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‘‘(A) The term ‘certified EHR technology’ means 
a qualified electronic health record (as defined in 
3000(13) of the Public Health Service Act) that is cer-
tified pursuant to section 3001(c)(5) of such Act as 
meeting standards adopted under section 3004 of such 
Act that are applicable to the type of record involved 
(as determined by the Secretary, such as an ambula-
tory electronic health record for office-based physi-
cians or an inpatient hospital electronic health record 
for hospitals). 
‘‘(B) The term ‘eligible professional’ means a 
physician as defined in paragraphs (1) and (2) of 
section 1861(r), and includes a nurse mid-wife and a 
nurse practitioner. 
‘‘(C) The term ‘hospital-based’ means, with re-
spect to an eligible professional, a professional (such 
as a pathologist, anesthesiologist, or emergency physi-
cian) who furnishes substantially all of the individ-
ual’s professional services in a hospital setting 
(whether inpatient or outpatient) and through the use 
of the facilities and equipment, including qualified 
electronic health records, of the hospital. 
‘‘(4)(A) The term ‘allowable costs’ means, with respect 
to certified EHR technology of a Medicaid provider, costs 
of such technology (and support services including mainte-
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nance and training that is for, or is necessary for the adop-
tion and operation of, such technology) as determined by 
the Secretary to be reasonable. 
‘‘(B) The term ‘net allowable costs’ means allowable 
costs reduced by any payment that is made to the Medicaid 
provider involved from any other source that is directly at-
tributable to payment for certified EHR technology or serv-
ices described in subparagraph (A). 
‘‘(C) In no case shall— 
‘‘(i) the aggregate allowable costs under this sub-
section (covering one or more years) with respect to 
a Medicaid provider described in paragraph (2)(A) 
for purchase and initial implementation of certified 
EHR technology (and services described in subpara-
graph (A)) exceed $25,000 or include costs over a pe-
riod of longer than 5 years; 
‘‘(ii) for costs not described in clause (i) relating 
to the operation, maintenance, or use of certified 
EHR technology, the annual allowable costs under 
this subsection with respect to such a Medicaid pro-
vider for costs not described in clause (i) for any year 
exceed $10,000; 
‘‘(iii) payment described in paragraph (1) for 
costs described in clause (ii) be made with respect to 
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such a Medicaid provider over a period of more than 
5 years; 
‘‘(iv) the aggregate allowable costs under this 
subsection with respect to such a Medicaid provider 
for all costs exceed $75,000; or 
‘‘(v) the allowable costs, whether for purchase 
and initial implementation, maintenance, or other-
wise, for a Medicaid provider described in paragraph 
(2)(B)(iii) exceed such aggregate or annual limitation 
as the Secretary shall establish, based on an amount 
determined by the Secretary as being adequate to 
adopt and maintain certified EHR technology, con-
sistent with paragraph (6). 
‘‘(5) Payments described in paragraph (1) are not in 
accordance with this subsection unless the following require-
ments are met: 
‘‘(A) The State provides assurances satisfactory 
to the Secretary that amounts received under sub-
section (a)(3)(F) with respect to costs of a Medicaid 
provider are paid directly to such provider without 
any deduction or rebate. 
‘‘(B) Such Medicaid provider is responsible for 
payment of the costs described in such paragraph that 
are not provided under this title. 
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‘‘(C) With respect to payments to such Medicaid 
provider for costs other than costs related to the ini-
tial adoption of certified EHR technology, the Med-
icaid provider demonstrates meaningful use of cer-
tified EHR technology through a means that is ap-
proved by the State and acceptable to the Secretary, 
and that may be based upon the methodologies ap-
plied under section 1848(o) or 1886(n). In estab-
lishing such means, which may include the reporting 
of clinical quality measures to the State, the State 
shall ensure that populations with unique needs, such 
as children, are appropriately addressed. 
‘‘(D) To the extent specified by the Secretary, the 
certified EHR technology is compatible with State or 
Federal administrative management systems. 
‘‘(6)(A) In no case shall the payments described in 
paragraph (1), with respect to a hospital, exceed in the ag-
gregate the product of— 
‘‘(i) the overall hospital EHR amount for the 
hospital computed under subparagraph (B); and 
‘‘(ii) the Medicaid share for such hospital com-
puted under subparagraph (C). 
‘‘(B) For purposes of this paragraph, the overall hos-
pital EHR amount, with respect to a hospital, is the sum 
of the applicable amounts specified in section 1886(n)(2)(A) 
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for such hospital for the first 4 payment years (as estimated 
by the Secretary) determined as if the Medicare share speci-
fied in clause (ii) of such section were 1. The Secretary shall 
publish in the Federal Register the overall hospital EHR 
amount for each hospital eligible for payments under this 
subsection. In computing amounts under clause (ii) for 
payment years after the first payment year, the Secretary 
shall assume that in subsequent payment years discharges 
increase at the average annual rate of growth of the most 
recent three years for which discharge data are available. 
‘‘(C) The Medicaid share computed under this sub-
paragraph, for a hospital for a period specified by the Sec-
retary, shall be calculated in the same manner as the Medi-
care share under section 1886(n)(2)(D) for such a hospital 
and period, except that there shall be substituted for the nu-
merator under clause (i) of such section the amount that 
is equal to the number of inpatient-bed-days (as established 
by the Secretary) which are attributable to individuals who 
are receiving medical assistance under this title and who 
are not described in section 1886(n)(2)(D)(i). In computing 
inpatient-bed-days under the previous sentence, the Sec-
retary shall take into account inpatient-bed-days attrib-
utable to inpatient-bed-days that are paid for individuals 
enrolled in a Medicaid managed care plan (under section 
1903(m) or section 1932). 
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‘‘(7) With respect to health care providers other than 
hospitals, the Secretary shall establish and implement a de-
tailed process to ensure coordination of the different pro-
grams for payment of such health care providers for adop-
tion or use of health information technology (including cer-
tified EHR technology), as well as payments for such health 
care providers provided under this title or title XVIII, to 
assure no duplication of funding. The Secretary shall pro-
mulgate regulations to carry out the preceding sentence. 
‘‘(8) In carrying out paragraph (5)(C), the State and 
Secretary shall seek, to the maximum extent practicable, to 
avoid duplicative requirements from Federal and State 
Governments to demonstrate meaningful use of certified 
EHR technology under this title and title XVIII. In doing 
so, the Secretary may deem satisfaction of requirements for 
such meaningful use for a payment year under title XVIII 
to be sufficient to qualify as meaningful use under this sub-
section. The Secretary may also specify the reporting peri-
ods under this subsection in order to carry out this para-
graph. 
‘‘(9) In order to be provided Federal financial partici-
pation under subsection (a)(3)(F)(ii), a State must dem-
onstrate to the satisfaction of the Secretary, that the State— 
‘‘(A) is using the funds provided for the purposes 
of administering payments under this subsection, in-
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cluding tracking of meaningful use by Medicaid pro-
viders; 
‘‘(B) is conducting adequate oversight of the pro-
gram under this subsection, including routine track-
ing of meaningful use attestations and reporting 
mechanisms; and 
‘‘(C) is pursuing initiatives to encourage the 
adoption of certified EHR technology to promote 
health care quality and the exchange of health care 
information under this title, subject to applicable 
laws and regulations governing such exchange. 
‘‘(10) The Secretary shall periodically submit reports 
to the Committee on Energy and Commerce of the House 
of Representatives and the Committee on Finance of the 
Senate on status, progress, and oversight of payments under 
paragraph (1).’’. 
(b) IMPLEMENTATION FUNDING.—In addition to funds 
otherwise available, out of any funds in the Treasury not 
otherwise appropriated, there are appropriated to the Sec-
retary of Health and Human Services for the Center for 
Medicare & Medicaid Services Program Management Ac-
count, $40,000,000 for each of fiscal years 2009 through 
2015 and $20,000,000 for each succeeding fiscal year 
through fiscal year 2018, which shall be available for pur-
poses of carrying out the provisions of (and the amendments 
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made by) this part. Amounts appropriated under this sub-
section for a fiscal year shall be available until expended. 
(c) HHS REPORT ON IMPLEMENTATION OF DETAILED 
PROCESS TO ASSURE NO DUPLICATION OF FUNDING.—Not 
later than July 1, 2012, the Secretary of Health and 
Human Services shall submit to Congress a report on the 
establishment and implementation of the detailed process 
under section 1903(t)(7) of the Social Security Act, as 
added by subsection (a), together with recommendations for 
such legislation and administrative action as the Secretary 
determines appropriate. 
TITLE V—STATE FISCAL RELIEF 
SEC. 5000. PURPOSES; TABLE OF CONTENTS. 
(a) PURPOSES.—The purposes of this title are as fol-
lows: 
(1) To provide fiscal relief to States in a period 
of economic downturn. 
(2) To protect and maintain State Medicaid 
programs during a period of economic downturn, in-
cluding by helping to avert cuts to provider payment 
rates and benefits or services, and to prevent constric-
tions of income eligibility requirements for such pro-
grams, but not to promote increases in such require-
ments. 
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(b) TABLE OF CONTENTS.—The table of contents for 
this title is as follows: 
TITLE V—STATE FISCAL RELIEF 
Sec. 5000. Purposes; table of contents. 
Sec. 5001. Temporary increase of Medicaid FMAP. 
Sec. 5002. Extension and update of special rule for increase of Medicaid DSH 
allotments for low DSH States. 
Sec. 5003. Payment of Medicare liability to States as a result of the Special Dis-
ability Workload Project. 
Sec. 5004. Funding for the Department of Health and Human Services Office of 
the Inspector General. 
Sec. 5005. GAO study and report regarding State needs during periods of na-
tional economic downturn. 
SEC. 5001. TEMPORARY INCREASE OF MEDICAID FMAP. 
(a) PERMITTING MAINTENANCE OF FMAP.—Subject to 
subsections (e), (f), and (g), if the FMAP determined with-
out regard to this section for a State for— 
(1) fiscal year 2009 is less than the FMAP as so 
determined for fiscal year 2008, the FMAP for the 
State for fiscal year 2008 shall be substituted for the 
State’s FMAP for fiscal year 2009, before the applica-
tion of this section; 
(2) fiscal year 2010 is less than the FMAP as so 
determined for fiscal year 2008 or fiscal year 2009 
(after the application of paragraph (1)), the greater 
of such FMAP for the State for fiscal year 2008 or 
fiscal year 2009 shall be substituted for the State’s 
FMAP for fiscal year 2010, before the application of 
this section; and 
(3) fiscal year 2011 is less than the FMAP as so 
determined for fiscal year 2008, fiscal year 2009 
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(after the application of paragraph (1)), or fiscal 
year 2010 (after the application of paragraph (2)), 
the greatest of such FMAP for the State for fiscal year 
2008, fiscal year 2009, or fiscal year 2010 shall be 
substituted for the State’s FMAP for fiscal year 2011, 
before the application of this section, but only for the 
first calendar quarter in fiscal year 2011. 
(b) GENERAL 7.6 PERCENTAGE POINT INCREASE.— 
Subject to subsections (e), (f), and (g), for each State for 
calendar quarters during the recession adjustment period 
(as defined in subsection (h)(2)) , the FMAP (after the ap-
plication of subsection (a)) shall be increased (without re-
gard to any limitation otherwise specified in section 
1905(b) of the Social Security Act) by 7.6 percentage 
points. 
(c) ADDITIONAL RELIEF BASED ON INCREASE IN UN-
EMPLOYMENT.— 
(1) IN GENERAL.—Subject to subsections (e), (f), 
and (g), if a State is a qualifying State under para-
graph (2) for a calendar quarter occurring during the 
recession adjustment period, the FMAP for the State 
shall be further increased by the number of percentage 
points equal to the product of the State percentage 
applicable for the State under section 1905(b) of the 
Social Security Act (42 U.S.C. 1396d(b)) after the 
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application of subsections (a) and (b) and the appli-
cable percent determined in paragraph (3) for the cal-
endar quarter (or, if greater, for a previous such cal-
endar quarter, subject to paragraph (4)) . 
(2) QUALIFYING CRITERIA.— 
(A) IN GENERAL.—For purposes of para-
graph (1), a State qualifies for additional relief 
under this subsection for a calendar quarter oc-
curring during the recession adjustment period if 
the State is 1 of the 50 States or the District of 
Columbia and the State satisfies any of the fol-
lowing criteria for the quarter: 
(i) An increase of at least 1.5 percent-
age points, but less than 2.5 percentage 
points, in the average monthly unemploy-
ment rate, seasonally adjusted, for the State 
or District, as determined by comparing 
months in the most recent previous 3-con-
secutive month period for which data are 
available for the State or District to the 
lowest average monthly unemployment rate, 
seasonally adjusted, for the State or District 
for any 3-consecutive-month period pre-
ceding that period and beginning on or 
after January 1, 2006 (based on the most 
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recently available monthly publications of 
the Bureau of Labor Statistics of the De-
partment of Labor). 
(ii) An increase of at least 2.5 percent-
age points, but less than 3.5 percentage 
points, in the average monthly unemploy-
ment rate, seasonally adjusted, for the State 
or District (as so determined). 
(iii) An increase of at least 3.5 per-
centage points for the State or District, in 
the average monthly unemployment rate, 
seasonally adjusted, for the State or District 
(as so determined). 
(B) MAINTENANCE OF STATUS.—If a State 
qualifies for additional relief under this sub-
section for a calendar quarter, it shall be deemed 
to have qualified for such relief for each subse-
quent calendar quarter ending before July 1, 
2010. 
(3) APPLICABLE
PERCENT.—For purposes of 
paragraph (1), the applicable percent is— 
(A) 2.5 percent, if the State satisfies the cri-
teria described in paragraph (2)(A)(i) for the 
calendar quarter; 
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(B) 4.5 percent if the State satisfies the cri-
teria described in paragraph (2)(A)(ii) for the 
calendar quarter; and 
(C) 6.5 percent if the State satisfies the cri-
teria described in paragraph (2)(A)(iii) for the 
calendar quarter. 
(4) MAINTENANCE OF HIGHER PERCENTAGE RE-
DUCTION
FOR
PERIOD
AFTER
LOWER
PERCENTAGE 
DEDUCTION WOULD OTHERWISE TAKE EFFECT.— 
(A) HOLD HARMLESS PERIOD.—If the per-
centage reduction applied to a State under para-
graph (3) for any calendar quarter in the reces-
sion adjustment period beginning on or after 
January 1, 2009, and ending before July 1, 
2010, (determined without regard to this para-
graph) is less than the percentage reduction ap-
plied for the preceding quarter (as so deter-
mined), the higher percentage reduction shall 
continue in effect for each subsequent calendar 
quarter ending before July 1, 2010. 
(B) NOTICE OF DECREASE IN PERCENTAGE 
REDUCTION.—The Secretary shall notify a State 
at least 3 months prior to applying any lower 
percentage reduction to the State under para-
graph (3). 
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(d) INCREASE IN CAP ON MEDICAID PAYMENTS TO 
TERRITORIES.—Subject to subsections (f) and (g), with re-
spect to entire fiscal years occurring during the recession 
adjustment period and with respect to fiscal years only a 
portion of which occurs during such period (and in propor-
tion to the portion of the fiscal year that occurs during such 
period), the amounts otherwise determined for Puerto Rico, 
the Virgin Islands, Guam, the Northern Mariana Islands, 
and American Samoa under subsections (f) and (g) of sec-
tion 1108 of the Social Security Act (42 6 U.S.C. 1308) 
shall each be increased by 15.2 percent. 
(e) SCOPE OF APPLICATION.—The increases in the 
FMAP for a State under this section shall apply for pur-
poses of title XIX of the Social Security Act and shall not 
apply with respect to— 
(1) disproportionate share hospital payments de-
scribed in section 1923 of such Act (42 U.S.C. 1396r– 
4); 
(2) payments under title IV of such Act (42 
U.S.C. 601 et seq.) (except that the increases under 
subsections (a) and (b) shall apply to payments under 
part E of title IV of such Act (42 U.S.C. 670 et seq.)); 
(3) payments under title XXI of such Act (42 
U.S.C. 1397aa et seq.); 
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(4) any payments under title XIX of such Act 
that are based on the enhanced FMAP described in 
section 2105(b) of such Act (42 U.S.C. 1397ee(b)); or 
(5) any payments under title XIX of such Act 
that are attributable to expenditures for medical as-
sistance provided to individuals made eligible under 
a State plan under title XIX of the Social Security 
Act (including under any waiver under such title or 
under section 1115 of such Act (42 U.S.C. 1315)) be-
cause of income standards (expressed as a percentage 
of the poverty line) for eligibility for medical assist-
ance that are higher than the income standards (as 
so expressed) for such eligibility as in effect on July 
1, 2008. 
(f) STATE INELIGIBILITY.— 
(1) MAINTENANCE
OF
ELIGIBILITY
REQUIRE-
MENTS.— 
(A) IN
GENERAL.—Subject to subpara-
graphs (B) and (C), a State is not eligible for 
an increase in its FMAP under subsection (a), 
(b), or (c), or an increase in a cap amount 
under subsection (d), if eligibility standards, 
methodologies, or procedures under its State plan 
under title XIX of the Social Security Act (in-
cluding any waiver under such title or under 
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section 1115 of such Act (42 U.S.C. 1315)) are 
more restrictive than the eligibility standards, 
methodologies, or procedures, respectively, under 
such plan (or waiver) as in effect on July 1, 
2008. 
(B) STATE REINSTATEMENT OF ELIGIBILITY 
PERMITTED.—Subject to subparagraph (C), a 
State that has restricted eligibility standards, 
methodologies, or procedures under its State plan 
under title XIX of the Social Security Act (in-
cluding any waiver under such title or under 
section 1115 of such Act (42 U.S.C. 1315)) after 
July 1, 2008, is no longer ineligible under sub-
paragraph (A) beginning with the first calendar 
quarter in which the State has reinstated eligi-
bility standards, methodologies, or procedures 
that are no more restrictive than the eligibility 
standards, methodologies, or procedures, respec-
tively, under such plan (or waiver) as in effect 
on July 1, 2008. 
(C) SPECIAL RULES.—A State shall not be 
ineligible under subparagraph (A)— 
(i) for the calendar quarters before 
July 1, 2009, on the basis of a restriction 
that was applied after July 1, 2008, and be-
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fore the date of the enactment of this Act, if 
the State prior to July 1, 2009, has rein-
stated eligibility standards, methodologies, 
or procedures that are no more restrictive 
than the eligibility standards, methodolo-
gies, or procedures, respectively, under such 
plan (or waiver) as in effect on July 1, 
2008; or 
(ii) on the basis of a restriction that 
was directed to be made under State law as 
of July 1, 2008, and would have been in ef-
fect as of such date, but for a delay in the 
request for, and approval of, a waiver under 
section 1115 of such Act with respect to 
such restriction. 
(2) COMPLIANCE WITH PROMPT PAY REQUIRE-
MENTS.—No State shall be eligible for an increased 
FMAP rate as provided under this section for any 
claim submitted by a provider subject to the terms of 
section 1902(a)(37)(A) of the Social Security Act (42 
U.S.C. 1396a(a)(37)(A)) during any period in which 
that State has failed to pay claims in accordance 
with section 1902(a)(37)(A) of such Act. Each State 
shall report to the Secretary, no later than 30 days 
following the 1st day of the month, its compliance 
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with the requirements of section 1902(a)(37)(A) of the 
Social Security Act as they pertain to claims made 
for covered services during the preceding month. 
(3) NO WAIVER AUTHORITY.—The Secretary may 
not waive the application of this subsection or sub-
section (g) under section 1115 of the Social Security 
Act or otherwise. 
(g) REQUIREMENTS.— 
(1) IN GENERAL.—A State may not deposit or 
credit the additional Federal funds paid to the State 
as a result of this section to any reserve or rainy day 
fund maintained by the State. 
(2) STATE REPORTS.—Each State that is paid 
additional Federal funds as a result of this section 
shall, not later than September 30, 2011, submit a re-
port to the Secretary, in such form and such manner 
as the Secretary shall determine, regarding how the 
additional Federal funds were expended. 
(3) ADDITIONAL
REQUIREMENT
FOR
CERTAIN 
STATES.—In the case of a State that requires political 
subdivisions within the State to contribute toward the 
non-Federal share of expenditures under the State 
Medicaid plan required under section 1902(a)(2) of 
the Social Security Act (42 U.S.C. 1396a(a)(2)), the 
State is not eligible for an increase in its FMAP 
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