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to any aggregate limitation on such allowances which 
the State law may establish (but which aggregate lim-
itation on the total allowance for dependents paid to 
an individual may not be less than $50 for each week 
of unemployment or 50 percent of the individual’s 
weekly benefit amount for the benefit year, whichever 
is less). 
‘‘(4)(A) Any State seeking an incentive payment under 
this subsection shall submit an application therefor at such 
time, in such manner, and complete with such information 
as the Secretary of Labor may within 60 days after the 
date of the enactment of this subsection prescribe (whether 
by regulation or otherwise), including information relating 
to compliance with the requirements of paragraph (2) or 
(3), as well as how the State intends to use the incentive 
payment to improve or strengthen the State’s unemploy-
ment compensation program. The Secretary of Labor shall, 
within 30 days after receiving a complete application, no-
tify the State agency of the State of the Secretary’s findings 
with respect to the requirements of paragraph (2) or (3) 
(or both). 
‘‘(B)(i) If the Secretary of Labor finds that the State 
law provisions (disregarding any State law provisions 
which are not then currently in effect as permanent law 
or which are subject to discontinuation) meet the require-
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ments of paragraph (2) or (3), as the case may be, the Sec-
retary of Labor shall thereupon make a certification to that 
effect to the Secretary of the Treasury, together with a cer-
tification as to the amount of the incentive payment to be 
transferred to the State account pursuant to that finding. 
The Secretary of the Treasury shall make the appropriate 
transfer within 7 days after receiving such certification. 
‘‘(ii) For purposes of clause (i), State law provisions 
which are to take effect within 12 months after the date 
of their certification under this subparagraph shall be con-
sidered to be in effect as of the date of such certification. 
‘‘(C)(i) No certification of compliance with the require-
ments of paragraph (2) or (3) may be made with respect 
to any State whose State law is not otherwise eligible for 
certification under section 303 or approvable under section 
3304 of the Federal Unemployment Tax Act. 
‘‘(ii) No certification of compliance with the require-
ments of paragraph (3) may be made with respect to any 
State whose State law is not in compliance with the re-
quirements of paragraph (2). 
‘‘(iii) No application under subparagraph (A) may be 
considered if submitted before the date of the enactment of 
this subsection or after the latest date necessary (as specified 
by the Secretary of Labor) to ensure that all incentive pay-
ments under this subsection are made before October 1, 
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2010. In the case of a State in which the first day of the 
first regularly scheduled session of the State legislature be-
ginning after the date of enactment of this subsection begins 
after December 31, 2010, the preceding sentence shall be ap-
plied by substituting ‘October 1, 2011’ for ‘October 1, 2010’. 
‘‘(5)(A) Except as provided in subparagraph (B), any 
amount transferred to the account of a State under this sub-
section may be used by such State only in the payment of 
cash benefits to individuals with respect to their unemploy-
ment (including for dependents’ allowances and for unem-
ployment compensation under paragraph (3)(C)), exclusive 
of expenses of administration. 
‘‘(B) A State may, subject to the same conditions as 
set forth in subsection (c)(2) (excluding subparagraph (B) 
thereof, and deeming the reference to ‘subsections (a) and 
(b)’ in subparagraph (D) thereof to include this subsection), 
use any amount transferred to the account of such State 
under this subsection for the administration of its unem-
ployment compensation law and public employment offices. 
‘‘(6) Out of any money in the Federal unemployment 
account not otherwise appropriated, the Secretary of the 
Treasury shall reserve $7,000,000,000 for incentive pay-
ments under this subsection. Any amount so reserved shall 
not be taken into account for purposes of any determination 
under section 902, 910, or 1203 of the amount in the Fed-
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eral unemployment account as of any given time. Any 
amount so reserved for which the Secretary of the Treasury 
has not received a certification under paragraph (4)(B) by 
the deadline described in paragraph (4)(C)(iii) shall, upon 
the close of fiscal year 2011, become unrestricted as to use 
as part of the Federal unemployment account. 
‘‘(7) For purposes of this subsection, the terms ‘benefit 
year’, ‘base period’, and ‘week’ have the respective meanings 
given such terms under section 205 of the Federal-State Ex-
tended Unemployment Compensation Act of 1970 (26 
U.S.C. 3304 note). 
‘‘Special Transfer in Fiscal Year 2009 for Administration 
‘‘(g)(1) In addition to any other amounts, the Sec-
retary of the Treasury shall transfer from the employment 
security administration account to the account of each 
State in the Unemployment Trust Fund, within 30 days 
after the date of the enactment of this subsection, the 
amount determined with respect to such State under para-
graph (2). 
‘‘(2) The amount to be transferred under this sub-
section to a State account shall (as determined by the Sec-
retary of Labor and certified by such Secretary to the Sec-
retary of the Treasury) be equal to the amount obtained 
by multiplying $500,000,000 by the same ratio as deter-
mined under subsection (f)(1)(B) with respect to such State. 
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‘‘(3) Any amount transferred to the account of a State 
as a result of the enactment of this subsection may be used 
by the State agency of such State only in the payment of 
expenses incurred by it for— 
‘‘(A) the administration of the provisions of its 
State law carrying out the purposes of subsection 
(f)(2) or any subparagraph of subsection (f)(3); 
‘‘(B) improved outreach to individuals who 
might be eligible for regular unemployment compensa-
tion by virtue of any provisions of the State law 
which are described in subparagraph (A); 
‘‘(C) the improvement of unemployment benefit 
and unemployment tax operations, including respond-
ing to increased demand for unemployment com-
pensation; and 
‘‘(D) staff-assisted reemployment services for un-
employment compensation claimants.’’. 
(b) REGULATIONS.—The Secretary of Labor may pre-
scribe any regulations, operating instructions, or other 
guidance necessary to carry out the amendment made by 
subsection (a). 
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SEC. 2004. TEMPORARY ASSISTANCE FOR STATES WITH AD-
VANCES. 
Section 1202(b) of the Social Security Act (42 U.S.C. 
1322(b)) is amended by adding at the end the following new 
paragraph: 
‘‘(10)(A) With respect to the period beginning on the 
date of enactment of this paragraph and ending on Decem-
ber 31, 2010— 
‘‘(i) any interest payment otherwise due from a 
State under this subsection during such period shall 
be deemed to have been made by the State; and 
‘‘(ii) no interest shall accrue on any advance or 
advances made under section 1201 to a State during 
such period. 
‘‘(B) The provisions of subparagraph (A) shall have 
no effect on the requirement for interest payments under 
this subsection after the period described in such subpara-
graph or on the accrual of interest under this subsection 
after such period.’’. 
Subtitle B—Assistance for 
Vulnerable Individuals 
SEC. 2101. EMERGENCY FUND FOR TANF PROGRAM. 
(a) TEMPORARY FUND.— 
(1) IN GENERAL.—Section 403 of the Social Se-
curity Act (42 U.S.C. 603) is amended by adding at 
the end the following: 
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‘‘(c) EMERGENCY FUND.— 
‘‘(1) ESTABLISHMENT.—There is established in 
the Treasury of the United States a fund which shall 
be known as the ‘Emergency Contingency Fund for 
State Temporary Assistance for Needy Families Pro-
grams’ (in this subsection referred to as the ‘Emer-
gency Fund’). 
‘‘(2) DEPOSITS INTO FUND.— 
‘‘(A) IN GENERAL.—Out of any money in 
the Treasury of the United States not otherwise 
appropriated, there are appropriated for fiscal 
year 2009, $3,000,000,000 for payment to the 
Emergency Fund. 
‘‘(B) AVAILABILITY AND USE OF FUNDS.— 
The amounts appropriated to the Emergency 
Fund under subparagraph (A) shall remain 
available through fiscal year 2010 and shall be 
used to make grants to States in each of fiscal 
years 2009 and 2010 in accordance with the re-
quirements of paragraph (3). 
‘‘(C) LIMITATION.—In no case may the Sec-
retary make a grant from the Emergency Fund 
for a fiscal year after fiscal year 2010. 
‘‘(3) GRANTS.— 
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‘‘(A) GRANT
RELATED
TO
CASELOAD
IN-
CREASES.— 
‘‘(i) IN GENERAL.—For each calendar 
quarter in fiscal year 2009 or 2010, the 
Secretary shall make a grant from the 
Emergency Fund to each State that— 
‘‘(I) requests a grant under this 
subparagraph for the quarter; and 
‘‘(II) meets the requirement of 
clause (ii) for the quarter. 
‘‘(ii) CASELOAD
INCREASE
REQUIRE-
MENT.—A State meets the requirement of 
this clause for a quarter if the average 
monthly assistance caseload of the State for 
the quarter exceeds the average monthly as-
sistance caseload of the State for the cor-
responding quarter in the emergency fund 
base year of the State. 
‘‘(iii) AMOUNT OF GRANT.—Subject to 
paragraph (5), the amount of the grant to 
be made to a State under this subparagraph 
for a quarter shall be 80 percent of the 
amount (if any) by which the total expendi-
tures of the State for basic assistance (as de-
fined by the Secretary) in the quarter, 
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whether under the State program funded 
under this part or as qualified State ex-
penditures, exceeds the total expenditures of 
the State for such assistance for the cor-
responding quarter in the emergency fund 
base year of the State. 
‘‘(B) GRANT RELATED TO INCREASED EX-
PENDITURES FOR NON-RECURRENT SHORT TERM 
BENEFITS.— 
‘‘(i) IN GENERAL.—For each calendar 
quarter in fiscal year 2009 or 2010, the 
Secretary shall make a grant from the 
Emergency Fund to each State that— 
‘‘(I) requests a grant under this 
subparagraph for the quarter; and 
‘‘(II) meets the requirement of 
clause (ii) for the quarter. 
‘‘(ii) NON-RECURRENT
SHORT
TERM 
EXPENDITURE
REQUIREMENT.—A 
State 
meets the requirement of this clause for a 
quarter if the total expenditures of the State 
for non-recurrent short term benefits in the 
quarter, whether under the State program 
funded under this part or as qualified State 
expenditures, exceeds the total such expendi-
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tures of the State for non-recurrent short 
term benefits in the corresponding quarter 
in the emergency fund base year of the 
State. 
‘‘(iii) AMOUNT OF GRANT.—Subject to 
paragraph (5), the amount of the grant to 
be made to a State under this subparagraph 
for a quarter shall be an amount equal to 
80 percent of the excess described in clause 
(ii). 
‘‘(C) GRANT RELATED TO INCREASED EX-
PENDITURES FOR SUBSIDIZED EMPLOYMENT.— 
‘‘(i) IN GENERAL.—For each calendar 
quarter in fiscal year 2009 or 2010, the 
Secretary shall make a grant from the 
Emergency Fund to each State that— 
‘‘(I) requests a grant under this 
subparagraph for the quarter; and 
‘‘(II) meets the requirement of 
clause (ii) for the quarter. 
‘‘(ii) SUBSIDIZED
EMPLOYMENT
EX-
PENDITURE REQUIREMENT.—A State meets 
the requirement of this clause for a quarter 
if the total expenditures of the State for sub-
sidized employment in the quarter, whether 
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under the State program funded under this 
part or as qualified State expenditures, ex-
ceeds the total of such expenditures of the 
State in the corresponding quarter in the 
emergency fund base year of the State. 
‘‘(iii) AMOUNT OF GRANT.—Subject to 
paragraph (5), the amount of the grant to 
be made to a State under this subparagraph 
for a quarter shall be an amount equal to 
80 percent of the excess described in clause 
(ii). 
‘‘(4) AUTHORITY TO MAKE NECESSARY ADJUST-
MENTS TO DATA AND COLLECT NEEDED DATA.—In de-
termining the size of the caseload of a State and the 
expenditures of a State for basic assistance, non-re-
current short-term benefits, and subsidized employ-
ment, during any period for which the State requests 
funds under this subsection, and during the emer-
gency fund base year of the State, the Secretary may 
make appropriate adjustments to the data to ensure 
that the data reflect expenditures under the State pro-
gram funded under this part and qualified State ex-
penditures. The Secretary may develop a mechanism 
for collecting expenditure data, including procedures 
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which allow States to make reasonable estimates, and 
may set deadlines for making revisions to the data. 
‘‘(5) LIMITATION.—The total amount payable to 
a single State under subsection (b) and this subsection 
for a fiscal year shall not exceed 25 percent of the 
State family assistance grant. 
‘‘(6) LIMITATIONS ON USE OF FUNDS.—A State 
to which an amount is paid under this subsection 
may use the amount only as authorized by section 
404. 
‘‘(7) TIMING
OF
IMPLEMENTATION.—The Sec-
retary shall implement this subsection as quickly as 
reasonably possible, pursuant to appropriate guidance 
to States. 
‘‘(8) DEFINITIONS.—In this subsection: 
‘‘(A) AVERAGE MONTHLY ASSISTANCE CASE-
LOAD DEFINED.—The term ‘average monthly as-
sistance caseload’ means, with respect to a State 
and a quarter, the number of families receiving 
assistance during the quarter under the State 
program funded under this part or as qualified 
State expenditures, subject to adjustment under 
paragraph (4). 
‘‘(B) EMERGENCY FUND BASE YEAR.— 
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(2) REPEAL.—Effective October 1, 2010, sub-
section (c) of section 403 of the Social Security Act 
(42 U.S.C. 603) (as added by paragraph (1)) is re-
pealed. 
(b) TEMPORARY MODIFICATION OF CASELOAD REDUC-
TION CREDIT.—Section 407(b)(3)(A)(i) of such Act (42 
U.S.C. 607(b)(3)(A)(i)) is amended by inserting ‘‘(or if the 
immediately preceding fiscal year is fiscal year 2008, 2009, 
or 2010, then, at State option, during the emergency fund 
base year of the State with respect to the average monthly 
assistance caseload of the State (within the meaning of sec-
tion 403(c)(8)(B), except that, if a State elects such option 
for fiscal year 2008, the emergency fund base year of the 
State with respect to such caseload shall be fiscal year 
2007))’’ before ‘‘under the State’’. 
(c) DISREGARD FROM LIMITATION ON TOTAL PAY-
MENTS TO TERRITORIES.—Section 1108(a)(2) of the Social 
Security Act (42 U.S.C. 1308(a)(2)) is amended by insert-
ing ‘‘403(c)(3),’’ after ‘‘403(a)(5),’’. 
(d) EFFECTIVE DATE.—The amendments made by this 
section shall take effect on the date of the enactment of this 
Act. 
SEC. 2102. EXTENSION OF TANF SUPPLEMENTAL GRANTS. 
(a) EXTENSION THROUGH FISCAL YEAR 2010.—Sec-
tion 7101(a) of the Deficit Reduction Act of 2005 (Public 
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Law 109–171; 120 Stat. 135), as amended by section 301(a) 
of the Medicare Improvements for Patients and Providers 
Act of 2008 (Public Law 110–275), is amended by striking 
‘‘fiscal year 2009’’ and inserting ‘‘fiscal year 2010’’. 
(b) 
CONFORMING
AMENDMENT.—Section 
403(a)(3)(H)(ii) of the Social Security Act (42 U.S.C. 
603(a)(3)(H)(ii)) is amended to read as follows: 
‘‘(ii) subparagraph (G) shall be ap-
plied as if ‘fiscal year 2010’ were sub-
stituted for ‘fiscal year 2001’; and’’. 
SEC. 2103. CLARIFICATION OF AUTHORITY OF STATES TO 
USE TANF FUNDS CARRIED OVER FROM 
PRIOR YEARS TO PROVIDE TANF BENEFITS 
AND SERVICES. 
Section 404(e) of the Social Security Act (42 U.S.C. 
604(e)) is amended to read as follows: 
‘‘(e) AUTHORITY TO CARRY OVER CERTAIN AMOUNTS 
FOR BENEFITS OR SERVICES OR FOR FUTURE CONTIN-
GENCIES.—A State or tribe may use a grant made to the 
State or tribe under this part for any fiscal year to provide, 
without fiscal year limitation, any benefit or service that 
may be provided under the State or tribal program funded 
under this part.’’. 
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SEC. 2104. TEMPORARY REINSTATEMENT OF AUTHORITY TO 
PROVIDE 
FEDERAL 
MATCHING 
PAYMENTS 
FOR STATE SPENDING OF CHILD SUPPORT 
INCENTIVE PAYMENTS. 
During the period that begins on October 1, 2008, and 
ends on December 31, 2010, section 455(a)(1) of the Social 
Security Act (42 U.S.C. 655(a)(1)) shall be applied without 
regard to the amendment made by section 7309(a) of the 
Deficit Reduction Act of 2005 (Public Law 109–171, 120 
Stat. 147). 
TITLE III—HEALTH INSURANCE 
ASSISTANCE 
SEC. 3000. TABLE OF CONTENTS OF TITLE. 
The table of contents for this title is as follows: 
TITLE III—HEALTH INSURANCE ASSISTANCE 
Sec. 3000. Table of contents of title. 
Subtitle A—Premium Subsidies for COBRA Continuation Coverage for 
Unemployed Workers 
Sec. 3001. Premium assistance for COBRA benefits. 
Subtitle B—Transitional Medical Assistance (TMA) 
Sec. 3101. Extension of transitional medical assistance (TMA). 
Subtitle C—Extension of the Qualified Individual (QI) Program 
Sec. 3201. Extension of the qualifying individual (QI) program. 
Subtitle D—Other Provisions 
Sec. 3301. Premiums and cost sharing protections under Medicaid, eligibility de-
terminations under Medicaid and CHIP, and protection of cer-
tain Indian property from Medicaid estate recovery. 
Sec. 3302. Rules applicable under Medicaid and CHIP to managed care entities 
with respect to Indian enrollees and Indian health care pro-
viders and Indian managed care entities. 
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Sec. 3303. Consultation on Medicaid, CHIP, and other health care programs 
funded under the Social Security Act involving Indian Health 
Programs and Urban Indian Organizations. 
Sec. 3304. Application of prompt pay requirements to nursing facilities. 
Sec. 3305. Period of application; sunset. 
Subtitle A—Premium Subsidies for 
COBRA Continuation Coverage 
for Unemployed Workers 
SEC. 3001. PREMIUM ASSISTANCE FOR COBRA BENEFITS. 
(a) TABLE OF CONTENTS OF SUBTITLE.—The table of 
contents of this subtitle is as follows: 
Sec. 3001. Premium assistance for COBRA benefits. 
(b) PREMIUM ASSISTANCE
FOR COBRA CONTINU-
ATION COVERAGE FOR UNEMPLOYED WORKERS AND THEIR 
FAMILIES.— 
(1) PROVISION OF PREMIUM ASSISTANCE.— 
(A) REDUCTION OF PREMIUMS PAYABLE.— 
In the case of any premium for a month of cov-
erage beginning after the date of the enactment 
of the Act for COBRA continuation coverage 
with respect to any assistance eligible indi-
vidual, such individual shall be treated for pur-
poses of any COBRA continuation provision as 
having paid the amount of such premium if such 
individual pays 50 percent of the amount of such 
premium (as determined without regard to this 
subsection). 
(B) PLAN ENROLLMENT OPTION.— 
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(i) IN GENERAL.—Notwithstanding the 
COBRA continuation provisions, an assist-
ance eligible individual may, not later than 
90 days after the date of notice of the plan 
enrollment option described in this subpara-
graph, elect to enroll in coverage under a 
plan offered by the employer involved, or the 
employee organization involved (including, 
for this purpose, a joint board of trustees of 
a multiemployer trust affiliated with one or 
more multiemployer plans), that is different 
than coverage under the plan in which such 
individual was enrolled at the time the 
qualifying event occurred, and such cov-
erage shall be treated as COBRA continu-
ation coverage for purposes of the applicable 
COBRA continuation coverage provision. 
(ii) REQUIREMENTS.—An assistance 
eligible individual may elect to enroll in 
different coverage as described in clause (i) 
only if— 
(I) the employer involved has 
made a determination that such em-
ployer will permit assistance eligible 
individuals to enroll in different cov-
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erage as provided for this subpara-
graph; 
(II) the premium for such dif-
ferent coverage does not exceed the pre-
mium for coverage in which the indi-
vidual was enrolled at the time the 
qualifying event occurred; 
(III) the different coverage in 
which the individual elects to enroll is 
coverage that is also offered to the ac-
tive employees of the employer at the 
time at which such election is made; 
and 
(IV) the different coverage is 
not— 
(aa) coverage that provides 
only dental, vision, counseling, or 
referral services (or a combination 
of such services); 
(bb) a health flexible spend-
ing account or health reimburse-
ment arrangement; or 
(cc) coverage that provides 
coverage for services or treatments 
furnished in an on-site medical 
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facility maintained by the em-
ployer and that consists primarily 
of first-aid services, prevention 
and wellness care, or similar care 
(or a combination of such care). 
(C) PREMIUM REIMBURSEMENT.—For pro-
visions providing the balance of such premium, 
see section 6432 of the Internal Revenue Code of 
1986, as added by paragraph (12). 
(2) LIMITATION OF PERIOD OF PREMIUM ASSIST-
ANCE.— 
(A) IN GENERAL.—Paragraph (1)(A) shall 
not apply with respect to any assistance eligible 
individual for months of coverage beginning on 
or after the earlier of— 
(i) the first date that such individual 
is eligible for coverage under any other 
group health plan (other than coverage con-
sisting of only dental, vision, counseling, or 
referral services (or a combination thereof), 
coverage under a health reimbursement ar-
rangement or a health flexible spending ar-
rangement, or coverage of treatment that is 
furnished in an on-site medical facility 
maintained by the employer and that con-
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sists primarily of first-aid services, preven-
tion and wellness care, or similar care (or 
a combination thereof)) or is eligible for 
benefits under title XVIII of the Social Se-
curity Act; or 
(ii) the earliest of— 
(I) the date which is 12 months 
after the first day of first month that 
paragraph (1)(A) applies with respect 
to such individual, 
(II) the date following the expira-
tion of the maximum period of con-
tinuation coverage required under the 
applicable COBRA continuation cov-
erage provision, or 
(III) the date following the expi-
ration of the period of continuation 
coverage 
allowed 
under 
paragraph 
(4)(B)(ii). 
(B) TIMING
OF
ELIGIBILITY
FOR
ADDI-
TIONAL
COVERAGE.—For purposes of subpara-
graph (A)(i), an individual shall not be treated 
as eligible for coverage under a group health 
plan before the first date on which such indi-
vidual could be covered under such plan. 
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(C) NOTIFICATION REQUIREMENT.—An as-
sistance eligible individual shall notify in writ-
ing the group health plan with respect to which 
paragraph (1)(A) applies if such paragraph 
ceases to apply by reason of subparagraph 
(A)(i). Such notice shall be provided to the group 
health plan in such time and manner as may be 
specified by the Secretary of Labor. 
(3) ASSISTANCE
ELIGIBLE
INDIVIDUAL.—For 
purposes of this section, the term ‘‘assistance eligible 
individual’’ means any qualified beneficiary if— 
(A) at any time during the period that be-
gins with September 1, 2008, and ends with De-
cember 31, 2009, such qualified beneficiary is el-
igible for COBRA continuation coverage, 
(B) such qualified beneficiary elects such 
coverage, and 
(C) the qualifying event with respect to the 
COBRA continuation coverage consists of the in-
voluntary termination of the covered employee’s 
employment and occurred during such period. 
(4) EXTENSION OF ELECTION PERIOD AND EF-
FECT ON COVERAGE.— 
(A) IN GENERAL.—Notwithstanding section 
605(a) of the Employee Retirement Income Secu-
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rity Act of 1974, section 4980B(f)(5)(A) of the 
Internal Revenue Code of 1986, section 2205(a) 
of the Public Health Service Act, and section 
8905a(c)(2) of title 5, United States Code, in the 
case of an individual who is a qualified bene-
ficiary described in paragraph (3)(A) as of the 
date of the enactment of this Act and has not 
made the election referred to in paragraph 
(3)(B) as of such date, such individual may elect 
the COBRA continuation coverage under the 
COBRA continuation coverage provisions con-
taining such sections during the 60-day period 
commencing with the date on which the notifica-
tion required under paragraph (7)(C) is pro-
vided to such individual. 
(B) COMMENCEMENT
OF
COVERAGE; NO 
REACH-BACK.—Any COBRA continuation cov-
erage elected by a qualified beneficiary during 
an extended election period under subparagraph 
(A)— 
(i) shall commence on the date of the 
enactment of this Act, and 
(ii) shall not extend beyond the period 
of COBRA continuation coverage that 
would have been required under the applica-
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ble COBRA continuation coverage provision 
if the coverage had been elected as required 
under such provision. 
(C) PREEXISTING
CONDITIONS.—With re-
spect to a qualified beneficiary who elects 
COBRA continuation coverage pursuant to sub-
paragraph (A), the period— 
(i) beginning on the date of the quali-
fying event, and 
(ii) ending with the day before the date 
of the enactment of this Act, 
shall be disregarded for purposes of determining 
the 63-day periods referred to in section 701)(2) 
of the Employee Retirement Income Security Act 
of 1974, section 9801(c)(2) of the Internal Rev-
enue Code of 1986, and section 2701(c)(2) of the 
Public Health Service Act. 
(5) EXPEDITED REVIEW OF DENIALS OF PRE-
MIUM ASSISTANCE.—In any case in which an indi-
vidual requests treatment as an assistance eligible in-
dividual and is denied such treatment by the group 
health plan by reason of such individual’s ineligi-
bility for COBRA continuation coverage, the Sec-
retary of Labor (or the Secretary of Health and 
Human services in connection with COBRA continu-
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ation coverage which is provided other than pursuant 
to part 6 of subtitle B of title I of the Employee Re-
tirement Income Security Act of 1974), in consulta-
tion with the Secretary of the Treasury, shall provide 
for expedited review of such denial. An individual 
shall be entitled to such review upon application to 
such Secretary in such form and manner as shall be 
provided by such Secretary. Such Secretary shall 
make a determination regarding such individual’s eli-
gibility within 10 business days after receipt of such 
individual’s application for review under this para-
graph. 
(6) DISREGARD OF SUBSIDIES FOR PURPOSES OF 
FEDERAL
AND
STATE
PROGRAMS.—Notwithstanding 
any other provision of law, any premium reduction 
with respect to an assistance eligible individual under 
this subsection shall not be considered income or re-
sources in determining eligibility for, or the amount 
of assistance or benefits provided under, any other 
public benefit provided under Federal law or the law 
of any State or political subdivision thereof. 
(7) NOTICES TO INDIVIDUALS.— 
(A) GENERAL NOTICE.— 
(i) IN GENERAL.—In the case of notices 
provided under section 606(4) of the Em-
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ployee Retirement Income Security Act of 
1974 
(29 
U.S.C. 
1166(4)), 
section 
4980B(f)(6)(D) of the Internal Revenue 
Code of 1986, section 2206(4) of the Public 
Health Service Act (42 U.S.C. 300bb–6(4)), 
or section 8905a(f)(2)(A) of title 5, United 
States Code, with respect to individuals 
who, during the period described in para-
graph (3)(A), become entitled to elect 
COBRA continuation coverage, such notices 
shall include an additional notification to 
the recipient of— 
(I) the availability of premium 
reduction with respect to such coverage 
under this subsection; and 
(II) the option to enroll in dif-
ferent coverage if an employer that 
permits assistance eligible individuals 
to elect enrollment in different coverage 
(as described in paragraph (1)(B)). 
(ii) ALTERNATIVE
NOTICE.—In the 
case of COBRA continuation coverage to 
which the notice provision under such sec-
tions does not apply, the Secretary of 
Labor, in consultation with the Secretary of 
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the Treasury and the Secretary of Health 
and Human Services, shall, in coordination 
with administrators of the group health 
plans (or other entities) that provide or ad-
minister the COBRA continuation coverage 
involved, provide rules requiring the provi-
sion of such notice. 
(iii) FORM.—The requirement of the 
additional notification under this subpara-
graph may be met by amendment of exist-
ing notice forms or by inclusion of a sepa-
rate document with the notice otherwise re-
quired. 
(B) SPECIFIC REQUIREMENTS.—Each addi-
tional notification under subparagraph (A) shall 
include— 
(i) the forms necessary for establishing 
eligibility for premium reduction under this 
subsection, 
(ii) the name, address, and telephone 
number necessary to contact the plan ad-
ministrator and any other person main-
taining relevant information in connection 
with such premium reduction, 
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(iii) a description of the extended elec-
tion period provided for in paragraph 
(4)(A), 
(iv) a description of the obligation of 
the qualified beneficiary under paragraph 
(2)(C) to notify the plan providing continu-
ation coverage of eligibility for subsequent 
coverage under another group health plan 
or eligibility for benefits under title XVIII 
of the Social Security Act and the penalty 
provided for failure to so notify the plan, 
(v) a description, displayed in a 
prominent manner, of the qualified bene-
ficiary’s right to a reduced premium and 
any conditions on entitlement to the re-
duced premium; and 
(vi) a description of the option of the 
qualified beneficiary to enroll in different 
coverage if the employer permits such bene-
ficiary to elect to enroll in such different 
coverage under paragraph (1)(B). 
(C) NOTICE
RELATING
TO
RETROACTIVE 
COVERAGE.—In the case of an individual de-
scribed in paragraph (3)(A) who has elected 
COBRA continuation coverage as of the date of 
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enactment of this Act or an individual described 
in paragraph (4)(A), the administrator of the 
group health plan (or other person) involved 
shall provide (within 60 days after the date of 
enactment of this Act) for the additional notifi-
cation required to be provided under subpara-
graph (A). 
(D) MODEL NOTICES.—Not later than 30 
days after the date of enactment of this Act, the 
Secretary of the Labor, in consultation with the 
Secretary of the Treasury and the Secretary of 
Health and Human Services, shall prescribe 
models for the additional notification required 
under this paragraph. 
(8) SAFEGUARDS.—The Secretary of the Treas-
ury shall provide such rules, procedures, regulations, 
and other guidance as may be necessary and appro-
priate to prevent fraud and abuse under this sub-
section. 
(9) OUTREACH.—The Secretary of Labor, in con-
sultation with the Secretary of the Treasury and the 
Secretary of Health and Human Services, shall pro-
vide outreach consisting of public education and en-
rollment assistance relating to premium reduction 
provided under this subsection. Such outreach shall 
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target employers, group health plan administrators, 
public assistance programs, States, insurers, and 
other entities as determined appropriate by such Sec-
retaries. Such outreach shall include an initial focus 
on those individuals electing continuation coverage 
who are referred to in paragraph (7)(C). Information 
on such premium reduction, including enrollment, 
shall also be made available on website of the Depart-
ments of Labor, Treasury, and Health and Human 
Services. 
(10) DEFINITIONS.—For purposes of this sub-
section— 
(A) ADMINISTRATOR.—The term ‘‘adminis-
trator’’ has the meaning given such term in sec-
tion 3(16) of the Employee Retirement Income 
Security Act of 1974 
(B) COBRA CONTINUATION
COVERAGE.— 
The term ‘‘COBRA continuation coverage’’ 
means continuation coverage provided pursuant 
to part 6 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 (other 
than under section 609), title XXII of the Public 
Health Service Act, section 4980B of the Internal 
Revenue Code of 1986 (other than subsection 
(f)(1) of such section insofar as it relates to pedi-
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atric vaccines), or section 8905a of title 5, 
United States Code, or under a State program 
that provides continuation coverage comparable 
to such continuation coverage. Such term does 
not include coverage under a health flexible 
spending arrangement. 
(C) COBRA CONTINUATION
PROVISION.— 
The term ‘‘COBRA continuation provision’’ 
means the provisions of law described in sub-
paragraph (B). 
(D) COVERED EMPLOYEE.—The term ‘‘cov-
ered employee’’ has the meaning given such term 
in section 607(2) of the Employee Retirement In-
come Security Act of 1974. 
(E) QUALIFIED
BENEFICIARY.—The term 
‘‘qualified beneficiary’’ has the meaning given 
such term in section 607(3) of the Employee Re-
tirement Income Security Act of 1974. 
(F) GROUP
HEALTH
PLAN.—The term 
‘‘group health plan’’ has the meaning given such 
term in section 607(1) of the Employee Retire-
ment Income Security Act of 1974. 
(G) STATE.—The term ‘‘State’’ includes the 
District of Columbia, the Commonwealth of 
Puerto Rico, the Virgin Islands, Guam, Amer-
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ican Samoa, and the Commonwealth of the 
Northern Mariana Islands. 
(11) REPORTS.— 
(A) INTERIM REPORT.—The Secretary of the 
Treasury shall submit an interim report to the 
Committee on Education and Labor, the Com-
mittee on Ways and Means, and the Committee 
on Energy and Commerce of the House of Rep-
resentatives and the Committee on Health, Edu-
cation, Labor, and Pensions and the Committee 
on Finance of the Senate regarding the premium 
reduction provided under this subsection that in-
cludes— 
(i) the number of individuals provided 
such assistance as of the date of the report; 
and 
(ii) the total amount of expenditures 
incurred (with administrative expenditures 
noted separately) in connection with such 
assistance as of the date of the report. 
(B) FINAL REPORT.—As soon as practicable 
after the last period of COBRA continuation cov-
erage for which premium reduction is provided 
under this section, the Secretary of the Treasury 
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shall submit a final report to each Committee re-
ferred to in subparagraph (A) that includes— 
(i) the number of individuals provided 
premium reduction under this section; 
(ii) the average dollar amount (month-
ly and annually) of premium reductions 
provided to such individuals; and 
(iii) the total amount of expenditures 
incurred (with administrative expenditures 
noted separately) in connection with pre-
mium reduction under this section. 
(12) COBRA PREMIUM ASSISTANCE.— 
(A) IN GENERAL.—Subchapter B of chapter 
65 of the Internal Revenue Code of 1986 is 
amended by adding at the end the following new 
section: 
‘‘SEC. 6432. COBRA PREMIUM ASSISTANCE. 
‘‘(a) IN GENERAL.—The person to whom premiums 
are payable under COBRA continuation coverage shall be 
reimbursed for the amount of premiums not paid by plan 
beneficiaries by reason of section 3001(b) of the American 
Recovery and Reinvestment Act of 2009. Such amount shall 
be treated as a credit against the requirement of such person 
to make deposits of payroll taxes and the liability of such 
person for payroll taxes. To the extent that such amount 
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exceeds the amount of such taxes, the Secretary shall pay 
to such person the amount of such excess. No payment may 
be made under this subsection to a person with respect to 
any assistance eligible individual until after such person 
has received the reduced premium from such individual re-
quired under section 3001(a)(1)(A) of such Act. 
‘‘(b) PAYROLL TAXES.—For purposes of this section, 
the term ‘payroll taxes’ means— 
‘‘(1) amounts required to be deducted and with-
held for the payroll period under section 3401 (relat-
ing to wage withholding), 
‘‘(2) amounts required to be deducted for the 
payroll period under section 3102 (relating to FICA 
employee taxes), and 
‘‘(3) amounts of the taxes imposed for the payroll 
period under section 3111 (relating to FICA employer 
taxes). 
‘‘(c) TREATMENT OF CREDIT.—Except as otherwise 
provided by the Secretary, the credit described in subsection 
(a) shall be applied as though the employer had paid to 
the Secretary, on the day that the qualified beneficiary’s 
premium payment is received, an amount equal to such 
credit. 
‘‘(d) TREATMENT OF PAYMENT.—For purposes of sec-
tion 1324(b)(2) of title 31, United States Code, any pay-
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ment under this subsection shall be treated in the same 
manner as a refund of the credit under section 35. 
‘‘(e) REPORTING.— 
‘‘(1) IN GENERAL.—Each person entitled to re-
imbursement under subsection (a) for any period 
shall submit such reports as the Secretary may re-
quire, including— 
‘‘(A) an attestation of involuntary termi-
nation of employment for each covered employee 
on the basis of whose termination entitlement to 
reimbursement is claimed under subsection (a), 
and 
‘‘(B) a report of the amount of payroll taxes 
offset under subsection (a) for the reporting pe-
riod and the estimated offsets of such taxes for 
the subsequent reporting period in connection 
with reimbursements under subsection (a). 
‘‘(2) TIMING OF REPORTS RELATING TO AMOUNT 
OF PAYROLL TAXES.—Reports required under para-
graph (1)(B) shall be submitted at the same time as 
deposits of taxes imposed by chapters 21, 22, and 24 
or at such time as is specified by the Secretary. 
‘‘(f) REGULATIONS.—The Secretary may issue such 
regulations or other guidance as may be necessary or appro-
priate to carry out this section, including the requirement 
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to report information or the establishment of other methods 
for verifying the correct amounts of payments and credits 
under this section, and the application of this section to 
group health plans which are multiemployer plans.’’. 
(B) SOCIAL SECURITY TRUST FUNDS HELD 
HARMLESS.—In determining any amount trans-
ferred or appropriated to any fund under the So-
cial Security Act, section 6432 of the Internal 
Revenue Code of 1986 shall not be taken into ac-
count. 
(C) CLERICAL AMENDMENT.—The table of 
sections for subchapter B of chapter 65 of the In-
ternal Revenue Code of 1986 is amended by add-
ing at the end the following new item: 
‘‘Sec. 6432. COBRA premium assistance.’’. 
(D) EFFECTIVE
DATE.—The amendments 
made by this paragraph shall apply to pre-
miums to which subsection (a)(1)(A) applies. 
(E) SPECIAL RULE.— 
(i) IN GENERAL.—In the case of an as-
sistance eligible individual who pays the 
full premium amount required for COBRA 
continuation coverage for any month during 
the 60-day period beginning on the first day 
of the first month after the date of enact-
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ment of this Act, the person to whom such 
payment is made shall— 
(I) make a reimbursement pay-
ment to such individual for the 
amount of such premium paid in ex-
cess of the amount required to be paid 
under subsection (b)(1)(A); or 
(II) provide credit to the indi-
vidual for such amount in a manner 
that reduces one or more subsequent 
premium payments that the individual 
is required to pay under such sub-
section for the coverage involved. 
(ii) REIMBURSING EMPLOYER.—A per-
son to which clause (i) applies shall be re-
imbursed as provided for in section 6432 of 
the Internal Revenue Code of 1986 for any 
payment made, or credit provided, to the 
employee under such clause. 
(iii) PAYMENT OR CREDITS.—Unless it 
is reasonable to believe that the credit for 
the excess payment in clause (i)(II) will be 
used by the assistance eligible individual 
within 180 days of the date on which the 
person receives from the individual the pay-
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ment of the full premium amount, a person 
to which clause (i) applies shall make the 
payment required under such clause to the 
individual within 60 days of such payment 
of the full premium amount. If, as of any 
day within the 180-day period, it is no 
longer reasonable to believe that the credit 
will be used during that period, payment 
equal to the remainder of the credit out-
standing shall be made to the individual 
within 60 days of such day. 
(13) PENALTY FOR FAILURE TO NOTIFY HEALTH 
PLAN OF CESSATION OF ELIGIBILITY FOR PREMIUM 
ASSISTANCE.— 
(A) IN GENERAL.—Part I of subchapter B 
of chapter 68 of the Internal Revenue Code of 
1986 is amended by adding at the end the fol-
lowing new section: 
‘‘SEC. 6720C. PENALTY FOR FAILURE TO NOTIFY HEALTH 
PLAN OF CESSATION OF ELIGIBILITY FOR 
COBRA PREMIUM ASSISTANCE. 
‘‘(a) IN GENERAL.—Any person required to notify a 
group health plan under section 3001(a)(2)(C) of the Amer-
ican Recovery and Reinvestment Act of 2009 who fails to 
make such a notification at such time and in such manner 
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as the Secretary of Labor may require shall pay a penalty 
of 110 percent of the premium reduction provided under 
such section after termination of eligibility under such sub-
section. 
‘‘(b) REASONABLE CAUSE EXCEPTION.—No penalty 
shall be imposed under subsection (a) with respect to any 
failure if it is shown that such failure is due to reasonable 
cause and not to willful neglect.’’. 
(B) CLERICAL AMENDMENT.—The table of 
sections of part I of subchapter B of chapter 68 
of such Code is amended by adding at the end 
the following new item: 
‘‘Sec. 6720C. Penalty for failure to notify health plan of cessation of eligibility 
for COBRA premium assistance.’’. 
(C) EFFECTIVE
DATE.—The amendments 
made by this paragraph shall apply to failures 
occurring after the date of the enactment of this 
Act. 
(14) COORDINATION WITH HCTC.— 
(A) IN GENERAL.—Subsection (g) of section 
35 of the Internal Revenue Code of 1986 is 
amended by redesignating paragraph (9) as 
paragraph (10) and inserting after paragraph 
(8) the following new paragraph: 
‘‘(9) COBRA PREMIUM
ASSISTANCE.—In the 
case of an assistance eligible individual who receives 
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premium reduction for COBRA continuation coverage 
under section 3001(a) of the American Recovery and 
Reinvestment Act of 2009 for any month during the 
taxable year, such individual shall not be treated as 
an eligible individual, a certified individual, or a 
qualifying family member for purposes of this section 
or section 7527 with respect to such month.’’. 
(B) EFFECTIVE
DATE.—The amendment 
made by subparagraph (A) shall apply to tax-
able years ending after the date of the enactment 
of this Act. 
(15) EXCLUSION
OF
COBRA
PREMIUM
ASSIST-
ANCE FROM GROSS INCOME.— 
(A) IN GENERAL.—Part III of subchapter B 
of chapter 1 of the Internal Revenue Code of 
1986 is amended by inserting after section 139B 
the following new section: 
‘‘SEC. 139C. COBRA PREMIUM ASSISTANCE. 
‘‘In the case of an assistance eligible individual (as 
defined in section 3001 of the American Recovery and Rein-
vestment Act of 2009), gross income does not include any 
premium reduction provided under subsection (a) of such 
section.’’. 
(B) CLERICAL AMENDMENT.—The table of 
sections for part III of subchapter B of chapter 
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1 of such Code is amended by inserting after the 
item relating to section 139B the following new 
item: 
‘‘Sec. 139C. COBRA premium assistance.’’. 
(C) EFFECTIVE
DATE.—The amendments 
made by this paragraph shall apply to taxable 
years ending after the date of the enactment of 
this Act. 
Subtitle B—Transitional Medical 
Assistance (TMA) 
SEC. 3101. EXTENSION OF TRANSITIONAL MEDICAL ASSIST-
ANCE (TMA). 
(a) 18-MONTH EXTENSION.— 
(1) IN
GENERAL.—Sections 1902(e)(1)(B) and 
1925(f) of the Social Security Act (42 U.S.C. 
1396a(e)(1)(B), 1396r–6(f)) are each amended by 
striking ‘‘September 30, 2003’’ and inserting ‘‘Decem-
ber 31, 2010’’. 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall take effect on July 1, 2009. 
(b) STATE OPTION
OF INITIAL 12-MONTH ELIGI-
BILITY.—Section 1925 of the Social Security Act (42 U.S.C. 
1396r–6) is amended— 
(1) in subsection (a)(1), by inserting ‘‘but subject 
to paragraph (5)’’ after ‘‘Notwithstanding any other 
provision of this title’’; 
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(2) by adding at the end of subsection (a) the fol-
lowing: 
‘‘(5) OPTION OF 12-MONTH INITIAL ELIGIBILITY 
PERIOD.—A State may elect to treat any reference in 
this subsection to a 6-month period (or 6 months) as 
a reference to a 12-month period (or 12 months). In 
the case of such an election, subsection (b) shall not 
apply.’’; and 
(3) in subsection (b)(1), by inserting ‘‘but subject 
to subsection (a)(5)’’ after ‘‘Notwithstanding any 
other provision of this title’’. 
(c) REMOVAL OF REQUIREMENT FOR PREVIOUS RE-
CEIPT OF MEDICAL ASSISTANCE.—Section 1925(a)(1) of 
such Act (42 U.S.C. 1396r–6(a)(1)), as amended by sub-
section (b)(1), is further amended— 
(1) by inserting ‘‘subparagraph (B) and’’ before 
‘‘paragraph (5)’’; 
(2) by redesignating the matter after ‘‘REQUIRE-
MENT.—’’ as a subparagraph (A) with the heading 
‘‘IN GENERAL.—’’ and with the same indentation as 
subparagraph (B) (as added by paragraph (3)); and 
(3) by adding at the end the following: 
‘‘(B) STATE
OPTION
TO
WAIVE
REQUIRE-
MENT FOR 3 MONTHS BEFORE RECEIPT OF MED-
ICAL ASSISTANCE.—A State may, at its option, 
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elect also to apply subparagraph (A) in the case 
of a family that was receiving such aid for fewer 
than three months or that had applied for and 
was eligible for such aid for fewer than 3 months 
during the 6 immediately preceding months de-
scribed in such subparagraph.’’. 
(d) CMS REPORT ON ENROLLMENT AND PARTICIPA-
TION RATES UNDER TMA.—Section 1925 of such Act (42 
U.S.C. 1396r–6), as amended by this section, is further 
amended by adding at the end the following new subsection: 
‘‘(g) COLLECTION AND REPORTING OF PARTICIPATION 
INFORMATION.— 
‘‘(1) 
COLLECTION
OF
INFORMATION
FROM 
STATES.—Each State shall collect and submit to the 
Secretary (and make publicly available), in a format 
specified by the Secretary, information on average 
monthly enrollment and average monthly participa-
tion rates for adults and children under this section 
and of the number and percentage of children who be-
come ineligible for medical assistance under this sec-
tion whose medical assistance is continued under an-
other eligibility category or who are enrolled under 
the State’s child health plan under title XXI. Such 
information shall be submitted at the same time and 
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frequency in which other enrollment information 
under this title is submitted to the Secretary. 
‘‘(2) ANNUAL
REPORTS
TO
CONGRESS.—Using 
the information submitted under paragraph (1), the 
Secretary shall submit to Congress annual reports 
concerning enrollment and participation rates de-
scribed in such paragraph.’’. 
(e) EFFECTIVE DATE.—The amendments made by sub-
sections (b) through (d) shall take effect on July 1, 2009. 
Subtitle C—Extension of the 
Qualified Individual (QI) Program 
SEC. 3201. EXTENSION OF THE QUALIFYING INDIVIDUAL 
(QI) PROGRAM. 
(a) EXTENSION.—Section 1902(a)(10)(E)(iv) of the 
Social Security Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is 
amended by striking ‘‘December 2009’’ and inserting ‘‘De-
cember 2010’’. 
(b) EXTENDING TOTAL AMOUNT AVAILABLE FOR AL-
LOCATION.—Section 1933(g) of such Act (42 U.S.C. 1396u– 
3(g)) is amended— 
(1) in paragraph (2)— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (K); 
(B) in subparagraph (L), by striking the 
period at the end and inserting a semicolon; and 
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(C) by adding at the end the following new 
subparagraphs: 
‘‘(M) for the period that begins on January 
1, 2010, and ends on September 30, 2010, the 
total allocation amount is $412,500,000; and 
‘‘(N) for the period that begins on October 
1, 2010, and ends on December 31, 2010, the 
total allocation amount is $150,000,000.’’; and 
(2) in paragraph (3), in the matter preceding 
subparagraph (A), by striking ‘‘or (L)’’ and inserting 
‘‘(L), or (N)’’. 
Subtitle D—Other Provisions 
SEC. 3301. PREMIUMS AND COST SHARING PROTECTIONS 
UNDER MEDICAID, ELIGIBILITY DETERMINA-
TIONS UNDER MEDICAID AND CHIP, AND PRO-
TECTION OF CERTAIN INDIAN PROPERTY 
FROM MEDICAID ESTATE RECOVERY. 
(a) PREMIUMS
AND COST SHARING PROTECTION 
UNDER MEDICAID.— 
(1) IN GENERAL.—Section 1916 of the Social Se-
curity Act (42 U.S.C. 1396o) is amended— 
(A) in subsection (a), in the matter pre-
ceding paragraph (1), by striking ‘‘and (i)’’ and 
inserting ‘‘, (i), and (j)’’; and 
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(B) by adding at the end the following new 
subsection: 
‘‘(j) NO PREMIUMS OR COST SHARING FOR INDIANS 
FURNISHED ITEMS OR SERVICES DIRECTLY BY INDIAN 
HEALTH PROGRAMS OR THROUGH REFERRAL UNDER CON-
TRACT HEALTH SERVICES.— 
‘‘(1) NO COST SHARING FOR ITEMS OR SERVICES 
FURNISHED TO INDIANS THROUGH INDIAN HEALTH 
PROGRAMS.— 
‘‘(A) IN GENERAL.—No enrollment fee, pre-
mium, or similar charge, and no deduction, co-
payment, cost sharing, or similar charge shall be 
imposed against an Indian who is furnished an 
item or service directly by the Indian Health 
Service, an Indian Tribe, Tribal Organization, 
or Urban Indian Organization or through refer-
ral under contract health services for which pay-
ment may be made under this title. 
‘‘(B) NO REDUCTION IN AMOUNT OF PAY-
MENT TO INDIAN HEALTH PROVIDERS.—Payment 
due under this title to the Indian Health Service, 
an Indian Tribe, Tribal Organization, or Urban 
Indian Organization, or a health care provider 
through referral under contract health services 
for the furnishing of an item or service to an In-
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dian who is eligible for assistance under such 
title, may not be reduced by the amount of any 
enrollment fee, premium, or similar charge, or 
any deduction, copayment, cost sharing, or simi-
lar charge that would be due from the Indian but 
for the operation of subparagraph (A). 
‘‘(2) RULE OF CONSTRUCTION.—Nothing in this 
subsection shall be construed as restricting the appli-
cation of any other limitations on the imposition of 
premiums or cost sharing that may apply to an indi-
vidual receiving medical assistance under this title 
who is an Indian.’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
1916A(b)(3) of such Act (42 U.S.C. 1396o–1(b)(3)) is 
amended— 
(A) in subparagraph (A), by adding at the 
end the following new clause: 
‘‘(vi) An Indian who is furnished an 
item or service directly by the Indian 
Health Service, an Indian Tribe, Tribal Or-
ganization or Urban Indian Organization 
or through referral under contract health 
services.’’; and 
(B) in subparagraph (B), by adding at the 
end the following new clause: 
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‘‘(ix) Items and services furnished to 
an Indian directly by the Indian Health 
Service, an Indian Tribe, Tribal Organiza-
tion or Urban Indian Organization or 
through referral under contract health serv-
ices.’’. 
(b) TREATMENT OF CERTAIN PROPERTY FROM RE-
SOURCES FOR MEDICAID AND CHIP ELIGIBILITY.— 
(1) MEDICAID.—Section 1902 of the Social Secu-
rity Act (42 U.S.C. 1396a) is amended by adding at 
the end the following new subsection: 
‘‘(dd) Notwithstanding any other requirement of this 
title or any other provision of Federal or State law, a State 
shall disregard the following property from resources for 
purposes of determining the eligibility of an individual who 
is an Indian for medical assistance under this title: 
‘‘(1) Property, including real property and im-
provements, that is held in trust, subject to Federal 
restrictions, or otherwise under the supervision of the 
Secretary of the Interior, located on a reservation, in-
cluding any federally recognized Indian Tribe’s res-
ervation, pueblo, or colony, including former reserva-
tions in Oklahoma, Alaska Native regions established 
by the Alaska Native Claims Settlement Act, and In-
dian allotments on or near a reservation as des-
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ignated and approved by the Bureau of Indian Af-
fairs of the Department of the Interior. 
‘‘(2) For any federally recognized Tribe not de-
scribed in paragraph (1), property located within the 
most recent boundaries of a prior Federal reservation. 
‘‘(3) Ownership interests in rents, leases, royal-
ties, or usage rights related to natural resources (in-
cluding extraction of natural resources or harvesting 
of timber, other plants and plant products, animals, 
fish, and shellfish) resulting from the exercise of feder-
ally protected rights. 
‘‘(4) Ownership interests in or usage rights to 
items not covered by paragraphs (1) through (3) that 
have unique religious, spiritual, traditional, or cul-
tural significance or rights that support subsistence or 
a traditional lifestyle according to applicable tribal 
law or custom.’’. 
(2) APPLICATION TO CHIP.—Section 2107(e)(1) 
of such Act (42 U.S.C. 1397gg(e)(1)) is amended— 
(A) by redesignating subparagraphs (B) 
through (E), as subparagraphs (C) through (F), 
respectively; and 
(B) by inserting after subparagraph (A), 
the following new subparagraph: 
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‘‘(B) Section 1902(dd) (relating to dis-
regard of certain property for purposes of mak-
ing eligibility determinations).’’. 
(c) CONTINUATION OF CURRENT LAW PROTECTIONS OF 
CERTAIN INDIAN PROPERTY FROM MEDICAID ESTATE RE-
COVERY.—Section 1917(b)(3) of the Social Security Act (42 
U.S.C. 1396p(b)(3)) is amended— 
(1) by inserting ‘‘(A)’’ after ‘‘(3)’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(B) The standards specified by the Sec-
retary under subparagraph (A) shall require that 
the procedures established by the State agency 
under subparagraph (A) exempt income, re-
sources, and property that are exempt from the 
application of this subsection as of April 1, 
2003, under manual instructions issued to carry 
out this subsection (as in effect on such date) be-
cause of the Federal responsibility for Indian 
Tribes and Alaska Native Villages. Nothing in 
this subparagraph shall be construed as pre-
venting the Secretary from providing additional 
estate recovery exemptions under this title for In-
dians.’’. 
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SEC. 3302. RULES APPLICABLE UNDER MEDICAID AND CHIP 
TO MANAGED CARE ENTITIES WITH RESPECT 
TO INDIAN ENROLLEES AND INDIAN HEALTH 
CARE PROVIDERS AND INDIAN MANAGED 
CARE ENTITIES. 
(a) IN GENERAL.—Section 1932 of the Social Security 
Act (42 U.S.C. 1396u–2) is amended by adding at the end 
the following new subsection: 
‘‘(h) SPECIAL RULES WITH RESPECT TO INDIAN EN-
ROLLEES, INDIAN HEALTH CARE PROVIDERS, AND INDIAN 
MANAGED CARE ENTITIES.— 
‘‘(1) ENROLLEE OPTION TO SELECT AN INDIAN 
HEALTH
CARE
PROVIDER
AS
PRIMARY
CARE
PRO-
VIDER.—In the case of a non-Indian Medicaid man-
aged care entity that— 
‘‘(A) has an Indian enrolled with the entity; 
and 
‘‘(B) has an Indian health care provider 
that is participating as a primary care provider 
within the network of the entity, 
insofar as the Indian is otherwise eligible to receive 
services from such Indian health care provider and 
the Indian health care provider has the capacity to 
provide primary care services to such Indian, the con-
tract with the entity under section 1903(m) or under 
section 1905(t)(3) shall require, as a condition of re-
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ceiving payment under such contract, that the Indian 
shall be allowed to choose such Indian health care 
provider as the Indian’s primary care provider under 
the entity. 
‘‘(2) ASSURANCE
OF
PAYMENT
TO
INDIAN 
HEALTH CARE PROVIDERS FOR PROVISION OF COV-
ERED
SERVICES.—Each contract with a managed 
care entity under section 1903(m) or under section 
1905(t)(3) shall require any such entity, as a condi-
tion of receiving payment under such contract, to sat-
isfy the following requirements: 
‘‘(A) DEMONSTRATION
OF
ACCESS
TO
IN-
DIAN HEALTH CARE PROVIDERS AND APPLICA-
TION
OF
ALTERNATIVE
PAYMENT
ARRANGE-
MENTS.—Subject to subparagraph (C), to— 
‘‘(i) demonstrate that the number of 
Indian health care providers that are par-
ticipating providers with respect to such en-
tity are sufficient to ensure timely access to 
covered Medicaid managed care services for 
those Indian enrollees who are eligible to re-
ceive services from such providers; and 
‘‘(ii) agree to pay Indian health care 
providers, whether such providers are par-
ticipating or nonparticipating providers 
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with respect to the entity, for covered Med-
icaid managed care services provided to 
those Indian enrollees who are eligible to re-
ceive services from such providers at a rate 
equal to the rate negotiated between such 
entity and the provider involved or, if such 
a rate has not been negotiated, at a rate 
that is not less than the level and amount 
of payment which the entity would make for 
the services if the services were furnished by 
a participating provider which is not an 
Indian health care provider. 
‘‘(B) PROMPT PAYMENT.—To agree to make 
prompt payment (consistent with rule for 
prompt payment of providers under section 
1932(f)) to Indian health care providers that are 
participating providers with respect to such enti-
ty or, in the case of an entity to which subpara-
graph (A)(ii) or (C) applies, that the entity is 
required to pay in accordance with that sub-
paragraph. 
‘‘(C) APPLICATION
OF
SPECIAL
PAYMENT 
REQUIREMENTS
FOR
FEDERALLY-QUALIFIED 
HEALTH CENTERS AND FOR SERVICES PROVIDED 
BY CERTAIN INDIAN HEALTH CARE PROVIDERS.— 
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‘‘(i) FEDERALLY-QUALIFIED
HEALTH 
CENTERS.— 
‘‘(I) MANAGED CARE ENTITY PAY-
MENT REQUIREMENT.—To agree to pay 
any Indian health care provider that 
is a federally-qualified health center 
under this title but not a participating 
provider with respect to the entity, for 
the provision of covered Medicaid man-
aged care services by such provider to 
an Indian enrollee of the entity at a 
rate equal to the amount of payment 
that the entity would pay a federally- 
qualified health center that is a par-
ticipating provider with respect to the 
entity but is not an Indian health care 
provider for such services. 
‘‘(II) CONTINUED APPLICATION OF 
STATE
REQUIREMENT
TO
MAKE
SUP-
PLEMENTAL
PAYMENT.—Nothing 
in 
subclause (I) or subparagraph (A) or 
(B) shall be construed as waiving the 
application of section 1902(bb)(5) re-
garding the State plan requirement to 
make any supplemental payment due 
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‘‘(D) 
CONSTRUCTION.—Nothing 
in 
this 
paragraph shall be construed as waiving the ap-
plication of section 1902(a)(30)(A) (relating to 
application of standards to assure that payments 
are consistent with efficiency, economy, and 
quality of care). 
‘‘(3) SPECIAL RULE FOR ENROLLMENT FOR IN-
DIAN MANAGED CARE ENTITIES.—Regarding the ap-
plication of a Medicaid managed care program to In-
dian Medicaid managed care entities, an Indian 
Medicaid managed care entity may restrict enroll-
ment under such program to Indians and to members 
of specific Tribes in the same manner as Indian 
Health Programs may restrict the delivery of services 
to such Indians and tribal members. 
‘‘(4) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) INDIAN
HEALTH
CARE
PROVIDER.— 
The term ‘Indian health care provider’ means an 
Indian Health Program or an Urban Indian Or-
ganization. 
‘‘(B) INDIAN MEDICAID MANAGED CARE EN-
TITY.—The term ‘Indian Medicaid managed care 
entity’ means a managed care entity that is con-
trolled (within the meaning of the last sentence 
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of section 1903(m)(1)(C)) by the Indian Health 
Service, a Tribe, Tribal Organization, or Urban 
Indian Organization, or a consortium, which 
may be composed of 1 or more Tribes, Tribal Or-
ganizations, or Urban Indian Organizations, 
and which also may include the Service. 
‘‘(C) NON-INDIAN MEDICAID MANAGED CARE 
ENTITY.—The term ‘non-Indian Medicaid man-
aged care entity’ means a managed care entity 
that is not an Indian Medicaid managed care 
entity. 
‘‘(D) COVERED MEDICAID MANAGED CARE 
SERVICES.—The term ‘covered Medicaid man-
aged care services’ means, with respect to an in-
dividual enrolled with a managed care entity, 
items and services for which benefits are avail-
able with respect to the individual under the con-
tract between the entity and the State involved. 
‘‘(E) 
MEDICAID
MANAGED
CARE
PRO-
GRAM.—The term ‘Medicaid managed care pro-
gram’ means a program under sections 1903(m), 
1905(t), and 1932 and includes a managed care 
program operating under a waiver under section 
1915(b) or 1115 or otherwise.’’. 
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(b) APPLICATION
TO
CHIP.—Subject to section 
l013(d), section 2107(e)(1) of such Act (42 U.S.C. 
1397gg(1)) is amended by adding at the end the following 
new subparagraph: 
‘‘(E) Subsections (a)(2)(C) and (h) of sec-
tion 1932.’’. 
SEC. 3303. CONSULTATION ON MEDICAID, CHIP, AND OTHER 
HEALTH CARE PROGRAMS FUNDED UNDER 
THE SOCIAL SECURITY ACT INVOLVING IN-
DIAN HEALTH PROGRAMS AND URBAN IN-
DIAN ORGANIZATIONS. 
(a) CONSULTATION WITH TRIBAL TECHNICAL ADVI-
SORY GROUP (TTAG).—The Secretary of Health and 
Human Services shall maintain within the Centers for 
Medicaid & Medicare Services (CMS) a Tribal Technical 
Advisory Group (TTAG), which was first established in ac-
cordance with requirements of the charter dated September 
30, 2003, and the Secretary of Health and Human Services 
shall include in such Group a representative of a national 
urban Indian health organization and a representative of 
the Indian Health Service. The inclusion of a representative 
of a national urban Indian health organization in such 
Group shall not affect the nonapplication of the Federal Ad-
visory Committee Act (5 U.S.C. App.) to such Group. 
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(b) SOLICITATION OF ADVICE UNDER MEDICAID AND 
CHIP.— 
(1) MEDICAID STATE PLAN AMENDMENT.—Sub-
ject to subsection (d), section 1902(a) of the Social Se-
curity Act (42 U.S.C. 1396a(a)) is amended— 
(A) in paragraph (70), by striking ‘‘and’’ 
at the end; 
(B) in paragraph (71), by striking the pe-
riod at the end and inserting ‘‘; and’’; and 
(C) by inserting after paragraph (71), the 
following new paragraph: 
‘‘(72) in the case of any State in which 1 or 
more Indian Health Programs or Urban Indian Or-
ganizations furnishes health care services, provide for 
a process under which the State seeks advice on a reg-
ular, ongoing basis from designees of such Indian 
Health Programs and Urban Indian Organizations 
on matters relating to the application of this title 
that are likely to have a direct effect on such Indian 
Health Programs and Urban Indian Organizations 
and that— 
‘‘(A) shall include solicitation of advice 
prior to submission of any plan amendments, 
waiver requests, and proposals for demonstration 
projects likely to have a direct effect on Indians, 
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Indian Health Programs, or Urban Indian Or-
ganizations; and 
‘‘(B) may include appointment of an advi-
sory committee and of a designee of such Indian 
Health Programs and Urban Indian Organiza-
tions to the medical care advisory committee ad-
vising the State on its State plan under this 
title.’’. 
(2) APPLICATION TO CHIP.—Subject to subsection 
(d), section 2107(e)(1) of such Act (42 U.S.C. 
1397gg(e)(1)), as amended by section 3302(b)(2), is 
amended— 
(A) by redesignating subparagraphs (B) 
through (E) as subparagraphs (C) through (F), 
respectively; and 
(B) by inserting after subparagraph (A), 
the following new subparagraph: 
‘‘(B) Section 1902(a)(72) (relating to re-
quiring certain States to seek advice from des-
ignees of Indian Health Programs and Urban 
Indian Organizations).’’. 
(c) RULE OF CONSTRUCTION.—Nothing in the amend-
ments made by this section shall be construed as super-
seding existing advisory committees, working groups, guid-
ance, or other advisory procedures established by the Sec-
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retary of Health and Human Services or by any State with 
respect to the provision of health care to Indians. 
(d) CONTINGENCY RULE.—If the Children’s Health In-
surance Program Reauthorization Act of 2009 (in this sub-
section referred to as ‘‘CHIPRA’’) has been enacted as of 
the date of enactment of this Act, the following shall apply: 
(1) Subparagraph (I) of section 2107(e) of the 
Social Security Act (as redesignated by CHIPRA) is 
redesignated as subparagraph (K) and the subpara-
graph (E) added to section 2107(e) of the Social Secu-
rity Act by section 3302(b) is redesignated as sub-
paragraph (J). 
(2) Subparagraphs (D) through (H) of section 
2107(e) of the Social Security Act (as added and re-
designated by CHIPRA) are redesignated as subpara-
graphs (E) through (I), respectively and the subpara-
graph (B) of section 2107(e) of the Social Security 
Act added by subsection (b)(2) of this section is redes-
ignated as subparagraph (D) and amended by strik-
ing ‘‘1902(a)(72)’’ and inserting ‘‘1902(a)(73)’’. 
(3) Section 1902(a) of the Social Security Act 
(as amended by CHIPRA) is amended by striking 
‘‘and’’ at the end of paragraph (71), by striking the 
period at the end of the paragraph (72) added by 
CHIPRA and inserting ‘‘; and’’ and by redesignated 
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the paragraph (72) added to such section by sub-
section (b)(1) of this section as paragraph (73). 
SEC. 3304. APPLICATION OF PROMPT PAY REQUIREMENTS 
TO NURSING FACILITIES. 
Section 1902(a)(37)(A) of the Social Security Act (42 
U.S.C. 1396a(a)(37)(A)) is amended by inserting ‘‘, or by 
nursing facilities,’’ after ‘‘health facilities’’ 
SEC. 3305. PERIOD OF APPLICATION; SUNSET. 
This subtitle and the amendments made by this sub-
title shall be in effect only during the period that begins 
on April 1, 2009, and ends on December 31, 2010. On and 
after January 1, 2011, the Social Security Act shall be ap-
plied as if this subtitle and the amendments made by this 
subtitle had not been enacted. 
TITLE IV—HEALTH 
INFORMATION TECHNOLOGY 
SEC. 4001. SHORT TITLE; TABLE OF CONTENTS OF TITLE. 
(a) SHORT TITLE.—This title may be cited as the 
‘‘Medicare and Medicaid Health Information Technology 
for Economic and Clinical Health Act’’ or the ‘‘M-HITECH 
Act’’. 
(b) TABLE OF CONTENTS OF TITLE.—The table of con-
tents for this title is as follows: 
TITLE IV—HEALTH INFORMATION TECHNOLOGY 
Sec. 4001. Short title; table of contents of title. 
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Subtitle A—Medicare Program 
Sec. 4201. Incentives for eligible professionals. 
Sec. 4202. Incentives for hospitals. 
Sec. 4203. Premium hold harmless and implementation funding. 
Sec. 4204. Non-application of phased-out indirect medical education (IME) ad-
justment factor for fiscal year 2009. 
Sec. 4205. Study on application of EHR payment incentives for providers not re-
ceiving other incentive payments. 
Sec. 4206. Study on availability of open source health information technology 
systems. 
Subtitle B—Medicaid Funding 
Sec. 4211. Medicaid provider EHR adoption and operation payments; implemen-
tation funding. 
Subtitle A—Medicare Program 
SEC. 4201. INCENTIVES FOR ELIGIBLE PROFESSIONALS. 
(a) INCENTIVE PAYMENTS.—Section 1848 of the Social 
Security Act (42 U.S.C. 1395w–4) is amended by adding 
at the end the following new subsection: 
‘‘(o) INCENTIVES FOR ADOPTION AND MEANINGFUL 
USE OF CERTIFIED EHR TECHNOLOGY.— 
‘‘(1) INCENTIVE PAYMENTS.— 
‘‘(A) IN GENERAL.— 
‘‘(i) IN
GENERAL.—Subject to clause 
(ii) and the succeeding subparagraphs of 
this paragraph, with respect to covered pro-
fessional services furnished by an eligible 
professional during a payment year (as de-
fined in subparagraph (E)), if the eligible 
professional is a meaningful EHR user (as 
determined under paragraph (2)) for the re-
porting period with respect to such year, in 
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addition to the amount otherwise paid 
under this part, there also shall be paid to 
the eligible professional (or to an employer 
or facility in the cases described in clause 
(A) of section 1842(b)(6)), from the Federal 
Supplementary Medical Insurance Trust 
Fund established under section 1841 an 
amount equal to 75 percent of the Sec-
retary’s estimate (based on claims submitted 
not later than 2 months after the end of the 
payment year) of the allowed charges under 
this part for all such covered professional 
services furnished by the eligible profes-
sional during such year. 
‘‘(ii) NO INCENTIVE PAYMENTS WITH 
RESPECT TO YEARS AFTER 2015.—No incen-
tive payments may be made under this sub-
section with respect to a year after 2015. 
‘‘(B) LIMITATIONS ON AMOUNTS OF INCEN-
TIVE PAYMENTS.— 
‘‘(i) IN GENERAL.—In no case shall the 
amount of the incentive payment provided 
under this paragraph for an eligible profes-
sional for a payment year exceed the appli-
cable amount specified under this subpara-
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graph with respect to such eligible profes-
sional and such year. 
‘‘(ii) AMOUNT.—Subject to clauses (iii) 
through (v), the applicable amount specified 
in this subparagraph for an eligible profes-
sional is as follows: 
‘‘(I) For the first payment year 
for such professional, $15,000 (or, if 
the first payment year for such eligible 
professional is 2011 or 2012, $18,000). 
‘‘(II) For the second payment 
year for such professional, $12,000. 
‘‘(III) For the third payment year 
for such professional, $8,000. 
‘‘(IV) For the fourth payment 
year for such professional, $4,000. 
‘‘(V) For the fifth payment year 
for such professional, $2,000. 
‘‘(VI) For any succeeding pay-
ment year for such professional, $0. 
‘‘(iii) PHASE
DOWN
FOR
ELIGIBLE 
PROFESSIONALS
FIRST
ADOPTING
EHR
IN 
2014.—If the first payment year for an eli-
gible professional is 2014, then the amount 
specified in this subparagraph for a pay-
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ment year for such professional is the same 
as the amount specified in clause (ii) for 
such payment year for an eligible profes-
sional whose first payment year is 2013. 
‘‘(iv) INCREASE FOR CERTAIN RURAL 
ELIGIBLE PROFESSIONALS.—In the case of 
an eligible professional who predominantly 
furnishes services under this part in a rural 
area that is designated by the Secretary 
(under section 332(a)(1)(A) of the Public 
Health Service Act) as a health professional 
shortage area, the amount that would other-
wise apply for a payment year for such 
professional under subclauses (I) through 
(V) of clause (ii) shall be increased by 25 
percent. In implementing the preceding sen-
tence, the Secretary may, as determined ap-
propriate, apply provisions of subsections 
(m) and (u) of section 1833 in a similar 
manner as such provisions apply under 
such subsection. 
‘‘(v) NO INCENTIVE PAYMENT IF FIRST 
ADOPTING
AFTER
2014.—If the first pay-
ment year for an eligible professional is 
after 2014 then the applicable amount spec-
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ified in this subparagraph for such profes-
sional for such year and any subsequent 
year shall be $0. 
‘‘(C) NON-APPLICATION TO HOSPITAL-BASED 
ELIGIBLE PROFESSIONALS.— 
‘‘(i) IN GENERAL.—No incentive pay-
ment may be made under this paragraph in 
the case of a hospital-based eligible profes-
sional. 
‘‘(ii) HOSPITAL-BASED ELIGIBLE PRO-
FESSIONAL.—For purposes of clause (i), the 
term ‘hospital-based eligible professional’ 
means, with respect to covered professional 
services furnished by an eligible professional 
during the reporting period for a payment 
year, an eligible professional, such as a pa-
thologist, anesthesiologist, or emergency 
physician, who furnishes substantially all of 
such services in a hospital setting (whether 
inpatient or outpatient) and through the 
use of the facilities and equipment, includ-
ing qualified electronic health records, of the 
hospital. 
‘‘(D) PAYMENT.— 
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‘‘(i) FORM
OF
PAYMENT.—The pay-
ment under this paragraph may be in the 
form of a single consolidated payment or in 
the form of such periodic installments as the 
Secretary may specify. 
‘‘(ii) COORDINATION
OF
APPLICATION 
OF LIMITATION FOR PROFESSIONALS IN DIF-
FERENT PRACTICES.—In the case of an eli-
gible professional furnishing covered profes-
sional services in more than one practice 
(as specified by the Secretary), the Sec-
retary shall establish rules to coordinate the 
incentive payments, including the applica-
tion of the limitation on amounts of such 
incentive payments under this paragraph, 
among such practices. 
‘‘(iii) 
COORDINATION
WITH
MED-
ICAID.—The Secretary shall seek, to the 
maximum extent practicable, to avoid du-
plicative requirements from Federal and 
State Governments to demonstrate meaning-
ful use of certified EHR technology under 
this title and title XIX. In doing so, the 
Secretary may deem satisfaction of State 
requirements for such meaningful use for a 
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payment year under title XIX to be suffi-
cient to qualify as meaningful use under 
this subsection and subsection (a)(7) and 
vice versa. The Secretary may also adjust 
the reporting periods under such title and 
such subsections in order to carry out this 
clause. 
‘‘(E) PAYMENT YEAR DEFINED.— 
‘‘(i) IN
GENERAL.—For purposes of 
this subsection, the term ‘payment year’ 
means a year beginning with 2011. 
‘‘(ii) FIRST, SECOND, ETC. PAYMENT 
YEAR.—The term ‘first payment year’ 
means, with respect to covered professional 
services furnished by an eligible profes-
sional, the first year for which an incentive 
payment is made for such services under 
this subsection. The terms ‘second payment 
year’, ‘third payment year’, ‘fourth pay-
ment year’, and ‘fifth payment year’ mean, 
with respect to covered professional services 
furnished by such eligible professional, each 
successive year immediately following the 
first payment year for such professional. 
‘‘(2) MEANINGFUL EHR USER.— 
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‘‘(A) IN GENERAL.—For purposes of para-
graph (1), an eligible professional shall be treat-
ed as a meaningful EHR user for a reporting 
period for a payment year (or, for purposes of 
subsection (a)(7), for a reporting period under 
such subsection for a year) if each of the fol-
lowing requirements is met: 
‘‘(i) MEANINGFUL USE OF CERTIFIED 
EHR
TECHNOLOGY.—The eligible profes-
sional demonstrates to the satisfaction of the 
Secretary, in accordance with subparagraph 
(C)(i), that during such period the profes-
sional is using certified EHR technology in 
a meaningful manner, which shall include 
the use of electronic prescribing as deter-
mined to be appropriate by the Secretary. 
‘‘(ii) INFORMATION
EXCHANGE.—The 
eligible professional demonstrates to the sat-
isfaction of the Secretary, in accordance 
with subparagraph (C)(i), that during such 
period such certified EHR technology is 
connected in a manner that provides, in ac-
cordance with law and standards applicable 
to the exchange of information, for the elec-
tronic exchange of health information to im-
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prove the quality of health care, such as 
promoting care coordination. 
‘‘(iii) REPORTING ON MEASURES USING 
EHR.—Subject to subparagraph (B)(ii) and 
using such certified EHR technology, the el-
igible professional submits information for 
such period, in a form and manner speci-
fied by the Secretary, on such clinical qual-
ity measures and such other measures as se-
lected by the Secretary under subparagraph 
(B)(i). 
The Secretary may provide for the use of alter-
native means for meeting the requirements of 
clauses (i), (ii), and (iii) in the case of an eligi-
ble professional furnishing covered professional 
services in a group practice (as defined by the 
Secretary). The Secretary shall seek to improve 
the use of electronic health records and health 
care quality over time by requiring more strin-
gent measures of meaningful use selected under 
this paragraph. 
‘‘(B) REPORTING ON MEASURES.— 
‘‘(i) SELECTION.—The Secretary shall 
select measures for purposes of subpara-
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graph (A)(iii) but only consistent with the 
following: 
‘‘(I) The Secretary shall provide 
preference to clinical quality measures 
that have been endorsed by the entity 
with a contract with the Secretary 
under section 1890(a). 
‘‘(II) Prior to any measure being 
selected under this subparagraph, the 
Secretary shall publish in the Federal 
Register such measure and provide for 
a period of public comment on such 
measure. 
‘‘(ii) LIMITATION.—The Secretary may 
not require the electronic reporting of infor-
mation on clinical quality measures under 
subparagraph (A)(iii) unless the Secretary 
has the capacity to accept the information 
electronically, which may be on a pilot 
basis. 
‘‘(iii) COORDINATION
OF
REPORTING 
OF INFORMATION.—In selecting such meas-
ures, and in establishing the form and man-
ner for reporting measures under subpara-
graph (A)(iii), the Secretary shall seek to 
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avoid redundant or duplicative reporting 
otherwise 
required, 
including 
reporting 
under subsection (k)(2)(C). 
‘‘(C) DEMONSTRATION OF MEANINGFUL USE 
OF CERTIFIED EHR TECHNOLOGY AND INFORMA-
TION EXCHANGE.— 
‘‘(i) IN GENERAL.—A professional may 
satisfy the demonstration requirement of 
clauses (i) and (ii) of subparagraph (A) 
through means specified by the Secretary, 
which may include— 
‘‘(I) an attestation; 
‘‘(II) the submission of claims 
with appropriate coding (such as a 
code indicating that a patient encoun-
ter was documented using certified 
EHR technology); 
‘‘(III) a survey response; 
‘‘(IV) reporting under subpara-
graph (A)(iii); and 
‘‘(V) other means specified by the 
Secretary. 
‘‘(ii) USE OF PART D DATA.—Notwith-
standing sections 1860D–15(d)(2)(B) and 
1860D–15(f)(2), the Secretary may use data 
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regarding drug claims submitted for pur-
poses of section 1860D–15 that are nec-
essary for purposes of subparagraph (A). 
‘‘(3) APPLICATION.— 
‘‘(A) 
PHYSICIAN
REPORTING
SYSTEM 
RULES.—Paragraphs (5), (6), and (8) of sub-
section (k) shall apply for purposes of this sub-
section in the same manner as they apply for 
purposes of such subsection. 
‘‘(B) COORDINATION
WITH
OTHER
PAY-
MENTS.—The provisions of this subsection shall 
not be taken into account in applying the provi-
sions of subsection (m) of this section and of sec-
tion 1833(m) and any payment under such pro-
visions shall not be taken into account in com-
puting allowable charges under this subsection. 
‘‘(C) LIMITATIONS ON REVIEW.—There shall 
be no administrative or judicial review under 
section 1869, section 1878, or otherwise of the de-
termination of any incentive payment under this 
subsection and the payment adjustment under 
subsection (a)(7), including the determination of 
a meaningful EHR user under paragraph (2), a 
limitation under paragraph (1)(B), and the ex-
ception under subsection (a)(7)(B). 
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‘‘(D) POSTING ON WEBSITE.—The Secretary 
shall post on the Internet website of the Centers 
for Medicare & Medicaid Services, in an easily 
understandable format, a list of the names, busi-
ness addresses, and business phone numbers of 
the eligible professionals who are meaningful 
EHR users and, as determined appropriate by 
the Secretary, of group practices receiving incen-
tive payments under paragraph (1). 
‘‘(4) CERTIFIED EHR TECHNOLOGY DEFINED.— 
For purposes of this section, the term ‘certified EHR 
technology’ means a qualified electronic health record 
(as defined in 3000(13) of the Public Health Service 
Act) that is certified pursuant to section 3001(c)(5) of 
such Act as meeting standards adopted under section 
3004 of such Act that are applicable to the type of 
record involved (as determined by the Secretary, such 
as an ambulatory electronic health record for office- 
based physicians or an inpatient hospital electronic 
health record for hospitals). 
‘‘(5) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) COVERED PROFESSIONAL SERVICES.— 
The term ‘covered professional services’ has the 
meaning given such term in subsection (k)(3). 
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‘‘(B) ELIGIBLE PROFESSIONAL.—The term 
‘eligible professional’ means a physician, as de-
fined in section 1861(r). 
‘‘(C) REPORTING
PERIOD.—The term ‘re-
porting period’ means any period (or periods), 
with respect to a payment year, as specified by 
the Secretary.’’. 
(b) 
INCENTIVE
PAYMENT
ADJUSTMENT.—Section 
1848(a) of the Social Security Act (42 U.S.C. 1395w–4(a)) 
is amended by adding at the end the following new para-
graph: 
‘‘(7) INCENTIVES FOR MEANINGFUL USE OF CER-
TIFIED EHR TECHNOLOGY.— 
‘‘(A) ADJUSTMENT.— 
‘‘(i) IN GENERAL.—Subject to subpara-
graphs (B) and (D), with respect to covered 
professional services furnished by an eligible 
professional during 2015 or any subsequent 
payment year, if the eligible professional is 
not a meaningful EHR user (as determined 
under subsection (o)(2)) for a reporting pe-
riod for the year, the fee schedule amount 
for such services furnished by such profes-
sional during the year (including the fee 
schedule amount for purposes of deter-
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mining a payment based on such amount) 
shall be equal to the applicable percent of 
the fee schedule amount that would other-
wise apply to such services under this sub-
section (determined after application of 
paragraph (3) but without regard to this 
paragraph). 
‘‘(ii) APPLICABLE
PERCENT.—Subject 
to clause (iii), for purposes of clause (i), the 
term ‘applicable percent’ means— 
‘‘(I) for 2015, 99 percent (or, in 
the case of an eligible professional who 
was subject to the application of the 
payment adjustment under section 
1848(a)(5) for 2014, 98 percent); 
‘‘(II) for 2016, 98 percent; and 
‘‘(III) for 2017 and each subse-
quent year, 97 percent. 
‘‘(iii) AUTHORITY
TO
DECREASE
AP-
PLICABLE PERCENTAGE FOR 2018 AND SUB-
SEQUENT YEARS.—For 2018 and each sub-
sequent year, if the Secretary finds that the 
proportion of eligible professionals who are 
meaningful EHR users (as determined 
under subsection (o)(2)) is less than 75 per-
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cent, the applicable percent shall be de-
creased by 1 percentage point from the ap-
plicable percent in the preceding year, but 
in no case shall the applicable percent be 
less than 95 percent. 
‘‘(B) SIGNIFICANT HARDSHIP EXCEPTION.— 
The Secretary may, on a case-by-case basis, ex-
empt an eligible professional from the applica-
tion of the payment adjustment under subpara-
graph (A) if the Secretary determines, subject to 
annual renewal, that compliance with the re-
quirement for being a meaningful EHR user 
would result in a significant hardship, such as 
in the case of an eligible professional who prac-
tices in a rural area without sufficient Internet 
access. In no case may an eligible professional be 
granted an exemption under this subparagraph 
for more than 5 years. 
‘‘(C) APPLICATION OF PHYSICIAN REPORT-
ING SYSTEM RULES.—Paragraphs (5), (6), and 
(8) of subsection (k) shall apply for purposes of 
this paragraph in the same manner as they 
apply for purposes of such subsection. 
‘‘(D) 
NON-APPLICATION
TO
HOSPITAL- 
BASED ELIGIBLE PROFESSIONALS.—No payment 
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adjustment may be made under subparagraph 
(A) in the case of hospital-based eligible profes-
sionals (as defined in subsection (o)(1)(C)(ii)). 
‘‘(E) DEFINITIONS.—For purposes of this 
paragraph: 
‘‘(i) COVERED
PROFESSIONAL
SERV-
ICES.—The term ‘covered professional serv-
ices’ has the meaning given such term in 
subsection (k)(3). 
‘‘(ii) ELIGIBLE
PROFESSIONAL.—The 
term ‘eligible professional’ means a physi-
cian, as defined in section 1861(r). 
‘‘(iii) REPORTING PERIOD.—The term 
‘reporting period’ means, with respect to a 
year, a period specified by the Secretary.’’. 
(c) APPLICATION TO CERTAIN MA-AFFILIATED ELIGI-
BLE PROFESSIONALS.—Section 1853 of the Social Security 
Act (42 U.S.C. 1395w–23) is amended by adding at the 
end the following new subsection: 
‘‘(l) APPLICATION OF ELIGIBLE PROFESSIONAL INCEN-
TIVES FOR CERTAIN MA ORGANIZATIONS FOR ADOPTION 
AND
MEANINGFUL
USE
OF
CERTIFIED
EHR TECH-
NOLOGY.— 
‘‘(1) IN GENERAL.—Subject to paragraphs (3) 
and (4), in the case of a qualifying MA organization, 
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the provisions of sections 1848(o) and 1848(a)(7) 
shall apply with respect to eligible professionals de-
scribed in paragraph (2) of the organization who the 
organization attests under paragraph (6) to be mean-
ingful EHR users in a similar manner as they apply 
to eligible professionals under such sections. Incentive 
payments under paragraph (3) shall be made to and 
payment adjustments under paragraph (4) shall 
apply to such qualifying organizations. 
‘‘(2) ELIGIBLE
PROFESSIONAL
DESCRIBED.— 
With respect to a qualifying MA organization, an eli-
gible professional described in this paragraph is an 
eligible professional (as defined for purposes of section 
1848(o)) who— 
‘‘(A)(i) is employed by the organization; or 
‘‘(ii)(I) is employed by, or is a partner of, 
an entity that through contract with the organi-
zation furnishes at least 80 percent of the enti-
ty’s patient care services to enrollees of such or-
ganization; and 
‘‘(II) furnishes at least 75 percent of the 
professional services of the eligible professional to 
enrollees of the organization; and 
‘‘(B) furnishes, on average, at least 20 hours 
per week of patient care services. 
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‘‘(3) ELIGIBLE PROFESSIONAL INCENTIVE PAY-
MENTS.— 
‘‘(A) IN
GENERAL.—In applying section 
1848(o) under paragraph (1), instead of the ad-
ditional 
payment 
amount 
under 
section 
1848(o)(1)(A) and subject to subparagraph (B), 
the Secretary may substitute an amount deter-
mined by the Secretary to the extent feasible and 
practical to be similar to the estimated amount 
in the aggregate that would be payable if pay-
ment for services furnished by such professionals 
was payable under part B instead of this part. 
‘‘(B) AVOIDING
DUPLICATION
OF
PAY-
MENTS.— 
‘‘(i) IN GENERAL.—If an eligible pro-
fessional described in paragraph (2) is eligi-
ble for the maximum incentive payment 
under section 1848(o)(1)(A) for the same 
payment period, the payment incentive 
shall be made only under such section and 
not under this subsection. 
‘‘(ii) METHODS.—In the case of an eli-
gible professional described in paragraph 
(2) who is eligible for an incentive payment 
under section 1848(o)(1)(A) but is not de-
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scribed in clause (i) for the same payment 
period, the Secretary shall develop a proc-
ess— 
‘‘(I) to ensure that duplicate pay-
ments are not made with respect to an 
eligible professional both under this 
subsection 
and 
under 
section 
1848(o)(1)(A); and 
‘‘(II) to collect data from Medi-
care Advantage organizations to ensure 
against such duplicate payments. 
‘‘(C) FIXED
SCHEDULE
FOR
APPLICATION 
OF
LIMITATION
ON
INCENTIVE
PAYMENTS
FOR 
ALL
ELIGIBLE
PROFESSIONALS.—In applying 
section 1848(o)(1)(B)(ii) under subparagraph 
(A), in accordance with rules specified by the 
Secretary, a qualifying MA organization shall 
specify a year (not earlier than 2011) that shall 
be treated as the first payment year for all eligi-
ble professionals with respect to such organiza-
tion. 
‘‘(D) CAP FOR ECONOMIES OF SCALE.—In 
no case may an incentive payment be made 
under this subsection, including under subpara-
graph (A), to a qualifying MA organization with 
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respect to more than 5,000 eligible professionals 
of the organization. 
‘‘(4) PAYMENT ADJUSTMENT.— 
‘‘(A) IN
GENERAL.—In applying section 
1848(a)(7) under paragraph (1), instead of the 
payment adjustment being an applicable percent 
of the fee schedule amount for a year under such 
section, subject to subparagraph (D), the pay-
ment adjustment under paragraph (1) shall be 
equal to the percent specified in subparagraph 
(B) for such year of the payment amount other-
wise provided under this section for such year. 
‘‘(B) SPECIFIED
PERCENT.—The percent 
specified under this subparagraph for a year is 
100 percent minus a number of percentage 
points equal to the product of— 
‘‘(i) a percentage equal to 100 percent 
reduced by the applicable percent (under 
section 1848(a)(7)(A)(ii)) for the year; and 
‘‘(ii) a percentage equal to the Sec-
retary’s estimate of the proportion for the 
year, of the expenditures under parts A and 
B that are not attributable to this part, that 
are attributable to expenditures for physi-
cians’ services. 
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‘‘(C) APPLICATION
OF
PAYMENT
ADJUST-
MENT.—In the case that a qualifying MA orga-
nization attests that not all eligible professionals 
of the organization are meaningful EHR users 
with respect to a year, the Secretary shall apply 
the payment adjustment under this paragraph 
based on the proportion of all eligible profes-
sionals of the organization that are not meaning-
ful EHR users for such year. If the number of 
eligible professionals of the organization that are 
not meaningful EHR users for such year exceeds 
5,000, such number shall be reduced to 5,000 for 
purposes of determining the proportion under the 
preceding sentence. 
‘‘(5) QUALIFYING MA ORGANIZATION DEFINED.— 
In this subsection and subsection (m), the term ‘quali-
fying MA organization’ means a Medicare Advantage 
organization that is organized as a health mainte-
nance organization (as defined in section 2791(b)(3) 
of the Public Health Service Act). 
‘‘(6) MEANINGFUL
EHR
USER
ATTESTATION.— 
For purposes of this subsection and subsection (m), a 
qualifying MA organization shall submit an attesta-
tion, in a form and manner specified by the Secretary 
which may include the submission of such attestation 
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as part of submission of the initial bid under section 
1854(a)(1)(A)(iv), identifying— 
‘‘(A) whether each eligible professional de-
scribed in paragraph (2), with respect to such 
organization is a meaningful EHR user (as de-
fined in section 1848(o)(2)) for a year specified 
by the Secretary; and 
‘‘(B) whether each eligible hospital described 
in subsection (m)(1), with respect to such organi-
zation, is a meaningful EHR user (as defined in 
section 1886(n)(3)) for an applicable period 
specified by the Secretary. 
‘‘(7) POSTING ON WEBSITE.—The Secretary shall 
post on the Internet website of the Centers for Medi-
care & Medicaid Services, in an easily understand-
able format, a list of the names, business addresses, 
and business phone numbers of— 
‘‘(A) each qualifying MA organization re-
ceiving an incentive payment under this sub-
section for eligible professionals of the organiza-
tion; and 
‘‘(B) the eligible professionals of such orga-
nization for which such incentive payment is 
based.’’. 
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(A) in subparagraph (A), by striking ‘‘For 
2009’’ and inserting ‘‘Subject to subparagraph 
(D), for 2009’’; and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(D) LIMITATION WITH RESPECT TO EHR 
INCENTIVE
PAYMENTS.—The provisions of this 
paragraph shall not apply to an eligible profes-
sional (or, in the case of a group practice under 
paragraph (3)(C), to the group practice) if, for 
the reporting period the eligible professional (or 
group practice) receives an incentive payment 
under subsection (o)(1)(A) with respect to a cer-
tified EHR technology (as defined in subsection 
(o)(4)) that has the capability of electronic pre-
scribing.’’. 
(f) PROVIDING ASSISTANCE
TO ELIGIBLE PROFES-
SIONALS AND CERTAIN HOSPITALS.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall provide assistance to eligible 
professionals (as defined in section 1848(o)(5), as 
added by subsection (a)), Medicaid providers (as de-
fined in section 1903(t)(2) of such Act, as added by 
section 4211(a)), and eligible hospitals (as defined in 
section 1886(n)(6)(A) of such Act, as added by section 
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4202(a)) located in rural or other medically under-
served areas to successfully choose, implement, and 
use certified EHR technology (as defined in section 
1848(o)(4) of the Social Security Act, as added by 
section 4201(a)). 
(2) USE OF ENTITIES WITH EXPERTISE.—To the 
extent practicable, the Secretary shall provide such 
assistance through entities that have expertise in the 
choice, implementation, and use of such certified 
EHR technology. 
SEC. 4202. INCENTIVES FOR HOSPITALS. 
(a) INCENTIVE PAYMENT.—Section 1886 of the Social 
Security Act (42 U.S.C. 1395ww) is amended by adding 
at the end the following new subsection: 
‘‘(n) INCENTIVES FOR ADOPTION AND MEANINGFUL 
USE OF CERTIFIED EHR TECHNOLOGY.— 
‘‘(1) IN
GENERAL.—Subject to the succeeding 
provisions of this subsection, with respect to inpatient 
hospital services furnished by an eligible hospital dur-
ing a payment year (as defined in paragraph 
(2)(G)), if the eligible hospital is a meaningful EHR 
user (as determined under paragraph (3)) for the re-
porting period with respect to such year, in addition 
to the amount otherwise paid under this section, there 
also shall be paid to the eligible hospital, from the 
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Federal Hospital Insurance Trust Fund established 
under section 1817, an amount equal to the applica-
ble amount specified in paragraph (2)(A) for the hos-
pital for such payment year. 
‘‘(2) PAYMENT AMOUNT.— 
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding subparagraphs of this paragraph, the ap-
plicable amount specified in this subparagraph 
for an eligible hospital for a payment year is 
equal to the product of the following: 
‘‘(i) INITIAL AMOUNT.—The sum of— 
‘‘(I) the base amount specified in 
subparagraph (B); plus 
‘‘(II) the discharge related amount 
specified in subparagraph (C) for a 12- 
month period selected by the Secretary 
with respect to such payment year. 
‘‘(ii) MEDICARE
SHARE.—The Medi-
care share as specified in subparagraph (D) 
for the hospital for a period selected by the 
Secretary with respect to such payment 
year. 
‘‘(iii) TRANSITION FACTOR.—The tran-
sition factor specified in subparagraph (E) 
for the hospital for the payment year. 
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‘‘(B) BASE
AMOUNT.—The base amount 
specified in this subparagraph is $2,000,000. 
‘‘(C) DISCHARGE RELATED AMOUNT.—The 
discharge related amount specified in this sub-
paragraph for a 12-month period selected by the 
Secretary shall be determined as the sum of the 
amount, based upon total discharges (regardless 
of any source of payment) for the period, for 
each discharge up to the 23,000th discharge as 
follows: 
‘‘(i) For the 1,150th through the 
9,200nd discharge, $200. 
‘‘(ii) For the 9,201st through the 
13,800th discharge, 50 percent of the 
amount specified in clause (i). 
‘‘(iii) For the 13,801st through the 
23,000th discharge, 30 percent of the 
amount specified in clause (i). 
‘‘(D) MEDICARE
SHARE.—The Medicare 
share specified under this subparagraph for a 
hospital for a period selected by the Secretary for 
a payment year is equal to the fraction— 
‘‘(i) the numerator of which is the sum 
(for such period and with respect to the hos-
pital) of— 
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‘‘(I) the number of inpatient-bed- 
days (as established by the Secretary) 
which are attributable to individuals 
with respect to whom payment may be 
made under part A; and 
‘‘(II) the number of inpatient-bed- 
days (as so established) which are at-
tributable to individuals who are en-
rolled with a Medicare Advantage or-
ganization under part C; and 
‘‘(ii) the denominator of which is the 
product of— 
‘‘(I) the total number of inpa-
tient-bed-days with respect to the hos-
pital during such period; and 
‘‘(II) the total amount of the hos-
pital’s charges during such period, not 
including any charges that are attrib-
utable to charity care (as such term is 
used for purposes of hospital cost re-
porting under this title), divided by the 
total amount of the hospital’s charges 
during such period. 
Insofar as the Secretary determines that data are 
not available on charity care necessary to cal-
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culate the portion of the formula specified in 
clause (ii)(II), the Secretary shall use data on 
uncompensated care and may adjust such data 
so as to be an appropriate proxy for charity care 
including a downward adjustment to eliminate 
bad debt data from uncompensated care data. In 
the absence of the data necessary, with respect to 
a hospital, for the Secretary to compute the 
amount described in clause (ii)(II), the amount 
under such clause shall be deemed to be 1. In the 
absence of data, with respect to a hospital, nec-
essary to compute the amount described in clause 
(i)(II), the amount under such clause shall be 
deemed to be 0. 
‘‘(E) TRANSITION FACTOR SPECIFIED.— 
‘‘(i) IN
GENERAL.—Subject to clause 
(ii), the transition factor specified in this 
subparagraph for an eligible hospital for a 
payment year is as follows: 
‘‘(I) For the first payment year 
for such hospital, 1. 
‘‘(II) For the second payment 
year for such hospital, 3⁄4. 
‘‘(III) For the third payment year 
for such hospital, 1⁄2. 
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‘‘(IV) For the fourth payment 
year for such hospital, 1⁄4. 
‘‘(V) For any succeeding payment 
year for such hospital, 0. 
‘‘(ii) PHASE DOWN FOR ELIGIBLE HOS-
PITALS FIRST ADOPTING EHR AFTER 2013.— 
If the first payment year for an eligible hos-
pital is after 2013, then the transition fac-
tor specified in this subparagraph for a 
payment year for such hospital is the same 
as the amount specified in clause (i) for 
such payment year for an eligible hospital 
for which the first payment year is 2013. If 
the first payment year for an eligible hos-
pital is after 2015 then the transition factor 
specified in this subparagraph for such hos-
pital and for such year and any subsequent 
year shall be 0. 
‘‘(F) FORM
OF
PAYMENT.—The payment 
under this subsection for a payment year may be 
in the form of a single consolidated payment or 
in the form of such periodic installments as the 
Secretary may specify. 
‘‘(G) PAYMENT YEAR DEFINED.— 
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‘‘(i) IN
GENERAL.—For purposes of 
this subsection, the term ‘payment year’ 
means a fiscal year beginning with fiscal 
year 2011. 
‘‘(ii) FIRST, SECOND, ETC. PAYMENT 
YEAR.—The term ‘first payment year’ 
means, with respect to inpatient hospital 
services furnished by an eligible hospital, 
the first fiscal year for which an incentive 
payment is made for such services under 
this subsection. The terms ‘second payment 
year’, ‘third payment year’, and ‘fourth 
payment year’ mean, with respect to an eli-
gible hospital, each successive year imme-
diately following the first payment year for 
that hospital. 
‘‘ ‘‘(H) LIMITATION FOR CRITICAL ACCESS 
HOSPITALS.—In no case shall the total amount 
of payments made under this subsection to a 
critical access hospital for all payment years ex-
ceed $1,500,000. 
‘‘(3) MEANINGFUL EHR USER.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), an eligible hospital shall be treated as 
a meaningful EHR user for a reporting period 
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for a payment year (or, for purposes of sub-
section (b)(3)(B)(ix), for a reporting period 
under such subsection for a fiscal year) if each 
of the following requirements are met: 
‘‘(i) MEANINGFUL USE OF CERTIFIED 
EHR
TECHNOLOGY.—The eligible hospital 
demonstrates to the satisfaction of the Sec-
retary, in accordance with subparagraph 
(C)(i), that during such period the hospital 
is using certified EHR technology in a 
meaningful manner. 
‘‘(ii) INFORMATION
EXCHANGE.—The 
eligible hospital demonstrates to the satis-
faction of the Secretary, in accordance with 
subparagraph (C)(i), that during such pe-
riod such certified EHR technology is con-
nected in a manner that provides, in ac-
cordance with law and standards applicable 
to the exchange of information, for the elec-
tronic exchange of health information to im-
prove the quality of health care, such as 
promoting care coordination. 
‘‘(iii) REPORTING ON MEASURES USING 
EHR.—Subject to subparagraph (B)(ii) and 
using such certified EHR technology, the el-
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igible hospital submits information for such 
period, in a form and manner specified by 
the Secretary, on such clinical quality 
measures and such other measures as se-
lected by the Secretary under subparagraph 
(B)(i). 
The Secretary shall seek to improve the use of 
electronic health records and health care quality 
over time by requiring more stringent measures 
of meaningful use selected under this paragraph. 
‘‘(B) REPORTING ON MEASURES.— 
‘‘(i) SELECTION.—The Secretary shall 
select measures for purposes of subpara-
graph (A)(iii) but only consistent with the 
following: 
‘‘(I) The Secretary shall provide 
preference to clinical quality measures 
that have been selected for purposes of 
applying subsection (b)(3)(B)(viii) or 
that have been endorsed by the entity 
with a contract with the Secretary 
under section 1890(a). 
‘‘(II) Prior to any measure (other 
than a clinical quality measure that 
has been selected for purposes of apply-
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ing subsection (b)(3)(B)(viii)) being se-
lected under this subparagraph, the 
Secretary shall publish in the Federal 
Register such measure and provide for 
a period of public comment on such 
measure. 
‘‘(ii) 
LIMITATIONS.—The 
Secretary 
may not require the electronic reporting of 
information on clinical quality measures 
under subparagraph (A)(iii) unless the Sec-
retary has the capacity to accept the infor-
mation electronically, which may be on a 
pilot basis. 
‘‘(iii) COORDINATION
OF
REPORTING 
OF INFORMATION.—In selecting such meas-
ures, and in establishing the form and man-
ner for reporting measures under subpara-
graph (A)(iii), the Secretary shall seek to 
avoid redundant or duplicative reporting 
with reporting otherwise required, including 
reporting under subsection (b)(3)(B)(viii). 
‘‘(C) DEMONSTRATION OF MEANINGFUL USE 
OF CERTIFIED EHR TECHNOLOGY AND INFORMA-
TION EXCHANGE.— 
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‘‘(i) IN
GENERAL.—A hospital may 
satisfy the demonstration requirement of 
clauses (i) and (ii) of subparagraph (A) 
through means specified by the Secretary, 
which may include— 
‘‘(I) an attestation; 
‘‘(II) the submission of claims 
with appropriate coding (such as a 
code indicating that inpatient care 
was documented using certified EHR 
technology); 
‘‘(III) a survey response; 
‘‘(IV) reporting under subpara-
graph (A)(iii); and 
‘‘(V) other means specified by the 
Secretary. 
‘‘(ii) USE OF PART D DATA.—Notwith-
standing sections 1860D–15(d)(2)(B) and 
1860D–15(f)(2), the Secretary may use data 
regarding drug claims submitted for pur-
poses of section 1860D–15 that are nec-
essary for purposes of subparagraph (A). 
‘‘(4) APPLICATION.— 
‘‘(A) LIMITATIONS ON REVIEW.—There shall 
be no administrative or judicial review under 
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section 1869, section 1878, or otherwise of the de-
termination of any incentive payment under this 
subsection and the payment adjustment under 
subsection (b)(3)(B)(ix), including the deter-
mination of a meaningful EHR user under 
paragraph (3), determination of measures appli-
cable to services furnished by eligible hospitals 
under this subsection, and the exception under 
subsection (b)(3)(B)(ix)(II). 
‘‘(B) POSTING ON WEBSITE.—The Secretary 
shall post on the Internet website of the Centers 
for Medicare & Medicaid Services, in an easily 
understandable format, a list of the names of the 
eligible hospitals that are meaningful EHR users 
under this subsection or subsection (b)(3)(B)(ix) 
and other relevant data as determined appro-
priate by the Secretary. The Secretary shall en-
sure that a hospital has the opportunity to re-
view the other relevant data that are to be made 
public with respect to the hospital prior to such 
data being made public. 
‘‘(5) CERTIFIED EHR TECHNOLOGY DEFINED.— 
The term ‘certified EHR technology’ has the meaning 
given such term in section 1848(o)(4). 
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