection (t)(9); plus’’; and 
(2) by inserting after subsection (s) the following 
new subsection: 
‘‘(t)(1)(A) For purposes of subsection (a)(3)(F), the 
payments for certified EHR technology (and support serv-
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01378
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1379 
HR 1 PP 
ices including maintenance that is for, or is necessary for 
the operation of, such technology) by Medicaid providers de-
scribed in this paragraph are payments made by the State 
in accordance with this subsection of the applicable percent 
of the net allowable costs of Medicaid providers (as defined 
in paragraph (2)) for such technology (and support serv-
ices). 
‘‘(B) For purposes of subparagraph (A), the term ‘ap-
plicable percent’ means— 
‘‘(i) in the case of a Medicaid provider described 
in paragraph (2)(A), 85 percent; 
‘‘(ii) in the case of a Medicaid provider described 
in clause (i) or (ii) of paragraph (2)(B), 100 percent; 
and 
‘‘(iii) in the case of a Medicaid provider de-
scribed in clause (iii) of paragraph (2)(B), a percent 
specified by the Secretary, but not less than 85 per-
cent. 
‘‘(2) In this subsection and subsection (a)(3)(F), the 
term ‘Medicaid provider’ means— 
‘‘(A) an eligible professional (as defined in para-
graph (3)(B)) who is not hospital-based and has at 
least 30 percent of the professional’s patient volume 
(as estimated in accordance with standards estab-
lished by the Secretary) attributable to individuals 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01379
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS
1380 
HR 1 PP 
who are receiving medical assistance under this title; 
and 
‘‘(B)(i) a children’s hospital, (ii) an acute-care 
hospital that is not described in clause (i) and that 
has at least 10 percent of the hospital’s patient vol-
ume (as estimated in accordance with standards es-
tablished by the Secretary) attributable to individuals 
who are receiving medical assistance under this title, 
or (iii) a Federally-qualified health center or rural 
health clinic that has at least 30 percent of the cen-
ter’s or clinic’s patient volume (as estimated in ac-
cordance with standards established by the Secretary) 
attributable to individuals who are receiving medical 
assistance under this title. 
An eligible professional shall not qualify as a Medicaid pro-
vider under this subsection unless the professional has 
waived, in a manner specified by the Secretary, any right 
to payment under section 1848(o) with respect to the adop-
tion or support of certified EHR technology by the eligible 
professional. In applying clauses (ii) and (iii) of subpara-
graph (B), the standards established by the Secretary for 
patient volume shall include individuals enrolled in a Med-
icaid managed care plan (under section 1903(m) or section 
1932). 
‘‘(3) In this subsection and subsection (a)(3)(F): 
VerDate Nov 24 2008 
23:49 Feb 10, 2009
Jkt 079200
PO 00000
Frm 01380
Fmt 6652
Sfmt 6203
E:\BILLS\H1.PP
H1
rfrederick on PROD1PC67 with BILLS