709 
SEC. 1632. ENHANCED MEDICARE, MEDICAID, AND CHIP 
PROGRAM DISCLOSURE REQUIREMENTS RE-
LATING TO PREVIOUS AFFILIATIONS. 
(a) IN GENERAL.—Section 1128G of the Social Secu-
rity Act, as inserted by section 1631, is amended by add-
ing at the end the following new subsection: 
‘‘(b) ENHANCED PROGRAM DISCLOSURE REQUIRE-
MENTS.— 
‘‘(1) DISCLOSURE.—A provider of services or 
supplier who submits on or after July 1, 2011, an 
application for enrollment and renewing enrollment 
in a program under title XVIII, XIX, or XXI shall 
disclose (in a form and manner determined by the 
Secretary) any current affiliation or affiliation with-
in the previous 10-year period with a provider of 
services or supplier that has uncollected debt or with 
a person or entity that has been suspended or ex-
cluded under such program, subject to a payment 
suspension, or has had its billing privileges revoked. 
‘‘(2) ENHANCED
SAFEGUARDS.—If the Sec-
retary determines that such previous affiliation of 
such provider or supplier poses a risk of fraud, 
waste, or abuse, the Secretary may apply such en-
hanced safeguards as the Secretary determines nec-
essary to reduce such risk associated with such pro-
vider or supplier enrolling or participating in the 
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program under title XVIII, XIX, or XXI. Such safe-
guards may include enhanced oversight, such as en-
hanced screening of claims, required or unannounced 
(or required and unannounced) site visits or inspec-
tions, additional information reporting requirements, 
and conditioning such enrollment on the provision of 
a surety bond. 
‘‘(3) AUTHORITY TO DENY PARTICIPATION.—If 
the Secretary determines that there has been at 
least one such affiliation and that such affiliation or 
affiliations, as applicable, of such provider or sup-
plier poses a serious risk of fraud, waste, or abuse, 
the Secretary may deny the application of such pro-
vider or supplier.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) MEDICAID.—Paragraph (74) of section 
1902(a) of such Act (42 U.S.C. 1396a(a)), as added 
by section 1631(b)(1), is amended— 
(A) by inserting ‘‘or subsection (b) of such 
section (relating to disclosure requirements)’’ 
before ‘‘, and that the State’’; and 
(B) by inserting before the period the fol-
lowing: ‘‘and apply any enhanced safeguards, 
with respect to a provider or supplier described 
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in such subsection (b), as the Secretary deter-
mines necessary under such subsection (b)’’. 
(2) CHIP.—Subsection (d) of section 2102 of 
such Act (42 U.S.C. 1397bb), as added by section 
1631(b)(2), is amended— 
(A) in paragraph (1), by striking at the 
end ‘‘and’’; 
(B) in paragraph (2) by striking the period 
at the end and inserting ‘‘; and’’ and 
(C) by adding at the end the following new 
paragraph: 
‘‘(3) to enforce any determination made by the 
Secretary under subsection (b) of section 1128G (re-
lating to disclosure requirements) and to apply any 
enhanced safeguards, with respect to a provider or 
supplier described in such subsection, as the Sec-
retary determines necessary under such subsection.’’. 
SEC. 1633. REQUIRED INCLUSION OF PAYMENT MODIFIER 
FOR CERTAIN EVALUATION AND MANAGE-
MENT SERVICES. 
Section 1848 of the Social Security Act (42 U.S.C. 
1395w–4), as amended by section 4101 of the HITECH 
Act (Public Law 111–5), is amended by adding at the end 
the following new subsection: 
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‘‘(p) PAYMENT MODIFIER FOR CERTAIN EVALUA-
TION AND MANAGEMENT SERVICES.—The Secretary shall 
establish a payment modifier under the fee schedule under 
this section for evaluation and management services (as 
specified in section 1842(b)(16)(B)(ii)) that result in the 
ordering of additional services (such as lab tests), the pre-
scription of drugs, the furnishing or ordering of durable 
medical equipment in order to enable better monitoring 
of claims for payment for such additional services under 
this title, or the ordering, furnishing, or prescribing of 
other items and services determined by the Secretary to 
pose a high risk of waste, fraud, and abuse. The Secretary 
may require providers of services or suppliers to report 
such modifier in claims submitted for payment.’’. 
SEC. 1634. EVALUATIONS AND REPORTS REQUIRED UNDER 
MEDICARE INTEGRITY PROGRAM. 
(a) IN GENERAL.—Section 1893(c) of the Social Se-
curity Act (42 U.S.C. 1395ddd(c)) is amended— 
(1) in paragraph (3), by striking at the end 
‘‘and’’; 
(2) by redesignating paragraph (4) as para-
graph (5); and 
(3) by inserting after paragraph (3) the fol-
lowing new paragraph: 
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‘‘(4) for the contract year beginning in 2011 
and each subsequent contract year, the entity pro-
vides assurances to the satisfaction of the Secretary 
that the entity will conduct periodic evaluations of 
the effectiveness of the activities carried out by such 
entity under the Program and will submit to the 
Secretary an annual report on such activities; and’’. 
(b) REFERENCE
TO MEDICAID INTEGRITY PRO-
GRAM.—For a similar provision with respect to the Med-
icaid Integrity Program, see section 1752. 
SEC. 1635. REQUIRE PROVIDERS AND SUPPLIERS TO 
ADOPT 
PROGRAMS 
TO 
REDUCE 
WASTE, 
FRAUD, AND ABUSE. 
(a) IN GENERAL.—Section 1874 of the Social Secu-
rity Act (42 U.S.C. 42 U.S.C. 1395kk) is amended by 
adding at the end the following new subsection: 
‘‘(d) COMPLIANCE PROGRAMS FOR PROVIDERS OF 
SERVICES AND SUPPLIERS.— 
‘‘(1) 
IN
GENERAL.—The 
Secretary 
may 
disenroll a provider of services or a supplier (other 
than a physician or a skilled nursing facility) under 
this title (or may impose any civil monetary penalty 
or other intermediate sanction under paragraph (4)) 
if such provider of services or supplier fails to, sub-
ject to paragraph (5), establish a compliance pro-
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gram that contains the core elements established 
under paragraph (2). 
‘‘(2) ESTABLISHMENT OF CORE ELEMENTS.— 
The Secretary, in consultation with the Inspector 
General of the Department of Health and Human 
Services, shall establish core elements for a compli-
ance program under paragraph (1). Such elements 
may include written policies, procedures, and stand-
ards of conduct, a designated compliance officer and 
a compliance committee; effective training and edu-
cation pertaining to fraud, waste, and abuse for the 
organization’s employees and contractors; a con-
fidential or anonymous mechanism, such as a hot-
line, to receive compliance questions and reports of 
fraud, waste, or abuse; disciplinary guidelines for en-
forcement of standards; internal monitoring and au-
diting procedures, including monitoring and auditing 
of contractors; procedures for ensuring prompt re-
sponses to detected offenses and development of cor-
rective action initiatives, including responses to po-
tential offenses; and procedures to return all identi-
fied overpayments to the programs under this title, 
title XIX, and title XXI. 
‘‘(3) TIMELINE
FOR
IMPLEMENTATION.—The 
Secretary shall determine a timeline for the estab-
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lishment of the core elements under paragraph (2) 
and the date on which a provider of services and 
suppliers (other than physicians) shall be required to 
have established such a program for purposes of this 
subsection. 
‘‘(4) CMS ENFORCEMENT
AUTHORITY.—The 
Administrator for the Centers of Medicare & Med-
icaid Services shall have the authority to determine 
whether a provider of services or supplier described 
in subparagraph (3) has met the requirement of this 
subsection and to impose a civil monetary penalty 
not to exceed $50,000 for each violation. The Sec-
retary may also impose other intermediate sanctions, 
including corrective action plans and additional mon-
itoring in the case of a violation of this subsection. 
‘‘(5) PILOT
PROGRAM.—The Secretary may 
conduct a pilot program on the application of this 
subsection with respect to a category of providers of 
services or suppliers (other than physicians) that the 
Secretary determines to be a category which is at 
high risk for waste, fraud, and abuse before imple-
menting the requirements of this subsection to all 
providers of services and suppliers described in para-
graph (3).’’. 
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(b) REFERENCE
TO
SIMILAR
MEDICAID
PROVI-
SION.—For a similar provision with respect to the Med-
icaid program under title XIX of the Social Security Act, 
see section 1753. 
SEC. 1636. MAXIMUM PERIOD FOR SUBMISSION OF MEDI-
CARE CLAIMS REDUCED TO NOT MORE THAN 
12 MONTHS. 
(a) PURPOSE.—In general, the 36-month period cur-
rently allowed for claims filing under parts A, B, C, and, 
D of title XVIII of the Social Security Act presents oppor-
tunities for fraud schemes in which processing patterns 
of the Centers for Medicare & Medicaid Services can be 
observed and exploited. Narrowing the window for claims 
processing will not overburden providers and will reduce 
fraud and abuse. 
(b) REDUCING MAXIMUM PERIOD
FOR SUBMIS-
SION.— 
(1) PART A.—Section 1814(a) of the Social Se-
curity Act (42 U.S.C. 1395f(a)) is amended— 
(A) in paragraph (1), by strikeing ‘‘period 
of 3 calendar years’’ and all that follows and in-
serting ‘‘period of 1 calendar year from which 
such services are furnished; and’’; and 
(B) by adding at the end the following new 
sentence: ‘‘In applying paragraph (1), the Sec-
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retary may specify exceptions to the 1 calendar 
year period specified in such paragraph.’’. 
(2) PART B.—Section 1835(a) of such Act (42 
U.S.C. 1395n(a)) is amended— 
(A) in paragraph (1), by strikeing ‘‘period 
of 3 calendar years’’ and all that follows and in-
serting ‘‘period of 1 calendar year from which 
such services are furnished; and’’; and 
(B) by adding at the end the following new 
sentence: ‘‘In applying paragraph (1), the Sec-
retary may specify exceptions to the 1 calendar 
year period specified in such paragraph.’’. 
(3) PARTS C AND D.—Section 1857(d) of such 
Act is amended by adding at the end the following 
new paragraph: 
‘‘(7) PERIOD FOR SUBMISSION OF CLAIMS.— 
The contract shall require an MA organization or 
PDP sponsor to require any provider of services 
under contract with, in partnership with, or affili-
ated with such organization or sponsor to ensure 
that, with respect to items and services furnished by 
such provider to an enrollee of such organization, 
written request, signed by such enrollee, except in 
cases in which the Secretary finds it impracticable 
for the enrollee to do so, is filed for payment for 
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such items and services in such form, in such man-
ner, and by such person or persons as the Secretary 
may by regulation prescribe, no later than the close 
of the 1 calendar year period after such items and 
services are furnished. In applying the previous sen-
tence, the Secretary may specify exceptions to the 1 
calendar year period specified.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
subsection (b) shall be effective for items and services fur-
nished on or after January 1, 2011. 
SEC. 1637. PHYSICIANS WHO ORDER DURABLE MEDICAL 
EQUIPMENT OR HOME HEALTH SERVICES RE-
QUIRED TO BE MEDICARE ENROLLED PHYSI-
CIANS OR ELIGIBLE PROFESSIONALS. 
(a) DME.—Section 1834(a)(11)(B) of the Social Se-
curity Act (42 U.S.C. 1395m(a)(11)(B)) is amended by 
striking ‘‘physician’’ and inserting ‘‘physician enrolled 
under section 1866(j) or an eligible professional under sec-
tion 1848(k)(3)(B)’’. 
(b) HOME HEALTH SERVICES.— 
(1) PART A.—Section 1814(a)(2) of such Act 
(42 U.S.C. 1395(a)(2)) is amended in the matter 
preceding subparagraph (A) by inserting ‘‘in the 
case of services described in subparagraph (C), a 
physician enrolled under section 1866(j) or an eligi-
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ble professional under section 1848(k)(3)(B),’’ be-
fore ‘‘or, in the case of services’’. 
(2) PART B.—Section 1835(a)(2) of such Act 
(42 U.S.C. 1395n(a)(2)) is amended in the matter 
preceding subparagraph (A) by inserting ‘‘, or in the 
case of services described in subparagraph (A), a 
physician enrolled under section 1866(j) or an eligi-
ble professional under section 1848(k)(3)(B),’’ after 
‘‘a physician’’. 
(c) DISCRETION TO EXPAND APPLICATION.—The 
Secretary may extend the requirement applied by the 
amendments made by subsections (a) and (b) to durable 
medical equipment and home health services (relating to 
requiring certifications and written orders to be made by 
enrolled physicians and health professions) to other cat-
egories of items or services under this title, including cov-
ered part D drugs as defined in section 1860D–2(e), if 
the Secretary determines that such application would help 
to reduce the risk of waste, fraud, and abuse with respect 
to such other categories under title XVIII of the Social 
Security Act. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply to written orders and certifications 
made on or after July 1, 2010. 
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SEC. 1638. REQUIREMENT FOR PHYSICIANS TO PROVIDE 
DOCUMENTATION ON REFERRALS TO PRO-
GRAMS AT HIGH RISK OF WASTE AND ABUSE. 
(a) PHYSICIANS AND OTHER SUPPLIERS.—Section 
1842(h) of the Social Security Act, as amended by section 
1635, is further amended by adding at the end the fol-
lowing new paragraph: 
‘‘(10) The Secretary may disenroll, for a period of 
not more than one year for each act, a physician or sup-
plier under section 1866(j) if such physician or supplier 
fails to maintain and, upon request of the Secretary, pro-
vide access to documentation relating to written orders or 
requests for payment for durable medical equipment, cer-
tifications for home health services, or referrals for other 
items or services written or ordered by such physician or 
supplier under this title, as specified by the Secretary.’’. 
(b) PROVIDERS OF SERVICES.—Section 1866(a)(1) 
of such Act (42 U.S.C. 1395cc), as amended by section 
1635, is further amended— 
(1) in subparagraph (V), by striking at the end 
‘‘and’’; 
(2) in subparagraph (W), by striking the period 
at the end and adding ‘‘; and’’; and 
(3) by adding at the end the following new sub-
paragraph: 
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‘‘(X) maintain and, upon request of the 
Secretary, provide access to documentation re-
lating to written orders or requests for payment 
for durable medical equipment, certifications for 
home health services, or referrals for other 
items or services written or ordered by the pro-
vider under this title, as specified by the Sec-
retary.’’. 
(c) OIG PERMISSIVE EXCLUSION AUTHORITY.—Sec-
tion 1128(b)(11) of the Social Security Act (42 U.S.C. 
1320a–7(b)(11)) is amended by inserting ‘‘, ordering, re-
ferring for furnishing, or certifying the need for’’ after 
‘‘furnishing’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply to orders, certifications, and refer-
rals made on or after January 1, 2010. 
SEC. 1639. FACE TO FACE ENCOUNTER WITH PATIENT RE-
QUIRED BEFORE PHYSICIANS MAY CERTIFY 
ELIGIBILITY FOR HOME HEALTH SERVICES 
OR DURABLE MEDICAL EQUIPMENT UNDER 
MEDICARE. 
(a) CONDITION OF PAYMENT FOR HOME HEALTH 
SERVICES.— 
(1) PART
A.—Section 1814(a)(2)(C) of such 
Act is amended— 
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(A) by striking ‘‘and such services’’ and in-
serting ‘‘such services’’; and 
(B) by inserting after ‘‘care of a physi-
cian’’ the following: ‘‘, and, in the case of a cer-
tification or recertification made by a physician 
after January 1, 2010, prior to making such 
certification the physician must document that 
the physician has had a face-to-face encounter 
(including through use of telehealth and other 
than with respect to encounters that are inci-
dent to services involved) with the individual 
during the 6-month period preceding such cer-
tification, or other reasonable timeframe as de-
termined by the Secretary’’. 
(2) PART B.—Section 1835(a)(2)(A) of the So-
cial Security Act is amended— 
(A) by striking ‘‘and’’ before ‘‘(iii)’’; and 
(B) by inserting after ‘‘care of a physi-
cian’’ the following: ‘‘, and (iv) in the case of 
a certification or recertification after January 
1, 2010, prior to making such certification the 
physician must document that the physician has 
had a face-to-face encounter (including through 
use of telehealth and other than with respect to 
encounters that are incident to services in-
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volved) with the individual during the 6-month 
period preceding such certification or recertifi-
cation, or other reasonable timeframe as deter-
mined by the Secretary’’. 
(b) CONDITION OF PAYMENT FOR DURABLE MED-
ICAL EQUIPMENT.—Section 1834(a)(11)(B) of the Social 
Security Act (42 U.S.C. 1395m(a)(11)(B)) is amended by 
adding at the end the following: ‘‘and shall require that 
such an order be written pursuant to the physician docu-
menting that the physician has had a face-to-face encoun-
ter (including through use of telehealth and other than 
with respect to encounters that are incident to services in-
volved) with the individual involved during the 6-month 
period preceding such written order, or other reasonable 
timeframe as determined by the Secretary’’. 
(c) APPLICATION TO OTHER AREAS UNDER MEDI-
CARE.—The Secretary may apply the face-to-face encoun-
ter requirement described in the amendments made by 
subsections (a) and (b) to other items and services for 
which payment is provided under title XVIII of the Social 
Security Act based upon a finding that such an decision 
would reduce the risk of waste, fraud, or abuse. 
(d) APPLICATION TO MEDICAID AND CHIP.—The re-
quirements pursuant to the amendments made by sub-
sections (a) and (b) shall apply in the case of physicians 
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making certifications for home health services under title 
XIX or XXI of the Social Security Act, in the same man-
ner and to the same extent as such requirements apply 
in the case of physicians making such certifications under 
title XVIII of such Act. 
SEC. 1640. EXTENSION OF TESTIMONIAL SUBPOENA AU-
THORITY TO PROGRAM EXCLUSION INVES-
TIGATIONS. 
(a) IN GENERAL.—Section 1128(f) of the Social Se-
curity Act (42 U.S.C. 1320a–7(f)) is amended by adding 
at the end the following new paragraph: 
‘‘(4) The provisions of subsections (d) and (e) of sec-
tion 205 shall apply with respect to this section to the 
same extent as they are applicable with respect to title 
II. The Secretary may delegate the authority granted by 
section 205(d) (as made applicable to this section) to the 
Inspector General of the Department of Health and 
Human Services or the Administrator of the Centers for 
Medicare & Medicaid Services for purposes of any inves-
tigation under this section.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply to investigations beginning on 
or after January 1, 2010. 
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SEC. 1641. REQUIRED REPAYMENTS OF MEDICARE AND 
MEDICAID OVERPAYMENTS. 
Section 1128G of the Social Security Act, as inserted 
by section 1631 and amended by section 1632, is further 
amended by adding at the end the following new sub-
section: 
‘‘(c) REPORTS ON AND REPAYMENT OF OVERPAY-
MENTS IDENTIFIED THROUGH INTERNAL AUDITS AND 
REVIEWS.— 
‘‘(1) REPORTING
AND
RETURNING
OVERPAY-
MENTS.—If a person knows of an overpayment, the 
person must— 
‘‘(A) report and return the overpayment to 
the Secretary, the State, an intermediary, a 
carrier, or a contractor, as appropriate, at the 
correct address, and 
‘‘(B) notify the Secretary, the State, inter-
mediary, carrier, or contractor to whom the 
overpayment was returned in writing of the rea-
son for the overpayment. 
‘‘(2) TIMING.—An overpayment must be re-
ported and returned under paragraph (1)(A) by not 
later than the date that is 60 days after the date the 
person knows of the overpayment. 
Any known overpayment retained later than the ap-
plicable date specified in this paragraph creates an 
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obligation as defined in section 3729(b)(3) of title 
31 of the United States Code. 
‘‘(3) CLARIFICATION.—Repayment of any over-
payments (or refunding by withholding of future 
payments) by a provider of services or supplier does 
not otherwise limit the provider or supplier’s poten-
tial liability for administrative obligations such as 
applicable interests, fines, and specialties or civil or 
criminal sanctions involving the same claim if it is 
determined later that the reason for the overpay-
ment was related to fraud by the provider or sup-
plier or the employees or agents of such provider or 
supplier. 
‘‘(4) DEFINITIONS.—In this subsection: 
‘‘(A) KNOWS.—The term ‘knows’ has the 
meaning given the terms ‘knowing’ and ‘know-
ingly’ in section 3729(b) of title 31 of the 
United States Code. 
‘‘(B) OVERPAYMENT.—The term ‘‘overpay-
ment’’ means any finally determined funds that 
a person receives or retains under title XVIII, 
XIX, or XXI to which the person, after applica-
ble reconciliation, is not entitled under such 
title. 
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‘‘(C) PERSON.—The term ‘person’ means a 
provider of services, supplier, Medicaid man-
aged care organization (as defined in section 
1903(m)(1)(A)), Medicare Advantage organiza-
tion (as defined in section 1859(a)(1)), or PDP 
sponsor 
(as 
defined 
in 
section 
1860D– 
41(a)(13)), but excluding a beneficiary.’’. 
SEC. 1642. EXPANDED APPLICATION OF HARDSHIP WAIV-
ERS 
FOR 
OIG 
EXCLUSIONS 
TO 
BENE-
FICIARIES OF ANY FEDERAL HEALTH CARE 
PROGRAM. 
Section 1128(c)(3)(B) of the Social Security Act (42 
U.S.C. 1320a–7(c)(3)(B)) is amended by striking ‘‘indi-
viduals entitled to benefits under part A of title XVIII 
or enrolled under part B of such title, or both’’ and insert-
ing ‘‘beneficiaries (as defined in section 1128A(i)(5)) of 
that program’’. 
SEC. 1643. ACCESS TO CERTAIN INFORMATION ON RENAL 
DIALYSIS FACILITIES. 
Section 1881(b) of the Social Security Act (42 U.S.C. 
1395rr(b)) is amended by adding at the end the following 
new paragraph: 
‘‘(15) For purposes of evaluating or auditing pay-
ments made to renal dialysis facilities for items and serv-
ices under this section under paragraph (1), each such 
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renal dialysis facility, upon the request of the Secretary, 
shall provide to the Secretary access to information relat-
ing to any ownership or compensation arrangement be-
tween such facility and the medical director of such facility 
or between such facility and any physician.’’. 
SEC. 1644. BILLING AGENTS, CLEARINGHOUSES, OR OTHER 
ALTERNATE PAYEES REQUIRED TO REG-
ISTER UNDER MEDICARE. 
(a) MEDICARE.—Section 1866(j)(1) of the Social Se-
curity Act (42 U.S.C. 1395cc(j)(1)) is amended by adding 
at the end the following new subparagraph: 
‘‘(D) BILLING
AGENTS
AND
CLEARING-
HOUSES
REQUIRED
TO
BE
REGISTER
UNDER 
MEDICARE.—Any agent, clearinghouse, or other 
alternate payee that submits claims on behalf of 
a health care provider must be registered with 
the Secretary in a form and manner specified 
by the Secretary.’’. 
(b) MEDICAID.—For a similar provision with respect 
to the Medicaid program under title XIX of the Social Se-
curity Act, see section 1759. 
(c) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply to claims submitted on or after 
January 1, 2012. 
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SEC. 1645. CONFORMING CIVIL MONETARY PENALTIES TO 
FALSE CLAIMS ACT AMENDMENTS. 
Section 1128A of the Social Security Act, as amended 
by sections 1611, 1612, 1613, and 1615, is further 
amended— 
(1) in subsection (a)— 
(A) in paragraph (1), by striking ‘‘to an 
officer, employee, or agent of the United States, 
or of any department or agency thereof, or of 
any State agency (as defined in subsection 
(i)(1))’’; 
(B) in paragraph (4)— 
(i) by striking ‘‘participating in a pro-
gram under title XVIII or a State health 
care program’’ and inserting ‘‘participating 
in a Federal health care program (as de-
fined in section 1128B(f))’’; and 
(ii) in subparagraph (A), by striking 
‘‘title XVIII or a State health care pro-
gram’’ and inserting ‘‘a Federal health 
care program (as defined in section 
1128B(f))’’; 
(C) by striking ‘‘or’’ at the end of para-
graph (10); 
(D) by inserting after paragraph (11) the 
following new paragraphs: 
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‘‘(12) conspires to commit a violation of this 
section; or 
‘‘(13) knowingly makes, uses, or causes to be 
made or used, a false record or statement material 
to an obligation to pay or transmit money or prop-
erty to a Federal health care program, or knowingly 
conceals or knowingly and improperly avoids or de-
creases an obligation to pay or transmit money or 
property to a Federal health care program;’’; and 
(E) in the matter following paragraph 
(13), as inserted by subparagraph (D), by strik-
ing ‘‘or in cases under paragraph (11), $50,000 
for each such violation’’ and inserting ‘‘in cases 
under paragraph (11), $50,000 for each such 
violation, in cases under paragraph (12), 
$50,000 for any violation described in this sec-
tion committed in furtherance of the conspiracy 
involved; or in cases under paragraph (13), 
$50,000 for each false record or statement, or 
concealment, avoidance, or decrease’’; and 
(F) in the second sentence, by striking 
‘‘such false statement or misrepresentation)’’ 
and inserting ‘‘such false statement or mis-
representation, in cases under paragraph (12), 
an assessment of not more than 3 times the 
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total amount that would otherwise apply for 
any violation described in this section com-
mitted in furtherance of the conspiracy in-
volved, or in cases under paragraph (13), an as-
sessment of not more than 3 times the total 
amount of the obligation to which the false 
record or statment was material or that was 
avoided or decreased)’’. 
(2) in subsection (c)(1), by striking ‘‘six years’’ 
and inserting ‘‘10 years’’; and 
(3) in subsection (i)— 
(A) by amending paragraph (2) to read as 
follows: 
‘‘(2) The term ‘‘claim’’ means any application, 
request, or demand, whether under contract, or oth-
erwise, for money or property for items and services 
under a Federal health care program (as defined in 
section 1128B(f)), whether or not the United States 
or a State agency has title to the money or property, 
that— 
‘‘(A) is presented or caused to be pre-
sented to an officer, employee, or agent of the 
United States, or of any department or agency 
thereof, or of any State agency (as defined in 
subsection (i)(1)); or 
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‘‘(B) is made to a contractor, grantee, or 
other recipient if the money or property is to be 
spent or used on the Federal health care pro-
gram’s behalf or to advance a Federal health 
care program interest, and if the Federal health 
care program— 
‘‘(i) provides or has provided any por-
tion of the money or property requested or 
demanded; or 
‘‘(ii) will reimburse such contractor, 
grantee, or other recipient for any portion 
of the money or property which is re-
quested or demanded.’’; 
(B) by amending paragraph (3) to read as 
follows: 
‘‘(3) The term ‘item or service’ means, without 
limitation, any medical, social, management, admin-
istrative, or other item or service used in connection 
with or directly or indirectly related to a Federal 
health care program.’’; 
(C) in paragraph (6)— 
(i) in subparagraph (C), by striking at 
the end ‘‘or’’; 
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(ii) in the first subparagraph (D), by 
striking at the end the period and inserting 
‘‘; or’’; and 
(iii) by redesignating the second sub-
paragraph (D) as a subparagraph (E); 
(D) by amending paragraph (7) to read as 
follows: 
‘‘(7) The terms ‘knowing’, ‘knowingly’, and 
‘should know’ mean that a person, with respect to 
information— 
‘‘(A) has actual knowledge of the informa-
tion; 
‘‘(B) acts in deliberate ignorance of the 
truth or falsity of the information; or 
‘‘(C) acts in reckless disregard of the truth 
or falsity of the information; 
and require no proof of specific intent to defraud.’’; 
and 
(E) by adding at the end the following new 
paragraphs: 
‘‘(8) The term ‘obligation’ means an established 
duty, whether or not fixed, arising from an express 
or implied contractual, grantor-grantee, or licensor- 
licensee relationship, from a fee-based or similar re-
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lationship, from statute or regulation, or from the 
retention of any overpayment. 
‘‘(9) The term ‘material’ means having a nat-
ural tendency to influence, or be capable of influ-
encing, the payment or receipt of money or prop-
erty.’’. 
Subtitle D—Access to Information 
Needed 
To 
Prevent 
Fraud, 
Waste, and Abuse 
SEC. 1651. ACCESS TO INFORMATION NECESSARY TO IDEN-
TIFY FRAUD, WASTE, AND ABUSE. 
Section 1128G of the Social Security Act, as added 
by section 1631 and amended by sections 1632 and 1641, 
is further amended by adding at the end the following new 
subsection; 
‘‘(d) ACCESS
TO
INFORMATION
NECESSARY
TO 
IDENTIFY FRAUD, WASTE, AND ABUSE.—For purposes of 
law enforcement activity, and to the extent consistent with 
applicable disclosure, privacy, and security laws, including 
the Health Insurance Portability and Accountability Act 
of 1996 and the Privacy Act of 1974, and subject to any 
information systems security requirements enacted by law 
or otherwise required by the Secretary, the Attorney Gen-
eral shall have access, facilitation by the Inspector General 
of the Department of Health and Human Services, to 
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claims and payment data relating to titles XVIII and XIX, 
in consultation with the Centers for Medicare & Medicaid 
Services or the owner of such data.’’. 
SEC. 1652. ELIMINATION OF DUPLICATION BETWEEN THE 
HEALTHCARE INTEGRITY AND PROTECTION 
DATA BANK AND THE NATIONAL PRACTI-
TIONER DATA BANK. 
(a) IN GENERAL.—To eliminate duplication between 
the Healthcare Integrity and Protection Data Bank 
(HIPDB) established under section 1128E of the Social 
Security Act and the National Practitioner Data Bank 
(NPBD) established under the Health Care Quality Im-
provement Act of 1986, section 1128E of the Social Secu-
rity Act (42 U.S.C. 1320a–7e) is amended— 
(1) in subsection (a), by striking ‘‘Not later 
than’’ and inserting ‘‘Subject to subsection (h), not 
later than’’; 
(2) in the first sentence of subsection (d)(2), by 
striking ‘‘(other than with respect to requests by 
Federal agencies)’’; and 
(3) by adding at the end the following new sub-
section: 
‘‘(h) SUNSET OF THE HEALTHCARE INTEGRITY AND 
PROTECTION DATA BANK; TRANSITION PROCESS.—Ef-
fective upon the enactment of this subsection, the Sec-
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retary shall implement a process to eliminate duplication 
between the Healthcare Integrity and Protection Data 
Bank (in this subsection referred to as the ‘HIPDB’ es-
tablished pursuant to subsection (a) and the National 
Practitioner Data Bank (in this subsection referred to as 
the ‘NPDB’) as implemented under the Health Care Qual-
ity Improvement Act of 1986 and section 1921 of this Act, 
including systems testing necessary to ensure that infor-
mation formerly collected in the HIPDB will be accessible 
through the NPDB, and other activities necessary to 
eliminate duplication between the two data banks. Upon 
the completion of such process, notwithstanding any other 
provision of law, the Secretary shall cease the operation 
of the HIPDB and shall collect information required to 
be reported under the preceding provisions of this section 
in the NPDB. Except as otherwise provided in this sub-
section, the provisions of subsections (a) through (g) shall 
continue to apply with respect to the reporting of (or fail-
ure to report), access to, and other treatment of the infor-
mation specified in this section.’’. 
(b) ELIMINATION OF THE RESPONSIBILITY OF THE 
HHS OFFICE OF THE INSPECTOR GENERAL.—Section 
1128C(a)(1) of the Social Security Act (42 U.S.C. 1320a– 
7c(a)(1)) is amended— 
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(1) in subparagraph (C), by adding at the end 
‘‘and’’; 
(2) in subparagraph (D), by striking at the end 
‘‘, and’’ and inserting a period; and 
(3) by striking subparagraph (E). 
(c) SPECIAL PROVISION FOR ACCESS TO THE NA-
TIONAL PRACTITIONER DATA BANK BY THE DEPART-
MENT OF VETERANS AFFAIRS.— 
(1) IN GENERAL.—Notwithstanding any other 
provision of law, during the one year period that be-
gins on the effective date specified in subsection 
(e)(1), the information described in paragraph (2) 
shall be available from the National Practitioner 
Data Bank (described in section 1921 of the Social 
Security Act) to the Secretary of Veterans Affairs 
without charge. 
(2) INFORMATION DESCRIBED.—For purposes 
of paragraph (1), the information described in this 
paragraph is the information that would, but for the 
amendments made by this section, have been avail-
able to the Secretary of Veterans Affairs from the 
Healthcare Integrity and Protection Data Bank. 
(d) FUNDING.—Notwithstanding any provisions of 
this Act, sections 1128E(d)(2) and 1817(k)(3) of the So-
cial Security Act, or any other provision of law, there shall 
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be available for carrying out the transition process under 
section 1128E(h) of the Social Security Act over the pe-
riod required to complete such process, and for operation 
of the National Practitioner Data Bank until such process 
is completed, without fiscal year limitation— 
(1) any fees collected pursuant to section 
1128E(d)(2) of such Act; and 
(2) such additional amounts as necessary, from 
appropriations available to the Secretary and to the 
Office of the Inspector General of the Department of 
Health and Human Services under clauses (i) and 
(ii), respectively, of section 1817(k)(3)(A) of such 
Act, for costs of such activities during the first 12 
months following the date of the enactment of this 
Act. 
(e) EFFECTIVE DATE.—The amendments made— 
(1) by subsection (a)(2) shall take effect on the 
first day after the Secretary of Health and Human 
Services certifies that the process implemented pur-
suant to section 1128E(h) of the Social Security Act 
(as added by subsection (a)(3)) is complete; and 
(2) by subsection (b) shall take effect on the 
earlier of the date specified in paragraph (1) or the 
first day of the second succeeding fiscal year after 
the fiscal year during which this Act is enacted. 
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SEC. 1653. COMPLIANCE WITH HIPAA PRIVACY AND SECU-
RITY STANDARDS. 
The provisions of sections 262(a) and 264 of the 
Health Insurance Portability and Accountability Act of 
1996 (and standards promulgated pursuant to such sec-
tions) and the Privacy Act of 1974 shall apply with respect 
to the provisions of this subtitle and amendments made 
by this subtitle. 
TITLE VII—MEDICAID AND CHIP 
Subtitle A—Medicaid and Health 
Reform 
SEC. 1701. ELIGIBILITY FOR INDIVIDUALS WITH INCOME 
BELOW 1331⁄3
PERCENT OF THE FEDERAL 
POVERTY LEVEL. 
(a) ELIGIBILITY
FOR NON-TRADITIONAL INDIVID-
UALS WITH INCOME BELOW 133 PERCENT OF THE FED-
ERAL POVERTY LEVEL.— 
(1) IN GENERAL.—Section 1902(a)(10)(A)(i) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396b(a)(10)(A)(i) is amended— 
(A) by striking ‘‘or’’ at the end of sub-
clause (VI); 
(B) by adding ‘‘or’’ at the end of subclause 
(VII); and 
(C) by adding at the end the following new 
subclause: 
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740 
‘‘(VIII) who are under 65 years 
of age, who are not described in a pre-
vious subclause of this clause, and 
who are in families whose income (de-
termined using methodologies and 
procedures specified by the Secretary 
in 
consultation 
with 
the 
Health 
Choices Commissioner) does not ex-
ceed 1331⁄3 percent of the income offi-
cial poverty line (as defined by the Of-
fice of Management and Budget, and 
revised annually in accordance with 
section 673(2) of the Omnibus Budget 
Reconciliation Act of 1981) applicable 
to a family of the size involved;’’. 
(2) 100% FMAP FOR NON-TRADITIONAL MED-
ICAID
ELIGIBLE
INDIVIDUALS.—Section 1905 of 
such Act (42 U.S.C. 1396d) is amended— 
(A) in the third sentence of subsection (b) 
by inserting before the period at the end the 
following: ‘‘and with respect to amounts de-
scribed in subsection (y)’’; and 
(B) by adding at the end the following new 
subsection: 
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741 
‘‘(y) ADDITIONAL
EXPENDITURES
SUBJECT
TO 
100% FMAP.—For purposes of section 1905(b), the 
amounts described in this subsection are the following: 
‘‘(1) Amounts expended for medical assistance 
for individuals described in subclause (VIII) of sec-
tion 1902(a)(10)(A)(i).’’. 
(3) CONSTRUCTION.—Nothing in this sub-
section shall be construed as not providing for cov-
erage 
under 
subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i) of the Social Security Act, as 
added by paragraph (1) of, and an increased FMAP 
under the amendment made by paragraph (2) for, 
an individual who has been provided medical assist-
ance under title XIX of the Act under a demonstra-
tion waiver approved under section 1115 of such Act 
or with State funds. 
(4) 
CONFORMING
AMENDMENT.—Section 
1903(f)(4) of the Social Security Act (42 U.S.C. 
1396b(f)(4)) 
is 
amended 
by 
inserting 
‘‘1902(a)(10)(A)(i)(VIII),’’ 
after 
‘‘1902(a)(10)(A)(i)(VII),’’. 
(b) ELIGIBILITY FOR TRADITIONAL MEDICAID ELI-
GIBLE INDIVIDUALS WITH INCOME NOT EXCEEDING 
1331⁄3 PERCENT OF THE FEDERAL POVERTY LEVEL.— 
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(1) IN GENERAL.—Section 1902(a)(10)(A)(i) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396b(a)(10)(A)(i)), as amended by subsection (a), 
is amended— 
(A) by striking ‘‘or’’ at the end of sub-
clause (VII); 
(B) by adding ‘‘or’’ at the end of subclause 
(VIII); and 
(C) by adding at the end the following new 
subclause: 
‘‘(IX) who are under 65 years of 
age, who would be eligible for medical 
assistance under the State plan under 
one of subclauses (I) through (VII) 
(based on the income standards, 
methodologies, and procedures in ef-
fect as of June 16, 2009) but for in-
come and who are in families whose 
income does not exceed 1331⁄3 percent 
of the income official poverty line (as 
defined by the Office of Management 
and Budget, and revised annually in 
accordance with section 673(2) of the 
Omnibus Budget Reconciliation Act of 
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1981) applicable to a family of the 
size involved;’’. 
(2) 100% FMAP
FOR
CERTAIN
TRADITIONAL 
MEDICAID ELIGIBLE INDIVIDUALS.—Section 1905(y) 
of such Act (42 U.S.C. 1396d(b)), as added by sub-
section (a)(2)(B), is amended by inserting ‘‘or (IX)’’ 
after ‘‘(VIII)’’. 
(3) CONSTRUCTION.—Nothing in this sub-
section shall be construed as not providing for cov-
erage 
under 
subclause 
(IX) 
of 
section 
1902(a)(10)(A)(i) of the Social Security Act, as 
added by paragraph (1) of, and an increased FMAP 
under the amendment made by paragraph (2) for, 
an individual who has been provided medical assist-
ance under title XIX of the Act under a demonstra-
tion waiver approved under section 1115 of such Act 
or with State funds. 
(4) 
CONFORMING
AMENDMENT.—Section 
1903(f)(4) of the Social Security Act (42 U.S.C. 
1396b(f)(4)), as amended by subsection (a)(4), is 
amended by inserting ‘‘1902(a)(10)(A)(i)(IX),’’ after 
‘‘1902(a)(10)(A)(i)(VIII),’’. 
(c) 100% MATCHING RATE FOR TEMPORARY COV-
ERAGE
OF CERTAIN NEWBORNS.—Section 1905(y) of 
such Act, as added by subsection (a)(2)(B), is amended— 
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744 
(1) in paragraph (1), by inserting before the pe-
riod at the end the following: ‘‘, and who is not pro-
vided medical assistance under section 1943(b)(2) of 
this title or section 205(d)(1)(B) of the America’s 
Affordable Health Choices Act of 2009’’; and 
(2) by adding at the end the following: 
‘‘(2) Amounts expended for medical assistance 
for children described in section 203(d)(1)(A) of the 
America’s Affordable Health Choices Act of 2009 
during the time period specified in such section.’’. 
(d) NETWORK ADEQUACY.—Section 1932(a)(2) of 
the Social Security Act (42 U.S.C. 1396u–2(a)(2)) is 
amended by adding at the end the following new subpara-
graph: 
‘‘(D) ENROLLMENT OF NON-TRADITIONAL 
MEDICAID
ELIGIBLES.—A State may not re-
quire under paragraph (1) the enrollment in a 
managed care entity of an individual described 
in section 1902(a)(10)(A)(i)(VIII) unless the 
State demonstrates, to the satisfaction of the 
Secretary, that the entity, through its provider 
network and other arrangements, has the ca-
pacity to meet the health, mental health, and 
substance abuse needs of such individuals.’’. 
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745 
(e) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on the first day of Y1, and 
shall apply with respect to items and services furnished 
on or after such date. 
SEC. 1702. REQUIREMENTS AND SPECIAL RULES FOR CER-
TAIN MEDICAID ELIGIBLE INDIVIDUALS. 
(a) IN GENERAL.—Title XIX of the Social Security 
Act is amended by adding at the end the following new 
section: 
‘‘REQUIREMENTS AND SPECIAL RULES FOR CERTAIN 
MEDICAID ELIGIBLE INDIVIDUALS 
‘‘SEC. 1943. (a) COORDINATION WITH NHI EX-
CHANGE
THROUGH
MEMORANDUM
OF
UNDER-
STANDING.— 
‘‘(1) IN GENERAL.—The State shall enter into 
a Medicaid memorandum of understanding described 
in section 204(e)(4) of the America’s Affordable 
Health Choices Act of 2009 with the Health Choices 
Commissioner, acting in consultation with the Sec-
retary, with respect to coordinating the implementa-
tion of the provisions of division A of such Act with 
the State plan under this title in order to ensure the 
enrollment of Medicaid eligible individuals in accept-
able coverage. Nothing in this section shall be con-
strued as permitting such memorandum to modify or 
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746 
vitiate any requirement of a State plan under this 
title. 
‘‘(2) ENROLLMENT
OF
EXCHANGE-REFERRED 
INDIVIDUALS.— 
‘‘(A) NON-TRADITIONAL
INDIVIDUALS.— 
Pursuant to such memorandum the State shall 
accept without further determination the enroll-
ment under this title of an individual deter-
mined by the Commissioner to be a non-tradi-
tional Medicaid eligible individual. The State 
shall not do any redeterminations of eligibility 
for such individuals unless the periodicity of 
such redeterminations is consistent with the pe-
riodicity for redeterminations by the Commis-
sioner of eligibility for affordability credits 
under subtitle C of title II of division A of the 
America’s Affordable Health Choices Act of 
2009, as specified under such memorandum. 
‘‘(B) TRADITIONAL INDIVIDUALS.— 
‘‘(i) 
REGULAR
ENROLLMENT
OP-
TION.—Pursuant to such memorandum, 
insofar as the memorandum has selected 
the 
option 
described 
in 
section 
205(e)(3)(A) of the America’s Affordable 
Health Choices Act of 2009, the State 
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shall accept without further determination 
the enrollment under this title of an indi-
vidual determined by the Commissioner to 
be a traditional Medicaid eligible indi-
vidual. The State may do redeterminations 
of eligibility of such individual consistent 
with such section and the memorandum. 
‘‘(ii) PRESUMPTIVE
ELIGIBILITY
OP-
TION.—Pursuant to such memorandum, 
insofar as the memorandum has selected 
the 
option 
described 
in 
section 
205(e)(3)(B) of the America’s Affordable 
Health Choices Act of 2009, the State 
shall provide for making medical assistance 
available during the presumptive eligibility 
period and shall, upon application of the 
individual for medical assistance under this 
title, promptly make a determination (and 
subsequent redeterminations) of eligibility 
in the same manner as if the individual 
had applied directly to the State for such 
assistance except that the State shall use 
the income-related information used by the 
Commissioner and provided to the State 
under the memorandum in making the pre-
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sumptive eligibility determination to the 
maximum extent feasible. 
‘‘(3) DETERMINATIONS
OF
ELIGIBILITY
FOR 
AFFORDABILITY CREDITS.—If the Commissioner de-
termines that a State Medicaid agency has the ca-
pacity to make determinations of eligibility for af-
fordability credits under subtitle C of title II of divi-
sion A of the America’s Affordable Health Choices 
Act of 2009, under such memorandum— 
‘‘(A) the State Medicaid agency shall con-
duct such determinations for any Exchange-eli-
gible individual who requests such a determina-
tion; 
‘‘(B) in the case that a State Medicaid 
agency determines that an Exchange-eligible in-
dividual is not eligible for affordability credits, 
the agency shall forward the information on the 
basis of which such determination was made to 
the Commissioner; and 
‘‘(C) the Commissioner shall reimburse the 
State Medicaid agency for the costs of con-
ducting such determinations. 
‘‘(b) TREATMENT OF CERTAIN NEWBORNS.— 
‘‘(1) IN GENERAL.—In the case of a child who 
is deemed under section 205(d)(1) of the America’s 
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Affordable Health Choices Act of 2009 to be a non- 
traditional Medicaid eligible individual and enrolled 
under this title pursuant to such section, the State 
shall provide for a determination, by not later than 
the end of the period referred to in subparagraph 
(A) of such section, of the child’s eligibility for med-
ical assistance under this title. 
‘‘(2) EXTENDED TREATMENT AS TRADITIONAL 
MEDICAID
ELIGIBLE
INDIVIDUAL.—In accordance 
with subparagraph (B) of section 205(d)(1) of the 
America’s Affordable Health Choices Act of 2009, in 
the case of a child described in subparagraph (A) of 
such section who at the end of the period referred 
to in such subparagraph is not otherwise covered 
under acceptable coverage, the child shall be deemed 
(until such time as the child obtains such coverage 
or the State otherwise makes a determination of the 
child’s eligibility for medical assistance under its 
plan under this title pursuant to paragraph (1)) to 
be a traditional Medicaid eligible individual de-
scribed in section 1902(l)(1)(B). 
‘‘(c) DEFINITIONS .—In this section: 
‘‘(1) MEDICAID
ELIGIBLE
INDIVIDUALS.—In 
this section, the terms ‘Medicaid eligible individual’, 
‘traditional Medicaid eligible individual’, and ‘non- 
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traditional Medicaid eligible individual’ have the 
meanings given such terms in section 205(e)(5) of 
the America’s Affordable Health Choices Act of 
2009. 
‘‘(2) MEMORANDUM.—The term ‘memorandum’ 
means a Medicaid memorandum of understanding 
under section 205(e)(4) of the America’s Affordable 
Health Choices Act of 2009. 
‘‘(3) Y1.—The term ‘Y1’ has the meaning given 
such term in section 100(c) of the America’s Afford-
able Health Choices Act of 2009.’’. 
(b) CONFORMING AMENDMENTS TO ERROR RATE.— 
(1) Section 1903(u)(1)(D) of the Social Secu-
rity Act (42 U.S.C. 1396b(u)(1)(D)) is amended by 
adding at the end the following new clause: 
‘‘(vi) In determining the amount of erroneous excess 
payments, there shall not be included any erroneous pay-
ments made that are attributable to an error in an eligi-
bility determination under subtitle C of title II of division 
A of the America’s Affordable Health Choices Act of 
2009.’’. 
(2) Section 2105(c)(11) of such Act (42 U.S.C. 
1397ee(c)(11)) is amended by adding at the end the 
following new sentence: ‘‘Clause (vi) of section 
1903(u)(1)(D) shall apply with respect to the appli-
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cation of such requirements under this title and title 
XIX.’’. 
SEC. 1703. CHIP AND MEDICAID MAINTENANCE OF EFFORT. 
(a) CHIP MAINTENANCE
OF
EFFORT.—Section 
1902 of the Social Security Act (42 U.S.C. 1396a) is 
amended— 
(1) in subsection (a), as amended by section 
1631(b)(1)(D)— 
(A) by striking ‘‘and’’ at the end of para-
graph (72); 
(B) by striking the period at the end of 
paragraph (73) and inserting ‘‘; and’’; and 
(C) by inserting after paragraph (74) the 
following new paragraph: 
‘‘(75) provide for maintenance of effort under 
the State child health plan under title XXI in ac-
cordance with subsection (gg).’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(gg) CHIP MAINTENANCE OF EFFORT REQUIRE-
MENT.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
as a condition of its State plan under this title under 
subsection (a)(75) and receipt of any Federal finan-
cial assistance under section 1903(a) for calendar 
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quarters beginning after the date of the enactment 
of this subsection and before CHIP MOE termi-
nation date specified in paragraph (3), a State shall 
not have in effect eligibility standards, methodolo-
gies, or procedures under its State child health plan 
under title XXI (including any waiver under such 
title or under section 1115 that is permitted to con-
tinue effect) that are more restrictive than the eligi-
bility standards, methodologies, or procedures, re-
spectively, under such plan (or waiver) as in effect 
on June 16, 2009. 
‘‘(2) LIMITATION.—Paragraph (1) shall not be 
construed as preventing a State from imposing a 
limitation described in section 2110(b)(5)(C)(i)(II) 
for a fiscal year in order to limit expenditures under 
its State child health plan under title XXI to those 
for which Federal financial participation is available 
under section 2105 for the fiscal year. 
‘‘(3) CHIP MOE TERMINATION DATE.—In para-
graph (1), the ‘CHIP MOE termination date’ for a 
State is the date that is the first day of Y1 (as de-
fined in section 100(c) of the America’s Affordable 
Health Choices Act of 2009) or, if later, the first 
day after such date that both of the following deter-
minations have been made: 
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‘‘(A) The Health Choices Commissioner 
has determined that the Health Insurance Ex-
change has the capacity to support the partici-
pation of CHIP enrollees who are Exchange-eli-
gible individuals (as defined in section 202(b) of 
the America’s Affordable Health Choices Act of 
2009), 
‘‘(B) The Secretary has determined that 
such Exchange, the State, and employers have 
procedures in effect to ensure the timely transi-
tion without interruption of coverage of CHIP 
enrollees from assistance under title XXI to ac-
ceptable coverage (as defined for purposes of 
such Act). 
In this paragraph, the term ‘CHIP enrollee’ means 
a targeted low-income child or (if the State has 
elected the option under section 2112, a targeted 
low-income pregnant woman) who is or otherwise 
would be (but for acceptable coverage) eligible for 
child health assistance or pregnancy-related assist-
ance, respectively, under the State child health plan 
referred to in paragraph (1).’’. 
(b) MEDICAID MAINTENANCE OF EFFORT; SIMPLI-
FYING
AND COORDINATING ELIGIBILITY RULES BE-
TWEEN EXCHANGE AND MEDICAID.— 
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(1) IN GENERAL.—Section 1903 of such Act 
(42 U.S.C. 1396b) is amended by adding at the end 
the following new subsection: 
‘‘(aa) MAINTENANCE OF MEDICAID EFFORT; SIMPLI-
FYING
AND COORDINATING ELIGIBILITY RULES BE-
TWEEN
HEALTH
INSURANCE
EXCHANGE
AND
MED-
ICAID.— 
‘‘(1) MAINTENANCE OF EFFORT.—A State is 
not eligible for payment under subsection (a) for a 
calendar quarter beginning after the date of the en-
actment of this subsection if eligibility standards, 
methodologies, or procedures under its plan under 
this title (including any waiver under this title or 
under section 1115 that is permitted to continue ef-
fect) that are more restrictive than the eligibility 
standards, methodologies, or procedures, respec-
tively, under such plan (or waiver) as in effect on 
June 16, 2009. The Secretary shall extend such a 
waiver (including the availability of Federal financial 
participation under such waiver) for such period as 
may be required for a State to meet the requirement 
of the previous sentence. 
‘‘(2) REMOVAL OF ASSET TEST FOR CERTAIN 
ELIGIBILITY CATEGORIES.— 
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‘‘(A) IN GENERAL.—A State is not eligible 
for payment under subsection (a) for a calendar 
quarter beginning on or after the first day of 
Y1 (as defined in section 100(c) of the Amer-
ica’s Affordable Health Choices Act of 2009), if 
the State applies any asset or resource test in 
determining (or redetermining) eligibility of any 
individual on or after such first day under any 
of the following: 
‘‘(i) Subclause (I), (III), (IV), or (VI) 
of section 1902(a)(10)(A)(i). 
‘‘(ii) Subclause (II), (IX), (XIV) or 
(XVII) of section 1902(a)(10)(A)(ii). 
‘‘(iii) Section 1931(b). 
‘‘(B) OVERRIDING CONTRARY PROVISIONS; 
REFERENCES.—The provisions of this title that 
prevent the waiver of an asset or resource test 
described in subparagraph (A) are hereby 
waived. 
‘‘(C) REFERENCES.—Any reference to a 
provision described in a provision in subpara-
graph (A) shall be deemed to be a reference to 
such provision as modified through the applica-
tion of subparagraphs (A) and (B).’’. 
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(2) CONFORMING AMENDMENTS.—(A) Section 
1902(a)(10)(A) 
of 
such 
Act 
(42 
U.S.C. 
1396a(a)(10)(A)) is amended, in the matter before 
clause 
(i), 
by 
inserting 
‘‘subject 
to 
section 
1903(aa)(2),’’ after ‘‘(A)’’. 
(B) Section 1931(b)(2) of such Act (42 U.S.C. 
1396u–1(b)(1)) is amended by inserting ‘‘subject to 
section 1903(aa)(2)’’ after ‘‘and (3)’’. 
(c) STANDARDS FOR BENCHMARK PACKAGES.—Sec-
tion 1937(b) of such Act (42 U.S.C. 1396u–7(b)) is 
amended— 
(1) in paragraph (1), by inserting ‘‘subject to 
paragraph (5)’’; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(5) MINIMUM STANDARDS.—Effective January 
1, 2013, any benchmark benefit package (or bench-
mark equivalent coverage under paragraph (2)) 
must meet the minimum benefits and cost-sharing 
standards of a basic plan offered through the Health 
Insurance Exchange.’’. 
SEC. 1704. REDUCTION IN MEDICAID DSH. 
(a) REPORT.— 
(1) IN GENERAL.—Not later than January 1, 
2016, the Secretary of Health and Human Services 
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(in this title referred to as the ‘‘Secretary’’) shall 
submit to Congress a report concerning the extent to 
which, based upon the impact of the health care re-
forms carried out under division A in reducing the 
number of uninsured individuals, there is a contin-
ued role for Medicaid DSH. In preparing the report, 
the Secretary shall consult with community-based 
health care networks serving low-income bene-
ficiaries. 
(2) MATTERS TO BE INCLUDED.—The report 
shall include the following: 
(A) 
RECOMMENDATIONS.—Recommenda-
tions regarding— 
(i) the appropriate targeting of Med-
icaid DSH within States; and 
(ii) the distribution of Medicaid DSH 
among the States. 
(B) SPECIFICATION OF DSH HEALTH RE-
FORM METHODOLOGY.—The DSH Health Re-
form methodology described in paragraph (2) of 
subsection (b) for purposes of implementing the 
requirements of such subsection. 
(3) COORDINATION WITH MEDICARE DSH RE-
PORT.—The Secretary shall coordinate the report 
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under this subsection with the report on Medicare 
DSH under section 1112. 
(4) MEDICAID DSH.—In this section, the term 
‘‘Medicaid DSH’’ means adjustments in payments 
under section 1923 of the Social Security Act for in-
patient hospital services furnished by dispropor-
tionate share hospitals. 
(b) MEDICAID DSH REDUCTIONS.— 
(1) IN GENERAL.—The Secretary shall reduce 
Medicaid DSH so as to reduce total Federal pay-
ments 
to 
all 
States 
for 
such 
purpose 
by 
$1,500,000,000 in fiscal year 2017, $2,500,000,000 
in fiscal year 2018, and $6,000,000,000 in fiscal 
year 2019. 
(2) DSH HEALTH REFORM METHODOLOGY.— 
The Secretary shall carry out paragraph (1) through 
use of a DSH Health Reform methodology issued by 
the Secretary that imposes the largest percentage re-
ductions on the States that— 
(A) have the lowest percentages of unin-
sured individuals (determined on the basis of 
audited hospital cost reports) during the most 
recent year for which such data are available; 
or 
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(B) do not target their DSH payments 
on— 
(i) hospitals with high volumes of 
Medicaid inpatients (as defined in section 
1923(b)(1)(A) of the Social Security Act 
(42 U.S.C. 1396r–4(b)(1)(A)); and 
(ii) hospitals that have high levels of 
uncompensated care (excluding bad debt). 
(3) DSH ALLOTMENT PUBLICATIONS.— 
(A) IN GENERAL.—Not later than the pub-
lication deadline specified in subparagraph (B), 
the Secretary shall publish in the Federal Reg-
ister a notice specifying the DSH allotment to 
each State under 1923(f) of the Social Security 
Act for the respective fiscal year specified in 
such subparagraph, consistent with the applica-
tion of the DSH Health Reform methodology 
described in paragraph (2). 
(B) PUBLICATAION DEADLINE.—The pub-
lication deadline specified in this subparagraph 
is— 
(i) January 1, 2016, with respect to 
DSH allotments described in subparagraph 
(A) for fiscal year 2017; 
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(ii) January 1, 2017, with respect to 
DSH allotments described in subparagraph 
(A) for fiscal year 2018; and 
(iii) January 1, 2018, with respect to 
DSH allotments described in subparagraph 
(A) for fiscal year 2019. 
(c) CONFORMING AMENDMENTS.— 
(1) Section 1923(f) of the Social Security Act 
(42 U.S.C. 1396r–4(f)) is amended— 
(A) by redesignating paragraph (7) as 
paragraph (8); and 
(B) by inserting after paragraph (6) the 
following new paragraph: 
‘‘(7) SPECIAL RULE FOR FISCAL YEARS 2017, 
2018, AND 2019.— 
‘‘(A) FISCAL YEAR 2017.—Notwithstanding 
paragraph (2), the total DSH allotments for all 
States for— 
‘‘(i) fiscal year 2017, shall be the total 
DSH allotments that would otherwise be 
determined under this subsection for such 
fiscal year decreased by $1,500,000,000; 
‘‘(ii) fiscal year 2018, shall be the 
total DSH allotments that would otherwise 
be determined under this subsection for 
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such 
fiscal 
year 
decreased 
by 
$2,500,000,000; and 
‘‘(iii) fiscal year 2019, shall be the 
total DSH allotments that would otherwise 
be determined under this subsection for 
such 
fiscal 
year 
decreased 
by 
$6,000,000,000.’’. 
(2) Section 1923(b)(4) of such Act (42 U.S.C. 
1396r–4(b)(4)) is amended by adding before the pe-
riod the following: ‘‘or to affect the authority of the 
Secretary to issue and implement the DSH Health 
Reform methodology under section 1704(b)(2) of the 
America’s Health Choices Act of 2009’’. 
(d) DISPROPORTIONATE SHARE HOSPITALS (DSH) 
AND ESSENTIAL ACCESS HOSPITAL (EAH) NON-DIS-
CRIMINATION.— 
(1) IN GENERAL.—Section 1923(d) of the So-
cial Security Act (42 U.S.C. 1396r-4) is amended by 
adding at the end the following new paragraph: 
‘‘(4) No hospital may be defined or deemed as 
a disproportionate share hospital, or as an essential 
access 
hospital 
(for 
purposes 
of 
subsection 
(f)(6)(A)(iv), under a State plan under this title or 
subsection (b) of this section (including any waiver 
under section 1115) unless the hospital— 
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‘‘(A) provides services to beneficiaries 
under this title without discrimination on the 
ground of race, color, national origin, creed, 
source of payment, status as a beneficiary 
under this title, or any other ground unrelated 
to such beneficiary’s need for the services or the 
availability of the needed services in the hos-
pital; and 
‘‘(B) makes arrangements for, and accepts, 
reimbursement under this title for services pro-
vided to eligible beneficiaries under this title.’’. 
(2) EFFECTIVE DATE.—The amendment made 
by subsection (a) shall be apply to expenditures 
made on or after July 1, 2010. 
SEC. 1705. EXPANDED OUTSTATIONING. 
(a) IN GENERAL.—Section 1902(a)(55) of the Social 
Security Act (42 U.S.C. 1396a(a)(55)) is amended by 
striking 
‘‘under 
subsection 
(a)(10)(A)(i)(IV), 
(a)(10)(A)(i)(VI), 
(a)(10)(A)(i)(VII), 
or 
(a)(10)(A)(ii)(IX)’’ and inserting ‘‘(including receipt and 
processing of applications of individuals for affordability 
credits under subtitle C of title II of division A of the 
America’s Affordable Health Choices Act of 2009 pursu-
ant to a Medicaid memorandum of understanding under 
section 1943(a)(1))’’. 
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(b) EFFECTIVE DATE.— 
(1) Except as provided in paragraph (2), the 
amendment made by subsection (a) shall apply to 
services furnished on or after July 1, 2010, without 
regard to whether or not final regulations to carry 
out such amendment have been promulgated by such 
date. 
(2) In the case of a State plan for medical as-
sistance under title XIX of the Social Security Act 
which the Secretary of Health and Human Services 
determines requires State legislation (other than leg-
islation appropriating funds) in order for the plan to 
meet the additional requirement imposed by the 
amendment made by this section, the State plan 
shall not be regarded as failing to comply with the 
requirements of such title solely on the basis of its 
failure to meet this additional requirement before 
the first day of the first calendar quarter beginning 
after the close of the first regular session of the 
State legislature that begins after the date of the en-
actment of this Act. For purposes of the previous 
sentence, in the case of a State that has a 2-year 
legislative session, each year of such session shall be 
deemed to be a separate regular session of the State 
legislature. 
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Subtitle B—Prevention 
SEC. 1711. REQUIRED COVERAGE OF PREVENTIVE SERV-
ICES. 
(a) COVERAGE.—Section 1905 of the Social Security 
Act (42 U.S.C. 1396d), as amended by section 
1701(a)(2)(B), is amended— 
(1) in subsection (a)(4)— 
(A) by striking ‘‘and’’ before ‘‘(C)’’; and 
(B) by inserting before the semicolon at 
the end the following: ‘‘and (D) preventive serv-
ices described in subsection (z)’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(z) PREVENTIVE SERVICES.—The preventive serv-
ices described in this subsection are services not otherwise 
described in subsection (a) or (r) that the Secretary deter-
mines are— 
‘‘(1)(A) recommended with a grade of A or B 
by the Task Force for Clinical Preventive Services; 
or 
‘‘(B) vaccines recommended for use as appro-
priate by the Director of the Centers for Disease 
Control and Prevention; and 
‘‘(2) appropriate for individuals entitled to med-
ical assistance under this title.’’. 
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(b) CONFORMING AMENDMENT.—Section 1928 of 
such Act (42 U.S.C. 1396s) is amended— 
(1) in subsection (c)(2)(B)(i), by striking ‘‘the 
advisory committee referred to in subsection (e)’’ 
and inserting ‘‘the Director of the Centers for Dis-
ease Control and Prevention’’; 
(2) in subsection (e), by striking ‘‘Advisory 
Committee’’ and all that follows and inserting ‘‘Di-
rector of the Centers for Disease Control and Pre-
vention.’’; and 
(3) by striking subsection (g). 
(c) EFFECTIVE DATE.— 
(1) Except as provided in paragraph (2), the 
amendments made by this section shall apply to 
services furnished on or after July 1, 2010, without 
regard to whether or not final regulations to carry 
out such amendments have been promulgated by 
such date. 
(2) In the case of a State plan for medical as-
sistance under title XIX of the Social Security Act 
which the Secretary of Health and Human Services 
determines requires State legislation (other than leg-
islation appropriating funds) in order for the plan to 
meet the additional requirements imposed by the 
amendments made by this section, the State plan 
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(A) by striking ‘‘and (XIV)’’ and inserting 
‘‘(XIV)’’; and 
(B) by inserting ‘‘, and (XV) the medical 
assistance made available to an individual de-
scribed in subsection (hh) shall be limited to 
family planning services and supplies described 
in section 1905(a)(4)(C) including medical di-
agnosis and treatment services that are pro-
vided pursuant to a family planning service in 
a family planning setting’’ after ‘‘cervical can-
cer’’. 
(4) 
CONFORMING
AMENDMENTS.—Section 
1905(a) of such Act (42 U.S.C. 1396d(a)), as 
amended by section 1731(c), is amended in the mat-
ter preceding paragraph (1)— 
(A) in clause (xiii), by striking ‘‘or’’ at the 
end; 
(B) in clause (xiv), by adding ‘‘or’’ at the 
end; and 
(C) by inserting after clause (xiv) the fol-
lowing: 
‘‘(xv) individuals described in section 
1902(hh),’’. 
(b) PRESUMPTIVE ELIGIBILITY.— 
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