333 
(c) CONFORMING AMENDMENT TO PART B ASP CAL-
CULATION.—Section 1847A(c)(3) of the Social Security 
Act (42 U.S.C. 1395w–3a(c)(3)) is amended by inserting 
‘‘or subsection (h)’’ after ‘‘section 1927’’. 
SEC. 374. MARKET BASED PART B PRICING INDEX. 
Notwithstanding any provision of part B of title 
XVIII of the Social Security Act, the Secretary of Health 
and Human Services may make payments for drugs pay-
able under such part based on an international pricing 
index. In using such an index, the Secretary shall take 
into account whether the market of each country included 
in such index is a price-controlled or free market and give 
more weight under such index to countries with market- 
based drug policies. 
SEC. 375. INNOVATION MODEL TESTING OF MEDICARE 
DRUG PAYMENTS. 
Notwithstanding any provision of section 1115A, the 
Secretary of Health and Human Services may, under such 
section, test a model to integrate benefits provided for 
drugs under parts A, B, and D of title XVIII of the Social 
Security Act. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00333
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
334 
SEC. 376. MODIFICATION OF MAXIMUM REBATE AMOUNT 
UNDER MEDICAID DRUG REBATE PROGRAM. 
(a) IN GENERAL.—Subparagraph (D) of section 
1927(c)(2) of the Social Security Act (42 U.S.C. 1396r– 
8(c)(2)) is amended to read as follows: 
‘‘(D) MAXIMUM REBATE AMOUNT.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), in no case shall the 
sum of the amounts applied under para-
graph (1)(A)(ii) and this paragraph with 
respect to each dosage form and strength 
of a single source drug or an innovator 
multiple source drug for a rebate period 
exceed— 
‘‘(I) for rebate periods beginning 
after December 31, 2009, and before 
September 30, 2023, 100 percent of 
the average manufacturer price of the 
drug; and 
‘‘(II) for rebate periods beginning 
on or after October 1, 2023, 125 per-
cent of the average manufacturer 
price of the drug. 
‘‘(ii) NO
MAXIMUM
AMOUNT
FOR 
DRUGS
IF
AMP
INCREASES
OUTPACE
IN-
FLATION.— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00334
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
335 
‘‘(I) IN GENERAL.—If the aver-
age manufacturer price with respect 
to each dosage form and strength of 
a single source drug or an innovator 
multiple source drug increases on or 
after October 1, 2022, and such in-
creased average manufacturer price 
exceeds the inflation-adjusted average 
manufacturer price determined with 
respect to such drug under subclause 
(II) for the rebate period, clause (i) 
shall not apply and there shall be no 
limitation on the sum of the amounts 
applied under paragraph (1)(A)(ii) 
and this paragraph for the rebate pe-
riod with respect to each dosage form 
and strength of the single source drug 
or innovator multiple source drug. 
‘‘(II) INFLATION-ADJUSTED
AV-
ERAGE
MANUFACTURER
PRICE
DE-
FINED.—In this clause, the term ‘in-
flation-adjusted average manufacturer 
price’ means, with respect to a single 
source drug or an innovator multiple 
source drug and a rebate period, the 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00335
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
336 
average manufacturer price for each 
dosage form and strength of the drug 
for the calendar quarter beginning 
July 1, 1990 (without regard to 
whether or not the drug has been sold 
or transferred to an entity, including 
a division or subsidiary of the manu-
facturer, after the 1st day of such 
quarter), increased by the percentage 
by which the consumer price index for 
all urban consumers (United States 
city average) for the month before the 
month in which the rebate period be-
gins exceeds such index for September 
1990.’’. 
(b) TREATMENT
OF
SUBSEQUENTLY
APPROVED 
DRUGS.—Section 1927(c)(2)(B) of the Social Security Act 
(42 U.S.C. 1396r–8(c)(2)(B)) is amended by inserting 
‘‘and clause (ii)(II) of subparagraph (D)’’ after ‘‘clause 
(ii)(II) of subparagraph (A)’’. 
(c) 
TECHNICAL
AMENDMENTS.—Section 
1927(c)(3)(C)(ii)(IV) of the Social Security Act (42 
U.S.C. 1396r–9(c)(3)(C)(ii)(IV)) is amended— 
(1) by striking ‘‘subparagraph (A)’’ and insert-
ing ‘‘paragraph (3)(A)’’; and 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00336
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
337 
(2) by striking ‘‘this subparagraph’’ and insert-
ing ‘‘paragraph (3)(C)’’. 
Subtitle F—Medical Malpractice 
Reform 
SEC. 381. DEFINITIONS. 
In this Act: 
(1) ALTERNATIVE DISPUTE RESOLUTION SYS-
TEM; ADR.—The term ‘‘alternative dispute resolution 
system’’ or ‘‘ADR’’ means a system that provides 
for the resolution of health care lawsuits in a man-
ner other than through a civil action brought in a 
State or Federal court. 
(2) CLAIMANT.—The term ‘‘claimant’’ means 
any person who brings a health care lawsuit, includ-
ing a person who asserts or claims a right to legal 
or equitable contribution, indemnity, or subrogation, 
arising out of a health care liability claim or action, 
and any person on whose behalf such a claim is as-
serted or such an action is brought, whether de-
ceased, incompetent, or a minor. 
(3) COLLATERAL
SOURCE
BENEFITS.—The 
term ‘‘collateral source benefits’’ means any amount 
paid or reasonably likely to be paid in the future to 
or on behalf of the claimant, or any service, product, 
or other benefit provided or reasonably likely to be 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00337
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
338 
provided in the future to or on behalf of the claim-
ant, as a result of the injury or wrongful death, pur-
suant to— 
(A) any State or Federal health, sickness, 
income-disability, accident, or workers’ com-
pensation law; 
(B) any health, sickness, income-disability, 
or accident insurance that provides health bene-
fits or income-disability coverage; 
(C) any contract or agreement of any 
group, organization, partnership, or corporation 
to provide, pay for, or reimburse the cost of 
medical, hospital, dental, or income-disability 
benefits; and 
(D) any other publicly or privately funded 
program. 
(4) CONTINGENT FEE.—The term ‘‘contingent 
fee’’ includes all compensation to any person or per-
sons which is payable only if a recovery is effected 
on behalf of one or more claimants. 
(5) ECONOMIC DAMAGES.—The term ‘‘economic 
damages’’ means objectively verifiable monetary 
losses incurred as a result of the provision or use of 
(or failure to provide or use) health care services or 
medical products, such as past and future medical 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00338
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
339 
expenses, loss of past and future earnings, cost of 
obtaining domestic services, loss of employment, and 
loss of business or employment opportunities, unless 
otherwise defined under applicable State law. In no 
circumstances shall damages for health care services 
or medical products exceed the amount actually paid 
or incurred by or on behalf of the claimant. 
(6) FUTURE
DAMAGES.—The term ‘‘future 
damages’’ means any damages that are incurred 
after the date of judgment, settlement, or other reso-
lution (including mediation, or any other form of al-
ternative dispute resolution). 
(7) 
HEALTH
CARE
LAWSUIT.—The 
term 
‘‘health care lawsuit’’ means any health care liability 
claim concerning the provision of goods or services 
for which coverage was provided in whole or in part 
via a Federal program, subsidy or tax benefit, or 
any health care liability action concerning the provi-
sion of goods or services for which coverage was pro-
vided in whole or in part via a Federal program, 
subsidy or tax benefit, brought in a State or Federal 
court or pursuant to an alternative dispute resolu-
tion system, against a health care provider regard-
less of the theory of liability on which the claim is 
based, or the number of claimants, plaintiffs, de-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00339
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
340 
fendants, or other parties, or the number of claims 
or causes of action, in which the claimant alleges a 
health care liability claim. Such term does not in-
clude a claim or action which is based on criminal 
liability; which seeks civil fines or penalties paid to 
Federal, State, or local government; or which is 
grounded in antitrust. 
(8) HEALTH
CARE
LIABILITY
ACTION.—The 
term ‘‘health care liability action’’ means a civil ac-
tion brought in a State or Federal court or pursuant 
to an alternative dispute resolution system, against 
a health care provider regardless of the theory of li-
ability on which the claim is based, or the number 
of plaintiffs, defendants, or other parties, or the 
number of causes of action, in which the claimant al-
leges a health care liability claim. 
(9) HEALTH
CARE
LIABILITY
CLAIM.—The 
term ‘‘health care liability claim’’ means a demand 
by any person, whether or not pursuant to ADR, 
against a health care provider, including, but not 
limited to, third-party claims, cross-claims, counter- 
claims, or contribution claims, which are based upon 
the provision or use of (or the failure to provide or 
use) health care services or medical products, re-
gardless of the theory of liability on which the claim 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00340
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
341 
is based, or the number of plaintiffs, defendants, or 
other parties, or the number of causes of action. 
(10) HEALTH
CARE
PROVIDER.—The term 
‘‘health care provider’’ means any person or entity 
required by State or Federal laws or regulations to 
be licensed, registered, or certified to provide health 
care services, and being either so licensed, reg-
istered, or certified, or exempted from such require-
ment by other statute or regulation, as well as any 
other individual or entity defined as a health care 
provider, health care professional, or health care in-
stitution under State law. 
(11) HEALTH
CARE
SERVICES.—The term 
‘‘health care services’’ means the provision of any 
goods or services (including safety, professional, or 
administrative services directly related to health 
care) by a health care provider, or by any individual 
working under the supervision of a health care pro-
vider, that relates to the diagnosis, prevention, or 
treatment of any human disease or impairment, or 
the assessment or care of the health of human 
beings. 
(12) MEDICAL PRODUCT.—The term ‘‘medical 
product’’ means a drug, device, or biological product 
intended for humans, and the terms ‘‘drug’’, ‘‘de-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00341
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
342 
vice’’, and ‘‘biological product’’ have the meanings 
given such terms in sections 201(g)(1) and 201(h) 
of the Federal Food, Drug and Cosmetic Act (21 
U.S.C. 321(g)(1) and (h)) and section 351(a) of the 
Public Health Service Act (42 U.S.C. 262(a)), re-
spectively, including any component or raw material 
used therein, but excluding health care services. 
(13) 
NONECONOMIC
DAMAGES.—The 
term 
‘‘noneconomic damages’’ means damages for phys-
ical and emotional pain, suffering, inconvenience, 
physical impairment, mental anguish, disfigurement, 
loss of enjoyment of life, loss of society and compan-
ionship, loss of consortium (other than loss of do-
mestic service), hedonic damages, injury to reputa-
tion, and all other nonpecuniary losses of any kind 
or nature incurred as a result of the provision or use 
of (or failure to provide or use) health care services 
or medical products, unless otherwise defined under 
applicable State law. 
(14) RECOVERY.—The term ‘‘recovery’’ means 
the net sum recovered after deducting any disburse-
ments or costs incurred in connection with prosecu-
tion or settlement of the claim, including all costs 
paid or advanced by any person. Costs of health care 
incurred by the plaintiff and the attorneys’ office 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00342
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
343 
overhead costs or charges for legal services are not 
deductible disbursements or costs for such purpose. 
(15) REPRESENTATIVE.—The term ‘‘represent-
ative’’ means a legal guardian, attorney, person des-
ignated to make decisions on behalf of a patient 
under a medical power of attorney, or any person 
recognized in law or custom as a patient’s agent. 
(16) STATE.—The term ‘‘State’’ means each of 
the several States, the District of Columbia, the 
Commonwealth of Puerto Rico, the Virgin Islands, 
Guam, American Samoa, the Northern Mariana Is-
lands, the Trust Territory of the Pacific Islands, and 
any other territory or possession of the United 
States, or any political subdivision thereof. 
SEC. 382. ENCOURAGING SPEEDY RESOLUTION OF CLAIMS. 
(a) STATUTE OF LIMITATIONS.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the time for the commencement of a 
health care lawsuit shall be, whichever occurs first of 
the following: 
(A) Three years after the date of the oc-
currence of the breach or tort. 
(B) Three years after the date the medical 
or health care treatment that is the subject of 
the claim is completed. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00343
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
344 
(C) One year after the claimant discovers, 
or through the use of reasonable diligence 
should have discovered, the injury. 
(2) TOLLING.—In no event shall the time for 
commencement of a health care lawsuit exceed 3 
years after the date of the occurrence of the breach 
or tort or 3 years after the date the medical or 
health care treatment that is the subject of the claim 
is completed (whichever occurs first) unless tolled 
for any of the following— 
(A) upon proof of fraud; 
(B) intentional concealment; or 
(C) the presence of a foreign body, which 
has no therapeutic or diagnostic purpose or ef-
fect, in the person of the injured person. 
(3) ACTIONS BY A MINOR.—Actions by a minor 
shall be commenced within 3 years after the date of 
the occurrence of the breach or tort or 3 years after 
the date of the medical or health care treatment that 
is the subject of the claim is completed (whichever 
occurs first) except that actions by a minor under 
the full age of 6 years shall be commenced within 3 
years after the date of the occurrence of the breach 
or tort, 3 years after the date of the medical or 
health care treatment that is the subject of the claim 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00344
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
345 
is completed, or 1 year after the injury is discovered, 
or through the use of reasonable diligence should 
have been discovered, or prior to the minor’s 8th 
birthday, whichever provides a longer period. Such 
time limitation shall be tolled for minors for any pe-
riod during which a parent or guardian and a health 
care provider have committed fraud or collusion in 
the failure to bring an action on behalf of the in-
jured minor. 
(b) STATE FLEXIBILITY.—No provision of subsection 
(a) shall be construed to preempt any State law (whether 
effective before, on, or after the date of the enactment of 
this Act) that— 
(1) specifies a time period of less than 3 years 
after the date of injury or less than 1 year after the 
claimant discovers, or through the use of reasonable 
diligence should have discovered, the injury, for the 
filing of a health care lawsuit; 
(2) that specifies a different time period for the 
filing of lawsuits by a minor; 
(3) that triggers the time period based on the 
date of the alleged negligence; or 
(4) establishes a statute of repose for the filing 
of a health care lawsuit. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00345
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
346 
SEC. 383. COMPENSATING PATIENT INJURY. 
(a) UNLIMITED AMOUNT OF DAMAGES FOR ACTUAL 
ECONOMIC LOSSES IN HEALTH CARE LAWSUITS.—In any 
health care lawsuit, nothing in this Act shall limit a claim-
ant’s recovery of the full amount of the available economic 
damages, notwithstanding the limitation in subsection (b). 
(b) ADDITIONAL NONECONOMIC DAMAGES.—In any 
health care lawsuit, the amount of noneconomic damages, 
if available, shall not exceed $250,000, regardless of the 
number of parties against whom the action is brought or 
the number of separate claims or actions brought with re-
spect to the same injury. 
(c) NO DISCOUNT OF AWARD FOR NONECONOMIC 
DAMAGES.—For purposes of applying the limitation in 
subsection (b), future noneconomic damages shall not be 
discounted to present value. The jury shall not be in-
formed about the maximum award for noneconomic dam-
ages. An award for noneconomic damages in excess of 
$250,000 shall be reduced either before the entry of judg-
ment, or by amendment of the judgment after entry of 
judgment, and such reduction shall be made before ac-
counting for any other reduction in damages required by 
law. If separate awards are rendered for past and future 
noneconomic damages and the combined awards exceed 
$250,000, the future noneconomic damages shall be re-
duced first. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00346
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
347 
(d) FAIR SHARE RULE.—In any health care lawsuit, 
each party shall be liable for that party’s several share 
of any damages only and not for the share of any other 
person. Each party shall be liable only for the amount of 
damages allocated to such party in direct proportion to 
such party’s percentage of responsibility. Whenever a 
judgment of liability is rendered as to any party, a sepa-
rate judgment shall be rendered against each such party 
for the amount allocated to such party. For purposes of 
this section, the trier of fact shall determine the propor-
tion of responsibility of each party for the claimant’s 
harm. 
(e) STATE FLEXIBILITY.—No provision of this sec-
tion shall be construed to preempt any State law (whether 
effective before, on, or after the date of the enactment of 
this Act) that specifies a particular monetary amount of 
economic or noneconomic damages (or the total amount 
of damages) that may be awarded in a health care lawsuit, 
regardless of whether such monetary amount is greater 
or lesser than is provided for under this section. 
SEC. 384. MAXIMIZING PATIENT RECOVERY. 
(a) COURT SUPERVISION OF SHARE OF DAMAGES 
ACTUALLY PAID TO CLAIMANTS.—In any health care law-
suit, the court shall supervise the arrangements for pay-
ment of damages to protect against conflicts of interest 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00347
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
348 
that may have the effect of reducing the amount of dam-
ages awarded that are actually paid to claimants. In par-
ticular, in any health care lawsuit in which the attorney 
for a party claims a financial stake in the outcome by vir-
tue of a contingent fee, the court shall have the power 
to restrict the payment of a claimant’s damage recovery 
to such attorney, and to redirect such damages to the 
claimant based upon the interests of justice and principles 
of equity. In no event shall the total of all contingent fees 
for representing all claimants in a health care lawsuit ex-
ceed the following limits: 
(1) Forty percent of the first $50,000 recovered 
by the claimant(s). 
(2) Thirty-three and one-third percent of the 
next $50,000 recovered by the claimant(s). 
(3) Twenty-five percent of the next $500,000 
recovered by the claimant(s). 
(4) Fifteen percent of any amount by which the 
recovery by the claimant(s) is in excess of $600,000. 
(b) APPLICABILITY.—The limitations in this section 
shall apply whether the recovery is by judgment, settle-
ment, mediation, arbitration, or any other form of alter-
native dispute resolution. In a health care lawsuit involv-
ing a minor or incompetent person, a court retains the 
authority to authorize or approve a fee that is less than 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00348
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
349 
the maximum permitted under this section. The require-
ment for court supervision in the first two sentences of 
subsection (a) applies only in civil actions. 
(c) STATE FLEXIBILITY.—No provision of this sec-
tion shall be construed to preempt any State law (whether 
effective before, on, or after the date of the enactment of 
this Act) that specifies a lesser percentage or lesser total 
value of damages which may be claimed by an attorney 
representing a claimant in a health care lawsuit. 
SEC. 385. AUTHORIZATION OF PAYMENT OF FUTURE DAM-
AGES TO CLAIMANTS IN HEALTH CARE LAW-
SUITS. 
(a) IN GENERAL.—In any health care lawsuit, if an 
award of future damages, without reduction to present 
value, equaling or exceeding $50,000 is made against a 
party with sufficient insurance or other assets to fund a 
periodic payment of such a judgment, the court shall, at 
the request of any party, enter a judgment ordering that 
the future damages be paid by periodic payments, in ac-
cordance with the Uniform Periodic Payment of Judg-
ments Act promulgated by the National Conference of 
Commissioners on Uniform State Laws. 
(b) APPLICABILITY.—This section applies to all ac-
tions which have not been first set for trial or retrial be-
fore the effective date of this Act. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00349
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
350 
(c) STATE FLEXIBILITY.—No provision of this sec-
tion shall be construed to preempt any State law (whether 
effective before, on, or after the date of the enactment of 
this Act) that specifies periodic payments for future dam-
ages at any amount other than $50,000 or that mandates 
such payments absent the request of either party. 
SEC. 386. PRODUCT LIABILITY FOR HEALTH CARE PRO-
VIDERS. 
A health care provider who prescribes, or who dis-
penses pursuant to a prescription, a medical product ap-
proved, licensed, or cleared by the Food and Drug Admin-
istration shall not be named as a party to a product liabil-
ity lawsuit involving such product and shall not be liable 
to a claimant in a class action lawsuit against the manu-
facturer, distributor, or seller of such product. 
SEC. 387. EFFECT ON OTHER LAWS. 
(a) VACCINE INJURY.— 
(1) To the extent that title XXI of the Public 
Health Service Act establishes a Federal rule of law 
applicable to a civil action brought for a vaccine-re-
lated injury or death— 
(A) this Act does not affect the application 
of the rule of law to such an action; and 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00350
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
351 
(B) any rule of law prescribed by this sub-
title in conflict with a rule of law of such title 
XXI shall not apply to such action. 
(2) If there is an aspect of a civil action 
brought for a vaccine-related injury or death to 
which a Federal rule of law under title XXI of the 
Public Health Service Act does not apply, then this 
subtitle or otherwise applicable law (as determined 
under this subtitle) will apply to such aspect of such 
action. 
(b) OTHER FEDERAL LAW.—Except as provided in 
this section, nothing in this subtitle shall be deemed to 
affect any defense available to a defendant in a health care 
lawsuit or action under any other provision of Federal law. 
SEC. 388. LIMITATION ON EXPERT WITNESS TESTIMONY. 
(a) IN GENERAL.—No person in a health care profes-
sion requiring licensure under the laws of a State shall 
be competent to testify in any court of law to establish 
the following facts— 
(1) the recognized standard of acceptable pro-
fessional practice and the specialty thereof, if any, 
that the defendant practices, which shall be the type 
of acceptable professional practice recognized in the 
defendant’s community or in a community similar to 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00351
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
352 
the defendant’s community that was in place at the 
time the alleged injury or wrongful action occurred; 
(2) that the defendant acted with less than or 
failed to act with ordinary and reasonable care in ac-
cordance with the recognized standard; and 
(3) that as a proximate result of the defend-
ant’s negligent act or omission, the claimant suf-
fered injuries which would not otherwise have oc-
curred, 
unless the person was licensed to practice, in the State 
or a contiguous bordering State, a profession or specialty 
which would make the person’s expert testimony relevant 
to the issues in the case and had practiced this profession 
or specialty in one of these States during the year pre-
ceding the date that the alleged injury or wrongful act 
occurred. 
(b) APPLICABILITY.—The requirements set forth in 
subsection (a) shall also apply to expert witnesses testi-
fying for the defendant as rebuttal witnesses. 
(c) WAIVER AUTHORITY.—The court may waive the 
requirements in this subsection if it determines that the 
appropriate witnesses otherwise would not be available. 
SEC. 389. EXPERT WITNESS QUALIFICATIONS. 
(a) IN GENERAL.—In any health care lawsuit, an in-
dividual shall not give expert testimony on the appropriate 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00352
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
353 
standard of practice or care involved unless the individual 
is licensed as a health professional in one or more States 
and the individual meets the following criteria: 
(1) If the party against whom or on whose be-
half the testimony is to be offered is or claims to be 
a specialist, the expert witness shall specialize at the 
time of the occurrence that is the basis for the law-
suit in the same specialty or claimed specialty as the 
party against whom or on whose behalf the testi-
mony is to be offered. If the party against whom or 
on whose behalf the testimony is to be offered is or 
claims to be a specialist who is board certified, the 
expert witness shall be a specialist who is board cer-
tified in that specialty or claimed specialty. 
(2) During the 1-year period immediately pre-
ceding the occurrence of the action that gave rise to 
the lawsuit, the expert witness shall have devoted a 
majority of the individual’s professional time to one 
or more of the following: 
(A) The active clinical practice of the same 
health profession as the defendant and, if the 
defendant is or claims to be a specialist, in the 
same specialty or claimed specialty. 
(B) The instruction of students in an ac-
credited health professional school or accredited 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00353
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
354 
residency or clinical research program in the 
same health profession as the defendant and, if 
the defendant is or claims to be a specialist, in 
an accredited health professional school or ac-
credited residency or clinical research program 
in the same specialty or claimed specialty. 
(3) If the defendant is a general practitioner, 
the expert witness shall have devoted a majority of 
the witness’s professional time in the 1-year period 
preceding the occurrence of the action giving rise to 
the lawsuit to one or more of the following: 
(A) Active clinical practice as a general 
practitioner. 
(B) Instruction of students in an accred-
ited health professional school or accredited 
residency or clinical research program in the 
same health profession as the defendant. 
(b) LAWSUITS AGAINST ENTITIES.—If the defendant 
in a health care lawsuit is an entity that employs a person 
against whom or on whose behalf the testimony is offered, 
the provisions of subsection (a) apply as if the person were 
the party or defendant against whom or on whose behalf 
the testimony is offered. 
(c) POWER OF COURT.—Nothing in this section shall 
limit the power of the trial court in a health care lawsuit 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00354
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
355 
to disqualify an expert witness on grounds other than the 
qualifications set forth under this subsection. 
(d) LIMITATION.—An expert witness in a health care 
lawsuit shall not be permitted to testify if the fee of the 
witness is in any way contingent on the outcome of the 
lawsuit. 
(e) STATE FLEXIBILITY.—No provision of this sec-
tion shall be construed to preempt any State law (whether 
effective before, on, or after the date of the enactment of 
this Act) that places additional qualification requirements 
upon any individual testifying as an expert witness. 
SEC. 390. COMMUNICATIONS FOLLOWING UNANTICIPATED 
OUTCOME. 
(a) PROVIDER COMMUNICATIONS.—In any health 
care liability action, any and all statements, affirmations, 
gestures, or conduct expressing apology, fault, sympathy, 
commiseration, condolence, compassion, or a general sense 
of benevolence which are made by a health care provider 
or an employee of a health care provider to the patient, 
a relative of the patient, or a representative of the patient 
and which relate to the discomfort, pain, suffering, injury, 
or death of the patient as the result of the unanticipated 
outcome of medical care shall be inadmissible for any pur-
pose as evidence of an admission of liability or as evidence 
of an admission against interest. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00355
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
356 
(b) STATE FLEXIBILITY.—No provision of this sec-
tion shall be construed to preempt any State law (whether 
effective before, on, or after the date of the enactment of 
this Act) that makes additional communications inadmis-
sible as evidence of an admission of liability or as evidence 
of an admission against interest. 
SEC. 391. AFFIDAVIT OF MERIT. 
(a) REQUIRED FILING.—Subject to subsection (b), 
the plaintiff in a health care lawsuit alleging negligence 
or, if the plaintiff is represented by an attorney, the plain-
tiff’s attorney shall file simultaneously with the health 
care lawsuit an affidavit of merit signed by a health pro-
fessional who meets the requirements for an expert wit-
ness under section 242 of this Act. The affidavit of merit 
shall certify that the health professional has reviewed the 
notice and all medical records supplied to him or her by 
the plaintiff’s attorney concerning the allegations con-
tained in the notice and shall contain a statement of each 
of the following: 
(1) The applicable standard of practice or care. 
(2) The health professional’s opinion that the 
applicable standard of practice or care was breached 
by the health professional or health facility receiving 
the notice. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00356
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
357 
(3) The actions that should have been taken or 
omitted by the health professional or health facility 
in order to have complied with the applicable stand-
ard of practice or care. 
(4) The manner in which the breach of the 
standard of practice or care was the proximate cause 
of the injury alleged in the notice. 
(5) A listing of the medical records reviewed. 
(b) FILING EXTENSION.—Upon motion of a party for 
good cause shown, the court in which the complaint is filed 
may grant the plaintiff or, if the plaintiff is represented 
by an attorney, the plaintiff’s attorney an additional 28 
days in which to file the affidavit required under sub-
section (a). 
(c) STATE FLEXIBILITY.—No provision of this sec-
tion shall be construed to preempt any State law (whether 
effective before, on, or after the date of the enactment of 
this Act) that establishes additional requirements for the 
filing of an affidavit of merit or similar pre-litigation docu-
mentation. 
SEC. 392. NOTICE OF INTENT TO COMMENCE LAWSUIT. 
(a) ADVANCE NOTICE.—A person shall not com-
mence a health care lawsuit against a health care provider 
unless the person has given the health care provider 90 
days written notice before the action is commenced. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00357
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
358 
(b) EXCEPTIONS.—A health care lawsuit against a 
health care provider filed within 6 months of the statute 
of limitations expiring as to any claimant, or within 1 year 
of the statute of repose expiring as to any claimant, shall 
be exempt from compliance with this section. 
(c) STATE FLEXIBILITY.—No provision of this sec-
tion shall be construed to preempt any State law (whether 
effective before, on, or after the date of the enactment of 
this Act) that establishes a different time period for the 
filing of written notice. 
SEC. 393. LIMITATION ON LIABILITY FOR VOLUNTEER 
HEALTH CARE PROFESSIONALS. 
(a) IN GENERAL.—Title II of the Public Health Serv-
ice Act (42 U.S.C. 202 et seq.) is amended by inserting 
after section 224 the following: 
‘‘SEC. 224A. LIMITATION ON LIABILITY FOR VOLUNTEER 
HEALTH CARE PROFESSIONALS. 
‘‘(a) LIMITATION ON LIABILITY.—A physician shall 
not be liable under Federal or State law in any civil action 
for any harm caused by an act or omission of such physi-
cian, or attending medical personnel supporting such phy-
sician, if such act or omission— 
‘‘(1) occurs in the course of furnishing qualified 
charity care (as such term is defined in section 
199B of the Internal Revenue Code of 1986); and 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00358
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
359 
‘‘(2) was not grossly negligent. 
‘‘(b) PREEMPTION.—This section preempts the laws 
of a State or any political subdivision of a State to the 
extent that such laws are inconsistent with this section, 
unless such laws provide greater protection from liability 
for a defendant. 
‘‘(c) DEFINITIONS.—In this section: 
‘‘(1) PHYSICIAN.—The term ‘physician’ has the 
meaning given such term by section 1861(r) of the 
Social Security Act. 
‘‘(2) ATTENDING MEDICAL PERSONNEL.—The 
term ‘attending medical personnel’ means an indi-
vidual who is licensed to directly support a physician 
in furnishing medical services.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply to any claim filed to the extent 
that it is with respect to acts or omissions occurring after 
the date of the enactment of this Act. 
SEC. 394. RULES OF CONSTRUCTION. 
(a) HEALTH CARE LAWSUITS.—Unless otherwise 
specified in this subtitle, the provisions governing health 
care lawsuits set forth in this subtitle preempt, subject to 
subsections (b) and (c), State law to the extent that State 
law prevents the application of any provisions of law estab-
lished by or under this subtitle. The provisions governing 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00359
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
360 
health care lawsuits set forth in this subtitle supersede 
chapter 171 of title 28, United States Code, to the extent 
that such chapter— 
(1) provides for a greater amount of damages 
or contingent fees, a longer period in which a health 
care lawsuit may be commenced, or a reduced appli-
cability or scope of periodic payment of future dam-
ages, than provided in this subtitle; or 
(2) prohibits the introduction of evidence re-
garding collateral source benefits, or mandates or 
permits subrogation or a lien on collateral source 
benefits. 
(b) PROTECTION OF STATES’ RIGHTS AND OTHER 
LAWS.—Any issue that is not governed by any provision 
of law established by or under this subtitle (including 
State standards of negligence) shall be governed by other-
wise applicable State or Federal law. 
(c) STATE FLEXIBILITY.—No provision of this sub-
title shall be construed to preempt any defense available 
to a party in a health care lawsuit under any other provi-
sion of State or Federal law. 
SEC. 395. EFFECTIVE DATE. 
This subtitle shall apply to any health care lawsuit 
brought in a Federal or State court, or subject to an alter-
native dispute resolution system, that is initiated on or 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00360
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
361 
after the date of the enactment of this subtitle, except that 
any health care lawsuit arising from an injury occurring 
prior to the date of the enactment of this subtitle shall 
be governed by the applicable statute of limitations provi-
sions in effect at the time the cause of action accrued. 
TITLE IV—MEDICARE AND 
MEDICAID REFORMS 
Subtitle A—Medicaid Reforms 
SEC. 401. MEDICAID PAYMENT REFORM. 
(a) IN GENERAL.—Title XIX of the Social Security 
Act (42 U.S.C. 1396 et seq.) is amended by inserting after 
section 1903 the following section: 
‘‘SEC. 1903A. REFORMED PAYMENT TO STATES. 
‘‘(a) REFORMED PAYMENT SYSTEM.— 
‘‘(1) IN GENERAL.—For quarters beginning on 
or after the implementation date (as defined in sub-
section (k)(1)), in the case of a State that elects (in 
a time and manner specified by the Secretary) to 
apply this section, in lieu of amounts otherwise pay-
able to such State under this title (including any 
payments attributable to section 1923), except as 
otherwise provided in this section, the amount pay-
able to such State shall be equal to the sum of the 
following: 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00361
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
362 
‘‘(A) 
ADJUSTED
AGGREGATE
BENE-
FICIARY-BASED AMOUNT.—The aggregate bene-
ficiary-based amount specified in subsection (b) 
for the quarter and the State, adjusted under 
subsection (e). 
‘‘(B) CHRONIC
CARE
QUALITY
BONUS.— 
The amount (if any) of the chronic care quality 
bonus payment specified in subsection (f) for 
the quarter for the State. 
‘‘(2) REQUIREMENT OF STATE SHARE.— 
‘‘(A) IN GENERAL.—A State shall make, 
from non-Federal funds, expenditures in an 
amount equal to its State share (as determined 
under subparagraph (B)) for a quarter for 
items, services, and other costs for which, but 
for paragraph (1), Federal funds would have 
been payable under this title. 
‘‘(B) STATE SHARE.—The State share for 
a State for a quarter in a fiscal year is equal 
to the product of— 
‘‘(i) the aggregate beneficiary-based 
amount specified in subsection (b) for the 
quarter and the State; and 
‘‘(ii) the ratio of— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00362
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
363 
‘‘(I) the State percentage de-
scribed in subparagraph (D)(ii) for 
such State and fiscal year; to 
‘‘(II) the Federal percentage de-
scribed in subparagraph (D)(i) for 
such State and fiscal year. 
‘‘(C) NONPAYMENT FOR FAILURE TO PAY 
STATE SHARE.— 
‘‘(i) IN GENERAL.—If a State fails to 
expend the amount required under sub-
paragraph (A) for a quarter in a fiscal 
year, the amount payable to the State 
under paragraph (1) shall be reduced by 
the product of the amount by which the 
State payment is less than the State share 
and the ratio of— 
‘‘(I) the Federal percentage de-
scribed in subparagraph (D)(i) for 
such State and fiscal year; to 
‘‘(II) the State percentage de-
scribed in subparagraph (D)(ii) for 
such State and fiscal year. 
‘‘(ii) GRACE PERIOD.—A State shall 
not be considered to have failed to provide 
payment of its required State share for a 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00363
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
364 
quarter under subparagraph (A) if the ag-
gregate State payment towards the State’s 
required State share for the 4-quarter pe-
riod beginning with such quarter exceeds 
the required State share amount for such 
4-quarter period. 
‘‘(D) FEDERAL
AND
STATE
PERCENT-
AGES.—In this paragraph, with respect to a 
State and a fiscal year: 
‘‘(i) 
FEDERAL
PERCENTAGE.—The 
Federal percentage described in this clause 
is 75 percent or, if higher, the Federal 
medical assistance percentage for such 
State for such fiscal year. 
‘‘(ii) STATE PERCENTAGE.—The State 
percentage described in this clause is 100 
percent minus the Federal percentage de-
scribed in clause (i). 
‘‘(E) RULES
FOR
CREDITING
TOWARD 
STATE SHARE.— 
‘‘(i) GENERAL LIMITATION TO MATCH-
ABLE EXPENDITURES.—A payment for ex-
penditures shall not be counted toward the 
State share under subparagraph (A) unless 
Federal payments may be used for such 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00364
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
365 
expenditures consistent with paragraph 
(3)(B). 
‘‘(ii) FURTHER LIMITATIONS ON AL-
LOWABLE EXPENDITURES.—A payment for 
expenditures shall not be counted towards 
the State share under subparagraph (A) if 
the expenditure is for any of the following: 
‘‘(I) 
ABORTION.—Expenditures 
for an abortion. 
‘‘(II) 
INTERGOVERNMENTAL 
TRANSFERS.—An expenditure that is 
attributable to an intergovernmental 
transfer. 
‘‘(III) CERTIFIED
PUBLIC
EX-
PENDITURES.—An expenditure that is 
attributable to certified public expend-
itures. 
‘‘(iii) CREDITING FRAUD AND ABUSE 
RECOVERIES.—Amounts recovered by a 
State through the operation of its Medicaid 
fraud and abuse control unit described in 
section 1903(q) shall be fully counted to-
ward the State share under subparagraph 
(A). 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00365
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
366 
‘‘(F) CONSTRUCTION.—Nothing in the 
paragraph shall be construed as preventing a 
State from expending, from non-Federal funds, 
an amount under this title in excess of the 
amount of the State share. 
‘‘(G) DETERMINATION BASED UPON SUB-
MITTED CLAIMS.—In applying this paragraph 
with respect to expenditures of a State for a 
quarter, the determination of the expenditures 
for such State for such quarter shall be made 
after the end of the period (which, as of the 
date of the enactment of this section, is 2 
years) for which the Secretary accepts claims 
for payment under this title with respect to 
such quarter. 
‘‘(3) USE OF FEDERAL PAYMENTS.— 
‘‘(A) APPLICATION OF MEDICAID LIMITA-
TIONS.—A State may only use Federal pay-
ments received under subsection (a) for expend-
itures for which Federal funds would have been 
payable under this title but for this section. 
‘‘(B) LIMITATION
FOR
CERTAIN
ELIGI-
BLES.— 
‘‘(i) APPLICATION
OF
100
PERCENT 
FEDERAL POVERTY LINE LIMIT ON ELIGI-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00366
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
367 
BILITY.—Subject to clause (iii), a State 
may not use such Federal payments to 
provide medical assistance for an indi-
vidual who has an income (as determined 
under clause (ii)) that exceeds 100 percent 
of the poverty line (as defined in section 
2110(c)(5)) applicable to a family of the 
size involved. 
‘‘(ii) DETERMINATION
OF
INCOME 
USING
MODIFIED
ADJUSTED
GROSS
IN-
COME
WITHOUT
ANY
PERCENT
IN-
CREASE.—In determining income for pur-
poses 
of 
clause 
(i) 
under 
section 
1902(e)(14) (relating to modified adjusted 
gross income), the following rules shall 
apply: 
‘‘(I) APPLICATION
OF
SPEND 
DOWN.—The State shall take into ac-
count the costs incurred for medical 
care or for any other type of remedial 
care recognized under State law in the 
same manner and to the same extent 
that such State takes such costs into 
account 
for 
purposes 
of 
section 
1902(a)(17). 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00367
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
368 
‘‘(II) DISREGARD OF 5 PERCENT 
INCREASE.—Subparagraph (I) of sec-
tion 1902(e)(14) (relating to a 5 per-
cent reduction) shall not apply. 
‘‘(iii) EXCEPTION.—Clause (i) shall 
not apply to an individual who is— 
‘‘(I) a woman described in clause 
(i) of section 1903(v)(4)(A); 
‘‘(II) a child who is an individual 
described in clause (i) of section 
1905(a); 
‘‘(III) enrolled in a State plan 
under this title as of the date of the 
enactment of this section for the pe-
riod of continuous enrollment; or 
‘‘(IV) 
described 
in 
section 
1902(e)(14)(D) (relating to modified 
adjusted gross income). 
‘‘(iv) CLARIFICATION
RELATED
TO 
COMMUNITY
SPOUSE.—Nothing in this 
subparagraph shall supersede the applica-
tion of section 1924 (related to community 
spouse income and assets). 
‘‘(4) EXCEPTIONS
FOR
PASS-THROUGH
PAY-
MENTS.— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00368
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
369 
‘‘(A) IN
GENERAL.—Paragraph (1) shall 
not apply, and amounts shall continue to be 
payable under this title (and not under sub-
section (a)), in the case of the following pay-
ments (and related administrative costs and ex-
penditures): 
‘‘(i) PAYMENTS
TO
TERRITORIES.— 
Payments to a State other than the 50 
States and the District of Columbia. 
‘‘(ii) 
MEDICARE
COST-SHARING.— 
Payments attributable to Medicare cost- 
sharing under section 1905(p). 
‘‘(iii) 
PEDIATRIC
VACCINES.—Pay-
ments attributable to section 1928. 
‘‘(iv) EMERGENCY SERVICES FOR CER-
TAIN
INDIVIDUALS.—Payments for treat-
ment of emergency medical conditions at-
tributable to the application of section 
1903(v)(2). 
‘‘(v) INDIAN
HEALTH
CARE
FACILI-
TIES.—Payments for medical assistance 
described in the third sentence of section 
1905(b). 
‘‘(vi) EMPLOYER-SPONSORED
INSUR-
ANCE (ESI).—Payments for medical assist-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00369
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
370 
ance attributable to payments to employers 
for employer-sponsored health benefits cov-
erage. 
‘‘(vii) OTHER
POPULATIONS
WITH 
LIMITED BENEFIT COVERAGE.—Other pay-
ments that are determined by the Sec-
retary to be related to a specified popu-
lation for which the medical assistance 
under this title is limited and does not in-
clude any inpatient, nursing facility, or 
long-term care services. 
‘‘(B) CERTAIN EXPENSES.—Paragraph (1) 
shall not apply, and amounts shall continue to 
be payable under this title (and not under sub-
section (a)), in the case of the following: 
‘‘(i) ADMINISTRATION
OF
MEDICARE 
PRESCRIPTION DRUG BENEFIT.—Expendi-
tures described in section 1935(b) (relating 
to administration of the Medicare prescrip-
tion drug benefit). 
‘‘(ii) PAYMENTS FOR HIT BONUSES.— 
Payments under section 1903(a)(3)(F) (re-
lating to payments to encourage the adop-
tion and use of certified EHR technology). 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00370
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
371 
‘‘(iii) PAYMENTS FOR DESIGN, DEVEL-
OPMENT, AND INSTALLATION OF MMIS AND 
ELIGIBILITY
SYSTEMS.—Payments under 
subparagraphs (A)(i) and (H)(i) of section 
1903(a)(3) for expenditures for design, de-
velopment, and installation of the Medicaid 
management 
information 
systems 
and 
mechanized verification and information 
retrieval systems (related to eligibility). 
‘‘(5) PAYMENT OF AMOUNTS.— 
‘‘(A) IN
GENERAL.—Except as the Sec-
retary may otherwise provide, amounts shall be 
payable to a State under subsection (a) in the 
same manner as amounts are payable under 
subsection (d) of section 1903 to a State under 
subsection (a) of such section. 
‘‘(B) INFORMATION AND FORMS.— 
‘‘(i) SUBMISSION.—As a condition of 
receiving payment under subsection (a), a 
State shall submit such information, in 
such form, and manner, as the Secretary 
shall specify, including information nec-
essary to make the computations under 
subsections (c)(2)(C) and (e). 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00371
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
372 
‘‘(ii) 
UNIFORM
REPORTING.—The 
Secretary shall develop such forms as may 
be needed to assure a system of uniform 
reporting 
of 
such 
information 
across 
States. 
‘‘(C) REQUIRED REPORTING OF INFORMA-
TION ON MEDICAL LOSS RATIOS FOR MANAGED 
CARE.—The information required to be reported 
under subparagraph (B)(i) shall include infor-
mation on the medical loss ratio with respect to 
coverage provided under each Medicaid man-
aged care plan with a contract with the State 
under section 1903(m) or 1932. 
‘‘(b) AGGREGATE BENEFICIARY-BASED AMOUNT.— 
‘‘(1) IN GENERAL.—The aggregate beneficiary- 
based amount specified in this subsection for a State 
for a quarter is equal to the sum of the products, 
for each of the categories of Medicaid beneficiaries 
specified in paragraph (2), of the following: 
‘‘(A) 
BENEFICIARY-BASED
QUARTERLY 
AMOUNT.—The 
beneficiary-based 
quarterly 
amount for such category computed under sub-
section (c) for such State for such quarter. 
‘‘(B) NUMBER
OF
INDIVIDUALS
IN
CAT-
EGORY.—Subject to subsection (d), the average 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00372
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
373 
number of Medicaid beneficiaries enrolled in 
such category in the State in such quarter. 
‘‘(2) CATEGORIES.—The categories specified in 
this paragraph are the following: 
‘‘(A) ELDERLY.—A category of Medicaid 
beneficiaries who are 65 years of age or older. 
‘‘(B) BLIND OR DISABLED.—A category of 
Medicaid beneficiaries not described in subpara-
graph (A) who are described in section 
1937(a)(2)(B)(ii). 
‘‘(C) CHILDREN.—A category of Medicaid 
beneficiaries not described in subparagraph (B) 
who are under 21 years of age. 
‘‘(D) OTHER ADULTS.—A category of any 
Medicaid beneficiaries who are not described in 
a previous subparagraph of this paragraph. 
‘‘(c) COMPUTATION OF PER BENEFICIARY, PER CAT-
EGORY QUARTERLY AMOUNT.— 
‘‘(1) IN GENERAL.—For a State, for each cat-
egory of beneficiary for a quarter— 
‘‘(A) FIRST REFORM YEAR.—For quarters 
in the first reform year (as defined in sub-
section (k)(2)), the beneficiary-based quarterly 
amount is equal to 1⁄4 of the base average per 
beneficiary Federal payments for such State for 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00373
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
374 
such category determined under paragraph (2), 
increased by a factor that reflects the sum of 
the following: 
‘‘(i) HISTORICAL MEDICAL CARE COM-
PONENT OF CPI THROUGH PREVIOUS RE-
FORM YEAR.—The percentage increase in 
the historical medical care component of 
the Consumer Price Index for all urban 
consumers (U.S. city average) from the 
midpoint of the base fiscal year (as defined 
in paragraph (6)) to the midpoint of the 
fiscal year preceding the first reform year. 
‘‘(ii) PROJECTED MEDICAL CARE COM-
PONENT OF CPI FOR THE FIRST REFORM 
YEAR.—The percentage increase in the 
projected medical care component of the 
Consumer Price Index for all urban con-
sumers (U.S. city average) from the mid-
point of the previous fiscal year referred to 
in clause (i) to the midpoint of the first re-
form year. 
‘‘(B) 
SECOND
AND
THIRD
REFORM 
YEARS.—The 
beneficiary-based 
quarterly 
amount for a State for a category for quarters 
in the second reform year or the third reform 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00374
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
375 
year is equal to the beneficiary-based quarterly 
amount under this paragraph for such State 
and category for the previous reform year in-
creased by the per beneficiary percentage in-
crease (as defined in subparagraph (E)) for 
such category and reform year. 
‘‘(C) FOURTH THROUGH TENTH REFORM 
YEARS.—The 
beneficiary-based 
quarterly 
amount for a State for a category for quarters 
in a reform year beginning with the fourth re-
form year and ending with the tenth reform 
year is— 
‘‘(i) in the case of a State that is a 
high per beneficiary State or a low per 
beneficiary State (as defined in paragraph 
(4)(B)(iii)) for the category, the amount 
determined under clause (i) or (ii) of para-
graph (4)(B) for such State, category, and 
reform year; or 
‘‘(ii) in the case of any other State, 
the beneficiary-based quarterly amount 
under this paragraph for such State and 
category for the previous reform year in-
creased by the per beneficiary percentage 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00375
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
376 
increase for such category and reform 
year. 
‘‘(D) ELEVENTH REFORM YEAR AND SUB-
SEQUENT
REFORM
YEARS.—The beneficiary- 
based quarterly amount for a State for a cat-
egory for quarters in a reform year beginning 
with the eleventh reform year is equal to the 
beneficiary-based quarterly amount under this 
paragraph for such State and category for the 
previous reform year increased by the per bene-
ficiary percentage increase for such category 
and reform year. 
‘‘(E) ANNUAL PERCENTAGE INCREASE BE-
GINNING
WITH
SECOND
REFORM
YEAR.—For 
purposes of this subsection, the term ‘per bene-
ficiary percentage increase’ means, for a reform 
year, the sum of— 
‘‘(i) the projected percentage change 
in nominal gross domestic product from 
the midpoint of the previous reform year to 
the midpoint of the reform year for which 
the percentage increase is being applied; 
and 
‘‘(ii) one percentage point. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00376
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
377 
‘‘(2) BASE PER BENEFICIARY, PER CATEGORY 
AMOUNT FOR EACH STATE.— 
‘‘(A) AVERAGE PER CATEGORY.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall determine, consistent with this para-
graph and paragraph (3), a base per bene-
ficiary, per category amount for each of 
the 50 States and the District of Columbia 
equal to the average amount, per Medicaid 
beneficiary, of Federal payments under 
this title, including payments attributable 
to disproportionate share hospital pay-
ments under section 1923, for each of the 
categories of beneficiaries under subsection 
(b)(2) for the base fiscal year for each of 
the 50 States and the District of Colum-
bia. 
‘‘(ii) BEST
AVAILABLE
DATA.—The 
determination under clause (i) shall ini-
tially be estimated by the Secretary, based 
upon the best available data at the time 
the determination is made. 
‘‘(iii) UPDATES.—The determination 
under clause (i) shall be updated by the 
Secretary on an annual basis based upon 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00377
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
378 
improved data. The Secretary shall adjust 
the amounts under subsection (a)(1)(A) to 
reflect changes in the amounts so deter-
mined based on such updates. 
‘‘(B) EXCLUSION OF PASS-THROUGH PAY-
MENTS.—In computing base per beneficiary, 
per category amounts under subparagraph 
(A)(i) the Secretary shall exclude payments de-
scribed in subsection (a)(4). 
‘‘(C) STANDARDIZATION.— 
‘‘(i) IN GENERAL.—In computing each 
such amount, the Secretary shall stand-
ardize the amount in order to remove the 
variation attributable to the following: 
‘‘(I) RISK FACTORS.—Such risk 
factors as age, health and disability 
status (including high cost medical 
conditions), gender, institutional sta-
tus, and such other factors as the 
Secretary determines to be appro-
priate, so as to ensure actuarial 
equivalence. 
‘‘(II) 
GEOGRAPHIC.—Variations 
in costs on a county-by-county basis. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00378
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
379 
‘‘(ii) 
METHOD
OF
STANDARDIZA-
TION.— 
‘‘(I) CONSULTATION
IN
DEVEL-
OPMENT
OF
RISK
STANDARDIZA-
TION.—In developing the methodology 
for risk standardization for purposes 
of clause (i)(I), the Secretary shall 
consult with the Medicaid and CHIP 
Payment and Access Commission, the 
Medicare Payment Advisory Commis-
sion, and the National Association of 
Medicaid Directors. 
‘‘(II) METHOD FOR RISK STAND-
ARDIZATION.—In carrying out clause 
(i)(I), the Secretary may apply the 
hierarchal condition category method-
ology under section 1853(a)(1)(C). If 
the Secretary uses such methodology, 
the Secretary shall adjust the applica-
tion of such methodology to take into 
account the differences in services 
provided under this title compared to 
title XVIII, such as the coverage of 
long term care, pregnancy, and pedi-
atric services. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00379
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
380 
‘‘(III) METHOD FOR GEOGRAPHIC 
STANDARDIZATION.—The 
Secretary 
shall apply the standardization under 
clause (i)(II) in a manner similar to 
that 
applied 
under 
section 
1853(c)(4)(A)(iii). 
‘‘(iii) APPLICATION ON A NATIONAL, 
BUDGET NEUTRAL BASIS.—The standard-
ization under clause (i) shall be designed 
and implemented on a uniform national 
basis and shall be budget neutral so as to 
not result in any aggregate change in pay-
ments under subsection (a). 
‘‘(iv) RESPONSE TO NEW RISK.—Sub-
ject to clause (iii), the Secretary may ad-
just the standardization under clause (i) to 
respond promptly to new instances of com-
municable diseases and other public health 
hazards. 
‘‘(v) REFERENCE TO APPLICATION OF 
RISK ADJUSTMENT.—For rules related to 
the application of risk adjustment to 
amounts under subsection (a)(1)(A), see 
subsection (e). 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00380
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
381 
‘‘(D) ADJUSTMENT FOR TEMPORARY FMAP 
INCREASES.—In computing each base per bene-
ficiary, per category amounts under subpara-
graph (A)(i) the Secretary shall disregard por-
tions of payments that are attributable to a 
temporary increase in the Federal matching 
rates, including those attributable to the fol-
lowing: 
‘‘(i) PPACA DISASTER
FMAP.—Sec-
tion 1905(aa). 
‘‘(ii) ARRA.—Section 5001 of the 
American Recovery and Reinvestment Act 
of 2009 (42 U.S.C. 1396d note). 
‘‘(iii) 
EXTRAORDINARY
EMPLOYER 
PENSION CONTRIBUTION.—Section 614 of 
the Children’s Health Insurance Program 
Reauthorization Act of 2009 (42 U.S.C. 
1396d note). 
‘‘(3) ALLOCATION OF NONMEDICAL ASSISTANCE 
PAYMENTS.—The Secretary shall establish rules for 
the allocation of payments under this title (other 
than those payments described in paragraph (1) or 
(5) of section 1903(a) and including such payments 
attributable to section 1923)— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00381
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
382 
‘‘(A) among different categories of bene-
ficiaries; and 
‘‘(B) between payments included under 
subsection (a)(1) and payments described in 
subsection (a)(4). 
‘‘(4) TRANSITION TO A CORRIDOR AROUND THE 
NATIONAL AVERAGE.— 
‘‘(A) DETERMINATION OF NATIONAL AVER-
AGE BASE PER BENEFICIARY, PER CATEGORY 
AMOUNT.—Subject to subparagraph (C), the 
Secretary shall determine a national average 
base per beneficiary, per category amount equal 
to the average of the base per beneficiary, per 
category amounts for each of the 50 States and 
the District of Columbia determined under 
paragraph (2), weighted by the average number 
of beneficiaries in each such category and State 
as determined by the Secretary consistent with 
subsection (d) for the base fiscal year. 
‘‘(B) TRANSITION ADJUSTMENT.— 
‘‘(i) 
HIGH
PER
BENEFICIARY 
STATES.—In the case of a high per bene-
ficiary State (as defined in clause (iii)(I)) 
for a category, the beneficiary-based quar-
terly amount for such State and category 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00382
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
383 
for a quarter in a reform year (beginning 
with the fourth reform year and ending 
with the tenth reform year) is equal to the 
sum of— 
‘‘(I) the product of the State-spe-
cific factor for such reform year (as 
defined in clause (iv)) and the bene-
ficiary-based quarterly amount that 
would otherwise be determined under 
paragraph (1) for such State and cat-
egory if the State were a State de-
scribed in clause (ii) of paragraph 
(1)(C), instead of a State described in 
clause (i) of such paragraph; and 
‘‘(II) the product of 1 minus the 
State-specific factor for such reform 
year and the beneficiary-based quar-
terly amount that would otherwise be 
determined under paragraph (1) for a 
State and category if the base per 
beneficiary, per category amount de-
termined under paragraph (2) for the 
State and category were equal to 110 
percent of the national average base 
per beneficiary, per category amount 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00383
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
385 
determined under paragraph (1) for a 
State and category if the base per 
beneficiary, per category amount de-
termined under paragraph (2) for the 
State and category were equal to 90 
percent of the national average base 
per beneficiary, per category amount 
determined under subparagraph (A) 
for such category. 
‘‘(iii) HIGH
AND
LOW
PER
BENE-
FICIARY
STATES
DEFINED.—In this sub-
paragraph: 
‘‘(I) HIGH
PER
BENEFICIARY 
STATE.—The term ‘high per bene-
ficiary State’ means, with respect to a 
category, a State for which the base 
per beneficiary, per category amount 
determined under paragraph (2) for 
such category is greater than 110 per-
cent of the national average base per 
beneficiary, per category amount de-
termined under subparagraph (A) for 
such category. 
‘‘(II) LOW
PER
BENEFICIARY 
STATE.—The term ‘low per bene-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00385
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
386 
ficiary State’ means, with respect to a 
category, a State for which the base 
per beneficiary, per category amount 
determined under paragraph (2) for 
such category is less than 90 percent 
of the national average base per bene-
ficiary, per category amount deter-
mined under subparagraph (A) for 
such category. 
‘‘(iv) STATE-SPECIFIC
FACTOR.—In 
this subparagraph, the term ‘State-specific 
factor’ means— 
‘‘(I) for the fourth reform year, 
7⁄8; and 
‘‘(II) for a subsequent reform 
year, the State-specific factor under 
this clause for the previous reform 
year minus 1⁄8. 
‘‘(C) NO ADDITIONAL EXPENDITURES.— 
‘‘(i) DETERMINATION OF INCREASE IN 
FEDERAL EXPENDITURES.—For each cat-
egory for each reform year (beginning with 
the fourth reform year and ending with the 
tenth reform year), the Secretary shall de-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00386
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
387 
termine whether the application of this 
paragraph— 
‘‘(I) to the category for the re-
form year will result in an aggregate 
increase in the aggregate Federal ex-
penditures under subsection (a); and 
‘‘(II) to all the categories for the 
reform year will result in a net aggre-
gate increase in the aggregate Federal 
expenditures under subsection (a). 
‘‘(ii) ADJUSTMENT.—If the Secretary 
determines under clause (i)(II) that the 
application of this paragraph to all the cat-
egories for a reform year will result in a 
net aggregate increase in the aggregate 
Federal expenditures under subsection (a), 
the Secretary shall reduce the national av-
erage base per beneficiary, per category 
amount computed under subparagraph (A) 
for each of the categories determined 
under clause (i)(I) for which there will be 
an aggregate increase in the aggregate 
Federal expenditures under subsection (a) 
by such uniform percentage as will ensure 
that there is no net aggregate Federal ex-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00387
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
388 
penditure increase described in clause 
(i)(II) for the reform year. 
‘‘(5) REPORTS
ON
PER
BENEFICIARY
RATES; 
APPEALS.— 
‘‘(A) REPORT TO STATES.—Not later than 
8 months after the date of the enactment of 
this section, the Secretary shall submit to each 
State the Secretary’s initial determination of— 
‘‘(i) the base per beneficiary, per cat-
egory amounts under paragraph (2) for 
such State; and 
‘‘(ii) the national average base per 
beneficiary, per category amounts under 
paragraph (4)(A). 
‘‘(B) OPPORTUNITY
TO
APPEAL.—Not 
later than 3 months after the date a State re-
ceives notice of the Secretary’s initial deter-
mination of such base per beneficiary, per cat-
egory amounts for such State under subpara-
graph (A)(i), the State may file with the Sec-
retary, in a form and manner specified by the 
Secretary, an appeal of such determination. 
‘‘(C) DETERMINATION
ON
APPEAL.—Not 
later than 3 months after receiving such an ap-
peal, the Secretary shall make a final deter-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00388
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
389 
mination on such amounts for such State. If no 
such appeal is received for a State, the Sec-
retary’s initial determination under subpara-
graph (A)(i) shall become final. 
‘‘(6) BASE
FISCAL
YEAR
DEFINED.—In this 
section, the term ‘base fiscal year’ means the latest 
fiscal year, ending before the date of the enactment 
of this section, for which the Secretary determines 
that adequate data are available to make the com-
putations required under this subsection. 
‘‘(d) NOT COUNTING INDIVIDUALS TO ACCOUNT FOR 
EXCLUDED PAYMENTS.—Under rules specified by the 
Secretary, individuals shall not be counted as Medicaid 
beneficiaries for purposes of subsection (b)(1)(B) and sub-
section (c)(2)(A) to the extent that such individuals— 
‘‘(1) are receiving medical assistance for which 
payments described under subsection (a)(4)(A) are 
made; or 
‘‘(2) would not have been eligible to enroll 
under the State plan (or waiver of such plan) in the 
State in which such individual is so enrolled if the 
rules for eligibility for enrollment under such plan 
(or waiver) were the same as such rules for eligi-
bility in effect as of January 1, 2009. 
‘‘(e) RISK ADJUSTMENT.— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00389
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
390 
‘‘(1) IN
GENERAL.—The amount under sub-
section (a)(1)(A) shall be adjusted under this sub-
section in an appropriate manner, specified by the 
Secretary and consistent with paragraph (2), to take 
into account— 
‘‘(A) the factors described in subsection 
(c)(2)(C)(i)(I) within a category of bene-
ficiaries; and 
‘‘(B) variations in costs on a county-by- 
county basis for medical assistance and admin-
istrative expenses. 
‘‘(2) METHOD OF ADJUSTMENT.— 
‘‘(A) 
IN
GENERAL.—The 
adjustments 
under paragraph (1) shall be made in a manner 
similar to the manner in which similar adjust-
ments are made under subsection (c)(2)(C) and 
consistent with the requirements of clause (iii) 
of such subsection and subparagraph (B). 
‘‘(B) BIANNUAL UPDATE OF RISK ADJUST-
MENT
METHODOLOGY.—In 
applying 
clause 
(i)(I) of subsection (c)(2)(C) for purposes of 
subparagraph (A), the Secretary shall, in con-
sultation with the entities described in clause 
(ii)(I) of such subsection, update the risk ad-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00390
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
391 
justment methodology applied as appropriate 
not less often than every 2 years. 
‘‘(f) CHRONIC CARE QUALITY BONUS PAYMENTS.— 
‘‘(1) DETERMINATION OF BONUS PAYMENTS.— 
If the Secretary determines that, based on the re-
ports under paragraph (5), with respect to cat-
egories of chronic disease for which chronic care per-
formance targets had been established under para-
graph (3) for each category of Medicaid beneficiaries 
specified under subsection (b)(2) such targets have 
been met by a State for a reform year, the Secretary 
shall make an additional payment to such State in 
the amount specified in paragraph (6) for each quar-
ter in the succeeding reform year. Such payments 
shall be made in a manner specified by the Secretary 
and may only be used consistent with subsection 
(a)(3). 
‘‘(2) IDENTIFICATION
OF
CATEGORIES
OF 
CHRONIC DISEASE.—The Secretary shall determine 
the categories of chronic disease for which bonus 
payments may be available under this subsection for 
each category of Medicaid beneficiaries. 
‘‘(3) ADOPTION
OF
QUALITY
MEASUREMENT 
SYSTEM
AND
IDENTIFICATION
OF
PERFORMANCE 
TARGETS.— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00391
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
392 
‘‘(A) SYSTEM AND DATA.—With respect to 
the categories of chronic disease under para-
graph (2), the Secretary shall adopt a quality 
measurement system that uses data described 
in paragraph (4) and is similar to the Five-Star 
Quality Rating System used to indicate the per-
formance of Medicare Advantage plans under 
part C of title XVIII. 
‘‘(B) TARGETS.—Using such system and 
data, the Secretary shall establish for each re-
form year the chronic care performance targets 
for purposes of the payments under paragraph 
(1). Such performance targets shall be estab-
lished in consultation with States, associations 
representing individuals with chronic illnesses, 
entities providing treatment to such individuals 
for such chronic illnesses, and other stake-
holders, including the National Association of 
Medicaid Directors and the National Governors 
Association. 
‘‘(4) DATA TO BE USED.—The data to be used 
under paragraph (3) shall include— 
‘‘(A) data collected through methods such 
as— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00392
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
393 
‘‘(i) the ‘Healthcare Effectiveness 
Data and Information Set’ (also known as 
‘HEDIS’) (or an appropriate successor 
performance measurement tool); 
‘‘(ii) the ‘Consumer Assessment of 
Healthcare Providers and Systems’ (also 
known as ‘CAHPS’) (or an appropriate 
successor performance measurement tool); 
and 
‘‘(iii) the ‘Health Outcomes Survey’ 
(also known as ‘HOS’) (or an appropriate 
successor performance measurement tool); 
and 
‘‘(B) other data collected by the State. 
‘‘(5) REPORTS.— 
‘‘(A) IN GENERAL.—Each State shall col-
lect, analyze, and report to the Secretary, at a 
frequency and in a manner to be established by 
the Secretary, data described in paragraph (4) 
that permit the Secretary to monitor the State’s 
performance relative to the chronic care per-
formance targets established under paragraph 
(3). 
‘‘(B) REVIEW
AND
VERIFICATION.—The 
Secretary may review the data collected by the 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00393
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
394 
State under subparagraph (A) to verify the 
State’s analysis of such data with respect to the 
performance targets under paragraph (3). 
‘‘(6) AMOUNT OF BONUS PAYMENTS.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graphs (B) and (C), with respect to each cat-
egory of Medicaid beneficiaries, in the case of 
a State that the Secretary determines, based on 
the chronic care performance targets set under 
paragraph (3) for a reform year for such cat-
egory, performs— 
‘‘(i) in the top five States in such cat-
egory, subject to subparagraph (C)(ii), the 
amount of the bonus for each quarter in 
the succeeding reform year shall be 10 per-
cent of the payment amount otherwise paid 
to the State under subsection (a) for indi-
viduals enrolled under the plan within such 
category; 
‘‘(ii) in the next five States in such 
category, subject to subparagraph (C)(ii), 
the amount of the bonus for each such 
quarter shall be 5 percent of the payment 
amount otherwise paid to the State under 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00394
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
395 
subsection (a) for individuals enrolled 
under the plan within such category; 
‘‘(iii) in the next five States in such 
category, subject to clauses (i) and (iii) of 
subparagraph (C), the amount of the 
bonus for each such quarter shall be 3 per-
cent of the payment amount otherwise paid 
to the State under subsection (a) for indi-
viduals enrolled under the plan within such 
category; 
‘‘(iv) in the next five States in such 
category, subject to clauses (i) and (iii) of 
subparagraph (C), the amount of the 
bonus for each such quarter shall be 2 per-
cent of the payment amount otherwise paid 
to the State under subsection (a) for indi-
viduals enrolled under the plan within such 
category; and 
‘‘(v) in the next five States in such 
category, subject to clauses (i) and (iii) of 
subparagraph (C), the amount of the 
bonus for each such quarter shall be 1 per-
cent of the payment amount otherwise paid 
to the State under subsection (a) for indi-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00395
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
396 
viduals enrolled under the plan within such 
category. 
‘‘(B) AGGREGATE
ANNUAL
LIMIT
FOR 
EACH
CATEGORY
OF
MEDICAID
BENE-
FICIARIES.— 
‘‘(i) IN GENERAL.—In no case may 
the aggregate amount of bonuses under 
this subsection for quarters in a reform 
year for a category of Medicaid bene-
ficiaries exceed the limit specified in clause 
(ii) for the reform year. 
‘‘(ii) LIMIT.—The limit specified in 
this clause— 
‘‘(I) for the second reform year is 
equal to $250,000,000; or 
‘‘(II) for a subsequent reform 
year is equal to the limit specified in 
this clause for the previous reform 
year increased by the per beneficiary 
percentage increase determined under 
paragraph (1)(E) of subsection (c). 
‘‘(C) LIMITATION AND PRORATION OF BO-
NUSES BASED ON APPLICATION OF AGGREGATE 
LIMIT.— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00396
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
398 
graph (A) for a category of Medicaid bene-
ficiaries for quarters in a reform year is 
less than the limit specified in subpara-
graph (B)(ii) for the reform year, but the 
aggregate amount of bonuses under clauses 
(i) through (v) of subparagraph (A) for the 
category and such quarters in the reform 
year exceeds the limit specified in subpara-
graph (B)(ii) for the reform year, the 
amount of each bonus in clauses (iii), (iv), 
and (v) of subparagraph (A) shall be pro-
rated in a manner so the aggregate 
amount of all the bonuses under subpara-
graph (A) is equal to such limit. 
‘‘(g) STATE OPTION FOR RECEIVING MEDICARE PAY-
MENTS FOR FULL-BENEFIT DUAL ELIGIBLE INDIVID-
UALS.— 
‘‘(1) IN
GENERAL.—Under this subsection a 
State may elect for quarters beginning on or after 
the implementation date in a reform year to receive 
payment from the Secretary under paragraph (3). 
As a condition of receiving such payment, the State 
shall agree to provide to full-benefit dual eligible in-
dividuals eligible for medical assistance under the 
State plan— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00398
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
399 
‘‘(A) the medical assistance to which such 
eligible individuals would otherwise be entitled 
under this title; and 
‘‘(B) any items and services which such eli-
gible individuals would otherwise receive under 
title XVIII. 
‘‘(2) PROVIDER PAYMENT REQUIREMENT.— 
‘‘(A) IN GENERAL.—A State electing the 
option under this subsection shall provide pay-
ment to health care providers for the items and 
services described under paragraph (1)(B) at a 
rate that is not less than the rate at which pay-
ments would be made to such providers for such 
items and services under title XVIII. 
‘‘(B) FLEXIBILITY
IN
PAYMENT
METH-
ODS.—Nothing in subparagraph (A) shall be 
construed as preventing a State from using al-
ternative payment methodologies (such as bun-
dled payments or the use of accountable care 
organizations (as such term is used in section 
1899)) for purposes of making payments to 
health care providers for items and services pro-
vided to dual eligible individuals in the State 
under the option under this subsection. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00399
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
400 
‘‘(3) PAYMENTS TO STATES IN LIEU OF MEDI-
CARE
PAYMENTS.—With respect to a full-benefit 
dual eligible individual, in the case of a State that 
elects the option under paragraph (1) for quarters in 
a reform year— 
‘‘(A) the Secretary shall not make any pay-
ment under title XVIII for items and services 
furnished to such individual for such quarters; 
and 
‘‘(B) the Secretary shall pay to the State, 
in addition to the amounts paid to such State 
under subsection (a), the amount that the Sec-
retary would, but for this subsection, otherwise 
pay under title XVIII for items and services 
furnished to such an individual in such State 
for such quarters. 
‘‘(4) FULL-BENEFIT
DUAL
ELIGIBLE
INDI-
VIDUAL
DEFINED.—In this subsection, the term 
‘full-benefit dual eligible individual’ means an indi-
vidual who meets the requirements of section 
1935(c)(6)(A)(ii). 
‘‘(h) AUDITS.—The Secretary shall conduct such au-
dits on the number and classification of Medicaid bene-
ficiaries under such subsections and expenditures under 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00400
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
401 
this section as may be necessary to ensure appropriate 
payments under this section. 
‘‘(i) TREATMENT OF WAIVERS.— 
‘‘(1) NO IMPACT ON CURRENT WAIVERS.—In 
the case of a waiver of requirements of this title pur-
suant to section 1115 or other law that is in effect 
as of the date of the enactment of this section, noth-
ing in this section shall be construed to affect such 
waiver for the period of the waiver as approved as 
of such date. 
‘‘(2) APPLICATION OF BUDGET NEUTRALITY TO 
SUBSEQUENT WAIVERS AND RENEWALS TAKING SEC-
TION INTO ACCOUNT.—In the case of a waiver of re-
quirements of this title pursuant to section 1115 or 
other law that is approved or renewed after the date 
of the enactment of this section, to the extent that 
such approval or renewal is conditioned upon a dem-
onstration of budget neutrality, budget neutrality 
shall be determined taking into account the applica-
tion of this section. 
‘‘(j) REPORT TO CONGRESS.—Not later than Janu-
ary 1 of the second reform year, the Secretary shall submit 
to Congress a report on the implementation of this section. 
‘‘(k) DEFINITIONS.—In this section: 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00401
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
402 
‘‘(1) IMPLEMENTATION DATE.—The term ‘im-
plementation date’ means— 
‘‘(A) July 1, 2023, if this section is en-
acted on or before July 1, 2022; or 
‘‘(B) July 1, 2024, if this section is en-
acted after July 1, 2022. 
‘‘(2) REFORM YEARS.— 
‘‘(A) The term ‘reform year’ means a fiscal 
year beginning with the first reform year. 
‘‘(B) The term ‘first reform year’ means 
the fiscal year in which the implementation date 
occurs. 
‘‘(C) The terms ‘second’, ‘third’, and suc-
cessive similar terms mean, with respect to a 
reform year, the second, third, or successive re-
form year, respectively, succeeding the first re-
form year.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) CONTINUED
APPLICATION
OF
CLAWBACK 
PROVISIONS.— 
(A) 
CONTINUED
APPLICATION.—Sub-
sections (a) and (c)(1)(C) of section 1935 of 
such Act (42 U.S.C. 1396u–5) are each amend-
ed by inserting ‘‘or 1903A(a)’’ after ‘‘1903(a)’’. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00402
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
403 
(B) 
TECHNICAL
AMENDMENT.—Section 
1935(d)(1) of the Social Security Act (42 
U.S.C. 1396u–5(d)(1)) is amended by inserting 
‘‘except as provided in section 1903A(g)’’ after 
‘‘any other provision of this title’’. 
(2) PAYMENT RULES UNDER SECTION 1903.— 
(A) Section 1903(a) of the Social Security 
Act (42 U.S.C. 1396b(a)) is amended, in the 
matter before paragraph (1), by inserting ‘‘and 
section 1903A’’ after ‘‘except as otherwise pro-
vided in this section’’. 
(B) Section 1903(d) of such Act (42 
U.S.C. 1396b(d)) is amended— 
(i) in paragraph (1), by inserting 
‘‘and under section 1903A’’ after ‘‘sub-
sections (a) and (b)’’; 
(ii) in paragraph (2)— 
(I) in subparagraph (A), by in-
serting ‘‘or section 1903A’’ after ‘‘was 
made under this section’’; and 
(II) in subparagraph (B), by in-
serting ‘‘or section 1903A’’ after 
‘‘under subsection (a)’’; 
(iii) in paragraph (4)— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00403
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
404 
(I) by striking ‘‘under this sub-
section’’ and inserting ‘‘, with respect 
to this section or section 1903A, 
under this subsection’’; and 
(II) by striking ‘‘under this sec-
tion’’ and inserting ‘‘under the respec-
tive section’’; and 
(iv) in paragraph (5), by inserting ‘‘or 
section 1903A’’ after ‘‘overpayment under 
this section’’. 
(3) CONFORMING WAIVER AUTHORITY.—Section 
1115(a)(2)(A) of the Social Security Act (42 U.S.C. 
1315(a)(2)(A)) is amended by striking ‘‘or 1903’’ 
and inserting ‘‘1903, or 1903A’’. 
(4) REPORT
ON
ADDITIONAL
CONFORMING 
AMENDMENTS NEEDED.—Not later than 6 months 
after the date of the enactment of this Act, the Sec-
retary of Health and Human Services shall submit 
to Congress a report that includes a description of 
any additional technical and conforming amend-
ments to law that are required to properly carry out 
this Act. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00404
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
405 
SEC. 402. INCOME LIMITATIONS FOR REFUNDABLE CRED-
ITS FOR COVERAGE UNDER A QUALIFIED 
HEALTH PLAN. 
(a) IN GENERAL.—Subparagraphs (A) and (B) of 
section 36B(c)(1) of the Internal Revenue Code of 1986 
are amended by inserting after ‘‘100 percent’’ each place 
such term appears the following: ‘‘(or, in the case of a 
taxpayer enrolled through an Exchange utilized by such 
State that makes the election described in section 1903A 
of the Social Security Act, the percentage established by 
such State under part A of title IV of such Act for pur-
poses of eligibility under title XIX of such Act as of Janu-
ary 1, 2009)’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to taxable years begin-
ning after the date of the enactment of this Act. 
SEC. 403. MEDICAID ELIGIBILITY DETERMINATIONS. 
(a) STATE FLEXIBILITY TO USE CONTRACTORS TO 
MAKE ELIGIBILITY DETERMINATIONS
ON BEHALF
OF 
STATE.—Section 1902(a)(5) of the Social Security Act 
(42 U.S.C. 1396a(a)(5)) is amended by inserting before 
the semicolon at the end the following: ‘‘, but such deter-
minations of eligibility may be made, at the option of a 
State, under a contract with another State or local agency 
or a contractor so long as the contract does not provide 
incentives for the agency or contractor to delay eligibility 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00405
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
406 
determinations or to deny eligibility for individuals other-
wise eligible for medical assistance’’. 
(b) FREQUENCY
OF ELIGIBILITY REDETERMINA-
TIONS.—Section 1902(e)(14) of the Social Security Act 
(42 U.S.C. 1396a(e)(14)) is amended by adding at the 
end the following: 
‘‘(L) FREQUENCY OF ELIGIBILITY REDE-
TERMINATIONS.—Beginning 
on 
October 
1, 
2022, and notwithstanding subparagraph (H), 
in the case of an individual whose eligibility for 
medical assistance under the State plan under 
this title (or a waiver of such plan) is deter-
mined based on the application of modified ad-
justed gross income under subparagraph (A) 
and who is so eligible on the basis of clause 
(i)(VIII), (ii)(XX), or (ii)(XXIII) of subsection 
(a)(10)(A), at the option of the State, the State 
plan may provide that the individual’s eligibility 
shall be redetermined every 6 months (or such 
shorter number of months as the State may 
elect).’’. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00406
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
407 
SEC. 404. LOWERING SAFE HARBOR THRESHOLD WITH RE-
SPECT TO STATE TAXES ON HEALTH CARE 
PROVIDERS. 
Section 1903(w)(4)(C)(ii) of the Social Security Act 
(42 U.S.C. 1396b(w)(4)(C)(ii)) is amended— 
(1) by striking ‘‘of fiscal years beginning’’ and 
inserting ‘‘of fiscal years— 
‘‘(I) beginning’’; and 
(2) by striking ‘‘it appears.’’ and inserting the 
following: ‘‘it appears; 
‘‘(II) beginning on or after January 1, 
2021, and before January 1, 2030, ‘4 percent’ 
shall be substituted for ‘6 percent’ each place it 
appears; 
‘‘(III) beginning on or after January 1, 
2030, and before January 1, 2035, ‘3 percent’ 
shall be substituted for ‘6 percent’ each place it 
appears; 
‘‘(IV) beginning on or after January 1, 
2035, and before January 1, 2040, ‘2 percent’ 
shall be substituted for ‘6 percent’ each place it 
appears; 
‘‘(V) beginning on or after January 1, 
2040, and before January 1, 2045, ‘1 percent’ 
shall be substituted for ‘6 percent’ each place it 
appears; and 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00407
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
408 
‘‘(VI) beginning on or after January 1, 
2045, ‘0 percent’ shall be substituted for ‘6 per-
cent’ each place it appears.’’. 
SEC. 405. PROVIDING FOR STATE APPROVAL AND IMPLE-
MENTATION OF SPECIFIED WAIVERS UNDER 
THE MEDICAID PROGRAM. 
Section 1115 of the Social Security Act (42 U.S.C. 
1315) is amended— 
(1) in subsection (d)— 
(A) in paragraph (1), by striking ‘‘An ap-
plication’’ and inserting ‘‘Subject to paragraph 
(4), an application’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(4)(A) An experimental, pilot, or demonstra-
tion project undertaken under subsection (a) may be 
approved or renewed by a State if such project is de-
scribed in subparagraph (B). 
‘‘(B) An experimental, pilot, or demonstration 
project is described in this subparagraph if such 
project provides for a waiver of requirements with 
respect to a State plan (or a waiver of such plan) 
under title XIX such that— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00408
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
409 
‘‘(i) individuals enrolled under such plan 
(or such waiver) may elect to participate in 
such project with respect to a year; and 
‘‘(ii) such individuals who elect to so par-
ticipate are furnished with primary care serv-
ices (as described in section 223(c)(1)(D)(ii)(I) 
of the Internal Revenue Code of 1986) through 
a direct primary care service arrangement (as 
defined in such section). 
‘‘(C) For purposes of a State’s approval or re-
newal of an experimental, pilot, or demonstration 
project under subparagraph (A), each reference to 
‘the Secretary’ in subsection (a) shall be deemed to 
be a reference to ‘the State’.’’; and 
(2) in subsection (e), by inserting ‘‘(other than 
such a project that is described in paragraph 
(4)(B))’’ before the period at the end. 
SEC. 406. DEDUCTION FOR QUALIFIED CHARITY CARE. 
(a) IN GENERAL.—Part VI of subchapter B of chap-
ter 1 of the Internal Revenue Code of 1986 is amended 
by adding at the end the following new section: 
‘‘SEC. 199B. QUALIFIED CHARITY CARE. 
‘‘(a) IN GENERAL.—There shall be allowed as a de-
duction for the taxable year an amount equal to— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00409
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
410 
‘‘(1) in the case of a direct primary care physi-
cian, an amount equal to the sum of— 
‘‘(A) the fee (as published on a publicly 
available website of such physician) for physi-
cians’ services that are qualified charity care 
furnished by such taxpayer during such year, 
and 
‘‘(B) for each visit by a patient to such 
physician during which qualified charity care is 
furnished, half of so much of the lowest sub-
scription fee of such physician that is attrib-
utable to a month, and 
‘‘(2) in the case of any other individual, the un-
reimbursed Medicare-based value of qualified charity 
care furnished by such taxpayer during such year. 
‘‘(b) DEFINITIONS.—For purposes of this section: 
‘‘(1) 
UNREIMBURSED
MEDICARE-BASED 
VALUE.—The term ‘unreimbursed Medicare-based 
value’ means, with respect to physicians’ services, 
the amount payable for such services under the phy-
sician fee schedule established under section 1848 of 
the Social Security Act. 
‘‘(2) QUALIFIED
CHARITY
CARE.—The term 
‘qualified charity care’ means physicians’ services 
that are furnished— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00410
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
411 
‘‘(A) without expectation of reimburse-
ment, and 
‘‘(B) to an individual enrolled— 
‘‘(i) under a State plan under title 
XIX of the Social Security Act (or a waiv-
er of such plan), or 
‘‘(ii) under a State child health plan 
under title XXI of the Social Security Act 
(or a waiver of such plan). 
‘‘(3) DIRECT PRIMARY CARE PHYSICIAN.—The 
term ‘direct primary care physician’ means a physi-
cian (as defined in section 1861(r) of the Social Se-
curity Act) who provides primary care— 
‘‘(A) to individuals who have paid a peri-
odic subscription fee, and 
‘‘(B) in exchange for a fee that is pub-
lished on a publicly available website of such 
physician. 
‘‘(4) PHYSICIANS’ SERVICES.—The term ‘physi-
cians’ services’ has the meaning given such term by 
section 1861(q) of the Social Security Act. 
‘‘(c) LIMITATION.—The amount allowed as a deduc-
tion under subsection (a) for a taxable year shall not ex-
ceed the gross receipts attributable to physicians’ services 
furnished by the taxpayer during the taxable year.’’. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00411
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
412 
(b) CLERICAL AMENDMENT.—The table of sections 
for part VI of subchapter B of chapter 1 of the Internal 
Revenue Code of 1986 is amended by adding at the end 
the following new item: 
‘‘Sec. 199B. Qualified charity care.’’. 
Subtitle B—Medicare Reforms 
SEC. 411. OFF-CAMPUS PROVIDER-BASED DEPARTMENT 
MEDICARE SITE NEUTRAL PAYMENT. 
(a) IN GENERAL.—Section 1834 of the Social Secu-
rity Act (42 U.S.C. 1395m) is amended by adding at the 
end the following new subsection: 
‘‘(x) OFF-CAMPUS PROVIDER-BASED DEPARTMENT 
MEDICARE SITE NEUTRAL PAYMENT.— 
‘‘(1) IN GENERAL.—With respect to items and 
services furnished in an off-campus provider-based 
department, payment under this section for such 
items and services shall be the amount determined 
under the fee schedule under section 1848 for such 
items and services furnished if furnished in a physi-
cian office setting. 
‘‘(2) OFF-CAMPUS
PROVIDER-BASED
DEPART-
MENT.—For purposes of this subsection, the term 
‘off-campus provider-based department’ has such 
meaning as specified by the Secretary.’’. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00412
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
413 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply with respect to items and serv-
ices furnished on or after January 1, 2023. 
SEC. 412. ELIMINATING FEHBP ELIGIBILITY FOR ANNU-
ITANTS. 
Section 8905(b) of title 5, United States Code, is 
amended— 
(1) in the matter preceding paragraph (1), by 
striking ‘‘An’’ and inserting ‘‘Consistent with the 
last sentence of this subsection, an’’; and 
(2) by adding at the end the following: ‘‘. An 
individual who is entitled to benefits under part A 
of title XVIII of the Social Security Act (42 U.S.C. 
1395c et seq.) by reason of section 226 or 226A of 
such Act (42 U.S.C. 426, 426–1), or otherwise eligi-
ble to enroll under such part pursuant to section 
1818 or 1818A of such Act (42 U.S.C. 1395i–2, 
1395i–2a), and who first becomes an annuitant after 
the date of enactment of this sentence may not con-
tinue enrollment in any health benefits plan under 
this chapter.’’. 
SEC. 413. ELIMINATION OF MEDICARE ELIGIBILITY FOR 
CERTAIN INDIVIDUALS. 
(a) ENROLLMENT PROHIBITION.— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00413
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
414 
(1) PART B.—Section 1836 of the Social Secu-
rity Act (42 U.S.C. 1395o) is amended by striking 
the period at the end and inserting ‘‘, except that an 
individual who attains age 65 on or after January 
1, 2032, and is an individual who, upon attaining 
such age, has earned $10,000,000 or more in life-
time wages, shall not be eligible to so enroll.’’. 
(2) PART
D.—Section 1860D–1(a)(3)(A) of 
such Act (42 U.S.C. 1395w–101(a)(3)(A)) is amend-
ed by striking the period at the end and inserting 
‘‘, excluding an individual who, upon attaining age 
65, has earned $10,000,000 or more in lifetime 
wages.’’. 
(b) MEDIGAP.—Section 1882 of the Social Security 
Act (42 U.S.C. 1395ss) is amended by adding at the end 
the following new subsection: 
‘‘(aa) ADDITIONAL LIMITATION ON NEWLY ELIGI-
BLE BENEFICIARIES.— 
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of this section, on or after January 1, 
2032, a medicare supplemental policy may not be 
sold or issued to a targeted newly eligible Medicare 
beneficiary. 
‘‘(2) TARGETED
NEWLY
ELIGIBLE
MEDICARE 
BENEFICIARY.—For purposes of this subsection, the 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00414
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
415 
term ‘targeted newly eligible Medicare beneficiary’ 
means an individual who, upon attaining the age of 
65, has earned $10,000,000 or more in lifetime 
wages.’’. 
SEC. 414. MEDICARE PART D TAX DEDUCTION. 
(a) IN GENERAL.—Section 139A of the Internal Rev-
enue Code of 1986 is amended by adding at the end the 
following: ‘‘This section shall not be taken into account 
for purposes of determining whether any deduction is al-
lowable with respect to any cost taken into account in de-
termining such payment.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply to taxable years beginning after 
December 31, 2022. 
SEC. 415. REPEAL OF NET INVESTMENT INCOME TAX. 
(a) IN GENERAL.—Subtitle A of the Internal Rev-
enue Code of 1986 is amended by striking chapter 2A. 
(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply to taxable years beginning after 
December 31, 2022. 
SEC. 416. MEDICARE COVERAGE OF BAD DEBT. 
Section 1861(v)(1) of the Social Security Act (42 
U.S.C. 1395(v)(1)) is amended— 
(1) in subparagraph (T)— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00415
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
416 
(A) in clause (iv), by striking ‘‘and’’ at the 
end; 
(B) in clause (v)— 
(i) by striking ‘‘during fiscal year’’ 
and inserting ‘‘during fiscal years’’; 
(ii) by striking ‘‘or a subsequent fiscal 
year’’ and inserting ‘‘through 2023’’; and 
(iii) by striking the period at the end 
and inserting ‘‘, and’’; and 
(C) by adding at the end the following new 
clause: 
‘‘(vi) for cost reporting periods beginning dur-
ing fiscal year 2023 or a subsequent fiscal year, by 
the percent applicable for cost reporting periods be-
ginning during the previous fiscal year, increased 
(through fiscal year 2026) by 10 percentage 
points.’’; 
(2) in subparagraph (V)— 
(A) in clause (i)— 
(i) in subclause (III), by striking 
‘‘and’’ at the end; 
(ii) in subclause (IV)— 
(I) by striking ‘‘during fiscal 
year’’ and inserting ‘‘during fiscal 
years 2017 through 2023’’; and 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00416
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
417 
(II) by striking the period at the 
end and inserting ‘‘; and’’; and 
(iii) by adding at the end the fol-
lowing new subclause: 
‘‘(V) for cost reporting periods beginning 
during fiscal year 2021 or a subsequent fiscal 
year, the percent applicable for cost reporting 
periods beginning during the previous fiscal 
year, increased (through fiscal year 2024) by 
10 percentage points.’’; and 
(B) in clause (ii)— 
(i) in subclause (III), by striking 
‘‘and’’ at the end; and 
(ii) in subclause (IV)— 
(I) by striking ‘‘a subsequent fis-
cal year’’ and inserting ‘‘fiscal years 
2015 through 2021’’; 
(II) by striking the period at the 
end and inserting ‘‘; and’’; and 
(III) by adding at the end the 
following new subclause: 
‘‘(V) for cost reporting periods beginning 
during fiscal year 2021 or a subsequent fiscal 
year, shall be reduced by the percent applicable 
for cost reporting periods beginning during the 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00417
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
418 
previous fiscal year, increased (through fiscal 
year 2024) by 10 percentage points.’’; and 
(3) in subparagraph (W)(i)— 
(A) in subclause (II), by striking ‘‘and’’ at 
the end; 
(B) in subclause (III)— 
(i) by striking ‘‘during a subsequent 
fiscal year’’ and inserting ‘‘during fiscal 
years 2015 through 2021’’; and 
(ii) by striking the period at the end 
and inserting ‘‘; and’’; and 
(C) by adding at the end the following new 
subclause: 
‘‘(IV) for cost reporting periods beginning dur-
ing fiscal year 2021 or a subsequent fiscal year, by 
the percent applicable for cost reporting periods be-
ginning during the previous fiscal year, increased 
(through fiscal year 2024) by 10 percentage 
points.’’. 
Subtitle C—Medicare Choice and 
Competition 
SEC. 421. COMPETITIVE BIDDING AND PREMIUMS UNDER 
UNIFIED MEDICARE. 
(a) IN GENERAL.—Part E of title XVIII of the Social 
Security Act, as added by section 101 and amended by 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00418
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
419 
section 103, is further amended by adding at the end the 
following: 
‘‘Subpart 3—Competitive Bidding and Premiums 
‘‘SEC. 1860E–31. APPLICATION OF COMPETITIVE BIDDING IN 
ENROLLMENT. 
‘‘(a) IN GENERAL.—Notwithstanding any other pro-
vision of this title, the Secretary shall, beginning with plan 
year 2023, establish a method whereby individuals enroll-
ing under this title so enroll through an online process 
designed to highlight enrollment options for such individ-
uals and allow such individuals to compare costs of enroll-
ment in such options. 
‘‘(b) ENROLLMENT OPTIONS.—For purposes of sub-
section (a), the Secretary shall make the following options 
available to individuals for enrollment under this title: 
‘‘(1) Traditional fee-for-service coverage. 
‘‘(2) Provider-led risk-bearing plans (also 
known as ACOs). 
‘‘(3) Medicare Advantage plans. 
‘‘(c) MEDICARE
ADVANTAGE
PLAN
ACTUARIAL 
VALUE REQUIREMENT.—Each Medicare Advantage plan 
offered through the process described in subsection (a) 
shall have an actuarial value equal to traditional fee-for- 
service coverage under parts A and B. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00419
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
420 
‘‘(d) MA DIRECT DEPOSIT OF CERTAIN REBATES.— 
In the case of an Medicare Advantage plan with a bid for 
a year that involves a premium differential between such 
bid and the benchmark for such year and plan, such plan 
shall provide for a direct deposit of such differential if the 
applicable enrollee in such plan does not elect any supple-
mental coverage under such plan. 
‘‘(e) ENROLLMENT IN PRESCRIPTION DRUG COV-
ERAGE.—As part of the method described in subsection 
(a), the Secretary shall establish a process to allow an in-
dividual to enroll in prescription drug coverage. In the 
case of an individual who enrolls in a Medicare Advantage 
plan, such coverage shall be provided under such plan. In 
a case of an individual who enrolls in an ACO, such cov-
erage shall be provided under such network. In the case 
of an individual who enrolls under traditional fee-for-serv-
ice coverage, such drug coverage shall be provided through 
a prescription drug plan. 
‘‘(f) SUPPLEMENTAL BENEFITS.— 
‘‘(1) MA PLANS.—An MA plan is allowed to 
offer two different packages of supplemental benefits 
(these packages are available only to individuals who 
select such plans). 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00420
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
421 
‘‘(2) ACOS.—ACOs may limit supplemental op-
tions for their enrollees to Medigap plans with con-
tractual ties. 
‘‘(3) FEE-FOR-SERVICE.—Fee-for-service indi-
viduals may select supplemental coverage from 
Medigap policies. 
‘‘SEC. 1860E–32. COMPETITION. 
‘‘(a) BID AREAS.—Market areas used for bid submis-
sions for Medicare Advantage plans, ACOs, and for cal-
culation per person fee-for-services costs shall be metro-
politan statistical regions plus associated regions. 
‘‘(b) PREMIUMS.—Medicare payment benchmark by 
market area shall be calculated based on weighted average 
(by enrollment in previous year) of the premium bids from 
MA plans, ACOs, and the per person costs of fee-for-serv-
ice, less the statutory part B premium. 
‘‘(c) BENEFICIARY RESPONSIBILITY.—Beneficiaries 
shall pay the difference between Medicare payment and 
required premium of the plan they choose, and get 100 
percent of the savings by choosing a plan with a premium 
below the benchmark. 
‘‘(d) TRANSITION.—For beneficiaries who are in fee- 
for-service at the time of the enactment of this section, 
there shall be a limit on the amount of a premium increase 
allowable by year of no more than $20 per month com-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00421
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
422 
pared to what such premium would have otherwise been 
if this subpart had not been enacted for each year through 
the fifth year. 
‘‘(e) MULTIYEAR CONTRACTS.—A Medicare Advan-
tage plan may offer to beneficiaries multiyear contracts 
with guaranteed premiums over such years, bearing the 
risk of any change in payments from the Secretary in sub-
sequent years. A beneficiary enrolling under such a con-
tract shall be exempt from the method described in sub-
section (a).’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 1853(a)(1)(A) of the Social Security 
Act is amended by striking ‘‘and section 1859(e)(4)’’ 
and inserting ‘‘, section 1859(e)(4), and subpart 3 
of part E’’. 
(2) Section 1853(j) of such Act is amended by 
inserting ‘‘and subpart 3 of part E’’ after ‘‘sub-
section (o)’’. 
(3) Section 1854 of such Act is amended— 
(A) in subsection (a), after the heading, by 
inserting ‘‘Subject to subpart 3 of part E:’’; 
(B) in subsection (b), after the heading, by 
inserting ‘‘Subject to subpart 3 of part E:’’; 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00422
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
423 
(C) in subsection (d), after the heading, by 
inserting ‘‘Subject to subpart 3 of part E:’’; 
and 
(D) in subsection (e), after the heading, by 
inserting ‘‘Subject to subpart 3 of part E:’’. 
SEC. 422. NEW UNIFIED ELIGIBILITY AND ENROLLMENT 
RULES. 
(a) IN GENERAL.—Title XVIII of the Social Security 
Act is amended— 
(1) by redesignating part E as part F; and 
(2) by inserting after part D the following new 
part: 
‘‘PART E—MEDICARE WITH CHOICE AND 
COMPETITION 
‘‘Subpart 1—Opt-Out and Auto-Enrollment 
‘‘SEC. 1860E–11. PART A OPT-OUT AND MA AUTO-ENROLL-
MENT. 
‘‘(a) PERMITTING INDIVIDUALS TO OPT OUT
OF 
PART A COVERAGE WITHOUT LOSING SOCIAL SECURITY 
BENEFITS.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish— 
‘‘(A) a process by which an individual oth-
erwise entitled to benefits under part A may 
elect (at a time and in a manner specified 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00423
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
424 
under the process) to waive such entitlement; 
and 
‘‘(B) a process by which an individual who 
elects to waive such entitlement may revoke (at 
a time and in a manner specified under the 
process) such waiver. 
The process under subparagraph (B) shall be coordi-
nated with the enrollment process under section 
1837 for part B. 
‘‘(2) APPLICATION OF LATE ENROLLMENT PEN-
ALTY.—An individual who revokes a waiver under 
paragraph (1)(B) shall be subject to a late enroll-
ment penalty as applied under section 1860E– 
32(c)(2)(C). 
‘‘(3) NO IMPACT ON TITLE II BENEFITS.—Not-
withstanding any other provision of law, an election 
of an individual to waive entitlement to benefits 
under part A under paragraph (1)(A) shall not re-
sult in any loss of benefits under title II. 
‘‘(4) DEEMED OPT-OUT.— 
‘‘(A) An election of an individual to waive 
entitlement to benefits under part A under 
paragraph (1)(A) is also deemed the filing of a 
notice of termination of benefits under part B 
pursuant to section 1838(b)(1). 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00424
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
425 
‘‘(B) The termination of benefits under 
part B pursuant to section 1838(b) is also 
deemed to be a waiver of any entitlement to 
benefits under part A. 
‘‘(b) SPECIAL OPEN ENROLLMENT PERIOD WITH-
OUT LATE ENROLLMENT PENALTY FOR CURRENT PART 
A ONLY
OR PART B ONLY ENROLLEES.—Notwith-
standing any other provision of law, in the case of an indi-
vidual who as of the general effective date, is entitled to 
benefits under part A but not enrolled under part B, or 
who is enrolled under part B but not entitled to benefits 
(or enrolled) under part A, beginning as of such date, such 
individual shall be deemed to be enrolled under part B 
or part A, respectively, unless such individual elects to be 
enrolled (or entitled to benefits) under neither of such 
parts during a special open enrollment period specified by 
the Secretary. No increase in the monthly premium of an 
individual pursuant to section 1839(b) or section 1818(c) 
shall be effected in the case of any such individual who 
is deemed enrolled under part B or part A pursuant to 
the previous sentence with respect to any period prior to 
the date of such enrollment. 
‘‘(c) AUTO ENROLLMENT OF DUAL ELIGIBLE INDI-
VIDUALS UNDER MEDICARE ADVANTAGE PLANS.— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00425
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
426 
‘‘(1) IN GENERAL.—Except in the case of a 
State that has elected the maintenance of effort op-
tion described in section 1944(b)(2), in the case of 
an individual described in subparagraph (A)(ii) of 
section 1935(c)(6) (taking into account the applica-
tion of subparagraph (B) of such section), the Sec-
retary shall establish a process for the enrollment in 
an MA–PD plan that is a managed care plan under 
part C that has a monthly beneficiary premium that 
does not exceed the premium assistance available 
under section 1860E–41(b)(1)(A). If there is more 
than one such plan available, the Secretary shall en-
roll such an individual on a random basis among all 
such plans in the PDP region. 
‘‘(2) RIGHT TO DISENROLL.—Nothing in para-
graph (1) shall prevent such an individual from de-
clining enrollment in any such plan (and thereby ob-
taining coverage under Medicare fee-for-service) or 
from changing enrollment in such a plan to another 
MA–PD plan. 
‘‘SEC. 1860E–12. COORDINATION WITH PART D. 
‘‘(a) DEEMED ENROLLMENT UNDER PART D.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish a process that, beginning as of the general effec-
tive date, provides for the enrollment in a prescrip-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00426
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
427 
tion drug plan that has a monthly base beneficiary 
premium that does not exceed the weighted average 
of premiums for such plans that provide standard 
prescription drug coverage (as defined in section 
1860D–2(b)) with respect to the area involved (on 
a random basis among all such plans in the applica-
ble PDP region) of each Medicare enrollee (as de-
fined in section 1860E–51) who— 
‘‘(A) failed to enroll in such a prescription 
drug plan during the applicable enrollment or 
coverage election period under section 1860D– 
1(b); and 
‘‘(B) failed to elect not to enroll in such a 
prescription drug plan during an applicable opt- 
out period described in paragraph (2). 
Nothing in the previous sentence shall prevent such 
an individual from declining or changing such enroll-
ment. Such process shall be carried out in the same 
manner as the process described in section 1860D– 
1(b)(1)(C). 
‘‘(2) OPT-OUT
PERIODS.—The process under 
paragraph (1) shall provide for the opportunity to 
make an election described in subparagraph (B) of 
such paragraph during an opt-out period that is co-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00427
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
428 
ordinated with the relevant enrollment or coverage 
election period under section 1860D–1. 
‘‘(3) LATE ENROLLMENT PENALTIES.—In the 
case of an individual who makes an election de-
scribed in paragraph (1)(B) and then enrolls in a 
prescription drug plan, the late enrollment penalty 
under section 1860D–13(b) shall apply to the 
monthly beneficiary premium of such individual, ex-
cept that in applying such section, any reference to 
the initial enrollment period of such individual shall 
be deemed to be a reference to the opt-out period 
under paragraph (2) during which the individual 
elected not to enroll in a prescription drug plan. 
‘‘(4) NO
LATE
ENROLLMENT
PENALTY
FOR 
CURRENT
FEE-FOR-SERVICE
BENEFICIARIES
WITH-
OUT DRUG COVERAGE.—In the case of an individual 
who is a Medicare enrollee before the date of enact-
ment of this section and who was not enrolled under 
a prescription drug plan before being enrolled under 
such a plan pursuant to paragraph (1), there shall 
be no increase in the base beneficiary premium of an 
individual under section 1860D–13 by a late enroll-
ment penalty under subsection (b) of such section 
with respect to any period prior to the date of such 
enrollment. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00428
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
429 
‘‘(b) REFERENCE
TO
REQUIRED
PRESCRIPTION 
DRUG COVERAGE UNDER PART C.—For provision requir-
ing coverage under MA plans to include prescription drug 
coverage, see section 1860E–26.’’. 
(b) LIMITATION ON MEDICAID BENEFITS FOR FULL- 
BENEFIT DUAL ELIGIBLE INDIVIDUALS.—Section 1902 
of the Social Security Act (42 U.S.C. 1396a) is amended 
by adding at the end the following new subsection: 
‘‘(ll) LIMITATION ON BENEFITS FOR FULL-BENEFIT 
DUAL ELIGIBLE INDIVIDUALS.—Effective as of the gen-
eral effective date (as specified in section 1860E–62), ex-
cept in the case of a State which has elected the option 
described in section 1944(b)(2), in the case of an indi-
vidual described in subparagraph (A)(ii) of section 
1935(c)(6) (taking into account the application of sub-
paragraph (B) of such section), notwithstanding any other 
provision of law, medical assistance shall not be available 
under this title for any items and services for which pay-
ment may be made under title XVIII.’’. 
(c) MEDICAID MAINTENANCE OF EFFORT AND AL-
TERNATIVES.—Title XIX of the Social Security Act is 
amended by inserting after section 1943 the following new 
section: 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00429
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
430 
‘‘MAINTENANCE OF EFFORT OPTIONS FOR FULL-BENEFIT 
DUAL ELIGIBLE INDIVIDUALS 
‘‘SEC. 1944. (a) IN GENERAL.—Effective as of the 
general effective date (as specified in section 1860E–62), 
a State shall elect, in a form and manner specified by the 
Secretary, a maintenance of effort option described in sub-
section (b). In the case of a State that fails to make such 
an election, the State shall be deemed to have elected the 
option described in subsection (b)(3). 
‘‘(b) MAINTENANCE
OF
EFFORT
OPTIONS
DE-
SCRIBED.—The following are maintenance of effort op-
tions described in this subsection for a State, which shall 
apply to all individuals described in subparagraph (A)(ii) 
of section 1935(c)(6) (taking into account the application 
of subparagraph (B) of such section) for such State: 
‘‘(1) ENROLLMENT
OF
DUAL
ELIGIBLES
IN 
COMPREHENSIVE MEDICAID MANAGED CARE PLAN.— 
‘‘(A) IN GENERAL.—The State enrolls all 
such individuals in a comprehensive Medicaid 
managed care plan offered by a managed care 
entity under section 1932. 
‘‘(B) PAYMENT OF SUBSIDY AMOUNT TO 
STATE.—In the case of a State that elects the 
option under this paragraph with respect to an 
individual, the Secretary established under sec-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00430
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
431 
tion 1860E–51 shall pay to the State the same 
amount that the individual would be entitled to 
have paid as an income-related premium sub-
sidy under section 1860E–41(b)(1)(A) plus the 
amount that the Secretary estimates would 
have been paid with respect to the individual 
under part D (including the actuarial value of 
subsidy payments under sections 1860D–13 
and 1860D–14). Such payment shall be made 
in appropriate part from the Federal Hospital 
Insurance Trust Fund under section 1817 and 
the Federal Supplementary Medical Insurance 
Trust Fund under section 1841. 
‘‘(C) RELATION
TO
PART
D
RULES.—In 
the case of a State that has elected the option 
under this paragraph, notwithstanding any 
other provision of law— 
‘‘(i) the coverage provided under this 
option shall be in lieu of any coverage that 
may otherwise be provided under part D; 
and 
‘‘(ii) the payment to the State under 
subparagraph (B) shall be in lieu of any 
payments otherwise made with respect to 
such individual under such part. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00431
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
432 
‘‘(2) OTHER INNOVATIVE ALTERNATIVES.— 
‘‘(A) IN GENERAL.—The State submits to 
the Secretary, and has approved by the Sec-
retary, an innovative alternative proposal relat-
ing to coordinating coverage of such individuals 
under Medicare and the State plan under title 
XIX. 
‘‘(B) PROCESS
FOR
REVIEW.—With re-
spect to proposals submitted to the Secretary 
under subparagraph (A), the Secretary shall ap-
prove such a proposal if the State demonstrates 
with respect to the proposal that— 
‘‘(i) there would be no increased cost 
to the Federal Government if it were ap-
proved; and 
‘‘(ii) there would be no reduction in 
the quality of care provided to such indi-
viduals if the proposal were approved.’’. 
(d) CONFORMING AMENDMENTS.— 
(1) SECTION 226.—Section 226 of the Social 
Security Act (42 U.S.C. 426) is amended— 
(A) in subsection (a), in the matter pre-
ceding paragraph (1), by inserting ‘‘, subject to 
section 1860E–11(a)’’ after ‘‘individual who’’; 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00432
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
434 
‘‘Subpart 2—Out-of-Pocket Limit 
‘‘SEC. 1860E–21. OUT-OF-POCKET LIMIT. 
‘‘(a) IN GENERAL.—Beginning with 2023, in the case 
of a Medicare enrollee, if the amount of the out-of-pocket 
cost-sharing of such enrollee for a calendar year equals 
or exceeds the catastrophic limit under subsection (b) for 
that year— 
‘‘(1) the enrollee shall not be responsible for ad-
ditional out-of-pocket cost-sharing incurred during 
that year; and 
‘‘(2) the Secretary shall establish procedures 
under which the Secretary shall, in appropriate part 
from the Part A Medicare FFS Account under sec-
tion 1817 and the Part B Medicare FFS Account 
under section 1841— 
‘‘(A) pay on behalf of the enrollee the 
amount of the additional out-of-pocket cost- 
sharing described in paragraph (1) attributable 
to deductibles and coinsurance described in sub-
section (c)(1); and 
‘‘(B) reimburse the enrollee the amount of 
the additional out-of-pocket cost-sharing de-
scribed in paragraph (1) attributable to 
deductibles and coinsurance described in sub-
section (c)(2). 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00434
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
435 
‘‘(b) CATASTROPHIC LIMIT.—The amount of the cat-
astrophic limit under this subsection for a year shall be 
the dollar amount in effect under section 223(c)(2)(A)(ii) 
of the Internal Revenue Code of 1986 for self-only cov-
erage for taxable years beginning in such year. 
‘‘(c) OUT-OF-POCKET COST-SHARING DEFINED.—In 
this section, the term ‘out-of-pocket cost-sharing’ means, 
with respect to an individual, the amount of costs incurred 
by the individual that are attributable to— 
‘‘(1) deductibles and coinsurance imposed under 
part A or part B; and 
‘‘(2) deductibles and coinsurance imposed under 
standard prescription drug coverage pursuant to sec-
tion 1860D–2(b) or alternative prescription drug 
coverage pursuant to section 1860D–2(c) offered by 
a prescription drug plan.’’. 
(b) APPLICATION OF OUT-OF-POCKET LIMIT TO MA– 
PD PLANS.— 
(1) IN GENERAL.—Section 1852(a)(1)(B) of the 
Social Security Act (42 U.S.C. 1395w–22(a)(1)(B)) 
is amended— 
(A) in clause (i), by striking ‘‘clause (iii)’’ 
and inserting ‘‘clauses (iii) and (vi)’’; and 
(B) by adding at the end the following new 
clause: 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00435
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
436 
‘‘(vi) OUT-OF-POCKET
LIMIT.—The 
provisions of section 1860E–21— 
‘‘(I) shall apply to individuals en-
rolled under an MA–PD plan in the 
same manner as such provisions apply 
to Medicare enrollees under such sec-
tion, except that in lieu of the applica-
tion of subsection (a)(2) of such sec-
tion the MA–PD plan shall establish 
procedures to provide for payment of 
any additional out-of-pocket cost-shar-
ing described in subsection (a)(1) of 
such section incurred by individuals 
enrolled under the MA–PD plan; and 
‘‘(II) as applied under subclause 
(I), may not be waived by application 
of this subparagraph. 
In applying subsection (b) of section 
1860E–21 pursuant to the previous sen-
tence, an MA–PD plan may substitute a 
dollar amount that is less than the dollar 
amount specified under such subsection.’’. 
(2) EXEMPTING MA–PD PLANS OFFERING AL-
TERNATIVE PRESCRIPTION DRUG COVERAGE FROM 
PART
D
DEDUCTIBLE
AND
OUT-OF-POCKET
LIMIT 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00436
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
437 
REQUIREMENTS.—Section 1860D–2(c) of the Social 
Security Act (42 U.S.C. 1395w–102(c)) is amend-
ed— 
(A) in paragraph (2), by striking ‘‘The de-
ductible’’ and inserting ‘‘In the case of a pre-
scription drug plan, the deductible’’; and 
(B) in paragraph (3), by striking ‘‘The 
coverage provides’’ and inserting ‘‘In the case 
of a prescription drug plan, the coverage pro-
vides’’. 
(c) PRESCRIPTION DRUG PLANS REQUIRED TO RE-
PORT ENROLLEES’ OUT-OF-POCKET COST-SHARING.— 
Section 1860D–12(b) of the Social Security Act (42 
U.S.C. 1395w–112(b)) is amended by adding at the end 
the following new paragraph: 
‘‘(7) 
OUT-OF-POCKET
COST-SHARING
RE-
PORTS.—Each contract entered into with a PDP 
sponsor under this part with respect to a prescrip-
tion drug plan offered by such sponsor shall require 
that, with respect to each claim submitted for items 
or services furnished to an individual enrolled under 
the plan pursuant to the contract, the sponsor sub-
mits to the Secretary information on the amount of 
out-of-pocket cost-sharing (as defined in section 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00437
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
438 
1860E–23(c)) applicable to such enrollee for such 
items or services.’’. 
(d) CONFORMING AMENDMENTS.— 
(1) Section 1813 of the Social Security Act (42 
U.S.C. 1395e) is amended— 
(A) in subsection (a), by inserting ‘‘Subject 
to subpart 2 of part E:’’ before paragraph (1); 
and 
(B) in subsection (b), by inserting ‘‘Sub-
ject to subpart 2 of part E:’’ before paragraph 
(1). 
(2) Section 1833 of such Act (42 U.S.C. 1395l) 
is amended— 
(A) in subsection (a), in the matter pre-
ceding paragraph (1), by inserting ‘‘and sub-
part 2 of part E’’ after ‘‘succeeding provisions 
of this section’’; 
(B) in subsection (b), in the first sentence, 
by striking ‘‘Before applying’’ and inserting 
‘‘Subject to subpart 2 of part E, before apply-
ing’’; 
(C) in subsection (c)(1), in the matter pre-
ceding subparagraph (A), by inserting ‘‘subject 
to subpart 2 of part E,’’ after ‘‘this part,’’; 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00438
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
439 
(D) in subsection (f), by striking ‘‘In es-
tablishing’’ and inserting ‘‘Subject to subpart 2 
of part E, in establishing’’; and 
(E) in subsection (g)(1), by inserting ‘‘and 
subpart 2 of part E’’ and ‘‘paragraphs (4) and 
(5)’’. 
(3) Section 1882(a)(2) of such Act is amended 
by striking ‘‘No medicare’’ and inserting ‘‘Subject to 
section 1860E–24(c), no medicare’’. 
SEC. 424. LATE ENROLLMENT PENALTY NOT TO APPLY FOR 
MONTHS OF ANY HEALTH COVERAGE. 
(a) IN GENERAL.—Section 1839(b) of the Social Se-
curity Act (42 U.S.C. 1395r) is amended in the second 
sentence, by inserting before the period at the end the fol-
lowing: ‘‘or months during which the individual has any 
other health coverage’’. 
(b) EFFECTIVE DATE.—The amendment made by 
paragraph (1) shall apply for months of coverage begin-
ning after the date of the enactment of this Act. 
SEC. 425. MEDIGAP REFORM. 
Notwithstanding any provision of section 1882 of the 
Social Security Act (42 U.S.C. 1395ss), as of the date 
of the enactment of this Act, no policy may be offered 
under such section that does not provide guaranteed cov-
erage (without regard to an individual’s preexisting condi-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00439
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
440 
tions, if any) to all individuals eligible to enroll under such 
policy. 
SEC. 426. ACO REVISION. 
(a) ENROLLMENT.—Enrollment in such an ACO 
under such title shall be based on the method established 
under part E of such title. Such a network shall bear full 
risk in the event payments under such title do not equal 
or exceed liabilities under such network. 
(b) DIRECTION OF PAYMENT.—An ACO may direct 
that any payments under such title be made to a central-
ized entity rather than to an individual provider or sup-
plier. 
(c) BIDS.—The Secretary of Health and Human 
Services shall establish a process whereby such networks 
compete using a bidding process similar to that described 
in part E of such title for Medicare Advantage plans. 
SEC. 427. PRIMARY CARE OPTIONS. 
(a) SELECTION OF PRIMARY CARE PHYSICIAN.—The 
Secretary shall establish a mechanism under which an in-
dividual enrolled under part B of title XVIII of the Social 
Security Act may select such individual’s primary care 
physician. Such an individual shall not be liable for more 
than $5 for each visit to such selected physician. 
(b) PAYMENT TO PHYSICIAN.—A physician selected 
under subsection (a) shall receive a monthly fee in lieu 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00440
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
441 
of any other payment under such part B for evaluation 
and monitoring of such individual. The Secretary shall 
provide a list of standardized benefits that are included 
in such payment, including telephone and email commu-
nications, office visits, preventive care, and vaccinations. 
SEC. 428. GENERAL PROVISIONS; EFFECTIVE DATE. 
Part E of title XVIII of the Social Security Act, as 
inserted by section 101(a)(2) and as previously amended, 
is further amended by adding at the end the following new 
subpart: 
‘‘Subpart 5.—General Provisions 
‘‘SEC. 1860E–51. APPLICABILITY; DEFINITIONS. 
‘‘(a) IN GENERAL.—The provisions of this Act are 
superseded to the extent inconsistent with the provisions 
of this part. 
‘‘(b) TERMINOLOGY.—For purposes of this part: 
‘‘(1) MEDICARE ENROLLEE.— 
‘‘(A) IN
GENERAL.—The term ‘Medicare 
enrollee’ means— 
‘‘(i) an individual entitled to (or en-
rolled for benefits) under part A and en-
rolled under part B; and 
‘‘(ii) except as otherwise specified, an 
individual described in section 1860E– 
11(a)(3). 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00441
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
442 
‘‘(B) TREATMENT.—Any reference in this 
Act (or any other Act) in effect before the date 
of the enactment of this part, to an individual 
entitled to benefits under part A or enrolled 
under part B shall be deemed a reference to a 
Medicare enrollee. 
‘‘(2) MEDICARE FEE-FOR-SERVICE.—The term 
‘Medicare fee-for-service’ means the original Medi-
care fee-for-service program under parts A and B, 
as modified by this part, and does not include part 
C or part D. 
‘‘(3) 
MEDICARE
FEE-FOR-SERVICE
EN-
ROLLEE.—The term ‘Medicare fee-for-service en-
rollee’ means a Medicare enrollee who is not enrolled 
under a Medicare Advantage plan under part C. 
‘‘SEC. 1860E–61. GENERAL EFFECTIVE DATE. 
‘‘Except as otherwise specified, the provisions of this 
part shall apply to items and services furnished on or after 
January 1, 2023, and to plan years beginning on or after 
such date (referred to in this title as the ‘general effective 
date’).’’. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00442
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
443 
Subtitle D—Telehealth 
Improvements and Expansion 
SEC. 431. EXPANSION OF COVERAGE OF TELEHEALTH 
SERVICES. 
(a) COVERED SERVICES.—Section 1834(m)(4)(F)(i) 
of the Social Security Act (42 U.S.C. 1395m(m)(4)(F)(i)) 
is amended— 
(1) by striking ‘‘and office’’ and inserting ‘‘of-
fice’’; and 
(2) by inserting: ‘‘respiratory services, audiology 
services (as defined in section 1861(ll)), outpatient 
therapy services (including physical therapy, occupa-
tional therapy, and speech-language pathology serv-
ices)’’ after ‘‘the Secretary)),’’. 
(b) PROVIDERS.—Subsection (m) of section 1834 of 
such Act (42 U.S.C. 1395m) is amended— 
(1) in paragraph (1), by striking ‘‘or a practi-
tioner (described in section 1842(b)(18)(C))’’ and 
inserting ‘‘, a practitioner (described in section 
1842(b)(18)(C)), or an applicable professional (as 
defined in paragraph (4)(G))’’; 
(2) by striking ‘‘physician or practitioner’’ each 
time it appears in such subsection and inserting 
‘‘physician, practitioner, or applicable professional’’; 
(3) in paragraph (3)(A)— 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00443
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
444 
(A) in the heading, by striking ‘‘PHYSI-
CIAN AND PRACTITIONER’’ and inserting ‘‘PHY-
SICIAN, PRACTITIONER, AND APPLICABLE PRO-
FESSIONAL’’; and 
(B) by striking ‘‘physicians or practi-
tioners’’ and inserting ‘‘physicians, practi-
tioners, or applicable professionals’’; and 
(4) in paragraph (4), by adding at the end the 
following new subparagraph: 
‘‘(G) APPLICABLE
PROFESSIONAL.—The 
term ‘applicable professional’ means, with re-
spect to services furnished on or after the date 
that is 6 months after the date of the enact-
ment of this subparagraph, a certified diabetes 
educator or licensed— 
‘‘(i) respiratory therapist; 
‘‘(ii) audiologist; 
‘‘(iii) occupational therapist; 
‘‘(iv) physical therapist; or 
‘‘(v) speech language pathologist.’’. 
(c) HOME-BASED MONITORING SERVICES FOR CON-
GESTIVE HEART FAILURE AND CHRONIC OBSTRUCTIVE 
PULMONARY DISEASE.— 
(1) COVERAGE
OF
REMOTE
PATIENT
MONI-
TORING SERVICES FOR CERTAIN CHRONIC HEALTH 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00444
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
445 
CONDITIONS.—Section 1861(s)(2) of the Social Se-
curity Act (42 U.S.C. 1395x(s)(2)) is amended— 
(A) in subparagraph (GG), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (HH), by inserting 
‘‘and’’ at the end; and 
(C) by inserting after subparagraph (HH) 
the following new subparagraph: 
‘‘(II) applicable remote patient monitoring 
services (as defined in paragraph (1)(A) of sub-
section (iii));’’. 
(2) SERVICES
DESCRIBED.—Section 1861 of 
the Social Security Act (42 U.S.C. 1395x) is amend-
ed by adding at the end the following new sub-
section: 
‘‘(kkk) REMOTE PATIENT MONITORING SERVICES 
FOR CHRONIC HEALTH CONDITIONS.— 
‘‘(1)(A) The term ‘applicable remote patient 
monitoring services’ means remote patient moni-
toring services (as defined in subparagraph (B)) fur-
nished to provide for the monitoring, evaluation, and 
management of an individual with a covered chronic 
condition (as defined in paragraph (2)), insofar as 
such services are for the management of such chron-
ic condition. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00445
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
446 
‘‘(B) The term ‘remote patient monitoring serv-
ices’ means services furnished through remote pa-
tient monitoring technology (as defined in subpara-
graph (C)). 
‘‘(C) The term ‘remote patient monitoring tech-
nology’ means a coordinated system that uses one or 
more home-based or mobile monitoring devices that 
automatically transmit vital sign data or information 
on activities of daily living and may include re-
sponses to assessment questions collected on the de-
vices wirelessly or through a telecommunications 
connection to a server that complies with the Fed-
eral regulations (concerning the privacy of individ-
ually identifiable health information) promulgated 
under section 264(c) of the Health Insurance Port-
ability and Accountability Act of 1996, as part of an 
established plan of care for that patient that in-
cludes the review and interpretation of that data by 
a health care professional. 
‘‘(2) For purposes of paragraph (1), the term 
‘covered chronic health condition’ means applicable 
conditions (as defined in and applied under section 
1886(q)(5)) when under chronic care management 
(identified as of July 1, 2015, by HCPCS code 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00446
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
447 
99490 (and as subsequently modified by the Sec-
retary)). 
‘‘(3)(A) Payment may be made under this part 
for applicable remote patient monitoring services 
provided to an individual during a period of up to 
90 days and such additional period as provided for 
under subparagraph (B). 
‘‘(B) The 90-day period described in subpara-
graph (A), with respect to an individual, may be re-
newed by the physician who provides chronic care 
management to such individual if the individual con-
tinues to qualify for such management.’’. 
(3) PAYMENT
UNDER
THE
PHYSICIAN
FEE 
SCHEDULE.—Section 1848 of the Social Security 
Act (42 U.S.C. 1395w–4) is amended— 
(A) in subsection (c)— 
(i) in paragraph (2)(B)— 
(I) in clause (ii)(II), by striking 
‘‘and (v)’’ and inserting ‘‘(v), and 
(vii)’’; and 
(II) by adding at the end the fol-
lowing new clause: 
‘‘(vii) BUDGETARY
TREATMENT
OF 
CERTAIN
SERVICES.—The additional ex-
penditures attributable to services de-
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00447
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
448 
scribed in section 1861(s)(2)(II) shall not 
be taken into account in applying clause 
(ii)(II).’’; and 
(ii) by adding at the end the following 
new paragraph: 
‘‘(7) TREATMENT OF APPLICABLE REMOTE PA-
TIENT MONITORING SERVICES.— 
‘‘(A) In determining relative value units 
for applicable remote patient monitoring serv-
ices (as defined in section 1861(iii)(1)(A)), the 
Secretary, in consultation with appropriate phy-
sician groups, practitioner groups, and supplier 
groups, shall take into consideration— 
‘‘(i) physician or practitioner re-
sources, including physician or practitioner 
time and the level of intensity of services 
provided, based on— 
‘‘(I) the frequency of evaluation 
necessary to manage the individual 
being furnished the services; 
‘‘(II) the complexity of the eval-
uation, including the information that 
must be obtained, reviewed, and ana-
lyzed; and 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00448
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
449 
‘‘(III) the number of possible di-
agnoses and the number of manage-
ment options that must be considered; 
‘‘(ii) practice expense costs associated 
with such services, including the direct 
costs associated with installation and infor-
mation transmission, costs of remote pa-
tient 
monitoring 
technology 
(including 
equipment and software), device delivery 
costs, and resource costs necessary for pa-
tient monitoring and followup (but not in-
cluding costs of any related item or non- 
physician service otherwise reimbursed 
under this title); and 
‘‘(iii) malpractice expense resources. 
‘‘(B) Using the relative value units deter-
mined in subparagraph (A), the Secretary shall 
provide for separate payment for such services 
and shall not adjust the relative value units as-
signed to other services that might otherwise 
have been determined to include such separately 
paid remote patient monitoring services.’’; and 
(B) in subsection (j)(3), by inserting 
‘‘(2)(II),’’ after ‘‘health risk assessment),’’. 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00449
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB
450 
SEC. 432. EXPANDING THE USE OF TELEHEALTH THROUGH 
THE WAIVER OF CERTAIN REQUIREMENTS. 
(a) IN GENERAL.—Section 1834(m) of the Social Se-
curity Act (42 U.S.C. 1395m(m)) is amended— 
(1) in paragraph (4)(C)(i), by striking ‘‘and 
(7)’’ and inserting ‘‘(7), and (8)’’; and 
(2) by adding at the end the following: 
‘‘(8) AUTHORITY
TO
WAIVE
REQUIREMENTS 
AND LIMITATIONS IF CERTAIN CONDITIONS MET.— 
‘‘(A) IN
GENERAL.—Notwithstanding the 
preceding provisions of this subsection, in the 
case of telehealth services furnished on or after 
January 1, 2023, the Secretary may waive any 
restriction applicable to payment for telehealth 
services under this subsection that is described 
in subparagraph (B), but only if the Secretary 
determines that such waiver would not deny or 
limit the coverage or provision of benefits under 
this title, and— 
‘‘(i) the Secretary determines that the 
waiver is expected to reduce spending 
under this title without reducing the qual-
ity of care or improve the quality of pa-
tient care without increasing spending; or 
‘‘(ii) the waiver would apply to tele-
health services furnished in originating 
VerDate Sep 11 2014 
02:46 Aug 17, 2022
Jkt 029200
PO 00000
Frm 00450
Fmt 6652
Sfmt 6201
E:\BILLS\H8588.IH
H8588
pbinns on DSKJLVW7X2PROD with $$_JOB