H. R. 1—381 
Subtitle C—Miscellaneous Medicare 
Provisions 
SEC. 4301. MORATORIA ON CERTAIN MEDICARE REGULATIONS. 
(a) DELAY IN PHASE OUT OF MEDICARE HOSPICE BUDGET NEU-
TRALITY ADJUSTMENT FACTOR DURING FISCAL YEAR 2009.—Notwith-
standing any other provision of law, including the final rule pub-
lished on August 8, 2008, 73 Federal Register 46464 et seq., relating 
to Medicare Program; Hospice Wage Index for Fiscal Year 2009, 
the Secretary of Health and Human Services shall not phase out 
or eliminate the budget neutrality adjustment factor in the Medicare 
hospice wage index before October 1, 2009, and the Secretary shall 
recompute and apply the final Medicare hospice wage index for 
fiscal year 2009 as if there had been no reduction in the budget 
neutrality adjustment factor. 
(b) NON-APPLICATION OF PHASED-OUT INDIRECT MEDICAL EDU-
CATION (IME) ADJUSTMENT FACTOR FOR FISCAL YEAR 2009.— 
(1) IN GENERAL.—Section 412.322 of title 42, Code of Fed-
eral Regulations, shall be applied without regard to paragraph 
(c) of such section, and the Secretary of Health and Human 
Services shall recompute payments for discharges occurring 
on or after October 1, 2008, as if such paragraph had never 
been in effect. 
(2) NO EFFECT ON SUBSEQUENT YEARS.—Nothing in para-
graph (1) shall be construed as having any effect on the applica-
tion of paragraph (d) of section 412.322 of title 42, Code of 
Federal Regulations. 
(c) FUNDING FOR IMPLEMENTATION.—In addition to funds other-
wise available, for purposes of implementing the provisions of sub-
sections (a) and (b), including costs incurred in reprocessing claims 
in carrying out such provisions, the Secretary of Health and Human 
Services shall provide for the transfer from the Federal Hospital 
Insurance Trust Fund established under section 1817 of the Social 
Security Act (42 U.S.C. 1395i) to the Centers for Medicare & Med-
icaid Services Program Management Account of $2,000,000 for fiscal 
year 2009. 
SEC. 4302. LONG-TERM CARE HOSPITAL TECHNICAL CORRECTIONS. 
(a) PAYMENT.—Subsection (c) of section 114 of the Medicare, 
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110– 
173) is amended— 
(1) in paragraph (1)— 
(A) by amending the heading to read as follows: ‘‘DELAY 
IN APPLICATION OF 25 PERCENT PATIENT THRESHOLD PAY-
MENT ADJUSTMENT’’; 
(B) by striking ‘‘the date of the enactment of this 
Act’’ and inserting ‘‘July 1, 2007,’’; and 
(C) in subparagraph (A), by inserting ‘‘or to a long- 
term care hospital, or satellite facility, that as of December 
29, 2007, was co-located with an entity that is a provider- 
based, off-campus location of a subsection (d) hospital which 
did not provide services payable under section 1886(d) of 
the Social Security Act at the off-campus location’’ after 
‘‘freestanding long-term care hospitals’’; and 
(2) in paragraph (2)—
H. R. 1—382 
(A) in subparagraph (B)(ii), by inserting ‘‘or that is 
described in section 412.22(h)(3)(i) of such title’’ before the 
period; and 
(B) in subparagraph (C), by striking ‘‘the date of the 
enactment of this Act’’ and inserting ‘‘October 1, 2007 (or 
July 1, 2007, in the case of a satellite facility described 
in section 412.22(h)(3)(i) of title 42, Code of Federal Regula-
tions)’’. 
(b) MORATORIUM.—Subsection (d)(3)(A) of such section is 
amended by striking ‘‘if the hospital or facility’’ and inserting ‘‘if 
the hospital or facility obtained a certificate of need for an increase 
in beds that is in a State for which such certificate of need is 
required and that was issued on or after April 1, 2005, and before 
December 29, 2007, or if the hospital or facility’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall be effective and apply as if included in the enactment of 
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public 
Law 110–173). 
TITLE V—STATE FISCAL RELIEF 
SEC. 5000. PURPOSES; TABLE OF CONTENTS. 
(a) PURPOSES.—The purposes of this title are as follows: 
(1) To provide fiscal relief to States in a period of economic 
downturn. 
(2) To protect and maintain State Medicaid programs 
during a period of economic downturn, including by helping 
to avert cuts to provider payment rates and benefits or services, 
and to prevent constrictions of income eligibility requirements 
for such programs, but not to promote increases in such require-
ments. 
(b) TABLE OF CONTENTS.—The table of contents for this title 
is as follows: 
TITLE V—STATE FISCAL RELIEF 
Sec. 5000. Purposes; table of contents. 
Sec. 5001. Temporary increase of Medicaid FMAP. 
Sec. 5002. Temporary increase in DSH allotments during recession. 
Sec. 5003. Extension of moratoria on certain Medicaid final regulations. 
Sec. 5004. Extension of transitional medical assistance (TMA). 
Sec. 5005. Extension of the qualifying individual (QI) program. 
Sec. 5006. Protections for Indians under Medicaid and CHIP. 
Sec. 5007. Funding for oversight and implementation. 
Sec. 5008. GAO study and report regarding State needs during periods of national 
economic downturn. 
SEC. 5001. TEMPORARY INCREASE OF MEDICAID FMAP. 
(a) PERMITTING MAINTENANCE OF FMAP.—Subject to subsections 
(e), (f), and (g), if the FMAP determined without regard to this 
section for a State for— 
(1) fiscal year 2009 is less than the FMAP as so determined 
for fiscal year 2008, the FMAP for the State for fiscal year 
2008 shall be substituted for the State’s FMAP for fiscal year 
2009, before the application of this section; 
(2) fiscal year 2010 is less than the FMAP as so determined 
for fiscal year 2008 or fiscal year 2009 (after the application 
of paragraph (1)), the greater of such FMAP for the State 
for fiscal year 2008 or fiscal year 2009 shall be substituted
H. R. 1—383 
for the State’s FMAP for fiscal year 2010, before the application 
of this section; and 
(3) fiscal year 2011 is less than the FMAP as so determined 
for fiscal year 2008, fiscal year 2009 (after the application 
of paragraph (1)), or fiscal year 2010 (after the application 
of paragraph (2)), the greatest of such FMAP for the State 
for fiscal year 2008, fiscal year 2009, or fiscal year 2010 shall 
be substituted for the State’s FMAP for fiscal year 2011, before 
the application of this section, but only for the first calendar 
quarter in fiscal year 2011. 
(b) GENERAL 6.2 PERCENTAGE POINT INCREASE.— 
(1) IN GENERAL.—Subject to subsections (e), (f), and (g) 
and paragraph (2), for each State for calendar quarters during 
the recession adjustment period (as defined in subsection (h)(3)), 
the FMAP (after the application of subsection (a)) shall be 
increased (without regard to any limitation otherwise specified 
in section 1905(b) of the Social Security Act (42 U.S.C. 
1396d(b))) by 6.2 percentage points. 
(2) SPECIAL ELECTION FOR TERRITORIES.—In the case of 
a State that is not one of the 50 States or the District of 
Columbia, paragraph (1) shall only apply if the State makes 
a one-time election, in a form and manner specified by the 
Secretary and for the entire recession adjustment period, to 
apply the increase in FMAP under paragraph (1) and a 15 
percent increase under subsection (d) instead of applying a 
30 percent increase under subsection (d). 
(c) ADDITIONAL RELIEF BASED
ON INCREASE
IN UNEMPLOY-
MENT.— 
(1) IN GENERAL.—Subject to subsections (e), (f), and (g), 
if a State is a qualifying State under paragraph (2) for a 
calendar quarter occurring during the recession adjustment 
period, the FMAP for the State shall be further increased 
by the number of percentage points equal to the product of— 
(A) the State percentage applicable for the State under 
section 1905(b) of the Social Security Act (42 U.S.C. 
1396d(b)) after the application of subsection (a) and after 
the application of 1⁄2 of the increase under subsection (b); 
and 
(B) the applicable percent determined in paragraph 
(3) for the calendar quarter (or, if greater, for a previous 
such calendar quarter). 
(2) QUALIFYING CRITERIA.— 
(A) IN
GENERAL.—For purposes of paragraph (1), a 
State qualifies for additional relief under this subsection 
for a calendar quarter occurring during the recession 
adjustment period if the State is 1 of the 50 States or 
the District of Columbia and the State satisfies any of 
the following criteria for the quarter: 
(i) The State unemployment increase percentage 
(as defined in paragraph (4)) for the quarter is at 
least 1.5 percentage points but less than 2.5 percentage 
points. 
(ii) The State unemployment increase percentage 
for the quarter is at least 2.5 percentage points but 
less than 3.5 percentage points. 
(iii) The State unemployment increase percentage 
for the quarter is at least 3.5 percentage points.
H. R. 1—384 
(B) MAINTENANCE OF STATUS.—If a State qualifies for 
additional relief under this subsection for a calendar 
quarter, it shall be deemed to have qualified for such 
relief for each subsequent calendar quarter ending before 
July 1, 2010. 
(3) APPLICABLE PERCENT.— 
(A) IN GENERAL.—For purposes of paragraph (1), sub-
ject to subparagraph (B), the applicable percent is— 
(i) 5.5 percent, if the State satisfies the criteria 
described in paragraph (2)(A)(i) for the calendar 
quarter; 
(ii) 8.5 percent if the State satisfies the criteria 
described in paragraph (2)(A)(ii) for the calendar 
quarter; and 
(iii) 11.5 percent if the State satisfies the criteria 
described in paragraph (2)(A)(iii) for the calendar 
quarter. 
(B) MAINTENANCE OF HIGHER APPLICABLE PERCENT.— 
(i) HOLD HARMLESS PERIOD.—If the percent applied 
to a State under subparagraph (A) for any calendar 
quarter in the recession adjustment period beginning 
on or after January 1, 2009, and ending before July 
1, 2010, (determined without regard to this subpara-
graph) is less than the percent applied for the pre-
ceding 
quarter 
(as 
so 
determined), 
the 
higher 
applicable percent shall continue in effect for each 
subsequent calendar quarter ending before July 1, 
2010. 
(ii) NOTICE OF LOWER APPLICABLE PERCENT.—The 
Secretary shall notify a State at least 60 days prior 
to applying any lower applicable percent to the State 
under this paragraph. 
(4) COMPUTATION
OF
STATE
UNEMPLOYMENT
INCREASE 
PERCENTAGE.— 
(A) IN
GENERAL.—In this subsection, the ‘‘State 
unemployment increase percentage’’ for a State for a cal-
endar quarter is equal to the number of percentage points 
(if any) by which— 
(i) the average monthly unemployment rate for 
the State for months in the most recent previous 3- 
consecutive-month period for which data are available, 
subject to subparagraph (C); exceeds 
(ii) the lowest average monthly unemployment rate 
for the State for any 3-consecutive-month period pre-
ceding the period described in clause (i) and beginning 
on or after January 1, 2006. 
(B) 
AVERAGE
MONTHLY
UNEMPLOYMENT
RATE 
DEFINED.—In this paragraph, the term ‘‘average monthly 
unemployment rate’’ means the average of the monthly 
number unemployed, divided by the average of the monthly 
civilian labor force, seasonally adjusted, as determined 
based on the most recent monthly publications of the 
Bureau of Labor Statistics of the Department of Labor. 
(C) SPECIAL RULE.—With respect to— 
(i) the first 2 calendar quarters of the recession 
adjustment period, the most recent previous 3-consecu-
tive-month period described in subparagraph (A)(i)
H. R. 1—385 
shall be the 3-consecutive-month period beginning with 
October 2008; and 
(ii) the last 2 calendar quarters of the recession 
adjustment period, the most recent previous 3-consecu-
tive-month period described in such subparagraph shall 
be the 3-consecutive-month period beginning with 
December 2009, or, if it results in a higher applicable 
percent under paragraph (3), the 3-consecutive-month 
period beginning with January 2010. 
(d) INCREASE IN CAP ON MEDICAID PAYMENTS TO TERRITORIES.— 
Subject to subsections (f) and (g), with respect to entire fiscal 
years occurring during the recession adjustment period and with 
respect to fiscal years only a portion of which occurs during such 
period (and in proportion to the portion of the fiscal year that 
occurs during such period), the amounts otherwise determined for 
Puerto Rico, the Virgin Islands, Guam, the Northern Mariana 
Islands, and American Samoa under subsections (f) and (g) of sec-
tion 1108 of the Social Security Act (42 6 U.S.C. 1308) shall each 
be increased by 30 percent (or, in the case of an election under 
subsection (b)(2), 15 percent). In the case of such an election by 
a territory, subsection (a)(1) of such section shall be applied without 
regard to any increase in payment made to the territory under 
part E of title IV of such Act that is attributable to the increase 
in FMAP effected under subsection (b) for the territory. 
(e) SCOPE OF APPLICATION.—The increases in the FMAP for 
a State under this section shall apply for purposes of title XIX 
of the Social Security Act and shall not apply with respect to— 
(1) disproportionate share hospital payments described in 
section 1923 of such Act (42 U.S.C. 1396r–4); 
(2) payments under title IV of such Act (42 U.S.C. 601 
et seq.) (except that the increases under subsections (a) and 
(b) shall apply to payments under part E of title IV of such 
Act (42 U.S.C. 670 et seq.) and, for purposes of the application 
of this section to the District of Columbia, payments under 
such part shall be deemed to be made on the basis of the 
FMAP applied with respect to such District for purposes of 
title XIX and as increased under subsection (b)); 
(3) payments under title XXI of such Act (42 U.S.C. 1397aa 
et seq.); 
(4) any payments under title XIX of such Act that are 
based on the enhanced FMAP described in section 2105(b) 
of such Act (42 U.S.C. 1397ee(b)); or 
(5) any payments under title XIX of such Act that are 
attributable to expenditures for medical assistance provided 
to individuals made eligible under a State plan under title 
XIX of the Social Security Act (including under any waiver 
under such title or under section 1115 of such Act (42 U.S.C. 
1315)) because of income standards (expressed as a percentage 
of the poverty line) for eligibility for medical assistance that 
are higher than the income standards (as so expressed) for 
such eligibility as in effect on July 1, 2008, (including as such 
standards were proposed to be in effect under a State law 
enacted but not effective as of such date or a State plan amend-
ment or waiver request under title XIX of such Act that was 
pending approval on such date). 
(f) STATE INELIGIBILITY; LIMITATION; SPECIAL RULES.— 
(1) MAINTENANCE OF ELIGIBILITY REQUIREMENTS.—
H. R. 1—386 
(A) IN GENERAL.—Subject to subparagraphs (B) and 
(C), a State is not eligible for an increase in its FMAP 
under subsection (a), (b), or (c), or an increase in a cap 
amount under subsection (d), if eligibility standards, meth-
odologies, or procedures under its State plan under title 
XIX of the Social Security Act (including any waiver under 
such title or under section 1115 of such Act (42 U.S.C. 
1315)) are more restrictive than the eligibility standards, 
methodologies, or procedures, respectively, under such plan 
(or waiver) as in effect on July 1, 2008. 
(B) STATE REINSTATEMENT OF ELIGIBILITY PERMITTED.— 
Subject to subparagraph (C), a State that has restricted 
eligibility standards, methodologies, or procedures under 
its State plan under title XIX of the Social Security Act 
(including any waiver under such title or under section 
1115 of such Act (42 U.S.C. 1315)) after July 1, 2008, 
is no longer ineligible under subparagraph (A) beginning 
with the first calendar quarter in which the State has 
reinstated eligibility standards, methodologies, or proce-
dures that are no more restrictive than the eligibility stand-
ards, methodologies, or procedures, respectively, under such 
plan (or waiver) as in effect on July 1, 2008. 
(C) SPECIAL RULES.—A State shall not be ineligible 
under subparagraph (A)— 
(i) for the calendar quarters before July 1, 2009, 
on the basis of a restriction that was applied after 
July 1, 2008, and before the date of the enactment 
of this Act, if the State prior to July 1, 2009, has 
reinstated eligibility standards, methodologies, or 
procedures that are no more restrictive than the eligi-
bility standards, methodologies, or procedures, respec-
tively, under such plan (or waiver) as in effect on 
July 1, 2008; or 
(ii) on the basis of a restriction that was directed 
to be made under State law as in effect on July 1, 
2008, and would have been in effect as of such date, 
but for a delay in the effective date of a waiver under 
section 1115 of such Act with respect to such restric-
tion. 
(2) COMPLIANCE WITH PROMPT PAY REQUIREMENTS.— 
(A) APPLICATION TO PRACTITIONERS.— 
(i) IN GENERAL.—Subject to the succeeding provi-
sions of this subparagraph, no State shall be eligible 
for an increased FMAP rate as provided under this 
section for any claim received by a State from a practi-
tioner subject to the terms of section 1902(a)(37)(A) 
of the Social Security Act (42 U.S.C. 1396a(a)(37)(A)) 
for such days during any period in which that State 
has failed to pay claims in accordance with such section 
as applied under title XIX of such Act. 
(ii) REPORTING
REQUIREMENT.—Each State shall 
report to the Secretary, on a quarterly basis, its compli-
ance with the requirements of clause (i) as such 
requirements pertain to claims made for covered serv-
ices during each month of the preceding quarter. 
(iii) WAIVER
AUTHORITY.—The Secretary may 
waive the application of clause (i) to a State, or the
H. R. 1—387 
reporting requirement imposed under clause (ii), 
during any period in which there are exigent cir-
cumstances, including natural disasters, that prevent 
the timely processing of claims or the submission of 
such a report. 
(iv) APPLICATION TO CLAIMS.—Clauses (i) and (ii) 
shall only apply to claims made for covered services 
after the date of enactment of this Act. 
(B) APPLICATION
TO
NURSING
FACILITIES
AND
HOS-
PITALS.— 
(i) IN GENERAL.—Subject to clause (ii), the provi-
sions of subparagraph (A) shall apply with respect 
to a nursing facility or hospital, insofar as it is paid 
under title XIX of the Social Security Act on the basis 
of submission of claims, in the same or similar manner 
(but within the same timeframe) as such provisions 
apply to practitioners described in such subparagraph. 
(ii) GRACE PERIOD.—Notwithstanding clause (i), no 
period of ineligibility shall be imposed against a State 
prior to June 1, 2009, on the basis of the State failing 
to pay a claim in accordance with such clause. 
(3) STATE’S APPLICATION TOWARD RAINY DAY FUND.—A State 
is not eligible for an increase in its FMAP under subsection 
(b) or (c), or an increase in a cap amount under subsection 
(d), if any amounts attributable (directly or indirectly) to such 
increase are deposited or credited into any reserve or rainy 
day fund of the State. 
(4) NO WAIVER AUTHORITY.—Except as provided in para-
graph (2)(A)(iii), the Secretary may not waive the application 
of this subsection or subsection (g) under section 1115 of the 
Social Security Act or otherwise. 
(5) LIMITATION OF FMAP TO 100 PERCENT.—In no case shall 
an increase in FMAP under this section result in an FMAP 
that exceeds 100 percent. 
(6) TREATMENT OF CERTAIN EXPENDITURES.—With respect 
to expenditures described in section 2105(a)(1)(B) of the Social 
Security Act (42 U.S.C. 1397ee(a)(1)(B)), as in effect before 
April 1, 2009, that are made during the period beginning on 
October 1, 2008, and ending on March 31, 2009, any additional 
Federal funds that are paid to a State as a result of this 
section that are attributable to such expenditures shall not 
be counted against any allotment under section 2104 of such 
Act (42 U.S.C. 1397dd). 
(g) REQUIREMENTS.— 
(1) STATE REPORTS.—Each State that is paid additional 
Federal funds as a result of this section shall, not later than 
September 30, 2011, submit a report to the Secretary, in such 
form and such manner as the Secretary shall determine, 
regarding how the additional Federal funds were expended. 
(2) ADDITIONAL REQUIREMENT FOR CERTAIN STATES.—In the 
case of a State that requires political subdivisions within the 
State to contribute toward the non-Federal share of expendi-
tures under the State Medicaid plan required under section 
1902(a)(2) of the Social Security Act (42 U.S.C. 1396a(a)(2)), 
the State is not eligible for an increase in its FMAP under 
subsection (b) or (c), or an increase in a cap amount under 
subsection (d), if it requires that such political subdivisions
H. R. 1—388 
pay for quarters during the recession adjustment period a 
greater percentage of the non-Federal share of such expendi-
tures, or a greater percentage of the non-Federal share of 
payments under section 1923, than the respective percentage 
that would have been required by the State under such plan 
on September 30, 2008, prior to application of this section. 
(h) DEFINITIONS.—In this section, except as otherwise provided: 
(1) FMAP.—The term ‘‘FMAP’’ means the Federal medical 
assistance percentage, as defined in section 1905(b) of the Social 
Security Act (42 U.S.C. 1396d(b)), as determined without regard 
to this section except as otherwise specified. 
(2) POVERTY
LINE.—The term ‘‘poverty line’’ has the 
meaning given such term in section 673(2) of the Community 
Services Block Grant Act (42 U.S.C. 9902(2)), including any 
revision required by such section. 
(3) RECESSION ADJUSTMENT PERIOD.—The term ‘‘recession 
adjustment period’’ means the period beginning on October 
1, 2008, and ending on December 31, 2010. 
(4) SECRETARY.—The term ‘‘Secretary’’ means the Secretary 
of Health and Human Services. 
(5) STATE.—The term ‘‘State’’ has the meaning given such 
term in section 1101(a)(1) of the Social Security Act (42 U.S.C. 
1301(a)(1)) for purposes of title XIX of the Social Security 
Act (42 U.S.C. 1396 et seq.). 
(i) SUNSET.—This section shall not apply to items and services 
furnished after the end of the recession adjustment period. 
(j) LIMITATION
ON FMAP CHANGE.—The increase in FMAP 
effected under section 614 of the Children’s Health Insurance Pro-
gram Reauthorization Act of 2009 shall not apply in the computation 
of the enhanced FMAP under title XXI or XIX of the Social Security 
Act for any period (notwithstanding subsection (i)). 
SEC. 5002. TEMPORARY INCREASE IN DSH ALLOTMENTS DURING 
RECESSION. 
Section 1923(f)(3) of the Social Security Act (42 U.S.C. 1396r– 
4(f)(3)) is amended— 
(1) in subparagraph (A), by striking ‘‘paragraph (6)’’ and 
inserting ‘‘paragraph (6) and subparagraph (E)’’; and 
(2) by adding at the end the following new subparagraph: 
‘‘(E) TEMPORARY
INCREASE
IN
ALLOTMENTS
DURING 
RECESSION.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the DSH 
allotment for any State— 
‘‘(I) for fiscal year 2009 is equal to 102.5 per-
cent of the DSH allotment that would be deter-
mined under this paragraph for the State for fiscal 
year 2009 without application of this subpara-
graph, notwithstanding subparagraphs (B) and (C); 
‘‘(II) for fiscal year 2010 is equal to 102.5 
percent of the DSH allotment for the State for 
fiscal year 2009, as determined under subclause 
(I); and 
‘‘(III) for each succeeding fiscal year is equal 
to the DSH allotment for the State under this 
paragraph determined without applying sub-
clauses (I) and (II).
H. R. 1—389 
‘‘(ii) APPLICATION.—Clause (i) shall not apply to 
a State for a year in the case that the DSH allotment 
for such State for such year under this paragraph 
determined without applying clause (i) would grow 
higher than the DSH allotment specified under clause 
(i) for the State for such year.’’. 
SEC. 5003. EXTENSION OF MORATORIA ON CERTAIN MEDICAID FINAL 
REGULATIONS. 
(a) FINAL REGULATIONS RELATING TO OPTIONAL CASE MANAGE-
MENT
SERVICES
AND
ALLOWABLE
PROVIDER
TAXES.—Section 
7001(a)(3)(A) of the Supplemental Appropriations Act, 2008 (Public 
Law 110–252) is amended by striking ‘‘April 1, 2009’’ and inserting 
‘‘July 1, 2009’’. 
(b) FINAL REGULATION RELATING TO SCHOOL-BASED ADMINIS-
TRATION AND SCHOOL-BASED TRANSPORTATION.—Section 206 of the 
Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public 
Law 110–173), as amended by section 7001(a)(2) of the Supple-
mental Appropriations Act, 2008 (Public Law 110–252), is amended 
by inserting ‘‘(July 1, 2009, in the case of the final regulation 
relating to school-based administration and school-based transpor-
tation)’’ after ‘‘April 1, 2009,’’. 
(c) FINAL REGULATION RELATING
TO OUTPATIENT HOSPITAL 
FACILITY SERVICES.—Notwithstanding any other provision of law, 
with respect to expenditures for services furnished during the period 
beginning on December 8, 2008, and ending on June 30, 2009, 
the Secretary of Health and Human Services shall not take any 
action (through promulgation of regulation, issuance of regulatory 
guidance, use of Federal payment audit procedures, or other 
administrative action, policy, or practice, including a Medical Assist-
ance Manual transmittal or letter to State Medicaid directors) to 
implement the final regulation relating to clarification of the defini-
tion of outpatient hospital facility services under the Medicaid 
program published on November 7, 2008 (73 Federal Register 
66187). 
(d) SENSE
OF CONGRESS.—It is the sense of Congress that 
the Secretary of Health and Human Services should not promulgate 
as final regulations any of the following proposed Medicaid regula-
tions: 
(1) COST LIMITS FOR CERTAIN PROVIDERS.—The proposed 
regulation published on January 18, 2007, (72 Federal Register 
2236) (and the purported final regulation published on May 
29, 2007 (72 Federal Register 29748) and determined by the 
United States District Court for the District of Columbia to 
have been ‘‘improperly promulgated’’, Alameda County Medical 
Center, et al., v. Leavitt, et al., Civil Action No. 08-0422, Mem. 
at 4 (D.D.C. May 23, 2008)). 
(2) PAYMENTS FOR GRADUATE MEDICAL EDUCATION.—The 
proposed regulation published on May 23, 2007 (72 Federal 
Register 28930). 
(3) REHABILITATIVE
SERVICES.—The proposed regulation 
published on August 13, 2007 (72 Federal Register 45201). 
SEC. 5004. EXTENSION OF TRANSITIONAL MEDICAL ASSISTANCE (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
H. R. 1—390 
each amended by striking ‘‘September 30, 2003’’ and inserting 
‘‘December 31, 2010’’. 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section shall take effect on July 1, 2009. 
(b) STATE OPTION OF INITIAL 12-MONTH ELIGIBILITY.—Section 
1925 of the Social Security Act (42 U.S.C. 1396r–6) is amended— 
(1) in subsection (a)(1), by inserting ‘‘but subject to para-
graph (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 subject to sub-
section (a)(5)’’ after ‘‘Notwithstanding any other provision of 
this title’’. 
(c) REMOVAL OF REQUIREMENT FOR PREVIOUS RECEIPT OF MED-
ICAL ASSISTANCE.—Section 1925(a)(1) of such Act (42 U.S.C. 1396r– 
6(a)(1)), as amended by subsection (b)(1), is further amended— 
(1) by inserting ‘‘subparagraph (B) and’’ before ‘‘paragraph 
(5)’’; 
(2) by redesignating the matter after ‘‘REQUIREMENT.—’’ 
as a subparagraph (A) with the heading ‘‘IN GENERAL.—’’ and 
with the same indentation as subparagraph (B) (as added by 
paragraph (3)); and 
(3) by adding at the end the following: 
‘‘(B) STATE
OPTION
TO
WAIVE
REQUIREMENT
FOR
MONTHS BEFORE RECEIPT OF MEDICAL ASSISTANCE.—A State 
may, at its option, 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 subpara-
graph.’’. 
(d) CMS REPORT ON ENROLLMENT AND PARTICIPATION 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 subsection: 
‘‘(g) COLLECTION AND REPORTING OF PARTICIPATION INFORMA-
TION.— 
‘‘(1) COLLECTION
OF
INFORMATION
FROM
STATES.—Each 
State shall collect and submit to the Secretary (and make 
publicly available), in a format specified by the Secretary, 
information on average monthly enrollment and average 
monthly participation 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
H. R. 1—391 
to Congress annual reports concerning enrollment and partici-
pation rates described in such paragraph.’’. 
(e) EFFECTIVE DATE.—The amendments made by subsections 
(b) through (d) shall take effect on July 1, 2009. 
SEC. 5005. EXTENSION OF THE QUALIFYING INDIVIDUAL (QI) PRO-
GRAM. 
(a) EXTENSION.—Section 1902(a)(10)(E)(iv) of the Social Security 
Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is amended by striking 
‘‘December 2009’’ and inserting ‘‘December 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 subparagraph (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 subpara-
graphs: 
‘‘(M) for the period that begins on January 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 inserting ‘‘(L), or (N)’’. 
SEC. 5006. PROTECTIONS FOR INDIANS UNDER MEDICAID AND CHIP. 
(a) PREMIUMS AND COST SHARING PROTECTION UNDER MED-
ICAID.— 
(1) IN GENERAL.—Section 1916 of the Social Security Act 
(42 U.S.C. 1396o) is amended— 
(A) in subsection (a), in the matter preceding 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 SERVICES 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 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 referral under contract 
health services for which payment may be made under 
this title. 
‘‘(B) NO REDUCTION IN AMOUNT OF PAYMENT TO INDIAN 
HEALTH PROVIDERS.—Payment due under this title to the 
Indian Health Service, an Indian Tribe, Tribal Organiza-
tion, or Urban Indian Organization, or a health care pro-
vider 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
H. R. 1—392 
sharing, or similar charge that would be due from the 
Indian but for the operation of subparagraph (A). 
‘‘(2) RULE OF CONSTRUCTION.—Nothing in this subsection 
shall be construed as restricting the application of any other 
limitations on the imposition of premiums or cost sharing that 
may apply to 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: 
‘‘(vii) 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 referral under contract health services.’’; and 
(B) in subparagraph (B), by adding at the end the 
following new clause: 
‘‘(x) Items and services furnished to an Indian 
directly by the Indian Health Service, an Indian Tribe, 
Tribal Organization or Urban Indian Organization or 
through referral under contract health services.’’. 
(b) TREATMENT OF CERTAIN PROPERTY FROM RESOURCES FOR 
MEDICAID AND CHIP ELIGIBILITY.— 
(1) MEDICAID.—Section 1902 of the Social Security Act 
(42 U.S.C. 1396a), as amended by sections 203(c) and 
211(a)(1)(A)(ii) of the Children’s Health Insurance Program 
Reauthorization Act of 2009 (Public Law 111–3), is amended 
by adding at the end the following new subsection: 
‘‘(ff) 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 assist-
ance under this title: 
‘‘(1) Property, including real property and improvements, 
that is held in trust, subject to Federal restrictions, or otherwise 
under the supervision of the Secretary of the Interior, located 
on a reservation, including any federally recognized Indian 
Tribe’s reservation, pueblo, or colony, including former reserva-
tions in Oklahoma, Alaska Native regions established by the 
Alaska Native Claims Settlement Act, and Indian allotments 
on or near a reservation as designated and approved by the 
Bureau of Indian Affairs of the Department of the Interior. 
‘‘(2) For any federally recognized Tribe not described in 
paragraph (1), property located within the most recent bound-
aries of a prior Federal reservation. 
‘‘(3) Ownership interests in rents, leases, royalties, or usage 
rights related to natural resources (including extraction of nat-
ural resources or harvesting of timber, other plants and plant 
products, animals, fish, and shellfish) resulting from the exer-
cise of federally protected rights. 
‘‘(4) Ownership interests in or usage rights to items not 
covered by paragraphs (1) through (3) that have unique reli-
gious, spiritual, traditional, or cultural significance or rights 
that support subsistence 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)), as amended by sections 203(a)(2),
H. R. 1—393 
203(d)(2), 214(b), 501(d)(2), and 503(a)(1) of the Children’s 
Health Insurance Program Reauthorization Act of 2009 (Public 
Law 111–3), is amended— 
(A) by redesignating subparagraphs (C) through (I), 
as subparagraphs (D) through (J), respectively; and 
(B) by inserting after subparagraph (B), the following 
new subparagraph: 
‘‘(C) Section 1902(ff) (relating to disregard of certain 
property for purposes of making eligibility determina-
tions).’’. 
(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 
(2) by adding at the end the following new subparagraph: 
‘‘(B) The standards specified by the Secretary under 
subparagraph (A) shall require that the procedures estab-
lished 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 responsi-
bility for Indian Tribes and Alaska Native Villages. Nothing 
in this subparagraph shall be construed as preventing the 
Secretary from providing additional estate recovery exemp-
tions under this title for Indians.’’. 
(d) 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.— 
(1) IN GENERAL.—Section 1932 of the Social Security Act 
(42 U.S.C. 1396u–2) is amended by adding at the end the 
following new subsection: 
‘‘(h) SPECIAL RULES WITH RESPECT
TO INDIAN ENROLLEES, 
INDIAN HEALTH CARE PROVIDERS, AND INDIAN MANAGED CARE ENTI-
TIES.— 
‘‘(1) ENROLLEE OPTION TO SELECT AN INDIAN HEALTH CARE 
PROVIDER AS PRIMARY CARE PROVIDER.—In the case of a non- 
Indian Medicaid managed care entity that— 
‘‘(A) has an Indian enrolled with the entity; and 
‘‘(B) has an Indian health care provider that is partici-
pating 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 condition 
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 PRO-
VIDERS FOR PROVISION OF COVERED SERVICES.—Each contract 
with a managed care entity under section 1903(m) or under 
section 1905(t)(3) shall require any such entity, as a condition 
of receiving payment under such contract, to satisfy the fol-
lowing requirements:
H. R. 1—394 
‘‘(A) DEMONSTRATION
OF
ACCESS
TO
INDIAN
HEALTH 
CARE PROVIDERS AND APPLICATION OF ALTERNATIVE PAY-
MENT ARRANGEMENTS.—Subject to subparagraph (C), to— 
‘‘(i) demonstrate that the number of Indian health 
care providers that are participating 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 serv-
ices from such providers; and 
‘‘(ii) agree to pay Indian health care providers, 
whether such providers are participating or nonpartici-
pating providers with respect to the entity, for covered 
Medicaid managed care services provided to those 
Indian enrollees who are eligible to receive services 
from such providers at a rate equal to the rate nego-
tiated between such entity and the provider involved 
or, if such a rate has not been negotiated, at a 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. 
The Secretary shall establish procedures for applying the 
requirements of clause (i) in States where there are no 
or few Indian health providers. 
‘‘(B) PROMPT PAYMENT.—To agree to make prompt pay-
ment (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 subparagraph (A)(ii) 
or (C) applies, that the entity is required to pay in accord-
ance with that subparagraph. 
‘‘(C) APPLICATION OF SPECIAL PAYMENT REQUIREMENTS 
FOR FEDERALLY-QUALIFIED HEALTH CENTERS AND FOR SERV-
ICES
PROVIDED
BY
CERTAIN
INDIAN
HEALTH
CARE
PRO-
VIDERS.— 
‘‘(i) FEDERALLY-QUALIFIED HEALTH CENTERS.— 
‘‘(I) MANAGED CARE ENTITY PAYMENT REQUIRE-
MENT.—To agree to pay any Indian health care 
provider that is a federally-qualified health center 
under this title but not a participating 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 enrollee of a managed care entity (regardless
H. R. 1—395 
of whether the federally-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-qualified 
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 services 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 nonparticipating 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 services. 
‘‘(D) CONSTRUCTION.—Nothing in this paragraph shall 
be construed as waiving the application of section 
1902(a)(30)(A) (relating to application of standards to 
assure that payments are consistent with efficiency, 
economy, and quality of care). 
‘‘(3) SPECIAL RULE FOR ENROLLMENT FOR INDIAN MANAGED 
CARE ENTITIES.—Regarding the application of a Medicaid man-
aged care program to Indian Medicaid managed care entities, 
an Indian Medicaid managed care entity may restrict enroll-
ment under such program to Indians in the same manner 
as Indian Health Programs may restrict the delivery of services 
to Indians. 
‘‘(4) DEFINITIONS.—For purposes of this subsection: 
‘‘(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 man-
aged care entity that is controlled (within the meaning 
of the last sentence of section 1903(m)(1)(C)) by the Indian 
Health Service, a Tribe, Tribal Organization, or Urban 
Indian Organization, or a consortium, which may be com-
posed of 1 or more 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 entity that is not an Indian Medicaid 
managed care entity. 
‘‘(D) COVERED MEDICAID MANAGED CARE SERVICES.— 
The term ‘covered Medicaid managed 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 involved. 
‘‘(E) MEDICAID
MANAGED
CARE
PROGRAM.—The term 
‘Medicaid managed care program’ means a program under 
sections 1903(m), 1905(t), and 1932 and includes a man-
aged care program operating under a waiver under section 
1915(b) or 1115 or otherwise.’’.
H. R. 1—396 
(2) APPLICATION TO CHIP.—Section 2107(e)(1) of such Act 
(42 U.S.C. 1397gg(1)), as amended by subsection (b)(2), is 
amended— 
(A) by redesignating subparagraph (J) as subparagraph 
(K); and 
(B) by inserting after subparagraph (I) the following 
new subparagraph: 
‘‘(J) Subsections (a)(2)(C) and (h) of section 1932.’’. 
(e) CONSULTATION ON MEDICAID, CHIP, AND OTHER HEALTH 
CARE
PROGRAMS
FUNDED
UNDER
THE
SOCIAL
SECURITY
ACT 
INVOLVING
INDIAN
HEALTH
PROGRAMS
AND
URBAN
INDIAN 
ORGANIZATIONS.— 
(1) CONSULTATION WITH TRIBAL TECHNICAL ADVISORY 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 September 30, 2003, and the Secretary of Health and 
Human Services shall include in such Group a representative 
of a national urban Indian health organization and a represent-
ative of the Indian Health Service. The inclusion of a represent-
ative of a national urban Indian health organization in such 
Group shall not affect the nonapplication of the Federal 
Advisory Committee Act (5 U.S.C. App.) to such Group. 
(2) SOLICITATION OF ADVICE UNDER MEDICAID AND CHIP.— 
(A) 
MEDICAID
STATE
PLAN
AMENDMENT.—Section 
1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), 
as amended by section 501(d)(1) of the Children’s Health 
Insurance Program Reauthorization Act of 2009 (Public 
Law 111–3), (42 U.S.C. 1396a(a)) is amended— 
(i) in paragraph (71), by striking ‘‘and’’ at the 
end; 
(ii) in paragraph (72), by striking the period at 
the end and inserting ‘‘; and’’; and 
(iii) by inserting after paragraph (72), the following 
new paragraph: 
‘‘(73) in the case of any State in which 1 or more Indian 
Health Programs or Urban Indian Organizations furnishes 
health care services, provide for a process under which the 
State seeks advice on a regular, ongoing basis from designees 
of such Indian 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 Pro-
grams and Urban Indian Organizations and that— 
‘‘(A) shall include solicitation of advice prior to submis-
sion of any plan amendments, waiver requests, and pro-
posals for demonstration projects likely to have a direct 
effect on Indians, Indian Health Programs, or Urban Indian 
Organizations; and 
‘‘(B) may include appointment of an advisory committee 
and of a designee of such Indian Health Programs and 
Urban Indian Organizations to the medical care advisory 
committee advising the State on its State plan under this 
title.’’. 
(B) APPLICATION TO CHIP.—Section 2107(e)(1) of such 
Act (42 U.S.C. 1397gg(1)), as amended by subsections (b)(2) 
and (d) (2), is amended—
H. R. 1—397 
(i) by redesignating subparagraphs (B), (C), (D), 
(E), (F), (G), (H), (I), (J), and (K) as subparagraphs 
(D), (F), (B), (E), (G), (I), (H), (J), (K), and (L), respec-
tively; 
(ii) by moving such subparagraphs so as to appear 
in alphabetical order; and 
(iii) by inserting after subparagraph (B) (as so 
redesiganted and moved) the following new subpara-
graph: 
‘‘(C) Section 1902(a)(73) (relating to requiring certain 
States to seek advice from designees of Indian Health 
Programs and Urban Indian Organizations).’’. 
(3) RULE OF CONSTRUCTION.—Nothing in the amendments 
made by this subsection shall be construed as superseding 
existing advisory committees, working groups, guidance, or 
other advisory procedures established by the Secretary of 
Health and Human Services or by any State with respect 
to the provision of health care to Indians. 
(f) EFFECTIVE DATE.—The amendments made by this section 
shall take effect on July 1, 2009. 
SEC. 5007. FUNDING FOR OVERSIGHT AND IMPLEMENTATION. 
(a) OVERSIGHT.—For purposes of ensuring the proper expendi-
ture of Federal funds under title XIX of the Social Security Act 
(42 U.S.C. 1396 et seq.), there is appropriated to the Office of 
the Inspector General of the Department of Health and Human 
Services, out of any money in the Treasury not otherwise appro-
priated and without further appropriation, $31,250,000 for fiscal 
year 2009, which shall remain available for expenditure until Sep-
tember 30, 2011, and shall be in addition to any other amounts 
appropriated or made available to such Office for such purposes. 
(b) IMPLEMENTATION OF INCREASED FMAP.—For purposes of 
carrying out section 5001, there is appropriated to the Secretary 
of Health and Human Services, out of any money in the Treasury 
not otherwise appropriated and without further appropriation, 
$5,000,000 for fiscal year 2009, which shall remain available for 
expenditure until September 30, 2011, and shall be in addition 
to any other amounts appropriated or made available to such Sec-
retary for such purposes. 
SEC. 5008. GAO STUDY AND REPORT REGARDING STATE NEEDS 
DURING PERIODS OF NATIONAL ECONOMIC DOWNTURN. 
(a) IN GENERAL.—The Comptroller General of the United States 
shall study the period of national economic downturn in effect 
on the date of enactment of this Act, as well as previous periods 
of national economic downturn since 1974, for the purpose of devel-
oping recommendations for addressing the needs of States during 
such periods. As part of such analysis, the Comptroller General 
shall study the past and projected effects of temporary increases 
in the Federal medical assistance percentage under the Medicaid 
program with respect to such periods. 
(b) REPORT.—Not later than April 1, 2011, the Comptroller 
General of the United States shall submit a report to the appro-
priate committees of Congress on the results of the study conducted 
under paragraph (1). Such report shall include the following: 
(1) Such recommendations as the Comptroller General 
determines appropriate for modifying the national economic 
downturn assistance formula for temporary adjustment of the
H. R. 1—398 
Federal medical assistance percentage under Medicaid (also 
referred to as a ‘‘countercyclical FMAP’’) described in GAO 
report number GAO–07–97 to improve the effectiveness of the 
application of such percentage in addressing the needs of States 
during periods of national economic downturn, including rec-
ommendations for— 
(A) improvements to the factors that would begin and 
end the application of such percentage; 
(B) how the determination of the amount of such 
percentage could be adjusted to address State and regional 
economic variations during such periods; and 
(C) how the determination of the amount of such 
percentage could be adjusted to be more responsive to 
actual Medicaid costs incurred by States during such 
periods. 
(2) An analysis of the impact on States during such periods 
of— 
(A) declines in private health benefits coverage; 
(B) declines in State revenues; and 
(C) caseload maintenance and growth under Medicaid, 
the Children’s Health Insurance Program, or any other 
publicly-funded programs to provide health benefits cov-
erage for State residents. 
(3) Identification of, and recommendations for addressing, 
the effects on States of any other specific economic indicators 
that the Comptroller General determines appropriate. 
TITLE VI—BROADBAND TECHNOLOGY 
OPPORTUNITIES PROGRAM 
SEC. 6000. TABLE OF CONTENTS. 
The table of contents of this title is as follows: 
TITLE VI—BROADBAND TECHNOLOGY OPPORTUNITIES PROGRAM 
Sec. 6000. Table of contents. 
Sec. 6001. Broadband Technology Opportunities Program. 
SEC. 6001. BROADBAND TECHNOLOGY OPPORTUNITIES PROGRAM. 
(a) The Assistant Secretary of Commerce for Communications 
and Information (Assistant Secretary), in consultation with the 
Federal Communications Commission (Commission), shall establish 
a national broadband service development and expansion program 
in conjunction with the technology opportunities program, which 
shall be referred to as the Broadband Technology Opportunities 
Program. The Assistant Secretary shall ensure that the program 
complements and enhances and does not conflict with other Federal 
broadband initiatives and programs. 
(b) The purposes of the program are to— 
(1) provide access to broadband service to consumers 
residing in unserved areas of the United States; 
(2) provide improved access to broadband service to con-
sumers residing in underserved areas of the United States; 
(3) provide broadband education, awareness, training, 
access, equipment, and support to— 
(A) schools, libraries, medical and healthcare providers, 
community colleges and other institutions of higher edu-
cation, and other community support organizations and
H. R. 1—399 
entities to facilitate greater use of broadband service by 
or through these organizations; 
(B) organizations and agencies that provide outreach, 
access, equipment, and support services to facilitate greater 
use of broadband service by low-income, unemployed, aged, 
and otherwise vulnerable populations; and 
(C) job-creating strategic facilities located within a 
State-designated economic zone, Economic Development 
District designated by the Department of Commerce, 
Renewal Community or Empowerment Zone designated by 
the Department of Housing and Urban Development, or 
Enterprise Community designated by the Department of 
Agriculture; 
(4) improve access to, and use of, broadband service by 
public safety agencies; and 
(5) stimulate the demand for broadband, economic growth, 
and job creation. 
(c) The Assistant Secretary may consult a State, the District 
of Columbia, or territory or possession of the United States with 
respect to— 
(1) the identification of areas described in subsection (b)(1) 
or (2) located in that State; and 
(2) the allocation of grant funds within that State for 
projects in or affecting the State. 
(d) The Assistant Secretary shall— 
(1) establish and implement the grant program as expedi-
tiously as practicable; 
(2) ensure that all awards are made before the end of 
fiscal year 2010; 
(3) seek such assurances as may be necessary or appro-
priate from grantees under the program that they will substan-
tially complete projects supported by the program in accordance 
with project timelines, not to exceed 2 years following an award; 
and 
(4) report on the status of the program to the Committees 
on Appropriations of the House of Representatives and the 
Senate, the Committee on Energy and Commerce of the House 
of Representatives, and the Committee on Commerce, Science, 
and Transportation of the Senate, every 90 days. 
(e) To be eligible for a grant under the program, an applicant 
shall— 
(1)(A) be a State or political subdivision thereof, the District 
of Columbia, a territory or possession of the United States, 
an Indian tribe (as defined in section 4 of the Indian Self- 
Determination and Education Assistance Act (25 U.S.C. 450(b)) 
or native Hawaiian organization; 
(B) a nonprofit— 
(i) foundation, 
(ii) corporation, 
(iii) institution, or 
(iv) association; or 
(C) any other entity, including a broadband service 
or infrastructure provider, that the Assistant Secretary 
finds by rule to be in the public interest. In establishing 
such rule, the Assistant Secretary shall to the extent prac-
ticable promote the purposes of this section in a techno-
logically neutral manner;