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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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HR 1 EAS 
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
655 
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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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HR 1 EAS 
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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HR 1 EAS 
‘‘(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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HR 1 EAS 
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
669 
HR 1 EAS 
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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HR 1 EAS 
(d) CONFORMING AMENDMENTS.—Section 1853 of the 
Social Security Act (42 U.S.C. 1395w–23) is amended— 
(1) in subsection (a)(1)(A), by striking ‘‘and (i)’’ 
and inserting ‘‘(i), and (l)’’; 
(2) in subsection (c)— 
(A) in paragraph (1)(D)(i), by striking 
‘‘section 
1886(h)’’ 
and 
inserting 
‘‘sections 
1848(o) and 1886(h)’’; and 
(B) in paragraph (6)(A), by inserting after 
‘‘under part B,’’ the following: ‘‘excluding ex-
penditures attributable to subsections (a)(7) and 
(o) of section 1848,’’; and 
(3) in subsection (f), by inserting ‘‘and for pay-
ments under subsection (l)’’ after ‘‘with the organiza-
tion’’. 
(e) CONFORMING AMENDMENTS TO E-PRESCRIBING.— 
(1) Section 1848(a)(5)(A) of the Social Security 
Act (42 U.S.C. 1395w–4(a)(5)(A)) is amended— 
(A) in clause (i), by striking ‘‘or any subse-
quent year’’ and inserting ‘‘, 2013, or 2014’’; 
and 
(B) in clause (ii), by striking ‘‘and each 
subsequent year’’. 
(2) Section 1848(m)(2) of such Act (42 U.S.C. 
1395w–4(m)(2)) is amended—
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HR 1 EAS 
(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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HR 1 EAS 
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
675 
HR 1 EAS 
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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HR 1 EAS 
‘‘(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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HR 1 EAS 
‘‘(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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HR 1 EAS 
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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HR 1 EAS 
‘‘(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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HR 1 EAS 
‘‘(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
681 
HR 1 EAS 
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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HR 1 EAS 
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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HR 1 EAS 
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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HR 1 EAS 
‘‘(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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HR 1 EAS 
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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HR 1 EAS 
‘‘(6) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) ELIGIBLE HOSPITAL.—The term ‘eligi-
ble hospital’ means— 
‘‘(i) a subsection (d) hospital; and 
‘‘(ii) a critical access hospital (as de-
fined in section 1861(mm)(1)). 
‘‘(B) REPORTING
PERIOD.—The term ‘re-
porting period’ means any period (or periods), 
with respect to a payment year, as specified by 
the Secretary.’’. 
(b) INCENTIVE MARKET BASKET ADJUSTMENT.— 
(1) IN GENERAL.—Section 1886(b)(3)(B) of the 
Social Security Act (42 U.S.C. 1395ww(b)(3)(B)) is 
amended— 
(A) in clause (viii)(I), by inserting ‘‘(or, be-
ginning with fiscal year 2016, by one-quarter)’’ 
after ‘‘2.0 percentage points’’; and 
(B) by adding at the end the following new 
clause: 
‘‘(ix)(I) For purposes of clause (i) for fiscal year 2015 
and each subsequent fiscal year, in the case of an eligible 
hospital (as defined in subsection (n)(6)(A)) that is not a 
meaningful EHR user (as defined in subsection (n)(3)) for 
the reporting period for such fiscal year, three-quarters of
687 
HR 1 EAS 
the applicable percentage increase otherwise applicable 
under clause (i) for such fiscal year shall be reduced by 
331⁄3 percent for fiscal year 2015, 662⁄3 percent for fiscal 
year 2016, and 100 percent for fiscal year 2017 and each 
subsequent fiscal year. Such reduction shall apply only with 
respect to the fiscal year involved and the Secretary shall 
not take into account such reduction in computing the ap-
plicable percentage increase under clause (i) for a subse-
quent fiscal year. 
‘‘(II) The Secretary may, on a case-by-case basis, ex-
empt a subsection (d) hospital from the application of sub-
clause (I) with respect to a fiscal year if the Secretary deter-
mines, subject to annual renewal, that requiring such hos-
pital to be a meaningful EHR user during such fiscal year 
would result in a significant hardship, such as in the case 
of a hospital in a rural area without sufficient Internet ac-
cess. In no case may a hospital be granted an exemption 
under this subclause for more than 5 years. 
‘‘(III) For fiscal year 2015 and each subsequent fiscal 
year, a State in which hospitals are paid for services under 
section 1814(b)(3) shall adjust the payments to each sub-
section (d) hospital in the State that is not a meaningful 
EHR user (as defined in subsection (n)(3)) in a manner 
that is designed to result in an aggregate reduction in pay-
ments to hospitals in the State that is equivalent to the ag-
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HR 1 EAS 
gregate reduction that would have occurred if payments had 
been reduced to each subsection (d) hospital in the State 
in a manner comparable to the reduction under the pre-
vious provisions of this clause. The State shall report to 
the Secretary the methodology it will use to make the pay-
ment adjustment under the previous sentence. 
‘‘(IV) For purposes of this clause, the term ‘reporting 
period’ means, with respect to a fiscal year, any period (or 
periods), with respect to the fiscal year, as specified by the 
Secretary.’’. 
(2) 
CRITICAL
ACCESS
HOSPITALS.—Section 
1814(l) of the Social Security Act (42 U.S.C. 
1395f(l)) is amended— 
(A) in subparagraph (1), by striking ‘‘para-
graph (2)’’ and inserting ‘‘paragraphs (2) and 
(3)’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(3)(A) Subject to subparagraph (B), for fiscal year 
2015 and each subsequent fiscal year, in the case of a crit-
ical access hospital that is not a meaningful EHR user (as 
defined in section 1886(n)(3)) for the reporting period for 
such fiscal year, paragraph (1) shall be applied by sub-
stituting the applicable percent under subparagraph (C) for 
the percent described in such paragraph (1).
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HR 1 EAS 
‘‘(B) The Secretary may, on a case-by-case basis, ex-
empt a critical access hospital from the application of sub-
paragraph (A) with respect to a fiscal year if the Secretary 
determines, subject to annual renewal, that requiring such 
hospital to be a meaningful EHR user during such fiscal 
year would result in a significant hardship, such as in the 
case of a hospital in a rural area without sufficient Internet 
access. In no case may a hospital be granted an exemption 
under this subparagraph for more than 5 years. 
‘‘(C) The percent described in this subparagraph is— 
‘‘(i) for fiscal year 2015, 100.66 percent; 
‘‘(ii) for fiscal year 2016, 100.33 percent; and 
‘‘(iii) for fiscal year 2017 and each subsequent 
fiscal year, 100 percent.’’. 
(c) APPLICATION TO CERTAIN MA-AFFILIATED ELIGI-
BLE HOSPITALS.—Section 1853 of the Social Security Act 
(42 U.S.C. 1395w–23), as amended by section 4201(c), is 
further amended by adding at the end the following new 
subsection: 
‘‘(m) APPLICATION OF ELIGIBLE HOSPITAL INCEN-
TIVES FOR CERTAIN MA ORGANIZATIONS FOR ADOPTION 
AND
MEANINGFUL
USE
OF
CERTIFIED
EHR TECH-
NOLOGY.— 
‘‘(1) APPLICATION.—Subject to paragraphs (3) 
and (4), in the case of a qualifying MA organization,
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HR 1 EAS 
the provisions of sections 1814(l)(3), 1886(n), and 
1886(b)(3)(B)(ix) shall apply with respect to eligible 
hospitals described in paragraph (2) of the organiza-
tion which the organization attests under subsection 
(l)(6) to be meaningful EHR users in a similar man-
ner as they apply to eligible hospitals under such sec-
tions. Incentive payments under paragraph (3) shall 
be made to and payment adjustments under para-
graph (4) shall apply to such qualifying organiza-
tions. 
‘‘(2) ELIGIBLE HOSPITAL DESCRIBED.—With re-
spect to a qualifying MA organization, an eligible 
hospital described in this paragraph is an eligible 
hospital (as defined in section 1886(n)(6)(A)) that is 
under common corporate governance with such orga-
nization and serves individuals enrolled under an MA 
plan offered by such organization. 
‘‘(3) 
ELIGIBLE
HOSPITAL
INCENTIVE
PAY-
MENTS.— 
‘‘(A) IN
GENERAL.—In applying section 
1886(n)(2) under paragraph (1), instead of the 
additional 
payment 
amount 
under 
section 
1886(n)(2), there shall be substituted an amount 
determined by the Secretary to be similar to the 
estimated amount in the aggregate that would be
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HR 1 EAS 
payable if payment for services furnished by 
such hospitals was payable under part A instead 
of this part. In implementing the previous sen-
tence, the Secretary— 
‘‘(i) shall, insofar as data to determine 
the discharge related amount under section 
1886(n)(2)(C) for an eligible hospital are 
not available to the Secretary, use such al-
ternative data and methodology to estimate 
such discharge related amount as the Sec-
retary determines appropriate; and 
‘‘(ii) shall, insofar as data to deter-
mine the medicare share described in sec-
tion 1886(n)(2)(D) for an eligible hospital 
are not available to the Secretary, use such 
alternative data and methodology to esti-
mate such share, which data and method-
ology may include use of the inpatient bed 
days (or discharges) with respect to an eli-
gible hospital during the appropriate period 
which are attributable to both individuals 
for whom payment may be made under 
part A or individuals enrolled in an MA 
plan under a Medicare Advantage organiza-
tion under this part as a proportion of the
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total number of patient-bed-days (or dis-
charges) with respect to such hospital dur-
ing such period. 
‘‘(B) AVOIDING
DUPLICATION
OF
PAY-
MENTS.— 
‘‘(i) IN GENERAL.—In the case of a 
hospital that for a payment year is an eli-
gible hospital described in paragraph (2) 
and for which at least one-third of their dis-
charges (or bed-days) of Medicare patients 
for the year are covered under part A, pay-
ment for the payment year shall be made 
only under section 1886(n) and not under 
this subsection. 
‘‘(ii) METHODS.—In the case of a hos-
pital that is an eligible hospital described 
in paragraph (2) and also is eligible for an 
incentive payment under section 1886(n) 
but is not described in clause (i) for the 
same payment period, the Secretary shall 
develop a process— 
‘‘(I) to ensure that duplicate pay-
ments are not made with respect to an 
eligible hospital both under this sub-
section and under section 1886(n); and
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‘‘(II) to collect data from Medi-
care Advantage organizations to ensure 
against such duplicate payments. 
‘‘(4) PAYMENT ADJUSTMENT.— 
‘‘(A) Subject to paragraph (3), in the case 
of a qualifying MA organization (as defined in 
section 1853(l)(5)), if, according to the attesta-
tion of the organization submitted under sub-
section (l)(6) for an applicable period, one or 
more eligible hospitals (as defined in section 
1886(n)(6)(A)) that are under common corporate 
governance with such organization and that 
serve individuals enrolled under a plan offered 
by such organization are not meaningful EHR 
users (as defined in section 1886(n)(3)) with re-
spect to a period, the payment amount payable 
under this section for such organization for such 
period shall be the percent specified in subpara-
graph (B) for such period of the payment 
amount otherwise provided under this section for 
such period. 
‘‘(B) SPECIFIED
PERCENT.—The percent 
specified under this subparagraph for a year is 
100 percent minus a number of percentage 
points equal to the product of—