H. R. 3590—794 
including qualified health plans and health plans that are 
not qualified health plans. 
‘‘(c) REPORT.—Not later than one year after the date of enact-
ment of this Act, the Comptroller General shall submit to the 
Secretaries of Health and Human Services and Labor a report 
describing the results of the study conducted under this section. 
‘‘(d) PUBLICATION OF REPORT.—The Secretaries of Health and 
Human Services and Labor shall make the report described in 
subsection (c) available to the public on an Internet website. 
‘‘SEC. 1563. SMALL BUSINESS PROCUREMENT. 
‘‘Part 19 of the Federal Acquisition Regulation, section 15 of 
the Small Business Act (15 U.S.C. 644), and any other applicable 
laws or regulations establishing procurement requirements relating 
to small business concerns (as defined in section 3 of the Small 
Business Act (15 U.S.C. 632)) may not be waived with respect 
to any contract awarded under any program or other authority 
under this Act or an amendment made by this Act.’’. 
SEC. 10108. FREE CHOICE VOUCHERS. 
(a) IN GENERAL.—An offering employer shall provide free choice 
vouchers to each qualified employee of such employer. 
(b) OFFERING EMPLOYER.—For purposes of this section, the 
term ‘‘offering employer’’ means any employer who— 
(1) offers minimum essential coverage to its employees 
consisting of coverage through an eligible employer-sponsored 
plan; and 
(2) pays any portion of the costs of such plan. 
(c) QUALIFIED EMPLOYEE.—For purposes of this section— 
(1) IN GENERAL.—The term ‘‘qualified employee’’ means, 
with respect to any plan year of an offering employer, any 
employee— 
(A) whose required contribution (as determined under 
section 5000A(e)(1)(B)) for minimum essential coverage 
through an eligible employer-sponsored plan— 
(i) exceeds 8 percent of such employee’s household 
income for the taxable year described in section 
1412(b)(1)(B) which ends with or within in the plan 
year; and 
(ii) does not exceed 9.8 percent of such employee’s 
household income for such taxable year; 
(B) whose household income for such taxable year is 
not greater than 400 percent of the poverty line for a 
family of the size involved; and 
(C) who does not participate in a health plan offered 
by the offering employer. 
(2) INDEXING.—In the case of any calendar year beginning 
after 2014, the Secretary shall adjust the 8 percent under 
paragraph (1)(A)(i) and 9.8 percent under paragraph (1)(A)(ii) 
for the calendar year to reflect the rate of premium growth 
between the preceding calendar year and 2013 over the rate 
of income growth for such period. 
(d) FREE CHOICE VOUCHER.— 
(1) AMOUNT.— 
(A) IN
GENERAL.—The amount of any free choice 
voucher provided under subsection (a) shall be equal to 
the monthly portion of the cost of the eligible employer- 
sponsored plan which would have been paid by the
H. R. 3590—795 
employer if the employee were covered under the plan 
with respect to which the employer pays the largest portion 
of the cost of the plan. Such amount shall be equal to 
the amount the employer would pay for an employee with 
self-only coverage unless such employee elects family cov-
erage (in which case such amount shall be the amount 
the employer would pay for family coverage). 
(B) DETERMINATION OF COST.—The cost of any health 
plan shall be determined under the rules similar to the 
rules of section 2204 of the Public Health Service Act, 
except that such amount shall be adjusted for age and 
category of enrollment in accordance with regulations 
established by the Secretary. 
(2) USE
OF
VOUCHERS.—An Exchange shall credit the 
amount of any free choice voucher provided under subsection 
(a) to the monthly premium of any qualified health plan in 
the Exchange in which the qualified employee is enrolled and 
the offering employer shall pay any amounts so credited to 
the Exchange. 
(3) PAYMENT OF EXCESS AMOUNTS.—If the amount of the 
free choice voucher exceeds the amount of the premium of 
the qualified health plan in which the qualified employee is 
enrolled for such month, such excess shall be paid to the 
employee. 
(e) OTHER DEFINITIONS.—Any term used in this section which 
is also used in section 5000A of the Internal Revenue Code of 
1986 shall have the meaning given such term under such section 
5000A. 
(f) EXCLUSION FROM INCOME FOR EMPLOYEE.— 
(1) IN GENERAL.—Part III of subchapter B of chapter 1 
of the Internal Revenue Code of 1986 is amended by inserting 
after section 139C the following new section: 
‘‘SEC. 139D. FREE CHOICE VOUCHERS. 
‘‘Gross income shall not include the amount of any free choice 
voucher provided by an employer under section 10108 of the Patient 
Protection and Affordable Care Act to the extent that the amount 
of such voucher does not exceed the amount paid for a qualified 
health plan (as defined in section 1301 of such Act) by the tax-
payer.’’. 
(2) CLERICAL AMENDMENT.—The table of sections for part 
III of subchapter B of chapter 1 of such Code is amended 
by inserting after the item relating to section 139C the following 
new item: 
‘‘Sec. 139D. Free choice vouchers.’’. 
(3) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to vouchers provided after December 31, 
2013. 
(g) DEDUCTION ALLOWED TO EMPLOYER.— 
(1) IN GENERAL.—Section 162(a) of the Internal Revenue 
Code of 1986 is amended by adding at the end the following 
new sentence: ‘‘For purposes of paragraph (1), the amount 
of a free choice voucher provided under section 10108 of the 
Patient Protection and Affordable Care Act shall be treated 
as an amount for compensation for personal services actually 
rendered.’’.
H. R. 3590—796 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to vouchers provided after December 31, 
2013. 
(h) VOUCHER TAKEN INTO ACCOUNT IN DETERMINING PREMIUM 
CREDIT.— 
(1) IN GENERAL.—Subsection (c)(2) of section 36B of the 
Internal Revenue Code of 1986, as added by section 1401, 
is amended by adding at the end the following new subpara-
graph: 
‘‘(D) EXCEPTION
FOR
INDIVIDUAL
RECEIVING
FREE 
CHOICE VOUCHERS.—The term ‘coverage month’ shall not 
include any month in which such individual has a free 
choice voucher provided under section 10108 of the Patient 
Protection and Affordable Care Act.’’. 
(2) EFFECTIVE DATE.—The amendment made by this sub-
section shall apply to taxable years beginning after December 
31, 2013. 
(i) COORDINATION WITH EMPLOYER RESPONSIBILITIES.— 
(1) SHARED RESPONSIBILITY PENALTY.— 
(A) IN GENERAL.—Subsection (c) of section 4980H of 
the Internal Revenue Code of 1986, as added by section 
1513, is amended by adding at the end the following new 
paragraph: 
‘‘(3) SPECIAL RULES FOR EMPLOYERS PROVIDING FREE CHOICE 
VOUCHERS.—No assessable payment shall be imposed under 
paragraph (1) for any month with respect to any employee 
to whom the employer provides a free choice voucher under 
section 10108 of the Patient Protection and Affordable Care 
Act for such month.’’. 
(B) EFFECTIVE DATE.—The amendment made by this 
paragraph shall apply to months beginning after December 
31, 2013. 
(2) NOTIFICATION REQUIREMENT.—Section 18B(a)(3) of the 
Fair Labor Standards Act of 1938, as added by section 1512, 
is amended— 
(A) by inserting ‘‘and the employer does not offer a 
free choice voucher’’ after ‘‘Exchange’’; and 
(B) by striking ‘‘will lose’’ and inserting ‘‘may lose’’. 
(j) EMPLOYER REPORTING.— 
(1) IN
GENERAL.—Subsection (a) of section 6056 of the 
Internal Revenue Code of 1986, as added by section 1514, 
is amended by inserting ‘‘and every offering employer’’ before 
‘‘shall’’. 
(2) OFFERING EMPLOYERS.—Subsection (f) of section 6056 
of such Code, as added by section 1514, is amended to read 
as follows: 
‘‘(f) DEFINITIONS.—For purposes of this section— 
‘‘(1) OFFERING EMPLOYER.— 
‘‘(A) IN GENERAL.—The term ‘offering employer’ means 
any offering employer (as defined in section 10108(b) of 
the Patient Protection and Affordable Care Act) if the 
required contribution (within the meaning of section 
5000A(e)(1)(B)(i)) of any employee exceeds 8 percent of 
the wages (as defined in section 3121(a)) paid to such 
employee by such employer. 
‘‘(B) INDEXING.—In the case of any calendar year begin-
ning after 2014, the 8 percent under subparagraph (A)
H. R. 3590—797 
shall be adjusted for the calendar year to reflect the rate 
of premium growth between the preceding calendar year 
and 2013 over the rate of income growth for such period. 
‘‘(2) OTHER DEFINITIONS.—Any term used in this section 
which is also used in section 4980H shall have the meaning 
given such term by section 4980H.’’. 
(3) CONFORMING AMENDMENTS.— 
(A) The heading of section 6056 of such Code, as added 
by section 1514, is amended by striking ‘‘LARGE’’ and 
inserting ‘‘CERTAIN’’. 
(B) Section 6056(b)(2)(C) of such Code is amended— 
(i) by inserting ‘‘in the case of an applicable large 
employer,’’ before ‘‘the length’’ in clause (i); 
(ii) by striking ‘‘and’’ at the end of clause (iii); 
(iii) by striking ‘‘applicable large employer’’ in 
clause (iv) and inserting ‘‘employer’’; 
(iv) by inserting ‘‘and’’ at the end of clause (iv); 
and 
(v) by inserting at the end the following new 
clause: 
‘‘(v) in the case of an offering employer, the option 
for which the employer pays the largest portion of 
the cost of the plan and the portion of the cost paid 
by the employer in each of the enrollment categories 
under such option,’’. 
(C) Section 6056(d)(2) of such Code is amended by 
inserting ‘‘or offering employer’’ after ‘‘applicable large 
employer’’. 
(D) Section 6056(e) of such Code is amended by 
inserting ‘‘or offering employer’’ after ‘‘applicable large 
employer’’. 
(E) Section 6724(d)(1)(B)(xxv) of such Code, as added 
by section 1514, is amended by striking ‘‘large’’ and 
inserting ‘‘certain’’. 
(F) Section 6724(d)(2)(HH) of such Code, as added by 
section 1514, is amended by striking ‘‘large’’ and inserting 
‘‘certain’’. 
(G) The table of sections for subpart D of part III 
of subchapter A of chapter 1 of such Code, as amended 
by section 1514, is amended by striking ‘‘Large employers’’ 
in the item relating to section 6056 and inserting ‘‘Certain 
employers’’. 
(4) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to periods beginning after December 31, 
2013. 
SEC. 10109. DEVELOPMENT OF STANDARDS FOR FINANCIAL AND 
ADMINISTRATIVE TRANSACTIONS. 
(a) ADDITIONAL
TRANSACTION
STANDARDS
AND
OPERATING 
RULES.— 
(1) DEVELOPMENT OF ADDITIONAL TRANSACTION STANDARDS 
AND OPERATING RULES.—Section 1173(a) of the Social Security 
Act (42 U.S.C. 1320d–2(a)), as amended by section 1104(b)(2), 
is amended— 
(A) in paragraph (1)(B), by inserting before the period 
the following: ‘‘, and subject to the requirements under 
paragraph (5)’’; and
H. R. 3590—798 
(B) by adding at the end the following new paragraph: 
‘‘(5) CONSIDERATION
OF
STANDARDIZATION
OF
ACTIVITIES 
AND ITEMS.— 
‘‘(A) IN GENERAL.—For purposes of carrying out para-
graph (1)(B), the Secretary shall solicit, not later than 
January 1, 2012, and not less than every 3 years thereafter, 
input from entities described in subparagraph (B) on— 
‘‘(i) whether there could be greater uniformity in 
financial and administrative activities and items, as 
determined appropriate by the Secretary; and 
‘‘(ii) whether such activities should be considered 
financial and administrative transactions (as described 
in paragraph (1)(B)) for which the adoption of stand-
ards and operating rules would improve the operation 
of the health care system and reduce administrative 
costs. 
‘‘(B) SOLICITATION OF INPUT.—For purposes of subpara-
graph (A), the Secretary shall seek input from— 
‘‘(i) the National Committee on Vital and Health 
Statistics, the Health Information Technology Policy 
Committee, and the Health Information Technology 
Standards Committee; and 
‘‘(ii) standard setting organizations and stake-
holders, as determined appropriate by the Secretary.’’. 
(b) ACTIVITIES AND ITEMS FOR INITIAL CONSIDERATION.—For 
purposes of section 1173(a)(5) of the Social Security Act, as added 
by subsection (a), the Secretary of Health and Human Services 
(in this section referred to as the ‘‘Secretary’’) shall, not later 
than January 1, 2012, seek input on activities and items relating 
to the following areas: 
(1) Whether the application process, including the use of 
a uniform application form, for enrollment of health care pro-
viders by health plans could be made electronic and standard-
ized. 
(2) Whether standards and operating rules described in 
section 1173 of the Social Security Act should apply to the 
health care transactions of automobile insurance, worker’s com-
pensation, and other programs or persons not described in 
section 1172(a) of such Act (42 U.S.C. 1320d–1(a)). 
(3) Whether standardized forms could apply to financial 
audits required by health plans, Federal and State agencies 
(including State auditors, the Office of the Inspector General 
of the Department of Health and Human Services, and the 
Centers for Medicare & Medicaid Services), and other relevant 
entities as determined appropriate by the Secretary. 
(4) Whether there could be greater transparency and 
consistency of methodologies and processes used to establish 
claim edits used by health plans (as described in section 1171(5) 
of the Social Security Act (42 U.S.C. 1320d(5))). 
(5) Whether health plans should be required to publish 
their timeliness of payment rules. 
(c) ICD CODING CROSSWALKS.— 
(1) ICD–9 TO ICD–10 CROSSWALK.—The Secretary shall task 
the ICD–9–CM Coordination and Maintenance Committee to 
convene a meeting, not later than January 1, 2011, to receive 
input from appropriate stakeholders (including health plans, 
health care providers, and clinicians) regarding the crosswalk
H. R. 3590—799 
between the Ninth and Tenth Revisions of the International 
Classification of Diseases (ICD–9 and ICD–10, respectively) 
that is posted on the website of the Centers for Medicare 
& Medicaid Services, and make recommendations about appro-
priate revisions to such crosswalk. 
(2) REVISION OF CROSSWALK.—For purposes of the cross-
walk described in paragraph (1), the Secretary shall make 
appropriate revisions and post any such revised crosswalk on 
the website of the Centers for Medicare & Medicaid Services. 
(3) USE OF REVISED CROSSWALK.—For purposes of para-
graph (2), any revised crosswalk shall be treated as a code 
set for which a standard has been adopted by the Secretary 
for purposes of section 1173(c)(1)(B) of the Social Security Act 
(42 U.S.C. 1320d–2(c)(1)(B)). 
(4) SUBSEQUENT CROSSWALKS.—For subsequent revisions 
of the International Classification of Diseases that are adopted 
by the Secretary as a standard code set under section 1173(c) 
of the Social Security Act (42 U.S.C. 1320d–2(c)), the Secretary 
shall, after consultation with the appropriate stakeholders, post 
on the website of the Centers for Medicare & Medicaid Services 
a crosswalk between the previous and subsequent version of 
the International Classification of Diseases not later than the 
date of implementation of such subsequent revision. 
Subtitle B—Provisions Relating to Title II 
PART I—MEDICAID AND CHIP 
SEC. 10201. AMENDMENTS TO THE SOCIAL SECURITY ACT AND TITLE 
II OF THIS ACT. 
(a)(1) Section 1902(a)(10)(A)(i)(IX) of the Social Security Act 
(42 U.S.C. 1396a(a)(10)(A)(i)(IX)), as added by section 2004(a), is 
amended to read as follows: 
‘‘(IX) who— 
‘‘(aa) are under 26 years of age; 
‘‘(bb) are not described in or enrolled 
under any of subclauses (I) through (VII) of 
this clause or are described in any of such 
subclauses but have income that exceeds the 
level of income applicable under the State plan 
for eligibility to enroll for medical assistance 
under such subclause; 
‘‘(cc) were in foster care under the respon-
sibility of the State on the date of attaining 
18 years of age or such higher age as the 
State has elected under section 475(8)(B)(iii); 
and 
‘‘(dd) were enrolled in the State plan 
under this title or under a waiver of the plan 
while in such foster care;’’. 
(2) Section 1902(a)(10) of the Social Security Act (42 U.S.C. 
1396a(a)(10), as amended by section 2001(a)(5)(A), is amended in 
the matter following subparagraph (G), by striking ‘‘and (XV)’’ and 
inserting ‘‘(XV)’’, and by inserting ‘‘and (XVI) if an individual is 
described in subclause (IX) of subparagraph (A)(i) and is also 
described in subclause (VIII) of that subparagraph, the medical
H. R. 3590—800 
assistance shall be made available to the individual through sub-
clause (IX) instead of through subclause (VIII)’’ before the semicolon. 
(3) Section 2004(d) of this Act is amended by striking ‘‘2019’’ 
and inserting ‘‘2014’’. 
(b) Section 1902(k)(2) of the Social Security Act (42 U.S.C. 
1396a(k)(2)), as added by section 2001(a)(4)(A), is amended by 
striking ‘‘January 1, 2011’’ and inserting ‘‘April 1, 2010’’. 
(c) Section 1905 of the Social Security Act (42 U.S.C. 1396d), 
as amended by sections 2001(a)(3), 2001(a)(5)(C), 2006, and 
4107(a)(2), is amended— 
(1) in subsection (a), in the matter preceding paragraph 
(1), by inserting in clause (xiv), ‘‘or 1902(a)(10)(A)(i)(IX)’’ before 
the comma; 
(2) in subsection (b), in the first sentence, by inserting 
‘‘, (z),’’ before ‘‘and (aa)’’; 
(3) in subsection (y)— 
(A) in paragraph (1)(B)(ii)(II), in the first sentence, 
by inserting ‘‘includes inpatient hospital services,’’ after 
‘‘100 percent of the poverty line, that’’; and 
(B) in paragraph (2)(A), by striking ‘‘on the date of 
enactment of the Patient Protection and Affordable Care 
Act’’ and inserting ‘‘as of December 1, 2009’’; 
(4) by inserting after subsection (y) the following: 
‘‘(z) EQUITABLE SUPPORT FOR CERTAIN STATES.— 
‘‘(1)(A) During the period that begins on January 1, 2014, 
and ends on September 30, 2019, notwithstanding subsection 
(b), the Federal medical assistance percentage otherwise deter-
mined under subsection (b) with respect to a fiscal year occur-
ring during that period shall be increased by 2.2 percentage 
points for any State described in subparagraph (B) for amounts 
expended for medical assistance for individuals who are not 
newly eligible (as defined in subsection (y)(2)) individuals 
described in subclause (VIII) of section 1902(a)(10)(A)(i). 
‘‘(B) For purposes of subparagraph (A), a State described 
in this subparagraph is a State that— 
‘‘(i) is an expansion State described in subsection 
(y)(1)(B)(ii)(II); 
‘‘(ii) the Secretary determines will not receive any pay-
ments under this title on the basis of an increased Federal 
medical assistance percentage under subsection (y) for 
expenditures for medical assistance for newly eligible 
individuals (as so defined); and 
‘‘(iii) has not been approved by the Secretary to divert 
a portion of the DSH allotment for a State to the costs 
of providing medical assistance or other health benefits 
coverage under a waiver that is in effect on July 2009. 
‘‘(2)(A) During the period that begins on January 1, 2014, 
and ends on December 31, 2016, notwithstanding subsection (b), 
the Federal medical assistance percentage otherwise determined 
under subsection (b) with respect to all or any portion of a fiscal 
year occurring during that period shall be increased by .5 percentage 
point for a State described in subparagraph (B) for amounts 
expended for medical assistance under the State plan under this 
title or under a waiver of that plan during that period. 
‘‘(B) For purposes of subparagraph (A), a State described in 
this subparagraph is a State that—
H. R. 3590—801 
‘‘(i) is described in clauses (i) and (ii) of paragraph (1)(B); 
and 
‘‘(ii) is the State with the highest percentage of its popu-
lation insured during 2008, based on the Current Population 
Survey. 
‘‘(3) Notwithstanding subsection (b) and paragraphs (1) and 
(2) of this subsection, the Federal medical assistance percentage 
otherwise determined under subsection (b) with respect to all or 
any portion of a fiscal year that begins on or after January 1, 
2017, for the State of Nebraska, with respect to amounts expended 
for newly eligible individuals described in subclause (VIII) of section 
1902(a)(10)(A)(i), shall be determined as provided for under sub-
section (y)(1)(A) (notwithstanding the period provided for in such 
paragraph). 
‘‘(4) The increase in the Federal medical assistance percentage 
for a State under paragraphs (1), (2), or (3) shall apply only for 
purposes of this title and shall not apply with respect to— 
‘‘(A) disproportionate share hospital payments described 
in section 1923; 
‘‘(B) payments under title IV; 
‘‘(C) payments under title XXI; and 
‘‘(D) payments under this title that are based on the 
enhanced FMAP described in section 2105(b).’’; 
(5) in subsection (aa), is amended by striking ‘‘without 
regard to this subsection and subsection (y)’’ and inserting 
‘‘without regard to this subsection, subsection (y), subsection 
(z), and section 10202 of the Patient Protection and Affordable 
Care Act’’ each place it appears; 
(6) by adding after subsection (bb), the following: 
‘‘(cc) REQUIREMENT
FOR CERTAIN STATES.—Notwithstanding 
subsections (y), (z), and (aa), in the case of a State that requires 
political subdivisions within the State to contribute toward the 
non-Federal share of expenditures required under the State plan 
under section 1902(a)(2), the State shall not be eligible for an 
increase in its Federal medical assistance percentage under such 
subsections if it requires that political subdivisions pay a greater 
percentage of the non-Federal share of such expenditures, or a 
greater percentage of the non-Federal share of payments under 
section 1923, than the respective percentages that would have been 
required by the State under the State plan under this title, State 
law, or both, as in effect on December 31, 2009, and without 
regard to any such increase. Voluntary contributions by a political 
subdivision to the non-Federal share of expenditures under the 
State plan under this title or to the non-Federal share of payments 
under section 1923, shall not be considered to be required contribu-
tions for purposes of this subsection. The treatment of voluntary 
contributions, and the treatment of contributions required by a 
State under the State plan under this title, or State law, as provided 
by this subsection, shall also apply to the increases in the Federal 
medical assistance percentage under section 5001 of the American 
Recovery and Reinvestment Act of 2009.’’. 
(d) Section 1108(g)(4)(B) of the Social Security Act (42 U.S.C. 
1308(g)(4)(B)), as added by section 2005(b), is amended by striking 
‘‘income eligibility level in effect for that population under title 
XIX or under a waiver’’ and inserting ‘‘the highest income eligibility 
level in effect for parents under the commonwealth’s or territory’s 
State plan under title XIX or under a waiver of the plan’’.
H. R. 3590—802 
(e)(1) Section 1923(f) of the Social Security Act (42 U.S.C. 
1396r–4(f)), as amended by section 2551, is amended— 
(A) in paragraph (6)— 
(i) by striking the paragraph heading and inserting 
the following: ‘‘ALLOTMENT ADJUSTMENTS’’; and 
(ii) in subparagraph (B), by adding at the end the 
following: 
‘‘(iii) ALLOTMENT FOR 2D, 3RD, AND 4TH QUARTER 
OF FISCAL YEAR 2012, FISCAL YEAR 2013, AND SUCCEEDING 
FISCAL YEARS.—Notwithstanding the table set forth in 
paragraph (2) or paragraph (7): 
‘‘(I) 2D, 3RD, AND 4TH QUARTER OF FISCAL YEAR 
2012.—The DSH allotment for Hawaii for the 2d, 
3rd, and 4th quarters of fiscal year 2012 shall 
be $7,500,000. 
‘‘(II) TREATMENT
AS
A
LOW-DSH
STATE
FOR 
FISCAL YEAR 2013 AND SUCCEEDING FISCAL YEARS.— 
With respect to fiscal year 2013, and each fiscal 
year thereafter, the DSH allotment for Hawaii 
shall be increased in the same manner as allot-
ments for low DSH States are increased for such 
fiscal year under clause (iii) of paragraph (5)(B). 
‘‘(III) CERTAIN HOSPITAL PAYMENTS.—The Sec-
retary may not impose a limitation on the total 
amount of payments made to hospitals under the 
QUEST section 1115 Demonstration Project except 
to the extent that such limitation is necessary 
to ensure that a hospital does not receive payments 
in excess of the amounts described in subsection 
(g), or as necessary to ensure that such payments 
under the waiver and such payments pursuant 
to the allotment provided in this clause do not, 
in the aggregate in any year, exceed the amount 
that the Secretary determines is equal to the Fed-
eral medical assistance percentage component 
attributable to disproportionate share hospital pay-
ment adjustments for such year that is reflected 
in the budget neutrality provision of the QUEST 
Demonstration Project.’’; and 
(B) in paragraph (7)— 
(i) in subparagraph (A), in the matter preceding clause 
(i), by striking ‘‘subparagraph (E)’’ and inserting ‘‘subpara-
graphs (E) and (G)’’; 
(ii) in subparagraph (B)— 
(I) in clause (i), by striking subclauses (I) and 
(II), and inserting the following: 
‘‘(I) if the State is a low DSH State described 
in paragraph (5)(B) and has spent not more than 
99.90 percent of the DSH allotments for the State 
on average for the period of fiscal years 2004 
through 2008, as of September 30, 2009, the 
applicable percentage is equal to 25 percent; 
‘‘(II) if the State is a low DSH State described 
in paragraph (5)(B) and has spent more than 99.90 
percent of the DSH allotments for the State on 
average for the period of fiscal years 2004 through