441 
•AMDT. NO. 2786 
‘‘(E) Section 1902(e)(14) (relating to in-
come determined using modified gross income 
and household income).’’. 
(e) APPLICATION OF STREAMLINED ENROLLMENT 
SYSTEM.—Section 2107(e)(1) of the Social Security Act 
(42 U.S.C. 1397gg(e)(1)), as amended by subsection 
(d)(2), is amended by adding at the end the following: 
‘‘(N) Section 1943(b) (relating to coordi-
nation with State Exchanges and the State 
Medicaid agency).’’. 
(f) CHIP ELIGIBILITY FOR CHILDREN INELIGIBLE 
FOR MEDICAID AS A RESULT OF ELIMINATION OF DIS-
REGARDS.—Notwithstanding any other provision of law, 
a State shall treat any child who is determined to be ineli-
gible for medical assistance under the State Medicaid plan 
or under a waiver of the plan as a result of the elimination 
of the application of an income disregard based on expense 
or type of income, as required under section 1902(e)(14) 
of the Social Security Act (as added by this Act), as a 
targeted low-income child under section 2110(b) (unless 
the child is excluded under paragraph (2) of that section) 
and shall provide child health assistance to the child under 
the State child health plan (whether implemented under 
title XIX or XXI, or both, of the Social Security Act). 
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•AMDT. NO. 2786 
SEC. 2102. TECHNICAL CORRECTIONS. 
(a) CHIPRA.—Effective as if included in the enact-
ment of the Children’s Health Insurance Program Reau-
thorization Act of 2009 (Public Law 111–3) (in this sec-
tion referred to as ‘‘CHIPRA’’): 
(1) Section 2104(m) of the Social Security Act, 
as added by section 102 of CHIPRA, is amended— 
(A) by redesignating paragraph (7) as 
paragraph (8); and 
(B) by inserting after paragraph (6), the 
following: 
‘‘(7) ADJUSTMENT OF FISCAL YEAR 2010 AL-
LOTMENTS
TO
ACCOUNT
FOR
CHANGES
IN
PRO-
JECTED SPENDING FOR CERTAIN PREVIOUSLY AP-
PROVED EXPANSION PROGRAMS.—For purposes of 
recalculating the fiscal year 2010 allotment, in the 
case of one of the 50 States or the District of Co-
lumbia that has an approved State plan amendment 
effective January 1, 2006, to provide child health as-
sistance through the provision of benefits under the 
State plan under title XIX for children from birth 
through age 5 whose family income does not exceed 
200 percent of the poverty line, the Secretary shall 
increase the allotment by an amount that would be 
equal to the Federal share of expenditures that 
would have been claimed at the enhanced FMAP 
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443 
•AMDT. NO. 2786 
rate rather than the Federal medical assistance per-
centage matching rate for such population.’’. 
(2) Section 605 of CHIPRA is amended by 
striking ‘‘legal residents’’ and insert ‘‘lawfully resid-
ing in the United States’’. 
(3) Subclauses (I) and (II) of paragraph 
(3)(C)(i) of section 2105(a) of the Social Security 
Act (42 U.S.C. 1397ee(a)(3)(ii)), as added by sec-
tion 104 of CHIPRA, are each amended by striking 
‘‘, respectively’’. 
(4) Section 2105(a)(3)(E)(ii) of the Social Se-
curity Act (42 U.S.C. 1397ee(a)(3)(E)(ii)), as added 
by section 104 of CHIPRA, is amended by striking 
subclause (IV). 
(5) Section 2105(c)(9)(B) of the Social Security 
Act (42 U.S.C. 1397e(c)(9)(B)), as added by section 
211(c)(1) of CHIPRA, is amended by striking ‘‘sec-
tion 
1903(a)(3)(F)’’ 
and 
inserting 
‘‘section 
1903(a)(3)(G)’’. 
(6) Section 2109(b)(2)(B) of the Social Secu-
rity Act (42 U.S.C. 1397ii(b)(2)(B)), as added by 
section 602 of CHIPRA, is amended by striking 
‘‘the child population growth factor under section 
2104(m)(5)(B)’’ and inserting ‘‘a high-performing 
State under section 2111(b)(3)(B)’’. 
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•AMDT. NO. 2786 
(7) Section 2110(c)(9)(B)(v) of the Social Secu-
rity Act (42 U.S.C. 1397jj(c)(9)(B)(v)), as added by 
section 505(b) of CHIPRA, is amended by striking 
‘‘school or school system’’ and inserting ‘‘local edu-
cational agency (as defined under section 9101 of 
the Elementary and Secondary Education Act of 
1965’’. 
(8) Section 211(a)(1)(B) of CHIPRA is amend-
ed— 
(A) by striking ‘‘is amended’’ and all that 
follows through ‘‘adding’’ and inserting ‘‘is 
amended by adding’’; and 
(B) by redesignating the new subpara-
graph to be added by such section to section 
1903(a)(3) of the Social Security Act as a new 
subparagraph (H). 
(b) ARRA.—Effective as if included in the enactment 
of section 5006(a) of division B of the American Recovery 
and Reinvestment Act of 2009 (Public Law 111–5), the 
second sentence of section 1916A(a)(1) of the Social Secu-
rity Act (42 U.S.C. 1396o–1(a)(1)) is amended by striking 
‘‘or (i)’’ and inserting ‘‘, (i), or (j)’’. 
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445 
•AMDT. NO. 2786 
Subtitle C—Medicaid and CHIP 
Enrollment Simplification 
SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINA-
TION WITH STATE HEALTH INSURANCE EX-
CHANGES. 
Title XIX of the Social Security Act (42 U.S.C. 
1397aa et seq.) is amended by adding at the end the fol-
lowing: 
‘‘SEC. 1943. ENROLLMENT SIMPLIFICATION AND COORDI-
NATION WITH STATE HEALTH INSURANCE EX-
CHANGES. 
‘‘(a) CONDITION
FOR
PARTICIPATION
IN
MED-
ICAID.—As a condition of the State plan under this title 
and receipt of any Federal financial assistance under sec-
tion 1903(a) for calendar quarters beginning after Janu-
ary 1, 2014, a State shall ensure that the requirements 
of subsection (b) is met. 
‘‘(b) ENROLLMENT SIMPLIFICATION AND COORDINA-
TION WITH STATE HEALTH INSURANCE EXCHANGES AND 
CHIP.— 
‘‘(1) IN GENERAL.—A State shall establish pro-
cedures for— 
‘‘(A) enabling individuals, through an 
Internet website that meets the requirements of 
paragraph (4), to apply for medical assistance 
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446 
•AMDT. NO. 2786 
under the State plan or under a waiver of the 
plan, to be enrolled in the State plan or waiver, 
to renew their enrollment in the plan or waiver, 
and to consent to enrollment or reenrollment in 
the State plan through electronic signature; 
‘‘(B) enrolling, without any further deter-
mination by the State and through such 
website, individuals who are identified by an 
Exchange established by the State under sec-
tion 1311 of the Patient Protection and Afford-
able Care Act as being eligible for— 
‘‘(i) medical assistance under the 
State plan or under a waiver of the plan; 
or 
‘‘(ii) child health assistance under the 
State child health plan under title XXI; 
‘‘(C) ensuring that individuals who apply 
for but are determined to be ineligible for med-
ical assistance under the State plan or a waiver 
or ineligible for child health assistance under 
the State child health plan under title XXI, are 
screened for eligibility for enrollment in quali-
fied health plans offered through such an Ex-
change and, if applicable, premium assistance 
for the purchase of a qualified health plan 
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449 
•AMDT. NO. 2786 
youth, children and youth with special health 
care needs, pregnant women, racial and ethnic 
minorities, rural populations, victims of abuse 
or trauma, individuals with mental health or 
substance-related disorders, and individuals 
with HIV/AIDS. 
‘‘(2) AGREEMENTS
WITH
STATE
HEALTH
IN-
SURANCE EXCHANGES.—The State Medicaid agency 
and the State CHIP agency may enter into an 
agreement with an Exchange established by the 
State under section 1311 of the Patient Protection 
and Affordable Care Act under which the State 
Medicaid agency or State CHIP agency may deter-
mine whether a State resident is eligible for pre-
mium assistance for the purchase of a qualified 
health plan under section 36B of the Internal Rev-
enue Code of 1986 (and, if applicable, advance pay-
ment of such assistance under section 1412 of the 
Patient Protection and Affordable Care Act), so long 
as the agreement meets such conditions and require-
ments as the Secretary of the Treasury may pre-
scribe to reduce administrative costs and the likeli-
hood of eligibility errors and disruptions in coverage. 
‘‘(3) STREAMLINED
ENROLLMENT
SYSTEM.— 
The State Medicaid agency and State CHIP agency 
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450 
•AMDT. NO. 2786 
shall participate in and comply with the require-
ments for the system established under section 1413 
of the Patient Protection and Affordable Care Act 
(relating to streamlined procedures for enrollment 
through an Exchange, Medicaid, and CHIP). 
‘‘(4) ENROLLMENT WEBSITE REQUIREMENTS.— 
The procedures established by State under para-
graph (1) shall include establishing and having in 
operation, not later than January 1, 2014, an Inter-
net website that is linked to any website of an Ex-
change established by the State under section 1311 
of the Patient Protection and Affordable Care Act 
and to the State CHIP agency (if different from the 
State Medicaid agency) and allows an individual who 
is eligible for medical assistance under the State 
plan or under a waiver of the plan and who is eligi-
ble to receive premium credit assistance for the pur-
chase of a qualified health plan under section 36B 
of the Internal Revenue Code of 1986 to compare 
the benefits, premiums, and cost-sharing applicable 
to the individual under the State plan or waiver with 
the benefits, premiums, and cost-sharing available to 
the individual under a qualified health plan offered 
through such an Exchange, including, in the case of 
a child, the coverage that would be provided for the 
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451 
•AMDT. NO. 2786 
child through the State plan or waiver with the cov-
erage that would be provided to the child through 
enrollment in family coverage under that plan and 
as supplemental coverage by the State under the 
State plan or waiver. 
‘‘(5) CONTINUED NEED FOR ASSESSMENT FOR 
HOME AND COMMUNITY-BASED SERVICES.—Nothing 
in paragraph (1) shall limit or modify the require-
ment that the State assess an individual for pur-
poses of providing home and community-based serv-
ices under the State plan or under any waiver of 
such plan for individuals described in subsection 
(a)(10)(A)(ii)(VI).’’. 
SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMP-
TIVE 
ELIGIBILITY 
DETERMINATIONS 
FOR 
ALL MEDICAID ELIGIBLE POPULATIONS. 
(a) IN GENERAL.—Section 1902(a)(47) of the Social 
Security Act (42 U.S.C. 1396a(a)(47)) is amended— 
(1) by striking ‘‘at the option of the State, pro-
vide’’ and inserting ‘‘provide— 
‘‘(A) at the option of the State,’’; 
(2) by inserting ‘‘and’’ after the semicolon; and 
(3) by adding at the end the following: 
‘‘(B) that any hospital that is a partici-
pating provider under the State plan may elect 
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•AMDT. NO. 2786 
to be a qualified entity for purposes of deter-
mining, on the basis of preliminary information, 
whether any individual is eligible for medical as-
sistance under the State plan or under a waiver 
of the plan for purposes of providing the indi-
vidual with medical assistance during a pre-
sumptive eligibility period, in the same manner, 
and subject to the same requirements, as apply 
to the State options with respect to populations 
described in section 1920, 1920A, or 1920B 
(but without regard to whether the State has 
elected to provide for a presumptive eligibility 
period under any such sections), subject to such 
guidance as the Secretary shall establish;’’. 
(b) 
CONFORMING
AMENDMENT.—Section 
1903(u)(1)(D)(v) 
of 
such 
Act 
(42 
U.S.C. 
1396b(u)(1)(D)v)) is amended— 
(1) by striking ‘‘or for’’ and inserting ‘‘for’’; 
and 
(2) by inserting before the period at the end the 
following: ‘‘, or for medical assistance provided to an 
individual during a presumptive eligibility period re-
sulting from a determination of presumptive eligi-
bility made by a hospital that elects under section 
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453 
•AMDT. NO. 2786 
1902(a)(47)(B) to be a qualified entity for such pur-
pose’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on January 1, 2014, and apply to 
services furnished on or after that date. 
Subtitle D—Improvements to 
Medicaid Services 
SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER 
SERVICES. 
(a) IN GENERAL.—Section 1905 of the Social Secu-
rity Act (42 U.S.C. 1396d), is amended— 
(1) in subsection (a)— 
(A) in paragraph (27), by striking ‘‘and’’ 
at the end; 
(B) by redesignating paragraph (28) as 
paragraph (29); and 
(C) by inserting after paragraph (27) the 
following new paragraph: 
‘‘(28) freestanding birth center services (as de-
fined in subsection (l)(3)(A)) and other ambulatory 
services that are offered by a freestanding birth cen-
ter (as defined in subsection (l)(3)(B)) and that are 
otherwise included in the plan; and’’; and 
(2) in subsection (l), by adding at the end the 
following new paragraph: 
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•AMDT. NO. 2786 
‘‘(3)(A) The term ‘freestanding birth center services’ 
means services furnished to an individual at a freestanding 
birth center (as defined in subparagraph (B)) at such cen-
ter. 
‘‘(B) The term ‘freestanding birth center’ means a 
health facility— 
‘‘(i) that is not a hospital; 
‘‘(ii) where childbirth is planned to occur away 
from the pregnant woman’s residence; 
‘‘(iii) that is licensed or otherwise approved by 
the State to provide prenatal labor and delivery or 
postpartum care and other ambulatory services that 
are included in the plan; and 
‘‘(iv) that complies with such other require-
ments relating to the health and safety of individuals 
furnished services by the facility as the State shall 
establish. 
‘‘(C) A State shall provide separate payments to pro-
viders administering prenatal labor and delivery or 
postpartum care in a freestanding birth center (as defined 
in subparagraph (B)), such as nurse midwives and other 
providers of services such as birth attendants recognized 
under State law, as determined appropriate by the Sec-
retary. For purposes of the preceding sentence, the term 
‘birth attendant’ means an individual who is recognized 
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455 
•AMDT. NO. 2786 
or registered by the State involved to provide health care 
at childbirth and who provides such care within the scope 
of practice under which the individual is legally authorized 
to perform such care under State law (or the State regu-
latory mechanism provided by State law), regardless of 
whether the individual is under the supervision of, or asso-
ciated with, a physician or other health care provider. 
Nothing in this subparagraph shall be construed as chang-
ing State law requirements applicable to a birth attend-
ant.’’. 
(b) 
CONFORMING
AMENDMENT.—Section 
1902(a)(10)(A) of the Social Security Act (42 U.S.C. 
1396a(a)(10)(A)), is amended in the matter preceding 
clause (i) by striking ‘‘and (21)’’ and inserting ‘‘, (21), 
and (28)’’. 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
shall take effect on the date of the enactment of this 
Act and shall apply to services furnished on or after 
such date. 
(2) EXCEPTION
IF
STATE
LEGISLATION
RE-
QUIRED.—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 
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456 
•AMDT. NO. 2786 
determines requires State legislation (other than leg-
islation appropriating funds) in order for the plan to 
meet the additional requirement imposed by the 
amendments made by this section, the State plan 
shall not be regarded as failing to comply with the 
requirements of such title solely on the basis of its 
failure to meet this additional requirement before 
the first day of the first calendar quarter beginning 
after the close of the first regular session of the 
State legislature that begins after the date of the en-
actment of this Act. For purposes of the previous 
sentence, in the case of a State that has a 2-year 
legislative session, each year of such session shall be 
deemed to be a separate regular session of the State 
legislature. 
SEC. 2302. CONCURRENT CARE FOR CHILDREN. 
(a) IN GENERAL.—Section 1905(o)(1) of the Social 
Security Act (42 U.S.C. 1396d(o)(1)) is amended— 
(1) in subparagraph (A), by striking ‘‘subpara-
graph (B)’’ and inserting ‘‘subparagraphs (B) and 
(C)’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(C) A voluntary election to have payment made for 
hospice care for a child (as defined by the State) shall 
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457 
•AMDT. NO. 2786 
not constitute a waiver of any rights of the child to be 
provided with, or to have payment made under this title 
for, services that are related to the treatment of the child’s 
condition for which a diagnosis of terminal illness has been 
made.’’. 
(b) APPLICATION TO CHIP.—Section 2110(a)(23) of 
the Social Security Act (42 U.S.C. 1397jj(a)(23)) is 
amended by inserting ‘‘(concurrent, in the case of an indi-
vidual who is a child, with care related to the treatment 
of the child’s condition with respect to which a diagnosis 
of terminal illness has been made’’ after ‘‘hospice care’’. 
SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLAN-
NING SERVICES. 
(a) 
COVERAGE
AS
OPTIONAL
CATEGORICALLY 
NEEDY GROUP.— 
(1) IN
GENERAL.—Section 1902(a)(10)(A)(ii) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396a(a)(10)(A)(ii)), 
as 
amended 
by 
section 
2001(e), is amended— 
(A) in subclause (XIX), by striking ‘‘or’’ at 
the end; 
(B) in subclause (XX), by adding ‘‘or’’ at 
the end; and 
(C) by adding at the end the following new 
subclause: 
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458 
•AMDT. NO. 2786 
‘‘(XXI) who are described in sub-
section (ii) (relating to individuals 
who meet certain income standards);’’. 
(2) GROUP DESCRIBED.—Section 1902 of such 
Act (42 U.S.C. 1396a), as amended by section 
2001(d), is amended by adding at the end the fol-
lowing new subsection: 
‘‘(ii)(1) Individuals described in this subsection are 
individuals— 
‘‘(A) whose income does not exceed an in-
come eligibility level established by the State 
that does not exceed the highest income eligi-
bility level established under the State plan 
under this title (or under its State child health 
plan under title XXI) for pregnant women; and 
‘‘(B) who are not pregnant. 
‘‘(2) At the option of a State, individuals de-
scribed in this subsection may include individuals 
who, had individuals applied on or before January 1, 
2007, would have been made eligible pursuant to the 
standards and processes imposed by that State for 
benefits described in clause (XV) of the matter fol-
lowing subparagraph (G) of section subsection 
(a)(10) pursuant to a waiver granted under section 
1115. 
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•AMDT. NO. 2786 
‘‘(3) At the option of a State, for purposes of 
subsection (a)(17)(B), in determining eligibility for 
services under this subsection, the State may con-
sider only the income of the applicant or recipient.’’. 
(3) 
LIMITATION
ON
BENEFITS.—Section 
1902(a)(10) of the Social Security Act (42 U.S.C. 
1396a(a)(10)), 
as 
amended 
by 
section 
2001(a)(5)(A), is amended in the matter following 
subparagraph (G)— 
(A) by striking ‘‘and (XV)’’ and inserting 
‘‘(XV)’’; and 
(B) by inserting ‘‘, and (XVI) the medical 
assistance made available to an individual de-
scribed in subsection (ii) shall be limited to 
family planning services and supplies described 
in section 1905(a)(4)(C) including medical di-
agnosis and treatment services that are pro-
vided pursuant to a family planning service in 
a family planning setting’’ before the semicolon. 
(4) CONFORMING AMENDMENTS.— 
(A) Section 1905(a) of the Social Security 
Act (42 U.S.C. 1396d(a)), as amended by sec-
tion 2001(e)(2)(A), is amended in the matter 
preceding paragraph (1)— 
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460 
•AMDT. NO. 2786 
(i) in clause (xiv), by striking ‘‘or’’ at 
the end; 
(ii) in clause (xv), by adding ‘‘or’’ at 
the end; and 
(iii) by inserting after clause (xv) the 
following: 
‘‘(xvi) individuals described in section 
1902(ii),’’. 
(B) Section 1903(f)(4) of such Act (42 
U.S.C. 1396b(f)(4)), as amended by section 
2001(e)(2)(B), 
is 
amended 
by 
inserting 
‘‘1902(a)(10)(A)(ii)(XXI),’’ 
after 
‘‘1902(a)(10)(A)(ii)(XX),’’. 
(b) PRESUMPTIVE ELIGIBILITY.— 
(1) IN GENERAL.—Title XIX of the Social Se-
curity Act (42 U.S.C. 1396 et seq.) is amended by 
inserting after section 1920B the following: 
‘‘PRESUMPTIVE ELIGIBILITY FOR FAMILY PLANNING 
SERVICES 
‘‘SEC. 1920C. (a) STATE OPTION.—State plan ap-
proved under section 1902 may provide for making med-
ical assistance available to an individual described in sec-
tion 1902(ii) (relating to individuals who meet certain in-
come eligibility standard) during a presumptive eligibility 
period. In the case of an individual described in section 
1902(ii), such medical assistance shall be limited to family 
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461 
•AMDT. NO. 2786 
planning services and supplies described in 1905(a)(4)(C) 
and, at the State’s option, medical diagnosis and treat-
ment services that are provided in conjunction with a fam-
ily planning service in a family planning setting. 
‘‘(b) DEFINITIONS.—For purposes of this section: 
‘‘(1) PRESUMPTIVE ELIGIBILITY PERIOD.—The 
term ‘presumptive eligibility period’ means, with re-
spect to an individual described in subsection (a), 
the period that— 
‘‘(A) begins with the date on which a 
qualified entity determines, on the basis of pre-
liminary information, that the individual is de-
scribed in section 1902(ii); and 
‘‘(B) ends with (and includes) the earlier 
of— 
‘‘(i) the day on which a determination 
is made with respect to the eligibility of 
such individual for services under the State 
plan; or 
‘‘(ii) in the case of such an individual 
who does not file an application by the last 
day of the month following the month dur-
ing which the entity makes the determina-
tion referred to in subparagraph (A), such 
last day. 
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•AMDT. NO. 2786 
‘‘(2) QUALIFIED ENTITY.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the term ‘qualified entity’ means 
any entity that— 
‘‘(i) is eligible for payments under a 
State plan approved under this title; and 
‘‘(ii) is determined by the State agen-
cy to be capable of making determinations 
of the type described in paragraph (1)(A). 
‘‘(B) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as pre-
venting a State from limiting the classes of en-
tities that may become qualified entities in 
order to prevent fraud and abuse. 
‘‘(c) ADMINISTRATION.— 
‘‘(1) IN GENERAL.—The State agency shall pro-
vide qualified entities with— 
‘‘(A) such forms as are necessary for an 
application to be made by an individual de-
scribed in subsection (a) for medical assistance 
under the State plan; and 
‘‘(B) information on how to assist such in-
dividuals in completing and filing such forms. 
‘‘(2) NOTIFICATION REQUIREMENTS.—A quali-
fied 
entity 
that 
determines 
under 
subsection 
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•AMDT. NO. 2786 
(b)(1)(A) that an individual described in subsection 
(a) is presumptively eligible for medical assistance 
under a State plan shall— 
‘‘(A) notify the State agency of the deter-
mination within 5 working days after the date 
on which determination is made; and 
‘‘(B) inform such individual at the time 
the determination is made that an application 
for medical assistance is required to be made by 
not later than the last day of the month fol-
lowing the month during which the determina-
tion is made. 
‘‘(3) 
APPLICATION
FOR
MEDICAL
ASSIST-
ANCE.—In the case of an individual described in 
subsection (a) who is determined by a qualified enti-
ty to be presumptively eligible for medical assistance 
under a State plan, the individual shall apply for 
medical assistance by not later than the last day of 
the month following the month during which the de-
termination is made. 
‘‘(d) PAYMENT.—Notwithstanding any other provi-
sion of law, medical assistance that— 
‘‘(1) is furnished to an individual described in 
subsection (a)— 
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•AMDT. NO. 2786 
‘‘(A) during a presumptive eligibility pe-
riod; and 
‘‘(B) by a entity that is eligible for pay-
ments under the State plan; and 
‘‘(2) is included in the care and services covered 
by the State plan, 
shall be treated as medical assistance provided by such 
plan for purposes of clause (4) of the first sentence of 
section 1905(b).’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1902(a)(47) of the Social Se-
curity Act (42 U.S.C. 1396a(a)(47)), as amend-
ed by section 2202(a), is amended— 
(i) in subparagraph (A), by inserting 
before the semicolon at the end the fol-
lowing: ‘‘and provide for making medical 
assistance available to individuals described 
in subsection (a) of section 1920C during 
a presumptive eligibility period in accord-
ance with such section’’; and 
(ii) in subparagraph (B), by striking 
‘‘or 1920B’’ and inserting ‘‘1920B, or 
1920C’’. 
(B) Section 1903(u)(1)(D)(v) of such Act 
(42 U.S.C. 1396b(u)(1)(D)(v)), as amended by 
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•AMDT. NO. 2786 
section 2202(b), is amended by inserting ‘‘or 
for medical assistance provided to an individual 
described in subsection (a) of section 1920C 
during a presumptive eligibility period under 
such section,’’ after ‘‘1920B during a presump-
tive eligibility period under such section,’’. 
(c) CLARIFICATION OF COVERAGE OF FAMILY PLAN-
NING SERVICES AND SUPPLIES.—Section 1937(b) of the 
Social Security Act (42 U.S.C. 1396u–7(b)), as amended 
by section 2001(c), is amended by adding at the end the 
following: 
‘‘(7) COVERAGE OF FAMILY PLANNING SERV-
ICES AND SUPPLIES.—Notwithstanding the previous 
provisions of this section, a State may not provide 
for medical assistance through enrollment of an indi-
vidual with benchmark coverage or benchmark-equiv-
alent coverage under this section unless such cov-
erage includes for any individual described in section 
1905(a)(4)(C), medical assistance for family plan-
ning services and supplies in accordance with such 
section.’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section take effect on the date of the enactment of 
this Act and shall apply to items and services furnished 
on or after such date. 
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•AMDT. NO. 2786 
SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL AS-
SISTANCE. 
Section 1905(a) of the Social Security Act (42 U.S.C. 
1396d(a)) is amended by inserting ‘‘or the care and serv-
ices themselves, or both’’ before ‘‘(if provided in or after’’. 
Subtitle E—New Options for States 
to Provide Long-Term Services 
and Supports 
SEC. 2401. COMMUNITY FIRST CHOICE OPTION. 
Section 1915 of the Social Security Act (42 U.S.C. 
1396n) is amended by adding at the end the following: 
‘‘(k) STATE PLAN OPTION TO PROVIDE HOME AND 
COMMUNITY-BASED ATTENDANT SERVICES
AND SUP-
PORTS.— 
‘‘(1) IN GENERAL.—Subject to the succeeding 
provisions of this subsection, beginning October 1, 
2010, a State may provide through a State plan 
amendment for the provision of medical assistance 
for home and community-based attendant services 
and supports for individuals who are eligible for 
medical assistance under the State plan whose in-
come does not exceed 150 percent of the poverty line 
(as defined in section 2110(c)(5)) or, if greater, the 
income level applicable for an individual who has 
been determined to require an institutional level of 
care to be eligible for nursing facility services under 
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•AMDT. NO. 2786 
the State plan and with respect to whom there has 
been a determination that, but for the provision of 
such services, the individuals would require the level 
of care provided in a hospital, a nursing facility, an 
intermediate care facility for the mentally retarded, 
or an institution for mental diseases, the cost of 
which could be reimbursed under the State plan, but 
only if the individual chooses to receive such home 
and community-based attendant services and sup-
ports, and only if the State meets the following re-
quirements: 
‘‘(A) 
AVAILABILITY.—The 
State 
shall 
make available home and community-based at-
tendant services and supports to eligible indi-
viduals, as needed, to assist in accomplishing 
activities of daily living, instrumental activities 
of daily living, and health-related tasks through 
hands-on assistance, supervision, or cueing— 
‘‘(i) under a person-centered plan of 
services and supports that is based on an 
assessment of functional need and that is 
agreed to in writing by the individual or, 
as appropriate, the individual’s representa-
tive; 
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•AMDT. NO. 2786 
‘‘(ii) in a home or community setting, 
which does not include a nursing facility, 
institution for mental diseases, or an inter-
mediate care facility for the mentally re-
tarded; 
‘‘(iii) under an agency-provider model 
or other model (as defined in paragraph 
(6)(C )); and 
‘‘(iv) the furnishing of which— 
‘‘(I) is selected, managed, and 
dismissed by the individual, or, as ap-
propriate, with assistance from the in-
dividual’s representative; 
‘‘(II) is controlled, to the max-
imum extent possible, by the indi-
vidual or where appropriate, the indi-
vidual’s representative, regardless of 
who may act as the employer of 
record; and 
‘‘(III) provided by an individual 
who is qualified to provide such serv-
ices, including family members (as de-
fined by the Secretary). 
‘‘(B) INCLUDED
SERVICES
AND
SUP-
PORTS.—In addition to assistance in accom-
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•AMDT. NO. 2786 
plishing activities of daily living, instrumental 
activities of daily living, and health related 
tasks, the home and community-based attend-
ant services and supports made available in-
clude— 
‘‘(i) the acquisition, maintenance, and 
enhancement of skills necessary for the in-
dividual to accomplish activities of daily 
living, instrumental activities of daily liv-
ing, and health related tasks; 
‘‘(ii) back-up systems or mechanisms 
(such as the use of beepers or other elec-
tronic devices) to ensure continuity of serv-
ices and supports; and 
‘‘(iii) voluntary training on how to se-
lect, manage, and dismiss attendants. 
‘‘(C) EXCLUDED
SERVICES
AND
SUP-
PORTS.—Subject to subparagraph (D), the 
home and community-based attendant services 
and supports made available do not include— 
‘‘(i) room and board costs for the in-
dividual; 
‘‘(ii) special education and related 
services provided under the Individuals 
with Disabilities Education Act and voca-
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•AMDT. NO. 2786 
tional 
rehabilitation 
services 
provided 
under the Rehabilitation Act of 1973; 
‘‘(iii) assistive technology devices and 
assistive technology services other than 
those under (1)(B)(ii); 
‘‘(iv) medical supplies and equipment; 
or 
‘‘(v) home modifications. 
‘‘(D) PERMISSIBLE
SERVICES
AND
SUP-
PORTS.—The home and community-based at-
tendant services and supports may include— 
‘‘(i) expenditures for transition costs 
such as rent and utility deposits, first 
month’s rent and utilities, bedding, basic 
kitchen supplies, and other necessities re-
quired for an individual to make the tran-
sition from a nursing facility, institution 
for mental diseases, or intermediate care 
facility for the mentally retarded to a com-
munity-based home setting where the indi-
vidual resides; and 
‘‘(ii) expenditures relating to a need 
identified in an individual’s person-cen-
tered plan of services that increase inde-
pendence or substitute for human assist-
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•AMDT. NO. 2786 
ance, to the extent that expenditures would 
otherwise be made for the human assist-
ance. 
‘‘(2) INCREASED FEDERAL FINANCIAL PARTICI-
PATION.—For purposes of payments to a State 
under section 1903(a)(1), with respect to amounts 
expended by the State to provide medical assistance 
under the State plan for home and community-based 
attendant services and supports to eligible individ-
uals in accordance with this subsection during a fis-
cal year quarter occurring during the period de-
scribed in paragraph (1), the Federal medical assist-
ance percentage applicable to the State (as deter-
mined under section 1905(b)) shall be increased by 
6 percentage points. 
‘‘(3) STATE REQUIREMENTS.—In order for a 
State plan amendment to be approved under this 
subsection, the State shall— 
‘‘(A) develop and implement such amend-
ment in collaboration with a Development and 
Implementation Council established by the 
State that includes a majority of members with 
disabilities, elderly individuals, and their rep-
resentatives and consults and collaborates with 
such individuals; 
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•AMDT. NO. 2786 
‘‘(B) provide consumer controlled home 
and community-based attendant services and 
supports to individuals on a statewide basis, in 
a manner that provides such services and sup-
ports in the most integrated setting appropriate 
to the individual’s needs, and without regard to 
the individual’s age, type or nature of disability, 
severity of disability, or the form of home and 
community-based attendant services and sup-
ports that the individual requires in order to 
lead an independent life; 
‘‘(C) with respect to expenditures during 
the first full fiscal year in which the State plan 
amendment is implemented, maintain or exceed 
the level of State expenditures for medical as-
sistance that is provided under section 1905(a), 
section 1915, section 1115, or otherwise to indi-
viduals with disabilities or elderly individuals 
attributable to the preceding fiscal year; 
‘‘(D) establish and maintain a comprehen-
sive, continuous quality assurance system with 
respect to community- based attendant services 
and supports that— 
‘‘(i) includes standards for agency- 
based and other delivery models with re-
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•AMDT. NO. 2786 
spect to training, appeals for denials and 
reconsideration procedures of an individual 
plan, and other factors as determined by 
the Secretary; 
‘‘(ii) incorporates feedback from con-
sumers and their representatives, disability 
organizations, providers, families of dis-
abled or elderly individuals, members of 
the community, and others and maximizes 
consumer independence and consumer con-
trol; 
‘‘(iii) monitors the health and well- 
being of each individual who receives home 
and community-based attendant services 
and supports, including a process for the 
mandatory reporting, investigation, and 
resolution of allegations of neglect, abuse, 
or exploitation in connection with the pro-
vision of such services and supports; and 
‘‘(iv) provides information about the 
provisions of the quality assurance re-
quired under clauses (i) through (iii) to 
each individual receiving such services; and 
‘‘(E) collect and report information, as de-
termined necessary by the Secretary, for the 
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•AMDT. NO. 2786 
purposes of approving the State plan amend-
ment, providing Federal oversight, and con-
ducting an evaluation under paragraph (5)(A), 
including data regarding how the State provides 
home and community-based attendant services 
and supports and other home and community- 
based services, the cost of such services and 
supports, and how the State provides individ-
uals with disabilities who otherwise qualify for 
institutional care under the State plan or under 
a waiver the choice to instead receive home and 
community-based services in lieu of institutional 
care. 
‘‘(4) COMPLIANCE
WITH
CERTAIN
LAWS.—A 
State shall ensure that, regardless of whether the 
State uses an agency-provider model or other models 
to provide home and community-based attendant 
services and supports under a State plan amend-
ment under this subsection, such services and sup-
ports are provided in accordance with the require-
ments of the Fair Labor Standards Act of 1938 and 
applicable Federal and State laws regarding— 
‘‘(A) withholding and payment of Federal 
and State income and payroll taxes; 
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•AMDT. NO. 2786 
‘‘(B) the provision of unemployment and 
workers compensation insurance; 
‘‘(C) maintenance of general liability insur-
ance; and 
‘‘(D) occupational health and safety. 
‘‘(5) EVALUATION, DATA COLLECTION, AND RE-
PORT TO CONGRESS.— 
‘‘(A) EVALUATION.—The Secretary shall 
conduct an evaluation of the provision of home 
and community-based attendant services and 
supports under this subsection in order to de-
termine the effectiveness of the provision of 
such services and supports in allowing the indi-
viduals receiving such services and supports to 
lead an independent life to the maximum extent 
possible; the impact on the physical and emo-
tional health of the individuals who receive such 
services; and an comparative analysis of the 
costs of services provided under the State plan 
amendment under this subsection and those 
provided under institutional care in a nursing 
facility, institution for mental diseases, or an 
intermediate care facility for the mentally re-
tarded. 
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•AMDT. NO. 2786 
‘‘(B) DATA COLLECTION.—The State shall 
provide the Secretary with the following infor-
mation regarding the provision of home and 
community-based attendant services and sup-
ports under this subsection for each fiscal year 
for which such services and supports are pro-
vided: 
‘‘(i) The number of individuals who 
are estimated to receive home and commu-
nity-based attendant services and supports 
under this subsection during the fiscal 
year. 
‘‘(ii) The number of individuals that 
received such services and supports during 
the preceding fiscal year. 
‘‘(iii) The specific number of individ-
uals served by type of disability, age, gen-
der, education level, and employment sta-
tus. 
‘‘(iv) Whether the specific individuals 
have been previously served under any 
other home and community based services 
program under the State plan or under a 
waiver. 
‘‘(C) REPORTS.—Not later than— 
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•AMDT. NO. 2786 
‘‘(i) December 31, 2013, the Sec-
retary shall submit to Congress and make 
available to the public an interim report on 
the findings of the evaluation under sub-
paragraph (A); and 
‘‘(ii) December 31, 2015, the Sec-
retary shall submit to Congress and make 
available to the public a final report on the 
findings of the evaluation under subpara-
graph (A). 
‘‘(6) DEFINITIONS.—In this subsection: 
‘‘(A) ACTIVITIES OF DAILY LIVING.—The 
term ‘activities of daily living’ includes tasks 
such as eating, toileting, grooming, dressing, 
bathing, and transferring. 
‘‘(B) CONSUMER CONTROLLED.—The term 
‘consumer controlled’ means a method of select-
ing and providing services and supports that 
allow the individual, or where appropriate, the 
individual’s representative, maximum control of 
the home and community-based attendant serv-
ices and supports, regardless of who acts as the 
employer of record. 
‘‘(C) DELIVERY MODELS.— 
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•AMDT. NO. 2786 
‘‘(i) AGENCY-PROVIDER MODEL.—The 
term ‘agency-provider model’ means, with 
respect to the provision of home and com-
munity-based attendant services and sup-
ports for an individual, subject to para-
graph (4), a method of providing consumer 
controlled services and supports under 
which entities contract for the provision of 
such services and supports. 
‘‘(ii) OTHER
MODELS.—The term 
‘other models’ means, subject to paragraph 
(4), methods, other than an agency-pro-
vider model, for the provision of consumer 
controlled services and supports. Such 
models may include the provision of vouch-
ers, direct cash payments, or use of a fiscal 
agent to assist in obtaining services. 
‘‘(D) 
HEALTH-RELATED
TASKS.—The 
term ‘health-related tasks’ means specific tasks 
related to the needs of an individual, which can 
be delegated or assigned by licensed health-care 
professionals under State law to be performed 
by an attendant. 
‘‘(E) INDIVIDUAL’S
REPRESENTATIVE.— 
The term ‘individual’s representative’ means a 
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•AMDT. NO. 2786 
parent, family member, guardian, advocate, or 
other authorized representative of an individual 
‘‘(F) INSTRUMENTAL ACTIVITIES OF DAILY 
LIVING.—The term ‘instrumental activities of 
daily living’ includes (but is not limited to) meal 
planning and preparation, managing finances, 
shopping for food, clothing, and other essential 
items, performing essential household chores, 
communicating by phone or other media, and 
traveling around and participating in the com-
munity.’’. 
SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME 
AND COMMUNITY-BASED SERVICES. 
(a) OVERSIGHT AND ASSESSMENT OF THE ADMINIS-
TRATION OF HOME AND COMMUNITY-BASED SERVICES.— 
The Secretary of Health and Human Services shall pro-
mulgate regulations to ensure that all States develop serv-
ice systems that are designed to— 
(1) allocate resources for services in a manner 
that is responsive to the changing needs and choices 
of beneficiaries receiving non-institutionally-based 
long-term services and supports (including such 
services and supports that are provided under pro-
grams other the State Medicaid program), and that 
provides strategies for beneficiaries receiving such 
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•AMDT. NO. 2786 
services to maximize their independence, including 
through the use of client-employed providers; 
(2) provide the support and coordination needed 
for a beneficiary in need of such services (and their 
family caregivers or representative, if applicable) to 
design an individualized, self-directed, community- 
supported life; and 
(3) improve coordination among, and the regu-
lation of, all providers of such services under feder-
ally and State-funded programs in order to— 
(A) achieve a more consistent administra-
tion of policies and procedures across programs 
in relation to the provision of such services; and 
(B) oversee and monitor all service system 
functions to assure— 
(i) coordination of, and effectiveness 
of, eligibility determinations and individual 
assessments; 
(ii) development and service moni-
toring of a complaint system, a manage-
ment system, a system to qualify and mon-
itor providers, and systems for role-setting 
and individual budget determinations; and 
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•AMDT. NO. 2786 
(iii) an adequate number of qualified 
direct care workers to provide self-directed 
personal assistance services. 
(b) ADDITIONAL STATE OPTIONS.—Section 1915(i) 
of the Social Security Act (42 U.S.C. 1396n(i)) is amend-
ed by adding at the end the following new paragraphs: 
‘‘(6) STATE OPTION TO PROVIDE HOME AND 
COMMUNITY-BASED SERVICES TO INDIVIDUALS ELI-
GIBLE FOR SERVICES UNDER A WAIVER.— 
‘‘(A) IN GENERAL.—A State that provides 
home and community-based services in accord-
ance with this subsection to individuals who 
satisfy the needs-based criteria for the receipt 
of such services established under paragraph 
(1)(A) may, in addition to continuing to provide 
such services to such individuals, elect to pro-
vide home and community-based services in ac-
cordance with the requirements of this para-
graph to individuals who are eligible for home 
and community-based services under a waiver 
approved for the State under subsection (c), 
(d), or (e) or under section 1115 to provide 
such services, but only for those individuals 
whose income does not exceed 300 percent of 
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•AMDT. NO. 2786 
the supplemental security income benefit rate 
established by section 1611(b)(1). 
‘‘(B) APPLICATION
OF
SAME
REQUIRE-
MENTS FOR INDIVIDUALS SATISFYING NEEDS- 
BASED
CRITERIA.—Subject to subparagraph 
(C), a State shall provide home and community- 
based services to individuals under this para-
graph in the same manner and subject to the 
same requirements as apply under the other 
paragraphs of this subsection to the provision 
of home and community-based services to indi-
viduals who satisfy the needs-based criteria es-
tablished under paragraph (1)(A). 
‘‘(C) AUTHORITY
TO
OFFER
DIFFERENT 
TYPE, AMOUNT, DURATION, OR SCOPE OF HOME 
AND
COMMUNITY-BASED
SERVICES.—A State 
may offer home and community-based services 
to individuals under this paragraph that differ 
in type, amount, duration, or scope from the 
home and community-based services offered for 
individuals who satisfy the needs-based criteria 
established under paragraph (1)(A), so long as 
such services are within the scope of services 
described in paragraph (4)(B) of subsection (c) 
for which the Secretary has the authority to ap-
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•AMDT. NO. 2786 
prove a waiver and do not include room or 
board. 
‘‘(7) STATE OPTION TO OFFER HOME AND COM-
MUNITY-BASED SERVICES TO SPECIFIC, TARGETED 
POPULATIONS.— 
‘‘(A) IN GENERAL.—A State may elect in 
a State plan amendment under this subsection 
to target the provision of home and community- 
based services under this subsection to specific 
populations and to differ the type, amount, du-
ration, or scope of such services to such specific 
populations. 
‘‘(B) 5-YEAR TERM.— 
‘‘(i) IN GENERAL.—An election by a 
State under this paragraph shall be for a 
period of 5 years. 
‘‘(ii) PHASE-IN OF SERVICES AND ELI-
GIBILITY
PERMITTED
DURING
INITIAL
5- 
YEAR PERIOD.—A State making an elec-
tion under this paragraph may, during the 
first 5-year period for which the election is 
made, phase-in the enrollment of eligible 
individuals, or the provision of services to 
such individuals, or both, so long as all eli-
gible individuals in the State for such serv-
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484 
•AMDT. NO. 2786 
ices are enrolled, and all such services are 
provided, before the end of the initial 5- 
year period. 
‘‘(C) RENEWAL.—An election by a State 
under this paragraph may be renewed for addi-
tional 5-year terms if the Secretary determines, 
prior to beginning of each such renewal period, 
that the State has— 
‘‘(i) adhered to the requirements of 
this subsection and paragraph in providing 
services under such an election; and 
‘‘(ii) met the State’s objectives with 
respect to quality improvement and bene-
ficiary outcomes.’’. 
(c) REMOVAL OF LIMITATION ON SCOPE OF SERV-
ICES.—Paragraph (1) of section 1915(i) of the Social Se-
curity Act (42 U.S.C. 1396n(i)), as amended by sub-
section (a), is amended by striking ‘‘or such other services 
requested by the State as the Secretary may approve’’. 
(d) OPTIONAL ELIGIBILITY CATEGORY TO PROVIDE 
FULL MEDICAID BENEFITS TO INDIVIDUALS RECEIVING 
HOME
AND COMMUNITY-BASED SERVICES UNDER
A 
STATE PLAN AMENDMENT.— 
(1) IN
GENERAL.—Section 1902(a)(10)(A)(ii) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
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485 
•AMDT. NO. 2786 
1396a(a)(10)(A)(ii)), 
as 
amended 
by 
section 
2304(a)(1), is amended— 
(A) in subclause (XX), by striking ‘‘or’’ at 
the end; 
(B) in subclause (XXI), by adding ‘‘or’’ at 
the end; and 
(C) by inserting after subclause (XXI), the 
following new subclause: 
‘‘(XXII) who are eligible for 
home and community-based services 
under needs-based criteria established 
under paragraph (1)(A) of section 
1915(i), or who are eligible for home 
and community-based services under 
paragraph (6) of such section, and 
who will receive home and community- 
based services pursuant to a State 
plan amendment under such sub-
section;’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1903(f)(4) of the Social Secu-
rity Act (42 U.S.C. 1396b(f)(4)), as amended 
by section 2304(a)(4)(B), is amended in the 
matter preceding subparagraph (A), by insert-
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486 
•AMDT. NO. 2786 
ing 
‘‘1902(a)(10)(A)(ii)(XXII),’’ 
after 
‘‘1902(a)(10)(A)(ii)(XXI),’’. 
(B) Section 1905(a) of the Social Security 
Act (42 U.S.C. 1396d(a)), as so amended, is 
amended in the matter preceding paragraph 
(1)— 
(i) in clause (xv), by striking ‘‘or’’ at 
the end; 
(ii) in clause (xvi), by adding ‘‘or’’ at 
the end; and 
(iii) by inserting after clause (xvi) the 
following new clause: 
‘‘(xvii) individuals who are eligible for home and 
community-based services under needs-based criteria 
established under paragraph (1)(A) of section 
1915(i), or who are eligible for home and commu-
nity-based services under paragraph (6) of such sec-
tion, and who will receive home and community- 
based services pursuant to a State plan amendment 
under such subsection,’’. 
(e) ELIMINATION OF OPTION TO LIMIT NUMBER OF 
ELIGIBLE INDIVIDUALS
OR LENGTH
OF PERIOD
FOR 
GRANDFATHERED INDIVIDUALS IF ELIGIBILITY CRITERIA 
IS MODIFIED.—Paragraph (1) of section 1915(i) of such 
Act (42 U.S.C. 1396n(i)) is amended— 
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487 
•AMDT. NO. 2786 
(1) by striking subparagraph (C) and inserting 
the following: 
‘‘(C) PROJECTION OF NUMBER OF INDI-
VIDUALS TO BE PROVIDED HOME AND COMMU-
NITY-BASED SERVICES.—The State submits to 
the Secretary, in such form and manner, and 
upon such frequency as the Secretary shall 
specify, the projected number of individuals to 
be provided home and community-based serv-
ices.’’; and 
(2) in subclause (II) of subparagraph (D)(ii), 
by striking ‘‘to be eligible for such services for a pe-
riod of at least 12 months beginning on the date the 
individual first received medical assistance for such 
services’’ and inserting ‘‘to continue to be eligible for 
such services after the effective date of the modifica-
tion and until such time as the individual no longer 
meets the standard for receipt of such services under 
such pre-modified criteria’’. 
(f) 
ELIMINATION
OF
OPTION
TO
WAIVE 
STATEWIDENESS; ADDITION OF OPTION TO WAIVE COM-
PARABILITY.—Paragraph (3) of section 1915(i) of such 
Act (42 U.S.C. 1396n(3)) is amended by striking 
‘‘1902(a)(1) (relating to statewideness)’’ and inserting 
‘‘1902(a)(10)(B) (relating to comparability)’’. 
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488 
•AMDT. NO. 2786 
(g) EFFECTIVE DATE.—The amendments made by 
subsections (b) through (f) take effect on the first day of 
the first fiscal year quarter that begins after the date of 
enactment of this Act. 
SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING 
DEMONSTRATION. 
(a) EXTENSION OF DEMONSTRATION.— 
(1) IN GENERAL.—Section 6071(h) of the Def-
icit Reduction Act of 2005 (42 U.S.C. 1396a note) 
is amended— 
(A) in paragraph (1)(E), by striking ‘‘fis-
cal year 2011’’ and inserting ‘‘each of fiscal 
years 2011 through 2016’’; and 
(B) in paragraph (2), by striking ‘‘2011’’ 
and inserting ‘‘2016’’. 
(2) EVALUATION.—Paragraphs (2) and (3) of 
section 6071(g) of such Act is amended are each 
amended by striking ‘‘2011’’ and inserting ‘‘2016’’. 
(b) REDUCTION OF INSTITUTIONAL RESIDENCY PE-
RIOD.— 
(1) IN GENERAL.—Section 6071(b)(2) of the 
Deficit Reduction Act of 2005 (42 U.S.C. 1396a 
note) is amended— 
(A) in subparagraph (A)(i), by striking ‘‘, 
for a period of not less than 6 months or for 
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489 
•AMDT. NO. 2786 
such longer minimum period, not to exceed 2 
years, as may be specified by the State’’ and in-
serting ‘‘for a period of not less than 90 con-
secutive days’’; and 
(B) by adding at the end the following: 
‘‘Any days that an individual resides in an institu-
tion on the basis of having been admitted solely for 
purposes of receiving short-term rehabilitative serv-
ices for a period for which payment for such services 
is limited under title XVIII shall not be taken into 
account for purposes of determining the 90-day pe-
riod required under subparagraph (A)(i).’’. 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection take effect 30 days after the date 
of enactment of this Act. 
SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND 
COMMUNITY-BASED 
SERVICES 
AGAINST 
SPOUSAL IMPOVERISHMENT. 
During the 5-year period that begins on January 1, 
2014, section 1924(h)(1)(A) of the Social Security Act (42 
U.S.C. 1396r–5(h)(1)(A)) shall be applied as though ‘‘is 
eligible for medical assistance for home and community- 
based services provided under subsection (c), (d), or (i) 
of section 1915, under a waiver approved under section 
1115, or who is eligible for such medical assistance by rea-
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490 
•AMDT. NO. 2786 
son 
of 
being 
determined 
eligible 
under 
section 
1902(a)(10)(C) or by reason of section 1902(f) or other-
wise on the basis of a reduction of income based on costs 
incurred for medical or other remedial care, or who is eligi-
ble for medical assistance for home and community-based 
attendant services and supports under section 1915(k)’’ 
were substituted in such section for ‘‘(at the option of the 
State) is described in section 1902(a)(10)(A)(ii)(VI)’’. 
SEC. 2405. FUNDING TO EXPAND STATE AGING AND DIS-
ABILITY RESOURCE CENTERS. 
Out of any funds in the Treasury not otherwise ap-
propriated, there is appropriated to the Secretary of 
Health and Human Services, acting through the Assistant 
Secretary for Aging, $10,000,000 for each of fiscal years 
2010 
through 
2014, 
to 
carry 
out 
subsections 
(a)(20)(B)(iii) and (b)(8) of section 202 of the Older 
Americans Act of 1965 (42 U.S.C. 3012). 
SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM 
CARE. 
(a) FINDINGS.—The Senate makes the following 
findings: 
(1) Nearly 2 decades have passed since Con-
gress seriously considered long-term care reform. 
The United States Bipartisan Commission on Com-
prehensive Health Care, also know as the ‘‘Pepper 
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491 
•AMDT. NO. 2786 
Commission’’, released its ‘‘Call for Action’’ blue-
print for health reform in September 1990. In the 
20 years since those recommendations were made, 
Congress has never acted on the report. 
(2) In 1999, under the United States Supreme 
Court’s decision in Olmstead v. L.C., 527 U.S. 581 
(1999), individuals with disabilities have the right to 
choose to receive their long-term services and sup-
ports in the community, rather than in an institu-
tional setting. 
(3) Despite the Pepper Commission and 
Olmstead decision, the long-term care provided to 
our Nation‘s elderly and disabled has not improved. 
In fact, for many, it has gotten far worse. 
(4) In 2007, 69 percent of Medicaid long-term 
care spending for elderly individuals and adults with 
physical disabilities paid for institutional services. 
Only 6 states spent 50 percent or more of their 
Medicaid long-term care dollars on home and com-
munity-based services for elderly individuals and 
adults with physical disabilities while 1⁄2 of the 
States spent less than 25 percent. This disparity 
continues even though, on average, it is estimated 
that Medicaid dollars can support nearly 3 elderly 
individuals and adults with physical disabilities in 
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492 
•AMDT. NO. 2786 
home and community-based services for every indi-
vidual in a nursing home. Although every State has 
chosen to provide certain services under home and 
community-based waivers, these services are un-
evenly available within and across States, and reach 
a small percentage of eligible individuals. 
(b) SENSE OF THE SENATE.—It is the sense of the 
Senate that— 
(1) during the 111th session of Congress, Con-
gress should address long-term services and supports 
in a comprehensive way that guarantees elderly and 
disabled individuals the care they need; and 
(2) long term services and supports should be 
made available in the community in addition to in 
institutions. 
Subtitle F—Medicaid Prescription 
Drug Coverage 
SEC. 2501. PRESCRIPTION DRUG REBATES. 
(a) INCREASE IN MINIMUM REBATE PERCENTAGE 
FOR SINGLE SOURCE DRUGS AND INNOVATOR MULTIPLE 
SOURCE DRUGS.— 
(1) IN GENERAL.—Section 1927(c)(1)(B) of the 
Social Security Act (42 U.S.C. 1396r–8(c)(1)(B)) is 
amended— 
(A) in clause (i)— 
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493 
•AMDT. NO. 2786 
(i) in subclause (IV), by striking 
‘‘and’’ at the end; 
(ii) in subclause (V)— 
(I) by inserting ‘‘and before Jan-
uary 1, 2010’’ after ‘‘December 31, 
1995,’’; and 
(II) by striking the period at the 
end and inserting ‘‘; and’’; and 
(iii) by adding at the end the fol-
lowing new subclause: 
‘‘(VI) except as provided in 
clause (iii), after December 31, 2009, 
23.1 percent.’’; and 
(B) by adding at the end the following new 
clause: 
‘‘(iii) MINIMUM REBATE PERCENTAGE 
FOR CERTAIN DRUGS.— 
‘‘(I) IN GENERAL.—In the case 
of a single source drug or an inno-
vator multiple source drug described 
in subclause (II), the minimum rebate 
percentage for rebate periods specified 
in clause (i)(VI) is 17.1 percent. 
‘‘(II) DRUG
DESCRIBED.—For 
purposes of subclause (I), a single 
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494 
•AMDT. NO. 2786 
source drug or an innovator multiple 
source drug described in this sub-
clause is any of the following drugs: 
‘‘(aa) A clotting factor for 
which a separate furnishing pay-
ment is made under section 
1842(o)(5) and which is included 
on a list of such factors specified 
and updated regularly by the 
Secretary. 
‘‘(bb) A drug approved by 
the Food and Drug Administra-
tion exclusively for pediatric indi-
cations.’’. 
(2) RECAPTURE OF TOTAL SAVINGS DUE TO IN-
CREASE.—Section 1927(b)(1) of such Act (42 
U.S.C. 1396r–8(b)(1)) is amended by adding at the 
end the following new subparagraph: 
‘‘(C) SPECIAL RULE FOR INCREASED MIN-
IMUM REBATE PERCENTAGE.— 
‘‘(i) IN GENERAL.—In addition to the 
amounts applied as a reduction under sub-
paragraph (B), for rebate periods begin-
ning on or after January 1, 2010, during 
a fiscal year, the Secretary shall reduce 
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495 
•AMDT. NO. 2786 
payments to a State under section 1903(a) 
in the manner specified in clause (ii), in an 
amount equal to the product of— 
‘‘(I) 100 percent minus the Fed-
eral medical assistance percentage ap-
plicable to the rebate period for the 
State; and 
‘‘(II) the amounts received by the 
State under such subparagraph that 
are attributable (as estimated by the 
Secretary based on utilization and 
other data) to the increase in the min-
imum rebate percentage effected by 
the amendments made by subsections 
(a)(1), (b), and (d) of section 2501 of 
the Patient Protection and Affordable 
Care Act, taking into account the ad-
ditional drugs included under the 
amendments made by subsection (c) 
of section 2501 of such Act. 
The Secretary shall adjust such payment 
reduction for a calendar quarter to the ex-
tent the Secretary determines, based upon 
subsequent utilization and other data, that 
the reduction for such quarter was greater 
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496 
•AMDT. NO. 2786 
or less than the amount of payment reduc-
tion that should have been made. 
‘‘(ii) MANNER OF PAYMENT REDUC-
TION.—The amount of the payment reduc-
tion under clause (i) for a State for a 
quarter shall be deemed an overpayment to 
the State under this title to be disallowed 
against the State’s regular quarterly draw 
for all Medicaid spending under section 
1903(d)(2). Such a disallowance is not 
subject to a reconsideration under section 
1116(d).’’. 
(b) INCREASE IN REBATE FOR OTHER DRUGS.—Sec-
tion 1927(c)(3)(B) of such Act (42 U.S.C. 1396r– 
8(c)(3)(B)) is amended— 
(1) in clause (i), by striking ‘‘and’’ at the end; 
(2) in clause (ii)— 
(A) by inserting ‘‘and before January 1, 
2010,’’ after ‘‘December 31, 1993,’’; and 
(B) by striking the period and inserting ‘‘; 
and’’; and 
(3) by adding at the end the following new 
clause: 
‘‘(iii) after December 31, 2009, is 13 
percent.’’. 
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497 
•AMDT. NO. 2786 
(c) EXTENSION OF PRESCRIPTION DRUG DISCOUNTS 
TO ENROLLEES OF MEDICAID MANAGED CARE ORGANI-
ZATIONS.— 
(1) IN
GENERAL.—Section 1903(m)(2)(A) of 
such Act (42 U.S.C. 1396b(m)(2)(A)) is amended— 
(A) in clause (xi), by striking ‘‘and’’ at the 
end; 
(B) in clause (xii), by striking the period 
at the end and inserting ‘‘; and’’; and 
(C) by adding at the end the following: 
‘‘(xiii) such contract provides that (I) 
covered outpatient drugs dispensed to indi-
viduals eligible for medical assistance who 
are enrolled with the entity shall be subject 
to the same rebate required by the agree-
ment entered into under section 1927 as 
the State is subject to and that the State 
shall collect such rebates from manufactur-
ers, (II) capitation rates paid to the entity 
shall be based on actual cost experience re-
lated to rebates and subject to the Federal 
regulations requiring actuarially sound 
rates, and (III) the entity shall report to 
the State, on such timely and periodic 
basis as specified by the Secretary in order 
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498 
•AMDT. NO. 2786 
to include in the information submitted by 
the State to a manufacturer and the Sec-
retary under section 1927(b)(2)(A), infor-
mation on the total number of units of 
each dosage form and strength and pack-
age size by National Drug Code of each 
covered outpatient drug dispensed to indi-
viduals eligible for medical assistance who 
are enrolled with the entity and for which 
the entity is responsible for coverage of 
such drug under this subsection (other 
than covered outpatient drugs that under 
subsection (j)(1) of section 1927 are not 
subject to the requirements of that section) 
and such other data as the Secretary de-
termines necessary to carry out this sub-
section.’’. 
(2) CONFORMING AMENDMENTS.—Section 1927 
(42 U.S.C. 1396r–8) is amended— 
(A) in subsection (b)— 
(i) in paragraph (1)(A), in the first 
sentence, by inserting ‘‘, including such 
drugs dispensed to individuals enrolled 
with a medicaid managed care organization 
if the organization is responsible for cov-
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499 
•AMDT. NO. 2786 
erage of such drugs’’ before the period; 
and 
(ii) in paragraph (2)(A), by inserting 
‘‘including such information reported by 
each medicaid managed care organization,’’ 
after ‘‘for which payment was made under 
the plan during the period,’’; and 
(B) in subsection (j), by striking para-
graph (1) and inserting the following: 
‘‘(1) Covered outpatient drugs are not subject 
to the requirements of this section if such drugs 
are— 
‘‘(A) dispensed by health maintenance or-
ganizations, including Medicaid managed care 
organizations 
that 
contract 
under 
section 
1903(m); and 
‘‘(B) subject to discounts under section 
340B of the Public Health Service Act.’’. 
(d) ADDITIONAL REBATE FOR NEW FORMULATIONS 
OF EXISTING DRUGS.— 
(1) IN
GENERAL.—Section 1927(c)(2) of the 
Social Security Act (42 U.S.C. 1396r–8(c)(2)) is 
amended by adding at the end the following new 
subparagraph: 
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500 
•AMDT. NO. 2786 
‘‘(C) TREATMENT
OF
NEW
FORMULA-
TIONS.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), in the case of a drug 
that is a new formulation, such as an ex-
tended-release formulation, of a single 
source drug or an innovator multiple 
source drug, the rebate obligation with re-
spect to the drug under this section shall 
be the amount computed under this section 
for the new formulation of the drug or, if 
greater, the product of— 
‘‘(I) the average manufacturer 
price for each dosage form and 
strength of the new formulation of the 
single source drug or innovator mul-
tiple source drug; 
‘‘(II) the highest additional re-
bate (calculated as a percentage of av-
erage manufacturer price) under this 
section for any strength of the origi-
nal single source drug or innovator 
multiple source drug; and 
‘‘(III) the total number of units 
of each dosage form and strength of 
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501 
•AMDT. NO. 2786 
the new formulation paid for under 
the State plan in the rebate period (as 
reported by the State). 
‘‘(ii) NO APPLICATION TO NEW FOR-
MULATIONS
OF
ORPHAN
DRUGS.—Clause 
(i) shall not apply to a new formulation of 
a covered outpatient drug that is or has 
been designated under section 526 of the 
Federal Food, Drug, and Cosmetic Act (21 
U.S.C. 360bb) for a rare disease or condi-
tion, without regard to whether the period 
of market exclusivity for the drug under 
section 527 of such Act has expired or the 
specific indication for use of the drug.’’. 
(2) EFFECTIVE DATE.—The amendment made 
by paragraph (1) shall apply to drugs that are paid 
for by a State after December 31, 2009. 
(e) 
MAXIMUM
REBATE
AMOUNT.—Section 
1927(c)(2) of such Act (42 U.S.C. 1396r–8(c)(2)), as 
amended by subsection (d), is amended by adding at the 
end the following new subparagraph: 
‘‘(D) MAXIMUM REBATE AMOUNT.—In no 
case shall the sum of the amounts applied 
under paragraph (1)(A)(ii) and this paragraph 
with respect to each dosage form and strength 
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502 
•AMDT. NO. 2786 
of a single source drug or an innovator multiple 
source drug for a rebate period beginning after 
December 31, 2009, exceed 100 percent of the 
average manufacturer price of the drug.’’. 
(f) CONFORMING AMENDMENTS.— 
(1) IN GENERAL.—Section 340B of the Public 
Health Service Act (42 U.S.C. 256b) is amended— 
(A) in subsection (a)(2)(B)(i), by striking 
‘‘1927(c)(4)’’ and inserting ‘‘1927(c)(3)’’; and 
(B) by striking subsection (c); and 
(C) redesignating subsection (d) as sub-
section (c). 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection take effect on January 1, 2010. 
SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF 
CERTAIN DRUGS. 
(a) IN GENERAL.—Section 1927(d) of the Social Se-
curity Act (42 U.S.C. 1397r–8(d)) is amended— 
(1) in paragraph (2)— 
(A) by striking subparagraphs (E), (I), 
and (J), respectively; and 
(B) by redesignating subparagraphs (F), 
(G), (H), and (K) as subparagraphs (E), (F), 
(G), and (H), respectively; and 
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•AMDT. NO. 2786 
(2) by adding at the end the following new 
paragraph: 
‘‘(7) NON-EXCLUDABLE DRUGS.—The following 
drugs or classes of drugs, or their medical uses, shall 
not be excluded from coverage: 
‘‘(A) Agents when used to promote smok-
ing cessation, including agents approved by the 
Food and Drug Administration under the over- 
the-counter monograph process for purposes of 
promoting, and when used to promote, tobacco 
cessation. 
‘‘(B) Barbiturates. 
‘‘(C) Benzodiazepines.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply to services furnished on or after 
January 1, 2014. 
SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSE-
MENT. 
(a) PHARMACY REIMBURSEMENT LIMITS.— 
(1) IN GENERAL.—Section 1927(e) of the So-
cial Security Act (42 U.S.C. 1396r–8(e)) is amend-
ed— 
(A) in paragraph (4), by striking ‘‘(or, ef-
fective January 1, 2007, two or more)’’; and 
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•AMDT. NO. 2786 
(B) by striking paragraph (5) and insert-
ing the following: 
‘‘(5) USE OF AMP IN UPPER PAYMENT LIM-
ITS.—The Secretary shall calculate the Federal 
upper reimbursement limit established under para-
graph (4) as no less than 175 percent of the weight-
ed average (determined on the basis of utilization) of 
the most recently reported monthly average manu-
facturer prices for pharmaceutically and therapeuti-
cally equivalent multiple source drug products that 
are available for purchase by retail community phar-
macies on a nationwide basis. The Secretary shall 
implement a smoothing process for average manu-
facturer prices. Such process shall be similar to the 
smoothing process used in determining the average 
sales price of a drug or biological under section 
1847A.’’. 
(2) DEFINITION OF AMP.—Section 1927(k)(1) 
of such Act (42 U.S.C. 1396r–8(k)(1)) is amend-
ed— 
(A) in subparagraph (A), by striking ‘‘by’’ 
and all that follows through the period and in-
serting ‘‘by— 
‘‘(i) wholesalers for drugs distributed 
to retail community pharmacies; and 
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•AMDT. NO. 2786 
‘‘(ii) retail community pharmacies 
that purchase drugs directly from the man-
ufacturer.’’; and 
(B) by striking subparagraph (B) and in-
serting the following: 
‘‘(B) EXCLUSION OF CUSTOMARY PROMPT 
PAY DISCOUNTS AND OTHER PAYMENTS.— 
‘‘(i) IN GENERAL.—The average man-
ufacturer price for a covered outpatient 
drug shall exclude— 
‘‘(I) customary prompt pay dis-
counts extended to wholesalers; 
‘‘(II) bona fide service fees paid 
by manufacturers to wholesalers or re-
tail community pharmacies, including 
(but not limited to) distribution serv-
ice fees, inventory management fees, 
product stocking allowances, and fees 
associated with administrative services 
agreements and patient care programs 
(such as medication compliance pro-
grams and patient education pro-
grams); 
‘‘(III) reimbursement by manu-
facturers for recalled, damaged, ex-
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•AMDT. NO. 2786 
pired, or otherwise unsalable returned 
goods, including (but not limited to) 
reimbursement for the cost of the 
goods and any reimbursement of costs 
associated with return goods handling 
and processing, reverse logistics, and 
drug destruction; and 
‘‘(IV) payments received from, 
and rebates or discounts provided to, 
pharmacy benefit managers, managed 
care organizations, health mainte-
nance organizations, insurers, hos-
pitals, clinics, mail order pharmacies, 
long term care providers, manufactur-
ers, or any other entity that does not 
conduct business as a wholesaler or a 
retail community pharmacy. 
‘‘(ii) INCLUSION
OF
OTHER
DIS-
COUNTS
AND
PAYMENTS.—Notwith-
standing clause (i), any other discounts, 
rebates, payments, or other financial trans-
actions that are received by, paid by, or 
passed through to, retail community phar-
macies shall be included in the average 
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508 
•AMDT. NO. 2786 
macy that is licensed as a pharmacy by the State 
and that dispenses medications to the general public 
at retail prices. Such term does not include a phar-
macy that dispenses prescription medications to pa-
tients primarily through the mail, nursing home 
pharmacies, long-term care facility pharmacies, hos-
pital pharmacies, clinics, charitable or not-for-profit 
pharmacies, government pharmacies, or pharmacy 
benefit managers. 
‘‘(11) WHOLESALER.—The term ‘wholesaler’ 
means a drug wholesaler that is engaged in whole-
sale distribution of prescription drugs to retail com-
munity pharmacies, including (but not limited to) 
manufacturers, repackers, distributors, own-label 
distributors, private-label distributors, jobbers, bro-
kers, warehouses (including manufacturer’s and dis-
tributor’s warehouses, chain drug warehouses, and 
wholesale drug warehouses) independent wholesale 
drug traders, and retail community pharmacies that 
conduct wholesale distributions.’’. 
(b) DISCLOSURE OF PRICE INFORMATION TO THE 
PUBLIC.—Section 1927(b)(3) of such Act (42 U.S.C. 
1396r–8(b)(3)) is amended— 
(1) in subparagraph (A)— 
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•AMDT. NO. 2786 
(A) in the first sentence, by inserting after 
clause (iii) the following: 
‘‘(iv) not later than 30 days after the 
last day of each month of a rebate period 
under the agreement, on the manufactur-
er’s total number of units that are used to 
calculate the monthly average manufac-
turer price for each covered outpatient 
drug;’’; and 
(B) in the second sentence, by inserting 
‘‘(relating to the weighted average of the most 
recently reported monthly average manufacturer 
prices)’’ after ‘‘(D)(v)’’; and 
(2) in subparagraph (D)(v), by striking ‘‘aver-
age manufacturer prices’’ and inserting ‘‘the weight-
ed average of the most recently reported monthly av-
erage manufacturer prices and the average retail 
survey price determined for each multiple source 
drug in accordance with subsection (f)’’. 
(c) CLARIFICATION OF APPLICATION OF SURVEY OF 
RETAIL PRICES.—Section 1927(f)(1) of such Act (42 
U.S.C. 1396r–8(b)(1)) is amended— 
(1) in subparagraph (A)(i), by inserting ‘‘with 
respect to a retail community pharmacy,’’ before 
‘‘the determination’’; and 
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•AMDT. NO. 2786 
(2) in subparagraph (C)(ii), by striking ‘‘retail 
pharmacies’’ and inserting ‘‘retail community phar-
macies’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on the first day of the first 
calendar year quarter that begins at least 180 days after 
the date of enactment of this Act, without regard to 
whether or not final regulations to carry out such amend-
ments have been promulgated by such date. 
Subtitle 
G—Medicaid 
Dispropor-
tionate Share Hospital (DSH) 
Payments 
SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAY-
MENTS. 
(a) IN GENERAL.—Section 1923(f) of the Social Se-
curity Act (42 U.S.C. 1396r–4(f)) is amended— 
(1) in paragraph (1), by striking ‘‘and (3)’’ and 
inserting ‘‘, (3), and (7)’’; 
(2) in paragraph (3)(A), by striking ‘‘paragraph 
(6)’’ and inserting ‘‘paragraphs (6) and (7)’’; 
(3) by redesignating paragraph (7) as para-
graph (8); and 
(4) by inserting after paragraph (6) the fol-
lowing new paragraph: 
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•AMDT. NO. 2786 
‘‘(7) REDUCTION OF STATE DSH ALLOTMENTS 
ONCE
REDUCTION
IN
UNINSURED
THRESHOLD 
REACHED.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (E), the DSH allotment for a State for 
fiscal years beginning with the fiscal year de-
scribed in subparagraph (C) (with respect to 
the State), is equal to— 
‘‘(i) in the case of the first fiscal year 
described in subparagraph (C) with respect 
to a State, the DSH allotment that would 
be determined under this subsection for 
the State for the fiscal year without appli-
cation of this paragraph (but after the ap-
plication of subparagraph (D)), reduced by 
the applicable percentage determined for 
the State for the fiscal year under sub-
paragraph (B)(i); and 
‘‘(ii) in the case of any subsequent fis-
cal year with respect to the State, the 
DSH allotment determined under this 
paragraph for the State for the preceding 
fiscal year, reduced by the applicable per-
centage determined for the State for the 
fiscal year under subparagraph (B)(ii). 
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•AMDT. NO. 2786 
‘‘(B) 
APPLICABLE
PERCENTAGE.—For 
purposes of subparagraph (A), the applicable 
percentage for a State for a fiscal year is the 
following: 
‘‘(i) UNINSURED REDUCTION THRESH-
OLD FISCAL YEAR.—In the case of the first 
fiscal year described in subparagraph (C) 
with respect to the State— 
‘‘(I) if the State is a low DSH 
State described in paragraph (5)(B), 
the applicable percentage is equal to 
25 percent; and 
‘‘(II) if the State is any other 
State, the applicable percentage is 50 
percent. 
‘‘(ii) SUBSEQUENT FISCAL YEARS IN 
WHICH THE PERCENTAGE OF UNINSURED 
DECREASES.—In the case of any fiscal 
year after the first fiscal year described in 
subparagraph (C) with respect to a State, 
if the Secretary determines on the basis of 
the most recent American Community Sur-
vey of the Bureau of the Census, that the 
percentage of uncovered individuals resid-
ing in the State is less than the percentage 
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513 
•AMDT. NO. 2786 
of such individuals determined for the 
State for the preceding fiscal year— 
‘‘(I) if the State is a low DSH 
State described in paragraph (5)(B), 
the applicable percentage is equal to 
the product of the percentage reduc-
tion in uncovered individuals for the 
fiscal year from the preceding fiscal 
year and 25 percent; and 
‘‘(II) if the State is any other 
State, the applicable percentage is 
equal to the product of the percentage 
reduction in uncovered individuals for 
the fiscal year from the preceding fis-
cal year and 50 percent. 
‘‘(C) FISCAL YEAR DESCRIBED.—For pur-
poses of subparagraph (A), the fiscal year de-
scribed in this subparagraph with respect to a 
State is the first fiscal year that occurs after 
fiscal year 2012 for which the Secretary deter-
mines, on the basis of the most recent Amer-
ican Community Survey of the Bureau of the 
Census, that the percentage of uncovered indi-
viduals residing in the State is at least 45 per-
cent less than the percentage of such individ-
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•AMDT. NO. 2786 
uals determined for the State for fiscal year 
2009. 
‘‘(D) EXCLUSION OF PORTIONS DIVERTED 
FOR COVERAGE EXPANSIONS.—For purposes of 
applying the applicable percentage reduction 
under subparagraph (A) to the DSH allotment 
for a State for a fiscal year, the DSH allotment 
for a State that would be determined under this 
subsection for the State for the fiscal year with-
out the application of this paragraph (and prior 
to any such reduction) shall not include any 
portion of the allotment for which the Secretary 
has approved the State’s diversion to the costs 
of providing medical assistance or other health 
benefits coverage under a waiver that is in ef-
fect on July 2009. 
‘‘(E) MINIMUM ALLOTMENT.—In no event 
shall the DSH allotment determined for a State 
in accordance with this paragraph for fiscal 
year 2013 or any succeeding fiscal year be less 
than the amount equal to 35 percent of the 
DSH allotment determined for the State for fis-
cal year 2012 under this subsection (and after 
the application of this paragraph, if applicable), 
increased by the percentage change in the con-
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•AMDT. NO. 2786 
sumer price index for all urban consumers (all 
items, U.S. city average) for each previous fis-
cal year occurring before the fiscal year. 
‘‘(F) UNCOVERED INDIVIDUALS.—In this 
paragraph, the term ‘uncovered individuals’ 
means individuals with no health insurance cov-
erage at any time during a year (as determined 
by the Secretary based on the most recent data 
available).’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) take effect on October 1, 2011. 
Subtitle 
H—Improved 
Coordina-
tion for Dual Eligible Bene-
ficiaries 
SEC. 
2601. 
5-YEAR 
PERIOD 
FOR 
DEMONSTRATION 
PROJECTS. 
(a) IN GENERAL.—Section 1915(h) of the Social Se-
curity Act (42 U.S.C. 1396n(h)) is amended— 
(1) by inserting ‘‘(1)’’ after ‘‘(h)’’; 
(2) by inserting ‘‘, or a waiver described in 
paragraph (2)’’ after ‘‘(e)’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(2)(A) Notwithstanding subsections (c)(3) and (d) 
(3), any waiver under subsection (b), (c), or (d), or a waiv-
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•AMDT. NO. 2786 
er under section 1115, that provides medical assistance 
for dual eligible individuals (including any such waivers 
under which non dual eligible individuals may be enrolled 
in addition to dual eligible individuals) may be conducted 
for a period of 5 years and, upon the request of the State, 
may be extended for additional 5-year periods unless the 
Secretary determines that for the previous waiver period 
the conditions for the waiver have not been met or it would 
no longer be cost-effective and efficient, or consistent with 
the purposes of this title, to extend the waiver. 
‘‘(B) In this paragraph, the term ‘dual eligible indi-
vidual’ means an individual who is entitled to, or enrolled 
for, benefits under part A of title XVIII, or enrolled for 
benefits under part B of title XVIII, and is eligible for 
medical assistance under the State plan under this title 
or under a waiver of such plan.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 1915 of such Act (42 U.S.C. 
1396n) is amended— 
(A) in subsection (b), by adding at the end 
the following new sentence: ‘‘Subsection (h)(2) 
shall apply to a waiver under this subsection.’’; 
(B) in subsection (c)(3), in the second sen-
tence, by inserting ‘‘(other than a waiver de-
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•AMDT. NO. 2786 
scribed in subsection (h)(2))’’ after ‘‘A waiver 
under this subsection’’; 
(C) in subsection (d)(3), in the second sen-
tence, by inserting ‘‘(other than a waiver de-
scribed in subsection (h)(2))’’ after ‘‘A waiver 
under this subsection’’. 
(2) Section 1115 of such Act (42 U.S.C. 1315) 
is amended— 
(A) in subsection (e)(2), by inserting ‘‘(5 
years, in the case of a waiver described in sec-
tion 1915(h)(2))’’ after ‘‘3 years’’; and 
(B) in subsection (f)(6), by inserting ‘‘(5 
years, in the case of a waiver described in sec-
tion 1915(h)(2))’’ after ‘‘3 years’’. 
SEC. 2602. PROVIDING FEDERAL COVERAGE AND PAYMENT 
COORDINATION FOR DUAL ELIGIBLE BENE-
FICIARIES. 
(a) ESTABLISHMENT
OF FEDERAL COORDINATED 
HEALTH CARE OFFICE.— 
(1) IN
GENERAL.—Not later than March 1, 
2010, the Secretary of Health and Human Services 
(in this section referred to as the ‘‘Secretary’’) shall 
establish a Federal Coordinated Health Care Office. 
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•AMDT. NO. 2786 
(2) ESTABLISHMENT AND REPORTING TO CMS 
ADMINISTRATOR.—The Federal Coordinated Health 
Care Office— 
(A) shall be established within the Centers 
for Medicare & Medicaid Services; and 
(B) have as the Office a Director who shall 
be appointed by, and be in direct line of author-
ity to, the Administrator of the Centers for 
Medicare & Medicaid Services. 
(b) PURPOSE.—The purpose of the Federal Coordi-
nated Health Care Office is to bring together officers and 
employees of the Medicare and Medicaid programs at the 
Centers for Medicare & Medicaid Services in order to— 
(1) more effectively integrate benefits under the 
Medicare program under title XVIII of the Social 
Security Act and the Medicaid program under title 
XIX of such Act; and 
(2) improve the coordination between the Fed-
eral Government and States for individuals eligible 
for benefits under both such programs in order to 
ensure that such individuals get full access to the 
items and services to which they are entitled under 
titles XVIII and XIX of the Social Security Act. 
(c) GOALS.—The goals of the Federal Coordinated 
Health Care Office are as follows: 
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•AMDT. NO. 2786 
(1) Providing dual eligible individuals full ac-
cess to the benefits to which such individuals are en-
titled under the Medicare and Medicaid programs. 
(2) Simplifying the processes for dual eligible 
individuals to access the items and services they are 
entitled to under the Medicare and Medicaid pro-
grams. 
(3) Improving the quality of health care and 
long-term services for dual eligible individuals. 
(4) Increasing dual eligible individuals’ under-
standing of and satisfaction with coverage under the 
Medicare and Medicaid programs. 
(5) Eliminating regulatory conflicts between 
rules under the Medicare and Medicaid programs. 
(6) Improving care continuity and ensuring safe 
and effective care transitions for dual eligible indi-
viduals. 
(7) Eliminating cost-shifting between the Medi-
care and Medicaid program and among related 
health care providers. 
(8) Improving the quality of performance of 
providers of services and suppliers under the Medi-
care and Medicaid programs. 
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•AMDT. NO. 2786 
(d) SPECIFIC RESPONSIBILITIES.—The specific re-
sponsibilities of the Federal Coordinated Health Care Of-
fice are as follows: 
(1) Providing States, specialized MA plans for 
special needs individuals (as defined in section 
1859(b)(6) of the Social Security Act (42 U.S.C. 
1395w–28(b)(6))), physicians and other relevant en-
tities or individuals with the education and tools nec-
essary for developing programs that align benefits 
under the Medicare and Medicaid programs for dual 
eligible individuals. 
(2) Supporting State efforts to coordinate and 
align acute care and long-term care services for dual 
eligible individuals with other items and services fur-
nished under the Medicare program. 
(3) Providing support for coordination of con-
tracting and oversight by States and the Centers for 
Medicare & Medicaid Services with respect to the in-
tegration of the Medicare and Medicaid programs in 
a manner that is supportive of the goals described 
in paragraph (3). 
(4) To consult and coordinate with the Medi-
care Payment Advisory Commission established 
under section 1805 of the Social Security Act (42 
U.S.C. 1395b–6) and the Medicaid and CHIP Pay-
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521 
•AMDT. NO. 2786 
ment and Access Commission established under sec-
tion 1900 of such Act (42 U.S.C. 1396) with respect 
to policies relating to the enrollment in, and provi-
sion of, benefits to dual eligible individuals under the 
Medicare program under title XVIII of the Social 
Security Act and the Medicaid program under title 
XIX of such Act. 
(5) To study the provision of drug coverage for 
new full-benefit dual eligible individuals (as defined 
in section 1935(c)(6) of the Social Security Act (42 
U.S.C. 1396u–5(c)(6)), as well as to monitor and re-
port annual total expenditures, health outcomes, and 
access to benefits for all dual eligible individuals. 
(e) REPORT.—The Secretary shall, as part of the 
budget transmitted under section 1105(a) of title 31, 
United States Code, submit to Congress an annual report 
containing recommendations for legislation that would im-
prove care coordination and benefits for dual eligible indi-
viduals. 
(f) DUAL ELIGIBLE DEFINED.—In this section, the 
term ‘‘dual eligible individual’’ means an individual who 
is entitled to, or enrolled for, benefits under part A of title 
XVIII of the Social Security Act, or enrolled for benefits 
under part B of title XVIII of such Act, and is eligible 
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•AMDT. NO. 2786 
for medical assistance under a State plan under title XIX 
of such Act or under a waiver of such plan. 
Subtitle I—Improving the Quality 
of Medicaid for Patients and 
Providers 
SEC. 2701. ADULT HEALTH QUALITY MEASURES. 
Title XI of the Social Security Act (42 U.S.C. 1301 
et seq.), as amended by section 401 of the Children’s 
Health Insurance Program Reauthorization Act of 2009 
(Public Law 111-3), is amended by inserting after section 
1139A the following new section: 
‘‘SEC. 1139B. ADULT HEALTH QUALITY MEASURES. 
‘‘(a) DEVELOPMENT OF CORE SET OF HEALTH CARE 
QUALITY MEASURES FOR ADULTS ELIGIBLE FOR BENE-
FITS UNDER MEDICAID.—The Secretary shall identify 
and publish a recommended core set of adult health qual-
ity measures for Medicaid eligible adults in the same man-
ner as the Secretary identifies and publishes a core set 
of child health quality measures under section 1139A, in-
cluding with respect to identifying and publishing existing 
adult health quality measures that are in use under public 
and privately sponsored health care coverage arrange-
ments, or that are part of reporting systems that measure 
both the presence and duration of health insurance cov-
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•AMDT. NO. 2786 
erage over time, that may be applicable to Medicaid eligi-
ble adults. 
‘‘(b) DEADLINES.— 
‘‘(1) RECOMMENDED
MEASURES.—Not later 
than January 1, 2011, the Secretary shall identify 
and publish for comment a recommended core set of 
adult health quality measures for Medicaid eligible 
adults. 
‘‘(2) DISSEMINATION.—Not later than January 
1, 2012, the Secretary shall publish an initial core 
set of adult health quality measures that are appli-
cable to Medicaid eligible adults. 
‘‘(3) STANDARDIZED
REPORTING.—Not later 
than January 1, 2013, the Secretary, in consultation 
with States, shall develop a standardized format for 
reporting information based on the initial core set of 
adult health quality measures and create procedures 
to encourage States to use such measures to volun-
tarily report information regarding the quality of 
health care for Medicaid eligible adults. 
‘‘(4) REPORTS TO CONGRESS.—Not later than 
January 1, 2014, and every 3 years thereafter, the 
Secretary shall include in the report to Congress re-
quired under section 1139A(a)(6) information simi-
lar to the information required under that section 
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•AMDT. NO. 2786 
with respect to the measures established under this 
section. 
‘‘(5) ESTABLISHMENT OF MEDICAID QUALITY 
MEASUREMENT PROGRAM.— 
‘‘(A) IN
GENERAL.—Not later than 12 
months after the release of the recommended 
core set of adult health quality measures under 
paragraph (1)), the Secretary shall establish a 
Medicaid Quality Measurement Program in the 
same manner as the Secretary establishes the 
pediatric quality measures program under sec-
tion 1139A(b). The aggregate amount awarded 
by the Secretary for grants and contracts for 
the development, testing, and validation of 
emerging and innovative evidence-based meas-
ures under such program shall equal the aggre-
gate amount awarded by the Secretary for 
grants under section 1139A(b)(4)(A) 
‘‘(B) REVISING, STRENGTHENING, AND IM-
PROVING INITIAL CORE MEASURES.—Beginning 
not later than 24 months after the establish-
ment of the Medicaid Quality Measurement 
Program, and annually thereafter, the Sec-
retary shall publish recommended changes to 
the initial core set of adult health quality meas-
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•AMDT. NO. 2786 
ures that shall reflect the results of the testing, 
validation, and consensus process for the devel-
opment of adult health quality measures. 
‘‘(c) CONSTRUCTION.—Nothing in this section shall 
be construed as supporting the restriction of coverage, 
under title XIX or XXI or otherwise, to only those services 
that are evidence-based, or in anyway limiting available 
services. 
‘‘(d) ANNUAL STATE REPORTS REGARDING STATE- 
SPECIFIC QUALITY OF CARE MEASURES APPLIED UNDER 
MEDICAID.— 
‘‘(1) ANNUAL
STATE
REPORTS.—Each State 
with a State plan or waiver approved under title 
XIX shall annually report (separately or as part of 
the annual report required under section 1139A(c)), 
to the Secretary on the— 
‘‘(A) State-specific adult health quality 
measures applied by the State under the such 
plan, including measures described in sub-
section (a)(5); and 
‘‘(B) State-specific information on the 
quality of health care furnished to Medicaid eli-
gible adults under such plan, including informa-
tion collected through external quality reviews 
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•AMDT. NO. 2786 
of managed care organizations under section 
1932 and benchmark plans under section 1937. 
‘‘(2) PUBLICATION.—Not later than September 
30, 2014, and annually thereafter, the Secretary 
shall collect, analyze, and make publicly available the 
information reported by States under paragraph (1). 
‘‘(e) APPROPRIATION.—Out of any funds in the 
Treasury not otherwise appropriated, there is appro-
priated for each of fiscal years 2010 through 2014, 
$60,000,000 for the purpose of carrying out this section. 
Funds appropriated under this subsection shall remain 
available until expended.’’. 
SEC. 2702. PAYMENT ADJUSTMENT FOR HEALTH CARE-AC-
QUIRED CONDITIONS. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services (in this subsection referred to as the 
‘‘Secretary’’) shall identify current State practices that 
prohibit payment for health care-acquired conditions and 
shall incorporate the practices identified, or elements of 
such practices, which the Secretary determines appro-
priate for application to the Medicaid program in regula-
tions. Such regulations shall be effective as of July 1, 
2011, and shall prohibit payments to States under section 
1903 of the Social Security Act for any amounts expended 
for providing medical assistance for health care-acquired 
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•AMDT. NO. 2786 
conditions specified in the regulations. The regulations 
shall ensure that the prohibition on payment for health 
care-acquired conditions shall not result in a loss of access 
to care or services for Medicaid beneficiaries. 
(b) HEALTH CARE-ACQUIRED CONDITION.—In this 
section. the term ‘‘health care-acquired condition’’ means 
a medical condition for which an individual was diagnosed 
that could be identified by a secondary diagnostic code de-
scribed in section 1886(d)(4)(D)(iv) of the Social Security 
Act (42 U.S.C. 1395ww(d)(4)(D)(iv)). 
(c) MEDICARE PROVISIONS.—In carrying out this 
section, the Secretary shall apply to State plans (or waiv-
ers) under title XIX of the Social Security Act the regula-
tions promulgated pursuant to section 1886(d)(4)(D) of 
such Act (42 U.S.C. 1395ww(d)(4)(D)) relating to the 
prohibition of payments based on the presence of a sec-
ondary diagnosis code specified by the Secretary in such 
regulations, as appropriate for the Medicaid program. The 
Secretary may exclude certain conditions identified under 
title XVIII of the Social Security Act for non-payment 
under title XIX of such Act when the Secretary finds the 
inclusion of such conditions to be inapplicable to bene-
ficiaries under title XIX. 
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•AMDT. NO. 2786 
SEC. 2703. STATE OPTION TO PROVIDE HEALTH HOMES 
FOR ENROLLEES WITH CHRONIC CONDI-
TIONS. 
(a) STATE PLAN AMENDMENT.—Title XIX of the So-
cial Security Act (42 U.S.C. 1396a et seq.), as amended 
by sections 2201 and 2305, is amended by adding at the 
end the following new section: 
‘‘SEC. 1945. STATE OPTION TO PROVIDE COORDI-
NATED CARE THROUGH A HEALTH HOME FOR INDIVID-
UALS WITH CHRONIC CONDITIONS.— 
‘‘(a) 
IN
GENERAL.—Notwithstanding 
section 
1902(a)(1) 
(relating 
to 
statewideness), 
section 
1902(a)(10)(B) (relating to comparability), and any other 
provision of this title for which the Secretary determines 
it is necessary to waive in order to implement this section, 
beginning January 1, 2011, a State, at its option as a 
State plan amendment, may provide for medical assistance 
under this title to eligible individuals with chronic condi-
tions who select a designated provider (as described under 
subsection (h)(5)), a team of health care professionals (as 
described under subsection (h)(6)) operating with such a 
provider, or a health team (as described under subsection 
(h)(7)) as the individual’s health home for purposes of 
providing the individual with health home services. 
‘‘(b) HEALTH HOME QUALIFICATION STANDARDS.— 
The Secretary shall establish standards for qualification 
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•AMDT. NO. 2786 
as a designated provider for the purpose of being eligible 
to be a health home for purposes of this section. 
‘‘(c) PAYMENTS.— 
‘‘(1) IN GENERAL.—A State shall provide a des-
ignated provider, a team of health care professionals 
operating with such a provider, or a health team 
with payments for the provision of health home serv-
ices to each eligible individual with chronic condi-
tions that selects such provider, team of health care 
professionals, or health team as the individual’s 
health home. Payments made to a designated pro-
vider, a team of health care professionals operating 
with such a provider, or a health team for such serv-
ices shall be treated as medical assistance for pur-
poses of section 1903(a), except that, during the 
first 8 fiscal year quarters that the State plan 
amendment is in effect, the Federal medical assist-
ance percentage applicable to such payments shall be 
equal to 90 percent. 
‘‘(2) METHODOLOGY.— 
‘‘(A) IN GENERAL.—The State shall speci-
fy in the State plan amendment the method-
ology the State will use for determining pay-
ment for the provision of health home services. 
Such methodology for determining payment— 
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•AMDT. NO. 2786 
‘‘(i) may be tiered to reflect, with re-
spect to each eligible individual with chron-
ic conditions provided such services by a 
designated provider, a team of health care 
professionals operating with such a pro-
vider, or a health team, as well as the se-
verity or number of each such individual’s 
chronic conditions or the specific capabili-
ties of the provider, team of health care 
professionals, or health team; and 
‘‘(ii) shall be established consistent 
with section 1902(a)(30)(A). 
‘‘(B) ALTERNATE MODELS OF PAYMENT.— 
The methodology for determining payment for 
provision of health home services under this 
section shall not be limited to a per-member 
per-month basis and may provide (as proposed 
by the State and subject to approval by the 
Secretary) for alternate models of payment. 
‘‘(3) PLANNING GRANTS.— 
‘‘(A) IN GENERAL.—Beginning January 1, 
2011, the Secretary may award planning grants 
to States for purposes of developing a State 
plan amendment under this section. A planning 
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•AMDT. NO. 2786 
grant awarded to a State under this paragraph 
shall remain available until expended. 
‘‘(B) STATE
CONTRIBUTION.—A State 
awarded a planning grant shall contribute an 
amount equal to the State percentage deter-
mined under section 1905(b) (without regard to 
section 5001 of Public Law 111–5) for each fis-
cal year for which the grant is awarded. 
‘‘(C) LIMITATION.—The total amount of 
payments made to States under this paragraph 
shall not exceed $25,000,000. 
‘‘(d) HOSPITAL REFERRALS.—A State shall include 
in the State plan amendment a requirement for hospitals 
that are participating providers under the State plan or 
a waiver of such plan to establish procedures for referring 
any eligible individuals with chronic conditions who seek 
or need treatment in a hospital emergency department to 
designated providers. 
‘‘(e) COORDINATION.—A State shall consult and co-
ordinate, as appropriate, with the Substance Abuse and 
Mental Health Services Administration in addressing 
issues regarding the prevention and treatment of mental 
illness and substance abuse among eligible individuals with 
chronic conditions. 
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•AMDT. NO. 2786 
‘‘(f) MONITORING.—A State shall include in the State 
plan amendment— 
‘‘(1) a methodology for tracking avoidable hos-
pital readmissions and calculating savings that re-
sult from improved chronic care coordination and 
management under this section; and 
‘‘(2) a proposal for use of health information 
technology in providing health home services under 
this section and improving service delivery and co-
ordination across the care continuum (including the 
use of wireless patient technology to improve coordi-
nation and management of care and patient adher-
ence to recommendations made by their provider). 
‘‘(g) REPORT ON QUALITY MEASURES.—As a condi-
tion for receiving payment for health home services pro-
vided to an eligible individual with chronic conditions, a 
designated provider shall report to the State, in accord-
ance with such requirements as the Secretary shall specify, 
on all applicable measures for determining the quality of 
such services. When appropriate and feasible, a designated 
provider shall use health information technology in pro-
viding the State with such information. 
‘‘(h) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE
INDIVIDUAL
WITH
CHRONIC 
CONDITIONS.— 
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•AMDT. NO. 2786 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the term ‘eligible individual with 
chronic conditions’ means an individual who— 
‘‘(i) is eligible for medical assistance 
under the State plan or under a waiver of 
such plan; and 
‘‘(ii) has at least— 
‘‘(I) 2 chronic conditions; 
‘‘(II) 1 chronic condition and is 
at risk of having a second chronic 
condition; or 
‘‘(III) 1 serious and persistent 
mental health condition. 
‘‘(B) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall prevent the Secretary 
from establishing higher levels as to the number 
or severity of chronic or mental health condi-
tions for purposes of determining eligibility for 
receipt of health home services under this sec-
tion. 
‘‘(2) CHRONIC CONDITION.—The term ‘chronic 
condition’ has the meaning given that term by the 
Secretary and shall include, but is not limited to, the 
following: 
‘‘(A) A mental health condition. 
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•AMDT. NO. 2786 
‘‘(B) Substance use disorder. 
‘‘(C) Asthma. 
‘‘(D) Diabetes. 
‘‘(E) Heart disease. 
‘‘(F) Being overweight, as evidenced by 
having a Body Mass Index (BMI) over 25. 
‘‘(3) HEALTH HOME.—The term ‘health home’ 
means a designated provider (including a provider 
that operates in coordination with a team of health 
care professionals) or a health team selected by an 
eligible individual with chronic conditions to provide 
health home services. 
‘‘(4) HEALTH HOME SERVICES.— 
‘‘(A) IN
GENERAL.—The term ‘health 
home services’ means comprehensive and timely 
high-quality services described in subparagraph 
(B) that are provided by a designated provider, 
a team of health care professionals operating 
with such a provider, or a health team. 
‘‘(B) SERVICES DESCRIBED.—The services 
described in this subparagraph are— 
‘‘(i) comprehensive care management; 
‘‘(ii) care coordination and health pro-
motion; 
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•AMDT. NO. 2786 
‘‘(iii) comprehensive transitional care, 
including appropriate follow-up, from inpa-
tient to other settings; 
‘‘(iv) patient and family support (in-
cluding authorized representatives); 
‘‘(v) referral to community and social 
support services, if relevant; and 
‘‘(vi) use of health information tech-
nology to link services, as feasible and ap-
propriate. 
‘‘(5) DESIGNATED PROVIDER.—The term ‘des-
ignated provider’ means a physician, clinical practice 
or clinical group practice, rural clinic, community 
health center, community mental health center, 
home health agency, or any other entity or provider 
(including pediatricians, gynecologists, and obstetri-
cians) that is determined by the State and approved 
by the Secretary to be qualified to be a health home 
for eligible individuals with chronic conditions on the 
basis of documentation evidencing that the physi-
cian, practice, or clinic— 
‘‘(A) has the systems and infrastructure in 
place to provide health home services; and 
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•AMDT. NO. 2786 
‘‘(B) satisfies the qualification standards 
established by the Secretary under subsection 
(b). 
‘‘(6) 
TEAM
OF
HEALTH
CARE
PROFES-
SIONALS.—The term ‘team of health care profes-
sionals’ means a team of health professionals (as de-
scribed in the State plan amendment) that may— 
‘‘(A) include physicians and other profes-
sionals, such as a nurse care coordinator, nutri-
tionist, social worker, behavioral health profes-
sional, or any professionals deemed appropriate 
by the State; and 
‘‘(B) be free standing, virtual, or based at 
a hospital, community health center, community 
mental health center, rural clinic, clinical prac-
tice or clinical group practice, academic health 
center, or any entity deemed appropriate by the 
State and approved by the Secretary. 
‘‘(7) HEALTH TEAM.—The term ‘health team’ 
has the meaning given such term for purposes of 
section 3502 of the Patient Protection and Afford-
able Care Act.’’. 
(b) EVALUATION.— 
(1) INDEPENDENT EVALUATION.— 
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•AMDT. NO. 2786 
(A) IN
GENERAL.—The Secretary shall 
enter into a contract with an independent entity 
or organization to conduct an evaluation and 
assessment of the States that have elected the 
option to provide coordinated care through a 
health home for Medicaid beneficiaries with 
chronic conditions under section 1945 of the 
Social Security Act (as added by subsection (a)) 
for the purpose of determining the effect of 
such option on reducing hospital admissions, 
emergency room visits, and admissions to 
skilled nursing facilities. 
(B) EVALUATION REPORT.—Not later than 
January 1, 2017, the Secretary shall report to 
Congress on the evaluation and assessment con-
ducted under subparagraph (A). 
(2) SURVEY AND INTERIM REPORT.— 
(A) IN GENERAL.—Not later than January 
1, 2014, the Secretary of Health and Human 
Services shall survey States that have elected 
the option under section 1945 of the Social Se-
curity Act (as added by subsection (a)) and re-
port to Congress on the nature, extent, and use 
of such option, particularly as it pertains to— 
(i) hospital admission rates; 
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•AMDT. NO. 2786 
(ii) chronic disease management; 
(iii) coordination of care for individ-
uals with chronic conditions; 
(iv) assessment of program implemen-
tation; 
(v) processes and lessons learned (as 
described in subparagraph (B)); 
(vi) assessment of quality improve-
ments and clinical outcomes under such 
option; and 
(vii) estimates of cost savings. 
(B) 
IMPLEMENTATION
REPORTING.—A 
State that has elected the option under section 
1945 of the Social Security Act (as added by 
subsection (a)) shall report to the Secretary, as 
necessary, on processes that have been devel-
oped and lessons learned regarding provision of 
coordinated care through a health home for 
Medicaid beneficiaries with chronic conditions 
under such option. 
SEC. 2704. DEMONSTRATION PROJECT TO EVALUATE INTE-
GRATED CARE AROUND A HOSPITALIZATION. 
(a) AUTHORITY TO CONDUCT PROJECT.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the 
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•AMDT. NO. 2786 
‘‘Secretary’’) shall establish a demonstration project 
under title XIX of the Social Security Act to evalu-
ate the use of bundled payments for the provision of 
integrated care for a Medicaid beneficiary— 
(A) with respect to an episode of care that 
includes a hospitalization; and 
(B) for concurrent physicians services pro-
vided during a hospitalization. 
(2) DURATION.—The demonstration project 
shall begin on January 1, 2012, and shall end on 
December 31, 2016. 
(b) REQUIREMENTS.—The demonstration project 
shall be conducted in accordance with the following: 
(1) The demonstration project shall be con-
ducted in up to 8 States, determined by the Sec-
retary based on consideration of the potential to 
lower costs under the Medicaid program while im-
proving care for Medicaid beneficiaries. A State se-
lected to participate in the demonstration project 
may target the demonstration project to particular 
categories of beneficiaries, beneficiaries with par-
ticular diagnoses, or particular geographic regions of 
the State, but the Secretary shall insure that, as a 
whole, the demonstration project is, to the greatest 
extent possible, representative of the demographic 
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•AMDT. NO. 2786 
and geographic composition of Medicaid beneficiaries 
nationally. 
(2) The demonstration project shall focus on 
conditions where there is evidence of an opportunity 
for providers of services and suppliers to improve the 
quality of care furnished to Medicaid beneficiaries 
while reducing total expenditures under the State 
Medicaid programs selected to participate, as deter-
mined by the Secretary. 
(3) A State selected to participate in the dem-
onstration project shall specify the 1 or more epi-
sodes of care the State proposes to address in the 
project, the services to be included in the bundled 
payments, and the rationale for the selection of such 
episodes of care and services. The Secretary may 
modify the episodes of care as well as the services 
to be included in the bundled payments prior to or 
after approving the project. The Secretary may also 
vary such factors among the different States partici-
pating in the demonstration project. 
(4) The Secretary shall ensure that payments 
made under the demonstration project are adjusted 
for severity of illness and other characteristics of 
Medicaid beneficiaries within a category or having a 
diagnosis targeted as part of the demonstration 
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•AMDT. NO. 2786 
project. States shall ensure that Medicaid bene-
ficiaries are not liable for any additional cost sharing 
than if their care had not been subject to payment 
under the demonstration project. 
(5) Hospitals participating in the demonstration 
project shall have or establish robust discharge plan-
ning programs to ensure that Medicaid beneficiaries 
requiring post-acute care are appropriately placed in, 
or have ready access to, post-acute care settings. 
(6) The Secretary and each State selected to 
participate in the demonstration project shall ensure 
that the demonstration project does not result in the 
Medicaid beneficiaries whose care is subject to pay-
ment under the demonstration project being pro-
vided with less items and services for which medical 
assistance is provided under the State Medicaid pro-
gram than the items and services for which medical 
assistance would have been provided to such bene-
ficiaries under the State Medicaid program in the 
absence of the demonstration project. 
(c) WAIVER OF PROVISIONS.—Notwithstanding sec-
tion 1115(a) of the Social Security Act (42 U.S.C. 
1315(a)), the Secretary may waive such provisions of titles 
XIX, XVIII, and XI of that Act as may be necessary to 
accomplish the goals of the demonstration, ensure bene-
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•AMDT. NO. 2786 
ficiary access to acute and post-acute care, and maintain 
quality of care. 
(d) EVALUATION AND REPORT.— 
(1) DATA.—Each State selected to participate 
in the demonstration project under this section shall 
provide to the Secretary, in such form and manner 
as the Secretary shall specify, relevant data nec-
essary to monitor outcomes, costs, and quality, and 
evaluate the rationales for selection of the episodes 
of care and services specified by States under sub-
section (b)(3). 
(2) REPORT.—Not later than 1 year after the 
conclusion of the demonstration project, the Sec-
retary shall submit a report to Congress on the re-
sults of the demonstration project. 
SEC. 2705. MEDICAID GLOBAL PAYMENT SYSTEM DEM-
ONSTRATION PROJECT. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services (referred to in this section as the ‘‘Sec-
retary’’) shall, in coordination with the Center for Medi-
care and Medicaid Innovation (as established under sec-
tion 1115A of the Social Security Act, as added by section 
3021 of this Act), establish the Medicaid Global Payment 
System Demonstration Project under which a partici-
pating State shall adjust the payments made to an eligible 
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•AMDT. NO. 2786 
safety net hospital system or network from a fee-for-serv-
ice payment structure to a global capitated payment 
model. 
(b) DURATION
AND
SCOPE.—The demonstration 
project conducted under this section shall operate during 
a period of fiscal years 2010 through 2012. The Secretary 
shall select not more than 5 States to participate in the 
demonstration project. 
(c) ELIGIBLE SAFETY NET HOSPITAL SYSTEM OR 
NETWORK.—For purposes of this section, the term ‘‘eligi-
ble safety net hospital system or network’’ means a large, 
safety net hospital system or network (as defined by the 
Secretary) that operates within a State selected by the 
Secretary under subsection (b). 
(d) EVALUATION.— 
(1) TESTING.—The Innovation Center shall test 
and evaluate the demonstration project conducted 
under this section to examine any changes in health 
care quality outcomes and spending by the eligible 
safety net hospital systems or networks. 
(2) BUDGET NEUTRALITY.—During the testing 
period under paragraph (1), any budget neutrality 
requirements under section 1115A(b)(3) of the So-
cial Security Act (as so added) shall not be applica-
ble. 
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•AMDT. NO. 2786 
(3) MODIFICATION.—During the testing period 
under paragraph (1), the Secretary may, in the Sec-
retary’s discretion, modify or terminate the dem-
onstration project conducted under this section. 
(e) REPORT.—Not later than 12 months after the 
date of completion of the demonstration project under this 
section, the Secretary shall submit to Congress a report 
containing the results of the evaluation and testing con-
ducted under subsection (d), together with recommenda-
tions for such legislation and administrative action as the 
Secretary determines appropriate. 
(f) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as are nec-
essary to carry out this section. 
SEC. 2706. PEDIATRIC ACCOUNTABLE CARE ORGANIZATION 
DEMONSTRATION PROJECT. 
(a) AUTHORITY TO CONDUCT DEMONSTRATION.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services (referred to in this section as the 
‘‘Secretary’’) shall establish the Pediatric Account-
able Care Organization Demonstration Project to 
authorize a participating State to allow pediatric 
medical providers that meet specified requirements 
to be recognized as an accountable care organization 
for purposes of receiving incentive payments (as de-
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•AMDT. NO. 2786 
scribed under subsection (d)), in the same manner 
as an accountable care organization is recognized 
and provided with incentive payments under section 
1899 of the Social Security Act (as added by section 
3022). 
(2) DURATION.—The demonstration project 
shall begin on January 1, 2012, and shall end on 
December 31, 2016. 
(b) APPLICATION.—A State that desires to partici-
pate in the demonstration project under this section shall 
submit to the Secretary an application at such time, in 
such manner, and containing such information as the Sec-
retary may require. 
(c) REQUIREMENTS.— 
(1) PERFORMANCE
GUIDELINES.—The Sec-
retary, in consultation with the States and pediatric 
providers, shall establish guidelines to ensure that 
the quality of care delivered to individuals by a pro-
vider recognized as an accountable care organization 
under this section is not less than the quality of care 
that would have otherwise been provided to such in-
dividuals. 
(2) SAVINGS
REQUIREMENT.—A participating 
State, in consultation with the Secretary, shall es-
tablish an annual minimal level of savings in expend-
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•AMDT. NO. 2786 
itures for items and services covered under the Med-
icaid program under title XIX of the Social Security 
Act and the CHIP program under title XXI of such 
Act that must be reached by an accountable care or-
ganization in order for such organization to receive 
an incentive payment under subsection (d). 
(3) MINIMUM PARTICIPATION PERIOD.—A pro-
vider desiring to be recognized as an accountable 
care organization under the demonstration project 
shall enter into an agreement with the State to par-
ticipate in the project for not less than a 3-year pe-
riod. 
(d) INCENTIVE PAYMENT.—An accountable care or-
ganization that meets the performance guidelines estab-
lished by the Secretary under subsection (c)(1) and 
achieves savings greater than the annual minimal savings 
level established by the State under subsection (c)(2) shall 
receive an incentive payment for such year equal to a por-
tion (as determined appropriate by the Secretary) of the 
amount of such excess savings. The Secretary may estab-
lish an annual cap on incentive payments for an account-
able care organization. 
(e) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as are nec-
essary to carry out this section. 
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•AMDT. NO. 2786 
SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC DEM-
ONSTRATION PROJECT. 
(a) AUTHORITY
TO
CONDUCT
DEMONSTRATION 
PROJECT.—The Secretary of Health and Human Services 
(in this section referred to as the ‘‘Secretary’’) shall estab-
lish a demonstration project under which an eligible State 
(as described in subsection (c)) shall provide payment 
under the State Medicaid plan under title XIX of the So-
cial Security Act to an institution for mental diseases that 
is not publicly owned or operated and that is subject to 
the requirements of section 1867 of the Social Security 
Act (42 U.S.C. 1395dd) for the provision of medical as-
sistance available under such plan to individuals who— 
(1) have attained age 21, but have not attained 
age 65; 
(2) are eligible for medical assistance under 
such plan; and 
(3) require such medical assistance to stabilize 
an emergency medical condition. 
(b) STABILIZATION REVIEW.—A State shall specify 
in its application described in subsection (c)(1) establish 
a mechanism for how it will ensure that institutions par-
ticipating in the demonstration will determine whether or 
not such individuals have been stabilized (as defined in 
subsection (h)(5)) . This mechanism shall commence be-
fore the third day of the inpatient stay. States partici-
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•AMDT. NO. 2786 
pating in the demonstration project may manage the pro-
vision of services for the stabilization of medical emer-
gency conditions through utilization review, authorization, 
or management practices, or the application of medical ne-
cessity and appropriateness criteria applicable to behav-
ioral health. 
(c) ELIGIBLE STATE DEFINED.— 
(1) IN GENERAL.—An eligible State is a State 
that has made an application and has been selected 
pursuant to paragraphs (2) and (3). 
(2) APPLICATION.—A State seeking to partici-
pate in the demonstration project under this section 
shall submit to the Secretary, at such time and in 
such format as the Secretary requires, an applica-
tion that includes such information, provisions, and 
assurances, as the Secretary may require. 
(3) SELECTION.—A State shall be determined 
eligible for the demonstration by the Secretary on a 
competitive basis among States with applications 
meeting the requirements of paragraph (1). In se-
lecting State applications for the demonstration 
project, the Secretary shall seek to achieve an appro-
priate national balance in the geographic distribu-
tion of such projects. 
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•AMDT. NO. 2786 
(d) LENGTH OF DEMONSTRATION PROJECT.—The 
demonstration project established under this section shall 
be conducted for a period of 3 consecutive years. 
(e) LIMITATIONS ON FEDERAL FUNDING.— 
(1) APPROPRIATION.— 
(A) IN GENERAL.—Out of any funds in the 
Treasury not otherwise appropriated, there is 
appropriated 
to 
carry 
out 
this 
section, 
$75,000,000 for fiscal year 2011. 
(B) BUDGET AUTHORITY.—Subparagraph 
(A) constitutes budget authority in advance of 
appropriations Act and represents the obliga-
tion of the Federal Government to provide for 
the payment of the amounts appropriated under 
that subparagraph. 
(2) 
5-YEAR
AVAILABILITY.—Funds 
appro-
priated under paragraph (1) shall remain available 
for obligation through December 31, 2015. 
(3) LIMITATION
ON
PAYMENTS.—In no case 
may— 
(A) the aggregate amount of payments 
made by the Secretary to eligible States under 
this section exceed $75,000,000; or 
(B) payments be provided by the Secretary 
under this section after December 31, 2015. 
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•AMDT. NO. 2786 
(4) FUNDS
ALLOCATED
TO
STATES.—Funds 
shall be allocated to eligible States on the basis of 
criteria, including a State’s application and the 
availability of funds, as determined by the Secretary. 
(5) PAYMENTS
TO
STATES.—The Secretary 
shall pay to each eligible State, from its allocation 
under paragraph (4), an amount each quarter equal 
to the Federal medical assistance percentage of ex-
penditures in the quarter for medical assistance de-
scribed in subsection (a). As a condition of receiving 
payment, a State shall collect and report informa-
tion, as determined necessary by the Secretary, for 
the purposes of providing Federal oversight and con-
ducting an evaluation under subsection (f)(1). 
(f) EVALUATION AND REPORT TO CONGRESS.— 
(1) EVALUATION.—The Secretary shall conduct 
an evaluation of the demonstration project in order 
to determine the impact on the functioning of the 
health and mental health service system and on indi-
viduals enrolled in the Medicaid program and shall 
include the following: 
(A) An assessment of access to inpatient 
mental health services under the Medicaid pro-
gram; average lengths of inpatient stays; and 
emergency room visits. 
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•AMDT. NO. 2786 
(B) An assessment of discharge planning 
by participating hospitals. 
(C) An assessment of the impact of the 
demonstration project on the costs of the full 
range of mental health services (including inpa-
tient, emergency and ambulatory care). 
(D) An analysis of the percentage of con-
sumers with Medicaid coverage who are admit-
ted to inpatient facilities as a result of the dem-
onstration project as compared to those admit-
ted to these same facilities through other 
means. 
(E) A recommendation regarding whether 
the demonstration project should be continued 
after December 31, 2013, and expanded on a 
national basis. 
(2) REPORT.—Not later than December 31, 
2013, the Secretary shall submit to Congress and 
make available to the public a report on the findings 
of the evaluation under paragraph (1). 
(g) WAIVER AUTHORITY.— 
(1) IN GENERAL.—The Secretary shall waive 
the limitation of subdivision (B) following paragraph 
(28) of section 1905(a) of the Social Security Act 
(42 U.S.C. 1396d(a)) (relating to limitations on pay-
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•AMDT. NO. 2786 
ments for care or services for individuals under 65 
years of age who are patients in an institution for 
mental diseases) for purposes of carrying out the 
demonstration project under this section. 
(2) LIMITED OTHER WAIVER AUTHORITY.—The 
Secretary may waive other requirements of titles XI 
and XIX of the Social Security Act (including the 
requirements of sections 1902(a)(1) (relating to 
statewideness) and 1902(1)(10)(B) (relating to com-
parability)) only to extent necessary to carry out the 
demonstration project under this section. 
(h) DEFINITIONS.—In this section: 
(1) EMERGENCY
MEDICAL
CONDITION.—The 
term ‘‘emergency medical condition’’ means, with re-
spect to an individual, an individual who expresses 
suicidal or homicidal thoughts or gestures, if deter-
mined dangerous to self or others. 
(2) FEDERAL MEDICAL ASSISTANCE PERCENT-
AGE.—The term ‘‘Federal medical assistance per-
centage’’ has the meaning given that term with re-
spect to a State under section 1905(b) of the Social 
Security Act (42 U.S.C. 1396d(b)). 
(3) INSTITUTION FOR MENTAL DISEASES.—The 
term ‘‘institution for mental diseases’’ has the mean-
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553 
•AMDT. NO. 2786 
ing given to that term in section 1905(i) of the So-
cial Security Act (42 U.S.C. 1396d(i)). 
(4) MEDICAL ASSISTANCE.—The term ‘‘medical 
assistance’’ has the meaning given that term in sec-
tion 1905(a) of the Social Security Act (42 U.S.C. 
1396d(a)). 
(5) 
STABILIZED.—The 
term 
‘‘stabilized’’ 
means, with respect to an individual, that the emer-
gency medical condition no longer exists with respect 
to the individual and the individual is no longer dan-
gerous to self or others. 
(6) STATE.—The term ‘‘State’’ has the mean-
ing given that term for purposes of title XIX of the 
Social Security Act (42 U.S.C. 1396 et seq.). 
Subtitle J—Improvements to the 
Medicaid and CHIP Payment 
and 
Access 
Commission 
(MACPAC) 
SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING 
ALL MEDICAID BENEFICIARIES. 
(a) IN GENERAL.—Section 1900 of the Social Secu-
rity Act (42 U.S.C. 1396) is amended— 
(1) in subsection (b)— 
(A) in paragraph (1)— 
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•AMDT. NO. 2786 
(i) in the paragraph heading, by in-
serting ‘‘FOR ALL STATES’’ before ‘‘AND 
ANNUAL’’; and 
(ii) in subparagraph (A), by striking 
‘‘children’s’’; 
(iii) in subparagraph (B), by inserting 
‘‘, the Secretary, and States’’ after ‘‘Con-
gress’’; 
(iv) in subparagraph (C), by striking 
‘‘March 1’’ and inserting ‘‘March 15’’; and 
(v) in subparagraph (D), by striking 
‘‘June 1’’ and inserting ‘‘June 15’’; 
(B) in paragraph (2)— 
(i) in subparagraph (A)— 
(I) in clause (i)— 
(aa) by inserting ‘‘the effi-
cient provision of’’ after ‘‘expend-
itures for’’; and 
(bb) by striking ‘‘hospital, 
skilled nursing facility, physician, 
Federally-qualified health center, 
rural health center, and other 
fees’’ and inserting ‘‘payments to 
medical, dental, and health pro-
fessionals, hospitals, residential 
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•AMDT. NO. 2786 
and long-term care providers, 
providers of home and commu-
nity based services, Federally- 
qualified health centers and rural 
health clinics, managed care enti-
ties, and providers of other cov-
ered items and services’’; and 
(II) in clause (iii), by inserting 
‘‘(including how such factors and 
methodologies 
enable 
such 
bene-
ficiaries to obtain the services for 
which they are eligible, affect provider 
supply, and affect providers that serve 
a disproportionate share of low-income 
and other vulnerable populations)’’ 
after ‘‘beneficiaries’’; 
(ii) by redesignating subparagraphs 
(B) and (C) as subparagraphs (F) and 
(H), respectively; 
(iii) by inserting after subparagraph 
(A), the following: 
‘‘(B) 
ELIGIBILITY
POLICIES.—Medicaid 
and CHIP eligibility policies, including a deter-
mination of the degree to which Federal and 
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•AMDT. NO. 2786 
State policies provide health care coverage to 
needy populations. 
‘‘(C) ENROLLMENT AND RETENTION PROC-
ESSES.—Medicaid and CHIP enrollment and 
retention processes, including a determination 
of the degree to which Federal and State poli-
cies encourage the enrollment of individuals 
who are eligible for such programs and screen 
out individuals who are ineligible, while mini-
mizing the share of program expenses devoted 
to such processes. 
‘‘(D) COVERAGE POLICIES.—Medicaid and 
CHIP benefit and coverage policies, including a 
determination of the degree to which Federal 
and State policies provide access to the services 
enrollees require to improve and maintain their 
health and functional status. 
‘‘(E) QUALITY
OF
CARE.—Medicaid and 
CHIP policies as they relate to the quality of 
care provided under those programs, including 
a determination of the degree to which Federal 
and State policies achieve their stated goals and 
interact with similar goals established by other 
purchasers of health care services.’’; 
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•AMDT. NO. 2786 
(iv) by inserting after subparagraph 
(F) (as redesignated by clause (ii) of this 
subparagraph), the following: 
‘‘(G) INTERACTIONS WITH MEDICARE AND 
MEDICAID.—Consistent with paragraph (11), 
the interaction of policies under Medicaid and 
the Medicare program under title XVIII, in-
cluding with respect to how such interactions 
affect access to services, payments, and dual el-
igible individuals.’’ and 
(v) in subparagraph (H) (as so redes-
ignated), by inserting ‘‘and preventive, 
acute, and long-term services and sup-
ports’’ after ‘‘barriers’’; 
(C) 
by 
redesignating 
paragraphs 
(3) 
through (9) as paragraphs (4) through (10), re-
spectively; 
(D) by inserting after paragraph (2), the 
following new paragraph: 
‘‘(3) RECOMMENDATIONS
AND
REPORTS
OF 
STATE-SPECIFIC DATA.—MACPAC shall— 
‘‘(A) review national and State-specific 
Medicaid and CHIP data; and 
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•AMDT. NO. 2786 
‘‘(B) submit reports and recommendations 
to Congress, the Secretary, and States based on 
such reviews.’’; 
(E) in paragraph (4), as redesignated by 
subparagraph (C), by striking ‘‘or any other 
problems’’ and all that follows through the pe-
riod and inserting ‘‘, as well as other factors 
that adversely affect, or have the potential to 
adversely affect, access to care by, or the health 
care status of, Medicaid and CHIP bene-
ficiaries. MACPAC shall include in the annual 
report required under paragraph (1)(D) a de-
scription of all such areas or problems identi-
fied with respect to the period addressed in the 
report.’’; 
(F) in paragraph (5), as so redesig-
nated,— 
(i) in the paragraph heading, by in-
serting ‘‘AND
REGULATIONS’’ after ‘‘RE-
PORTS’’; and 
(ii) by striking ‘‘If’’ and inserting the 
following: 
‘‘(A) CERTAIN SECRETARIAL REPORTS.— 
If’’; and 
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•AMDT. NO. 2786 
(iii) in the second sentence, by insert-
ing ‘‘and the Secretary’’ after ‘‘appropriate 
committees of Congress’’; and 
(iv) by adding at the end the fol-
lowing: 
‘‘(B) REGULATIONS.—MACPAC shall re-
view Medicaid and CHIP regulations and may 
comment through submission of a report to the 
appropriate committees of Congress and the 
Secretary, on any such regulations that affect 
access, quality, or efficiency of health care.’’; 
(G) in paragraph (10), as so redesignated, 
by inserting ‘‘, and shall submit with any rec-
ommendations, a report on the Federal and 
State-specific budget consequences of the rec-
ommendations’’ before the period; and 
(H) by adding at the end the following: 
‘‘(11) 
CONSULTATION
AND
COORDINATION 
WITH MEDPAC.— 
‘‘(A) IN GENERAL.—MACPAC shall con-
sult with the Medicare Payment Advisory Com-
mission (in this paragraph referred to as 
‘MedPAC’) established under section 1805 in 
carrying out its duties under this section, as ap-
propriate and particularly with respect to the 
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•AMDT. NO. 2786 
issues specified in paragraph (2) as they relate 
to those Medicaid beneficiaries who are dually 
eligible for Medicaid and the Medicare program 
under title XVIII, adult Medicaid beneficiaries 
(who are not dually eligible for Medicare), and 
beneficiaries under Medicare. Responsibility for 
analysis of and recommendations to change 
Medicare policy regarding Medicare bene-
ficiaries, including Medicare beneficiaries who 
are dually eligible for Medicare and Medicaid, 
shall rest with MedPAC. 
‘‘(B) INFORMATION
SHARING.—MACPAC 
and MedPAC shall have access to deliberations 
and records of the other such entity, respec-
tively, upon the request of the other such enti-
ty. 
‘‘(12) 
CONSULTATION
WITH
STATES.— 
MACPAC shall regularly consult with States in car-
rying out its duties under this section, including 
with respect to developing processes for carrying out 
such duties, and shall ensure that input from States 
is taken into account and represented in MACPAC’s 
recommendations and reports. 
‘‘(13) COORDINATE AND CONSULT WITH THE 
FEDERAL COORDINATED HEALTH CARE OFFICE.— 
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•AMDT. NO. 2786 
MACPAC shall coordinate and consult with the Fed-
eral Coordinated Health Care Office established 
under section 2081 of the Patient Protection and 
Affordable Care Act before making any rec-
ommendations regarding dual eligible individuals. 
‘‘(14) PROGRAMMATIC OVERSIGHT VESTED IN 
THE
SECRETARY.—MACPAC’s authority to make 
recommendations in accordance with this section 
shall not affect, or be considered to duplicate, the 
Secretary’s authority to carry out Federal respon-
sibilities with respect to Medicaid and CHIP.’’; 
(2) in subsection (c)(2)— 
(A) by striking subparagraphs (A) and (B) 
and inserting the following: 
‘‘(A) IN
GENERAL.—The membership of 
MACPAC shall include individuals who have 
had direct experience as enrollees or parents or 
caregivers of enrollees in Medicaid or CHIP and 
individuals with national recognition for their 
expertise in Federal safety net health programs, 
health finance and economics, actuarial science, 
health plans and integrated delivery systems, 
reimbursement for health care, health informa-
tion technology, and other providers of health 
services, public health, and other related fields, 
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•AMDT. NO. 2786 
who provide a mix of different professions, 
broad geographic representation, and a balance 
between urban and rural representation. 
‘‘(B) INCLUSION.—The membership of 
MACPAC shall include (but not be limited to) 
physicians, dentists, and other health profes-
sionals, employers, third-party payers, and indi-
viduals with expertise in the delivery of health 
services. Such membership shall also include 
representatives of children, pregnant women, 
the elderly, individuals with disabilities, care-
givers, and dual eligible individuals, current or 
former representatives of State agencies respon-
sible for administering Medicaid, and current or 
former representatives of State agencies respon-
sible for administering CHIP.’’. 
(3) in subsection (d)(2), by inserting ‘‘and 
State’’ after ‘‘Federal’’; 
(4) in subsection (e)(1), in the first sentence, by 
inserting ‘‘and, as a condition for receiving payments 
under sections 1903(a) and 2105(a), from any State 
agency responsible for administering Medicaid or 
CHIP,’’ after ‘‘United States’’; and 
(5) in subsection (f)— 
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•AMDT. NO. 2786 
(A) in the subsection heading, by striking 
‘‘AUTHORIZATION
OF APPROPRIATIONS’’ and 
inserting ‘‘FUNDING’’; 
(B) in paragraph (1), by inserting ‘‘(other 
than for fiscal year 2010)’’ before ‘‘in the same 
manner’’; and 
(C) by adding at the end the following: 
‘‘(3) FUNDING FOR FISCAL YEAR 2010.— 
‘‘(A) IN GENERAL.—Out of any funds in 
the Treasury not otherwise appropriated, there 
is appropriated to MACPAC to carry out the 
provisions of this section for fiscal year 2010, 
$9,000,000. 
‘‘(B) TRANSFER
OF
FUNDS.—Notwith-
standing 
section 
2104(a)(13), 
from 
the 
amounts appropriated in such section for fiscal 
year 2010, $2,000,000 is hereby transferred 
and made available in such fiscal year to 
MACPAC to carry out the provisions of this 
section. 
‘‘(4) AVAILABILITY.—Amounts made available 
under paragraphs (2) and (3) to MACPAC to carry 
out the provisions of this section shall remain avail-
able until expended.’’. 
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•AMDT. NO. 2786 
(b) CONFORMING MEDPAC AMENDMENTS.—Section 
1805(b) of the Social Security Act (42 U.S.C. 1395b– 
6(b)), is amended— 
(1) in paragraph (1)(C), by striking ‘‘March 1 
of each year (beginning with 1998)’’ and inserting 
‘‘March 15’’; 
(2) in paragraph (1)(D), by inserting ‘‘, and 
(beginning with 2012) containing an examination of 
the topics described in paragraph (9), to the extent 
feasible’’ before the period; and 
(3) by adding at the end the following: 
‘‘(9) REVIEW AND ANNUAL REPORT ON MED-
ICAID AND COMMERCIAL TRENDS.—The Commission 
shall review and report on aggregate trends in 
spending, utilization, and financial performance 
under the Medicaid program under title XIX and 
the private market for health care services with re-
spect to providers for which, on an aggregate na-
tional basis, a significant portion of revenue or serv-
ices is associated with the Medicaid program. Where 
appropriate, the Commission shall conduct such re-
view in consultation with the Medicaid and CHIP 
Payment and Access Commission established under 
section 1900 (in this section referred to as 
‘MACPAC’). 
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565 
•AMDT. NO. 2786 
‘‘(10) COORDINATE AND CONSULT WITH THE 
FEDERAL COORDINATED HEALTH CARE OFFICE.— 
The Commission shall coordinate and consult with 
the Federal Coordinated Health Care Office estab-
lished under section 2081 of the Patient Protection 
and Affordable Care Act before making any rec-
ommendations regarding dual eligible individuals. 
‘‘(11) INTERACTION OF MEDICAID AND MEDI-
CARE.—The 
Commission 
shall 
consult 
with 
MACPAC in carrying out its duties under this sec-
tion, as appropriate. Responsibility for analysis of 
and recommendations to change Medicare policy re-
garding Medicare beneficiaries, including Medicare 
beneficiaries who are dually eligible for Medicare and 
Medicaid, shall rest with the Commission. Responsi-
bility for analysis of and recommendations to change 
Medicaid policy regarding Medicaid beneficiaries, in-
cluding Medicaid beneficiaries who are dually eligible 
for 
Medicare 
and 
Medicaid, 
shall 
rest 
with 
MACPAC.’’. 
Subtitle K—Protections for Amer-
ican Indians and Alaska Natives 
SEC. 2901. SPECIAL RULES RELATING TO INDIANS. 
(a) NO COST-SHARING FOR INDIANS WITH INCOME 
AT OR BELOW 300 PERCENT OF POVERTY ENROLLED IN 
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•AMDT. NO. 2786 
COVERAGE THROUGH A STATE EXCHANGE.—For provi-
sions prohibiting cost sharing for Indians enrolled in any 
qualified health plan in the individual market through an 
Exchange, see section 1402(d) of the Patient Protection 
and Affordable Care Act. 
(b) PAYER OF LAST RESORT.—Health programs op-
erated by the Indian Health Service, Indian tribes, tribal 
organizations, and Urban Indian organizations (as those 
terms are defined in section 4 of the Indian Health Care 
Improvement Act (25 U.S.C. 1603)) shall be the payer 
of last resort for services provided by such Service, tribes, 
or organizations to individuals eligible for services through 
such programs, notwithstanding any Federal, State, or 
local law to the contrary. 
(c) FACILITATING ENROLLMENT OF INDIANS UNDER 
THE
EXPRESS
LANE
OPTION.—Section 
1902(e)(13)(F)(ii) of the Social Security Act (42 U.S.C. 
1396a(e)(13)(F)(ii)) is amended— 
(1) in the clause heading, by inserting ‘‘AND IN-
DIAN
TRIBES
AND
TRIBAL
ORGANIZATIONS’’ after 
‘‘AGENCIES’’; and 
(2) by adding at the end the following: 
‘‘(IV) The Indian Health Service, 
an Indian Tribe, Tribal Organization, 
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802 
•AMDT. NO. 2786 
SEC. 3105. EXTENSION OF AMBULANCE ADD-ONS. 
(a) GROUND AMBULANCE.—Section 1834(l)(13)(A) 
of the Social Security Act (42 U.S.C. 1395m(l)(13)(A)) 
is amended— 
(1) in the matter preceding clause (i)— 
(A) by striking ‘‘2007, and for’’ and in-
serting ‘‘2007, for’’; and 
(B) by striking ‘‘2010’’ and inserting 
‘‘2010, and for such services furnished on or 
after April 1, 2010, and before January 1, 
2011,’’; and 
(2) in each of clauses (i) and (ii), by inserting 
‘‘, and on or after April 1, 2010, and before January 
1, 2011’’ after ‘‘January 1, 2010’’ each place it ap-
pears. 
(b) AIR AMBULANCE.—Section 146(b)(1) of the 
Medicare Improvements for Patients and Providers Act of 
2008 (Public Law 110–275) is amended by striking ‘‘De-
cember 31, 2009’’ and inserting ‘‘December 31, 2009, and 
during the period beginning on April 1, 2010, and ending 
on January 1, 2011’’. 
(c) 
SUPER
RURAL
AMBULANCE.—Section 
1834(l)(12)(A) of the Social Security Act (42 U.S.C. 
1395m(l)(12)(A)) is amended by striking ‘‘2010’’ and in-
serting ‘‘2010, and on or after April 1, 2010, and before 
January 1, 2011’’. 
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