H. R. 133—1779 
of the partnership (as described in section 1128C(a)(6) of the Social 
Security Act, as added by subsection (a)) establishing a system 
to conduct real-time data analysis to proactively identify ongoing 
as well as emergent fraud trends for the entities participating 
in the partnership and provide such entities with real-time feedback 
on potentially fraudulent claims. Such report shall include the 
estimated cost of and any potential barriers to the partnership 
establishing such a system. 
SEC. 125. MEDICARE PAYMENT FOR RURAL EMERGENCY HOSPITAL 
SERVICES. 
(a) IN GENERAL.— 
(1) DEFINITIONS.—Section 1861 of the Social Security Act 
(42 U.S.C. 1395x) is amended— 
(A) in subsection (e), in the last sentence of the matter 
following paragraph (9), by inserting ‘‘or a rural emergency 
hospital (as defined in subsection (kkk)(2))’’ before the 
period at the end; and 
(B) by adding at the end the following subsection: 
‘‘Rural Emergency Hospital Services; Rural Emergency Hospital 
‘‘(kkk)(1) RURAL EMERGENCY HOSPITAL SERVICES.— 
‘‘(A) IN GENERAL.—The term ‘rural emergency hospital serv-
ices ’ means the following services furnished by a rural emer-
gency hospital (as defined in paragraph (2)) that do not exceed 
an annual per patient average of 24 hours in such rural emer-
gency hospital: 
‘‘(i) Emergency department services and observation 
care. 
‘‘(ii) At the election of the rural emergency hospital, 
with respect to services furnished on an outpatient basis, 
other medical and health services as specified by the Sec-
retary through rulemaking. 
‘‘(B) STAFFED EMERGENCY DEPARTMENT.—For purposes of 
subparagraph (A)(i), an emergency department of a rural emer-
gency hospital shall be considered a staffed emergency depart-
ment if it meets the following requirements: 
‘‘(i) The emergency department is staffed 24 hours 
a day, 7 days a week. 
‘‘(ii) A physician (as defined in section 1861(r)(1)), nurse 
practitioner, clinical nurse specialist, or physician assistant 
(as those terms are defined in section 1861(aa)(5)) is avail-
able to furnish rural emergency hospital services in the 
facility 24 hours a day. 
‘‘(iii) Applicable staffing and staffing responsibilities 
under section 485.631 of title 42, Code of Federal Regula-
tions (or any successor regulation). 
‘‘(2) RURAL EMERGENCY HOSPITAL.—The term ‘rural emergency 
hospital’ means a facility described in paragraph (3) that— 
‘‘(A) is enrolled under section 1866(j), submits the addi-
tional information described in paragraph (4)(A) for purposes 
of such enrollment, and makes the detailed transition plan 
described in clause (i) of such paragraph available to the public, 
in a form and manner determined appropriate by the Secretary; 
‘‘(B) does not provide any acute care inpatient services, 
other than those described in paragraph (6)(A);
H. R. 133—1780 
‘‘(C) has in effect a transfer agreement with a level I 
or level II trauma center; 
‘‘(D) meets— 
‘‘(i) licensure requirements as described in paragraph 
(5); 
‘‘(ii) the requirements of a staffed emergency depart-
ment as described in paragraph (1)(B); 
‘‘(iii) such staff training and certification requirements 
as the Secretary may require; 
‘‘(iv) conditions of participation applicable to— 
‘‘(I) critical access hospitals, with respect to emer-
gency services under section 485.618 of title 42, Code 
of Federal Regulations (or any successor regulation); 
and 
‘‘(II) hospital emergency departments under this 
title, as determined applicable by the Secretary; 
‘‘(v) such other requirements as the Secretary finds 
necessary in the interest of the health and safety of individ-
uals who are furnished rural emergency hospital services; 
and 
‘‘(vi) in the case where the rural emergency hospital 
includes a distinct part unit of the facility that is licensed 
as a skilled nursing facility, such distinct part meets the 
requirements applicable to skilled nursing facilities under 
this title. 
‘‘(3) FACILITY DESCRIBED.—A facility described in this para-
graph is a facility that as of the date of the enactment of this 
subsection— 
‘‘(A) was a critical access hospital; or 
‘‘(B) was a subsection (d) hospital (as defined in section 
1886(d)(1)(B)) with not more than 50 beds located in a county 
(or equivalent unit of local government) in a rural area (as 
defined in section 1886(d)(2)(D)), or was a subsection (d) hos-
pital (as so defined) with not more than 50 beds that was 
treated as being located in a rural area pursuant to section 
1886(d)(8)(E). 
‘‘(4) ADDITIONAL INFORMATION.— 
‘‘(A) INFORMATION.—For purposes of paragraph (2)(A), a 
facility that submits an application for enrollment under section 
1866(j) as a rural emergency hospital shall submit the following 
information at such time and in such form as the Secretary 
may require: 
‘‘(i) An action plan for initiating rural emergency hos-
pital services (as defined in paragraph (1)), including a 
detailed transition plan that lists the specific services that 
the facility will— 
‘‘(I) retain; 
‘‘(II) modify 
‘‘(III) add; and 
‘‘(IV) discontinue. 
‘‘(ii) A description of services that the facility intends 
to furnish on an outpatient basis pursuant to paragraph 
(1)(A)(ii). 
‘‘(iii) Information regarding how the facility intends 
to use the additional facility payment provided under sec-
tion 1834(x)(2), including a description of the services cov-
ered under this title that the additional facility payment
H. R. 133—1781 
would be supporting, such as furnishing telehealth services 
and ambulance services, including operating the facility 
and maintaining the emergency department to provide such 
services covered under this title. 
‘‘(iv) Such other information as the Secretary deter-
mines appropriate. 
‘‘(B) EFFECT
OF
ENROLLMENT.—Such enrollment shall 
remain effective with respect to a facility until such time as— 
‘‘(i) the facility elects to convert back to its prior des-
ignation as a critical access hospital or a subsection (d) 
hospital (as defined in section 1886(d)(1)(B)), subject to 
requirements applicable under this title for such designa-
tion and in accordance with procedures established by the 
Secretary; or 
‘‘(ii) the Secretary determines the facility does not meet 
the requirements applicable to a rural emergency hospital 
under this subsection. 
‘‘(5) LICENSURE.—A facility may not operate as a rural emer-
gency hospital in a State unless the facility— 
‘‘(A) is located in a State that provides for the licensing 
of such hospitals under State or applicable local law; and 
‘‘(B)(i) is licensed pursuant to such law; or 
‘‘(ii) is approved by the agency of such State or locality 
responsible for licensing hospitals, as meeting the standards 
established for such licensing. 
‘‘(6) DISCRETIONARY AUTHORITY.—A rural emergency hospital 
may— 
‘‘(A) include a unit of the facility that is a distinct part 
licensed as a skilled nursing facility to furnish post-hospital 
extended care services; and 
‘‘(B) be considered a hospital with less than 50 beds for 
purposes of the exception to the payment limit for rural health 
clinics under section 1833(f). 
‘‘(7) QUALITY MEASUREMENT.— 
‘‘(A) IN GENERAL.—The Secretary shall establish quality 
measurement reporting requirements for rural emergency hos-
pitals, which may include the use of a small number of claims- 
based outcomes measures or surveys of patients with respect 
to their experience in the rural emergency hospital, in accord-
ance with the succeeding provisions of this paragraph. 
‘‘(B) QUALITY
REPORTING
BY
RURAL
EMERGENCY
HOS-
PITALS.— 
‘‘(i) IN GENERAL.—With respect to each year beginning 
with 2023, (or each year beginning on or after the date 
that is one year after one or more measures are first 
specified under subparagraph (C)), a rural emergency hos-
pital shall submit data to the Secretary in accordance 
with clause (ii). 
‘‘(ii) SUBMISSION OF QUALITY DATA.—With respect to 
each such year, a rural emergency hospital shall submit 
to the Secretary data on quality measures specified under 
subparagraph (C). Such data shall be submitted in a form 
and manner, and at a time, specified by the Secretary 
for purposes of this subparagraph. 
‘‘(C) QUALITY MEASURES.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), any measure 
specified by the Secretary under this subparagraph must
H. R. 133—1782 
have been endorsed by the entity with a contract under 
section 1890(a). 
‘‘(ii) EXCEPTION.—In the case of a specified area or 
medical topic determined appropriate by the Secretary for 
which a feasible and practical measure has not been 
endorsed by the entity with a contract under section 
1890(a), the Secretary may specify a measure that is not 
so endorsed as long as due consideration is given to meas-
ures that have been endorsed or adopted by a consensus 
organization identified by the Secretary. 
‘‘(iii) CONSIDERATION
OF
LOW
CASE
VOLUME
WHEN 
SPECIFYING PERFORMANCE MEASURES.—The Secretary shall, 
in the selection of measures specified under this subpara-
graph, take into consideration ways to account for rural 
emergency hospitals that lack sufficient case volume to 
ensure that the performance rates for such measures are 
reliable. 
‘‘(D) PUBLIC AVAILABILITY OF DATA SUBMITTED.—The Sec-
retary shall establish procedures for making data submitted 
under subparagraph (B) available to the public regarding the 
performance of individual rural emergency hospitals. Such 
procedures shall ensure that a rural emergency hospital has 
the opportunity to review, and submit corrections for, the data 
that is to be made public with respect to the rural emergency 
hospital prior to such data being made public. Such information 
shall be posted on the Internet website of the Centers for 
Medicare & Medicaid Services in an easily understandable 
format as determined appropriate by the Secretary. 
‘‘(8) CLARIFICATION REGARDING APPLICATION
OF PROVISIONS 
RELATING
TO OFF-CAMPUS OUTPATIENT DEPARTMENT
OF
A PRO-
VIDER.—Nothing in this subsection, section 1833(a)(10), or section 
1834(x) shall affect the application of paragraph (1)(B)(v) of section 
1833(t), relating to applicable items and services (as defined in 
subparagraph (A) of paragraph (21) of such section) that are fur-
nished by an off-campus outpatient department of a provider (as 
defined in subparagraph (B) of such paragraph). 
‘‘(9) IMPLEMENTATION.—There shall be no administrative or 
judicial review under section 1869, 1878, or otherwise of the fol-
lowing: 
‘‘(A) The determination of whether a rural emergency hos-
pital meets the requirements of this subsection. 
‘‘(B) The establishment of requirements under this sub-
section by the Secretary, including requirements described in 
paragraphs (2)(D), (4), and (7). 
‘‘(C) The determination of payment amounts under section 
1834(x), including the additional facility payment described 
in paragraph (2) of such section.’’. 
(2) PAYMENT FOR RURAL EMERGENCY HOSPITAL SERVICES.— 
(A) IN GENERAL.—Section 1833(a) of the Social Security 
Act (42 U.S.C. 1395l(a)) is amended— 
(i) in paragraph (8), by striking ‘‘and’’ at the end; 
(ii) in paragraph (9), by striking the period at 
the end and inserting ‘‘; and’’; and 
(iii) by inserting after paragraph (9) the following 
new paragraph:
H. R. 133—1783 
‘‘(10) with respect to rural emergency hospital services 
furnished on or after January 1, 2023, the amounts determined 
under section 1834(x).’’. 
(B) PAYMENT
AMOUNT.—Section 1834 of the Social 
Security Act (42 U.S.C. 1395m) is amended by adding 
at the end the following subsection: 
‘‘(x) PAYMENT RULES RELATING TO RURAL EMERGENCY HOS-
PITALS.— 
‘‘(1) PAYMENT FOR RURAL EMERGENCY HOSPITAL SERVICES.— 
In the case of rural emergency hospital services (as defined 
in section 1861(kkk)(1)), furnished by a rural emergency hos-
pital (as defined in section 1861(kkk)(2)) on or after January 
1, 2023, the amount of payment for such services shall be 
equal to the amount of payment that would otherwise apply 
under section 1833(t) for covered OPD services (as defined 
in section 1833(t)(1)(B) (other than clause (ii) of such section)), 
increased by 5 percent to reflect the higher costs incurred 
by such hospitals, and shall include the application of any 
copayment amount determined under section 1833(t)(8) as if 
such increase had not occurred. 
‘‘(2) ADDITIONAL FACILITY PAYMENT.— 
‘‘(A) IN GENERAL.—The Secretary shall make monthly 
payments to a rural emergency hospital in an amount 
that is equal to 1⁄12 of the annual additional facility pay-
ment specified in subparagraph (B). 
‘‘(B) ANNUAL ADDITIONAL FACILITY PAYMENT AMOUNT.— 
The annual additional facility payment amount specified 
in this subparagraph is— 
‘‘(i) for 2023, a Medicare subsidy amount deter-
mined under subparagraph (C); and 
‘‘(ii) for 2024 and each subsequent year, the 
amount determined under this subparagraph for the 
preceding year, increased by the hospital market 
basket percentage increase. 
‘‘(C) DETERMINATION OF MEDICARE SUBSIDY AMOUNT.— 
For purposes of subparagraph (B)(i), the Medicare subsidy 
amount determined under this subparagraph is an amount 
equal to— 
‘‘(i) the excess (if any) of— 
‘‘(I) the total amount that the Secretary deter-
mines was paid under this title to all critical access 
hospitals in 2019; over 
‘‘(II) the estimated total amount that the Sec-
retary determines would have been paid under 
this title to such hospitals in 2019 if payment 
were made for inpatient hospital, outpatient hos-
pital, and skilled nursing facility services under 
the applicable prospective payment systems for 
such services during such year; divided by 
‘‘(ii) the total number of such hospitals in 2019. 
‘‘(D) REPORTING ON USE OF THE ADDITIONAL FACILITY 
PAYMENT.—A rural emergency hospital receiving the addi-
tional facility payment under this paragraph shall maintain 
detailed information as specified by the Secretary as to 
how the facility has used the additional facility payments. 
Such information shall be made available to the Secretary 
upon request.
H. R. 133—1785 
(B) Section 1867(e)(5) of such Act (42 U.S.C. 
1395dd(e)(5)) is amended by inserting ‘‘and a rural emer-
gency hospital (as defined in section 1861(kkk)(2))’’ before 
the period. 
(c) TREATMENT
AS TELEHEALTH ORIGINATING SITE.—Section 
1834(m)(4)(C)(ii) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395m(m)(4)(C)(ii)) is amended by adding at the end the following 
new subclause: 
‘‘(XI) A rural emergency hospital (as defined 
in section 1861(kkk)(2)).’’. 
(d) CONFORMING AMENDMENTS.— 
(1) Section 1861(u) of the Social Security Act (42 U.S.C. 
1395x(u)) is amended by inserting ‘‘rural emergency hospital,’’ 
after ‘‘critical access hospital,’’. 
(2) Section 1864 of the Social Security Act (42 U.S.C. 
1395aa) is amended by inserting before the period at the end 
of the first sentence ‘‘, or whether a facility is a rural emergency 
hospital as defined in section 1861(kkk)(2). 
(e) STUDIES AND REPORTS.— 
(1) STUDIES.—The Secretary of Health and Human Services 
shall conduct 3 studies to evaluate the impact of rural emer-
gency hospitals on the availability of health care and health 
outcomes in rural areas (as defined in section 1886(d)(2)(D) 
of the Social Security Act (42 U.S.C. 1395ww(d)(2)(D))). The 
Secretary shall conduct a study— 
(A) 4 years after the date of the enactment of this 
Act; 
(B) 7 years after the date of the enactment of this 
Act; and 
(C) 10 years after the date of the enactment of this 
Act. 
(2) REPORTS.—Not later than 6 months after each date 
that the Secretary of Health and Human Services is required 
to conduct a study under paragraph (1), the Secretary shall 
submit to Congress a report containing the results of each 
such study. 
(3) FUNDING.—For purposes of carrying out this subsection, 
the Secretary of Health and Human Services shall provide 
for the transfer, from the Federal Hospital Insurance Trust 
Fund under section 1817 of the Social Security Act (42 U.S.C. 
1395i) and the Federal Supplementary Medical Insurance Trust 
Fund under section 1841 of such Act (42 U.S.C. 1395t), in 
such proportion as the Secretary determines appropriate, to 
the Centers for Medicare & Medicaid Services Program 
Management Account, of $9,000,000. Amounts transferred 
under the preceding sentence shall remain available until 
expended. 
(f) MEDPAC REVIEW OF PAYMENTS TO RURAL EMERGENCY HOS-
PITALS.—Each report submitted by the Medicare Payment Advisory 
Commission under section 1805(b)(1)(C) of the Social Security Act 
(42 U.S.C. 1395b–6(b)(1)(C)) (beginning with 2024), shall include 
a review of payments to rural emergency hospitals under section 
1834(x), as added by subsection (a). 
(g) EFFECTIVE DATE.—The amendments made by this section 
shall apply to items and services furnished on or after January 
1, 2023.
H. R. 133—1786 
SEC. 126. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS. 
(a) IN GENERAL.—Section 1886(h) of the Social Security Act 
(42 U.S.C. 1395ww(h)) is amended— 
(1) in paragraph (4)(F)(i), by striking ‘‘paragraphs (7) and 
(8)’’ and inserting ‘‘paragraphs (7), (8), and (9)’’; 
(2) in paragraph (4)(H)(i), by striking ‘‘paragraphs (7) and 
(8)’’ and inserting ‘‘paragraphs (7), (8), and (9)’’; 
(3) in paragraph (7)(E), by inserting ‘‘paragraph (9),’’ after 
‘‘paragraph (8),’’; and 
(4) by adding at the end the following new paragraph: 
‘‘(9) DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.— 
‘‘(A) ADDITIONAL RESIDENCY POSITIONS.— 
‘‘(i) IN GENERAL.—For fiscal year 2023, and for 
each succeeding fiscal year until the aggregate number 
of full-time equivalent residency positions distributed 
under this paragraph is equal to the aggregate number 
of such positions made available (as specified in clause 
(ii)(I)), the Secretary shall, subject to the succeeding 
provisions of this paragraph, increase the otherwise 
applicable resident limit for each qualifying hospital 
(as defined in subparagraph (F)) that submits a timely 
application under this subparagraph by such number 
as the Secretary may approve effective beginning July 
1 of the fiscal year of the increase. 
‘‘(ii) NUMBER AVAILABLE FOR DISTRIBUTION.— 
‘‘(I) TOTAL NUMBER AVAILABLE.—The aggregate 
number of such positions made available under 
this paragraph shall be equal to 1,000. 
‘‘(II) ANNUAL LIMIT.—The aggregate number 
of such positions so made available shall not exceed 
200 for a fiscal year. 
‘‘(iii) PROCESS FOR DISTRIBUTING POSITIONS.— 
‘‘(I) ROUNDS OF APPLICATIONS.—The Secretary 
shall initiate a separate round of applications for 
an increase under clause (i) for each fiscal year 
for which such an increase is to be provided. 
‘‘(II) TIMING.—The Secretary shall notify hos-
pitals of the number of positions distributed to 
the hospital under this paragraph as a result of 
an increase in the otherwise applicable resident 
limit by January 31 of the fiscal year of the 
increase. Such increase shall be effective beginning 
July 1 of such fiscal year. 
‘‘(B) DISTRIBUTION.—For purposes of providing an 
increase in the otherwise applicable resident limit under 
subparagraph (A), the following shall apply: 
‘‘(i) CONSIDERATIONS IN DISTRIBUTION.—In deter-
mining for which qualifying hospitals such an increase 
is provided under subparagraph (A), the Secretary 
shall take into account the demonstrated likelihood 
of the hospital filling the positions made available 
under this paragraph within the first 5 training years 
beginning after the date the increase would be effec-
tive, as determined by the Secretary. 
‘‘(ii) MINIMUM
DISTRIBUTION
FOR
CERTAIN
CAT-
EGORIES OF HOSPITALS.—With respect to the aggregate 
number of such positions available for distribution
H. R. 133—1787 
under this paragraph, the Secretary shall distribute 
not less than 10 percent of such aggregate number 
to each of the following categories of hospitals: 
‘‘(I) Hospitals that are located in a rural area 
(as defined in section 1886(d)(2)(D)) or are treated 
as being located in a rural area pursuant to section 
1886(d)(8)(E). 
‘‘(II) Hospitals in which the reference resident 
level of the hospital (as specified in subparagraph 
(F)(iii)) is greater than the otherwise applicable 
resident limit. 
‘‘(III) Hospitals in States with— 
‘‘(aa) new medical schools that received 
‘Candidate School’ status from the Liaison 
Committee on Medical Education or that 
received ‘Pre-Accreditation’ status from the 
American Osteopathic Association Commission 
on Osteopathic College Accreditation on or 
after January 1, 2000, and that have achieved 
or continue to progress toward ‘Full Accredita-
tion’ status (as such term is defined by the 
Liaison Committee on Medical Education) or 
toward ‘Accreditation’ status (as such term is 
defined by the American Osteopathic Associa-
tion Commission on Osteopathic College 
Accreditation); or 
‘‘(bb) additional locations and branch cam-
puses established on or after January 1, 2000, 
by medical schools with ‘Full Accreditation’ 
status (as such term is defined by the Liaison 
Committee on Medical Education) or ‘Accredi-
tation’ status (as such term is defined by the 
American Osteopathic Association Commission 
on Osteopathic College Accreditation). 
‘‘(IV) Hospitals that serve areas designated 
as health professional shortage areas under section 
332(a)(1)(A) of the Public Health Service Act, as 
determined by the Secretary. 
‘‘(C) LIMITATIONS.— 
‘‘(i) IN GENERAL.—A hospital may not receive more 
than 25 additional full-time equivalent residency posi-
tions under this paragraph. 
‘‘(ii) PROHIBITION ON DISTRIBUTION TO HOSPITALS 
WITHOUT
AN
INCREASE
AGREEMENT.—No increase in 
the otherwise applicable resident limit of a hospital 
may be made under this paragraph unless such hos-
pital agrees to increase the total number of full-time 
equivalent residency positions under the approved 
medical residency training program of such hospital 
by the number of such positions made available by 
such increase under this paragraph. 
‘‘(D) APPLICATION OF PER RESIDENT AMOUNTS FOR PRI-
MARY CARE AND NONPRIMARY CARE.—With respect to addi-
tional residency positions in a hospital attributable to the 
increase provided under this paragraph, the approved FTE 
per resident amounts are deemed to be equal to the hospital
H. R. 133—1788 
per resident amounts for primary care and nonprimary 
care computed under paragraph (2)(D) for that hospital. 
‘‘(E) PERMITTING
FACILITIES
TO
APPLY
AGGREGATION 
RULES.—The Secretary shall permit hospitals receiving 
additional residency positions attributable to the increase 
provided under this paragraph to, beginning in the fifth 
year after the effective date of such increase, apply such 
positions to the limitation amount under paragraph (4)(F) 
that may be aggregated pursuant to paragraph (4)(H) 
among members of the same affiliated group. 
‘‘(F) DEFINITIONS.—In this paragraph: 
‘‘(i) OTHERWISE APPLICABLE RESIDENT LIMIT.—The 
term ‘otherwise applicable resident limit’ means, with 
respect to a hospital, the limit otherwise applicable 
under subparagraphs (F)(i) and (H) of paragraph (4) 
on the resident level for the hospital determined with-
out regard to this paragraph but taking into account 
paragraphs (7)(A), (7)(B), (8)(A), and (8)(B). 
‘‘(ii) QUALIFYING HOSPITAL.—The term ‘qualifying 
hospital’ means a hospital described in any of sub-
clauses (I) through (IV) of subparagraph (B)(ii). 
‘‘(iii) REFERENCE RESIDENT LEVEL.—The term ‘ref-
erence resident level’ means, with respect to a hospital, 
the resident level for the most recent cost reporting 
period of the hospital ending on or before the date 
of enactment of this paragraph, for which a cost report 
has been settled (or, if not, submitted (subject to 
audit)), as determined by the Secretary. 
‘‘(iv) RESIDENT LEVEL.—The term ‘resident level’ 
has the meaning given such term in paragraph 
(7)(C)(i).’’. 
(b) IME.—Section 1886(d)(5)(B) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(B)) is amended— 
(1) in clause (v), in the third sentence, by striking ‘‘and 
(h)(8)’’ and inserting ‘‘(h)(8), and (h)(9)’’; 
(2) by redesignating clause (x), as added by section 5505(b) 
of the Patient Protection and Affordable Care Act (Public Law 
111–148), as clause (xi) and moving such clause 4 ems to 
the left; and 
(3) by adding after clause (xi), as redesignated by subpara-
graph (A), the following new clause: 
‘‘(xii) For discharges occurring on or after July 
1, 2023, insofar as an additional payment amount 
under this subparagraph is attributable to resident 
positions distributed to a hospital under subsection 
(h)(9), the indirect teaching adjustment factor shall 
be computed in the same manner as provided under 
clause (ii) with respect to such resident positions.’’. 
(c) PROHIBITION ON JUDICIAL REVIEW.—Section 1886(h)(7)(E) 
of the Social Security Act (42 U.S.C. 1395ww–4(h)(7)(E)) is amended 
by inserting ‘‘paragraph (9),’’ after ‘‘paragraph (8),’’. 
(d) REPORTS.— 
(1) IN GENERAL.—Not later than September 30, 2025, and 
again not later than September 30, 2027, the Comptroller Gen-
eral of the United States (in this subsection referred to as 
the ‘‘Comptroller General’’) shall conduct a study and submit 
to Congress a report on—
H. R. 133—1789 
(A) the distribution of additional full-time equivalent 
resident positions under paragraph (9) of section 1886(h) 
of the Social Security Act, as added by subsection (a); 
and 
(B) rural track and rotator programs under such sec-
tion. 
(2) CONTENTS.—Each report described in paragraph (1) 
shall include— 
(A) a description of the distribution described in para-
graph (1)(A) and an analysis of the use of such positions 
so distributed, including a description of the effects of such 
distribution on rural track and rotator programs; 
(B) a specification, with respect to each hospital that 
has received such a distribution, of whether such hospital 
has abided by the agreement described in paragraph 
(9)(C)(ii) of section 1886(h) of the Social Security Act, as 
added by subsection (a); and 
(C) to the extent practicable, a description of— 
(i) the type of program in which each such position 
so distributed is being used; 
(ii) the total number of full-time equivalent resi-
dency positions available in each such program; 
(iii) the number of instances in which residents 
filling such positions so distributed treated individuals 
entitled to benefits under part A, or enrolled under 
part B, of title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.); 
(iv) the location where each resident that filled 
a position so distributed went on to practice. 
SEC. 127. PROMOTING RURAL HOSPITAL GME FUNDING OPPORTUNITY. 
Section 1886(h)(4)(H)(iv) of the Social Security Act (42 U.S.C. 
1395ww(h)(4)(iv)) is amended— 
(1) by striking ‘‘(iv) NONRURAL
HOSPITAL
OPERATING 
TRAINING PROGRAMS IN RURAL AREAS.—In the case of’’ and 
inserting the following: 
‘‘(iv) TRAINING PROGRAMS IN RURAL AREAS.— 
‘‘(I) COST
REPORTING
PERIODS
BEGINNING 
BEFORE
OCTOBER
1, 
2022.—For cost reporting 
periods beginning before October 1, 2022, in the 
case of’’; and 
(2) by adding at the end the following new subclause: 
‘‘(II) COST REPORTING PERIODS BEGINNING ON 
OR
AFTER
OCTOBER
1, 2022.—For cost reporting 
periods beginning on or after October 1, 2022, 
in the case of a hospital not located in a rural 
area that established or establishes a medical resi-
dency training program (or rural tracks) in a rural 
area or establishes an accredited program where 
greater than 50 percent of the program occurs 
in a rural area, the Secretary shall consistent with 
the principles of subparagraphs (F) and (G) and 
subject to paragraphs (7) and (8), prescribe rules 
for the application of such subparagraphs with 
respect to such a program and, in accordance with 
such rules, adjust in an appropriate manner the
H. R. 133—1793 
‘‘(II) the limit described in paragraph (2)(A); and 
‘‘(ii) in a subsequent year, at an amount equal to the 
greater of— 
‘‘(I) the amount established under clause (i)(I) or this 
subclause for the previous year with respect to such rural 
health clinic, increased by the percentage increase in the 
MEI applicable to primary care services furnished as of 
the first day of such subsequent year; or 
‘‘(II) the limit established under paragraph (2) for such 
subsequent year. 
‘‘(B) A rural health clinic described in this subparagraph is 
a rural health clinic that, as of December 31, 2019, was— 
‘‘(i) in a hospital with less than 50 beds; and 
‘‘(ii) enrolled under section 1866(j).’’. 
SEC. 131. MEDICARE GME TREATMENT OF HOSPITALS ESTABLISHING 
NEW MEDICAL RESIDENCY TRAINING PROGRAMS AFTER 
HOSTING MEDICAL RESIDENT ROTATORS FOR SHORT 
DURATIONS. 
(a) REDETERMINATION OF APPROVED FTE RESIDENT AMOUNT.— 
Section 1886(h)(2)(F) of the Social Security Act (42 U.S.C. 
1395ww(h)(2)(F)) is amended— 
(1) by inserting ‘‘(i)’’ before ‘‘In the case of’’; and 
(2) by adding at the end the following: 
‘‘(ii) In applying this subparagraph in the case of a 
hospital that trains residents and has not entered into 
a GME affiliation agreement (as defined by the Secretary 
for purposes of paragraph (4)(H)(ii)), on or after the date 
of the enactment of this clause, the Secretary shall not 
establish an FTE resident amount until such time as the 
Secretary determines that the hospital has trained at least 
1.0 full-time-equivalent resident in an approved medical 
residency training program in a cost reporting period. 
‘‘(iii) In applying this subparagraph for cost reporting 
periods beginning on or after the date of enactment of 
this clause, in the case of a hospital that, as of such 
date of enactment, has an approved FTE resident amount 
based on the training in an approved medical residency 
program or programs of— 
‘‘(I) less than 1.0 full-time-equivalent resident in 
any cost reporting period beginning before October 1, 
1997, as determined by the Secretary; or 
‘‘(II) no more than 3.0 full-time-equivalent resi-
dents in any cost reporting period beginning on or 
after October 1, 1997, and before the date of the enact-
ment of this clause, as determined by the Secretary, 
in lieu of such FTE resident amount the Secretary shall, 
in accordance with the methodology described in section 
413.77(e) of title 42 of the Code of Federal Regulations 
(or any successor regulation), establish a new FTE resident 
amount if the hospital trains at least 1.0 full-time-equiva-
lent resident (in the case of a hospital described in sub-
clause (I)) or more than 3.0 full-time-equivalent residents 
(in the case of a hospital described in subclause (II)) in 
a cost reporting period beginning on or after such date 
of enactment and before the date that is 5 years after 
such date of enactment.
H. R. 133—1794 
‘‘(iv) For purposes of carrying out this subparagraph 
for cost reporting periods beginning on or after the date 
of the enactment of this clause, a hospital shall report 
full-time-equivalent residents on its cost report for a cost 
reporting period if the hospital trains at least 1.0 full- 
time-equivalent residents in an approved medical residency 
training program or programs in such period. 
‘‘(v) As appropriate, the Secretary may consider 
information from any cost reporting period necessary to 
establish a new FTE resident amount as described in clause 
(iii).’’. 
(b) REDETERMINATION OF FTE RESIDENT LIMITATION.—Section 
1886(h)(4)(H)(i) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395ww(h)(4)(H)(i)) is amended— 
(1) by inserting ‘‘(I)’’ before ‘‘The Secretary’’; and 
(2) by adding at the end the following: 
‘‘(II) In applying this clause in the case of a hos-
pital that, on or after the date of the enactment of 
this subclause, begins training residents in a new 
approved medical residency training program or pro-
grams (as defined by the Secretary), the Secretary 
shall not determine a limitation applicable to the hos-
pital under subparagraph (F) until such time as the 
Secretary determines that the hospital has trained at 
least 1.0 full-time-equivalent resident in such new 
approved medical residency training program or pro-
grams in a cost reporting period. 
‘‘(III) In applying this clause in the case of a hos-
pital that, as of the date of the enactment of this 
subclause, has a limitation under subparagraph (F), 
based on a cost reporting period beginning before 
October 1, 1997, of less than 1.0 full-time-equivalent 
resident, the Secretary shall adjust the limitation in 
the manner applicable to a new approved medical resi-
dency training program if the Secretary determines 
the hospital begins training at least 1.0 full-time- 
equivalent residents in a program year beginning on 
or after such date of enactment and before the date 
that is 5 years after such date of enactment. 
‘‘(IV) In applying this clause in the case of a hos-
pital that, as of the date of the enactment of this 
subclause, has a limitation under subparagraph (F), 
based on a cost reporting period beginning on or after 
October 1, 1997, and before such date of enactment, 
of no more than 3.0 full-time-equivalent residents, the 
Secretary shall adjust the limitation in the manner 
applicable to a new approved medical residency 
training program if the Secretary determines the hos-
pital begins training more than 3.0 full-time-equivalent 
residents in a program year beginning on or after 
such date of enactment and before the date that is 
5 years after such date of enactment. 
‘‘(V) An adjustment to the limitation applicable 
to a hospital made pursuant to subclause (III) or (IV) 
shall be made in a manner consistent with the method-
ology, as appropriate, in section 413.79(e) of title 42,
H. R. 133—1795 
Code of Federal Regulations (or any successor regula-
tion). As appropriate, the Secretary may consider 
information from any cost reporting periods necessary 
to make such an adjustment to the limitation.’’. 
(c) TECHNICAL AND CONFORMING AMENDMENTS.—Section 1886 
of the Social Security Act (42 U.S.C. 1395ww) is amended— 
(1) in subsection (d)(5)(B)(viii), by striking ‘‘subsection 
(h)(4)(H)’’ and inserting ‘‘paragraphs (2)(F)(iv) and (4)(H) of 
subsection (h)’’; and 
(2) in subsection (h)— 
(A) in paragraph (4)(H)(iv), by striking ‘‘an rural area’’ 
and inserting ‘‘a rural area’’; and 
(B) in paragraph (7)(E), by striking ‘‘under this’’ and 
all that follows through the period at the end and inserting 
the following: ‘‘under this paragraph, paragraph (8), clause 
(i), (ii), (iii), or (v) of paragraph (2)(F), or clause (i) or 
(vi) of paragraph (4)(H).’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to payment under section 1886 of the Social Security 
Act (42 U.S.C. 1395ww) for cost reporting periods beginning on 
or after the date of the enactment of this Act. 
SEC. 132. MEDICARE PAYMENT FOR CERTAIN FEDERALLY QUALIFIED 
HEALTH CENTER AND RURAL HEALTH CLINIC SERVICES 
FURNISHED TO HOSPICE PATIENTS. 
Section 1834 of the Social Security Act (42 U.S.C. 1395m), 
as amended by section 125(a)(2)(B), is amended— 
(1) in subsection (o), by adding at the end the following 
new paragraph: 
‘‘(4) PAYMENT
FOR
ATTENDING
PHYSICIAN
SERVICES
FUR-
NISHED BY FEDERALLY QUALIFIED HEALTH CENTERS TO HOSPICE 
PATIENTS.—In 
the 
case 
of 
services 
described 
in 
sec-
tion 1812(d)(2)(A)(ii) furnished on or after January 1, 2022, 
by an attending physician (as defined in section 1861(dd)(3)(B), 
other than a physician or practitioner who is employed by 
a hospice program) who is employed by or working under con-
tract with a Federally qualified health center, a Federally quali-
fied health center shall be paid for such services under the 
prospective payment system under this subsection.’’; and 
(2) by adding at the end the following new subsection: 
‘‘(y) PAYMENT FOR ATTENDING PHYSICIAN SERVICES FURNISHED 
BY RURAL HEALTH CLINICS TO HOSPICE PATIENTS.—In the case 
of services described in section 1812(d)(2)(A)(ii) furnished on or 
after January 1, 2022, by an attending physician (as defined in 
section 1861(dd)(3)(B), other than a physician or practitioner who 
is employed by a hospice program) who is employed by or working 
under contract with a rural health clinic, a rural health clinic 
shall be paid for such services under the methodology for all- 
inclusive rates (established by the Secretary) under section 
1833(a)(3), subject to the limits described in section 1833(f).’’. 
SEC. 133. DELAY TO THE IMPLEMENTATION OF THE RADIATION 
ONCOLOGY MODEL UNDER THE MEDICARE PROGRAM. 
Notwithstanding any provision of section 1115A of the Social 
Security Act (42 U.S.C. 1315a), the Secretary of Health and Human 
Services may not implement the radiation oncology model described 
in the rule entitled ‘‘Medicare Program; Specialty Care Models 
To Improve Quality of Care and Reduce Expenditures’’ (85 Fed.
H. R. 133—1796 
Reg. 61114 et seq.), or any substantially similar model, pursuant 
to such section before January 1, 2022. 
SEC. 134. IMPROVING ACCESS TO SKILLED NURSING FACILITY SERV-
ICES FOR HEMOPHILIA PATIENTS. 
(a) IN GENERAL.—Section 1888(e)(2)(A)(iii) of the Social Security 
Act (42 U.S.C. 1395yy(e)(2)(A)(iii)) is amended by adding at the 
end the following: 
‘‘(VI) Blood clotting factors indicated for the 
treatment of patients with hemophilia and other 
bleeding disorders (identified as of July 1, 2020, 
by HCPCS codes J7170, J7175, J7177–J7183, 
J7185–J7190, J7192–J7195, J7198–J7203, J7205, 
J7207–J7211, and as subsequently modified by the 
Secretary) and items and services related to the 
furnishing 
of 
such 
factors 
under 
section 
1842(o)(5)(C), and any additional blood clotting fac-
tors identified by the Secretary and items and 
services related to the furnishing of such factors 
under such section.’’. 
(b) EFFECTIVE DATE.—The amendment made by subsection (a) 
shall apply to items and services furnished on or after October 
1, 2021. 
TITLE II—MEDICAID EXTENDERS AND 
OTHER POLICIES 
SEC. 201. ELIMINATING DSH REDUCTIONS FOR FISCAL YEARS 2021 
THROUGH 2023. 
Section 1923(f) of the Social Security Act (42 U.S.C. 1396r– 
4(f)), as amended by section 1106 of the Further Continuing Appro-
priations Act, 2021, and Other Extensions Act, is amended— 
(1) in paragraph (7)(A)— 
(A) in clause (i), in the matter preceding subclause 
(I), by striking ‘‘For the period’’ and all that follows through 
‘‘2025’’ and inserting ‘‘For each of fiscal years 2024 through 
2027,’’; and 
(B) in clause (ii), by striking ‘‘equal to—’’ and all that 
follows through the period at the end and inserting ‘‘equal 
to $8,000,000,000 for each of fiscal years 2024 through 
2027’’; and 
(2) in paragraph (8), by striking ‘‘2025’’ and inserting 
‘‘2027’’. 
SEC. 202. SUPPLEMENTAL PAYMENT REPORTING REQUIREMENTS. 
Section 1903 of the Social Security Act (42 U.S.C. 1396b) is 
amended by adding at the end the following new subsection: 
‘‘(bb) SUPPLEMENTAL PAYMENT REPORTING REQUIREMENTS.— 
‘‘(1) COLLECTION AND AVAILABILITY OF SUPPLEMENTAL PAY-
MENT DATA.— 
‘‘(A) IN
GENERAL.—Not later than October 1, 2021, 
the Secretary shall establish a system for each State to 
submit reports, as determined appropriate by the Secretary, 
on supplemental payments data, as a requirement for a 
State plan or State plan amendment that would provide 
for a supplemental payment.
H. R. 133—1797 
‘‘(B) REQUIREMENTS.—Each report submitted by a State 
in accordance with the requirement established under 
subparagraph (A) shall include the following: 
‘‘(i) An explanation of how supplemental payments 
made under the State plan or a State plan amendment 
will result in payments that are consistent with section 
1902(a)(30)(A), including standards with respect to effi-
ciency, economy, quality of care, and access, along with 
the stated purpose and intended effects of the supple-
mental payment. 
‘‘(ii) The criteria used to determine which providers 
are eligible to receive the supplemental payment. 
‘‘(iii) A comprehensive description of the method-
ology used to calculate the amount of, and distribute, 
the supplemental payment to each eligible provider, 
including— 
‘‘(I) data on the amount of the supplemental 
payment made to each eligible provider, if known, 
or, if the total amount is distributed using a for-
mula based on data from 1 or more fiscal years, 
data on the total amount of the supplemental pay-
ments for the fiscal year or years available to 
all providers eligible to receive a supplemental 
payment; 
‘‘(II) if applicable, the specific criteria with 
respect to Medicaid service, utilization, or cost data 
to be used as the basis for calculations regarding 
the amount or distribution of the supplemental 
payment; and 
‘‘(III) the timing of the supplemental payment 
made to each eligible provider. 
‘‘(iv) An assurance that the total Medicaid pay-
ments made to an inpatient hospital provider, 
including the supplemental payment, will not exceed 
upper payment limits. 
‘‘(v) If not already submitted, an upper payment 
limit demonstration under section 447.272 of title 42, 
Code of Federal Regulations (as such section is in 
effect as of the date of enactment of this subsection). 
‘‘(C) PUBLIC AVAILABILITY.—The Secretary shall make 
all reports and related data submitted under this para-
graph publicly available on the website of the Centers 
for Medicare & Medicaid Services on a timely basis. 
‘‘(2) SUPPLEMENTAL PAYMENT DEFINED.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), in this 
subsection, the term ‘supplemental payment’ means a pay-
ment to a provider that is in addition to any base payment 
made to the provider under the State plan under this 
title or under demonstration authority. 
‘‘(B) DSH PAYMENTS EXCLUDED.—Such term does not 
include a disproportionate share hospital payment made 
under section 1923.’’. 
SEC. 203. MEDICAID SHORTFALL AND THIRD PARTY PAYMENTS. 
(a) IN GENERAL.—Subsection (g) of section 1923 of the Social 
Security Act (42 U.S.C. 1396r–4) is amended to read as follows: 
‘‘(g) LIMIT ON AMOUNT OF PAYMENT TO HOSPITAL.—
H. R. 133—1801 
(d) FUNDING
FOR QUALITY ASSURANCE
AND IMPROVEMENT; 
TECHNICAL ASSISTANCE; OVERSIGHT.—Section 6071(f) of the Deficit 
Reduction Act of 2005 (42 U.S.C. 1396a note) is amended by striking 
paragraph (2) and inserting the following: 
‘‘(2) FUNDING.—From the amounts appropriated under sub-
section (h)(1), $3,000,000 shall be available to the Secretary 
to carry out this subsection. Such amount shall remain avail-
able until expended.’’. 
(e) BEST PRACTICES EVALUATION.—Section 6071 of the Deficit 
Reduction Act of 2005 (42 U.S.C. 1396a note) is amended by adding 
at the end the following: 
‘‘(i) BEST PRACTICES.— 
‘‘(1) REPORT.—The Secretary, directly or through grant or 
contract, shall submit a report to the President and Congress 
not later than September 30, 2022, that contains findings and 
conclusions on best practices from MFP demonstration projects 
carried out with grants made under this section. The report 
shall include information and analyses with respect to the 
following: 
‘‘(A) 
The 
most 
effective 
State 
strategies 
for 
transitioning beneficiaries from institutional to qualified 
community settings carried out under MFP demonstration 
projects and how such strategies may vary for different 
types of beneficiaries, such as beneficiaries who are aged, 
physically disabled, intellectually or developmentally dis-
abled, or individuals with serious mental illnesses, and 
other targeted waiver beneficiary populations under section 
1915(c) of the Social Security Act. 
‘‘(B) The most common and the most effective State 
uses of grant funds carried out under demonstration 
projects for transitioning beneficiaries from institutional 
to qualified community settings and improving health out-
comes, including differentiating funding for current initia-
tives that are designed for such purpose and funding for 
proposed initiatives that are designed for such purpose. 
‘‘(C) The most effective State approaches carried out 
under MFP demonstration projects for improving person- 
centered care and planning. 
‘‘(D) Identification of program, financing, and other 
flexibilities available under MFP demonstration projects, 
that are not available under the traditional Medicaid pro-
gram, and which directly contributed to successful transi-
tions and improved health outcomes under MFP dem-
onstration projects. 
‘‘(E) State strategies and financing mechanisms for 
effective coordination of housing financed or supported 
under MFP demonstration projects with local housing 
authorities and other resources. 
‘‘(F) Effective State approaches for delivering Money 
Follows the Person transition services through managed 
care entities. 
‘‘(G) Other best practices and effective transition strate-
gies demonstrated by States with approved MFP dem-
onstration projects, as determined by the Secretary.
H. R. 133—1802 
‘‘(H) Identification and analyses of opportunities and 
challenges to integrating effective Money Follows the Per-
son practices and State strategies into the traditional Med-
icaid program. 
‘‘(2) COLLABORATION.—In preparing the report required 
under this subsection, the Secretary shall collect and incor-
porate information from States with approved MFP demonstra-
tion projects and beneficiaries participating in such projects, 
and providers participating in such projects. 
‘‘(3) WAIVER OF PAPERWORK REDUCTION ACT.—Chapter 35 
of title 44, United States Code, shall not apply to preparation 
of the report described in paragraph (1) or collection of informa-
tion described in paragraph (2). 
‘‘(4) FUNDING.—From the amounts appropriated under sub-
section (h)(1) for each of fiscal years 2021 and 2022, not more 
than $300,000 shall be available to the Secretary for each 
such fiscal year to carry out this subsection.’’. 
(f) MACPAC REPORT ON QUALIFIED SETTINGS CRITERIA.—Sec-
tion 6071 of the Deficit Reduction Act of 2005 (42 U.S.C. 1396a 
note), as amended by subsection (e), is further amended by adding 
at the end the following: 
‘‘(j) MACPAC REPORT.—Prior to the final implementation date 
established by the Secretary for the criteria established for home 
and community-based settings in section 441.301(c)(4) of title 42, 
Code of Federal Regulations, as part of final implementation of 
the Home and Community Based Services (HCBS) Final Rule pub-
lished on January 16, 2014 (79 Fed. Reg. 2947) (referred to in 
this subsection as the ‘HCBS final rule’), the Medicaid and CHIP 
Payment and Access Commission (MACPAC) shall submit to Con-
gress a report that— 
‘‘(1) identifies the types of home and community-based set-
tings and associated services that are available to eligible 
individuals in both the MFP demonstration program and sites 
in compliance with the HCBS final rule; and 
‘‘(2) if determined appropriate by the Commission, rec-
ommends policies to align the criteria for a qualified residence 
under subsection (b)(6) (as in effect on October 1, 2017) with 
the criteria in the HCBS final rule.’’. 
(g) APPLICATION TO CURRENT PROJECTS.—Not later than 1 year 
after the date of the enactment of this Act, the Secretary shall 
update the terms and conditions of any approved MFP demonstra-
tion project under section 6071 of the Deficit Reduction Act of 
2005 (42 U.S.C. 1396a note) in effect on the date of the enactment 
of this Act to ensure that such terms and conditions are the same 
as are required for any new State applicant for such project under 
the amendments made by this section. 
SEC. 205. EXTENSION OF SPOUSAL IMPOVERISHMENT PROTECTIONS. 
(a) IN GENERAL.—Section 2404 of the Patient Protection and 
Affordable Care Act (42 U.S.C. 1396r-5 note) is amended by striking 
‘‘December 18, 2020’’ and inserting ‘‘September 30, 2023’’. 
(b) RULE OF CONSTRUCTION.—Nothing in section 2404 of Public 
Law 111-148 (42 U.S.C. 1396r-5 note) or section 1902(a)(17) or 
1924 of the Social Security Act (42 U.S.C. 1396a(a)(17), 1396r- 
5) shall be construed as prohibiting a State from—
H. R. 133—1803 
(1) applying an income or resource disregard under a meth-
odology authorized under section 1902(r)(2) of such Act (42 
U.S.C. 1396a(r)(2))— 
(A) to the income or resources of an individual 
described in section 1902(a)(10)(A)(ii)(VI) of such Act (42 
U.S.C. 1396a(a)(10)(A)(ii)(VI)) (including a disregard of the 
income or resources of such individual’s spouse); or 
(B) on the basis of an individual’s need for home and 
community-based services authorized under subsection (c), 
(d), (i), or (k) of section 1915 of such Act (42 U.S.C. 1396n) 
or under section 1115 of such Act (42 U.S.C. 1315); or 
(2) disregarding an individual’s spousal income and assets 
under a plan amendment to provide medical assistance for 
home and community-based services for individuals by reason 
of being determined eligible under section 1902(a)(10)(C) of 
such Act (42 U.S.C. 1396a(a)(10)(C)) or by reason of section 
1902(f) of such Act (42 U.S.C. 1396a(f)) or otherwise on the 
basis of a reduction of income based on costs incurred for 
medical or other remedial care under which the State dis-
regarded the income and assets of the individual’s spouse in 
determining the initial and ongoing financial eligibility of an 
individual for such services in place of the spousal impoverish-
ment provisions applied under section 1924 of such Act (42 
U.S.C. 1396r-5). 
SEC. 206. EXTENSION OF COMMUNITY MENTAL HEALTH SERVICES 
DEMONSTRATION PROGRAM. 
Section 223(d) of the Protecting Access to Medicare Act of 
2014 (42 U.S.C. 1396a note), as amended by section 1104 of the 
Further Continuing Appropriations Act, 2021, and Other Extensions 
Act, is amended— 
(1) in paragraph (3), by striking ‘‘under this subsection’’ 
and all that follows through the period and inserting ‘‘that 
meet the requirements of this subsection through September 
30, 2023.’’; 
(2) in paragraph (5)(C)(iii)(I), by striking ‘‘during the 8 
fiscal quarter period (or any portion of the period) that begins 
on January 1, 2020’’ and inserting ‘‘through September 30, 
2023’’; 
(3) in paragraph (5)(C)(iii)(II), by inserting before the period 
at the end ‘‘or through September 30, 2023, whichever is 
longer’’; 
(4) in paragraph (8)(A), by striking ‘‘to participate’’ and 
all that follows through the period and inserting ‘‘to conduct 
demonstration programs that meet the requirements of this 
subsection for 2 years or through September 30, 2023, which-
ever is longer.’’. 
SEC. 207. CLARIFYING AUTHORITY OF STATE MEDICAID FRAUD AND 
ABUSE CONTROL UNITS TO INVESTIGATE AND PROS-
ECUTE CASES OF MEDICAID PATIENT ABUSE AND 
NEGLECT IN ANY SETTING. 
(a) IN GENERAL.—Section 1903(q)(4)(A)(ii) of the Social Security 
Act (42 U.S.C. 1396b(q)(4)(A)(ii)) is amended by inserting after 
‘‘patients residing in board and care facilities’’ the following: ‘‘and 
of patients (who are receiving medical assistance under the State 
plan under this title (or waiver of such plan)) in a noninstitutional 
or other setting’’.
H. R. 133—1804 
(b) AVAILABILITY OF FUNDING.—Section 1903(a)(6) of the Social 
Security Act (42 U.S.C. 1396b(a)(6)) is amended, in the matter 
following subparagraph (B), by striking ‘‘(as found necessary by 
the Secretary for the elimination of fraud in the provision and 
administration of medical assistance provided under the State plan 
(or waiver of such plan))’’. 
SEC. 208. MEDICAID COVERAGE FOR CITIZENS OF FREELY ASSOCI-
ATED STATES. 
(a) IN GENERAL.—Section 402(b)(2) of the Personal Responsi-
bility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 
1612(b)(2)) is amended by adding at the end the following new 
subparagraph: 
‘‘(G) MEDICAID
EXCEPTION
FOR
CITIZENS
OF
FREELY 
ASSOCIATED STATES.—With respect to eligibility for benefits 
for the designated Federal program defined in paragraph 
(3)(C) (relating to the Medicaid program), paragraph (1) 
shall not apply to any individual who lawfully resides 
in 1 of the 50 States or the District of Columbia in accord-
ance with the Compacts of Free Association between the 
Government of the United States and the Governments 
of the Federated States of Micronesia, the Republic of 
the Marshall Islands, and the Republic of Palau and shall 
not apply, at the option of the Governor of Puerto Rico, 
the Virgin Islands, Guam, the Northern Mariana Islands, 
or American Samoa as communicated to the Secretary of 
Health and Human Services in writing, to any individual 
who lawfully resides in the respective territory in accord-
ance with such Compacts.’’. 
(b) EXCEPTION TO 5–YEAR LIMITED ELIGIBILITY.—Section 403(b) 
of such Act (8 U.S.C. 1613(b)) is amended by adding at the end 
the following new paragraph: 
‘‘(3) EXCEPTION
FOR
CITIZENS
OF
FREELY
ASSOCIATED 
STATES.—An individual described in section 402(b)(2)(G), but 
only with respect to the designated Federal program defined 
in section 402(b)(3)(C).’’. 
(c) DEFINITION OF QUALIFIED ALIEN.—Section 431(b) of such 
Act (8 U.S.C. 1641(b)) is amended— 
(1) in paragraph (6), by striking ‘‘; or’’ at the end and 
inserting a comma; 
(2) in paragraph (7), by striking the period at the end 
and inserting ‘‘, or’’; and 
(3) by adding at the end the following new paragraph: 
‘‘(8) an individual who lawfully resides in the United States 
in accordance with a Compact of Free Association referred 
to in section 402(b)(2)(G), but only with respect to the des-
ignated Federal program defined in section 402(b)(3)(C) 
(relating to the Medicaid program).’’. 
(d) CONFORMING AMENDMENTS.—Section 1108 of the Social 
Security Act (42 U.S.C. 1308) is amended— 
(1) in subsection (f), in the matter preceding paragraph 
(1), by striking ‘‘subsection (g) and section 1935(e)(1)(B)’’ and 
inserting ‘‘subsections (g) and (h) and section 1935(e)(1)(B)’’; 
and 
(2) by adding at the end the following: 
‘‘(h) EXCLUSION OF MEDICAL ASSISTANCE EXPENDITURES FOR 
CITIZENS OF FREELY ASSOCIATED STATES.—Expenditures for medical