199
tives, and the Committee on Aging of the Senate a report
on the operation of the rebate agreements required for
covered outpatient drugs under this section in the preced-
ing fiscal year, and shall include in the report such infor-
mation in addition to the information required to be re-
ported under section 601(d) of the Veterans Health Care
Act of 1992 as the Secretary considers appropriate.’’.
(9) Section 1927(j) (42 U.S.C. 1396r–8(j)) is amend-
ed to read as follows:
‘‘(j) EXEMPTION FROM CERTAIN REQUIREMENTS
FOR CERTAIN HEALTH MAINTENANCE ORGANIZATIONS
AND HOSPITALS.—
‘‘(1) CERTAIN HEALTH MAINTENANCE ORGANI-
ZATIONS
AND
PHARMACIES.—The requirements of
subsections (g) and (h) shall not apply with respect
to covered outpatient drugs dispensed by—
‘‘(A) an entity which receives payment
under a prepaid capitation basis or under any
other risk basis in accordance with section
1903(m)(2)(A) for services provided under the
State plan; or
‘‘(B) a pharmacy that is owned or operated
by a qualified health maintenance organization
(as defined in section 1310(d) of the Public
200
Health Service Act) that operates its own pro-
spective drug use review program.
‘‘(2) HOSPITALS
WITH
INDEPENDENT
FOR-
MULARY SYSTEMS.—
‘‘(A) IN GENERAL.—The requirements of
subsections (g) and (h) shall not apply with re-
spect to covered outpatient drugs dispensed by
a hospital providing medical assistance under
the State plan that dispenses such drugs under
a drug formulary system.
‘‘(B) 
APPLICATION
OF
STATE
FOR-
MULARY.—Nothing in subparagraph (A) shall
be construed to permit payment to be made
under the State plan for a covered outpatient
drug that is included in a drug formulary but
that is not included in the State formulary
under subsection (d)(5).
‘‘(3) CONSTRUCTION
IN
DETERMINING
BEST
PRICE.—Nothing in this subsection shall be con-
strued to exclude any covered outpatient drugs sub-
ject to the provisions of this subsection from the de-
termination of the best price (as defined in sub-
section (c)(1)(C)) for such drugs.’’.
(10) Section 1927(k) (42 U.S.C. 1396r–8(k)) is
amended—
201
(A) in paragraph (1), by striking ‘‘calendar
quarter’’ and inserting ‘‘rebate period’’;
(B) in paragraph (2)—
(i) in the matter before clause (i) of sub-
paragraph (A), strike ‘‘paragraph (5)’’ and in-
sert ‘‘subparagraph (D)’’,
(ii) by striking ‘‘and’’ at the end of sub-
paragraph (A),
(iii) by striking the period at the end of
subparagraph (C) and inserting ‘‘; and’’, and
(iv) by adding at the end the following new
subparagraph:
‘‘(D) a drug which may be sold without a
prescription (commonly referred to as an ‘over-
the-counter drug’), if the drug is prescribed by
a physician (or other person authorized to pre-
scribe under State law).’’;
(C) in paragraph (3)—
(i) in subparagraph (E), by striking ‘‘****
emergency room visits’’,
(ii) in subparagraph (F), by striking
‘‘sevices’’ and inserting ‘‘services’’, and
(iii) in subparagraph (H), by inserting
‘‘services’’ after ‘‘dialysis’’;
(D) by striking paragraph (4);
202
(E) by amending paragraph (5) to read as fol-
lows:
‘‘(5) MANUFACTURER.—The term ‘manufac-
turer’ means, with respect to a covered outpatient
drug—
‘‘(A) the entity (if any) that both manufac-
tures and distributes the drug, or
‘‘(B) if no such entity exists, the entity
that distributes the drug.
Such term does not include a wholesale distributor
of the drug that does not hold a National Drug Code
number for the drug or a retail pharmacy licensed
under State law.’’;
(F) in paragraph (6), by striking ‘‘, which ap-
pears’’ and all that follows and inserting ‘‘which is
accepted by any of the compendia described in sub-
section (g)(2)(C)(ii).’’;
(G) in paragraph (7)—
(i) in subparagraph (A)(i), by striking
‘‘calendar quarter’’ and inserting ‘‘rebate pe-
riod’’,
(ii) in subparagraph (A)(i), by striking
‘‘paragraph (5)’’ and inserting ‘‘paragraph
(2)(D)’’,
203
(iii) in subparagraph (A)(ii), by inserting
‘‘or product licensing application’’ after ‘‘appli-
cation’’,
(iv) in subparagraph (C)(i), by striking
‘‘pharmaceuutically’’ and inserting ‘‘pharma-
ceutically’’, and
(v) in subparagraph (C)(iii), by striking ‘‘,
provided that’’ and inserting ‘‘and’’; and
(H) by redesignating paragraph (8) as para-
graph (9) and by inserting after paragraph (7) the
following new paragraph:
‘‘(8) REBATE PERIOD.—The term ‘rebate pe-
riod’ means, with respect to an agreement under
subsection (a), a calendar quarter or other period
specified with respect to the agreement under sub-
section (b)(1)(A) for the payment of rebates.’’.
(d) FUNDING.—Section 4401(b)(2) of OBRA–1990
is amended by striking ‘‘75 percent,’’ and all that follows
and inserting ‘‘75 percent.’’.
(e) 
DEMONSTRATION
PROJECTS.—Section
4401(c)(1) of OBRA–1990 is amended—
(A) in subparagraph (A), by striking ‘‘10’’ and
inserting ‘‘5’’; and
(B) in subparagraph (C), by striking ‘‘regi-
ment’’ and inserting ‘‘regimen’’.
204
(f) STUDIES.—Section 4401(d) of OBRA–1990 is
amended—
(1) in paragraph (1)(A), by striking ‘‘other in-
stitutional facilities, and managed care plans’’ and
inserting ‘‘nursing facilities, intermediate care facili-
ties for the mentally retarded, and health mainte-
nance organizations’’;
(2) in paragraph (1)(B), by striking ‘‘under
this subsection’’ and inserting ‘‘under this para-
graph’’;
(3) in paragraph (1)(B)(i), by striking ‘‘under
this section’’ and inserting ‘‘under section 1927 of
the Social Security Act’’;
(4) in paragraph (1)(B)(ii)—
(A) by striking ‘‘drug use review’’ and in-
serting ‘‘the type of drug use review that is’’,
and
(B) by striking ‘‘under this section’’ and
inserting ‘‘under such section’’;
(5) in paragraph (1)(B)(iii), by striking ‘‘under
this title’’ and inserting ‘‘under title XIX of the So-
cial Security Act’’;
(6) in paragraph (1)(C)—
(A) by striking ‘‘May 1, 1991’’ and insert-
ing ‘‘May 1, 1992’’, and
205
(B) by striking ‘‘hereafter’’;
(7) in paragraph (2), by striking ‘‘the Commit-
tees on Aging of the Senate and House of Rep-
resentatives an annual report and inserting ‘‘the
Committee on Aging of the Senate a report’’;
(8) in paragraph (3)—
(A) in subparagraph (A), by striking ‘‘,
acting in consultation with the Comptroller
General,’’,
(B) by indenting subparagraph (B) an ad-
ditional 2 ems, and
(C) in subparagraph (B)—
(i) by striking ‘‘December 31, 1991,
the Secretary and the Comptroller Gen-
eral’’ and inserting ‘‘June 1, 1993, the
Secretary’’, and
(ii) by striking ‘‘the Committees on
Aging of the Senate and the House of Rep-
resentatives’’ and inserting ‘‘the Commit-
tee on Aging of the Senate’’;
(9) in paragraph (4)(A), by striking ‘‘each’’ and
by striking the semicolon and inserting a comma;
and
(10) by striking paragraphs (5) and (6).
206
PART III—RESTRICTIONS ON DIVESTITURE OF
ASSETS AND ESTATE RECOVERY
SEC. 5111. TRANSFER OF ASSETS.
(a) PERIOD OF INELIGIBILITY.—
(1) EXTENDING
LOOK-BACK
PERIOD
TO
MONTHS.—Section 
1917(c)(1) 
(42 
U.S.C.
1396p(c)(1)) is amended by striking ‘‘30-month pe-
riod’’ and inserting ‘‘36-month period’’.
(2) ELIMINATING 30-MONTH LIMIT ON PERIOD
OF
INELIGIBILITY.—The second sentence of such
section is amended by striking ‘‘equal to’’ and all
that follows and inserting the following: ‘‘equal to—
‘‘(A) the total uncompensated value of the re-
sources so transferred; divided by
‘‘(B) the average monthly cost, to a private pa-
tient at the time of the application, of nursing facil-
ity services in the State or, at State option, in the
community in which the individual is institutional-
ized.’’.
(3) CUMULATIVE PERIODS OF INELIGIBILITY IN
THE
CASE
OF
MULTIPLE
TRANSFERS.—Such sen-
tence is further amended by inserting ‘‘(or, in the
case of a transfer which occurs during a period of
ineligibility attributable to a previous transfer, the
first month after the end of all periods of ineligibil-
207
ity attributable to any previous transfer)’’ after
‘‘shall begin with the month in which such resources
were transferred’’.
(b) CRITERIA FOR UNDUE HARDSHIP EXCEPTION.—
Section 1917(c)(2)(D) (42 U.S.C. 1396p(c)(2)(D)) is
amended to read as follows:
‘‘(D) the State agency determines, under proce-
dures established by the State (in accordance with
standards specified by the Secretary) that the denial
of eligibility would work an undue hardship (in ac-
cordance with criteria established by the Sec-
retary).’’.
(c) TREATMENT OF JOINTLY HELD ASSETS.—Sec-
tion 1917(c) (42 U.S.C. 1936p(c)) is further amended by
adding at the end the following new paragraph:
‘‘(6) For purposes of this subsection, in the case of
an asset held by an individual in common with another
person or persons in a joint tenancy or a similar arrange-
ment, the asset (or the affected portion thereof) shall be
considered to be transferred by such individual when any
action is taken, either by such individual or by any other
person, that reduces or eliminates such individual’s owner-
ship or control of such asset.’’.
208
(d) 
MEDICAID
QUALIFYING
TRUSTS.—Section
1902(k) (42 U.S.C. 1396a(k)) is amended to read as fol-
lows:
‘‘(k) TREATMENT OF TRUST AMOUNTS.—
‘‘(1) IN GENERAL.—For purposes of determin-
ing an individual’s eligibility for or amount of bene-
fits under a State plan under this title, subject to
paragraph (4), the following rules shall apply to a
trust (which term includes, for purposes of this sub-
section, any similar legal instrument or device, such
as an annuity) established by such individual:
‘‘(A) REVOCABLE TRUSTS.—In the case of
a revocable trust—
‘‘(i) the corpus of the trust shall be
considered resources available to the indi-
vidual,
‘‘(ii) payments from the trust to or
for the benefit of the individual shall be
considered income of the individual, and
‘‘(iii) any other payments from the
trust shall be considered a transfer of as-
sets by the individual subject to section
1917(c).
‘‘(B) IRREVOCABLE
TRUSTS
WHICH
MAY
BENEFIT GRANTOR.—In the case of an irrev-
209
ocable trust, if there are any circumstances
under which payment from the trust could be
made to or for the benefit of the individual—
‘‘(i) the corpus of the trust (or that
portion of the corpus from which, or from
the increase whereof, payment to the indi-
vidual could be made) shall be considered
resources available to the individual, and
payments from that portion of the corpus
(or increase)—
‘‘(I) to or for the benefit of the
individual, shall be considered income
of the individual, and
‘‘(II) for any other purpose, shall
be considered a transfer of assets by
the individual subject to the provisions
of section 1917(c); and
‘‘(ii) any portion of the trust from
which (or from the income whereof) no
payment could under any circumstances be
made to the individual shall be considered,
as of the date of establishment of the trust
(or, if later, the date on which payment to
the individual was foreclosed), a transfer of
assets by the individual subject to section
210
1917(c), and payments from such portion
of the trust after such date shall be dis-
regarded.
‘‘(C) IRREVOCABLE TRUSTS WHICH CAN-
NOT BENEFIT GRANTOR.—In the case of an ir-
revocable trust, if no payment may be made
from the trust under any circumstances to or
for the benefit of the individual—
‘‘(i) the corpus of the trust shall be
considered, as of the date of establishment
of the trust (or, if later, the date on which
payment to the individual was foreclosed),
a transfer of assets subject to section
1917(c), and
‘‘(ii) payments from the trust after
the date specified in clause (i) shall be dis-
regarded.
‘‘(2) DETERMINATION OF GRANTOR.—
‘‘(A) TREATMENT OF ACTS BY INDIVIDUAL
AND OTHERS.—For purposes of this subsection,
an individual shall be considered to have estab-
lished a trust if—
‘‘(i) the individual (or the individual’s
spouse), or a person (including a court or
administrative body) with legal authority
211
to act in place of or on behalf of such indi-
vidual (or spouse), or any person (includ-
ing any court or administrative body) act-
ing at the direction or upon the request of
such individual (or spouse), established
(other than by will) such a trust, and
‘‘(ii) assets of the individual (as de-
fined in subparagraph (B)) were used to
form all or part of the corpus of such
trust.
‘‘(B) ASSETS.—For purposes of this para-
graph, assets of an individual include all income
and resources of the individual and of the indi-
vidual’s spouse, including any income or re-
sources which the individual (or spouse) is enti-
tled to but does not receive because of action by
the individual (or spouse), by a person (includ-
ing a court or administrative body) with legal
authority to act in place of or on behalf of such
individual (or spouse), or by any person (includ-
ing any court or administrative body) acting at
the direction or upon the request of such indi-
vidual (or spouse).
‘‘(C) TRUSTS
CONTAINING
ASSETS
OF
MORE THAN ONE INDIVIDUAL.—In the case of
212
a trust whose corpus includes assets of an indi-
vidual (as determined pursuant to subpara-
graph (A)) and assets of any other person or
persons, the provisions of this subsection shall
apply to the portion of the trust attributable to
the assets of the individual.
‘‘(3) APPLICATION; RELATION TO OTHER PRO-
VISIONS.—Subject to paragraph (4), this subsection
shall apply without regard to—
‘‘(A) the purposes for which the trust is es-
tablished,
‘‘(B) whether the trustees have or exercise
any discretion under the trust,
‘‘(C) any restrictions on when or whether
distributions may be made from the trust, or
‘‘(D) any restrictions on the use of dis-
tributions from the trust.
‘‘(4) EXCEPTIONS AND HARDSHIP WAIVER.—
‘‘(A) EXCEPTION FOR CERTAIN TRUSTS.—
This subsection shall not apply to any of the
following trusts:
‘‘(i) A trust established for the benefit
of a disabled individual (as determined
under section 1614(a)(3)) by a parent,
213
grandparent, or other representative payee
of the individual.
‘‘(ii) A trust established in a State for
the benefit of an individual if—
‘‘(I) the trust is composed only of
pension, Social Security, and other in-
come to the individual (and accumu-
lated income in the trust),
‘‘(II) the State will receive any
amounts remaining in the trust upon
the death of the individual, and
‘‘(III) the State makes medical
assistance available to individuals de-
scribed 
in 
section
1902(a)(10)(A)(ii)(V), but does not
make such assistance available to any
group of individuals under section
1902(a)(10)(C).
‘‘(B) SPECIAL
TREATMENT
OF
ANNU-
ITIES.—In this subsection, the term ‘trust’ in-
cludes an annuity only to such extent and in
such manner as the Secretary specifies.
‘‘(C) 
HARDSHIP
WAIVER.—The 
State
agency shall establish procedures (in accordance
with standards specified by the Secretary)
214
under which the agency waives the application
of this subsection with respect to an individual
if the individual establishes (under criteria es-
tablished by the Secretary) that such applica-
tion would work an undue hardship on the indi-
vidual.’’.
(e) EFFECTIVE DATE.—(1) The amendments made
by this section shall apply, except as provided in this sub-
section, to payments under title XIX of the Social Security
Act for calendar quarters beginning on or after October
1, 1993, without regard to whether or not final regulations
to carry out such amendments have been promulgated by
such date.
(2) The amendments made by this section shall not
apply—
(A) to medical assistance provided for services
furnished before October 1, 1993,
(B) with respect to resources disposed of before
May 11, 1993,
(C) with respect to trusts established before
May 11, 1993, or
(D) with respect to inter-spousal transfers.
SEC. 5112. MEDICAID ESTATE RECOVERIES.
(a) REQUIRING ESTABLISHMENT OF ESTATE RECOV-
ERY PROGRAMS.—
215
(1) IN
GENERAL.—Section 1902(a)(51) (42
U.S.C. 1396a(a)(51)) is amended by striking ‘‘and
(B)’’ and inserting ‘‘(B) provide for an estate recov-
ery program that meets the requirements of section
1917(b)(1), and (C)’’.
(2) REQUIREMENTS
FOR
ESTATE
RECOVERY
PROGRAMS.—Section 1917(b) (42 U.S.C. 1396p(b))
is amended—
(A) in paragraph (1)—
(i) by striking ‘‘(b)(1)’’ and inserting
‘‘(2)’’, and
(ii) by striking ‘‘(a)(1)(B)’’ and in-
serting ‘‘(a)(1)(B)(i)’’;
(B) in paragraph (2), by striking ‘‘(2) Any
adjustment or recovery under’’ and inserting
‘‘(3) Any adjustment or recovery under an es-
tate recovery program under’’; and
(C) by inserting before paragraph (2), as
designated by subparagraph (A), the following:
‘‘(b)(1) For purposes of section 1902(a)(51)(B), the
requirements for an estate recovery program of a State
are as follows:
‘‘(A) The program provides for identifying and
tracking (and, at the option of the State, preserving)
resources (whether excluded or not) of individuals
216
who are furnished any of the following long-term
care services for which medical assistance is pro-
vided under this title:
‘‘(i) Nursing facility services.
‘‘(ii) Home and community-based services
(as defined in section 1915(d)(5)(C)(i)).
‘‘(iii) 
Services 
described 
in 
section
1905(a)(14) (relating to services in an institu-
tion for mental diseases).
‘‘(iv) Home and community care provided
under section 1929.
‘‘(v) Community supported living arrange-
ments services provided under section 1930.
‘‘(B) The program provides for promptly
ascertaining—
‘‘(i) when such an individual dies;
‘‘(ii) in the case of such an individual who
was married at the time of death, when the sur-
viving spouse dies; and
‘‘(iii) at the option of the State, cases in
which adjustment or recovery may not be made
at the time of death because of the application
of paragraph (3)(A) or paragraph (3)(B).
217
‘‘(C)(i) The program provides for the collection
consistent with paragraph (3) of an amount (not to
exceed the amount described in clause (ii)) from—
‘‘(I) the estate of the individual;
‘‘(II) in the case of an individual described
in subparagraph (B)(ii), from the estate of the
surviving spouse; or
‘‘(III) at the option of the State, in a case
described in subparagraph (B)(iii), from the ap-
propriate person.
‘‘(ii) The amount described in this clause is the
amount of medical assistance correctly paid under
this title for long-term care services described in
subparagraph (A) furnished on behalf of the individ-
ual.’’.
(b) HARDSHIP WAIVER.—Section 1917(b) (42 U.S.C.
1396p(b)) is further amended by adding at the end the
following new paragraph:
‘‘(4) The State agency shall establish procedures (in
accordance with standards specified by the Secretary)
under which the agency waives the application of this sub-
section if such application would work an undue hardship
(in accordance with criteria established by the Sec-
retary).’’.
218
(c) DEFINITION OF ESTATE.—Section 1917(b) (42
U.S.C. 1396(b)) is further amended by adding at the end
the following new paragraph:
‘‘(5) For purposes of this section, the term ‘estate’,
with respect to a deceased individual, includes all real and
personal property and other assets in which the individual
had any legally cognizable title or interest at the time of
his death, including such assets conveyed to a survivor,
heir, or assign of the deceased individual through joint
tenancy, survivorship, life estate, living trust, or other ar-
rangement.’’.
(d) EFFECTIVE DATE.—
(1)(A) The amendments made by subsections
(a) and (b) apply (except as provided under subpara-
graph (B)) to payments under title XIX of the So-
cial Security Act for calendar quarters beginning on
or after October 1, 1993, without regard to whether
or not final regulations or standards to carry out
such amendments have been promulgated by such
date.
(B) In the case of a State plan for medical as-
sistance under title XIX of the Social Security Act
which the Secretary of Health and Human Services
determines requires State legislation (other than leg-
islation appropriating funds) in order for the plan to
219
meet the additional requirements imposed by the
amendments made by subsections (a) and (b), the
State plan shall not be regarded as failing to comply
with the requirements of such title solely on the
basis of its failure to meet these additional require-
ments before the first day of the first calendar quar-
ter beginning after the close of the first regular ses-
sion of the State legislature that begins after the
date of the enactment of this Act. For purposes of
the previous sentence, in the case of a State that has
a 2-year legislative session, each year of such session
shall be deemed to be a separate regular session of
the State legislature.
(2) The amendments made by this section shall
not apply to individuals who died before October 1,
1993.
SEC. 5113. CLOSING LOOPHOLE PERMITTING WEALTHY IN-
DIVIDUALS TO QUALIFY FOR MEDICAID.
(a) IN GENERAL.—Section 1902(r)(2) (42 U.S.C.
1396a(r)(2)) is amended by adding at the end the follow-
ing:
‘‘(C)(i) Notwithstanding subparagraph (A), except as
provided in clause (ii), a State plan may not provide pur-
suant to this paragraph for disregarding any assets—
220
‘‘(I) to the extent that payments are made
under a long-term care insurance policy; or
‘‘(II) because an individual has received (or is
entitled to receive) benefits for a specified period of
time under a long-term care insurance policy.
‘‘(ii) Clause (i) shall not apply to State plan provi-
sions that are approved as of May 14, 1993.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall take effect on the date of the enact-
ment of this Act.
PART IV—IMPROVEMENT IN IDENTIFICATION
AND COLLECTION OF THIRD PARTY PAYMENTS
SEC. 5116. LIABILITY OF THIRD PARTIES TO PAY FOR CARE
AND SERVICES.
(a) LIABILITY
OF
ERISA PLANS.—(1) Section
1902(a)(25)(A) (42 U.S.C. 1396a(a)(25)(A)) is amended
by striking ‘‘insurers)’’ and inserting ‘‘insurers and group
health plans (as defined in section 607(1) of the Employee
Retirement Income Security Act of 1974) and including
a service benefit plan and a health maintenance organiza-
tion)’’.
(2) Section 1903(o) of such Act (42 U.S.C. 1396b(o))
is amended by striking ‘‘regulation)’’ and inserting ‘‘regu-
lation and including a group health plan (as defined in
section 607(1) of the Employee Retirement Income Secu-
221
rity Act of 1974)), a service benefit plan, and a health
maintenance organization’’.
(b) REQUIRING
STATE
TO
PROHIBIT
INSURERS
FROM TAKING MEDICAID STATUS INTO ACCOUNT.—Sec-
tion 1902(a)(25) (42 U.S.C. 1396a(a)(25)) is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (F);
(2) by adding ‘‘and’’ at the end of subpara-
graph (G); and
(3) by adding after subparagraph (G) the fol-
lowing new subparagraph:
‘‘(H) that the State prohibits any health
insurer (including a group health plan, as de-
fined in section 607(1) of the Employee Retire-
ment Income Security Act of 1974, a service
benefit plan, and a health maintenance organi-
zation), in enrolling an individual or in making
any payments for benefits to the individual or
on the individual’s behalf, from taking into ac-
count that the individual is eligible for or is
provided medical assistance under a State
plan;’’.
(c) STATE
RIGHT
TO
SUBROGATION.—Section
1902(a)(25) (42 U.S.C. 1396a(a)(25)), as amended by
subsection (b), is further amended—
222
(1) by striking ‘‘and’’ at the end of subpara-
graph (G);
(2) by adding ‘‘and’’ at the end of subpara-
graph (H); and
(3) by adding after subparagraph (H) the fol-
lowing new subparagraph:
‘‘(I) that to the extent that payment has
been made under the State plan for medical as-
sistance in any case where a third party has a
legal liability to make payment for such assist-
ance, the State is subrogated to the right of any
other party to payment for such assistance;’’.
(d) EFFECTIVE DATE.—(1) Except as provided in
paragraph (2), the amendments made by subsections
(a)(1), (b), and (c) shall apply to calendar quarters begin-
ning on or after October 1, 1993, without regard to wheth-
er or not final regulations to carry out such amendments
have been promulgated by such date.
(2) In the case of a State plan for medical assistance
under title XIX of the Social Security Act which the Sec-
retary of Health and Human Services determines requires
State legislation (other than legislation appropriating
funds) in order for the plan to meet the additional require-
ments imposed by the amendments made by subsections
(a) and (b), the State plan shall not be regarded as failing
223
to comply with the requirements of such title solely on the
basis of its failure to meet these additional requirements
before the first day of the first calendar quarter beginning
after the close of the first regular session of the State leg-
islature that begins after the date of the enactment of this
Act. For purposes of the previous sentence, in the case
of a State that has a 2-year legislative session, each year
of such session shall be deemed to be a separate regular
session of the State legislature.
(3) The amendment made by subsection (a)(2) shall
apply to items and services furnished on or after October
1, 1993.
SEC. 5117. HEALTH COVERAGE CLEARINGHOUSE.
(a) IN
GENERAL.—The Social Security Act is
amended by adding at the end the following new title:
‘‘TITLE XXI—HEALTH COVERAGE
CLEARINGHOUSE
‘‘ESTABLISHMENT OF CLEARINGHOUSE
‘‘SEC. 2101. (a) IN GENERAL.—The Secretary shall
establish and operate a Health Coverage Clearinghouse (in
this title referred to as the ‘Clearinghouse’) for the pur-
pose of identifying, for beneficiaries of a covered health
program (as defined in subsection (c)), third parties
(which may include a covered health program) which may
224
be liable for payment for health care items and services
furnished to such beneficiaries under such program.
‘‘(b) DIRECTOR.—The Clearinghouse shall be headed
by a Director (in this title referred to as the ‘Director’)
appointed by the Secretary.
‘‘(c) COVERED HEALTH PROGRAM DEFINED.—In
this title, the term ‘covered health program’ means any
of the following under which payment is made for health
care items or services furnished to a beneficiary:
‘‘(1) The medicare program under title XVIII.
‘‘(2) A State plan for medical assistance under
title XIX (including a State plan operating under a
Statewide waiver under section 1115).
‘‘(3) The Indian Health Service and any pro-
gram under the Indian Health Care Improvement
Act.
‘‘(4) A State program under title V that pro-
vides payment for items or services.
‘‘(d) OTHER DEFINITIONS.—In this title:
‘‘(1) The term ‘administrator’ means, with re-
spect to the covered health program described in—
‘‘(A) subsection (c)(1), the Administrator
of the Health Care Financing Administration;
‘‘(B) subsection (c)(2), the single State
agency referred to in section 1902(a)(5);
225
‘‘(C) subsection (c)(3), the Director of the
Indian Health Service; and
‘‘(D) subsection (c)(4), the State agency
receiving funds under title V.
‘‘(2) The term ‘group health plan’ has the
meaning 
given 
such 
term 
in 
section
6103(l)(12)(E)(ii) of such Code.
‘‘(3) The term ‘qualified employer’ has the
meaning 
given 
such 
term 
in 
section
6103(l)(12)(E)(iii) of the Internal Revenue Code of
1986.
‘‘PROVISION OF INFORMATION
‘‘SEC. 2102. (a) REQUEST FOR INFORMATION.—An
administrator of a covered health program may request
from the Director information concerning the employment
and group health coverage of a program beneficiary, the
beneficiary’s spouse, and (if the beneficiary is a dependent
child) the beneficiary’s parents. The Director shall provide
such information if the request—
‘‘(1) is in such form and manner and at such
a time as the Director may require, and
‘‘(2) specifies the name and tax identification
number of the beneficiary.
‘‘(b) DATA MATCHING PROGRAM.—
‘‘(1) REQUEST
BY
DIRECTOR.—The Director
shall, at such intervals as the Director finds appro-
226
priate, transmit to the Secretary of the Treasury the
names and tax identification numbers of bene-
ficiaries with respect to whom a request has been
made pursuant to subsection (a), and request that
such Secretary disclose to the Commissioner of So-
cial Security the following information:
‘‘(A) Whether the beneficiary is married
and, if so, the name of the spouse and such
spouse’s tax identification number.
‘‘(B) If the beneficiary is a dependent
child, the name of and tax identification num-
bers of the beneficiary’s parents.
‘‘(2) INFORMATION
FROM
COMMISSIONER
OF
SOCIAL SECURITY.—The Secretary, acting through
the Commissioner of Social Security, shall, upon
written request from the Director, disclose to the Di-
rector, the following information:
‘‘(A) For each individual who is identified
as having received wages (as defined in section
3401(a) of the Internal Revenue Code of 1986)
from, and as having available coverage under a
group health plan of, an employer in a previous
year—
‘‘(i) the name and taxpayer identifica-
tion number of the individual;
227
‘‘(ii) the name, address, and taxpayer
identification number of the employer, and
whether such employer is a qualified em-
ployer; and
‘‘(iii) whether the employer has made
available a group health plan to the em-
ployee and the plan coverage provided (if
any) with respect to the employee and fam-
ily members of the employee under the
group health plan.
‘‘(B) For each individual who is identified
as married and whose spouse is identified as
having received wages (as defined in section
3401(a) of the Internal Revenue Code of 1986)
from, and as having available coverage under a
group health plan of, an employer in a previous
year—
‘‘(i) the name and taxpayer identifica-
tion number of the individual and of the
individual’s spouse;
‘‘(ii) the name, address, and taxpayer
identification number of the spouse’s em-
ployer, and whether such employer is a
qualified employer; and
228
‘‘(iii) whether the spouse’s employer
has made available a group health plan to
the spouse and the plan coverage provided
(if any) with respect to the spouse and
family members of the spouse under the
group health plan.
‘‘(C) For each individual who is identified
as a dependent child and whose parent is iden-
tified as having received wages (as defined in
section 3401(a) of the Internal Revenue Code
of 1986) from, and as having available coverage
under a group health plan of, an employer in a
previous year—
‘‘(i) the name and taxpayer identifica-
tion number of the individual and of the
individual’s parent;
‘‘(ii) the name, address, and taxpayer
identification number of the parent’s em-
ployer, and whether such employer is a
qualified employer; and
‘‘(iii) whether the parent’s employer
has made available a group health plan to
the parent and the plan coverage provided
(if any) with respect to the parent and de-
229
pendent children of the parent under the
group health plan.
‘‘(3) INFORMATION
FROM
EMPLOYERS.—The
Director shall—
‘‘(A) request, from the employer of each
individual (including each spouse) with respect
to whom information was received from the
Commissioner of Social Security pursuant to
paragraph (2), specific information concerning
coverage of such individual (and of the individ-
ual’s spouse and dependent children) under the
employer’s group health plan (including the pe-
riod and nature of the coverage, and the name,
address, and identifying number of the plan),
and
‘‘(B) furnish the information received in
response to such request with respect to an in-
dividual (or such individual’s spouse or depend-
ent children) to the administrator requesting
such information pursuant to subsection (a).
‘‘REQUIREMENT THAT EMPLOYERS FURNISH
INFORMATION
‘‘SEC. 2103. (a) IN GENERAL.—An employer shall
furnish to the Director the information requested pursu-
ant to section 2102(b)(3) within 30 days after receipt of
such a request.
230
‘‘(b) SUNSET
ON REQUIREMENT.—Subsection (a)
shall not apply to inquiries made after September 30,
1998.
‘‘(c) CIVIL MONEY PENALTY FOR FAILURE TO CO-
OPERATE.—
‘‘(1) IN GENERAL.—An employer (other than a
Federal or other governmental entity) who willfully
or repeatedly fails to provide timely and accurate re-
sponse to a request for information pursuant to sec-
tion 2102(b)(3) shall be subject, in addition to any
other penalties that may be prescribed by law, to a
civil money penalty of not to exceed $1,000 for each
individual with respect to whom such a request is
made.
‘‘(2) ENFORCEMENT AUTHORITY.—In cases of
failure to respond to the Director in accordance with
subsection (a) to inquiries relating to requests pur-
suant to section 2102, the provisions of section
1128A (other than subsections (a) and (b)) shall
apply to civil money penalties under paragraph (1)
in the same manner as such provisions apply to pen-
alties or proceedings under section 1128A(a).
‘‘DATA BANK
‘‘SEC. 2104. (a) MAINTENANCE OF INFORMATION.—
The Clearinghouse shall maintain a data bank, containing
information on individuals obtained pursuant to this title.
231
Individual information in the data bank shall be retained
for not less than one year after the date the information
was obtained.
‘‘(b) DISCLOSURE
OF
INFORMATION
IN
DATA
BANK.—
‘‘(1) IN GENERAL.—The Director is authorized
(subject to paragraph (2)) to disclose any informa-
tion in the data bank established pursuant to sub-
section (a) with respect to an individual (or an indi-
vidual’s spouse or parent)—
‘‘(A) to the Commissioner of Social Secu-
rity, the Secretary of the Treasury, administra-
tors, employers, and insurers, to the extent nec-
essary to assist such administrators;
‘‘(B) to Federal and State law enforcement
officials responsible for enforcement of civil or
criminal laws, in connection with investigations
or administrative or judicial law enforcement
proceedings relating to a covered health pro-
gram; and
‘‘(C) for research or statistical purposes.
‘‘(2) RESTRICTIONS ON DISCLOSURE.—Informa-
tion in the data bank may be disclosed under this
subsection only for purposes of, and to the extent
232
necessary in, determining the extent to which an in-
dividual is covered under any group health plan.
‘‘(c) USE OF CONTRACTORS.—The responsibilities of
the Clearinghouse under this section may be carried out
by contract.
‘‘(d) FEES.—The Clearinghouse shall—
‘‘(1) establish fees for services under this sec-
tion designed to cover the full costs to the Clearing-
house of providing such services, and
‘‘(2) require the payment of such fees to pro-
vide such services.’’.
(b) CONFORMING MEDICARE AMENDMENTS.—Sec-
tion 1862(b)(5) (42 U.S.C. 1395y(b)(5)) is amended—
(1) in subparagraph (A)(i)—
(A) by striking ‘‘Secretary of the Treas-
ury’’ and inserting ‘‘Director of the Health Cov-
erage Clearinghouse’’,
(B) by striking ‘‘(as defined in section
6103(l)(12) of the Internal Revenue Code of
1986)’’ and inserting ‘‘(as defined in clause
(iii))’’, and
(C) by striking ‘‘and request’’ and all that
follows and inserting a period;
(2) in subparagraph (A)(ii)—
234
(2) by striking the period at the end of para-
graph (5) and inserting ‘‘; and’’, and
(3) by inserting after paragraph (5) the follow-
ing new paragraph:
‘‘(6) provides for an entity providing health
services with assistance from the State under this
title taking all reasonable steps—
‘‘(A) to ascertain the legal liability of third
parties to pay for such services, and
‘‘(B) where such liability is found to exist,
to seek reimbursement for such services.’’.
(e) EFFECTIVE DATES.—
(1) The amendments made by subsections (a),
(b), and (d) shall take effect on April 1, 1995.
(2) The amendments made by subsection (c)
shall apply to allotments for years beginning with
fiscal year 1994.
SEC. 5118. MEDICAL CHILD SUPPORT.
(a) 
STATE
PLAN
REQUIREMENT.—Section
1902(a)(45) (42 U.S.C. 1396a(a)(45)) is amended by
striking ‘‘owed to recipients’’ and inserting ‘‘and have in
effect laws relating to medical child support’’.
(b) MEDICAL CHILD SUPPORT LAWS.—Section 1912
of such Act (42 U.S.C. 1396k) is amended—
235
(1) by adding at the end of the heading the fol-
lowing: ‘‘; REQUIRED LAWS RELATING TO MEDICAL
CHILD SUPPORT’’; and
(2) by adding at the end the following new sub-
section:
‘‘(c) The laws relating to medical child support, which
a State is required to have in effect under section
1902(a)(45), are as follows:
‘‘(1) A law that prohibits an insurer from deny-
ing enrollment of a child under the health coverage
of the child’s parent on the ground that the child
was born out of wedlock, on the ground that the
child may not be claimed as a dependent on the par-
ent’s Federal income tax return, or on the ground
that the child does not reside with the parent or in
the insurer’s service area. In this subsection, the
term ‘insurer’ includes a group health plan, as de-
fined in section 607(1) of the Employee Retirement
Income Security Act of 1974, a health maintenance
organization, and an entity offering a service benefit
plan.
‘‘(2) A law that requires an insurer, in any case
in which a parent is required by court or administra-
tive order to provide health coverage for a child and
236
the parent is eligible for family health coverage
through the insurer—
‘‘(A) to permit such parent, upon applica-
tion and without regard to any enrollment sea-
son restrictions, to enroll the parent and such
child under such family coverage;
‘‘(B) if such a parent is enrolled but fails
to make application to obtain coverage of such
child, to enroll such child under such family
coverage upon application by the child’s other
parent or by the State agency administering the
program under this title or part D of title IV;
and
‘‘(C) not to disenroll (or eliminate coverage
of) such a child unless the insurer is provided
satisfactory written evidence that—
‘‘(i) such court or administrative
order is no longer in effect, or
‘‘(ii) the child is or will be enrolled in
comparable health coverage through an-
other insurer which will take effect not
later than the effective date of such
disenrollment.
‘‘(3) A law that requires an employer doing
business in the State, in the case of health coverage
237
offered through employment with the employer and
providing coverage of a child of an employee pursu-
ant to a court or administrative order, to withhold
from such employee’s compensation the employee’s
share (if any) of premiums for health coverage (to
the maximum amount permitted under section
303(b) of the Consumer Credit Protection Act) and
to pay such share of premiums to the insurer.
‘‘(4) A law that prohibits an insurer from im-
posing requirements upon a State agency, which is
acting as an agent or subrogee of an individual eligi-
ble for medical assistance under this title and cov-
ered for health benefits from the insurer, that are
different from requirements applicable to an agent
or subrogee of any other individual so covered.
‘‘(5) A law that requires an insurer, in any case
in which a child has health coverage through the in-
surer of a noncustodial parent—
‘‘(A) to provide such information to the
custodial parent as may be necessary for the
child to obtain benefits through such coverage;
‘‘(B) to permit the custodial parent (or
provider, with the custodial parent’s approval)
to submit claims for covered services without
the approval of the noncustodial parent; and
238
‘‘(C) to make payment on claims submitted
in accordance with subparagraph (B) directly to
the custodial parent or the provider.
‘‘(6) A law that requires the State agency under
this title to garnish the wages, salary, or other em-
ployment income of, and to withhold amounts from
State tax refunds to, any person who—
‘‘(A) is required by court or administrative
order to provide coverage of the costs of health
services to a child who is eligible for medical as-
sistance under this title,
‘‘(B) has received payment from a third
party for the costs of such services to such
child, but
‘‘(C) has not used such payments to reim-
burse, as appropriate, either the other parent or
guardian of such child or the provider of such
services,
to the extent necessary to reimburse the State agen-
cy for expenditures for such costs under its plan
under this title, but any claims for current or past-
due child support shall take priority over any such
claims for the costs of such services.’’.
(c) EFFECTIVE DATE.—(1) Except as provided in
paragraph (2), the amendments made by this section
239
apply to calendar quarters beginning on or after April 1,
1994, without regard to whether or not final regulations
to carry out such amendments have been promulgated by
such date.
(2) In the case of a State plan under title XIX of
the Social Security Act which the Secretary of Health and
Human Services determines requires State legislation in
order for the plan to meet the additional requirements im-
posed by the amendments made by this section, the State
plan shall not be regarded as failing to comply with the
requirements of such title solely on the basis of its failure
to meet these additional requirements before the first day
of the first calendar quarter beginning after the close of
the first regular session of the State legislature that be-
gins after the date of enactment of this Act. For purposes
of the previous sentence, in the case of a State that has
a 2-year legislative session, each year of such session shall
be deemed to be a separate regular session of the State
legislature.
PART V—ASSURING PROPER PAYMENTS TO
DISPROPORTIONATE SHARE HOSPITALS
SEC. 5121. ASSURING PROPER PAYMENTS TO DISPROPOR-
TIONATE SHARE HOSPITALS.
(a) DISPROPORTIONATE
SHARE
HOSPITALS
RE-
QUIRED TO PROVIDE MINIMUM LEVEL OF SERVICES TO
240
MEDICAID PATIENTS.—Section 1923 (42 U.S.C. 1396r–
4) is amended—
(1) in subsection (a)(1)(A), by striking ‘‘re-
quirement’’ and inserting ‘‘requirements’’;
(2) in subsection (b)(1), by striking ‘‘require-
ment’’ and inserting ‘‘requirements’’;
(3) in the heading to subsection (d), by striking
‘‘REQUIREMENT’’ and inserting ‘‘REQUIREMENTS’’;
(4) by adding at the end of subsection (d) the
following new paragraph:
‘‘(3) No hospital may be defined or deemed as
a disproportionate share hospital under a State plan
under this title or under subsection (b) or (e) of this
section unless the hospital has a medicaid inpatient
utilization rate (as defined in subsection (b)(2)) of
not less than 1 percent.’’;
(5) in subsection (e)(1)—
(A) by striking ‘‘and’’ before ‘‘(B)’’, and
(B) by inserting before the period at the
end the following: ‘‘, and (C) the plan meets the
requirement of subsection (d)(3) and such pay-
ment adjustments are made consistent with the
fourth sentence of subsection (c)’’; and
(6) in subsection (e)(2)—
241
(A) in subparagraph (A), by inserting
‘‘(other than the fourth sentence of subsection
(c))’’ after ‘‘(c)’’,
(B) by striking ‘‘and’’ at the end of sub-
paragraph (A),
(C) by striking the period at the end of
subparagraph (B) and inserting ‘‘, and’’, and
(D) by adding at the end the following new
subparagraph:
‘‘(C) subsection (d)(3) shall apply.’’.
(b) LIMITING AMOUNT OF PAYMENT ADJUSTMENTS
FOR STATE
OR COUNTY HOSPITALS
TO UNCOVERED
COSTS.—Subsection (c) of such section is amended by
adding at the end the following: ‘‘A payment adjustment
during a year is not considered to be consistent with this
subsection with respect to a hospital owned or operated
by a State (or by an instrumentality or a unit of govern-
ment within a State) if the payment adjustment exceeds
the costs of furnishing hospital services (as determined by
the Secretary and net of payments under this title, other
than under this section, and by uninsured patients) by the
hospital to individuals who either are eligible for medical
assistance under the State plan or have no health insur-
ance (or other source of third party payment) for such
services during the year. For purposes of the preceding
242
sentence, payments made to a hospital for services pro-
vided to indigent patients made by a State or a unit of
local government within a State shall not be considered
to be a source of third party payment.’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to payments to States under sec-
tion 1903(a) of the Social Security Act for payments to
hospitals made under State plans after—
(1) the end of the State fiscal year that ends
during 1994, or
(2) in the case of a State with a State legisla-
ture which is not scheduled to have a regular legisla-
tive session in 1994, the end of the State fiscal year
that ends during 1995;
without regard to whether or not final regulations to carry
out such amendments have been promulgated by either
such date.
Subchapter B—Miscellaneous Provisions
PART I—ANTI-FRAUD AND ABUSE PROVISIONS
SEC. 5131. APPLICATION OF MEDICARE RULES LIMITING
CERTAIN PHYSICIAN REFERRALS.
(a) IN
GENERAL.—Section 1903(i) (42 U.S.C.
1396b(i)), as amended by section 5174(b), is amended—
(A) in paragraph (12), by striking or at
the end,
243
(B) in paragraph (13), by striking the pe-
riod at the end and inserting ‘‘; or’’, and
(C) by inserting after paragraph (13) the
following new paragraph:
‘‘(14) with respect to any amount expended for
an item or service for which payment would be de-
nied under section 1877(g)(1) if the item or service
were furnished to an individual entitled to benefits
under title XVIII.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to items and services furnished
on or after October 1, 1993.
SEC. 5132. INTERMEDIATE SANCTIONS FOR KICKBACK VIO-
LATIONS.
(a) PENALTY FOR KICKBACKS.—Section 1128A(a)
(42 U.S.C. 1320a–7a(a)) is amended—
(1) by striking ‘‘or’’ at the end of paragraphs
(1) and (2);
(2) by adding ‘‘or’’ at the end of paragraph (3);
(3) by inserting after paragraph (3) the follow-
ing new paragraph:
‘‘(4) carries out any activity in violation of
paragraph (1) or (2) of section 1128B(b);’’;
244
(4) by striking ‘‘given).’’ at the end of the first
sentence and inserting ‘‘given or, in cases under
paragraph (4), $50,000 for each such violation).’’;
(5) in the second sentence, by inserting ‘‘in
cases under paragraphs (1), (2), and (3),’’ after ‘‘In
addition,’’; and
(6) by inserting after the second sentence, the
following new sentence: ‘‘In cases under paragraph
(4), such a person shall be subject to an assessment
of not more than twice the total amount of the re-
muneration offered, paid, solicited, or received in
violation of section 1128B(b), determined without
regard to whether a portion of such remuneration
was offered, paid, solicited, or received for a lawful
purpose.’’.
(b) AUTHORIZATION TO ACT.—The first sentence of
section 1128A(c)(1) (42 U.S.C. 1320a–7a(c)(1)) is
amended by striking all that follows ‘‘(b)’’ and inserting
the following: ‘‘unless, within one year after the date the
Secretary presents a case to the Attorney General for con-
sideration, the Attorney General brings an action in a dis-
trict court of the United States.’’.
(c) EFFECTIVE DATES.—
(1) The amendments made by subsection (a)
shall apply to remuneration offered, paid, solicited,
245
or received before, on, or after the date of the enact-
ment of this Act.
(2) The amendment made by subsection (b)
shall apply to cases presented by the Secretary of
Health and Human Services for consideration on or
after the date of the enactment of this Act.
SEC. 5133. REQUIRING MAINTENANCE OF EFFORT FOR
STATE MEDICAID FRAUD CONTROL UNITS.
(a) IN GENERAL.—Section 1902(a)(49) (42 U.S.C.
1396a(a)(49)) is amended—
(1) by inserting ‘‘(A)’’ after ‘‘(49)’’, and
(2) by adding at the end the following new sub-
paragraph:
‘‘(B) provide that the State will expend for its
medicaid fraud and abuse control unit (as defined in
section 1903(q)), for each State fiscal year, an
amount that is not less than the amount expended
for such unit in the State fiscal year that ended in
1992 adjusted to reflect the percentage increase in
total expenditures under the State plan between
such State fiscal year and the State fiscal year in-
volved;’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to State fiscal years ending after
1993.
246
PART II—MANAGED CARE PROVISIONS
SEC. 5135. MEDICAID MANAGED CARE ANTI-FRAUD PROVI-
SIONS.
(a) PROHIBITING AFFILIATIONS WITH INDIVIDUALS
DEBARRED BY FEDERAL AGENCIES.—
(1) IN GENERAL.—Section 1903(m) (42 U.S.C.
1396b(m)) is amended—
(A) in paragraph (2)(A)—
(i) by striking ‘‘and’’ at the end of
clause (x),
(ii) by striking the period at the end
of clause (xi) and inserting ‘‘; and’’, and
(iii) by adding at the end the follow-
ing new clause:
‘‘(xii) the entity complies with the requirements
of paragraph (3) (relating to certain protections
against fraud and abuse).’’;
(B) in paragraph (2)(B), as amended by
section 5158(b), by striking ‘‘clause (ix)’’ and
inserting ‘‘clauses (ix) and (xii)’’; and
(C) by inserting after paragraph (2) the
following new paragraph:
‘‘(3)(A)(i) A health maintenance organization may
not have a person described in clause (iv) as a director,
247
officer, partner, or person with beneficial ownership of
more than 5 percent of organization’s equity.
‘‘(ii) A health maintenance organization may not have
an employment, consulting, or other agreement with a per-
son described in clause (iv) for the provision of goods and
services that are significant and material to the organiza-
tion’s obligations under its contract with the State de-
scribed in paragraph (2)(A)(iii).
‘‘(iii) If a health maintenance organization is not in
compliance with clause (i) or clause (ii)—
‘‘(I) a State may continue an existing agree-
ment with the organization unless the Secretary (in
consultation with the Inspector General of the De-
partment of Health and Human Services) directs
otherwise; and
‘‘(II) a State may not renew or otherwise ex-
tend the duration of an existing agreement with the
organization unless the Secretary (in consultation
with the Inspector General of the Department of
Health and Human Services) provides a written
statement describing compelling reasons that exist
for renewing or extending the agreement.
‘‘(iv) A person described in this clause is a person
that—
248
‘‘(I) is debarred or suspended by the Federal
Government, pursuant to the Federal acquisition
regulation, from Government contracting and sub-
contracting, or
‘‘(II) is an affiliate (within the meaning of the
Federal acquisition regulation) of a person described
in subclause (I).’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall apply to agreements between
a State and an entity under section 1903(m) of the
Social Security Act entered into or renewed on or
after October 1, 1993, without regard to whether
regulations to carry out such amendments are pro-
mulgated by such date.
(b) REQUIREMENT FOR STATE CONFLICT-OF-INTER-
EST SAFEGUARDS IN MEDICAID RISK CONTRACTING.—
(1) IN GENERAL.—Section 1903(m)(2)(A) (42
U.S.C. 1396b(m)(2)(A)), as amended by subsection
(a)(1)(C), is amended—
(A) by striking ‘‘and’’ at the end of clause
(xi),
(B) by striking the period at the end of
clause (xii) and inserting ‘‘; and’’, and
(C) by adding at the end the following new
clause:
249
‘‘(xiii) the State certifies to the Secretary that
it has in effect conflict-of-interest safeguards with
respect to officers and employees of the State with
responsibility with respect to contracts with organi-
zations under this subsection that are at least as ef-
fective as the Federal safeguards, provided under
section 27 of the Office of Federal Procurement Pol-
icy Act (41 U.S.C. 423), against conflicts of interest
that apply with respect to Federal procurement offi-
cials with comparable responsibilities with respect to
such contracts.’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall apply as of July 1, 1994,
without regard to whether regulations to carry out
such amendments are promulgated by such date.
(c) REQUIRING DISCLOSURE OF FINANCIAL INFOR-
MATION.—
(1) IN GENERAL.—Section 1903(m)(3), as in-
serted by subsection (a)(1)(C), is amended by add-
ing at the end the following new subparagraph:
‘‘(B) The contract between the State and an entity
referred to in paragraph (2)(A)(iii) shall provide that—
‘‘(i) the entity agrees to report to the State
such financial information as the Secretary or the
250
State may require to demonstrate that the entity has
a fiscally sound operation; and
‘‘(ii) the entity agrees to make available to its
enrollees upon reasonable request—
‘‘(I) the information reported under para-
graph (1),
‘‘(II) the information required to be dis-
closed under sections 1124 and 1126, and
‘‘(III) a description of each transaction,
described in subparagraphs (A) through (C) of
section 1318(a)(3) of the Public Health Service
Act, between the entity and a party in interest
(as defined in section 1318(b) of such Act).’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to contract years begin-
ning on or after October 1, 1993, without regard to
whether regulations to carry out such amendments
are promulgated by such date, with respect to infor-
mation reported or required to be disclosed, or
transactions occurring, before, on, or after such
date.
(d) PROHIBITING MARKETING FRAUD.—
(1) IN GENERAL.—Section 1903(m)(3), as in-
serted by subsection (a)(1) and as amended by sub-
251
section (c)(1), is amended by adding at the end the
following new subparagraph:
‘‘(C) The contract between the State and an entity
referred to in paragraph (2)(A)(iii) shall provide that the
entity agrees to comply with such procedures and condi-
tions as the Secretary prescribes in order to ensure that,
before an individual is enrolled with the entity, the individ-
ual is provided accurate and sufficient information to
make an informed decision whether or not to enroll.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to contract years that
begin on or after October 1, 1993, without regard
to whether regulations to carry out such amendment
are promulgated by such date.
(e) REQUIRING ADEQUATE EQUITY FOR FOR-PROFIT
ENTITIES.—
(1) IN GENERAL.—Section 1903(m)(3), as pre-
viously amended by this section, is further amended
by adding at the end the following new subpara-
graph:
‘‘(D)(i) The contract between the State and an entity
referred to in paragraph (2)(A)(iii) shall require, in the
case of a for-profit entity, that the entity shall maintain
an average ratio of—
‘‘(I) equity capital to
252
‘‘(II) payments made by the State to the entity
under the contract on a capitation basis or any other
risk basis,
of not less than such minimum ratio as the Secretary shall
specify.
‘‘(ii) The contract between the State and a non-profit
entity referred to in paragraph (2)(A)(iii) shall require
that no payment shall be made directly or indirectly under
an agreement between the non-profit entity and a related
for-profit entity (as defined by the Secretary) unless the
for-profit entity maintains an average ratio of equity cap-
ital to payments under such agreement of not less than
such ratio as the Secretary shall specify.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to contract years begin-
ning on or after July 1, 1994, without regard to
whether regulations to carry out such amendment
are promulgated by such date.
(f) REQUIRING ADEQUATE PROVISION AGAINST RISK
OF INSOLVENCY.—
(1) IN
GENERAL.—Section 1903(m)(1)(A)(ii)
(42 U.S.C. 1396b(m)(1)(A)(ii)) is amended by in-
serting ‘‘, which meets such standards as the Sec-
retary shall prescribe’’ after ‘‘satisfactory to the
State’’.
253
(2) EFFECTIVE DATE AND TRANSITION.—(A)
The amendment made by paragraph (1) shall apply
to contract years beginning on or after July 1, 1994,
without regard to whether regulations to carry out
such amendments are promulgated by such date.
(B) If the Secretary of Health and Human
Services has not promulgated standards to carry out
the amendment made by paragraph (1) by July 1,
1994, until such standards have been promulgated a
provision of a health maintenance organization
against the risk of insolvency shall not be considered
to meet standards prescribed by the Secretary, for
purposes of section 1903(m)(1)(A)(ii) of the Social
Security Act, unless such provision has been found
satisfactory 
by 
the 
Secretary 
under 
section
1876(b)(2)(E) of such Act.
(g) REQUIRING REPORT ON NET EARNINGS AND AD-
DITIONAL BENEFITS.—
(1) IN GENERAL.—Section 1903(m)(3), as pre-
viously amended by this section, is amended by add-
ing at the end the following new subparagraph:
‘‘(E) The contract between the State and an entity
referred to in paragraph (2)(A)(iii) shall provide that the
entity shall submit a report to the State and the Secretary
254
not later than 12 months after the close of a contract year
containing—
‘‘(i) a financial statement of the entity’s net
earnings under the contract during the contract
year, which statement has been audited using audit-
ing standards established by the Secretary in con-
sultation with the States; and
‘‘(ii) a description of any benefits that are in
addition to the benefits required to be provided
under the contract that were provided during the
contract year to members enrolled with the entity
and entitled to medical assistance under the plan.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to contract years begin-
ning on or after October 1, 1993, without regard to
whether regulations to carry out such amendments
are promulgated by such date.
(h) REPORT ON NET EARNINGS OF CONTRACTORS.—
Not later than 6 months after the date of the enactment
of this Act, the Secretary of Health and Human Services
shall submit a report to Congress on the earnings of orga-
nizations with contracts to receive payment for providing
medical assistance under title XIX of the Social Security
Act on a prepaid capitation or any other risk basis. The
report shall include the Secretary’s recommendations on
255
options for requiring such organizations, as a condition
of participation under such title, to dedicate a portion of
such earnings to the provision of additional benefits to in-
dividuals enrolled with the organization.
SEC. 5136. CLARIFICATION OF TREATMENT OF HMO EN-
ROLLEES IN COMPUTING THE MEDICAID IN-
PATIENT UTILIZATION RATE IN QUALIFYING
HOSPITALS AS DISPROPORTIONATE SHARE
HOSPITALS.
(a) IN GENERAL.—Section 1923(b)(2) (42 U.S.C.
1396r–4(b)(2)) is amended by inserting before the period
at the end the following: ‘‘and whether or not the individ-
ual is enrolled with an entity contracting with the State
on a prepaid capitation basis or other risk basis under sec-
tion 1903(m)’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to payments to States under sec-
tion 1903(a) of the Social Security Act for payments to
hospitals made under State plans on and after the first
day of the first calendar quarter beginning after the date
of the enactment of this Act.
256
SEC. 5137. EXTENSION OF PERIOD OF APPLICABILITY OF
ENROLLMENT MIX REQUIREMENT TO CER-
TAIN 
HEALTH 
MAINTENANCE 
ORGANIZA-
TIONS PROVIDING SERVICES UNDER DAYTON
AREA HEALTH PLAN.
Section 2 of Public Law 102–276 is amended by
striking ‘‘January 31, 1994’’ and inserting ‘‘December 31,
1995’’.
SEC. 5138. EXTENSION OF MEDICAID WAIVER FOR TEN-
NESSEE PRIMARY CARE NETWORK.
Section 6411(f) of the Omnibus Budget Reconcili-
ation Act of 1989, as amended by section 1 of Public Law
102–317, is amended by striking ‘‘January 31, 1994’’ and
inserting ‘‘December 31, 1995’’.
SEC. 5139. WAIVER OF APPLICATION OF MEDICAID EN-
ROLLMENT MIX REQUIREMENT TO DISTRICT
OF COLUMBIA CHARTERED HEALTH PLAN,
INC.
(a) IN GENERAL.—The Secretary of Health and
Human Services shall waive the application of the require-
ment described in section 1903(m)(2)(A)(ii) of the Social
Security Act to the entity known as the District of Colum-
bia Chartered Health Plan, Inc., for the period described
in subsection (b), if the Secretary determines that the en-
tity is making continuous efforts and progress toward
achieving compliance with such requirement.
257
(b) PERIOD OF APPLICABILITY.—The period referred
to in subsection (a) is the period that begins on October
1, 1992, and ends on December 31, 1995.
SEC. 5140. EXTENSION OF MINNESOTA PREPAID MEDICAID
DEMONSTRATION PROJECT.
(a) IN GENERAL.—Section 507 of the Family Sup-
port Act of 1988, as amended by section 6411(j) of
OBRA–1989 and by section 4733 of OBRA–1990, is
amended by striking ‘‘1996’’ and inserting ‘‘1998’’.
(b) AUTHORITY TO IMPOSE PREMIUM.—
(1) IN
GENERAL.—Notwithstanding section
1916 of the Social Security Act and subject to para-
graph (2), the State of Minnesota may impose a pre-
mium on individuals receiving medical assistance
under the Minnesota Prepaid Demonstration Project
operated under a waiver granted by the Secretary of
Health and Human Services under section 1115(a)
of the Social Security Act and other individuals eligi-
ble under the State’s plan for medical assistance
under title XIX of such Act.
(2) LIMITATION ON AMOUNT OF PREMIUM.—In
no case may the amount of any premium imposed on
an individual receiving medical assistance under the
State plan or under the Demonstration Project de-
scribed in paragraph (1) exceed 10 percent of the
258
amount by which the family income (less expenses
for the care of a dependent child) of the individual
exceeds 110 percent of the income official poverty
line (as defined by the Office of Management and
Budget), and revised annually in accordance with
section 673(2) of the Omnibus Budget Reconcili-
ation Act of 1981) applicable to a family of the size
involved.
PART III—EMERGENCY SERVICES TO
UNDOCUMENTED ALIENS
SEC. 5141. INCREASE IN FEDERAL FINANCIAL PARTICIPA-
TION FOR EMERGENCY MEDICAL ASSIST-
ANCE TO UNDOCUMENTED ALIENS.
(a) IN
GENERAL.—Section 1905(b) (42 U.S.C.
1396d(b)) is amended by adding at the end the following:
‘‘Notwithstanding the first sentence of this section, sub-
ject to 1903(v)(4), the Federal medical assistance percent-
age shall be 100 per centum with respect to amounts ex-
pended by an eligible State in a covered fiscal year (as
defined in section 1903(v)(4)(C)) as medical assistance for
care and services described in section 1903(v)(2) to aliens
described in section 1903(v)(1).’’.
(b) LIMITATION.—Section 1903(v) (42 U.S.C.
1396b(v)) is amended by adding at the end the following
new paragraph:
259
‘‘(4)(A) With respect to any eligible State (as defined
in subparagraph (C)(i)), the amount of the increase in
payments to a State under subsection (a) in a covered fis-
cal year (as defined in subparagraph (C)(ii)), resulting
from the increase in the Federal medical assistance per-
centage under the fourth sentence of section 1905(b), shall
not exceed the State’s allotment determined under sub-
paragraph (B).
‘‘(B)(i) The total of the allotments to all States for
a covered fiscal year under this paragraph shall be
$300,000,000.
‘‘(ii) From the total allotment under clause (i) for
a covered fiscal year, the Secretary shall determine the
amount of the allotment for each eligible State. Subject
to clause (iii), the amount of such allotment for such a
fiscal year shall bear the same ratio to the total amount
specified in clause (i) for the fiscal year as the ratio of—
‘‘(I) the allotment to the State for fiscal year
1993 under section 204 of the Immigration Reform
and Control Act of 1986, to
‘‘(II) the total of such allotments for all such el-
igible States for fiscal year 1993.
‘‘(iii) In the case of an eligible State which notifies
the Secretary that an amount of its allotment will not be
used by the State under this paragraph, the State’s allot-
260
ment shall be reduced by such amount and such amount
shall be redistributed among the other eligible States in
proportion to the amount otherwise allotted to such State
under clause (ii).
‘‘(C) For purposes of this paragraph and the fourth
sentence of section 1905(b):
‘‘(i) The term ‘eligible State’ means a State—
‘‘(I) with a plan approved under this title
(including a State which is providing medical
assistance to its residents under a statewide
waiver granted under section 1115), and
‘‘(II) for which its allotment for fiscal year
1993 under section 204 of the Immigration Re-
form and Control Act of 1986 is at least 1 per-
cent of the total of such allotments for all the
States for fiscal year 1993.
‘‘(ii) The term ‘covered fiscal year’ means only
fiscal year 1994.
‘‘(D) Nothing in this paragraph or the fourth sen-
tence of section 1905(b) shall be construed as establishing
entitlement authority (within the meaning of section 3(9)
of the Congressional Budget Act of 1974) for any fiscal
year other than a covered fiscal year.’’.
261
SEC. 5142. LIMITING FEDERAL MEDICAID MATCHING PAY-
MENT TO BONA FIDE EMERGENCY SERVICES
FOR UNDOCUMENTED ALIENS.
(a) IN GENERAL.—Section 1903(v)(2) (42 U.S.C.
1396b(v)(2)) is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (A),
(2) by striking the period at the end of sub-
paragraph (B) and inserting ‘‘, and’’, and
(3) by adding at the end the following new sub-
paragraph:
‘‘(C) such care and services are not related to
an organ transplant procedure.’’.
(b) EFFECTIVE DATE.—(1) Subject to paragraph
(2), the amendments made by subsection (a) shall apply
as if included in the enactment of OBRA–1986.
(2) The Secretary of Health and Human Services
shall not disallow expenditures made for the care and serv-
ices described in section 1903(v)(2)(C) of the Social Secu-
rity Act, as added by subsection (a), furnished before the
date of the enactment of this Act.
262
PART IV—MISCELLANEOUS PROVISIONS
SEC. 5144. INCREASE IN LIMIT ON FEDERAL MEDICAID
MATCHING PAYMENTS TO PUERTO RICO AND
OTHER TERRITORIES.
(a) IN GENERAL.—Paragraphs (1) through (5) of
section 1108(c) (42 U.S.C. 1308(c)) are amended to read
as follows:
‘‘(1) 
Puerto 
Rico 
shall 
not 
exceed 
(A)
$104,000,000 for fiscal year 1994 and (B) for each
succeeding fiscal year the amount provided in this
paragraph for the preceding fiscal year increased by
percentage increase in the medical care component
of the consumer price index for all urban consumers
(as published by the Bureau of Labor Statistics) for
the twelve-month period ending in March preceding
the beginning of the fiscal year, rounded to the near-
est $100,000;
‘‘(2) the Virgin Islands shall not exceed (A)
$3,425,000 for fiscal year 1994, and (B) for each
succeeding fiscal year the amount provided in this
paragraph for the preceding fiscal year increased by
percentage increase referred to in paragraph (1)(B),
rounded to the nearest $10,000;
‘‘(3) Guam shall not exceed (A) $3,290,000 for
fiscal year 1994, and (B) for each succeeding fiscal
263
year the amount provided in this paragraph for the
preceding fiscal year increased by percentage in-
crease referred to in paragraph (1)(B), rounded to
the nearest $10,000;
‘‘(4) Northern Mariana Islands shall not exceed
(A) $990,000 for fiscal year 1994, and (B) for each
succeeding fiscal year the amount provided in this
paragraph for the preceding fiscal year increased by
percentage increase referred to in paragraph (1)(B),
rounded to the nearest $10,000; and
‘‘(5) American Samoa shall not exceed (A)
$1,910,000 for fiscal year 1994, and (B) for each
succeeding fiscal year the amount provided in this
paragraph for the preceding fiscal year increased by
percentage increase referred to in paragraph (1)(B),
rounded to the nearest $10,000.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply beginning with fiscal year 1994.
SEC. 5145. CRITERIA FOR MAKING DETERMINATIONS OF
DENIAL OF FEDERAL MEDICAID MATCHING
PAYMENTS TO STATES.
(a) IN GENERAL.—Section 1903 (42 U.S.C. 1396b)
is amended by adding at the end the following new sub-
section:
264
‘‘(x)(1) In any case in which the Secretary proposes
to disallow under section 1116(d) a claim by a State under
this section and the State exercises its right of reconsider-
ation under section 1116(d), the Departmental Appeals
Board established in the Department of Health and
Human Services shall, if such Board upholds the basis for
the disallowance, determine whether the amount of the
disallowance should be reduced. In making this determina-
tion, the Board shall take into account (to the extent the
State makes a showing) factors which shall include—
‘‘(A) the nature of the basis for the disallow-
ance;
‘‘(B) whether the amount of the disallowance is
proportionate to the error or deficiency on which the
disallowance is based;
‘‘(C) whether the basis of the disallowance con-
stitutes noncompliance that prevented or materially
affected the provision of appropriate services to indi-
viduals eligible under this title; or
‘‘(D) whether Federal guidance with respect to
the action that is the basis for the proposed dis-
allowance was insufficient and the State made good
faith efforts to conform its action to the intent of
the applicable Federal statute or regulation.
265
‘‘(2) No disallowance shall be taken or upheld if the
action of the State on which the disallowance would be
based is consistent with its approved State plan.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to disallowances made after the
date of the enactment of this Act and shall take effect
without regard to the promulgation of implementing regu-
lations.
SEC. 5146. RENEWAL OF UNFUNDED DEMONSTRATION
PROJECT 
FOR 
LOW-INCOME 
PREGNANT
WOMEN AND CHILDREN.
(a) IN GENERAL.—Section 6407 of OBRA–89 is
amended—
(1) in subsection (d), by striking ‘‘3 years’’ and
inserting ‘‘5 years’’;
(2) in subsection (f), by striking ‘‘$10,000,000
in each of fiscal years 1990, 1991, and 1992’’ and
inserting ‘‘$30,000,000’’; and
(3) in subsection (g)(2), by striking ‘‘January
1, 1994’’ and inserting ‘‘one year after the termi-
nation of the demonstration projects’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall take effect as if included in the enact-
ment of OBRA–89.
268
(c) 
LIMITATION
ON
BENEFITS.—Section
1902(a)(10), as amended by section 5162(a), is amended,
in the matter following subparagraph (F)—
(1) by striking ‘‘, and (XII)’’ and inserting ‘‘,
(XII)’’, and
(2) by inserting before the semicolon at the end
the following: ‘‘, and (XIII) the medical assistance
made available to an individual described in sub-
section (z)(1) who is eligible for medical assistance
only because of subparagraph (A)(ii)(XII) shall be
limited to medical assistance for TB-related services
(as defined in subsection (z)(2))’’.
(d) CONFORMING EXPANSION
OF CASE MANAGE-
MENT SERVICES OPTION.—Section 1915(g)(1) (42 U.S.C.
1396n(g)(1)) is amended by inserting ‘‘or to individuals
described in section 1902(z)(1)(A),’’ after ‘‘or with ei-
ther,’’.
(e) CONFORMING AMENDMENT.—Section 1905(a)
(42 U.S.C. 1396d(a)) is amended—
(1) by striking ‘‘or’’ at the end of clause (ix),
(2) by adding ‘‘or’’ at the end of clause (x),
(3) by inserting after clause (x) the following
new clause:
‘‘(xi) 
individuals 
described 
in 
section
1902(z)(1),’’, and
269
(4) by amending paragraph (19) to read as fol-
lows:
‘‘(19) case management services (as defined in
section 1915(g)(2)) and TB-related services de-
scribed in section 1902(z)(2)(F);’’.
(f) EFFECTIVE DATE.—The amendments made by
this section shall apply to medical assistance furnished on
or after January 1, 1994, without regard to whether or
not final regulations to carry out such amendments have
been promulgated by such date.
SEC. 5148. APPLICATION OF MAMMOGRAPHY CERTIFI-
CATION REQUIREMENTS UNDER THE MEDIC-
AID PROGRAM.
(a) IN GENERAL.—Section 1902(a)(9) (42 U.S.C.
1396a(a)(9)) is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (B),
(2) by striking the semicolon at the end of sub-
paragraph (C) and inserting ‘‘, and’’, and
(3) by adding at the end the following new sub-
paragraph:
‘‘(D) that any mammography paid for
under such plan must be conducted by a facility
that has a certificate (or provisional certificate)
270
issued under section 354 of the Public Health
Service Act;’’.
(b) EFFECTIVE DATE.—(1) Except as provided in
paragraph (2), the amendments made by subsection (a)
shall apply to mammography furnished by a facility during
calendar quarters beginning on or after the first date that
the certificate requirements of section 354(b) of the Public
Health Service Act apply to such mammography con-
ducted by such facility, without regard to whether or not
final regulations to carry out such amendments have been
promulgated by such date.
(2) In the case of a State plan for medical assistance
under title XIX of the Social Security Act which the Sec-
retary of Health and Human Services determines requires
State legislation (other than legislation appropriating
funds) in order for the plan to meet the additional require-
ment imposed by the amendment made by subsection
(a)(3), the State plan shall not be regarded as failing to
comply with the requirements of such title solely on the
basis of its failure to meet this additional requirement be-
fore the first day of the first calendar quarter beginning
after the close of the first regular session of the State leg-
islature that begins after the date of the enactment of this
Act. For purposes of the previous sentence, in the case
of a State that has a 2-year legislative session, each year
271
of such session shall be deemed to be a separate regular
session of the State legislature.
SEC. 5149. REMOVAL OF SUNSET ON EXTENSION OF ELIGI-
BILITY FOR WORKING FAMILIES.
Subsection (f) of section 1925 (42 U.S.C. 1396r–6)
is repealed.
SEC. 5150. EXTENSION OF MORATORIUM ON TREATMENT
OF CERTAIN FACILITIES AS INSTITUTIONS
FOR MENTAL DISEASES.
Effective as if included in the enactment of OBRA–
1989, section 6408(a)(3) of such Act is amended by strik-
ing ‘‘180 days’’ and all that follows and inserting ‘‘Decem-
ber 31, 1995.’’.
SEC. 5150A. TREATMENT OF CERTAIN CLINICS AS FEDER-
ALLY-QUALIFIED HEALTH CENTERS.
(a) IN GENERAL.—Section 1905(l)(2)(B) (42 U.S.C.
1396d(l)(2)(B)), as amended by section 5158(c), is
amended—
(1) by striking ‘‘or’’ at the end of clause
(ii)(II),
(2) by adding ‘‘or’’ at the end of clause (iii),
and
(3) by inserting after clause (iii) the following
new clause:
272
‘‘(iv) was treated by the Secretary, for purposes
of part B of title XVIII, as a comprehensive Feder-
ally funded health center as of January 1, 1990;’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to calendar quarters beginning
on or after July 1, 1993.
SEC. 5150B. NURSING HOME REFORM.
(a) SUSPENSION OF DECERTIFICATION OF NURSES
AIDE TRAINING AND COMPETENCY EVALUATION PRO-
GRAMS BASED ON EXTENDED SURVEYS.—
(1) 
IN
GENERAL.—Section
1919(f)(2)(B)(iii)(I)(b) 
(42 
U.S.C.
1396r(f)(2)(B)(iii)(I)(b)) is amended by striking the
semicolon and inserting the following: ‘‘, unless the
survey shows that the facility is in compliance with
the requirements of subsections (b), (c), and (d) of
this section;’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect as included in the
enactment of OBRA–1990.
(b) REQUIREMENTS FOR CONSULTANTS CONDUCT-
ING REVIEWS ON USE OF DRUGS.—
(1) IN GENERAL.—Section 1919(c)(1)(D) (42
U.S.C. 1396r(c)(1)(D)) is amended by adding at the
end the following sentence: ‘‘In determining whether
273
such a consultant is qualified to conduct reviews
under the previous sentence, the Secretary shall take
into account the needs of nursing facilities under
this title to have access to the services of such a con-
sultant on a timely basis.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect as included in the
enactment of OBRA–1987.
(c) INCREASE IN MINIMUM AMOUNT REQUIRED FOR
SEPARATE DEPOSIT OF PERSONAL FUNDS.—
(1) IN GENERAL.—Section 1919(c)(6)(B)(i) (42
U.S.C. 1396r(c)(6)(B)(i)) is amended by striking
‘‘$50’’ and inserting ‘‘$100’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect October 1, 1993.
(d) DUE
PROCESS
PROTECTIONS
FOR
NURSES
AIDES.—
(1) PROHIBITING STATE FROM INCLUDING UN-
DOCUMENTED ALLEGATIONS IN NURSES AIDE REG-
ISTRY.—Section 
1919(e)(2)(B) 
(42 
U.S.C.
1396r(e)(2)(B)) is amended by striking the period at
the end of the first sentence and inserting the fol-
lowing: ‘‘, but shall not include any allegations of
resident abuse or neglect or misappropriation of
274
resident property that are not specifically docu-
mented by the State under such subsection.’’.
(2) DUE PROCESS REQUIREMENTS FOR REBUT-
TING
ALLEGATIONS.—Section 1919(g)(1)(C) (42
U.S.C. 1396r(g)(1)(C)) is amended by striking the
second sentence and inserting the following: ‘‘The
State shall, after providing the individual involved
with a written notice of the allegations (including a
statement of the availability of a hearing for the in-
dividual to rebut the allegations) and the oppor-
tunity for a hearing on the record, make a written
finding as to the accuracy of the allegations.’’.
(3) EFFECTIVE DATE.—The amendments made
by this subsection shall take effect October 1, 1993.
Subchapter C—Miscellaneous and Technical
Corrections Relating to OBRA–1990
SEC. 5151. EFFECTIVE DATE.
Except as otherwise provided, the amendments made
by this subchapter shall take effect as if included in the
enactment of OBRA–1990.
SEC. 5152. CORRECTIONS RELATING TO SECTION 4402 (EN-
ROLLMENT UNDER GROUP HEALTH PLANS).
Section 4402(b) of OBRA–1990 is amended by strik-
ing ‘‘1903(u)(1)(C)(iv) (42 U.S.C. 1395b(u)(1)(C)(iv))’’
275
and 
inserting 
‘‘1903(u)(1)(D)(iv) 
(42 
U.S.C.
1395b(u)(1)(D)(iv))’’.
SEC. 5153. CORRECTIONS RELATING TO SECTION 4501
(LOW-INCOME MEDICARE BENEFICIARIES).
(a) Section 1902(a)(10)(E)(iii), as added by section
4501(b)(3) of OBRA–1990, is amended by striking ‘‘cost
sharing’’ and inserting ‘‘cost-sharing’’.
(b) Section 1905(p)(4)(B), as amended by section
4501(c)(1) of OBRA–1990, is amended by striking
‘‘1902(a)(10)(E)(iii)’’ 
and 
inserting 
‘‘section
1902(a)(10)(E)(iii)’’.
SEC. 5154. CORRECTIONS RELATING TO SECTION 4601
(CHILD HEALTH).
(a) Section 1902(a)(10)(A)(i)(VII), as added by sec-
tion 4601(a)(10)(A)(iii) of OBRA–1990, is amended by
striking ‘‘family;’’ and inserting ‘‘family; and’’.
(b) Section 1902(l), as amended by section
4601(a)(1)(C) of OBRA–1990, is amended—
(1) in paragraph (1)(C), by striking ‘‘children’’
after ‘‘(C)’’;
(2) 
in 
paragraph 
(3), 
by 
striking
‘‘(a)(10)(A)(i)(VII),,’’ 
and 
inserting
‘‘(a)(10)(A)(i)(VII),’’; and
(3) in paragraph (4)(B), by inserting a comma
before ‘‘(a)(10)(A)(i)(VI),’’.
276
(c) Subsections (a)(3)(C) and (b)(3)(C)(i) of section
1925, as amended by section 4601(a) of OBRA–1990, are
each amended by striking ‘‘(i)(VI)’’ and inserting
‘‘(i)(VI),’’.
SEC. 5155. CORRECTIONS RELATING TO SECTION 4602 (OUT-
REACH LOCATIONS).
(a) Section 1902(a)(55), as added by section
4602(a)(3) of OBRA–1990, is amended—
(1) in the matter preceding subparagraph (A)—
(A) by striking ‘‘subsection’’ and inserting
‘‘paragraph’’, and
(B) by striking ‘‘(a)’’ each place it ap-
pears; and
(2) 
in 
subparagraph 
(A), 
by 
striking
‘‘1905(1)(2)(B)’’ and inserting ‘‘1905(l)(2)(B)’’.
(b) Section 1902(l)(1) is amended by striking ‘‘who
are not described in any of subclauses (I) through (III)
of subsection (a)(10)(A)(i) and’’.
SEC. 5156. CORRECTIONS RELATING TO SECTION 4604 (PAY-
MENT FOR HOSPITAL SERVICES FOR CHIL-
DREN UNDER 6 YEARS OF AGE).
(a) Section 1902(a)(10) is amended in clause (X) in
the matter following subparagraph (F) by striking ‘‘under
one year of age’’ and inserting ‘‘under 6 years of age’’.
277
(b) Section 1902(s), as added by section 4604(a) of
OBRA–1990, is amended to read as follows:
‘‘(s) In order to meet the requirements of subsection
(a)(56), the State plan must provide that payments to hos-
pitals under the plan for inpatient services furnished to
infants who have not attained the age of 1 year (or, in
the case of such an individual who is an inpatient on his
first birthday, until such individual is discharged) shall—
‘‘(1) if made on a prospective basis (whether
per diem, per case, or otherwise) provide for an
outlier adjustment in payment amounts for medi-
cally necessary inpatient hospital services involving
exceptionally high costs or exceptionally long lengths
of stay;
‘‘(2) not be limited by the imposition of day
limits; and
‘‘(3) not be limited by the imposition of dollar
limits (other than dollar limits resulting from pro-
spective payments as adjusted pursuant to para-
graph (1)).’’.
(c) Section 1923(a)(2)(C) is amended by striking
‘‘provided on or after July 1, 1989,’’ and all that follows
and inserting the following: ‘‘involving exceptionally high
costs or exceptionally long lengths of stay—
278
‘‘(i) for individuals under 1 year of age, in the
case of services provided on or after July 1, 1989,
and on or before June 30, 1991; and
‘‘(ii) for individuals under 6 years of age, in the
case of services provided on or after July 1, 1991.’’.
SEC. 5157. CORRECTIONS RELATING TO SECTION 4703 (PAY-
MENT ADJUSTMENTS FOR DISPROPORTION-
ATE SHARE HOSPITALS).
(a) Section 1923(c) is amended—
(1) in paragraph (2), by striking ‘‘paragraph
(b)(3)’’ and inserting ‘‘subsection (b)(3)’’;
(2) by striking the period at the end of para-
graph (3)(B) and inserting a comma; and
(3) in the third sentence, by striking ‘‘the pay-
ment adjustment described in paragraph (2)’’ and
inserting ‘‘a payment adjustment described in para-
graph (2) or (3)’’.
(b) 
Effective 
December 
22, 
1987, 
section
1923(d)(2)(A)(ii) is amended by striking ‘‘the date of the
enactment of this Act’’ and inserting ‘‘December 22,
1987’’.
(c) Section 4703(d) of OBRA–1990 is amended by
striking ‘‘412(a)(2)’’ and inserting ‘‘4112(a)(2)’’.
279
SEC. 5158. CORRECTIONS RELATING TO SECTION 4704 (FED-
ERALLY-QUALIFIED HEALTH CENTERS).
(a) Clause (ix) of section 1903(m)(2)(A), as added
by section 4704(b)(1)(C) of OBRA–1990, is amended—
(1) by striking ‘‘of such center’’ the first place
it appears;
(2) by striking ‘‘federally qualified’’ and insert-
ing ‘‘Federally-qualified’’;
(3) 
by 
inserting 
‘‘section’’ 
before
‘‘1905(a)(2)(C)’’; and
(4) by moving such clause 2 ems to the left.
(b) Section 1903(m)(2)(B), as amended by section
4704(b)(2) of OBRA–1990, is amended by striking ‘‘ex-
cept with respect to clause (ix) of subparagraph (A),’’ and
inserting ‘‘(except with respect to clause (ix) of such sub-
paragraph)’’.
(c) Section 1905(l)(2), as amended by section
4704(c) of OBRA–1990, is amended—
(1) in subparagraph (A)—
(A) by striking ‘‘Federally-qualififed’’ and
inserting ‘‘Federally-qualified’’, and
(B) by striking ‘‘an patient’’ and inserting
‘‘a patient’’; and
(2) in subparagraph (B)—
(A) in the matter preceding clause (i), by
striking ‘‘a entity’’ and inserting ‘‘an entity’’,
280
(B) by striking ‘‘or’’ at the end of clause
(i),
(C) by striking the semicolon at the end of
clause (ii)(II) and inserting ‘‘, or’’,
(D) by moving clause (ii) 4 ems to the left,
and
(E) in the last sentence, by striking
‘‘clause (ii)’’ and inserting ‘‘clause (iii)’’.
SEC. 5159. CORRECTIONS RELATING TO SECTION 4708 (SUB-
STITUTE PHYSICIANS).
Section 
1902(a)(32)(C), 
as 
added 
by 
section
4708(a)(3) of OBRA–1990, is amended to read as follows:
‘‘(C) payment may be made to a physician
for physicians’ services (and services furnished
incident to such services) furnished by a second
physician to patients of the first physician if (i)
the first physician is unavailable to provide the
services; (ii) the services are furnished pursuant
to an arrangement between the two physicians
that (I) is informal and reciprocal, or (II) in-
volves per diem or other fee-for-time compensa-
tion for such services; (iii) the services are not
provided by the second physician over a contin-
uous period of more than 60 days; and (iv) the
claim form submitted to the carrier for such
281
services includes the second physician’s unique
identifier (provided under the system estab-
lished under subsection (x)) and indicates that
the claim meets the requirements of this clause
for payment to the first physician;’’.
SEC. 5160. CORRECTIONS RELATING TO SECTION 4711
(HOME AND COMMUNITY CARE FOR FRAIL
ELDERLY).
(a) Section 1929, as added by section 4711(b) of
OBRA–1990, is amended—
(1) in subsection (c)(2)(F), by moving the sec-
ond sentence 2 ems to the right;
(2) in subsection (d)(2)(F)(ii), by striking ‘‘they
manage’’ and inserting ‘‘it manages’’;
(3) in subsection (d)(2)(F)(iii), by inserting
‘‘the agency or organization’’ after ‘‘(iii)’’;
(4) in subsection (e)(2)(B), by striking ‘‘fiscal
year 1989’’ and inserting ‘‘fiscal year 1990’’;
(5) in subsection (f)(1), by striking ‘‘Commu-
nity care’’ and inserting ‘‘community care’’;
(6) in subsection (g)(1)—
(A) by striking ‘‘SETTINGS’’ and inserting
‘‘SETTING’’, and
(B) in subparagraph (B), by striking ‘‘set-
ting.’’ and inserting ‘‘setting in which home and
282
community care under this section is pro-
vided.’’;
(7) in subsection (g)(2), by striking ‘‘commu-
nity care’’ the second, third, and fourth places it ap-
pears and inserting ‘‘home and community care’’;
(8) in subsection (h)(1)—
(A) by striking ‘‘more than 8’’ each place
it appears and inserting ‘‘8 or more’’, and
(B) in subparagraph (B), by inserting
‘‘(other than merely board)’’ after ‘‘personal
services’’;
(9) in subsection (h)(2), by striking ‘‘commu-
nity care’’ the second and third places it appears
and inserting ‘‘home and community care’’;
(10) in subsection (j)(1)—
(A) in subparagraph (B)(ii), by striking
‘‘1990’’ and inserting ‘‘1991’’, and
(B) by adding at the end the following new
subparagraph:
‘‘(C) APPLICABILITY TO COMMUNITY CARE
SETTINGS.—Subparagraphs (A) and (B) shall
apply to community care settings in the same
manner as such subparagraphs apply to provid-
ers of home or community care.’’;
283
(11) in subsection (j)(2), by adding at the end
the following new subparagraph:
‘‘(D) APPLICABILITY TO COMMUNITY CARE
SETTINGS.—Subparagraphs (A), (B), and (C)
shall apply to community care settings in the
same manner as such subparagraphs apply to
providers of home or community care.’’;
(12) in subsection (k)(1)(A)(i)—
(A) by striking ‘‘(d)(2)(E)’’ and inserting
‘‘(d)(2)’’, and
(B) by striking ‘‘settings,’’ and inserting
‘‘settings),’’;
(13) in subsection (l), by striking ‘‘State wide-
ness’’ and inserting ‘‘Statewideness’’;
(14) in subsection (m)—
(A) in paragraph (2), by striking ‘‘Individ-
ual Community Care Plan’’ and inserting ‘‘indi-
vidual community care plan’’,
(B) in paragraph (3), by striking ‘‘and
need for services’’ and inserting ‘‘need for serv-
ices, and income’’,
(C) in the second sentence in paragraph
(4), by striking ‘‘elderly individuals’’ and all
that follows and inserting ‘‘individuals receiving
home and community care under this section
284
who reside in such State in relation to the total
number of individuals receiving home and com-
munity care under this section.’’, and
(D) by adding at the end the following new
paragraph:
‘‘(5) NOTICE TO STATES OF AMOUNTS AVAIL-
ABLE FOR ASSISTANCE.—
‘‘(A) NOTICE TO SECRETARY.—In order to
receive Federal medical assistance for expendi-
tures for home and community care under this
section for a fiscal year (beginning with fiscal
year 1994), a State shall submit a notice to the
Secretary of its intention to provide such care
under this section not later than 3 months be-
fore the beginning of the fiscal year.
‘‘(B) NOTICE TO STATES.—Not later than
2 months before the beginning of each fiscal
year (beginning with fiscal year 1994), the Sec-
retary shall notify each State that has submit-
ted a notice to the Secretary under subpara-
graph (A) for the fiscal year of the amount of
Federal medical assistance that will be available
to the State for the fiscal year (as established
under paragraph (4)).’’; and
285
(15) by adding at the end the following new
subsection:
‘‘(n) COMMUNITY CARE SETTING DEFINED.—In this
section, the term ‘community care setting’ means a small
community care setting (as defined in subsection (g)(1))
or a large community care setting (as defined in sub-
section (h)(1)).’’.
(b) Section 1905(r)(5) is amended by striking
‘‘1905(a)’’ and inserting ‘‘subsection (a) (other than serv-
ices described in paragraph (22) or (23) of such sub-
section)’’.
(c) Section 4711(f) of OBRA–1990 is amended by
striking ‘‘Act’’ each place it appears and inserting ‘‘sec-
tion’’.
SEC. 5161. CORRECTIONS RELATING TO SECTION 4712
(COMMUNITY SUPPORTED LIVING ARRANGE-
MENTS SERVICES).
(a) Section 1930, as added by section 4712(b)(2) of
OBRA–1990, is amended—
(1) in subsection (b)—
(A) by striking ‘‘title the term,’’ and in-
serting ‘‘title, the term’’,
(B) by striking ‘‘guardian’’ and inserting
‘‘guardian or’’, and
286
(C) by striking ‘‘3 other’’ and inserting
‘‘3’’;
(2) in subsection (d)—
(A) in the matter preceding paragraph (1),
by striking ‘‘program,’’ and inserting ‘‘pro-
gram’’, and
(B) in the second sentence, by striking
‘‘plan’’ each place it appears and inserting
‘‘program’’; and
(3) in subsection (i), by striking ‘‘FUNDS’’ and
inserting ‘‘FUNDS’’.
(b) Section 4712(c) of OBRA–1990 is amended—
(1) in paragraph (1), by inserting ‘‘of section
1930 of the Social Security’’ after ‘‘subsection (h)’’;
and
(2) in paragraph (2), by striking ‘‘this section’’
and inserting ‘‘such section’’.
SEC. 5162. CORRECTION RELATING TO SECTION 4713
(COBRA CONTINUATION COVERAGE).
(a) Section 1902(a)(10) is amended in the matter fol-
lowing subparagraph (F)—
(1) by striking ‘‘; and (XI)’’ and inserting
‘‘, (XI)’’;
(2) by striking ‘‘individuals, and (XI)’’ and in-
serting ‘‘individuals, and (XII); and
287
(3) by striking ‘‘COBRA continuation pre-
miums’’ and inserting ‘‘COBRA premiums’’.
(b) Section 1902(u)(3), as added by section
4713(a)(2) of OBRA–1990, is amended by striking ‘‘title
VI’’ and inserting ‘‘part 6 of subtitle B of title I’’.
SEC. 5163. CORRECTION RELATING TO SECTION 4716 (MED-
ICAID 
TRANSITION 
FOR 
FAMILY 
ASSIST-
ANCE).
Section 4716(a) of OBRA–1990 is amended by strik-
ing ‘‘AMENDMENTS.—Subsection (f) of section’’ and in-
serting ‘‘IN GENERAL.—Section’’.
SEC. 5164. CORRECTIONS RELATING TO SECTION 4723
(MEDICAID SPENDDOWN OPTION).
Section 1903(f)(2), as amended by section 4723(a)
of OBRA–1990, is amended—
(1) by striking ‘‘(A)’’ after ‘‘(2)’’;
(2) by striking ‘‘or, (B)’’ and inserting ‘‘. There
shall also be excluded,’’;
(3) by striking ‘‘to the State, provided that’’
and inserting ‘‘to the State if’’; and
(4) by striking ‘‘pursuant to this subpara-
graph.’’ and inserting ‘‘pursuant to the previous sen-
tence’’.
288
SEC. 5165. CORRECTIONS RELATING TO SECTION 4724 (OP-
TIONAL 
STATE 
DISABILITY 
DETERMINA-
TIONS).
Section 1902(v), as added by section 4724 of OBRA–
1990, is amended—
(1) by striking ‘‘(v)(1)’’ and inserting ‘‘(v)’’;
and
(2) by striking ‘‘of the Social Security Act’’.
SEC. 5166. CORRECTION RELATING TO SECTION 4732 (SPE-
CIAL RULES FOR HEALTH MAINTENANCE OR-
GANIZATIONS).
Section 1903(m)(2)(F)(i), as amended by section
4732(b)(2)(B) of OBRA–1990, is amended by striking
‘‘or’’ before ‘‘with an eligible organization’’.
SEC. 5167. CORRECTIONS RELATING TO SECTION 4741
(HOME AND COMMUNITY-BASED WAIVERS).
The first sentence of section 1915(d)(3) is amended
by striking the period at the end and inserting the follow-
ing: ‘‘, and a waiver of the requirements of section
1902(a)(23) (relating to choice of providers) insofar as
such requirements relate to the provision of case manage-
ment services and the State provides assurances satisfac-
tory to the Secretary that a waiver of such requirements
will not substantially limit access to such services).’’
289
SEC. 5168. CORRECTIONS RELATING TO SECTION 4744
(FRAIL ELDERLY WAIVERS).
(a) Section 1924(a)(5), as added by section
4744(b)(1) of OBRA–1990, is amended by striking
‘‘1986.’’ and inserting ‘‘1986 or a waiver under section
603(c) of the Social Security Amendments of 1983.’’.
(b) Section 603(c) of the Social Security Amend-
ments of 1983 is amended—
(1) by striking ‘‘(c)’’ and inserting ‘‘(c)(1)’’;
(2) by redesignating paragraphs (1) and (2) as
subparagraphs (A) and (B); and
(3) by adding at the end the following new
paragraph:
‘‘(2) Section 1924 of the Social Security Act shall
apply to any individual receiving services from an organi-
zation receiving a waiver under this subsection.’’.
SEC. 5169. CORRECTIONS RELATING TO SECTION 4747 (COV-
ERAGE OF HIV-POSITIVE INDIVIDUALS).
Section 4747 of OBRA–1990 is amended—
(1) in subsection (a), by striking ‘‘subsection
(c)’’ and inserting ‘‘subsection (b)’’;
(2) in subsection (b)(2)—
(A) by striking ‘‘preventative’’ each place it
appears and inserting ‘‘preventive’’, and
(B) by adding a period at the end of sub-
paragraph (J);
290
(3) in subsection (c)(1)—
(A) by striking ‘‘subsection (c)’’ and in-
serting ‘‘subsection (b)’’, and
(B) by striking ‘‘paragraphs (1) and (2)
of’’; and
(4) in subsection (d)—
(A) by striking ‘‘paragraph (3)’’ and in-
serting ‘‘subsection (b)’’, and
(B) by striking ‘‘paragraph (1)’’ and in-
serting ‘‘subsection (a)’’.
SEC. 5170. CORRECTION RELATING TO SECTION 4751 (AD-
VANCE DIRECTIVES).
Section 1903(m)(1)(A), as amended by section
4751(b)(1) of OBRA–1990, is amended—
(1) by striking ‘‘1902(w)’’ and inserting
‘‘1902(w) and’’; and
(2) by striking ‘‘1902(a)’’ and inserting
‘‘1902(w)’’.
SEC. 5171. CORRECTIONS RELATING TO SECTION 4752 (PHY-
SICIANS’ SERVICES).
(a) The paragraph (58) of section 1902(a) added by
section 4752(c)(1)(C) of OBRA–1990 is amended by
striking ‘‘subsection (v)’’ and inserting ‘‘subsection (x)’’.
291
(b) Subparagraphs (A) and (B) of the paragraph (14)
of section 1903(i) added by section 4752(e)(2) of OBRA–
1990 are each amended—
(1) by striking ‘‘or’’ at the end of clause (v);
(2) by redesignating clause (vi) as clause (vii);
and
(3) by inserting after clause (v) the following
new clause:
‘‘(vi) delivers such services in the
emergency department of a hospital par-
ticipating in the state plan approved under
this title, or’’.
SEC. 5172. CORRECTIONS RELATING TO SECTION 4801
(NURSING HOME REFORM).
(a) Section 1919(b)(3)(C)(i)(I), as amended by sec-
tion 4801(e)(3) of OBRA–1990, is amended by striking
‘‘no later than’’ before ‘‘not to exceed 14 days’’.
(b) Section 1919(b)(5)(D), as amended by section
4801(a)(4) of OBRA–1990, is amended by striking the
comma before ‘‘or a new competency evaluation pro-
gram.’’.
(c) Section 1919(b)(5)(G) is amended by striking ‘‘or
licensed or certified social worker’’ and inserting ‘‘licensed
or certified social worker, registered respiratory therapist,
or certified respiratory therapy technician’’.
292
(d) Section 1919(f)(2)(B)(i) is amended by striking
‘‘facilities,’’ and inserting ‘‘facilities (subject to clause
(iii)),’’.
(e) Section 1919(f)(2)(B)(iii)(I)(c) is amended by
striking ‘‘clauses’’ each place it appears and inserting
‘‘clause’’.
(f) Section 1919(g)(5)(B) is amended by striking
‘‘paragraphs’’ and inserting ‘‘paragraph’’.
(g) Section 4801(a)(6)(B) of OBRA–1990 is amend-
ed—
(1) by striking ‘‘The amendments’’ and insert-
ing ‘‘(i) The amendments’’;
(2) by redesignating clauses (i) through (v) as
subclauses (I) through (V); and
(3) by adding at the end the following new
clause:
‘‘(ii) Notwithstanding clause (i) and sub-
ject to section 1919(f)(2)(B)(iii) of the Social
Security Act (as amended by subparagraph
(A)), a State may approve a training and com-
petency evaluation program or a competency
evaluation program offered by or in a nursing
facility described in clause (i) if, during the pre-
vious 2 years, none of the subclauses of clause
(i) applied to the facility.’’.
293
SEC. 5173. OTHER TECHNICAL CORRECTIONS.
(a) Section 1905(o)(1)(A) is amended—
(1) in the first sentence, by striking ‘‘intermedi-
ate care facility services’’ and inserting ‘‘for nursing
facility services or intermediate care facility services
for the mentally retarded’’; and
(2) in the second sentence, by striking ‘‘or in-
termediate care facility’’ and inserting ‘‘(for pur-
poses of title XVIII), a nursing facility, or an inter-
mediate care facility for the mentally retarded’’.
(b) Section 1915(d) is amended—
(1) by striking ‘‘skilled nursing facility or inter-
mediate care facility’’ each place it appears in para-
graphs (1), (2)(B), and (2)(C) and inserting ‘‘nurs-
ing facility’’;
(2) in paragraph (2)(B)(i), by striking ‘‘skilled
nursing or intermediate care facility’’ and inserting
‘‘nursing facility’’;
(3) in paragraph (5)(A), by striking ‘‘under’’
the second place it appears and inserting ‘‘(or, in the
case of waiver years beginning on or after October
1, 1990, with respect to nursing facility services and
home and community-based services) under’’; and
(4) in paragraph (5)(B)—
(A) in clause (i), by striking ‘‘furnished’’
and inserting ‘‘(or, with respect to waiver years
294
beginning on or after October 1, 1990, for
nursing facility services) furnished’’; and
(B) in clause (iii)(I), by striking ‘‘(regard-
less’’ and inserting ‘‘(or, with respect to waiver
years beginning on or after October 1, 1990,
which comprise nursing facility services) (re-
gardless’’.
SEC. 5174. CORRECTIONS TO DESIGNATIONS OF NEW PRO-
VISIONS.
(a) PARAGRAPHS ADDED TO SECTION 1902(a).—
Section 1902(a) is amended—
(1) by striking ‘‘and’’ at the end of paragraph
(54);
(2) in the paragraph (55) inserted by section
4602(a)(3) of OBRA–1990, by striking the period at
the end and inserting a semicolon;
(3) by redesignating the paragraph (55) in-
serted by section 4604(b)(3) of OBRA–1990 as
paragraph (56), by transferring and inserting it
after the paragraph (55) inserted by section
4602(a)(3) of such Act, and by striking the period
at the end and inserting a semicolon;
(4) by placing paragraphs (57) and (58), in-
serted by section 4751(a)(1)(C) of OBRA–1990, im-
295
mediately after paragraph (56), as redesignated by
paragraph (3);
(5) in the paragraph (58) inserted by section
4751(a)(1)(C) of OBRA–1990, by striking the pe-
riod at the end and inserting ‘‘; and’’; and
(6) by redesignating the paragraph (58) in-
serted by section 4752(c)(1)(C) of OBRA–1990 as
paragraph (59) and by transferring and inserting it
after the paragraph (58) inserted by section
4751(a)(1)(C) of such Act.
(b) PARAGRAPHS ADDED TO SECTION 1903(i).—Sec-
tion 1903(i), as amended by section 2(b)(2) of the Medic-
aid Voluntary Contribution and Provider-Specific Tax
Amendments of 1991, is amended—
(1) in the paragraph (10) inserted by section
4401(a)(1)(B) of OBRA–1990, by striking all that
follows ‘‘1927(g)’’ and inserting a semicolon;
(2) by redesignating the paragraph (12) in-
serted by section 4752(a)(2) of OBRA–1990 as
paragraph (11), by transferring and inserting it
after the paragraph (10) inserted by section
4401(a)(1)(B) of OBRA–1990, and by striking the
period at the end and inserting a semicolon;
(3) by redesignating the paragraph (14) in-
serted by section 4752(e) of OBRA–1990 as para-
296
graph (12), by transferring and inserting it after
paragraph (11), as redesignated by paragraph (2),
and by striking the period at the end and inserting
‘‘; or’’; and
(4) by redesignating the paragraph (11) in-
serted by section 4801(e)(16)(A) of OBRA–1990 as
paragraph (13) and by transferring and inserting it
after paragraph (12), as redesignated by paragraph
(3).
(c) PARAGRAPHS ADDED TO SECTION 1905(a).—
(1) IN GENERAL.—Section 1905(a) is amend-
ed—
(A) by striking ‘‘and’’ at the end of para-
graph (21);
(B) in paragraph (24), by striking the
comma at the end and inserting ‘‘; and’’; and
(C) by redesignating paragraphs (22),
(23), and (24) as paragraphs (24), (22), and
(23), respectively, and by transferring and in-
serting paragraph (24) after paragraph (23), as
so redesignated.
(2) CONFORMING AMENDMENTS.—(A) Effective
July 1, 1991, section 1902(a)(10)(C)(iv), as amend-
ed by section 4755(c)(1)(A) of OBRA–1990, is
297
amended by striking ‘‘through (21)’’ and inserting
‘‘through (23)’’.
(B) Effective July 1, 1991, section 1902(j), as
amended by section 4711(d)(1) of OBRA–1990, is
amended by striking ‘‘through (22)’’ and inserting
‘‘through (24)’’.
(d) FINAL SECTIONS.—Section 1928, as redesignated
by section 4401(a)(3) of OBRA–1990, is amended—
(1) by transferring such section to the end of
title XIX of the Social Security Act; and
(2) by redesignating such section as section
1931.
CHAPTER 2—UNIVERSAL ACCESS TO
CHILDHOOD IMMUNIZATIONS
SEC. 5181. ESTABLISHMENT OF ENTITLEMENT AND MON-
ITORING 
PROGRAMS 
WITH 
RESPECT 
TO
CHILDHOOD IMMUNIZATIONS.
(a) IN GENERAL.—Title XXI of the Public Health
Service Act (42 U.S.C. 300aa-1 et seq.) is amended by
adding at the end the following subtitle:
298
‘‘Subtitle 3—Entitlement and Monitoring Programs With
Respect to Childhood Immunizations
‘‘PART A—ENTITLEMENT PROGRAM
‘‘SEC. 2151. DELIVERY TO STATES OF SUFFICIENT QUAN-
TITIES OF PEDIATRIC VACCINES.
‘‘(a) IN GENERAL.—In the case of any State that
submits to the Secretary an application in accordance with
section 2157, the Secretary, acting through the Director
of the Centers for Disease Control and Prevention, shall
provide for the purchase and delivery on behalf of the
State of such quantities of pediatric vaccines as may be
necessary for the immunization of each eligible child in
the State. The preceding sentence is subject to sections
2152(d) and 2159(a).
‘‘(b) ELIGIBLE CHILDREN.—For purposes of this
part, the term ‘eligible child’ means an individual 18 years
of age or younger who—
‘‘(1) with respect to the State involved, is enti-
tled to medical assistance under the plan approved
for the State under title XIX of the Social Security
Act (including a State operating under a statewide
waiver under section 1115 of such Act);
‘‘(2)(A) is uninsured with respect to health in-
surance policies or plans (including group health
plans or prepaid health plans and including em-
299
ployee welfare benefit plans under the Employee Re-
tirement Income Security Act of 1974); or
‘‘(B) is covered under such a policy or plan, but
under the policy or plan benefits are not available
with respect to immunizations; or
‘‘(3) is an Indian.
‘‘SEC. 2152. ENTITLEMENTS.
‘‘(a) ENTITLEMENT OF STATES.—Subject to sub-
section (d), in the case of any State that submits to the
Secretary an application in accordance with section 2157,
the State is entitled to have the Secretary provide for the
purchase and delivery on behalf of the State of pediatric
vaccines under section 2151. The preceding sentence con-
stitutes budget authority in advance of appropriations
Acts, and represents the obligation of the Federal Govern-
ment to provide for the purchase and delivery to the State
of the vaccines.
‘‘(b) ENTITLEMENTS OF CHILDREN AND HEALTH
CARE PROVIDERS.—Subject to subsection (d), the Sec-
retary may provide for the purchase and delivery of pedi-
atric vaccines under section 2151 on behalf of a State only
if the State agrees as follows:
‘‘(1) Each eligible child in the State, in receiv-
ing an immunization with a pediatric vaccine from
a program-registered provider (as defined in section
300
2153(a)), is entitled to receive the immunization
without charge for the cost of such vaccine.
‘‘(2) Each program-registered provider in the
State who administers a pediatric vaccine to an eligi-
ble child in the State is entitled to receive such vac-
cine from the State without charge.
‘‘(3) The State will carry out a program to ad-
minister the entitlements established pursuant to
paragraphs (1) and (2).
‘‘(c) ENFORCEMENT OF PROVIDER RIGHTS BY ELI-
GIBLE CHILDREN.—With respect to the obligation of a
State under the entitlement established in subsection
(b)(2), an eligible child (or representative of the child)
may enforce the rights of the provider under such para-
graph if—
‘‘(1) the provider administered a pediatric vac-
cine to the child notwithstanding the failure of the
State to carry out such obligation with respect to the
vaccine; or
‘‘(2) an immunization with the vaccine was
sought for the child by a parent of the child, but the
provider, on the basis of such failure of the State,
did not administer the vaccine to the child.
‘‘(d) CERTAIN CONDITIONS.—
301
‘‘(1) IN GENERAL.—This part does not apply
with respect to any vaccine administered before Oc-
tober 1, 1994.
‘‘(2) RELATIONSHIP TO PURCHASE CONTRACTS
WITH
MANUFACTURERS.—With respect to a pedi-
atric vaccine, the obligation of the Federal Govern-
ment pursuant to subsection (a), and the obligations
of the State pursuant to subsection (b), are effective
only to the extent that there is in effect a contract
under section 2158 for the purchase and delivery of
the vaccine.
‘‘(3) SUBMISSION OF APPLICATION.—
‘‘(A) Subject to subparagraph (C), the en-
titlements established pursuant to subsections
(a) and (b) are established with respect to a
State upon the State submitting to the Sec-
retary an application in accordance with section
2157.
‘‘(B) An application submitted to the Sec-
retary under section 2157 is deemed to have
been submitted in accordance with such section
unless the Secretary, not later than 30 days
after the date on which the application is sub-
mitted, notifies the State that the application is
not in accordance with such section.
302
‘‘(C) In the case of a State whose applica-
tion submitted under section 2157 is not sub-
mitted in accordance with such section, the Sec-
retary may, upon the submission by the State
of an application that is in accordance with
such section, provide that the entitlements es-
tablished pursuant to such submission are
deemed to have been established on the date on
which the State first submitted the application.
‘‘SEC. 2153. VOLUNTARY PARTICIPATION OF HEALTH CARE
PROVIDERS.
‘‘(a) IN GENERAL.—
‘‘(1) REQUEST FOR PARTICIPATION; REQUIRED
APPROVAL.—The Secretary may provide for the pur-
chase and delivery of pediatric vaccines under sec-
tion 2151 on behalf of a State only if the State
agrees that federally-supplied pediatric vaccines will
not be distributed to a health care provider unless—
‘‘(A) the provider submits to the State a
written request to participate in the program
established by the State pursuant to section
2152(b)(3);
‘‘(B) the request is in such form and is
made in such manner as the Secretary may re-
quire; and
303
‘‘(C) the provider makes the agreements
described in this section.
‘‘(2) PROGRAM-REGISTERED
PROVIDERS.—For
purposes of this part, the term ‘program-registered
provider’ means a health care provider that meets
the conditions specified in subparagraphs (A)
through (C) of paragraph (1).
‘‘(b) ELIGIBILITY OF CHILDREN.—
‘‘(1) IN GENERAL.—An agreement for a health
care provider under subsection (a) is that the pro-
vider—
‘‘(A) before administering a pediatric vac-
cine to a child, will ask a parent of the child
such questions as are necessary to determine
whether the child is an eligible child;
‘‘(B) will, for a period of time specified by
the Secretary, maintain records of responses
made to the questions; and
‘‘(C) will, upon request, make such records
available to the State involved and to the Sec-
retary, subject to paragraph (2).
‘‘(2) RESTRICTION ON USE OF INFORMATION.—
Records provided to a State or to the Secretary
under paragraph (1)(C) may be used only for pur-
304
poses of audit of the program carried out under sec-
tion 2152(b)(3) by the State.
‘‘(c) CHARGES FOR VACCINES.—
‘‘(1) VACCINES PER SE.—An agreement for a
health care provider under subsection (a) is that, in
administering a federally-supplied pediatric vaccine
to an eligible child, the provider will not impose a
charge for the cost of the vaccine.
‘‘(2) ADMINISTRATION OF VACCINES.—With re-
spect to compliance with an agreement under para-
graph (1), a program-registered provider may im-
pose a charge for the administration of a federally-
supplied pediatric vaccine, subject to an agreement
by the provider that the provider will not impose
such charge with respect to a child if a parent of the
child certifies to the provider that the parent is un-
able to pay the charge.
‘‘(d) RULES OF CONSTRUCTION.—
‘‘(1) EXTENT OF PARTICIPATION.—This section
may not be construed as requiring that a program-
registered provider administer a federally-supplied
pediatric vaccine to each eligible child for whom an
immunization with the vaccine is sought from the
provider.
305
‘‘(2) VERIFICATION
OF
INFORMATION.—With
respect to compliance with agreements under sub-
sections (b) and (c), such agreements may not be
construed as requiring a program-registered provider
to verify independently the information provided to
the provider by a parent pursuant to such sub-
sections.
‘‘SEC. 2154. INTRASTATE DISTRIBUTION OF PEDIATRIC VAC-
CINES.
‘‘(a) IN GENERAL.—Not later than 180 days after
the date of the enactment of the Omnibus Budget Rec-
onciliation Act of 1993, the Secretary shall, through publi-
cation in the Federal Register, establish criteria for the
delivery on behalf of the States of federally-supplied pedi-
atric vaccines to program-registered providers in the
State.
‘‘(b) INVOLVEMENT OF CERTAIN PROVIDERS.—
‘‘(1) IN
GENERAL.—In establishing criteria
under subsection (a), the Secretary shall establish
criteria with respect to encouraging the entities de-
scribed in paragraph (2) to become program-reg-
istered providers.
‘‘(2) RELEVANT PROVIDERS.—The entities re-
ferred to in paragraph (1) are—
‘‘(A) private health care providers; and
306
‘‘(B)(i) health care providers that receive
funds under title V of the Indian Health Care
Improvement Act;
‘‘(ii) the Indian Health Service; and
‘‘(iii) health programs or facilities operated
by Indian tribes or tribal organizations.
‘‘(c) CULTURAL CONTEXT OF SERVICES.—In estab-
lishing criteria under subsection (a), the Secretary shall
require that, in providing a federally-supplied pediatric
vaccine to any population of eligible children a substantial
portion of whose parents have a limited ability to speak
the English language, a State have in effect a reasonable
plan to administer the vaccines through program-reg-
istered providers who are able to communicate with the
population involved in the language and cultural context
that is most appropriate.
‘‘(d) COMPLIANCE BY STATES.—The Secretary may
provide for the purchase and delivery of pediatric vaccines
under section 2151 on behalf of a State only if the State
agrees to maintain compliance with the criteria established
under subsection (a).
‘‘SEC. 2155. GENERAL PROVISIONS.
‘‘(a) FEDERAL STANDARDS ON ACCOUNTABILITY.—
‘‘(1) ESTABLISHMENT
OF
STANDARDS.—Not
later than 180 days after the date of the enactment
307
of the Omnibus Budget Reconciliation Act of 1993,
the Secretary shall, through publication in the Fed-
eral Register, establish standards with respect to de-
termining the extent to which States and program-
registered providers are in compliance with the
agreements made under this part.
‘‘(2) COMPLIANCE BY STATES.— The Secretary
may provide for the purchase and delivery of pedi-
atric vaccines under section 2151 on behalf of a
State only if the State agrees to maintain compli-
ance with the standards established under subsection
(a).
‘‘(b) STATE
MAINTENANCE
OF
IMMUNIZATION
LAWS.—The Secretary may provide for the purchase and
delivery of vaccines under section 2151 on behalf of a
State only if the State certifies to the Secretary that, if
it had in effect as of May 1, 1993, a law that requires
some or all health insurance policies or plans to provide
some coverage with respect to a pediatric vaccine, the
State has not modified or repealed such law in a manner
that reduces the amount of coverage so required.
‘‘(c) PARTICIPATION IN NATIONAL MONITORING SYS-
TEM.—On and after January 1, 1998, the Secretary may
provide for the purchase and delivery of vaccines under
section 2151 on behalf of a State only if the State certifies
308
to the Secretary that the State is operating a registry in
accordance with part B.
‘‘SEC. 2156. STATE OPTION REGARDING IMMUNIZATION OF
ADDITIONAL CATEGORIES OF CHILDREN.
‘‘(a) STATE PURCHASES.—Subject to subsections (b)
and (c), for the purpose of administering a pediatric vac-
cine to children in addition to eligible children, any partici-
pating State under section 2151 may, pursuant to section
2158(a)(2), purchase the vaccine from a manufacturer of
the vaccine at the price in effect under section 2158.
‘‘(b) REQUIREMENTS.—A State may purchase pedi-
atric vaccines pursuant to subsection (a) only if the follow-
ing conditions are met:
‘‘(1) The State agrees that the vaccines will be
used to provide immunizations for children who are
not eligible children.
‘‘(2) The State designates the particular cat-
egories of children who are to receive the immuniza-
tions, and submits to the Secretary a description of
the categories so designated.
‘‘(3) The State provides to the Secretary such
information as the Secretary determines to be nec-
essary to provide for quantities of pediatric vaccines
for the State to purchase pursuant to section
2158(a)(2).
309
‘‘(4) The State agrees, subject to subsection (c),
that the program established by the State pursuant
to section 2152(b)(3) applies to children designated
under paragraph (2) to the same extent and in the
same manner as the program applies to eligible chil-
dren (except for the State being the purchaser of the
pediatric vaccines involved).
‘‘(c) CERTAIN LIMITATIONS.—A State may purchase
pediatric vaccines pursuant to subsection (a) only if the
State agrees as follows:
‘‘(1) The authorization established in such sub-
section with respect to a pediatric vaccine is subject
to the quantity of the vaccine that, on behalf of the
State, the Secretary provides for under section
2158(a)(2).
‘‘(2) In any case in which multiple contracts are
in effect under section 2158 with respect to such a
vaccine and the State elects to purchase the vaccine
pursuant to subsection (a), the Secretary will deter-
mine which of such contracts will be applicable to
the purchase.
‘‘SEC. 2157. STATE APPLICATION FOR VACCINES.
‘‘(a) IN GENERAL.—An application by a State for pe-
diatric vaccines under section 2151(a) is in accordance
with this section if the application—
310
‘‘(1) is submitted not later than the date speci-
fied by the Secretary;
‘‘(2) contains each agreement required in this
part (including the agreements required in section
2156, if the State is electing to purchase pediatric
vaccines pursuant to such section);
‘‘(3) contains any information required in this
part to be submitted to the Secretary (including the
information required in section 2156, if the State is
electing to purchase pediatric vaccines pursuant to
such section);
‘‘(4) contains the certification required in sub-
section (b) of section 2155 and, as applicable, the
certification required in subsection (c) of such sec-
tion; and
‘‘(5) is in such form, is made in such manner,
and contains such agreements, assurances, and in-
formation as the Secretary determines to be nec-
essary to carry out this part.
‘‘(b) FAILURE TO APPLY.—
‘‘(1) IN GENERAL.—If, as of January 1, 1998,
a State is not receiving pediatric vaccines under sec-
tion 2151 and carrying out a program pursuant to
section 2152(b)(3), the Secretary shall, subject to
311
paragraph (2), terminate payments to the State
under part A of title XIX.
‘‘(2) EXCEPTIONS.—Paragraph (1) does not
apply in the case of a State described in such para-
graph that—
‘‘(A) is, through all willing health care pro-
viders, providing for the immunization of eligi-
ble children with pediatric vaccines, and is not
imposing a charge on such providers or children
for the costs of the vaccines; or
‘‘(B) meets or exceeds the objectives estab-
lished by the Secretary for the year 2000 for
the immunization status of children in the
United States who are 2 years of age.
‘‘SEC. 2158. CONTRACTS WITH MANUFACTURERS OF PEDI-
ATRIC VACCINES.
‘‘(a) IN GENERAL.—Subject to the provisions of this
section, the Secretary shall periodically enter into negotia-
tions with manufacturers of pediatric vaccines for the pur-
pose of maintaining contracts under which—
‘‘(1) the Secretary provides for the purchase of
quantities of pediatric vaccines necessary for carry-
ing out section 2151, and provides for the delivery
of the vaccines to participating States under such
section; and
312
‘‘(2) each participating State, at the option of
the State under section 2156, is permitted to obtain
additional quantities of pediatric vaccines (subject to
limits in such contracts regarding quantities)
through purchasing the vaccines from the manufac-
turers at the price negotiated by the Secretary for
the quantities specified in paragraph (1).
The Secretary shall enter into the initial negotiations
under the preceding sentence not later than 180 days after
the date of the enactment of the Omnibus Budget Rec-
onciliation Act of 1993.
‘‘(b) NEGOTIATION OF PURCHASE PRICE.—
‘‘(1) IN GENERAL.—In negotiating the prices at
which pediatric vaccines will be purchased from a
manufacturer under subsection (a), the Secretary
shall negotiate a price that provides a reasonable
profit for the manufacturer.
‘‘(2) CERTAIN FACTORS.—
‘‘(A) In determining a reasonable profit for
a manufacturer under paragraph (1), the Sec-
retary shall consider the following factors:
‘‘(i) The costs of the manufacturer in
researching, developing, and producing the
pediatric vaccine involved.
313
‘‘(ii) The costs of the manufacturer in
researching and developing new or im-
proved vaccines (pediatric or otherwise).
‘‘(iii) The costs of shipping and han-
dling pediatric vaccines in compliance with
the agreement under subsection (c).
‘‘(iv) Such other factors as the Sec-
retary determines to be appropriate.
‘‘(B) With respect to factors considered
under subparagraph (A), the Secretary may
enter into a contract under subsection (a) only
if the manufacturer involved provides to the
Secretary such information regarding the fac-
tors as the Secretary determines to be appro-
priate.
‘‘(3) CONFIDENTIALITY.—With respect to infor-
mation provided to the Secretary by a manufacturer
under paragraph (2), the following applies:
‘‘(A) The Secretary shall maintain the con-
fidentiality of the information, with provision
for reasonable disclosures.
‘‘(B) For purposes of section 552(b)(4) of
title 5, United States Code, the information
shall be considered to be trade secrets and com-
314
mercial or financial information obtained from
a person and privileged or confidential.
‘‘(C) Section 1905 of title 18, United
States Code, applies to information maintained
confidentially under subparagraph (A).
‘‘(c) CHARGES FOR SHIPPING AND HANDLING.—The
Secretary may enter into a contract under subsection (a)
only if the manufacturer involved agrees that the manu-
facturer will provide for delivering the vaccines on behalf
of the States in accordance with the programs established
by the States pursuant to section 2152(b)(3), and will not
impose any charges for the costs of such delivery (except
to the extent such costs are provided for in the price nego-
tiated under subsection (b)).
‘‘(d) QUANTITY OF VACCINES.—For the purpose of
ensuring that the Federal Government has the ability to
carry out section 2151, the Secretary, in negotiations
under subsection (a), shall negotiate for maintaining a
supply of pediatric vaccines to meet unanticipated needs
for the vaccines. For purposes of the preceding sentence,
the Secretary shall negotiate for a 6-month supply of vac-
cines in addition to the quantity that the Secretary other-
wise would provide for in such negotiations. In carrying
out this paragraph, the Secretary shall consider the poten-
315
tial for outbreaks of the diseases with respect to which
the vaccines have been developed.
‘‘(e) NEGOTIATING AUTHORITY OF SECRETARY.—In
carrying out subsection (a), the Secretary, to the extent
determined by the Secretary to be appropriate, may enter
into contracts described in such subsection, may decline
to enter into such contracts, and with the consent of the
manufacturers involved, may modify such agreements and
may extend such agreements.
‘‘(f) CERTAIN CONTRACT PROVISIONS.—
‘‘(1) DURATION.—A contract entered into by
the Secretary under subsection (a) is effective for
such period as the Secretary and the manufacturer
involved may agree in the contract.
‘‘(2) ADVANCE FUNDING.—The Secretary may,
pursuant to section 2152(a), enter into contracts
under subsection (a) under which the Federal Gov-
ernment is obligated to make outlays, the budget au-
thority for which is not provided for in advance in
appropriations Acts.
‘‘(g) REPORTS TO SECRETARY.—The Secretary may
enter into a contract under subsection (a) only if the man-
ufacturer involved agrees to submit to the Secretary such
reports as the Secretary determines to be appropriate with
respect to compliance with the contract. For purposes of
316
paragraph (3) of subsection (b), such reports shall be con-
sidered to be information provided by the manufacturer
to the Secretary under paragraph (2) of such subsection.
‘‘(h) MULTIPLE SUPPLIERS.—
‘‘(1) IN GENERAL.—In the case of the pediatric
vaccine involved, the Secretary shall, as appropriate,
enter into a contract under subsection (a) with each
manufacturer of the vaccine that meets the terms
and conditions of the Secretary for an award of such
a contract (including terms and conditions regarding
safety, quality, and price).
‘‘(2) RULE OF CONSTRUCTION.—With respect
to multiple contracts entered into pursuant to para-
graph (1), such paragraph may not be construed as
prohibiting the Secretary from having in effect dif-
ferent prices under each of such contracts.
‘‘SEC. 2159. CERTAIN ADMINISTRATIVE VARIATIONS.
‘‘(a) TRIBES AND TRIBAL ORGANIZATIONS.—
‘‘(1) IN GENERAL.—Subject to paragraph (2),
the Secretary shall provide for the purchase and de-
livery on behalf of each Indian tribe and each tribal
organization of such quantities of pediatric vaccines
as may be necessary for the immunization of each
Indian child in the State in which the tribe or orga-
nization (as the case may be) is located.
317
‘‘(2) ENTITLEMENTS; 
ADMINISTERING
PRO-
GRAM.—The Secretary may provide for the purchase
and delivery of pediatric vaccines under paragraph
(1) on behalf of an Indian tribe or tribal organiza-
tion only if the tribe or organization (as the case
may be) agrees that this part applies to the tribe or
organization (in relation to Indian children) to the
same extent and in the manner as such part applies
to States (in relation to eligible children).
‘‘(b) STATE AS MANUFACTURER.—
‘‘(1) PAYMENTS IN LIEU OF VACCINES.—In the
case of a participating State under section 2151 that
manufactures a pediatric vaccine and is not receiv-
ing the vaccine under such section, if the Secretary
determines that the program of the State under
2152(b)(3) is carried out with respect to the vaccine,
the Secretary shall provide to the State an amount
equal to the value of the quantity of such vaccine
that otherwise would have been delivered to the
State under section 2151, subject to the provisions
of this subsection.
‘‘(2) DETERMINATION
OF
VALUE.—In deter-
mining the amount to pay a State under paragraph
(1) with respect to a pediatric vaccine, the value of
the quantity of vaccine shall be determined on the
318
basis of the price in effect for the vaccine under con-
tracts under section 2158. If more than 1 such con-
tract is in effect, the Secretary shall determine such
value on the basis of the average of the prices under
the contracts, after weighting each such price in re-
lation to the quantity of vaccine under the contract
involved.
‘‘(3) USE OF PAYMENTS.—A State may expend
payments received under paragraph (1) only for pur-
poses relating to pediatric vaccines.
‘‘SEC. 2160. LIST OF PEDIATRIC VACCINES; SCHEDULE FOR
ADMINISTRATION.
‘‘(a) RECOMMENDED PEDIATRIC VACCINES.—
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish a list of the vaccines that the Secretary rec-
ommends for administration to all children for the
purpose of immunizing the children, subject to such
contraindications for particular medical categories of
children as the Secretary may establish under sub-
section (b)(1)(D). The Secretary shall periodically
review the list, and shall revise the list as appro-
priate.
‘‘(2) RULE OF CONSTRUCTION.—
319
‘‘(A) The list of vaccines specified in sub-
paragraph (B) is deemed to be the list of vac-
cines maintained under paragraph (1).
‘‘(B) The list of vaccines specified in this
subparagraph is the list of vaccines that, for
purposes of paragraph (1), is established (and
periodically reviewed and as appropriate re-
vised) by the Advisory Committee on Immuni-
zation Practices, an advisory committee estab-
lished by the Secretary, acting through the Di-
rector of the Centers for Disease Control and
Prevention.
‘‘(b) RECOMMENDED SCHEDULE FOR ADMINISTRA-
TION.—
‘‘(1) IN GENERAL.—Subject to paragraph (2),
in the case of a pediatric vaccine, the Secretary shall
establish (and periodically review and as appropriate
revise) a schedule of nonbinding recommendations
for the following:
‘‘(A) The number of immunizations with
the vaccine that children should receive.
‘‘(B) The ages at which children should re-
ceive the immunizations.
‘‘(C) The dosage of vaccine that should be
administered in the immunizations.
320
‘‘(D) Any contraindications regarding ad-
ministration of the vaccine to particular medical
categories of children.
‘‘(E) Such other guidelines as the Sec-
retary determines to be appropriate with re-
spect to administering the vaccine to children.
‘‘(2) VARIATIONS IN MEDICAL PRACTICE.—In
establishing and revising a schedule under para-
graph (1), the Secretary shall ensure that, in the
case of the pediatric vaccine involved, the schedule
provides for the full range of variations in medical
judgment regarding the administration of the vac-
cine, subject to remaining within medical norms.
‘‘(3) RULE OF CONSTRUCTION.—
‘‘(A) The schedule specified in subpara-
graph (B) is deemed to be the schedule main-
tained under paragraph (1).
‘‘(B) The schedule specified in this sub-
paragraph is the schedule that, for purposes of
paragraph (1), is established (and periodically
reviewed and as appropriate revised) by the ad-
visory 
committee 
specified 
in 
subsection
(a)(2)(B).
‘‘(c) GENERALLY APPLICABLE RULES OF CONSTRUC-
TION.—
321
‘‘(1) IN GENERAL.—The list established under
subsection (a) and the schedules established under
subsection (b) do not constitute guidelines, stand-
ards, performance measures, or review criteria for
purposes of the program carried out by the Adminis-
trator for Health Care Policy and Research under
part B of title IX or under section 1142 of the So-
cial Security Act.
‘‘(2) STATE LAWS.—This section does not su-
persede any State law on requirements with respect
to receiving immunizations (including any such law
relating to religious exemptions or medical exemp-
tions).
‘‘(d) ISSUANCE OF LIST AND SCHEDULES.—Not later
than 180 days after the date of the enactment of the Om-
nibus Budget Reconciliation Act of 1993, the Secretary
shall establish the initial list required in subsection (a) and
the schedule required in subsection (b).
‘‘SEC. 2161. CHILDHOOD IMMUNIZATION TRUST FUND.
‘‘(a) ESTABLISHMENT OF FUND.—There is estab-
lished in the Treasury of the United States a fund to be
known as the National Childhood Immunization Trust
Fund (in this section referred to as the ‘Fund’). The Fund
shall consist of such amounts as may be appropriated to
the Fund in appropriations Acts, in the Internal Revenue
322
Code of 1986, or in subsection (c)(3). Amounts appro-
priated to the Fund shall remain available until expended.
‘‘(b) EXPENDITURES FROM FUND.—Amounts in the
Fund are available to the Secretary for the purpose of car-
rying out this part. Payments under the program under
this part, and the costs of carrying out such program,
shall be exempt from reduction under any order issued
under part C of the Balanced Budget and Emergency Def-
icit Control Act of 1985.
‘‘(c) INVESTMENT.—
‘‘(1) IN
GENERAL.—The Secretary of the
Treasury shall invest such amounts of the Fund as
such Secretary determines are not required to meet
current withdrawals from the Fund. Such invest-
ments may be made only in interest-bearing obliga-
tions of the United States. For such purpose, such
obligations may be acquired on original issue at the
issue price, or by purchase of outstanding obliga-
tions at the market price.
‘‘(2) SALE
OF
OBLIGATIONS.—Any obligation
acquired by the Fund may be sold by the Secretary
of the Treasury at the market price.
‘‘(3) AVAILABILITY OF INCOME.—Any interest
derived from obligations acquired by the Fund, and
323
proceeds from any sale or redemption of such obliga-
tions, are hereby appropriated to the Fund.
‘‘SEC. 2162. DEFINITIONS.
‘‘For purposes of this subtitle:
‘‘(1) The term ‘eligible child’ has the meaning
given such term in section 2151(b).
‘‘(2) The term ‘federally-supplied’, with respect
to a pediatric vaccine, means that such vaccine is
purchased and delivered on behalf of a State under
section 2151(a).
‘‘(3) The term ‘health care provider’, with re-
spect to the administration of vaccines to children,
means an entity that is licensed or otherwise author-
ized for such administration under the law of the
State in which the entity administers the vaccine,
subject to section 333(e).
‘‘(4) The term ‘immunization’ means an immu-
nization against a vaccine-preventable disease.
‘‘(5) Each of the terms ‘Indian’, ‘Indian tribe’,
and ‘tribal organization’ has the meaning given such
term in section 4 of the Indian Health Care Im-
provement Act.
‘‘(6) The term ‘Indian child’ means an Indian
who is 18 years of age or younger.
324
‘‘(7) The term ‘manufacturer’ means any cor-
poration, organization, or institution, whether public
or private (including Federal, State, and local de-
partments, agencies, and instrumentalities), which
manufactures, imports, processes, or distributes
under its label any pediatric vaccine. The term
‘manufacture’ means to manufacture, import, proc-
ess, or distribute a vaccine.
‘‘(8) The term ‘parent’, with respect to a child,
means a legal guardian of the child.
‘‘(9) The term ‘participating State under sec-
tion 2151’ means a State that has submitted to the
Secretary an application in accordance with section
2157.
‘‘(10) The term ‘pediatric vaccine’ means a vac-
cine included on the list established under section
2160(a).
‘‘(11) The term ‘program-registered provider’
has the meaning given such term in 2153(a)(2).
‘‘SEC. 2163. TERMINATION OF PROGRAM.
This part shall cease to be in effect beginning on such
date as may be prescribed in Federal law providing for
immunization services for all children as part of a broad-
based reform of the national health care system.
325
‘‘PART B—NATIONAL SYSTEM FOR MONITORING
IMMUNIZATION STATUS OF CHILDREN
‘‘SEC. 2171. FORMULA GRANTS FOR STATE REGISTRIES
WITH RESPECT TO MONITORING.
‘‘(a) IN GENERAL.—For the purpose described in
subsection (b), the Secretary, acting through the Director
of the Centers for Disease Control and Prevention, shall
make an allotment each fiscal year for each State in an
amount determined in accordance with section 2175. The
Secretary shall make a grant to the State of the allotment
made for the State for the fiscal year if the State submits
to the Secretary an application in accordance with section
2174.
‘‘(b) AUTHORIZED ACTIVITIES.—The Secretary may
make a grant under subsection (a) only if the State agrees
to expend the grant for the purpose of—
‘‘(1) collecting the data described in section
2172;
‘‘(2) operating registries to maintain the data
(and establishing such registries, in the case of a
State that is not operating such a registry);
‘‘(3) utilizing the data to monitor the extent to
which children have received immunizations in ac-
cordance with the schedule established under section
2160(b);
326
‘‘(4) notifying parents if children have not re-
ceived immunizations in accordance with such sched-
ule; and
‘‘(5) such other activities as the Secretary may
authorize with respect to achieving the objectives es-
tablished by the Secretary for the year 2000 for the
immunization status of children in the United
States.
‘‘(c) REQUIREMENT REGARDING STATE LAWS.—
‘‘(1) IN GENERAL.—The Secretary may make a
grant under subsection (a) only if the State in-
volved—
‘‘(A) provides assurances satisfactory to
the Secretary that, not later than October 1,
1996, the State will be operating a registry in
accordance with this part, including having in
effect such laws and regulations as may be nec-
essary to so operate such a registry; and
‘‘(B) agrees that, prior to such date, the
State will make such efforts to operate a reg-
istry in accordance with this part as may be au-
thorized in the law and regulations of the State.
‘‘(2) RULES OF CONSTRUCTION.—
‘‘(A) With respect to the agreements made
by a State under this part, other than the
327
agreement under paragraph (1)(B), the Sec-
retary may require compliance with the agree-
ments only to the extent consistent with such
paragraph.
‘‘(B) This part does not authorize the Sec-
retary, as a condition of the receipt of a grant
under subsection (a) by a State, to prohibit the
State from providing any parent, upon the re-
quest of the parent, with an exemption from the
requirements established by the State pursuant
to this part for the collection of data regarding
any child of the parent.
‘‘SEC. 2172. REGISTRY DATA.
‘‘(a) 
IN
GENERAL.—For 
purposes 
of 
section
2171(b)(1), the data described in this section are the data
described in subsection (b) and the data described in sub-
section (c). This section applies to data regarding a child
without regard to whether the child is an eligible child as
defined in section 2162.
‘‘(b) DATA REGARDING BIRTH OF CHILD.—With re-
spect to the birth of a child, the data described in this
subsection is as follows:
‘‘(1) The name of each child born in the State
involved on or after October 1, 1993.
‘‘(2) Demographic data on the child.
328
‘‘(3) The name of one or both of the parents of
the child.
‘‘(4) The address, as of the date of the birth of
the child, of each parent whose name is received in
the registry pursuant to paragraph (3).
‘‘(c) DATA
REGARDING
INDIVIDUAL
IMMUNIZA-
TIONS.—With respect to a child to whom a pediatric vac-
cine is administered in the State involved, the data de-
scribed in this subsection is as follows:
‘‘(1) The name, age, and address of the child.
‘‘(2) The date on which the vaccine was admin-
istered to the child.
‘‘(3) The name and business address of the
health care provider that administered the vaccine.
‘‘(4) The address of the facility at which the
vaccine was administered.
‘‘(5) The name and address of one or both par-
ents of the child as of the date on which the vaccine
was administered, if such information is available to
the health care provider.
‘‘(6) The type of vaccine.
‘‘(7) The number or other information identify-
ing the particular manufacturing batch of the vac-
cine, if such information appears on the container or
329
packaging for the vaccine or is otherwise readily ac-
cessible to the health care provider.
‘‘(8) The dosage of vaccine that was adminis-
tered.
‘‘(9) A description of any adverse medical reac-
tions that the child experienced in relation to the
vaccine and of which the health care provider is
aware.
‘‘(10) Any other contraindications noted by the
health care provider with respect to administration
of the vaccine to the child.
‘‘(11) Such other data regarding immunizations
for the child, including identifying data, as the Sec-
retary may require consistent with applicable law
(including social security account numbers furnished
pursuant to section 205(c)(2)(E) of the Social Secu-
rity Act).
‘‘(d) DATE CERTAIN
FOR SUBMISSION
TO REG-
ISTRY.—The Secretary may make a grant under section
2171 only if the State involved agrees to ensure that, with
respect to a child—
‘‘(1) the data described in subsection (b) are
submitted to the registry under such section not
later than 6 weeks after the date on which the child
is born; and
330
‘‘(2) the data described in subsection (c) with
respect to a vaccine are submitted to such registry
not later than 6 weeks after the date on which the
vaccine is administered to the child.
‘‘SEC. 2173. GENERAL PROVISIONS.
‘‘(a) FEDERAL STANDARDS ON CONFIDENTIALITY.—
The Secretary shall by regulation establish standards pro-
viding for maintaining the confidentiality of the identity
of individuals with respect to whom data are maintained
in a registries under section 2171. Such standards shall,
with respect to a State, provide that the State is to have
in effect laws regarding such confidentiality, including ap-
propriate penalties for violation of the laws. The Secretary
may make a grant under such section only if the State
involved agrees to comply with the standards.
‘‘(b) USE
OF SOCIAL SECURITY ACCOUNT NUM-
BERS.—Any usage or disclosure of data in registries under
section 2171 that consists of social security account num-
bers and related information which is otherwise permitted
under this part may be exercised only to the extent per-
mitted under section 205(c)(2)(E) of the Social Security
Act. For purposes of the preceding sentence, the term ‘re-
lated information’ has the meaning given such term in
clause (iv)(II) of such section.
331
‘‘(c) UNIFORMITY IN METHODOLOGIES.—The Sec-
retary shall establish standards regarding the methodolo-
gies used in establishing and operating registries under
section 2171, and may make a grant under such section
only if the State agrees to comply with the standards. The
Secretary shall provide for a reasonable degree of uniform-
ity among the States in such methodologies for the pur-
pose of ensuring the utility, comparability, and exchange
of the data maintained in such registries.
‘‘(d) COORDINATION AMONG STATES.—The Sec-
retary may make a grant under section 2171 to a State
only if, with respect to the operation of the registry of
the State under such section, the State agrees to cooperate
with the Secretary and with other States in carrying out
activities with respect to achieving the objectives estab-
lished by the Secretary for the year 2000 for the immuni-
zation status of children in the United States.
‘‘(e) REPORTS TO SECRETARY.—The Secretary may
make a grant under section 2171 only if the State involved
agrees to submit to the Secretary such reports as the Sec-
retary determines to be appropriate with respect to the
activities of the State under this part.
‘‘SEC. 2174. APPLICATION FOR GRANT.
‘‘An application by a State for a grant under section
2171 is in accordance with this section if the application—
332
‘‘(1) is submitted not later than the date speci-
fied by the Secretary;
‘‘(2) contains each agreement required in this
part;
‘‘(3) contains any information required in this
part to be submitted to the Secretary; and
‘‘(4) is in such form, is made in such manner,
and contains such agreements, assurances, and in-
formation as the Secretary determines to be nec-
essary to carry out this part.
‘‘SEC. 2175. DETERMINATION OF AMOUNT OF ALLOTMENT.
‘‘The Secretary shall determine the amount of the al-
lotments required in section 2171 for States for a fiscal
year in accordance with a formula established by the Sec-
retary that allots the amounts appropriated under section
2177 for the fiscal year on the basis of the costs of the
States in establishing and operating registries under sec-
tion 2171.
‘‘SEC. 2176. DEFINITIONS.
‘‘For purposes of this part, each of the terms ‘health
care provider, ‘pediatric vaccine’ and ‘parent’ has the
meaning given the term in section 2162.
‘‘SEC. 2177. AUTHORIZATION OF APPROPRIATIONS.
‘‘For the purpose of carrying out this part, there are
authorized to be appropriated $50,000,000, for fiscal year
333
1994, $152,000,000 for fiscal year 1995, $125,000,000
for fiscal year 1996, and $35,000,000 for each of the fis-
cal years 1997 through 1999.
‘‘PART C—FUNDING FOR OTHER PURPOSES REGARDING
CHILDHOOD IMMUNIZATIONS
‘‘SEC. 2181. GRANTS REGARDING YEAR 2000 HEALTH OBJEC-
TIVES.
‘‘(a) IN GENERAL.—The Secretary, acting through
the Director of the Centers for Disease Control and Pre-
vention, may make grants to States for the purpose of car-
rying out activities with respect to achieving the objectives
established by the Secretary for the year 2000 for the im-
munization status of children in the United States, other
than providing for the purchase and delivery on behalf of
the State of any pediatric vaccine (as defined in section
2162).
‘‘(b) CERTAIN ACTIVITIES.—Subject to subsection
(a), the purposes for which a grant under such subsection
may be expended include the following:
‘‘(1) Research into the prevention and control
of diseases that may be prevented through vaccina-
tion.
‘‘(2) Demonstration projects for the prevention
and control of such diseases.
334
‘‘(3) Public information and education pro-
grams for the prevention and control of such dis-
eases.
‘‘(4) Education, training, and clinical skills im-
provement activities in the prevention and control of
such diseases for health professionals (including al-
lied health personnel).
‘‘(5) Such other activities as the Secretary de-
termines to be appropriate.
‘‘(c) APPLICATION FOR GRANT.—The Secretary may
make a grant under subsection (a) only if an application
for the grant is submitted to the Secretary and the appli-
cation is in such form, is made in such manner, and con-
tains such agreements, assurances, and information as the
Secretary determines to be necessary to carry out this sec-
tion.
‘‘(d) SUPPLIES AND SERVICES IN LIEU OF GRANT
FUNDS.— The Secretary, at the request of a recipient of
a grant under subsection (a), may reduce the amount of
such grant by—
‘‘(1) the fair market value of any supplies or
equipment furnished the grant recipient, and
‘‘(2) the amount of the pay, allowances, and
travel expenses of any officer or employee of the
Federal Government when detailed to the grant re-
335
cipient and the amount of any other costs incurred
in connection with the detail of such officer or em-
ployee.
When the furnishing of such supplies or equipment or the
detail of such an officer or employee is for the convenience
of and at the request of such grant recipient and for the
purpose of carrying out a program with respect to which
the grant under subsection (a) is made. The amount by
which any such grant is so reduced shall be available for
payment by the Secretary of the costs incurred in furnish-
ing the supplies or equipment, or in detailing the person-
nel, on which the reduction of such grant is based, and
such amount shall be deemed as part of the grant and
shall be deemed to have been paid to the grant recipient.
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—For the
purpose of carrying out this part, there are authorized to
be appropriated $580,000,000 for fiscal year 1993,
$680,000,000 for fiscal year 1994, and such sums as may
be necessary for each of the fiscal years 1995 through
1999.’’.
(b) AUTHORITY TO USE SOCIAL SECURITY ACCOUNT
NUMBERS.—Section 205(c)(2) of the Social Security Act
(42 U.S.C. 405(c)(2)) is amended—
(1) by redesignating subparagraphs (E) and
(F) as subparagraphs (F) and (G), respectively; and
336
(2) by inserting after subparagraph (D) the fol-
lowing new subparagraph:
‘‘(E)(i) The Secretary and each State receiving
grants under section 2171(a) of the Public Health Service
Act may utilize social security account numbers issued by
the Secretary under this subsection for purposes of—
‘‘(I) operating registries under such section to
maintain information including such numbers (and
establishing such registries, in the case of a State
that is not operating such a registry),
‘‘(II) utilizing such numbers to monitor the ex-
tent to which children have received immunizations
in accordance with the schedule established under
section 2160(b) of the Public Health Service Act,
and
‘‘(III) notifying parents if children have not re-
ceived immunizations in accordance with such sched-
ule.
‘‘(ii) Disclosure by individuals of social security ac-
count numbers may be required by a State for purposes
of identification of children in a registry operated pursu-
ant to a grant referred to in clause (i), except that such
disclosure may be required to be made only to persons spe-
cifically authorized in regulations of the Secretary pre-
scribed under part B of subtitle 3 of title XXI of the Pub-
337
lic Health Service Act. The Secretary shall take such ac-
tions as are necessary to restrict access to information
consisting of such numbers and related information only
to such authorized persons whose duties or responsibilities
require access for the purposes described in clause (i). The
Secretary shall issue regulations governing the use, main-
tenance, and disclosure by any holder of such information,
including appropriate administrative, technical, and phys-
ical safeguards, to ensure that only such authorized per-
sons have access to such information. Any use or disclo-
sure of such information in violation of such regulations
shall be deemed a disclosure in violation of subparagraph
(C)(vii).
‘‘(iii) The Secretary shall submit a report to the Com-
mittee on Ways and Means of the House of Representa-
tives and the Committee on Finance of the Senate not
later than January 1, 1996, and biennially thereafter, on
the operation of this subparagraph.
‘‘(iv) For purposes of this subparagraph—
‘‘(I) the term ‘State’ has the meaning provided
such term under section 2(f) of the Public Health
Service Act, and
‘‘(II) the term ‘related information’ means any
record, list, or compilation which indicates, directly
or indirectly, the identity of any individual with re-
338
spect to whom a social security account number is
maintained pursuant to this subparagraph and part
B of subtitle 3 of title XXI of the Public Health
Service Act.’’.
(c) RELATIONSHIP OF NEW PROGRAM OF IMMUNIZA-
TION GRANTS TO CURRENT PROGRAM.—
(1) STRIKING OF CURRENT PROGRAM.—Section
317 of the Public Health Service Act (42 U.S.C.
247b) is amended—
(A) in subsection (j)—
(i) by striking paragraph (1); and
(ii) by striking the remaining para-
graph designation; and
(B) in subsection (k)—
(i) by striking paragraph (1); and
(ii) by redesignating paragraphs (2)
and (3) as paragraphs (1) and (2), respec-
tively.
(2) TRANSITIONAL
AUTHORITY
UNDER
NEW
PROGRAM.—With respect to activities that the Sec-
retary of Health and Human Services was author-
ized to carry out pursuant to section 317(j)(1) of
the Public Health Service Act (as in effect on the
day before the date of the enactment of this Act),
the Secretary may, for fiscal year 1994, carry out
339
any such activity under section 2181 of the Public
Health Service Act (as added by subsection (a) of
this section), notwithstanding the provisions of such
section 2181. The authority established in the pre-
ceding sentence includes the authority to purchase
vaccines.
(d) CONTINUED COVERAGE OF COSTS OF A PEDI-
ATRIC VACCINE UNDER GROUP HEALTH PLANS.—
(1) REQUIREMENT.—The requirement of this
paragraph, with respect to a group health plan for
plan years beginning after the date of the enactment
of this Act, is that the group health plan not reduce
its coverage of the costs of pediatric vaccines (as de-
fined under section 2162 of the Public Health Serv-
ice Act) below the coverage it provided as of May 1,
1993.
(2) ENFORCEMENT.—
(A) For purposes of section 2207 of the
Public Health Service Act, the requirement of
paragraph (1) is deemed a requirement of title
XXII of such Act.
(B) For purposes of subsections (a)
through (e) of section 4980B of the Internal
Revenue Code of 1986, paragraph (1) is
340
deemed a requirement of subsection (f) of such
section.
(C) For purposes of section 502 of the
Employee Retirement Income Security Act of
1974, paragraph (1) is deemed a provision of
part 6 of subtitle B of title I of such Act.
SEC. 5182. NATIONAL VACCINE INJURY COMPENSATION
PROGRAM AMENDMENTS.
(a) USE OF VACCINE INJURY COMPENSATION TRUST
FUND.—Section 6601(r) of the Omnibus Budget Rec-
onciliation Act of 1989 is amended by striking
‘‘$2,500,000 for each of fiscal years 1991 and 1992’’ each
place it appears and inserting ‘‘$3,000,000 for fiscal year
1994 and each fiscal year thereafter’’ (in three places).
(b) AMENDMENT OF VACCINE INJURY TABLE.—Sec-
tion 2116(b) of the Public Health Service Act (42 U.S.C.
300aa–16(b)) is amended by striking ‘‘such person may
file’’ and inserting ‘‘or to significantly increase the likeli-
hood of obtaining compensation, such person may, not-
withstanding section 2111(b)(2), file’’.
(c) EXTENSION OF TIME FOR DECISION.—Section
2112(d)(3)(D) 
of 
such 
Act 
(42 
U.S.C. 
300aa–
12(d)(3)(D)) is amended by striking ‘‘540 days’’ and in-
serting ‘‘30 months (but for no more than 6 months at
a time)’’.
341
(d) SIMPLIFICATION OF VACCINE INFORMATION MA-
TERIALS.—
(1) Section 2126(b) of such Act (42 U.S.C.
300aa–26(b)) is amended—
(A) by striking ‘‘by rule’’ in the matter
preceding paragraph (1);
(B) by striking, in paragraph (1), ‘‘, op-
portunity for a public hearing, and 90’’ and in-
serting ‘‘and 30’’; and
(C) by striking, in paragraph (2), ‘‘, appro-
priate health care providers and parent organi-
zations’’.
(2) Section 2126(c) of such Act (42 U.S.C.
300aa–26(c)) is amended—
(A) by inserting ‘‘shall be based on avail-
able data and information,’’ after ‘‘such mate-
rials’’ in the matter preceding paragraph (1),
and
(B) by striking paragraphs (1) through
(10) and inserting the following:
‘‘(1) a concise description of the benefits of the
vaccine,
‘‘(2) a concise description of the risks associ-
ated with the vaccine,
342
‘‘(3) a statement of the availability of the Na-
tional Vaccine Injury Compensation Program, and
‘‘(4) such other relevant information as may be
determined by the Secretary.’’.
(3) Subsections (a) and (d) of section 2126 of
such Act (42 U.S.C. 300aa–26) are each amended
by inserting ‘‘or to any other individual’’ after ‘‘to
the legal representative of any child’’.
(4) Subsection (d) of section 2126 of such Act
(42 U.S.C. 300aa–26) is amended—
(A) by striking all after ‘‘subsection (a),’’
the second place it appears in the first sentence
and inserting ‘‘supplemented with visual presen-
tations or oral explanations, in appropriate
cases.’’, and
(B) by striking ‘‘or other information’’ in
the last sentence.
SEC. 5183. MEDICAID IMMUNIZATION PROVISIONS.
(a) OUTREACH AND EDUCATION.—
(1) IMMUNIZATION OUTREACH THROUGH EPSDT
PROGRAM.—Section 
1902(a)(43)(A) 
(42 
U.S.C.
1396a(a)(43)(A)) is amended by inserting before the
comma at the end the following: ‘‘and the need for
age-appropriate immunizations against vaccine-pre-
ventable diseases’’.
343
(2) COORDINATION
WITH
MATERNAL
AND
CHILD HEALTH BLOCK GRANT PROGRAMS AND WIC
PROGRAMS.—Section 
1902(a)(11) 
(42 
U.S.C.
1396a(a)(11)) is amended—
(A) in clause (B)—
(i) by striking ‘‘effective July 1,
1969,’’,
(ii) by striking ‘‘and’’ before ‘‘(ii)’’,
and
(iii) by striking ‘‘to him under section
1903’’ and inserting ‘‘to the individual
under section 1903, and (iii) providing for
coordination of information and education
on childhood vaccinations and delivery of
immunization services’’; and
(B) in clause (C), by inserting ‘‘(including
the provision of information and education on
childhood vaccinations and the delivery of im-
munization services)’’ after ‘‘operations under
this title’’.
(3) COVERAGE OF PUBLIC HOUSING HEALTH
CENTERS AS FEDERALLY-QUALIFIED HEALTH CEN-
TERS.—Section 
1905(l)(2)(B) 
(42 
U.S.C.
1396d(l)(2)(B)) is amended by striking ‘‘or 340’’
each place it appears and inserting ‘‘340, or 340A’’.
344
(4) EFFECTIVE DATE.—(A) Except as provided
in subparagraph (B), the amendments made by this
subsection shall apply to calendar quarters beginning
on or after October 1, 1993, without regard to
whether or not final regulations to carry out such
amendments have been promulgated by such date.
(B) In the case of a State plan for medical as-
sistance under title XIX of the Social Security Act
which the Secretary of Health and Human Services
determines requires State legislation (other than leg-
islation appropriating funds) in order for the plan to
meet the additional requirements imposed by the
amendments made by this subsection, the State plan
shall not be regarded as failing to comply with the
requirements of such title solely on the basis of its
failure to meet these additional requirements before
the first day of the first calendar quarter beginning
after the close of the first regular session of the
State legislature that 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.
345
(b) 
SCHEDULE
OF
IMMUNIZATIONS
UNDER
EPSDT.—
(1) IN
GENERAL.—Section 1905(r)(1) (42
U.S.C. 1396d(r)(1)) is amended—
(A) in subparagraph (A)(i), by inserting
‘‘and, with respect to immunizations under sub-
paragraph (B)(iii), in accordance with the
schedule recommended by the Secretary under
section 2160 of the Public Health Service Act’’
after ‘‘child health care’’; and
(B) in subparagraph (B)(iii), by inserting
‘‘(according to the schedule recommended by
the Secretary under section 2160 of the Public
Health Service Act)’’ after ‘‘appropriate immu-
nizations’’.
(2) EFFECTIVE DATE.—The amendments made
by subparagraphs (A) and (B) of paragraph (1)
shall first apply 90 days after the date the Secretary
of Health and Human Services first issues the rec-
ommended schedule referred to in subparagraphs
(A)(i) 
and 
subparagraph 
(B)(iii) 
of 
section
1905(r)(1) of the Social Security Act (as amended
by such respective subparagraphs).
(c) ASSURING ADEQUATE PAYMENT RATES FOR AD-
MINISTRATION OF VACCINES TO CHILDREN.—
346
(1) PAYMENT
RATES.—Section 1926(a)(4)(B)
(42 U.S.C. 1396r–7(a)(4)(B)) is amended by insert-
ing ‘‘(including the administration of vaccines)’’
after ‘‘means services’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to the plan amendment
required to be submitted under section 1926(a)(2) of
the Social Security Act by not later than April 1,
1994.
(d) DENIAL OF FEDERAL FINANCIAL PARTICIPATION
FOR INAPPROPRIATE ADMINISTRATION OF SINGLE–ANTI-
GEN VACCINE.—
(1) IN GENERAL.—Section 1903(i) (42 U.S.C.
1396b(i)), as amended by sections 5174(b) and
5131(a), is amended—
(A) in paragraph (13), by striking ‘‘or’’ at
the end,
(B) in paragraph (14), by striking the pe-
riod at the end and inserting ‘‘; or’’, and
(C) by inserting after paragraph (14) the
following new paragraph:
‘‘(15) with respect to any amount expended for
a single-antigen vaccine and its administration in
any case in which the administration of a combined-
347
antigen vaccine was medically appropriate (as deter-
mined by the Secretary).’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall apply to amounts expended
for vaccines administered on or after October 1,
1993.
(e) REQUIRING MEDICAID MANAGED CARE PLANS
T±±O COMPLY WITH IMMUNIZATION AND OTHER EPSDT
REQUIREMENTS.—
(1) IN GENERAL.—Section 1903(m) (42 U.S.C.
1396b(m)) is amended—
(A) in paragraph (2)(A), as amended by
subsections (a)(1) and (b)(1) of section 5135—
(i) by striking ‘‘and’’ at the end of
clause (xii),
(ii) by striking the period at the end
of clause (xiii) and inserting ‘‘; and’’, and
(iii) by adding at the end the follow-
ing new clause:
‘‘(xiv) the entity complies with the requirements
of paragraph (7) (relating to EPSDT compliance).’’;
and
(B) by adding at the end the following new
paragraph:
348
‘‘(7) The contract between the State and an entity
referred to in paragraph (2)(A)(iii) shall—
‘‘(A) specify which early and periodic screening,
diagnostic, and treatment services are to be provided
under the contract to individuals under age 21 en-
rolled with the entity;
‘‘(B) in the case of such services which are not
to be so provided, specify the steps the entity will
take (through referrals or other arrangements) to
assure that such individuals will receive such serv-
ices; and
‘‘(C) require the entity to submit such periodic
reports as may be necessary to enable the State to
prepare and submit timely reports under section
1902(a)(43)(D) and section 506(a)(2).’’.
(2) APPLICATION
OF
INTERMEDIATE
SANC-
TIONS FOR FAILURE TO PROVIDE IMMUNIZATIONS
AND
OTHER
EPSDT
SERVICES.—Section
1903(m)(5)(A) (42 U.S.C. 1396b(m)(5)(A)) is
amended—
(A) by striking ‘‘, or’’ at the end of clause
(iv) and inserting a semicolon,
(B) by striking the comma at the end of
clause (v) and inserting ‘‘; or’’, and
349
(C) by inserting after clause (v) the follow-
ing new clause:
‘‘(vi) fails substantially to provide early and
periodic screening, diagnostic, and treatment serv-
ices to the extent specified in the contract under
paragraph (7)(A);’’.
(3) EFFECTIVE DATE.—The amendments made
by this subsection shall apply to contract years be-
ginning on or after October 1, 1993, without regard
to whether or not final regulations to carry out such
amendments have been promulgated by such date.
(f) TRANSITION RULE.—
(1) MEDICAID USE OF CDC CONTRACT PRICE.—
The Secretary of Health and Human Services shall
not, on or after the date of the enactment of this
Act, enter into a contract for the purchase by the
Centers for Disease Control and Prevention of pedi-
atric vaccines for distribution (as provided for in
section 317 or section 2181 of the Public Health
Service Act) unless such contract provides that the
charge for such vaccines, for which medical assist-
ance is provided under a State plan under title XIX
of the Social Security Act, will not exceed the price
negotiated under the contract. The previous sentence
shall not apply, with respect to a vaccine for which
350
medical assistance is provided by a State, on and
after such date as the State becomes entitled to have
the Secretary provide for the purchase and delivery
on behalf of the State of that vaccine under section
2151 of the Public Health Service Act.
(2) OPTIONAL USE BY STATES OF CDC CON-
TRACT PRICE.—Nothing in paragraph (1) shall be
construed as limiting the Federal financial participa-
tion available to States, under title XIX of the So-
cial Security Act, for the cost of a pediatric vaccine
to the contract price described in such paragraph for
the vaccine.
SEC. 5184. AVAILABILITY OF MEDICAID PAYMENTS FOR
CHILDHOOD VACCINE REPLACEMENT PRO-
GRAMS.
(a) IN GENERAL.—Section 1902(a)(32) (42 U.S.C.
1396a(a)(32)) is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (B),
(2) by striking the period at the end of sub-
paragraph (C) and inserting ‘‘; and’’, and
(3) by adding at the end the following new sub-
paragraph:
‘‘(D) in the case of payment for a child-
hood vaccine administered to individuals enti-
351
tled to medical assistance under the State plan,
the State plan may make payment directly to
the manufacturer of the vaccine under a vol-
untary replacement program agreed to by the
State pursuant to which the manufacturer (i)
supplies doses of the vaccine to providers ad-
ministering the vaccine, (ii) periodically replaces
the supply of the vaccine, and (iii) charges the
State the manufacturer’s bid price to the Cen-
ters for Disease Control and Prevention for the
vaccine so administered plus a reasonable pre-
mium to cover shipping and the handling of re-
turns;’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall take effect on the date of the enact-
ment of this Act.
SEC. 5185. HEALTHY START FOR INFANTS.
(a) IN GENERAL.—Part D of title III of the Public
Health Service Act (42 U.S.C. 254b et seq.) is amended
by inserting after section 330 the following section:
‘‘HEALTHY START FOR INFANTS
‘‘SEC. 330A. (a) GRANTS
FOR COMPREHENSIVE
SERVICES.—
‘‘(1) IN GENERAL.—The Secretary may make
grants for the operation of not more than 21 dem-
onstration projects to provide the services described
352
in subsection (b) for the purpose of reducing, in the
geographic areas in which the projects are carried
out—
‘‘(A) the incidence of infant mortality and
morbidity;
‘‘(B) the incidence of fetal deaths;
‘‘(C) the incidence of maternal mortality;
‘‘(D) the incidence of fetal alcohol syn-
drome; and
‘‘(E) the incidence of low-birthweight
births.
‘‘(2) ACHIEVEMENT OF YEAR 2000 HEALTH STA-
TUS OBJECTIVES.—With respect to the objectives es-
tablished by the Secretary for the health status of
the population of the United States for the year
2000, the Secretary shall, in providing for a dem-
onstration project under paragraph (1) in a geo-
graphic area, seek to meet the objectives that are
applicable to the purpose described in such para-
graph and the populations served by the project.
‘‘(b) AUTHORIZED SERVICES.—
‘‘(1) IN GENERAL.—Subject to subsection (h),
the services referred to in this subsection are com-
prehensive services (including preventive and pri-
mary health services for pregnant women and in-
353
fants and childhood immunizations in accordance
with the schedule recommended by the Secretary
under section 2160) for carrying out the purpose de-
scribed in subsection (a), including services other
than health services.
‘‘(2) CERTAIN PROVIDERS.—The Secretary may
make a grant under subsection (a) only if the appli-
cant involved agrees that, in making any arrange-
ments under which other entities provide authorized
services in the demonstration project involved, the
applicant will include among the entities with which
the arrangements are made grantees under any of
sections 329, 330, 340, and 340A, if such grantees
are providing services in the service area of such
project and the grantees are willing to make such
arrangements with the applicant.
‘‘(c) ELIGIBLE GEOGRAPHIC AREAS.—The Secretary
may make a grant under subsection (a) only if—
‘‘(1) the applicant for the grant specifies the
geographic area in which the demonstration project
under such subsection is to be carried out and
agrees that the project will not be carried out in
other areas; and
354
‘‘(2) the rate of infant mortality in the geo-
graphic area equals or exceeds 150 percent of the
national average in the United States of such rates.
‘‘(d) MINIMUM QUALIFICATIONS OF GRANTEES.—
‘‘(1) PUBLIC
OR
NONPROFIT
PRIVATE
ENTI-
TIES.—The Secretary may make a grant under sub-
section (a) only if the applicant for the grant is a
State or local department of health, or other public
or nonprofit private entity, or a consortium of public
or nonprofit private entities.
‘‘(2) APPROVAL OF POLITICAL SUBDIVISIONS.—
With respect to a proposed demonstration project
under subsection (a), the Secretary may make a
grant under such subsection only if—
‘‘(A) the chief executive officer of each po-
litical subdivision in the service area of such
project approves the applicant for the grant as
being qualified to carry out the project; and
‘‘(B) the leadership of any Indian tribe or
tribal organization with jurisdiction over any
portion of such area so approves the applicant.
‘‘(3) STATUS AS MEDICAID PROVIDER.—
‘‘(A) In the case of any service described
in subsection (b) that is available pursuant to
the State plan approved under title XIX of the
355
Social Security Act for a State in which a dem-
onstration project under subsection (a) is car-
ried out, the Secretary may make a grant under
such subsection for the project only if, subject
to subparagraph (B)—
‘‘(i) the applicant for the grant will
provide the service directly, and the appli-
cant has entered into a participation agree-
ment under the State plan and is qualified
to receive payments under such plan; or
‘‘(ii) the applicant will enter into an
agreement with a public or private entity
under which the entity will provide the
service, and the entity has entered into
such a participation agreement under the
State plan and is qualified to receive such
payments.
‘‘(B)(i) In the case of an entity making an
agreement pursuant to subparagraph (A)(ii) re-
garding the provision of services, the require-
ment established in such subparagraph regard-
ing a participation agreement shall be waived
by the Secretary if the entity does not, in pro-
viding health care services, impose a charge or
accept reimbursement available from any third-
356
party payor, including reimbursement under
any insurance policy or under any Federal or
State health benefits plan.
‘‘(ii) A determination by the Secretary of
whether an entity referred to in clause (i) meets
the criteria for a waiver under such clause shall
be made without regard to whether the entity
accepts voluntary donations regarding the pro-
vision of services to the public.
‘‘(e) STATE APPROVAL OF PROJECT.—With respect
to a proposed demonstration project under subsection (a),
the Secretary may make a grant under such subsection
to the applicant involved only if—
‘‘(1) the chief executive officer of the State in
which the project is to be carried out approves the
proposal of the applicant for carrying out the
project; and
‘‘(2) the leadership of any Indian tribe or tribal
organization with jurisdiction over any portion of the
service area of the project so approves the proposal.
‘‘(f) ELIGIBILITY FOR SERVICES PROVIDED WITH
GRANT FUNDS.—
‘‘(1) IN GENERAL.—With respect to any au-
thorized service under subsection (b), if the service
is a service that States are required or authorized to
357
provide under title XIX of the Social Security Act,
the Secretary may make a grant under subsection
(a) only if the applicant involved agrees that the
grant will not be expended to provide the service to
any individual to whom States are required or au-
thorized under such title to provide the service. The
Secretary may not make a grant under subsection
(a) unless the State involved agrees that the grant
will not be expended to make payment for any item
or service to the extent that payment has been
made, or can reasonably be expected to be made,
with respect to such item or service—
‘‘(A) under a health insurance policy or
plan (including a group health plan or a pre-
paid health plan),
‘‘(B) under any Federal or State health
benefits program, including any program under
title V, XVIII, or XIX of the Social Security
Act, or
‘‘(C) under subpart 2 of part B of title
XIX of this Act.
‘‘(2) RULES OF CONSTRUCTION.—For purposes
of paragraph (1):
‘‘(A) Individuals to whom States are au-
thorized to provide services under title XIX of
358
the Social Security Act include, pursuant to
section 1902(l) of such title, pregnant women,
infants, and children with an income level not
less than 133 percent, and not more than 185
percent, of the official poverty line.
‘‘(B) Authorized services under subsection
(b) that are authorized to be provided under
title XIX of such Act include, pursuant to sec-
tion 1920 of such title, ambulatory prenatal
services during a period of presumptive eligi-
bility.
‘‘(C) Authorized services under subsection
(b) that are required to be provided under title
XIX of such Act include, pursuant to section
1905(a)(4)(B) of such title, early and periodic
screening, diagnostic, and treatment services for
children under the age of 21.
‘‘(D) Authorized services under subsection
(b) that are authorized to be provided under
title XIX of such Act include, pursuant to sec-
tion 1905(a)(19) of such title, case-manage-
ment services.
‘‘(g) MAINTENANCE OF EFFORT.—
‘‘(1) GRANTEE.—With respect to authorized
services under subsection (b), the Secretary may
359
make a grant under subsection (a) only if the appli-
cant involved agrees to maintain expenditures of
non-Federal amounts for such services at a level
that is not less than the level of such expenditures
maintained by the applicant for fiscal year 1991.
‘‘(2) RELEVANT
POLITICAL
SUBDIVISIONS.—
With respect to authorized services under subsection
(b), the Secretary may make a grant under sub-
section (a) only if each political subdivision in the
service area of the demonstration project involved
agrees to maintain expenditures of non-Federal
amounts for such services at a level that is not less
than the level of such expenditures maintained by
the political subdivision for fiscal year 1991.
‘‘(h) RESTRICTIONS ON EXPENDITURE OF GRANT.—
‘‘(1) IN GENERAL.—Except as provided in para-
graph (3), the Secretary may make a grant under
subsection (a) only if the applicant involved agrees
that the grant will not be expended—
‘‘(A) to provide inpatient services, except
with respect to residential treatment for sub-
stance abuse provided in settings other than
hospitals;
360
‘‘(B) to make cash payments to intended
recipients of health services or mental health
services; or
‘‘(C) to purchase or improve real property
(other than minor remodeling of existing im-
provements to real property) or to purchase
major medical equipment (other than mobile
medical units for providing ambulatory prenatal
services).
‘‘(2) ADMINISTRATIVE
EXPENSES; DATA
COL-
LECTION.—The Secretary may make a grant under
subsection (a) only if the applicant involved agrees
that not more than an aggregate 10 percent of the
grant will be expended for administering the grant
and the collection and analysis of data.
‘‘(3) WAIVER.—If the Secretary finds that the
purpose described in subsection (a) cannot otherwise
be carried out, the Secretary may, with respect to an
otherwise qualified applicant, waive the restriction
established in paragraph (1)(C).
‘‘(i) 
DETERMINATION
OF
CAUSE
OF
INFANT
DEATHS.—The Secretary may make a grant under sub-
section (a) only if the applicant involved—
361
‘‘(1) agrees to provide for a determination of
the cause of each infant death in the service area of
the demonstration project involved; and
‘‘(2) the applicant has made such arrangements
with public entities as may be necessary to carry out
paragraph (1).
‘‘(j) ANNUAL REPORTS TO SECRETARY.—The Sec-
retary may make a grant under subsection (a) only if the
applicant involved agrees that, for each fiscal year for
which the applicant operates a demonstration project
under such subsection the applicant will, not later than
April 1 of the subsequent fiscal year, submit to the Sec-
retary a report providing the following information with
respect to the project:
‘‘(1) The number of individuals that received
authorized services, and the demographic character-
istics of the population of such individuals.
‘‘(2) The types of authorized services provided,
including the types of ambulatory prenatal services
provided and the trimester of the pregnancy in
which the services were provided.
‘‘(3) The sources of payment for the authorized
services provided.
‘‘(4) The extent to which children under age 2
receiving authorized services have received the ap-
362
propriate number and variety of immunizations
against vaccine-preventable diseases.
‘‘(5) An analysis of the causes of death deter-
mined under subsection (i).
‘‘(6) The extent of progress being made toward
meeting the health status objectives specified in sub-
section (a)(2).
‘‘(7) The extent to which, in the service area in-
volved, progress is being made toward meeting the
participation goals established for the State by the
Secretary under section 1905(r) of the Social Secu-
rity Act (relating to early periodic screening, diag-
nostic, and treatment services for children under the
age of 21).
‘‘(k) COMMUNITY PARTICIPATION.—The Secretary
may make a grant under subsection (a) only if the appli-
cant involved agrees that, in preparing the proposal of the
applicant for the demonstration project involved, and in
the operation of the project, the applicant will consult with
the residents of the service area for the project and with
public and nonprofit private entities that provide author-
ized services to such residents.
‘‘(l) APPLICATION FOR GRANT.—The Secretary may
make a grant under subsection (a) only if an application
for the grant is submitted to the Secretary and the appli-
363
cation is in such form, is made in such manner, and con-
tains such agreements, assurances, and information as the
Secretary determines to be necessary to carry out this sub-
section.
‘‘(m) REPORT TO CONGRESS.—Not later than Feb-
ruary 1, 1998, the Secretary shall submit to the Commit-
tee on Energy and Commerce of the House of Representa-
tives, and the Committee on Labor and Human Resources
of the Senate, a report—
‘‘(1) summarizing the reports received by the
Secretary under subsection (j);
‘‘(2) describing the extent to which demonstra-
tion projects under subsection (a) have been cost ef-
fective; and
‘‘(3) describing the extent to which the Sec-
retary has, in the service areas of such projects,
been successful in meeting the health status objec-
tives specified in subsection (a)(2).
‘‘(n) LIMITATION ON CERTAIN EXPENSES OF SEC-
RETARY.—Of the amounts appropriated under subsection
(o) for a fiscal year, the Secretary may not obligate more
than an aggregate 5 percent for the administrative costs
of the Secretary in carrying out this section, for the provi-
sion of technical assistance regarding demonstration
364
projects under subsection (a), and for evaluations of such
projects.
‘‘(o) DEFINITIONS.—For purposes of this section:
‘‘(1) The term ‘authorized services’ means the
services specified in subsection (b).
‘‘(2) The terms ‘Indian tribe’ and ‘tribal organi-
zation’ have the meaning given such terms in section
4(b) and section 4(c) of the Indian Self-Determina-
tion and Education Assistance Act.
‘‘(3) The term ‘service area’, with respect to a
demonstration project under subsection (a), means
the geographic area specified in subsection (c).
‘‘(p) AUTHORIZATION OF APPROPRIATIONS.—For the
purpose of carrying out this section, there are authorized
to be appropriated for each of the fiscal years 1994
through 1997 such sums as may be necessary.
‘‘(q) SUNSET.—Effective October 1, 1997, this sec-
tion is repealed.’’.
(b) REPORT FOR FISCAL YEAR 1993.—With respect
to grants under section 330A of the Public Health Service
Act, as added by subsection (a) of this section, the Sec-
retary of Health and Human Services may make a grant
under such section for fiscal year 1994 only if the appli-
cant for the grant agrees to submit to the Secretary, not
later than April 1 of such year, a report on any federally-
365
supported project of the applicant that is substantially
similar to the demonstration projects authorized in such
section 330A, which report provides, to the extent prac-
ticable, the information described in subsection (j) of such
section.
(c) SAVINGS PROVISION.—With respect to grants
under section 330A of the Public Health Service Act, as
added by subsection (a) of this section and in effect for
the fiscal years 1994 through 1997, such grants remain
available for obligation and expenditure in accordance with
the terms upon which the grants were made, notwith-
standing the repeal of such section 330A pursuant to sub-
section (q) of such section.
(d) USE OF GENERAL AUTHORITY UNDER PUBLIC
HEALTH SERVICE ACT.—With respect to the program es-
tablished in section 330A of the Public Health Service Act,
as added by subsection (a) of this section, section 301 of
the Public Health Service Act may not be construed as
providing to the Secretary of Health and Human Services
any authority to carry out, during any fiscal year in which
such program is in operation, any demonstration project
to provide any of the services specified in subsection (b)
of such section 330A.
366
SEC. 5186. INCREASE IN AUTHORIZATION OF APPROPRIA-
TIONS FOR THE MATERNAL AND CHILD
HEALTH SERVICES BLOCK GRANT PROGRAM.
Section 501(a) (42 U.S.C. 701(a)) is amended by
striking ‘‘$686,000,000 for fiscal year 1990’’ and insert-
ing ‘‘$705,000,000 for fiscal year 1994’’.
SEC. 5187. MISCELLANEOUS TECHNICAL CORRECTIONS TO
PUBLIC HEALTH SERVICE ACT PROVISIONS.
(a) COMPENSATION FOR MEMBERS OF NATIONAL
ADVISORY COUNCIL
ON NATIONAL HEALTH SERVICE
CORPS.—
(1) IN
GENERAL.—Section 337(b)(2) of the
Public Health Service Act (42 U.S.C. 254j(b)(2)) is
amended—
(A) by inserting after ‘‘so serving’’ the fol-
lowing: ‘‘compensation at a rate fixed by the
Secretary (but not to exceed’’, and
(B) by striking ‘‘Schedule;’’ and inserting
‘‘Schedule);’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall take effect on the date of the
enactment of this Act.
(b) LIABILITY PROTECTIONS FOR INDIVIDUALS PRO-
VIDING SERVICES AT CERTAIN CLINICS.—
(1) CLARIFICATION OF VOLUNTARY PARTICIPA-
TION BY CERTAIN ENTITIES.—(A) Section 224(g) of
367
the 
Public 
Health 
Service 
Act 
(42 
U.S.C.
133(g)(1)), as added by section 2(a) of the Federally
Supported Health Centers Assistance Act of 1992, is
amended—
(i) in paragraph (4), by striking ‘‘An en-
tity’’ and inserting ‘‘Except as provided in
paragraph (6), an entity’’, and
(ii) by adding at the end the following new
paragraph:
‘‘(6) An entity may elect not to be treated as being
described in paragraph (4) if the entity establishes that
on a continuous basis since October 24, 1992, the entity
has been a participant in, and partial owner of, a nonprofit
risk retention group which offers malpractice and other
liability coverage to the entity.’’.
(B) Section 224(k)(2) of such Act (42 U.S.C.
233(k)(2)), as added by section 4 of the Federally
Supported Health Centers Assistance Act of 1992, is
amended by striking ‘‘entities receiving funds’’ and
all that follows through ‘‘subsection (g)’’ and insert-
ing the following: ‘‘entities described in subsection
(g)(4) and receiving funds under each of the grant
programs described in such subsection’’.
(2) CLARIFICATION OF COVERAGE OF OFFICERS
AND EMPLOYEES OF CLINICS.—The first sentence of
368
section 224(g)(1) of the Public Health Service Act
(42 U.S.C. 233(g)(1)) is amended by striking ‘‘offi-
cer, employee, or contractor’’ and inserting the fol-
lowing: ‘‘officer or employee of such an entity, and
any contractor’’.
(3) COVERAGE FOR SERVICES FURNISHED TO
INDIVIDUALS OTHER THAN PATIENTS OF CLINIC.—
Section 224(g) of such Act (42 U.S.C. 233(g)(1)),
as amended by paragraph (1), is amended—
(A) in the first sentence of paragraph (1),
by inserting after ‘‘Service’’ the following: ‘‘with
respect to services provided to patients of the
entity and (subject to paragraph (7)) to certain
other individuals’’; and
(B) by adding at the end the following new
paragraph:
‘‘(7) For purposes of paragraph (1), an officer, em-
ployee, or contractor described in such paragraph may be
deemed to be an employee of the Public Health Service
with respect to services provided to individuals who are
not patients of an entity described in paragraph (4) only
if the Secretary determines—
‘‘(A) that the provision of the services to such
individuals is necessary to assure the treatment of
patients of such an entity; or
369
‘‘(B) that such services are otherwise required
to be provided to such individuals under an employ-
ment contract (or other similar arrangement) be-
tween the individual and the entity.’’.
(4) DETERMINING
COMPLIANCE
OF
ENTITY
WITH
REQUIREMENTS
FOR
COVERAGE.—Section
224(h) of such Act (42 U.S.C. 233(h)), as added by
section 2(b) of the Federally Supported Health Cen-
ters Assistance Act of 1992, is amended by striking
‘‘the entity—’’ and inserting the following: ‘‘the Sec-
retary, after receiving such assurances and conduct-
ing such investigation as the Secretary considers
necessary, finds that the entity—’’.
(5) EFFECTIVE DATE.—The amendments made
by this subsection shall take effect as if included in
the enactment of the Federally Supported Health
Centers Assistance Act of 1992.
(c) ELIMINATION OF DUPLICATE WAIVER AUTHOR-
ITY FOR PARTICIPANTS IN NATIONAL HEALTH SERVICE
CORPS.—Section 338E(c) of the Public Health Service
Act (42 U.S.C. 254o(c)) is amended by striking paragraph
(3) and redesignating paragraph (4) as paragraph (3).
(d) CLARIFICATION OF PROHIBITION AGAINST RE-
SALE OF DRUGS UNDER DRUG REBATE AGREEMENTS.—
Section 340B(a)(5)(B) of the Public Health Service Act
370
(42 U.S.C. 256b(a)(5)(B)), as added by section 602(a) of
the Veterans Health Care of 1992, is amended by striking
‘‘entity.’’ and inserting ‘‘covered entity.’’.
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