612 
AMDT. NO. 570 
‘‘(I) requests a grant under this 
subparagraph for the quarter; and 
‘‘(II) meets the requirement of 
clause (ii) for the quarter. 
‘‘(ii) SUBSIDIZED
EMPLOYMENT
EX-
PENDITURE
REQUIREMENT.—A 
State 
meets the requirement of this clause for a 
quarter if the total expenditures of the 
State for subsidized employment in the 
quarter, whether under the State program 
funded under this part or as qualified 
State expenditures, exceeds the total of 
such expenditures of the State in the cor-
responding quarter in the emergency fund 
base year of the State. 
‘‘(iii) AMOUNT OF GRANT.—Subject to 
paragraph (5), the amount of the grant to 
be made to a State under this subpara-
graph for a quarter shall be an amount 
equal to 80 percent of the excess described 
in clause (ii). 
‘‘(4) AUTHORITY TO MAKE NECESSARY ADJUST-
MENTS TO DATA AND COLLECT NEEDED DATA.—In 
determining the size of the caseload of a State and 
the expenditures of a State for basic assistance, non- 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00612
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
613 
AMDT. NO. 570 
recurrent short-term benefits, and subsidized em-
ployment, during any period for which the State re-
quests funds under this subsection, and during the 
emergency fund base year of the State, the Sec-
retary may make appropriate adjustments to the 
data to ensure that the data reflect expenditures 
under the State program funded under this part and 
qualified State expenditures. The Secretary may de-
velop a mechanism for collecting expenditure data, 
including procedures which allow States to make 
reasonable estimates, and may set deadlines for 
making revisions to the data. 
‘‘(5) LIMITATION.—The total amount payable 
to a single State under subsection (b) and this sub-
section for a fiscal year shall not exceed 25 percent 
of the State family assistance grant. 
‘‘(6) LIMITATIONS ON USE OF FUNDS.—A State 
to which an amount is paid under this subsection 
may use the amount only as authorized by section 
404. 
‘‘(7) TIMING OF IMPLEMENTATION.—The Sec-
retary shall implement this subsection as quickly as 
reasonably possible, pursuant to appropriate guid-
ance to States. 
‘‘(8) DEFINITIONS.—In this subsection: 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00613
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
614 
AMDT. NO. 570 
‘‘(A) 
AVERAGE
MONTHLY
ASSISTANCE 
CASELOAD
DEFINED.—The 
term 
‘average 
monthly assistance caseload’ means, with re-
spect to a State and a quarter, the number of 
families receiving assistance during the quarter 
under the State program funded under this 
part or as qualified State expenditures, subject 
to adjustment under paragraph (4). 
‘‘(B) EMERGENCY FUND BASE YEAR.— 
‘‘(i) IN GENERAL.—The term ‘emer-
gency fund base year’ means, with respect 
to a State and a category described in 
clause (ii), whichever of fiscal year 2007 or 
2008 is the fiscal year in which the 
amount described by the category with re-
spect to the State is the lesser. 
‘‘(ii) CATEGORIES
DESCRIBED.—The 
categories described in this clause are the 
following: 
‘‘(I) The average monthly assist-
ance caseload of the State. 
‘‘(II) The total expenditures of 
the State for non-recurrent short term 
benefits, whether under the State pro-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00614
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
615 
AMDT. NO. 570 
gram funded under this part or as 
qualified State expenditures. 
‘‘(III) The total expenditures of 
the State for subsidized employment, 
whether under the State program 
funded under this part or as qualified 
State expenditures. 
‘‘(C) QUALIFIED STATE EXPENDITURES.— 
The term ‘qualified State expenditures’ has the 
meaning given the term in section 409(a)(7).’’. 
(2) REPEAL.—Effective October 1, 2010, sub-
section (c) of section 403 of the Social Security Act 
(42 U.S.C. 603) (as added by paragraph (1)) is re-
pealed. 
(b) TEMPORARY MODIFICATION OF CASELOAD RE-
DUCTION CREDIT.—Section 407(b)(3)(A)(i) of such Act 
(42 U.S.C. 607(b)(3)(A)(i)) is amended by inserting ‘‘(or 
if the immediately preceding fiscal year is fiscal year 2008, 
2009, or 2010, then, at State option, during the emer-
gency fund base year of the State with respect to the aver-
age monthly assistance caseload of the State (within the 
meaning of section 403(c)(8)(B), except that, if a State 
elects such option for fiscal year 2008, the emergency fund 
base year of the State with respect to such caseload shall 
be fiscal year 2007))’’ before ‘‘under the State’’. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00615
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
616 
AMDT. NO. 570 
(c) DISREGARD FROM LIMITATION ON TOTAL PAY-
MENTS TO TERRITORIES.—Section 1108(a)(2) of the So-
cial Security Act (42 U.S.C. 1308(a)(2)) is amended by 
inserting ‘‘403(c)(3),’’ after ‘‘403(a)(5),’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on the date of the enactment 
of this Act. 
SEC. 2102. EXTENSION OF TANF SUPPLEMENTAL GRANTS. 
(a) EXTENSION THROUGH FISCAL YEAR 2010.—Sec-
tion 7101(a) of the Deficit Reduction Act of 2005 (Public 
Law 109–171; 120 Stat. 135), as amended by section 
301(a) of the Medicare Improvements for Patients and 
Providers Act of 2008 (Public Law 110–275), is amended 
by striking ‘‘fiscal year 2009’’ and inserting ‘‘fiscal year 
2010’’. 
(b) 
CONFORMING
AMENDMENT.—Section 
403(a)(3)(H)(ii) of the Social Security Act (42 U.S.C. 
603(a)(3)(H)(ii)) is amended to read as follows: 
‘‘(ii) subparagraph (G) shall be ap-
plied as if ‘fiscal year 2010’ were sub-
stituted for ‘fiscal year 2001’; and’’. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00616
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
617 
AMDT. NO. 570 
SEC. 2103. CLARIFICATION OF AUTHORITY OF STATES TO 
USE TANF FUNDS CARRIED OVER FROM 
PRIOR YEARS TO PROVIDE TANF BENEFITS 
AND SERVICES. 
Section 404(e) of the Social Security Act (42 U.S.C. 
604(e)) is amended to read as follows: 
‘‘(e) 
AUTHORITY
TO
CARRY
OVER
CERTAIN 
AMOUNTS FOR BENEFITS OR SERVICES OR FOR FUTURE 
CONTINGENCIES.—A State or tribe may use a grant made 
to the State or tribe under this part for any fiscal year 
to provide, without fiscal year limitation, any benefit or 
service that may be provided under the State or tribal pro-
gram funded under this part.’’. 
SEC. 2104. TEMPORARY REINSTATEMENT OF AUTHORITY 
TO PROVIDE FEDERAL MATCHING PAYMENTS 
FOR STATE SPENDING OF CHILD SUPPORT 
INCENTIVE PAYMENTS. 
During the period that begins on October 1, 2008, 
and ends on December 31, 2010, section 455(a)(1) of the 
Social Security Act (42 U.S.C. 655(a)(1)) shall be applied 
without regard to the amendment made by section 
7309(a) of the Deficit Reduction Act of 2005 (Public Law 
109–171, 120 Stat. 147). 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00617
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
618 
AMDT. NO. 570 
TITLE III—HEALTH INSURANCE 
ASSISTANCE 
SEC. 3000. TABLE OF CONTENTS OF TITLE. 
The table of contents for this title is as follows: 
TITLE III—HEALTH INSURANCE ASSISTANCE 
Sec. 3000. Table of contents of title. 
Subtitle A—Premium Subsidies for COBRA Continuation Coverage for 
Unemployed Workers 
Sec. 3001. Premium assistance for COBRA benefits. 
Subtitle B—Transitional Medical Assistance (TMA) 
Sec. 3101. Extension of transitional medical assistance (TMA). 
Subtitle C—Extension of the Qualified Individual (QI) Program 
Sec. 3201. Extension of the qualifying individual (QI) program. 
Subtitle D—Other Provisions 
Sec. 3301. Premiums and cost sharing protections under Medicaid, eligibility 
determinations under Medicaid and CHIP, and protection of 
certain Indian property from Medicaid estate recovery. 
Sec. 3302. Rules applicable under Medicaid and CHIP to managed care entities 
with respect to Indian enrollees and Indian health care pro-
viders and Indian managed care entities. 
Sec. 3303. Consultation on Medicaid, CHIP, and other health care programs 
funded under the Social Security Act involving Indian Health 
Programs and Urban Indian Organizations. 
Sec. 3304. Application of prompt pay requirements to nursing facilities. 
Sec. 3305. Period of application; sunset. 
Subtitle A—Premium Subsidies for 
COBRA Continuation Coverage 
for Unemployed Workers 
SEC. 3001. PREMIUM ASSISTANCE FOR COBRA BENEFITS. 
(a) TABLE OF CONTENTS OF SUBTITLE.—The table 
of contents of this subtitle is as follows: 
Sec. 3001. Premium assistance for COBRA benefits. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00618
Fmt 6654
Sfmt 6211
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
619 
AMDT. NO. 570 
(b) PREMIUM ASSISTANCE FOR COBRA CONTINU-
ATION COVERAGE
FOR UNEMPLOYED WORKERS
AND 
THEIR FAMILIES.— 
(1) PROVISION OF PREMIUM ASSISTANCE.— 
(A) 
REDUCTION
OF
PREMIUMS
PAY-
ABLE.—In the case of any premium for a 
month of coverage beginning after the date of 
the enactment of the Act for COBRA continu-
ation coverage with respect to any assistance el-
igible individual, such individual shall be treated 
for purposes of any COBRA continuation provi-
sion as having paid the amount of such pre-
mium if such individual pays 50 percent of the 
amount of such premium (as determined with-
out regard to this subsection). 
(B) PLAN ENROLLMENT OPTION.— 
(i) IN
GENERAL.—Notwithstanding 
the COBRA continuation provisions, an as-
sistance eligible individual may, not later 
than 90 days after the date of notice of the 
plan enrollment option described in this 
subparagraph, elect to enroll in coverage 
under a plan offered by the employer in-
volved, or the employee organization in-
volved (including, for this purpose, a joint 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00619
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
620 
AMDT. NO. 570 
board of trustees of a multiemployer trust 
affiliated with one or more multiemployer 
plans), that is different than coverage 
under the plan in which such individual 
was enrolled at the time the qualifying 
event occurred, and such coverage shall be 
treated as COBRA continuation coverage 
for purposes of the applicable COBRA con-
tinuation coverage provision. 
(ii) REQUIREMENTS.—An assistance 
eligible individual may elect to enroll in 
different coverage as described in clause (i) 
only if— 
(I) the employer involved has 
made a determination that such em-
ployer will permit assistance eligible 
individuals to enroll in different cov-
erage as provided for this subpara-
graph; 
(II) the premium for such dif-
ferent coverage does not exceed the 
premium for coverage in which the in-
dividual was enrolled at the time the 
qualifying event occurred; 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00620
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
621 
AMDT. NO. 570 
(III) the different coverage in 
which the individual elects to enroll is 
coverage that is also offered to the ac-
tive employees of the employer at the 
time at which such election is made; 
and 
(IV) the different coverage is 
not— 
(aa) coverage that provides 
only dental, vision, counseling, or 
referral services (or a combina-
tion of such services); 
(bb) a health flexible spend-
ing account or health reimburse-
ment arrangement; or 
(cc) coverage that provides 
coverage for services or treat-
ments furnished in an on-site 
medical facility maintained by 
the employer and that consists 
primarily of first-aid services, 
prevention and wellness care, or 
similar care (or a combination of 
such care). 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00621
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
622 
AMDT. NO. 570 
(C) PREMIUM REIMBURSEMENT.—For pro-
visions providing the balance of such premium, 
see section 6432 of the Internal Revenue Code 
of 1986, as added by paragraph (12). 
(2) LIMITATION OF PERIOD OF PREMIUM AS-
SISTANCE.— 
(A) IN GENERAL.—Paragraph (1)(A) shall 
not apply with respect to any assistance eligible 
individual for months of coverage beginning on 
or after the earlier of— 
(i) the first date that such individual 
is eligible for coverage under any other 
group health plan (other than coverage 
consisting of only dental, vision, coun-
seling, or referral services (or a combina-
tion thereof), coverage under a health re-
imbursement arrangement or a health 
flexible spending arrangement, or coverage 
of treatment that is furnished in an on-site 
medical facility maintained by the em-
ployer and that consists primarily of first- 
aid services, prevention and wellness care, 
or similar care (or a combination thereof)) 
or is eligible for benefits under title XVIII 
of the Social Security Act; or 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00622
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
623 
AMDT. NO. 570 
(ii) the earliest of— 
(I) the date which is 12 months 
after the first day of first month that 
paragraph (1)(A) applies with respect 
to such individual, 
(II) the date following the expira-
tion of the maximum period of con-
tinuation coverage required under the 
applicable COBRA continuation cov-
erage provision, or 
(III) the date following the expi-
ration of the period of continuation 
coverage allowed under paragraph 
(4)(B)(ii). 
(B) TIMING
OF
ELIGIBILITY
FOR
ADDI-
TIONAL COVERAGE.—For purposes of subpara-
graph (A)(i), an individual shall not be treated 
as eligible for coverage under a group health 
plan before the first date on which such indi-
vidual could be covered under such plan. 
(C) 
NOTIFICATION
REQUIREMENT.—An 
assistance eligible individual shall notify in writ-
ing the group health plan with respect to which 
paragraph (1)(A) applies if such paragraph 
ceases to apply by reason of subparagraph 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00623
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
624 
AMDT. NO. 570 
(A)(i). Such notice shall be provided to the 
group health plan in such time and manner as 
may be specified by the Secretary of Labor. 
(3) ASSISTANCE
ELIGIBLE
INDIVIDUAL.—For 
purposes of this section, the term ‘‘assistance eligible 
individual’’ means any qualified beneficiary if— 
(A) at any time during the period that be-
gins with September 1, 2008, and ends with 
December 31, 2009, such qualified beneficiary 
is eligible for COBRA continuation coverage, 
(B) such qualified beneficiary elects such 
coverage, and 
(C) the qualifying event with respect to the 
COBRA continuation coverage consists of the 
involuntary termination of the covered employ-
ee’s employment and occurred during such pe-
riod. 
(4) EXTENSION OF ELECTION PERIOD AND EF-
FECT ON COVERAGE.— 
(A) IN
GENERAL.—Notwithstanding sec-
tion 605(a) of the Employee Retirement Income 
Security Act of 1974, section 4980B(f)(5)(A) of 
the Internal Revenue Code of 1986, section 
2205(a) of the Public Health Service Act, and 
section 8905a(c)(2) of title 5, United States 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00624
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
625 
AMDT. NO. 570 
Code, in the case of an individual who is a 
qualified beneficiary described in paragraph 
(3)(A) as of the date of the enactment of this 
Act and has not made the election referred to 
in paragraph (3)(B) as of such date, such indi-
vidual may elect the COBRA continuation cov-
erage under the COBRA continuation coverage 
provisions containing such sections during the 
60-day period commencing with the date on 
which the notification required under paragraph 
(7)(C) is provided to such individual. 
(B) COMMENCEMENT
OF
COVERAGE; NO 
REACH-BACK.—Any COBRA continuation cov-
erage elected by a qualified beneficiary during 
an extended election period under subparagraph 
(A)— 
(i) shall commence on the date of the 
enactment of this Act, and 
(ii) shall not extend beyond the period 
of COBRA continuation coverage that 
would have been required under the appli-
cable COBRA continuation coverage provi-
sion if the coverage had been elected as re-
quired under such provision. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00625
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
626 
AMDT. NO. 570 
(C) PREEXISTING CONDITIONS.—With re-
spect to a qualified beneficiary who elects 
COBRA continuation coverage pursuant to sub-
paragraph (A), the period— 
(i) beginning on the date of the quali-
fying event, and 
(ii) ending with the day before the 
date of the enactment of this Act, 
shall be disregarded for purposes of deter-
mining the 63-day periods referred to in section 
701)(2) of the Employee Retirement Income 
Security Act of 1974, section 9801(c)(2) of the 
Internal Revenue Code of 1986, and section 
2701(c)(2) of the Public Health Service Act. 
(5) EXPEDITED REVIEW OF DENIALS OF PRE-
MIUM ASSISTANCE.—In any case in which an indi-
vidual requests treatment as an assistance eligible 
individual and is denied such treatment by the group 
health plan by reason of such individual’s ineligi-
bility for COBRA continuation coverage, the Sec-
retary of Labor (or the Secretary of Health and 
Human services in connection with COBRA continu-
ation coverage which is provided other than pursu-
ant to part 6 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974), in con-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00626
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
627 
AMDT. NO. 570 
sultation with the Secretary of the Treasury, shall 
provide for expedited review of such denial. An indi-
vidual shall be entitled to such review upon applica-
tion to such Secretary in such form and manner as 
shall be provided by such Secretary. Such Secretary 
shall make a determination regarding such individ-
ual’s eligibility within 10 business days after receipt 
of such individual’s application for review under this 
paragraph. 
(6) DISREGARD OF SUBSIDIES FOR PURPOSES 
OF
FEDERAL
AND
STATE
PROGRAMS.—Notwith-
standing any other provision of law, any premium 
reduction with respect to an assistance eligible indi-
vidual under this subsection shall not be considered 
income or resources in determining eligibility for, or 
the amount of assistance or benefits provided under, 
any other public benefit provided under Federal law 
or the law of any State or political subdivision there-
of. 
(7) NOTICES TO INDIVIDUALS.— 
(A) GENERAL NOTICE.— 
(i) IN GENERAL.—In the case of no-
tices provided under section 606(4) of the 
Employee Retirement Income Security Act 
of 1974 (29 U.S.C. 1166(4)), section 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00627
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
628 
AMDT. NO. 570 
4980B(f)(6)(D) of the Internal Revenue 
Code of 1986, section 2206(4) of the Pub-
lic Health Service Act (42 U.S.C. 300bb- 
6(4)), or section 8905a(f)(2)(A) of title 5, 
United States Code, with respect to indi-
viduals who, during the period described in 
paragraph (3)(A), become entitled to elect 
COBRA continuation coverage, such no-
tices shall include an additional notifica-
tion to the recipient of— 
(I) the availability of premium 
reduction with respect to such cov-
erage under this subsection; and 
(II) the option to enroll in dif-
ferent coverage if an employer that 
permits assistance eligible individuals 
to elect enrollment in different cov-
erage (as described in paragraph 
(1)(B)). 
(ii) ALTERNATIVE
NOTICE.—In the 
case of COBRA continuation coverage to 
which the notice provision under such sec-
tions does not apply, the Secretary of 
Labor, in consultation with the Secretary 
of the Treasury and the Secretary of 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00628
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
629 
AMDT. NO. 570 
Health and Human Services, shall, in co-
ordination with administrators of the 
group health plans (or other entities) that 
provide or administer the COBRA continu-
ation coverage involved, provide rules re-
quiring the provision of such notice. 
(iii) FORM.—The requirement of the 
additional notification under this subpara-
graph may be met by amendment of exist-
ing notice forms or by inclusion of a sepa-
rate document with the notice otherwise 
required. 
(B) SPECIFIC REQUIREMENTS.—Each ad-
ditional notification under subparagraph (A) 
shall include— 
(i) the forms necessary for estab-
lishing eligibility for premium reduction 
under this subsection, 
(ii) the name, address, and telephone 
number necessary to contact the plan ad-
ministrator and any other person main-
taining relevant information in connection 
with such premium reduction, 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00629
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
630 
AMDT. NO. 570 
(iii) a description of the extended elec-
tion period provided for in paragraph 
(4)(A), 
(iv) a description of the obligation of 
the qualified beneficiary under paragraph 
(2)(C) to notify the plan providing continu-
ation coverage of eligibility for subsequent 
coverage under another group health plan 
or eligibility for benefits under title XVIII 
of the Social Security Act and the penalty 
provided for failure to so notify the plan, 
(v) a description, displayed in a 
prominent manner, of the qualified bene-
ficiary’s right to a reduced premium and 
any conditions on entitlement to the re-
duced premium; and 
(vi) a description of the option of the 
qualified beneficiary to enroll in different 
coverage if the employer permits such ben-
eficiary to elect to enroll in such different 
coverage under paragraph (1)(B). 
(C) NOTICE
RELATING
TO
RETROACTIVE 
COVERAGE.—In the case of an individual de-
scribed in paragraph (3)(A) who has elected 
COBRA continuation coverage as of the date of 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00630
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
631 
AMDT. NO. 570 
enactment of this Act or an individual described 
in paragraph (4)(A), the administrator of the 
group health plan (or other person) involved 
shall provide (within 60 days after the date of 
enactment of this Act) for the additional notifi-
cation required to be provided under subpara-
graph (A). 
(D) MODEL NOTICES.—Not later than 30 
days after the date of enactment of this Act, 
the Secretary of the Labor, in consultation with 
the Secretary of the Treasury and the Secretary 
of Health and Human Services, shall prescribe 
models for the additional notification required 
under this paragraph. 
(8) SAFEGUARDS.—The Secretary of the Treas-
ury shall provide such rules, procedures, regulations, 
and other guidance as may be necessary and appro-
priate to prevent fraud and abuse under this sub-
section. 
(9) OUTREACH.—The Secretary of Labor, in 
consultation with the Secretary of the Treasury and 
the Secretary of Health and Human Services, shall 
provide outreach consisting of public education and 
enrollment assistance relating to premium reduction 
provided under this subsection. Such outreach shall 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00631
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
632 
AMDT. NO. 570 
target employers, group health plan administrators, 
public assistance programs, States, insurers, and 
other entities as determined appropriate by such 
Secretaries. Such outreach shall include an initial 
focus on those individuals electing continuation cov-
erage who are referred to in paragraph (7)(C). In-
formation on such premium reduction, including en-
rollment, shall also be made available on website of 
the Departments of Labor, Treasury, and Health 
and Human Services. 
(10) DEFINITIONS.—For purposes of this sub-
section— 
(A) ADMINISTRATOR.—The term ‘‘admin-
istrator’’ has the meaning given such term in 
section 3(16) of the Employee Retirement In-
come Security Act of 1974 
(B) COBRA CONTINUATION COVERAGE.— 
The term ‘‘COBRA continuation coverage’’ 
means continuation coverage provided pursuant 
to part 6 of subtitle B of title I of the Em-
ployee Retirement Income Security Act of 1974 
(other than under section 609), title XXII of 
the Public Health Service Act, section 4980B of 
the Internal Revenue Code of 1986 (other than 
subsection (f)(1) of such section insofar as it 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00632
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
633 
AMDT. NO. 570 
relates to pediatric vaccines), or section 8905a 
of title 5, United States Code, or under a State 
program that provides continuation coverage 
comparable to such continuation coverage. Such 
term does not include coverage under a health 
flexible spending arrangement. 
(C) COBRA CONTINUATION PROVISION.— 
The term ‘‘COBRA continuation provision’’ 
means the provisions of law described in sub-
paragraph (B). 
(D) 
COVERED
EMPLOYEE.—The 
term 
‘‘covered employee’’ has the meaning given such 
term in section 607(2) of the Employee Retire-
ment Income Security Act of 1974. 
(E) QUALIFIED BENEFICIARY.—The term 
‘‘qualified beneficiary’’ has the meaning given 
such term in section 607(3) of the Employee 
Retirement Income Security Act of 1974. 
(F) GROUP
HEALTH
PLAN.—The term 
‘‘group health plan’’ has the meaning given 
such term in section 607(1) of the Employee 
Retirement Income Security Act of 1974. 
(G) STATE.—The term ‘‘State’’ includes 
the District of Columbia, the Commonwealth of 
Puerto Rico, the Virgin Islands, Guam, Amer-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00633
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
634 
AMDT. NO. 570 
ican Samoa, and the Commonwealth of the 
Northern Mariana Islands. 
(11) REPORTS.— 
(A) INTERIM REPORT.—The Secretary of 
the Treasury shall submit an interim report to 
the Committee on Education and Labor, the 
Committee on Ways and Means, and the Com-
mittee on Energy and Commerce of the House 
of Representatives and the Committee on 
Health, Education, Labor, and Pensions and 
the Committee on Finance of the Senate re-
garding the premium reduction provided under 
this subsection that includes— 
(i) the number of individuals provided 
such assistance as of the date of the re-
port; and 
(ii) the total amount of expenditures 
incurred (with administrative expenditures 
noted separately) in connection with such 
assistance as of the date of the report. 
(B) FINAL
REPORT.—As soon as prac-
ticable after the last period of COBRA continu-
ation coverage for which premium reduction is 
provided under this section, the Secretary of the 
Treasury shall submit a final report to each 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00634
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
635 
AMDT. NO. 570 
Committee referred to in subparagraph (A) that 
includes— 
(i) the number of individuals provided 
premium reduction under this section; 
(ii) 
the 
average 
dollar 
amount 
(monthly and annually) of premium reduc-
tions provided to such individuals; and 
(iii) the total amount of expenditures 
incurred (with administrative expenditures 
noted separately) in connection with pre-
mium reduction under this section. 
(12) COBRA PREMIUM ASSISTANCE.— 
(A) IN GENERAL.—Subchapter B of chap-
ter 65 of the Internal Revenue Code of 1986 is 
amended by adding at the end the following 
new section: 
‘‘SEC. 6432. COBRA PREMIUM ASSISTANCE. 
‘‘(a) IN GENERAL.—The person to whom premiums 
are payable under COBRA continuation coverage shall be 
reimbursed for the amount of premiums not paid by plan 
beneficiaries by reason of section 3001(b) of the American 
Recovery and Reinvestment Act of 2009. Such amount 
shall be treated as a credit against the requirement of such 
person to make deposits of payroll taxes and the liability 
of such person for payroll taxes. To the extent that such 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00635
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
636 
AMDT. NO. 570 
amount exceeds the amount of such taxes, the Secretary 
shall pay to such person the amount of such excess. No 
payment may be made under this subsection to a person 
with respect to any assistance eligible individual until after 
such person has received the reduced premium from such 
individual required under section 3001(a)(1)(A) of such 
Act. 
‘‘(b) PAYROLL TAXES.—For purposes of this section, 
the term ‘payroll taxes’ means— 
‘‘(1) amounts required to be deducted and with-
held for the payroll period under section 3401 (relat-
ing to wage withholding), 
‘‘(2) amounts required to be deducted for the 
payroll period under section 3102 (relating to FICA 
employee taxes), and 
‘‘(3) amounts of the taxes imposed for the pay-
roll period under section 3111 (relating to FICA em-
ployer taxes). 
‘‘(c) TREATMENT OF CREDIT.—Except as otherwise 
provided by the Secretary, the credit described in sub-
section (a) shall be applied as though the employer had 
paid to the Secretary, on the day that the qualified bene-
ficiary’s premium payment is received, an amount equal 
to such credit. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00636
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
637 
AMDT. NO. 570 
‘‘(d) TREATMENT OF PAYMENT.—For purposes of 
section 1324(b)(2) of title 31, United States Code, any 
payment under this subsection shall be treated in the same 
manner as a refund of the credit under section 35. 
‘‘(e) REPORTING.— 
‘‘(1) IN GENERAL.—Each person entitled to re-
imbursement under subsection (a) for any period 
shall submit such reports as the Secretary may re-
quire, including— 
‘‘(A) an attestation of involuntary termi-
nation of employment for each covered em-
ployee on the basis of whose termination entitle-
ment to reimbursement is claimed under sub-
section (a), and 
‘‘(B) a report of the amount of payroll 
taxes offset under subsection (a) for the report-
ing period and the estimated offsets of such 
taxes for the subsequent reporting period in 
connection with reimbursements under sub-
section (a). 
‘‘(2) TIMING
OF
REPORTS
RELATING
TO 
AMOUNT
OF
PAYROLL
TAXES.—Reports required 
under paragraph (1)(B) shall be submitted at the 
same time as deposits of taxes imposed by chapters 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00637
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
638 
AMDT. NO. 570 
21, 22, and 24 or at such time as is specified by the 
Secretary. 
‘‘(f) REGULATIONS.—The Secretary may issue such 
regulations or other guidance as may be necessary or ap-
propriate to carry out this section, including the require-
ment to report information or the establishment of other 
methods for verifying the correct amounts of payments 
and credits under this section, and the application of this 
section to group health plans which are multiemployer 
plans.’’. 
(B) SOCIAL SECURITY TRUST FUNDS HELD 
HARMLESS.—In determining any amount trans-
ferred or appropriated to any fund under the 
Social Security Act, section 6432 of the Inter-
nal Revenue Code of 1986 shall not be taken 
into account. 
(C) CLERICAL AMENDMENT.—The table of 
sections for subchapter B of chapter 65 of the 
Internal Revenue Code of 1986 is amended by 
adding at the end the following new item: 
‘‘Sec. 6432. COBRA premium assistance.’’. 
(D) EFFECTIVE DATE.—The amendments 
made by this paragraph shall apply to pre-
miums to which subsection (a)(1)(A) applies. 
(E) SPECIAL RULE.— 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00638
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
639 
AMDT. NO. 570 
(i) IN GENERAL.—In the case of an 
assistance eligible individual who pays the 
full premium amount required for COBRA 
continuation coverage for any month dur-
ing the 60-day period beginning on the 
first day of the first month after the date 
of enactment of this Act, the person to 
whom such payment is made shall— 
(I) make a reimbursement pay-
ment to such individual for the 
amount of such premium paid in ex-
cess of the amount required to be paid 
under subsection (b)(1)(A); or 
(II) provide credit to the indi-
vidual for such amount in a manner 
that reduces one or more subsequent 
premium payments that the individual 
is required to pay under such sub-
section for the coverage involved. 
(ii) 
REIMBURSING
EMPLOYER.—A 
person to which clause (i) applies shall be 
reimbursed as provided for in section 6432 
of the Internal Revenue Code of 1986 for 
any payment made, or credit provided, to 
the employee under such clause. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00639
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
640 
AMDT. NO. 570 
(iii) PAYMENT OR CREDITS.—Unless 
it is reasonable to believe that the credit 
for the excess payment in clause (i)(II) will 
be used by the assistance eligible individual 
within 180 days of the date on which the 
person receives from the individual the 
payment of the full premium amount, a 
person to which clause (i) applies shall 
make the payment required under such 
clause to the individual within 60 days of 
such payment of the full premium amount. 
If, as of any day within the 180-day pe-
riod, it is no longer reasonable to believe 
that the credit will be used during that pe-
riod, payment equal to the remainder of 
the credit outstanding shall be made to the 
individual within 60 days of such day. 
(13) PENALTY
FOR
FAILURE
TO
NOTIFY 
HEALTH PLAN OF CESSATION OF ELIGIBILITY FOR 
PREMIUM ASSISTANCE.— 
(A) IN GENERAL.—Part I of subchapter B 
of chapter 68 of the Internal Revenue Code of 
1986 is amended by adding at the end the fol-
lowing new section: 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00640
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
641 
AMDT. NO. 570 
‘‘SEC. 6720C. PENALTY FOR FAILURE TO NOTIFY HEALTH 
PLAN OF CESSATION OF ELIGIBILITY FOR 
COBRA PREMIUM ASSISTANCE. 
‘‘(a) IN GENERAL.—Any person required to notify a 
group health plan under section 3001(a)(2)(C) of the 
American Recovery and Reinvestment Act of 2009 who 
fails to make such a notification at such time and in such 
manner as the Secretary of Labor may require shall pay 
a penalty of 110 percent of the premium reduction pro-
vided under such section after termination of eligibility 
under such subsection. 
‘‘(b) REASONABLE CAUSE EXCEPTION.—No penalty 
shall be imposed under subsection (a) with respect to any 
failure if it is shown that such failure is due to reasonable 
cause and not to willful neglect.’’. 
(B) CLERICAL AMENDMENT.—The table of 
sections of part I of subchapter B of chapter 68 
of such Code is amended by adding at the end 
the following new item: 
‘‘Sec. 6720C. Penalty for failure to notify health plan of cessation of eligibility 
for COBRA premium assistance.’’. 
(C) EFFECTIVE DATE.—The amendments 
made by this paragraph shall apply to failures 
occurring after the date of the enactment of 
this Act. 
(14) COORDINATION WITH HCTC.— 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00641
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
642 
AMDT. NO. 570 
(A) IN GENERAL.—Subsection (g) of sec-
tion 35 of the Internal Revenue Code of 1986 
is amended by redesignating paragraph (9) as 
paragraph (10) and inserting after paragraph 
(8) the following new paragraph: 
‘‘(9) COBRA PREMIUM
ASSISTANCE.—In the 
case of an assistance eligible individual who receives 
premium reduction for COBRA continuation cov-
erage under section 3001(a) of the American Recov-
ery and Reinvestment Act of 2009 for any month 
during the taxable year, such individual shall not be 
treated as an eligible individual, a certified indi-
vidual, or a qualifying family member for purposes 
of this section or section 7527 with respect to such 
month.’’. 
(B) EFFECTIVE
DATE.—The amendment 
made by subparagraph (A) shall apply to tax-
able years ending after the date of the enact-
ment of this Act. 
(15) EXCLUSION OF COBRA PREMIUM ASSIST-
ANCE FROM GROSS INCOME.— 
(A) IN GENERAL.—Part III of subchapter 
B of chapter 1 of the Internal Revenue Code of 
1986 is amended by inserting after section 
139B the following new section: 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00642
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
643 
AMDT. NO. 570 
‘‘SEC. 139C. COBRA PREMIUM ASSISTANCE. 
‘‘In the case of an assistance eligible individual (as 
defined in section 3001 of the American Recovery and Re-
investment Act of 2009), gross income does not include 
any premium reduction provided under subsection (a) of 
such section.’’. 
(B) CLERICAL AMENDMENT.—The table of 
sections for part III of subchapter B of chapter 
1 of such Code is amended by inserting after 
the item relating to section 139B the following 
new item: 
‘‘Sec. 139C. COBRA premium assistance.’’. 
(C) EFFECTIVE DATE.—The amendments 
made by this paragraph shall apply to taxable 
years ending after the date of the enactment of 
this Act. 
Subtitle B—Transitional Medical 
Assistance (TMA) 
SEC. 3101. EXTENSION OF TRANSITIONAL MEDICAL ASSIST-
ANCE (TMA). 
(a) 18-MONTH EXTENSION.— 
(1) IN GENERAL.—Sections 1902(e)(1)(B) and 
1925(f) of the Social Security Act (42 U.S.C. 
1396a(e)(1)(B), 1396r–6(f)) are each amended by 
striking ‘‘September 30, 2003’’ and inserting ‘‘De-
cember 31, 2010’’. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00643
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
644 
AMDT. NO. 570 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall take effect on July 1, 2009. 
(b) STATE OPTION OF INITIAL 12-MONTH ELIGI-
BILITY.—Section 1925 of the Social Security Act (42 
U.S.C. 1396r–6) is amended— 
(1) in subsection (a)(1), by inserting ‘‘but sub-
ject to paragraph (5)’’ after ‘‘Notwithstanding any 
other provision of this title’’; 
(2) by adding at the end of subsection (a) the 
following: 
‘‘(5) OPTION OF 12-MONTH INITIAL ELIGIBILITY 
PERIOD.—A State may elect to treat any reference 
in this subsection to a 6-month period (or 6 months) 
as a reference to a 12-month period (or 12 months). 
In the case of such an election, subsection (b) shall 
not apply.’’; and 
(3) in subsection (b)(1), by inserting ‘‘but sub-
ject to subsection (a)(5)’’ after ‘‘Notwithstanding 
any other provision of this title’’. 
(c) REMOVAL OF REQUIREMENT FOR PREVIOUS RE-
CEIPT OF MEDICAL ASSISTANCE.—Section 1925(a)(1) of 
such Act (42 U.S.C. 1396r–6(a)(1)), as amended by sub-
section (b)(1), is further amended— 
(1) by inserting ‘‘subparagraph (B) and’’ before 
‘‘paragraph (5)’’; 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00644
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
645 
AMDT. NO. 570 
(2) by redesignating the matter after ‘‘RE-
QUIREMENT.—’’ as a subparagraph (A) with the 
heading ‘‘IN GENERAL.—’’ and with the same inden-
tation as subparagraph (B) (as added by paragraph 
(3)); and 
(3) by adding at the end the following: 
‘‘(B) STATE OPTION TO WAIVE REQUIRE-
MENT
FOR
MONTHS
BEFORE
RECEIPT
OF 
MEDICAL ASSISTANCE.—A State may, at its op-
tion, elect also to apply subparagraph (A) in 
the case of a family that was receiving such aid 
for fewer than three months or that had applied 
for and was eligible for such aid for fewer than 
3 months during the 6 immediately preceding 
months described in such subparagraph.’’. 
(d) CMS REPORT ON ENROLLMENT AND PARTICIPA-
TION RATES UNDER TMA.—Section 1925 of such Act (42 
U.S.C. 1396r–6), as amended by this section, is further 
amended by adding at the end the following new sub-
section: 
‘‘(g) COLLECTION AND REPORTING OF PARTICIPA-
TION INFORMATION.— 
‘‘(1) COLLECTION
OF
INFORMATION
FROM 
STATES.—Each State shall collect and submit to the 
Secretary (and make publicly available), in a format 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00645
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
646 
AMDT. NO. 570 
specified by the Secretary, information on average 
monthly enrollment and average monthly participa-
tion rates for adults and children under this section 
and of the number and percentage of children who 
become ineligible for medical assistance under this 
section whose medical assistance is continued under 
another eligibility category or who are enrolled under 
the State’s child health plan under title XXI. Such 
information shall be submitted at the same time and 
frequency in which other enrollment information 
under this title is submitted to the Secretary. 
‘‘(2) ANNUAL REPORTS TO CONGRESS.—Using 
the information submitted under paragraph (1), the 
Secretary shall submit to Congress annual reports 
concerning enrollment and participation rates de-
scribed in such paragraph.’’. 
(e) EFFECTIVE DATE.—The amendments made by 
subsections (b) through (d) shall take effect on July 1, 
2009. 
Subtitle C—Extension of the 
Qualified Individual (QI) Program 
SEC. 3201. EXTENSION OF THE QUALIFYING INDIVIDUAL 
(QI) PROGRAM. 
(a) EXTENSION.—Section 1902(a)(10)(E)(iv) of the 
Social Security Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00646
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
647 
AMDT. NO. 570 
amended by striking ‘‘December 2009’’ and inserting ‘‘De-
cember 2010’’. 
(b) EXTENDING TOTAL AMOUNT AVAILABLE FOR 
ALLOCATION.—Section 1933(g) of such Act (42 U.S.C. 
1396u–3(g)) is amended— 
(1) in paragraph (2)— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (K); 
(B) in subparagraph (L), by striking the 
period at the end and inserting a semicolon; 
and 
(C) by adding at the end the following new 
subparagraphs: 
‘‘(M) for the period that begins on Janu-
ary 1, 2010, and ends on September 30, 2010, 
the total allocation amount is $412,500,000; 
and 
‘‘(N) for the period that begins on October 
1, 2010, and ends on December 31, 2010, the 
total allocation amount is $150,000,000.’’; and 
(2) in paragraph (3), in the matter preceding 
subparagraph (A), by striking ‘‘or (L)’’ and insert-
ing ‘‘(L), or (N)’’. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00647
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
648 
AMDT. NO. 570 
Subtitle D—Other Provisions 
SEC. 3301. PREMIUMS AND COST SHARING PROTECTIONS 
UNDER MEDICAID, ELIGIBILITY DETERMINA-
TIONS UNDER MEDICAID AND CHIP, AND 
PROTECTION OF CERTAIN INDIAN PROPERTY 
FROM MEDICAID ESTATE RECOVERY. 
(a) PREMIUMS
AND COST SHARING PROTECTION 
UNDER MEDICAID.— 
(1) IN GENERAL.—Section 1916 of the Social 
Security Act (42 U.S.C. 1396o) is amended— 
(A) in subsection (a), in the matter pre-
ceding paragraph (1), by striking ‘‘and (i)’’ and 
inserting ‘‘, (i), and (j)’’; and 
(B) by adding at the end the following new 
subsection: 
‘‘(j) NO PREMIUMS OR COST SHARING FOR INDIANS 
FURNISHED ITEMS OR SERVICES DIRECTLY BY INDIAN 
HEALTH PROGRAMS OR THROUGH REFERRAL UNDER 
CONTRACT HEALTH SERVICES.— 
‘‘(1) NO COST SHARING FOR ITEMS OR SERV-
ICES
FURNISHED
TO
INDIANS
THROUGH
INDIAN 
HEALTH PROGRAMS.— 
‘‘(A) IN
GENERAL.—No enrollment fee, 
premium, or similar charge, and no deduction, 
copayment, cost sharing, or similar charge shall 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00648
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
649 
AMDT. NO. 570 
be imposed against an Indian who is furnished 
an item or service directly by the Indian Health 
Service, an Indian Tribe, Tribal Organization, 
or Urban Indian Organization or through refer-
ral under contract health services for which 
payment may be made under this title. 
‘‘(B) NO REDUCTION IN AMOUNT OF PAY-
MENT TO INDIAN HEALTH PROVIDERS.—Pay-
ment due under this title to the Indian Health 
Service, an Indian Tribe, Tribal Organization, 
or Urban Indian Organization, or a health care 
provider through referral under contract health 
services for the furnishing of an item or service 
to an Indian who is eligible for assistance under 
such title, may not be reduced by the amount 
of any enrollment fee, premium, or similar 
charge, or any deduction, copayment, cost shar-
ing, or similar charge that would be due from 
the Indian but for the operation of subpara-
graph (A). 
‘‘(2) RULE
OF
CONSTRUCTION.—Nothing in 
this subsection shall be construed as restricting the 
application of any other limitations on the imposi-
tion of premiums or cost sharing that may apply to 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00649
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
650 
AMDT. NO. 570 
an individual receiving medical assistance under this 
title who is an Indian.’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
1916A(b)(3) of such Act (42 U.S.C. 1396o–1(b)(3)) 
is amended— 
(A) in subparagraph (A), by adding at the 
end the following new clause: 
‘‘(vi) An Indian who is furnished an 
item or service directly by the Indian 
Health Service, an Indian Tribe, Tribal 
Organization or Urban Indian Organiza-
tion or through referral under contract 
health services.’’; and 
(B) in subparagraph (B), by adding at the 
end the following new clause: 
‘‘(ix) Items and services furnished to 
an Indian directly by the Indian Health 
Service, an Indian Tribe, Tribal Organiza-
tion or Urban Indian Organization or 
through referral under contract health 
services.’’. 
(b) TREATMENT OF CERTAIN PROPERTY FROM RE-
SOURCES FOR MEDICAID AND CHIP ELIGIBILITY.— 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00650
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
651 
AMDT. NO. 570 
(1) MEDICAID.—Section 1902 of the Social Se-
curity Act (42 U.S.C. 1396a) is amended by adding 
at the end the following new subsection: 
‘‘(dd) Notwithstanding any other requirement of this 
title or any other provision of Federal or State law, a State 
shall disregard the following property from resources for 
purposes of determining the eligibility of an individual who 
is an Indian for medical assistance under this title: 
‘‘(1) Property, including real property and im-
provements, that is held in trust, subject to Federal 
restrictions, or otherwise under the supervision of 
the Secretary of the Interior, located on a reserva-
tion, including any federally recognized Indian 
Tribe’s reservation, pueblo, or colony, including 
former reservations in Oklahoma, Alaska Native re-
gions established by the Alaska Native Claims Set-
tlement Act, and Indian allotments on or near a res-
ervation as designated and approved by the Bureau 
of Indian Affairs of the Department of the Interior. 
‘‘(2) For any federally recognized Tribe not de-
scribed in paragraph (1), property located within the 
most recent boundaries of a prior Federal reserva-
tion. 
‘‘(3) Ownership interests in rents, leases, royal-
ties, or usage rights related to natural resources (in-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00651
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
652 
AMDT. NO. 570 
cluding extraction of natural resources or harvesting 
of timber, other plants and plant products, animals, 
fish, and shellfish) resulting from the exercise of fed-
erally protected rights. 
‘‘(4) Ownership interests in or usage rights to 
items not covered by paragraphs (1) through (3) 
that have unique religious, spiritual, traditional, or 
cultural significance or rights that support subsist-
ence or a traditional lifestyle according to applicable 
tribal law or custom.’’. 
(2) APPLICATION TO CHIP.—Section 2107(e)(1) 
of such Act (42 U.S.C. 1397gg(e)(1)) is amended— 
(A) by redesignating subparagraphs (B) 
through (E), as subparagraphs (C) through 
(F), respectively; and 
(B) by inserting after subparagraph (A), 
the following new subparagraph: 
‘‘(B) Section 1902(dd) (relating to dis-
regard of certain property for purposes of mak-
ing eligibility determinations).’’. 
(c) CONTINUATION OF CURRENT LAW PROTECTIONS 
OF CERTAIN INDIAN PROPERTY FROM MEDICAID ESTATE 
RECOVERY.—Section 1917(b)(3) of the Social Security 
Act (42 U.S.C. 1396p(b)(3)) is amended— 
(1) by inserting ‘‘(A)’’ after ‘‘(3)’’; and 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00652
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
653 
AMDT. NO. 570 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(B) The standards specified by the Sec-
retary under subparagraph (A) shall require 
that the procedures established by the State 
agency under subparagraph (A) exempt income, 
resources, and property that are exempt from 
the application of this subsection as of April 1, 
2003, under manual instructions issued to carry 
out this subsection (as in effect on such date) 
because of the Federal responsibility for Indian 
Tribes and Alaska Native Villages. Nothing in 
this subparagraph shall be construed as pre-
venting the Secretary from providing additional 
estate recovery exemptions under this title for 
Indians.’’. 
SEC. 3302. RULES APPLICABLE UNDER MEDICAID AND CHIP 
TO MANAGED CARE ENTITIES WITH RESPECT 
TO INDIAN ENROLLEES AND INDIAN HEALTH 
CARE PROVIDERS AND INDIAN MANAGED 
CARE ENTITIES. 
(a) IN GENERAL.—Section 1932 of the Social Secu-
rity Act (42 U.S.C. 1396u–2) is amended by adding at 
the end the following new subsection: 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00653
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
654 
AMDT. NO. 570 
‘‘(h) SPECIAL RULES WITH RESPECT TO INDIAN EN-
ROLLEES, INDIAN HEALTH CARE PROVIDERS, AND IN-
DIAN MANAGED CARE ENTITIES.— 
‘‘(1) ENROLLEE OPTION TO SELECT AN INDIAN 
HEALTH CARE PROVIDER AS PRIMARY CARE PRO-
VIDER.—In the case of a non-Indian Medicaid man-
aged care entity that— 
‘‘(A) has an Indian enrolled with the enti-
ty; and 
‘‘(B) has an Indian health care provider 
that is participating as a primary care provider 
within the network of the entity, 
insofar as the Indian is otherwise eligible to receive 
services from such Indian health care provider and 
the Indian health care provider has the capacity to 
provide primary care services to such Indian, the 
contract with the entity under section 1903(m) or 
under section 1905(t)(3) shall require, as a condi-
tion of receiving payment under such contract, that 
the Indian shall be allowed to choose such Indian 
health care provider as the Indian’s primary care 
provider under the entity. 
‘‘(2) ASSURANCE
OF
PAYMENT
TO
INDIAN 
HEALTH CARE PROVIDERS FOR PROVISION OF COV-
ERED
SERVICES.—Each contract with a managed 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00654
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
655 
AMDT. NO. 570 
care entity under section 1903(m) or under section 
1905(t)(3) shall require any such entity, as a condi-
tion of receiving payment under such contract, to 
satisfy the following requirements: 
‘‘(A) DEMONSTRATION OF ACCESS TO IN-
DIAN HEALTH CARE PROVIDERS AND APPLICA-
TION
OF
ALTERNATIVE
PAYMENT
ARRANGE-
MENTS.—Subject to subparagraph (C), to— 
‘‘(i) demonstrate that the number of 
Indian health care providers that are par-
ticipating providers with respect to such 
entity are sufficient to ensure timely access 
to covered Medicaid managed care services 
for those Indian enrollees who are eligible 
to receive services from such providers; and 
‘‘(ii) agree to pay Indian health care 
providers, whether such providers are par-
ticipating or nonparticipating providers 
with respect to the entity, for covered Med-
icaid managed care services provided to 
those Indian enrollees who are eligible to 
receive services from such providers at a 
rate equal to the rate negotiated between 
such entity and the provider involved or, if 
such a rate has not been negotiated, at a 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00655
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
656 
AMDT. NO. 570 
rate that is not less than the level and 
amount of payment which the entity would 
make for the services if the services were 
furnished by a participating provider which 
is not an Indian health care provider. 
‘‘(B) PROMPT
PAYMENT.—To agree to 
make prompt payment (consistent with rule for 
prompt payment of providers under section 
1932(f)) to Indian health care providers that 
are participating providers with respect to such 
entity or, in the case of an entity to which sub-
paragraph (A)(ii) or (C) applies, that the entity 
is required to pay in accordance with that sub-
paragraph. 
‘‘(C) APPLICATION OF SPECIAL PAYMENT 
REQUIREMENTS
FOR
FEDERALLY-QUALIFIED 
HEALTH
CENTERS
AND
FOR
SERVICES
PRO-
VIDED BY CERTAIN INDIAN HEALTH CARE PRO-
VIDERS.— 
‘‘(i) FEDERALLY-QUALIFIED HEALTH 
CENTERS.— 
‘‘(I) MANAGED
CARE
ENTITY 
PAYMENT
REQUIREMENT.—To agree 
to pay any Indian health care provider 
that is a federally-qualified health 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00656
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
657 
AMDT. NO. 570 
center under this title but not a par-
ticipating provider with respect to the 
entity, for the provision of covered 
Medicaid managed care services by 
such provider to an Indian enrollee of 
the entity at a rate equal to the 
amount of payment that the entity 
would pay a federally-qualified health 
center that is a participating provider 
with respect to the entity but is not 
an Indian health care provider for 
such services. 
‘‘(II) CONTINUED
APPLICATION 
OF
STATE
REQUIREMENT
TO
MAKE 
SUPPLEMENTAL
PAYMENT.—Nothing 
in subclause (I) or subparagraph (A) 
or (B) shall be construed as waiving 
the application of section 1902(bb)(5) 
regarding the State plan requirement 
to make any supplemental payment 
due under such section to a federally- 
qualified health center for services 
furnished by such center to an en-
rollee of a managed care entity (re-
gardless of whether the federally- 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00657
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
658 
AMDT. NO. 570 
qualified health center is or is not a 
participating provider with the entity). 
‘‘(ii) PAYMENT RATE FOR SERVICES 
PROVIDED
BY
CERTAIN
INDIAN
HEALTH 
CARE PROVIDERS.—If the amount paid by 
a managed care entity to an Indian health 
care provider that is not a federally-quali-
fied health center for services provided by 
the provider to an Indian enrollee with the 
managed care entity is less than the rate 
that applies to the provision of such serv-
ices by the provider under the State plan, 
the plan shall provide for payment to the 
Indian health care provider, whether the 
provider is a participating or nonpartici-
pating provider with respect to the entity, 
of the difference between such applicable 
rate and the amount paid by the managed 
care entity to the provider for such serv-
ices. 
‘‘(D) CONSTRUCTION.—Nothing in this 
paragraph shall be construed as waiving the ap-
plication of section 1902(a)(30)(A) (relating to 
application of standards to assure that pay-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00658
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
659 
AMDT. NO. 570 
ments are consistent with efficiency, economy, 
and quality of care). 
‘‘(3) SPECIAL RULE FOR ENROLLMENT FOR IN-
DIAN MANAGED CARE ENTITIES.—Regarding the ap-
plication of a Medicaid managed care program to In-
dian Medicaid managed care entities, an Indian 
Medicaid managed care entity may restrict enroll-
ment under such program to Indians and to mem-
bers of specific Tribes in the same manner as Indian 
Health Programs may restrict the delivery of serv-
ices to such Indians and tribal members. 
‘‘(4) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) INDIAN HEALTH CARE PROVIDER.— 
The term ‘Indian health care provider’ means 
an Indian Health Program or an Urban Indian 
Organization. 
‘‘(B) INDIAN
MEDICAID
MANAGED
CARE 
ENTITY.—The term ‘Indian Medicaid managed 
care entity’ means a managed care entity that 
is controlled (within the meaning of the last 
sentence of section 1903(m)(1)(C)) by the In-
dian Health Service, a Tribe, Tribal Organiza-
tion, or Urban Indian Organization, or a con-
sortium, which may be composed of 1 or more 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00659
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
660 
AMDT. NO. 570 
Tribes, Tribal Organizations, or Urban Indian 
Organizations, and which also may include the 
Service. 
‘‘(C) NON-INDIAN
MEDICAID
MANAGED 
CARE ENTITY.—The term ‘non-Indian Medicaid 
managed care entity’ means a managed care en-
tity that is not an Indian Medicaid managed 
care entity. 
‘‘(D) COVERED MEDICAID MANAGED CARE 
SERVICES.—The term ‘covered Medicaid man-
aged care services’ means, with respect to an 
individual enrolled with a managed care entity, 
items and services for which benefits are avail-
able with respect to the individual under the 
contract between the entity and the State in-
volved. 
‘‘(E) MEDICAID
MANAGED
CARE
PRO-
GRAM.—The term ‘Medicaid managed care pro-
gram’ 
means 
a 
program 
under 
sections 
1903(m), 1905(t), and 1932 and includes a 
managed care program operating under a waiv-
er under section 1915(b) or 1115 or other-
wise.’’. 
(b) APPLICATION
TO CHIP.—Subject to section 
l013(d), section 2107(e)(1) of such Act (42 U.S.C. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00660
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
661 
AMDT. NO. 570 
1397gg(1)) is amended by adding at the end the following 
new subparagraph: 
‘‘(E) Subsections (a)(2)(C) and (h) of sec-
tion 1932.’’. 
SEC. 3303. CONSULTATION ON MEDICAID, CHIP, AND 
OTHER HEALTH CARE PROGRAMS FUNDED 
UNDER THE SOCIAL SECURITY ACT INVOLV-
ING INDIAN HEALTH PROGRAMS AND URBAN 
INDIAN ORGANIZATIONS. 
(a) CONSULTATION WITH TRIBAL TECHNICAL ADVI-
SORY GROUP (TTAG).—The Secretary of Health and 
Human Services shall maintain within the Centers for 
Medicaid & Medicare Services (CMS) a Tribal Technical 
Advisory Group (TTAG), which was first established in 
accordance with requirements of the charter dated Sep-
tember 30, 2003, and the Secretary of Health and Human 
Services shall include in such Group a representative of 
a national urban Indian health organization and a rep-
resentative of the Indian Health Service. The inclusion of 
a representative of a national urban Indian health organi-
zation in such Group shall not affect the nonapplication 
of the Federal Advisory Committee Act (5 U.S.C. App.) 
to such Group. 
(b) SOLICITATION OF ADVICE UNDER MEDICAID AND 
CHIP.— 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00661
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
662 
AMDT. NO. 570 
(1) MEDICAID
STATE
PLAN
AMENDMENT.— 
Subject to subsection (d), section 1902(a) of the So-
cial Security Act (42 U.S.C. 1396a(a)) is amend-
ed— 
(A) in paragraph (70), by striking ‘‘and’’ 
at the end; 
(B) in paragraph (71), by striking the pe-
riod at the end and inserting ‘‘; and’’; and 
(C) by inserting after paragraph (71), the 
following new paragraph: 
‘‘(72) in the case of any State in which 1 or 
more Indian Health Programs or Urban Indian Or-
ganizations furnishes health care services, provide 
for a process under which the State seeks advice on 
a regular, ongoing basis from designees of such In-
dian Health Programs and Urban Indian Organiza-
tions on matters relating to the application of this 
title that are likely to have a direct effect on such 
Indian Health Programs and Urban Indian Organi-
zations and that— 
‘‘(A) shall include solicitation of advice 
prior to submission of any plan amendments, 
waiver requests, and proposals for demonstra-
tion projects likely to have a direct effect on In-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00662
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
663 
AMDT. NO. 570 
dians, Indian Health Programs, or Urban In-
dian Organizations; and 
‘‘(B) may include appointment of an advi-
sory committee and of a designee of such In-
dian Health Programs and Urban Indian Orga-
nizations to the medical care advisory com-
mittee advising the State on its State plan 
under this title.’’. 
(2) APPLICATION
TO
CHIP.—Subject to sub-
section (d), section 2107(e)(1) of such Act (42 
U.S.C. 1397gg(e)(1)), as amended by section 
3302(b)(2), is amended— 
(A) by redesignating subparagraphs (B) 
through (E) as subparagraphs (C) through (F), 
respectively; and 
(B) by inserting after subparagraph (A), 
the following new subparagraph: 
‘‘(B) Section 1902(a)(72) (relating to re-
quiring certain States to seek advice from des-
ignees of Indian Health Programs and Urban 
Indian Organizations).’’. 
(c) RULE
OF
CONSTRUCTION.—Nothing in the 
amendments made by this section shall be construed as 
superseding existing advisory committees, working groups, 
guidance, or other advisory procedures established by the 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00663
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
664 
AMDT. NO. 570 
Secretary of Health and Human Services or by any State 
with respect to the provision of health care to Indians. 
(d) CONTINGENCY RULE.—If the Children’s Health 
Insurance Program Reauthorization Act of 2009 (in this 
subsection referred to as ‘‘CHIPRA’’) has been enacted 
as of the date of enactment of this Act, the following shall 
apply: 
(1) Subparagraph (I) of section 2107(e) of the 
Social Security Act (as redesignated by CHIPRA) is 
redesignated as subparagraph (K) and the subpara-
graph (E) added to section 2107(e) of the Social Se-
curity Act by section 3302(b) is redesignated as sub-
paragraph (J). 
(2) Subparagraphs (D) through (H) of section 
2107(e) of the Social Security Act (as added and re-
designated by CHIPRA) are redesignated as sub-
paragraphs (E) through (I), respectively and the 
subparagraph (B) of section 2107(e) of the Social 
Security Act added by subsection (b)(2) of this sec-
tion is redesignated as subparagraph (D) and 
amended by striking ‘‘1902(a)(72)’’ and inserting 
‘‘1902(a)(73)’’. 
(3) Section 1902(a) of the Social Security Act 
(as amended by CHIPRA) is amended by striking 
‘‘and’’ at the end of paragraph (71), by striking the 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00664
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
665 
AMDT. NO. 570 
period at the end of the paragraph (72) added by 
CHIPRA and inserting ‘‘; and’’ and by redesignated 
the paragraph (72) added to such section by sub-
section (b)(1) of this section as paragraph (73). 
SEC. 3304. APPLICATION OF PROMPT PAY REQUIREMENTS 
TO NURSING FACILITIES. 
Section 1902(a)(37)(A) of the Social Security Act 
(42 U.S.C. 1396a(a)(37)(A)) is amended by inserting ‘‘, 
or by nursing facilities,’’ after ‘‘health facilities’’ 
SEC. 3305. PERIOD OF APPLICATION; SUNSET. 
This subtitle and the amendments made by this sub-
title shall be in effect only during the period that begins 
on April 1, 2009, and ends on December 31, 2010. On 
and after January 1, 2011, the Social Security Act shall 
be applied as if this subtitle and the amendments made 
by this subtitle had not been enacted. 
TITLE IV—HEALTH 
INFORMATION TECHNOLOGY 
SEC. 4001. SHORT TITLE; TABLE OF CONTENTS OF TITLE. 
(a) SHORT TITLE.—This title may be cited as the 
‘‘Medicare and Medicaid Health Information Technology 
for Economic and Clinical Health Act’’ or the ‘‘M- 
HITECH Act’’. 
(b) TABLE OF CONTENTS OF TITLE.—The table of 
contents for this title is as follows: 
TITLE IV—HEALTH INFORMATION TECHNOLOGY 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00665
Fmt 6654
Sfmt 6211
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
666 
AMDT. NO. 570 
Sec. 4001. Short title; table of contents of title. 
Subtitle A—Medicare Program 
Sec. 4201. Incentives for eligible professionals. 
Sec. 4202. Incentives for hospitals. 
Sec. 4203. Premium hold harmless and implementation funding. 
Sec. 4204. Non-application of phased-out indirect medical education (IME) ad-
justment factor for fiscal year 2009. 
Sec. 4205. Study on application of EHR payment incentives for providers not 
receiving other incentive payments. 
Sec. 4206. Study on availability of open source health information technology 
systems. 
Subtitle B—Medicaid Funding 
Sec. 4211. Medicaid provider EHR adoption and operation payments; imple-
mentation funding. 
Subtitle A—Medicare Program 
SEC. 4201. INCENTIVES FOR ELIGIBLE PROFESSIONALS. 
(a) INCENTIVE PAYMENTS.—Section 1848 of the So-
cial Security Act (42 U.S.C. 1395w–4) is amended by add-
ing at the end the following new subsection: 
‘‘(o) INCENTIVES FOR ADOPTION AND MEANINGFUL 
USE OF CERTIFIED EHR TECHNOLOGY.— 
‘‘(1) INCENTIVE PAYMENTS.— 
‘‘(A) IN GENERAL.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii) and the succeeding subparagraphs of 
this paragraph, with respect to covered 
professional services furnished by an eligi-
ble professional during a payment year (as 
defined in subparagraph (E)), if the eligi-
ble professional is a meaningful EHR user 
(as determined under paragraph (2)) for 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00666
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
667 
AMDT. NO. 570 
the reporting period with respect to such 
year, in addition to the amount otherwise 
paid under this part, there also shall be 
paid to the eligible professional (or to an 
employer or facility in the cases described 
in clause (A) of section 1842(b)(6)), from 
the Federal Supplementary Medical Insur-
ance Trust Fund established under section 
1841 an amount equal to 75 percent of the 
Secretary’s estimate (based on claims sub-
mitted not later than 2 months after the 
end of the payment year) of the allowed 
charges under this part for all such cov-
ered professional services furnished by the 
eligible professional during such year. 
‘‘(ii) NO INCENTIVE PAYMENTS WITH 
RESPECT TO YEARS AFTER 2015.—No in-
centive payments may be made under this 
subsection with respect to a year after 
2015. 
‘‘(B) LIMITATIONS
ON
AMOUNTS
OF
IN-
CENTIVE PAYMENTS.— 
‘‘(i) IN GENERAL.—In no case shall 
the amount of the incentive payment pro-
vided under this paragraph for an eligible 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00667
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
668 
AMDT. NO. 570 
professional for a payment year exceed the 
applicable amount specified under this sub-
paragraph with respect to such eligible 
professional and such year. 
‘‘(ii) AMOUNT.—Subject to clauses 
(iii) through (v), the applicable amount 
specified in this subparagraph for an eligi-
ble professional is as follows: 
‘‘(I) For the first payment year 
for such professional, $15,000 (or, if 
the first payment year for such eligi-
ble professional is 2011 or 2012, 
$18,000). 
‘‘(II) For the second payment 
year for such professional, $12,000. 
‘‘(III) For the third payment 
year for such professional, $8,000. 
‘‘(IV) For the fourth payment 
year for such professional, $4,000. 
‘‘(V) For the fifth payment year 
for such professional, $2,000. 
‘‘(VI) For any succeeding pay-
ment year for such professional, $0. 
‘‘(iii) PHASE
DOWN
FOR
ELIGIBLE 
PROFESSIONALS FIRST ADOPTING EHR IN 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00668
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
669 
AMDT. NO. 570 
2014.—If the first payment year for an eli-
gible professional is 2014, then the amount 
specified in this subparagraph for a pay-
ment year for such professional is the 
same as the amount specified in clause (ii) 
for such payment year for an eligible pro-
fessional whose first payment year is 2013. 
‘‘(iv) INCREASE FOR CERTAIN RURAL 
ELIGIBLE PROFESSIONALS.—In the case of 
an eligible professional who predominantly 
furnishes services under this part in a 
rural area that is designated by the Sec-
retary (under section 332(a)(1)(A) of the 
Public Health Service Act) as a health pro-
fessional shortage area, the amount that 
would otherwise apply for a payment year 
for such professional under subclauses (I) 
through (V) of clause (ii) shall be in-
creased by 25 percent. In implementing 
the preceding sentence, the Secretary may, 
as determined appropriate, apply provi-
sions of subsections (m) and (u) of section 
1833 in a similar manner as such provi-
sions apply under such subsection. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00669
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
670 
AMDT. NO. 570 
‘‘(v) NO
INCENTIVE
PAYMENT
IF 
FIRST ADOPTING AFTER 2014.—If the first 
payment year for an eligible professional is 
after 2014 then the applicable amount 
specified in this subparagraph for such 
professional for such year and any subse-
quent year shall be $0. 
‘‘(C) NON-APPLICATION
TO
HOSPITAL- 
BASED ELIGIBLE PROFESSIONALS.— 
‘‘(i) IN GENERAL.—No incentive pay-
ment may be made under this paragraph 
in the case of a hospital-based eligible pro-
fessional. 
‘‘(ii) HOSPITAL-BASED ELIGIBLE PRO-
FESSIONAL.—For purposes of clause (i), 
the term ‘hospital-based eligible profes-
sional’ means, with respect to covered pro-
fessional services furnished by an eligible 
professional during the reporting period for 
a payment year, an eligible professional, 
such as a pathologist, anesthesiologist, or 
emergency physician, who furnishes sub-
stantially all of such services in a hospital 
setting (whether inpatient or outpatient) 
and through the use of the facilities and 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00670
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
671 
AMDT. NO. 570 
equipment, including qualified electronic 
health records, of the hospital. 
‘‘(D) PAYMENT.— 
‘‘(i) FORM OF PAYMENT.—The pay-
ment under this paragraph may be in the 
form of a single consolidated payment or 
in the form of such periodic installments 
as the Secretary may specify. 
‘‘(ii) COORDINATION OF APPLICATION 
OF
LIMITATION
FOR
PROFESSIONALS
IN 
DIFFERENT PRACTICES.—In the case of an 
eligible professional furnishing covered pro-
fessional services in more than one practice 
(as specified by the Secretary), the Sec-
retary shall establish rules to coordinate 
the incentive payments, including the ap-
plication of the limitation on amounts of 
such incentive payments under this para-
graph, among such practices. 
‘‘(iii) 
COORDINATION
WITH
MED-
ICAID.—The Secretary shall seek, to the 
maximum extent practicable, to avoid du-
plicative requirements from Federal and 
State Governments to demonstrate mean-
ingful use of certified EHR technology 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00671
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
672 
AMDT. NO. 570 
under this title and title XIX. In doing so, 
the Secretary may deem satisfaction of 
State requirements for such meaningful 
use for a payment year under title XIX to 
be sufficient to qualify as meaningful use 
under this subsection and subsection (a)(7) 
and vice versa. The Secretary may also ad-
just the reporting periods under such title 
and such subsections in order to carry out 
this clause. 
‘‘(E) PAYMENT YEAR DEFINED.— 
‘‘(i) IN
GENERAL.—For purposes of 
this subsection, the term ‘payment year’ 
means a year beginning with 2011. 
‘‘(ii) FIRST, SECOND, ETC. PAYMENT 
YEAR.—The term ‘first payment year’ 
means, with respect to covered professional 
services furnished by an eligible profes-
sional, the first year for which an incentive 
payment is made for such services under 
this subsection. The terms ‘second pay-
ment year’, ‘third payment year’, ‘fourth 
payment year’, and ‘fifth payment year’ 
mean, with respect to covered professional 
services furnished by such eligible profes-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00672
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
673 
AMDT. NO. 570 
sional, each successive year immediately 
following the first payment year for such 
professional. 
‘‘(2) MEANINGFUL EHR USER.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), an eligible professional shall be 
treated as a meaningful EHR user for a report-
ing period for a payment year (or, for purposes 
of subsection (a)(7), for a reporting period 
under such subsection for a year) if each of the 
following requirements is met: 
‘‘(i) MEANINGFUL USE OF CERTIFIED 
EHR
TECHNOLOGY.—The eligible profes-
sional demonstrates to the satisfaction of 
the Secretary, in accordance with subpara-
graph (C)(i), that during such period the 
professional is using certified EHR tech-
nology in a meaningful manner, which 
shall include the use of electronic pre-
scribing as determined to be appropriate 
by the Secretary. 
‘‘(ii) INFORMATION EXCHANGE.—The 
eligible professional demonstrates to the 
satisfaction of the Secretary, in accordance 
with subparagraph (C)(i), that during such 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00673
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
674 
AMDT. NO. 570 
period such certified EHR technology is 
connected in a manner that provides, in 
accordance with law and standards appli-
cable to the exchange of information, for 
the electronic exchange of health informa-
tion to improve the quality of health care, 
such as promoting care coordination. 
‘‘(iii) 
REPORTING
ON
MEASURES 
USING
EHR.—Subject to subparagraph 
(B)(ii) and using such certified EHR tech-
nology, the eligible professional submits in-
formation for such period, in a form and 
manner specified by the Secretary, on such 
clinical quality measures and such other 
measures as selected by the Secretary 
under subparagraph (B)(i). 
The Secretary may provide for the use of alter-
native means for meeting the requirements of 
clauses (i), (ii), and (iii) in the case of an eligi-
ble professional furnishing covered professional 
services in a group practice (as defined by the 
Secretary). The Secretary shall seek to improve 
the use of electronic health records and health 
care quality over time by requiring more strin-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00674
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
675 
AMDT. NO. 570 
gent measures of meaningful use selected under 
this paragraph. 
‘‘(B) REPORTING ON MEASURES.— 
‘‘(i) SELECTION.—The Secretary shall 
select measures for purposes of subpara-
graph (A)(iii) but only consistent with the 
following: 
‘‘(I) The Secretary shall provide 
preference to clinical quality measures 
that have been endorsed by the entity 
with a contract with the Secretary 
under section 1890(a). 
‘‘(II) Prior to any measure being 
selected under this subparagraph, the 
Secretary shall publish in the Federal 
Register such measure and provide for 
a period of public comment on such 
measure. 
‘‘(ii) 
LIMITATION.—The 
Secretary 
may not require the electronic reporting of 
information on clinical quality measures 
under subparagraph (A)(iii) unless the 
Secretary has the capacity to accept the in-
formation electronically, which may be on 
a pilot basis. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00675
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
676 
AMDT. NO. 570 
‘‘(iii) COORDINATION OF REPORTING 
OF
INFORMATION.—In 
selecting 
such 
measures, and in establishing the form and 
manner for reporting measures under sub-
paragraph (A)(iii), the Secretary shall seek 
to avoid redundant or duplicative reporting 
otherwise required, including reporting 
under subsection (k)(2)(C). 
‘‘(C) DEMONSTRATION
OF
MEANINGFUL 
USE OF CERTIFIED EHR TECHNOLOGY AND IN-
FORMATION EXCHANGE.— 
‘‘(i) IN
GENERAL.—A professional 
may satisfy the demonstration requirement 
of clauses (i) and (ii) of subparagraph (A) 
through means specified by the Secretary, 
which may include— 
‘‘(I) an attestation; 
‘‘(II) the submission of claims 
with appropriate coding (such as a 
code indicating that a patient encoun-
ter was documented using certified 
EHR technology); 
‘‘(III) a survey response; 
‘‘(IV) reporting under subpara-
graph (A)(iii); and 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00676
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
677 
AMDT. NO. 570 
‘‘(V) other means specified by the 
Secretary. 
‘‘(ii) USE
OF
PART
D
DATA.—Not-
withstanding sections 1860D–15(d)(2)(B) 
and 1860D–15(f)(2), the Secretary may 
use data regarding drug claims submitted 
for purposes of section 1860D–15 that are 
necessary for purposes of subparagraph 
(A). 
‘‘(3) APPLICATION.— 
‘‘(A) 
PHYSICIAN
REPORTING
SYSTEM 
RULES.—Paragraphs (5), (6), and (8) of sub-
section (k) shall apply for purposes of this sub-
section in the same manner as they apply for 
purposes of such subsection. 
‘‘(B) COORDINATION
WITH
OTHER
PAY-
MENTS.—The provisions of this subsection shall 
not be taken into account in applying the provi-
sions of subsection (m) of this section and of 
section 1833(m) and any payment under such 
provisions shall not be taken into account in 
computing allowable charges under this sub-
section. 
‘‘(C) LIMITATIONS
ON
REVIEW.—There 
shall be no administrative or judicial review 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00677
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
678 
AMDT. NO. 570 
under section 1869, section 1878, or otherwise 
of the determination of any incentive payment 
under this subsection and the payment adjust-
ment under subsection (a)(7), including the de-
termination of a meaningful EHR user under 
paragraph (2), a limitation under paragraph 
(1)(B), and the exception under subsection 
(a)(7)(B). 
‘‘(D) POSTING
ON
WEBSITE.—The Sec-
retary shall post on the Internet website of the 
Centers for Medicare & Medicaid Services, in an 
easily understandable format, a list of the 
names, business addresses, and business phone 
numbers of the eligible professionals who are 
meaningful EHR users and, as determined ap-
propriate by the Secretary, of group practices 
receiving incentive payments under paragraph 
(1). 
‘‘(4) CERTIFIED EHR TECHNOLOGY DEFINED.— 
For purposes of this section, the term ‘certified 
EHR technology’ means a qualified electronic health 
record (as defined in 3000(13) of the Public Health 
Service Act) that is certified pursuant to section 
3001(c)(5) of such Act as meeting standards adopt-
ed under section 3004 of such Act that are applica-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00678
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
679 
AMDT. NO. 570 
ble to the type of record involved (as determined by 
the Secretary, such as an ambulatory electronic 
health record for office-based physicians or an inpa-
tient hospital electronic health record for hospitals). 
‘‘(5) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) 
COVERED
PROFESSIONAL
SERV-
ICES.—The term ‘covered professional services’ 
has the meaning given such term in subsection 
(k)(3). 
‘‘(B) ELIGIBLE PROFESSIONAL.—The term 
‘eligible professional’ means a physician, as de-
fined in section 1861(r). 
‘‘(C) REPORTING PERIOD.—The term ‘re-
porting period’ means any period (or periods), 
with respect to a payment year, as specified by 
the Secretary.’’. 
(b) INCENTIVE PAYMENT ADJUSTMENT.—Section 
1848(a) of the Social Security Act (42 U.S.C. 1395w– 
4(a)) is amended by adding at the end the following new 
paragraph: 
‘‘(7) INCENTIVES
FOR
MEANINGFUL
USE
OF 
CERTIFIED EHR TECHNOLOGY.— 
‘‘(A) ADJUSTMENT.— 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00679
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
680 
AMDT. NO. 570 
‘‘(i) IN
GENERAL.—Subject to sub-
paragraphs (B) and (D), with respect to 
covered professional services furnished by 
an eligible professional during 2015 or any 
subsequent payment year, if the eligible 
professional is not a meaningful EHR user 
(as determined under subsection (o)(2)) for 
a reporting period for the year, the fee 
schedule amount for such services fur-
nished by such professional during the year 
(including the fee schedule amount for pur-
poses of determining a payment based on 
such amount) shall be equal to the applica-
ble percent of the fee schedule amount that 
would otherwise apply to such services 
under this subsection (determined after ap-
plication of paragraph (3) but without re-
gard to this paragraph). 
‘‘(ii) APPLICABLE PERCENT.—Subject 
to clause (iii), for purposes of clause (i), 
the term ‘applicable percent’ means— 
‘‘(I) for 2015, 99 percent (or, in 
the case of an eligible professional 
who was subject to the application of 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00680
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
681 
AMDT. NO. 570 
the payment adjustment under section 
1848(a)(5) for 2014, 98 percent); 
‘‘(II) for 2016, 98 percent; and 
‘‘(III) for 2017 and each subse-
quent year, 97 percent. 
‘‘(iii) AUTHORITY TO DECREASE AP-
PLICABLE
PERCENTAGE
FOR
2018
AND 
SUBSEQUENT YEARS.—For 2018 and each 
subsequent year, if the Secretary finds that 
the proportion of eligible professionals who 
are meaningful EHR users (as determined 
under subsection (o)(2)) is less than 75 
percent, the applicable percent shall be de-
creased by 1 percentage point from the ap-
plicable percent in the preceding year, but 
in no case shall the applicable percent be 
less than 95 percent. 
‘‘(B) 
SIGNIFICANT
HARDSHIP
EXCEP-
TION.—The Secretary may, on a case-by-case 
basis, exempt an eligible professional from the 
application of the payment adjustment under 
subparagraph (A) if the Secretary determines, 
subject to annual renewal, that compliance with 
the requirement for being a meaningful EHR 
user would result in a significant hardship, such 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00681
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
682 
AMDT. NO. 570 
as in the case of an eligible professional who 
practices in a rural area without sufficient 
Internet access. In no case may an eligible pro-
fessional be granted an exemption under this 
subparagraph for more than 5 years. 
‘‘(C) APPLICATION OF PHYSICIAN REPORT-
ING SYSTEM RULES.—Paragraphs (5), (6), and 
(8) of subsection (k) shall apply for purposes of 
this paragraph in the same manner as they 
apply for purposes of such subsection. 
‘‘(D) NON-APPLICATION
TO
HOSPITAL- 
BASED
ELIGIBLE
PROFESSIONALS.—No pay-
ment adjustment may be made under subpara-
graph (A) in the case of hospital-based eligible 
professionals 
(as 
defined 
in 
subsection 
(o)(1)(C)(ii)). 
‘‘(E) DEFINITIONS.—For purposes of this 
paragraph: 
‘‘(i) COVERED
PROFESSIONAL
SERV-
ICES.—The 
term 
‘covered 
professional 
services’ has the meaning given such term 
in subsection (k)(3). 
‘‘(ii) ELIGIBLE PROFESSIONAL.—The 
term ‘eligible professional’ means a physi-
cian, as defined in section 1861(r). 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00682
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
683 
AMDT. NO. 570 
‘‘(iii) REPORTING PERIOD.—The term 
‘reporting period’ means, with respect to a 
year, a period specified by the Secretary.’’. 
(c) APPLICATION TO CERTAIN MA-AFFILIATED ELI-
GIBLE PROFESSIONALS.—Section 1853 of the Social Secu-
rity Act (42 U.S.C. 1395w–23) is amended by adding at 
the end the following new subsection: 
‘‘(l) APPLICATION OF ELIGIBLE PROFESSIONAL IN-
CENTIVES FOR CERTAIN MA ORGANIZATIONS FOR ADOP-
TION AND MEANINGFUL USE OF CERTIFIED EHR TECH-
NOLOGY.— 
‘‘(1) IN GENERAL.—Subject to paragraphs (3) 
and (4), in the case of a qualifying MA organization, 
the provisions of sections 1848(o) and 1848(a)(7) 
shall apply with respect to eligible professionals de-
scribed in paragraph (2) of the organization who the 
organization attests under paragraph (6) to be 
meaningful EHR users in a similar manner as they 
apply to eligible professionals under such sections. 
Incentive payments under paragraph (3) shall be 
made to and payment adjustments under paragraph 
(4) shall apply to such qualifying organizations. 
‘‘(2) ELIGIBLE
PROFESSIONAL
DESCRIBED.— 
With respect to a qualifying MA organization, an eli-
gible professional described in this paragraph is an 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00683
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
684 
AMDT. NO. 570 
eligible professional (as defined for purposes of sec-
tion 1848(o)) who— 
‘‘(A)(i) is employed by the organization; or 
‘‘(ii)(I) is employed by, or is a partner of, 
an entity that through contract with the organi-
zation furnishes at least 80 percent of the enti-
ty’s patient care services to enrollees of such or-
ganization; and 
‘‘(II) furnishes at least 75 percent of the 
professional services of the eligible professional 
to enrollees of the organization; and 
‘‘(B) furnishes, on average, at least 20 
hours per week of patient care services. 
‘‘(3) ELIGIBLE PROFESSIONAL INCENTIVE PAY-
MENTS.— 
‘‘(A) IN
GENERAL.—In applying section 
1848(o) under paragraph (1), instead of the ad-
ditional 
payment 
amount 
under 
section 
1848(o)(1)(A) and subject to subparagraph 
(B), the Secretary may substitute an amount 
determined by the Secretary to the extent fea-
sible and practical to be similar to the esti-
mated amount in the aggregate that would be 
payable if payment for services furnished by 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00684
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
685 
AMDT. NO. 570 
such professionals was payable under part B in-
stead of this part. 
‘‘(B) AVOIDING
DUPLICATION
OF
PAY-
MENTS.— 
‘‘(i) IN GENERAL.—If an eligible pro-
fessional described in paragraph (2) is eli-
gible for the maximum incentive payment 
under section 1848(o)(1)(A) for the same 
payment period, the payment incentive 
shall be made only under such section and 
not under this subsection. 
‘‘(ii) METHODS.—In the case of an el-
igible professional described in paragraph 
(2) who is eligible for an incentive payment 
under section 1848(o)(1)(A) but is not de-
scribed in clause (i) for the same payment 
period, the Secretary shall develop a proc-
ess— 
‘‘(I) to ensure that duplicate pay-
ments are not made with respect to 
an eligible professional both under 
this subsection and under section 
1848(o)(1)(A); and 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00685
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
686 
AMDT. NO. 570 
‘‘(II) to collect data from Medi-
care Advantage organizations to en-
sure against such duplicate payments. 
‘‘(C) FIXED SCHEDULE FOR APPLICATION 
OF LIMITATION ON INCENTIVE PAYMENTS FOR 
ALL
ELIGIBLE
PROFESSIONALS.—In applying 
section 1848(o)(1)(B)(ii) under subparagraph 
(A), in accordance with rules specified by the 
Secretary, a qualifying MA organization shall 
specify a year (not earlier than 2011) that shall 
be treated as the first payment year for all eli-
gible professionals with respect to such organi-
zation. 
‘‘(D) CAP FOR ECONOMIES OF SCALE.—In 
no case may an incentive payment be made 
under this subsection, including under subpara-
graph (A), to a qualifying MA organization with 
respect to more than 5,000 eligible profes-
sionals of the organization. 
‘‘(4) PAYMENT ADJUSTMENT.— 
‘‘(A) IN
GENERAL.—In applying section 
1848(a)(7) under paragraph (1), instead of the 
payment adjustment being an applicable per-
cent of the fee schedule amount for a year 
under such section, subject to subparagraph 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00686
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
687 
AMDT. NO. 570 
(D), the payment adjustment under paragraph 
(1) shall be equal to the percent specified in 
subparagraph (B) for such year of the payment 
amount otherwise provided under this section 
for such year. 
‘‘(B) SPECIFIED
PERCENT.—The percent 
specified under this subparagraph for a year is 
100 percent minus a number of percentage 
points equal to the product of— 
‘‘(i) a percentage equal to 100 percent 
reduced by the applicable percent (under 
section 1848(a)(7)(A)(ii)) for the year; and 
‘‘(ii) a percentage equal to the Sec-
retary’s estimate of the proportion for the 
year, of the expenditures under parts A 
and B that are not attributable to this 
part, that are attributable to expenditures 
for physicians’ services. 
‘‘(C) APPLICATION OF PAYMENT ADJUST-
MENT.—In the case that a qualifying MA orga-
nization attests that not all eligible profes-
sionals of the organization are meaningful EHR 
users with respect to a year, the Secretary shall 
apply the payment adjustment under this para-
graph based on the proportion of all eligible 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00687
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
688 
AMDT. NO. 570 
professionals of the organization that are not 
meaningful EHR users for such year. If the 
number of eligible professionals of the organiza-
tion that are not meaningful EHR users for 
such year exceeds 5,000, such number shall be 
reduced to 5,000 for purposes of determining 
the proportion under the preceding sentence. 
‘‘(5) 
QUALIFYING
MA
ORGANIZATION
DE-
FINED.—In this subsection and subsection (m), the 
term ‘qualifying MA organization’ means a Medicare 
Advantage organization that is organized as a health 
maintenance organization (as defined in section 
2791(b)(3) of the Public Health Service Act). 
‘‘(6) MEANINGFUL EHR USER ATTESTATION.— 
For purposes of this subsection and subsection (m), 
a qualifying MA organization shall submit an attes-
tation, in a form and manner specified by the Sec-
retary which may include the submission of such at-
testation as part of submission of the initial bid 
under section 1854(a)(1)(A)(iv), identifying— 
‘‘(A) whether each eligible professional de-
scribed in paragraph (2), with respect to such 
organization is a meaningful EHR user (as de-
fined in section 1848(o)(2)) for a year specified 
by the Secretary; and 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00688
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
689 
AMDT. NO. 570 
‘‘(B) whether each eligible hospital de-
scribed in subsection (m)(1), with respect to 
such organization, is a meaningful EHR user 
(as defined in section 1886(n)(3)) for an appli-
cable period specified by the Secretary. 
‘‘(7) POSTING
ON
WEBSITE.—The Secretary 
shall post on the Internet website of the Centers for 
Medicare & Medicaid Services, in an easily under-
standable format, a list of the names, business ad-
dresses, and business phone numbers of— 
‘‘(A) each qualifying MA organization re-
ceiving an incentive payment under this sub-
section for eligible professionals of the organiza-
tion; and 
‘‘(B) the eligible professionals of such or-
ganization for which such incentive payment is 
based.’’. 
(d) CONFORMING AMENDMENTS.—Section 1853 of 
the Social Security Act (42 U.S.C. 1395w–23) is amend-
ed— 
(1) in subsection (a)(1)(A), by striking ‘‘and 
(i)’’ and inserting ‘‘(i), and (l)’’; 
(2) in subsection (c)— 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00689
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
690 
AMDT. NO. 570 
(A) in paragraph (1)(D)(i), by striking 
‘‘section 1886(h)’’ and inserting ‘‘sections 
1848(o) and 1886(h)’’; and 
(B) in paragraph (6)(A), by inserting after 
‘‘under part B,’’ the following: ‘‘excluding ex-
penditures attributable to subsections (a)(7) 
and (o) of section 1848,’’; and 
(3) in subsection (f), by inserting ‘‘and for pay-
ments under subsection (l)’’ after ‘‘with the organi-
zation’’. 
(e) 
CONFORMING
AMENDMENTS
TO
E-PRE-
SCRIBING.— 
(1) Section 1848(a)(5)(A) of the Social Security 
Act (42 U.S.C. 1395w–4(a)(5)(A)) is amended— 
(A) in clause (i), by striking ‘‘or any sub-
sequent year’’ and inserting ‘‘, 2013, or 2014’’; 
and 
(B) in clause (ii), by striking ‘‘and each 
subsequent year’’. 
(2) Section 1848(m)(2) of such Act (42 U.S.C. 
1395w–4(m)(2)) is amended— 
(A) in subparagraph (A), by striking ‘‘For 
2009’’ and inserting ‘‘Subject to subparagraph 
(D), for 2009’’; and 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00690
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
691 
AMDT. NO. 570 
(B) by adding at the end the following new 
subparagraph: 
‘‘(D) LIMITATION WITH RESPECT TO EHR 
INCENTIVE PAYMENTS.—The provisions of this 
paragraph shall not apply to an eligible profes-
sional (or, in the case of a group practice under 
paragraph (3)(C), to the group practice) if, for 
the reporting period the eligible professional (or 
group practice) receives an incentive payment 
under subsection (o)(1)(A) with respect to a 
certified EHR technology (as defined in sub-
section (o)(4)) that has the capability of elec-
tronic prescribing.’’. 
(f) PROVIDING ASSISTANCE TO ELIGIBLE PROFES-
SIONALS AND CERTAIN HOSPITALS.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall provide assistance to eligible 
professionals (as defined in section 1848(o)(5), as 
added by subsection (a)), Medicaid providers (as de-
fined in section 1903(t)(2) of such Act, as added by 
section 4211(a)), and eligible hospitals (as defined in 
section 1886(n)(6)(A) of such Act, as added by sec-
tion 4202(a)) located in rural or other medically un-
derserved areas to successfully choose, implement, 
and use certified EHR technology (as defined in sec-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00691
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
692 
AMDT. NO. 570 
tion 1848(o)(4) of the Social Security Act, as added 
by section 4201(a)). 
(2) USE OF ENTITIES WITH EXPERTISE.—To 
the extent practicable, the Secretary shall provide 
such assistance through entities that have expertise 
in the choice, implementation, and use of such cer-
tified EHR technology. 
SEC. 4202. INCENTIVES FOR HOSPITALS. 
(a) INCENTIVE PAYMENT.—Section 1886 of the So-
cial Security Act (42 U.S.C. 1395ww) is amended by add-
ing at the end the following new subsection: 
‘‘(n) INCENTIVES FOR ADOPTION AND MEANINGFUL 
USE OF CERTIFIED EHR TECHNOLOGY.— 
‘‘(1) IN GENERAL.—Subject to the succeeding 
provisions of this subsection, with respect to inpa-
tient hospital services furnished by an eligible hos-
pital during a payment year (as defined in para-
graph (2)(G)), if the eligible hospital is a meaningful 
EHR user (as determined under paragraph (3)) for 
the reporting period with respect to such year, in ad-
dition to the amount otherwise paid under this sec-
tion, there also shall be paid to the eligible hospital, 
from the Federal Hospital Insurance Trust Fund es-
tablished under section 1817, an amount equal to 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00692
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
693 
AMDT. NO. 570 
the applicable amount specified in paragraph (2)(A) 
for the hospital for such payment year. 
‘‘(2) PAYMENT AMOUNT.— 
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding subparagraphs of this paragraph, the 
applicable amount specified in this subpara-
graph for an eligible hospital for a payment 
year is equal to the product of the following: 
‘‘(i) INITIAL AMOUNT.—The sum of— 
‘‘(I) the base amount specified in 
subparagraph (B); plus 
‘‘(II) 
the 
discharge 
related 
amount specified in subparagraph (C) 
for a 12-month period selected by the 
Secretary with respect to such pay-
ment year. 
‘‘(ii) MEDICARE
SHARE.—The Medi-
care share as specified in subparagraph 
(D) for the hospital for a period selected 
by the Secretary with respect to such pay-
ment year. 
‘‘(iii) 
TRANSITION
FACTOR.—The 
transition factor specified in subparagraph 
(E) for the hospital for the payment year. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00693
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
694 
AMDT. NO. 570 
‘‘(B) BASE
AMOUNT.—The base amount 
specified in this subparagraph is $2,000,000. 
‘‘(C) DISCHARGE RELATED AMOUNT.—The 
discharge related amount specified in this sub-
paragraph for a 12-month period selected by 
the Secretary shall be determined as the sum of 
the amount, based upon total discharges (re-
gardless of any source of payment) for the pe-
riod, for each discharge up to the 23,000th dis-
charge as follows: 
‘‘(i) For the 1,150th through the 
9,200nd discharge, $200. 
‘‘(ii) For the 9,201st through the 
13,800th discharge, 50 percent of the 
amount specified in clause (i). 
‘‘(iii) For the 13,801st through the 
23,000th discharge, 30 percent of the 
amount specified in clause (i). 
‘‘(D) MEDICARE
SHARE.—The Medicare 
share specified under this subparagraph for a 
hospital for a period selected by the Secretary 
for a payment year is equal to the fraction— 
‘‘(i) the numerator of which is the 
sum (for such period and with respect to 
the hospital) of— 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00694
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
695 
AMDT. NO. 570 
‘‘(I) the number of inpatient-bed- 
days (as established by the Secretary) 
which are attributable to individuals 
with respect to whom payment may be 
made under part A; and 
‘‘(II) the number of inpatient- 
bed-days (as so established) which are 
attributable to individuals who are en-
rolled with a Medicare Advantage or-
ganization under part C; and 
‘‘(ii) the denominator of which is the 
product of— 
‘‘(I) the total number of inpa-
tient-bed-days with respect to the hos-
pital during such period; and 
‘‘(II) the total amount of the hos-
pital’s charges during such period, not 
including any charges that are attrib-
utable to charity care (as such term is 
used for purposes of hospital cost re-
porting under this title), divided by 
the total amount of the hospital’s 
charges during such period. 
Insofar as the Secretary determines that data 
are not available on charity care necessary to 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00695
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
696 
AMDT. NO. 570 
calculate the portion of the formula specified in 
clause (ii)(II), the Secretary shall use data on 
uncompensated care and may adjust such data 
so as to be an appropriate proxy for charity 
care including a downward adjustment to elimi-
nate bad debt data from uncompensated care 
data. In the absence of the data necessary, with 
respect to a hospital, for the Secretary to com-
pute the amount described in clause (ii)(II), the 
amount under such clause shall be deemed to 
be 1. In the absence of data, with respect to a 
hospital, necessary to compute the amount de-
scribed in clause (i)(II), the amount under such 
clause shall be deemed to be 0. 
‘‘(E) TRANSITION FACTOR SPECIFIED.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), the transition factor specified in this 
subparagraph for an eligible hospital for a 
payment year is as follows: 
‘‘(I) For the first payment year 
for such hospital, 1. 
‘‘(II) For the second payment 
year for such hospital, 3⁄4. 
‘‘(III) For the third payment 
year for such hospital, 1⁄2. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00696
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
697 
AMDT. NO. 570 
‘‘(IV) For the fourth payment 
year for such hospital, 1⁄4. 
‘‘(V) For any succeeding pay-
ment year for such hospital, 0. 
‘‘(ii) PHASE
DOWN
FOR
ELIGIBLE 
HOSPITALS FIRST ADOPTING EHR AFTER 
2013.—If the first payment year for an eli-
gible hospital is after 2013, then the tran-
sition factor specified in this subparagraph 
for a payment year for such hospital is the 
same as the amount specified in clause (i) 
for such payment year for an eligible hos-
pital for which the first payment year is 
2013. If the first payment year for an eli-
gible hospital is after 2015 then the transi-
tion factor specified in this subparagraph 
for such hospital and for such year and 
any subsequent year shall be 0. 
‘‘(F) FORM OF PAYMENT.—The payment 
under this subsection for a payment year may 
be in the form of a single consolidated payment 
or in the form of such periodic installments as 
the Secretary may specify. 
‘‘(G) PAYMENT YEAR DEFINED.— 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00697
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
698 
AMDT. NO. 570 
‘‘(i) IN
GENERAL.—For purposes of 
this subsection, the term ‘payment year’ 
means a fiscal year beginning with fiscal 
year 2011. 
‘‘(ii) FIRST, SECOND, ETC. PAYMENT 
YEAR.—The term ‘first payment year’ 
means, with respect to inpatient hospital 
services furnished by an eligible hospital, 
the first fiscal year for which an incentive 
payment is made for such services under 
this subsection. The terms ‘second pay-
ment year’, ‘third payment year’, and 
‘fourth payment year’ mean, with respect 
to an eligible hospital, each successive year 
immediately following the first payment 
year for that hospital. 
‘‘ ‘‘(H) LIMITATION FOR CRITICAL ACCESS 
HOSPITALS.—In no case shall the total amount 
of payments made under this subsection to a 
critical access hospital for all payment years ex-
ceed $1,500,000. 
‘‘(3) MEANINGFUL EHR USER.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), an eligible hospital shall be treated 
as a meaningful EHR user for a reporting pe-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00698
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
699 
AMDT. NO. 570 
riod for a payment year (or, for purposes of 
subsection (b)(3)(B)(ix), for a reporting period 
under such subsection for a fiscal year) if each 
of the following requirements are met: 
‘‘(i) MEANINGFUL USE OF CERTIFIED 
EHR TECHNOLOGY.—The eligible hospital 
demonstrates to the satisfaction of the Sec-
retary, in accordance with subparagraph 
(C)(i), that during such period the hospital 
is using certified EHR technology in a 
meaningful manner. 
‘‘(ii) INFORMATION EXCHANGE.—The 
eligible hospital demonstrates to the satis-
faction of the Secretary, in accordance 
with subparagraph (C)(i), that during such 
period such certified EHR technology is 
connected in a manner that provides, in 
accordance with law and standards appli-
cable to the exchange of information, for 
the electronic exchange of health informa-
tion to improve the quality of health care, 
such as promoting care coordination. 
‘‘(iii) 
REPORTING
ON
MEASURES 
USING
EHR.—Subject to subparagraph 
(B)(ii) and using such certified EHR tech-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00699
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
700 
AMDT. NO. 570 
nology, the eligible hospital submits infor-
mation for such period, in a form and 
manner specified by the Secretary, on such 
clinical quality measures and such other 
measures as selected by the Secretary 
under subparagraph (B)(i). 
The Secretary shall seek to improve the use of 
electronic health records and health care quality 
over time by requiring more stringent measures 
of meaningful use selected under this para-
graph. 
‘‘(B) REPORTING ON MEASURES.— 
‘‘(i) SELECTION.—The Secretary shall 
select measures for purposes of subpara-
graph (A)(iii) but only consistent with the 
following: 
‘‘(I) The Secretary shall provide 
preference to clinical quality measures 
that have been selected for purposes 
of applying subsection (b)(3)(B)(viii) 
or that have been endorsed by the en-
tity with a contract with the Secretary 
under section 1890(a). 
‘‘(II) Prior to any measure (other 
than a clinical quality measure that 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00700
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
701 
AMDT. NO. 570 
has been selected for purposes of ap-
plying 
subsection 
(b)(3)(B)(viii)) 
being selected under this subpara-
graph, the Secretary shall publish in 
the Federal Register such measure 
and provide for a period of public 
comment on such measure. 
‘‘(ii) LIMITATIONS.—The Secretary 
may not require the electronic reporting of 
information on clinical quality measures 
under subparagraph (A)(iii) unless the 
Secretary has the capacity to accept the in-
formation electronically, which may be on 
a pilot basis. 
‘‘(iii) COORDINATION OF REPORTING 
OF
INFORMATION.—In 
selecting 
such 
measures, and in establishing the form and 
manner for reporting measures under sub-
paragraph (A)(iii), the Secretary shall seek 
to avoid redundant or duplicative reporting 
with reporting otherwise required, includ-
ing 
reporting 
under 
subsection 
(b)(3)(B)(viii). 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00701
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
702 
AMDT. NO. 570 
‘‘(C) DEMONSTRATION
OF
MEANINGFUL 
USE OF CERTIFIED EHR TECHNOLOGY AND IN-
FORMATION EXCHANGE.— 
‘‘(i) IN
GENERAL.—A hospital may 
satisfy the demonstration requirement of 
clauses (i) and (ii) of subparagraph (A) 
through means specified by the Secretary, 
which may include— 
‘‘(I) an attestation; 
‘‘(II) the submission of claims 
with appropriate coding (such as a 
code indicating that inpatient care 
was documented using certified EHR 
technology); 
‘‘(III) a survey response; 
‘‘(IV) reporting under subpara-
graph (A)(iii); and 
‘‘(V) other means specified by the 
Secretary. 
‘‘(ii) USE
OF
PART
D
DATA.—Not-
withstanding sections 1860D–15(d)(2)(B) 
and 1860D–15(f)(2), the Secretary may 
use data regarding drug claims submitted 
for purposes of section 1860D–15 that are 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00702
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
703 
AMDT. NO. 570 
necessary for purposes of subparagraph 
(A). 
‘‘(4) APPLICATION.— 
‘‘(A) LIMITATIONS
ON
REVIEW.—There 
shall be no administrative or judicial review 
under section 1869, section 1878, or otherwise 
of the determination of any incentive payment 
under this subsection and the payment adjust-
ment under subsection (b)(3)(B)(ix), including 
the determination of a meaningful EHR user 
under paragraph (3), determination of meas-
ures applicable to services furnished by eligible 
hospitals under this subsection, and the excep-
tion under subsection (b)(3)(B)(ix)(II). 
‘‘(B) POSTING
ON
WEBSITE.—The Sec-
retary shall post on the Internet website of the 
Centers for Medicare & Medicaid Services, in an 
easily understandable format, a list of the 
names of the eligible hospitals that are mean-
ingful EHR users under this subsection or sub-
section (b)(3)(B)(ix) and other relevant data as 
determined appropriate by the Secretary. The 
Secretary shall ensure that a hospital has the 
opportunity to review the other relevant data 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00703
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
704 
AMDT. NO. 570 
that are to be made public with respect to the 
hospital prior to such data being made public. 
‘‘(5) CERTIFIED EHR TECHNOLOGY DEFINED.— 
The term ‘certified EHR technology’ has the mean-
ing given such term in section 1848(o)(4). 
‘‘(6) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) ELIGIBLE HOSPITAL.—The term ‘eli-
gible hospital’ means— 
‘‘(i) a subsection (d) hospital; and 
‘‘(ii) a critical access hospital (as de-
fined in section 1861(mm)(1)). 
‘‘(B) REPORTING PERIOD.—The term ‘re-
porting period’ means any period (or periods), 
with respect to a payment year, as specified by 
the Secretary.’’. 
(b) INCENTIVE MARKET BASKET ADJUSTMENT.— 
(1) IN
GENERAL.—Section 1886(b)(3)(B) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395ww(b)(3)(B)) is amended— 
(A) in clause (viii)(I), by inserting ‘‘(or, 
beginning with fiscal year 2016, by one-quar-
ter)’’ after ‘‘2.0 percentage points’’; and 
(B) by adding at the end the following new 
clause: 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00704
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
705 
AMDT. NO. 570 
‘‘(ix)(I) For purposes of clause (i) for fiscal year 
2015 and each subsequent fiscal year, in the case of an 
eligible hospital (as defined in subsection (n)(6)(A)) that 
is not a meaningful EHR user (as defined in subsection 
(n)(3)) for the reporting period for such fiscal year, three- 
quarters of the applicable percentage increase otherwise 
applicable under clause (i) for such fiscal year shall be 
reduced by 331⁄3 percent for fiscal year 2015, 662⁄3 per-
cent for fiscal year 2016, and 100 percent for fiscal year 
2017 and each subsequent fiscal year. Such reduction 
shall apply only with respect to the fiscal year involved 
and the Secretary shall not take into account such reduc-
tion in computing the applicable percentage increase under 
clause (i) for a subsequent fiscal year. 
‘‘(II) The Secretary may, on a case-by-case basis, ex-
empt a subsection (d) hospital from the application of sub-
clause (I) with respect to a fiscal year if the Secretary 
determines, subject to annual renewal, that requiring such 
hospital to be a meaningful EHR user during such fiscal 
year would result in a significant hardship, such as in the 
case of a hospital in a rural area without sufficient Inter-
net access. In no case may a hospital be granted an ex-
emption under this subclause for more than 5 years. 
‘‘(III) For fiscal year 2015 and each subsequent fis-
cal year, a State in which hospitals are paid for services 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00705
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
706 
AMDT. NO. 570 
under section 1814(b)(3) shall adjust the payments to 
each subsection (d) hospital in the State that is not a 
meaningful EHR user (as defined in subsection (n)(3)) 
in a manner that is designed to result in an aggregate 
reduction in payments to hospitals in the State that is 
equivalent to the aggregate reduction that would have oc-
curred if payments had been reduced to each subsection 
(d) hospital in the State in a manner comparable to the 
reduction under the previous provisions of this clause. The 
State shall report to the Secretary the methodology it will 
use to make the payment adjustment under the previous 
sentence. 
‘‘(IV) For purposes of this clause, the term ‘reporting 
period’ means, with respect to a fiscal year, any period 
(or periods), with respect to the fiscal year, as specified 
by the Secretary.’’. 
(2) CRITICAL
ACCESS
HOSPITALS.—Section 
1814(l) of the Social Security Act (42 U.S.C. 
1395f(l)) is amended— 
(A) in subparagraph (1), by striking 
‘‘paragraph (2)’’ and inserting ‘‘paragraphs (2) 
and (3)’’; and 
(B) by adding at the end the following new 
paragraph: 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00706
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
707 
AMDT. NO. 570 
‘‘(3)(A) Subject to subparagraph (B), for fiscal year 
2015 and each subsequent fiscal year, in the case of a 
critical access hospital that is not a meaningful EHR user 
(as defined in section 1886(n)(3)) for the reporting period 
for such fiscal year, paragraph (1) shall be applied by sub-
stituting the applicable percent under subparagraph (C) 
for the percent described in such paragraph (1). 
‘‘(B) The Secretary may, on a case-by-case basis, ex-
empt a critical access hospital from the application of sub-
paragraph (A) with respect to a fiscal year if the Secretary 
determines, subject to annual renewal, that requiring such 
hospital to be a meaningful EHR user during such fiscal 
year would result in a significant hardship, such as in the 
case of a hospital in a rural area without sufficient Inter-
net access. In no case may a hospital be granted an ex-
emption under this subparagraph for more than 5 years. 
‘‘(C) The percent described in this subparagraph is— 
‘‘(i) for fiscal year 2015, 100.66 percent; 
‘‘(ii) for fiscal year 2016, 100.33 percent; and 
‘‘(iii) for fiscal year 2017 and each subsequent 
fiscal year, 100 percent.’’. 
(c) APPLICATION TO CERTAIN MA-AFFILIATED ELI-
GIBLE HOSPITALS.—Section 1853 of the Social Security 
Act (42 U.S.C. 1395w-23), as amended by section 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00707
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
708 
AMDT. NO. 570 
4201(c), is further amended by adding at the end the fol-
lowing new subsection: 
‘‘(m) APPLICATION OF ELIGIBLE HOSPITAL INCEN-
TIVES FOR CERTAIN MA ORGANIZATIONS FOR ADOPTION 
AND MEANINGFUL USE
OF CERTIFIED EHR TECH-
NOLOGY.— 
‘‘(1) APPLICATION.—Subject to paragraphs (3) 
and (4), in the case of a qualifying MA organization, 
the provisions of sections 1814(l)(3), 1886(n), and 
1886(b)(3)(B)(ix) shall apply with respect to eligible 
hospitals described in paragraph (2) of the organiza-
tion which the organization attests under subsection 
(l)(6) to be meaningful EHR users in a similar man-
ner as they apply to eligible hospitals under such 
sections. Incentive payments under paragraph (3) 
shall be made to and payment adjustments under 
paragraph (4) shall apply to such qualifying organi-
zations. 
‘‘(2) ELIGIBLE
HOSPITAL
DESCRIBED.—With 
respect to a qualifying MA organization, an eligible 
hospital described in this paragraph is an eligible 
hospital (as defined in section 1886(n)(6)(A)) that is 
under common corporate governance with such orga-
nization and serves individuals enrolled under an 
MA plan offered by such organization. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00708
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
709 
AMDT. NO. 570 
‘‘(3) ELIGIBLE
HOSPITAL
INCENTIVE
PAY-
MENTS.— 
‘‘(A) IN
GENERAL.—In applying section 
1886(n)(2) under paragraph (1), instead of the 
additional payment amount under section 
1886(n)(2), there shall be substituted an 
amount determined by the Secretary to be simi-
lar to the estimated amount in the aggregate 
that would be payable if payment for services 
furnished by such hospitals was payable under 
part A instead of this part. In implementing the 
previous sentence, the Secretary— 
‘‘(i) shall, insofar as data to deter-
mine the discharge related amount under 
section 1886(n)(2)(C) for an eligible hos-
pital are not available to the Secretary, use 
such alternative data and methodology to 
estimate such discharge related amount as 
the Secretary determines appropriate; and 
‘‘(ii) shall, insofar as data to deter-
mine the medicare share described in sec-
tion 1886(n)(2)(D) for an eligible hospital 
are not available to the Secretary, use such 
alternative data and methodology to esti-
mate such share, which data and method-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00709
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
710 
AMDT. NO. 570 
ology may include use of the inpatient bed 
days (or discharges) with respect to an eli-
gible hospital during the appropriate pe-
riod which are attributable to both individ-
uals for whom payment may be made 
under part A or individuals enrolled in an 
MA plan under a Medicare Advantage or-
ganization under this part as a proportion 
of the total number of patient-bed-days (or 
discharges) with respect to such hospital 
during such period. 
‘‘(B) AVOIDING
DUPLICATION
OF
PAY-
MENTS.— 
‘‘(i) IN GENERAL.—In the case of a 
hospital that for a payment year is an eli-
gible hospital described in paragraph (2) 
and for which at least one-third of their 
discharges (or bed-days) of Medicare pa-
tients for the year are covered under part 
A, payment for the payment year shall be 
made only under section 1886(n) and not 
under this subsection. 
‘‘(ii) METHODS.—In the case of a 
hospital that is an eligible hospital de-
scribed in paragraph (2) and also is eligi-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00710
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
711 
AMDT. NO. 570 
ble for an incentive payment under section 
1886(n) but is not described in clause (i) 
for the same payment period, the Secretary 
shall develop a process— 
‘‘(I) to ensure that duplicate pay-
ments are not made with respect to 
an eligible hospital both under this 
subsection and under section 1886(n); 
and 
‘‘(II) to collect data from Medi-
care Advantage organizations to en-
sure against such duplicate payments. 
‘‘(4) PAYMENT ADJUSTMENT.— 
‘‘(A) Subject to paragraph (3), in the case 
of a qualifying MA organization (as defined in 
section 1853(l)(5)), if, according to the attesta-
tion of the organization submitted under sub-
section (l)(6) for an applicable period, one or 
more eligible hospitals (as defined in section 
1886(n)(6)(A)) that are under common cor-
porate governance with such organization and 
that serve individuals enrolled under a plan of-
fered by such organization are not meaningful 
EHR users (as defined in section 1886(n)(3)) 
with respect to a period, the payment amount 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00711
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
712 
AMDT. NO. 570 
payable under this section for such organization 
for such period shall be the percent specified in 
subparagraph (B) for such period of the pay-
ment amount otherwise provided under this sec-
tion for such period. 
‘‘(B) SPECIFIED
PERCENT.—The percent 
specified under this subparagraph for a year is 
100 percent minus a number of percentage 
points equal to the product of— 
‘‘(i) the number of the percentage 
point reduction effected under section 
1886(b)(3)(B)(ix)(I) for the period; and 
‘‘(ii) the Medicare hospital expendi-
ture proportion specified in subparagraph 
(C) for the year. 
‘‘(C) MEDICARE HOSPITAL EXPENDITURE 
PROPORTION.—The Medicare hospital expendi-
ture proportion under this subparagraph for a 
year is the Secretary’s estimate of the propor-
tion, of the expenditures under parts A and B 
that are not attributable to this part, that are 
attributable to expenditures for inpatient hos-
pital services. 
‘‘(D) APPLICATION OF PAYMENT ADJUST-
MENT.—In the case that a qualifying MA orga-
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00712
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
713 
AMDT. NO. 570 
nization attests that not all eligible hospitals 
are meaningful EHR users with respect to an 
applicable period, the Secretary shall apply the 
payment adjustment under this paragraph 
based on a methodology specified by the Sec-
retary, taking into account the proportion of 
such eligible hospitals, or discharges from such 
hospitals, that are not meaningful EHR users 
for such period. 
‘‘(5) POSTING
ON
WEBSITE.—The Secretary 
shall post on the Internet website of the Centers for 
Medicare & Medicaid Services, in an easily under-
standable format— 
‘‘(A) a list of the names, business address-
es, and business phone numbers of each quali-
fying MA organization receiving an incentive 
payment under this subsection for eligible hos-
pitals described in paragraph (2); and 
‘‘(B) a list of the names of the eligible hos-
pitals for which such incentive payment is 
based.’’. 
(d) CONFORMING AMENDMENTS.— 
(1) Section 1814(b) of the Social Security Act 
(42 U.S.C. 1395f(b)) is amended— 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00713
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
714 
AMDT. NO. 570 
(A) in paragraph (3), in the matter pre-
ceding subparagraph (A), by inserting ‘‘, sub-
ject to section 1886(d)(3)(B)(ix)(III),’’ after 
‘‘then’’; and 
(B) by adding at the end the following: 
‘‘For purposes of applying paragraph (3), there 
shall be taken into account incentive payments, 
and payment adjustments under subsection 
(b)(3)(B)(ix) or (n) of section 1886.’’. 
(2) Section 1851(i)(1) of the Social Security 
Act (42 U.S.C. 1395w–21(i)(1)) is amended by 
striking 
‘‘and 
1886(h)(3)(D)’’ 
and 
inserting 
‘‘1886(h)(3)(D), and 1853(m)’’. 
(3) Section 1853 of the Social Security Act (42 
U.S.C. 
1395w–23), 
as 
amended 
by 
section 
4311(d)(1), is amended— 
(A) in subsection (c)— 
(i) in paragraph (1)(D)(i), by striking 
‘‘1848(o)’’ and inserting ‘‘, 1848(o), and 
1886(n)’’; and 
(ii) in paragraph (6)(A), by inserting 
‘‘and subsections (b)(3)(B)(ix) and (n) of 
section 1886’’ after ‘‘section 1848’’; and 
(B) in subsection (f), by inserting ‘‘and 
subsection (m)’’ after ‘‘under subsection (l)’’. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00714
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
715 
AMDT. NO. 570 
SEC. 4203. PREMIUM HOLD HARMLESS AND IMPLEMENTA-
TION FUNDING. 
(a) PREMIUM HOLD HARMLESS.— 
(1) IN GENERAL.—Section 1839(a)(1) of the 
Social Security Act (42 U.S.C. 1395r(a)(1)) is 
amended by adding at the end the following: ‘‘In ap-
plying this paragraph there shall not be taken into 
account additional payments under section 1848(o) 
and section 1853(l)(3) and the Government con-
tribution under section 1844(a)(3).’’. 
(2) PAYMENT.—Section 1844(a) of such Act 
(42 U.S.C. 1395w(a)) is amended— 
(A) in paragraph (2), by striking the pe-
riod at the end and inserting ‘‘; plus’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(3) a Government contribution equal to the 
amount of payment incentives payable under sec-
tions 1848(o) and 1853(l)(3).’’. 
(b) IMPLEMENTATION FUNDING.—In addition to 
funds otherwise available, out of any funds in the Treas-
ury not otherwise appropriated, there are appropriated to 
the Secretary of Health and Human Services for the Cen-
ter for Medicare & Medicaid Services Program Manage-
ment Account, $100,000,000 for each of fiscal years 2009 
through 2015 and $45,000,000 for each succeeding fiscal 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00715
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
716 
AMDT. NO. 570 
year through fiscal year 2018, which shall be available for 
purposes of carrying out the provisions of (and amend-
ments made by) this part. Amounts appropriated under 
this subsection for a fiscal year shall be available until ex-
pended. 
SEC. 4204. NON-APPLICATION OF PHASED-OUT INDIRECT 
MEDICAL EDUCATION (IME) ADJUSTMENT 
FACTOR FOR FISCAL YEAR 2009. 
(a) IN GENERAL.—Section 412.322 of title 42, Code 
of Federal Regulations, shall be applied without regard to 
paragraph (c) of such section, and the Secretary of Health 
and Human Services shall recompute payments for dis-
charges occurring on or after October 1, 2008, as if such 
paragraph had never been in effect. 
(b) NO EFFECT ON SUBSEQUENT YEARS.—Nothing 
in subsection (a) shall be construed as having any effect 
on the application of paragraph (d) of section 412.322 of 
title 42, Code of Federal Regulations. 
SEC. 4205. STUDY ON APPLICATION OF EHR PAYMENT IN-
CENTIVES FOR PROVIDERS NOT RECEIVING 
OTHER INCENTIVE PAYMENTS. 
(a) STUDY.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall conduct a study to determine 
the extent to which and manner in which payment 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00716
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
717 
AMDT. NO. 570 
incentives (such as under title XVIII or XIX of the 
Social Security Act) and other funding for purposes 
of implementing and using certified EHR technology 
(as defined in section 1848(o)(4) of the Social Secu-
rity Act, as added by section 4311(a)) should be 
made available to health care providers who are re-
ceiving minimal or no payment incentives or other 
funding under this Act, under title XVIII or XIX of 
such Act, or otherwise, for such purposes. 
(2) DETAILS OF STUDY.—Such study shall in-
clude an examination of— 
(A) the adoption rates of certified EHR 
technology (as so defined) by such health care 
providers; 
(B) the clinical utility of such technology 
by such health care providers; 
(C) whether the services furnished by such 
health care providers are appropriate for or 
would benefit from the use of such technology; 
(D) the extent to which such health care 
providers work in settings that might otherwise 
receive an incentive payment or other funding 
under this Act, title XVIII or XIX of the Social 
Security Act, or otherwise; 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00717
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
718 
AMDT. NO. 570 
(E) the potential costs and the potential 
benefits of making payment incentives and 
other funding available to such health care pro-
viders; and 
(F) any other issues the Secretary deems 
to be appropriate. 
(b) REPORT.—Not later than June 30, 2010, the 
Secretary shall submit to Congress a report on the find-
ings and conclusions of the study conducted under sub-
section (a). 
SEC. 4206. STUDY ON AVAILABILITY OF OPEN SOURCE 
HEALTH INFORMATION TECHNOLOGY SYS-
TEMS. 
(a) IN GENERAL.— 
(1) STUDY.—The Secretary of Health and 
Human Services shall, in consultation with the 
Under Secretary for Health of the Veterans Health 
Administration, the Director of the Indian Health 
Service, the Secretary of Defense, the Director of 
the Agency for Healthcare Research and Quality, 
the Administrator of the Health Resources and Serv-
ices Administration, and the Chairman of the Fed-
eral Communications Commission, conduct a study 
on— 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00718
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
719 
AMDT. NO. 570 
(A) the current availability of open source 
health information technology systems to Fed-
eral safety net providers (including small, rural 
providers); 
(B) the total cost of ownership of such sys-
tems in comparison to the cost of proprietary 
commercial products available; 
(C) the ability of such systems to respond 
to the needs of, and be applied to, various pop-
ulations (including children and disabled indi-
viduals); and 
(D) the capacity of such systems to facili-
tate interoperability. 
(2) CONSIDERATIONS.—In conducting the study 
under paragraph (1), the Secretary of Health and 
Human Services shall take into account the cir-
cumstances of smaller health care providers, health 
care providers located in rural or other medically un-
derserved areas, and safety net providers that deliver 
a significant level of health care to uninsured indi-
viduals, Medicaid beneficiaries, SCHIP beneficiaries, 
and other vulnerable individuals. 
(b) REPORT.—Not later than October 1, 2010, the 
Secretary of Health and Human Services shall submit to 
Congress a report on the findings and the conclusions of 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00719
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
720 
AMDT. NO. 570 
the study conducted under subsection (a), together with 
recommendations for such legislation and administrative 
action as the Secretary determines appropriate. 
Subtitle B—Medicaid Funding 
SEC. 4211. MEDICAID PROVIDER EHR ADOPTION AND OPER-
ATION PAYMENTS; IMPLEMENTATION FUND-
ING. 
(a) IN GENERAL.—Section 1903 of the Social Secu-
rity Act (42 U.S.C. 1396b) is amended— 
(1) in subsection (a)(3)— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (D); 
(B) by striking ‘‘plus’’ at the end of sub-
paragraph (E) and inserting ‘‘and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(F)(i) 100 percent of so much of the 
sums expended during such quarter as are at-
tributable to payments for certified EHR tech-
nology (and support services including mainte-
nance and training that is for, or is necessary 
for the adoption and operation of, such tech-
nology) by Medicaid providers described in sub-
section (t)(1); and 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00720
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
721 
AMDT. NO. 570 
‘‘(ii) 90 percent of so much of the sums ex-
pended during such quarter as are attributable 
to payments for reasonable administrative ex-
penses related to the administration of pay-
ments described in clause (i) if the State meets 
the condition described in subsection (t)(9); 
plus’’; and 
(2) by inserting after subsection (s) the fol-
lowing new subsection: 
‘‘(t)(1)(A) For purposes of subsection (a)(3)(F), the 
payments for certified EHR technology (and support serv-
ices including maintenance that is for, or is necessary for 
the operation of, such technology) by Medicaid providers 
described in this paragraph are payments made by the 
State in accordance with this subsection of the applicable 
percent of the net allowable costs of Medicaid providers 
(as defined in paragraph (2)) for such technology (and 
support services). 
‘‘(B) For purposes of subparagraph (A), the term 
‘applicable percent’ means— 
‘‘(i) in the case of a Medicaid provider de-
scribed in paragraph (2)(A), 85 percent; 
‘‘(ii) in the case of a Medicaid provider de-
scribed in clause (i) or (ii) of paragraph (2)(B), 100 
percent; and 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00721
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
722 
AMDT. NO. 570 
‘‘(iii) in the case of a Medicaid provider de-
scribed in clause (iii) of paragraph (2)(B), a percent 
specified by the Secretary, but not less than 85 per-
cent. 
‘‘(2) In this subsection and subsection (a)(3)(F), the 
term ‘Medicaid provider’ means— 
‘‘(A) an eligible professional (as defined in 
paragraph (3)(B)) who is not hospital-based and has 
at least 30 percent of the professional’s patient vol-
ume (as estimated in accordance with standards es-
tablished by the Secretary) attributable to individ-
uals who are receiving medical assistance under this 
title; and 
‘‘(B)(i) a children’s hospital, (ii) an acute-care 
hospital that is not described in clause (i) and that 
has at least 10 percent of the hospital’s patient vol-
ume (as estimated in accordance with standards es-
tablished by the Secretary) attributable to individ-
uals who are receiving medical assistance under this 
title, or (iii) a Federally-qualified health center or 
rural health clinic that has at least 30 percent of the 
center’s or clinic’s patient volume (as estimated in 
accordance with standards established by the Sec-
retary) attributable to individuals who are receiving 
medical assistance under this title. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00722
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
723 
AMDT. NO. 570 
An eligible professional shall not qualify as a Medicaid 
provider under this subsection unless the professional has 
waived, in a manner specified by the Secretary, any right 
to payment under section 1848(o) with respect to the 
adoption or support of certified EHR technology by the 
eligible professional. In applying clauses (ii) and (iii) of 
subparagraph (B), the standards established by the Sec-
retary for patient volume shall include individuals enrolled 
in a Medicaid managed care plan (under section 1903(m) 
or section 1932). 
‘‘(3) In this subsection and subsection (a)(3)(F): 
‘‘(A) The term ‘certified EHR technology’ 
means a qualified electronic health record (as de-
fined in 3000(13) of the Public Health Service Act) 
that is certified pursuant to section 3001(c)(5) of 
such Act as meeting standards adopted under sec-
tion 3004 of such Act that are applicable to the type 
of record involved (as determined by the Secretary, 
such as an ambulatory electronic health record for 
office-based physicians or an inpatient hospital elec-
tronic 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. 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00723
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
724 
AMDT. NO. 570 
‘‘(C) The term ‘hospital-based’ means, with re-
spect to an eligible professional, a professional (such 
as a pathologist, anesthesiologist, or emergency phy-
sician) 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 quali-
fied electronic health records, of the hospital. 
‘‘(4)(A) The term ‘allowable costs’ means, with re-
spect to certified EHR technology of a Medicaid provider, 
costs of such technology (and support services including 
maintenance and training that is for, or is necessary for 
the adoption and operation of, such technology) as deter-
mined by the Secretary to be reasonable. 
‘‘(B) The term ‘net allowable costs’ means allowable 
costs reduced by any payment that is made to the Med-
icaid provider involved from any other source that is di-
rectly attributable to payment for certified EHR tech-
nology or services described in subparagraph (A). 
‘‘(C) In no case shall— 
‘‘(i) the aggregate allowable costs under this 
subsection (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 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00724
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
725 
AMDT. NO. 570 
subparagraph (A)) exceed $25,000 or include costs 
over a period of longer than 5 years; 
‘‘(ii) for costs not described in clause (i) relat-
ing 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 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 limita-
tion as the Secretary shall establish, based on an 
amount determined by the Secretary as being ade-
quate to adopt and maintain certified EHR tech-
nology, consistent with paragraph (6). 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00725
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS
726 
AMDT. NO. 570 
‘‘(5) Payments described in paragraph (1) are not in 
accordance with this subsection unless the following re-
quirements 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. 
‘‘(C) With respect to payments to such Med-
icaid provider for costs other than costs related to 
the initial adoption of certified EHR technology, the 
Medicaid provider demonstrates meaningful use of 
certified EHR technology through a means that is 
approved by the State and acceptable to the Sec-
retary, and that may be based upon the methodolo-
gies applied under section 1848(o) or 1886(n). In 
establishing such means, which may include the re-
porting 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 
VerDate Nov 24 2008 
02:51 Feb 08, 2009
Jkt 079200
PO 00000
Frm 00726
Fmt 6654
Sfmt 6201
E:\BILLS\H1.AS2
H1
smartinez on PROD1PC64 with BILLS