657 
AMDT. NO. 98 
The Secretary may provide for the use of alter-
native means for meeting the requirements of 
clauses (i), (ii), and (iii) in the case of an eligi-
ble professional furnishing covered professional 
services in a group practice (as defined by the 
Secretary). The Secretary shall seek to improve 
the use of electronic health records and health 
care quality over time by requiring more strin-
gent measures of meaningful use selected under 
this paragraph. 
‘‘(B) REPORTING ON MEASURES.— 
‘‘(i) SELECTION.—The Secretary shall 
select measures for purposes of subpara-
graph (A)(iii) but only consistent with the 
following: 
‘‘(I) The Secretary shall provide 
preference to clinical quality measures 
that have been endorsed by the entity 
with a contract with the Secretary 
under section 1890(a). 
‘‘(II) Prior to any measure being 
selected under this subparagraph, the 
Secretary shall publish in the Federal 
Register such measure and provide for 
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AMDT. NO. 98 
a period of public comment on such 
measure. 
‘‘(ii) 
LIMITATION.—The 
Secretary 
may not require the electronic reporting of 
information on clinical quality measures 
under subparagraph (A)(iii) unless the 
Secretary has the capacity to accept the in-
formation electronically, which may be on 
a pilot basis. 
‘‘(iii) COORDINATION OF REPORTING 
OF
INFORMATION.—In 
selecting 
such 
measures, and in establishing the form and 
manner for reporting measures under sub-
paragraph (A)(iii), the Secretary shall seek 
to avoid redundant or duplicative reporting 
otherwise required, including reporting 
under subsection (k)(2)(C). 
‘‘(C) DEMONSTRATION
OF
MEANINGFUL 
USE OF CERTIFIED EHR TECHNOLOGY AND IN-
FORMATION EXCHANGE.— 
‘‘(i) IN
GENERAL.—A professional 
may satisfy the demonstration requirement 
of clauses (i) and (ii) of subparagraph (A) 
through means specified by the Secretary, 
which may include— 
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AMDT. NO. 98 
‘‘(I) an attestation; 
‘‘(II) the submission of claims 
with appropriate coding (such as a 
code indicating that a patient encoun-
ter was documented using certified 
EHR technology); 
‘‘(III) a survey response; 
‘‘(IV) reporting under subpara-
graph (A)(iii); and 
‘‘(V) other means specified by the 
Secretary. 
‘‘(ii) USE
OF
PART
D
DATA.—Not-
withstanding sections 1860D–15(d)(2)(B) 
and 1860D–15(f)(2), the Secretary may 
use data regarding drug claims submitted 
for purposes of section 1860D–15 that are 
necessary for purposes of subparagraph 
(A). 
‘‘(3) APPLICATION.— 
‘‘(A) 
PHYSICIAN
REPORTING
SYSTEM 
RULES.—Paragraphs (5), (6), and (8) of sub-
section (k) shall apply for purposes of this sub-
section in the same manner as they apply for 
purposes of such subsection. 
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AMDT. NO. 98 
‘‘(B) COORDINATION
WITH
OTHER
PAY-
MENTS.—The provisions of this subsection shall 
not be taken into account in applying the provi-
sions of subsection (m) of this section and of 
section 1833(m) and any payment under such 
provisions shall not be taken into account in 
computing allowable charges under this sub-
section. 
‘‘(C) LIMITATIONS
ON
REVIEW.—There 
shall be no administrative or judicial review 
under section 1869, section 1878, or otherwise 
of the determination of any incentive payment 
under this subsection and the payment adjust-
ment under subsection (a)(7), including the de-
termination of a meaningful EHR user under 
paragraph (2), a limitation under paragraph 
(1)(B), and the exception under subsection 
(a)(7)(B). 
‘‘(D) POSTING
ON
WEBSITE.—The Sec-
retary shall post on the Internet website of the 
Centers for Medicare & Medicaid Services, in an 
easily understandable format, a list of the 
names, business addresses, and business phone 
numbers of the eligible professionals who are 
meaningful EHR users and, as determined ap-
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AMDT. NO. 98 
propriate by the Secretary, of group practices 
receiving incentive payments under paragraph 
(1). 
‘‘(4) CERTIFIED EHR TECHNOLOGY DEFINED.— 
For purposes of this section, the term ‘certified 
EHR technology’ means a qualified electronic health 
record (as defined in 3000(13) of the Public Health 
Service Act) that is certified pursuant to section 
3001(c)(5) of such Act as meeting standards adopt-
ed under section 3004 of such Act that are applica-
ble to the type of record involved (as determined by 
the Secretary, such as an ambulatory electronic 
health record for office-based physicians or an inpa-
tient hospital electronic health record for hospitals). 
‘‘(5) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) 
COVERED
PROFESSIONAL
SERV-
ICES.—The term ‘covered professional services’ 
has the meaning given such term in subsection 
(k)(3). 
‘‘(B) ELIGIBLE PROFESSIONAL.—The term 
‘eligible professional’ means a physician, as de-
fined in section 1861(r). 
‘‘(C) REPORTING PERIOD.—The term ‘re-
porting period’ means any period (or periods), 
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AMDT. NO. 98 
with respect to a payment year, as specified by 
the Secretary.’’. 
(b) INCENTIVE PAYMENT ADJUSTMENT.—Section 
1848(a) of the Social Security Act (42 U.S.C. 1395w– 
4(a)) is amended by adding at the end the following new 
paragraph: 
‘‘(7) INCENTIVES
FOR
MEANINGFUL
USE
OF 
CERTIFIED EHR TECHNOLOGY.— 
‘‘(A) ADJUSTMENT.— 
‘‘(i) IN
GENERAL.—Subject to sub-
paragraphs (B) and (D), with respect to 
covered professional services furnished by 
an eligible professional during 2015 or any 
subsequent payment year, if the eligible 
professional is not a meaningful EHR user 
(as determined under subsection (o)(2)) for 
a reporting period for the year, the fee 
schedule amount for such services fur-
nished by such professional during the year 
(including the fee schedule amount for pur-
poses of determining a payment based on 
such amount) shall be equal to the applica-
ble percent of the fee schedule amount that 
would otherwise apply to such services 
under this subsection (determined after ap-
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AMDT. NO. 98 
plication of paragraph (3) but without re-
gard to this paragraph). 
‘‘(ii) APPLICABLE PERCENT.—Subject 
to clause (iii), for purposes of clause (i), 
the term ‘applicable percent’ means— 
‘‘(I) for 2015, 99 percent (or, in 
the case of an eligible professional 
who was subject to the application of 
the payment adjustment under section 
1848(a)(5) for 2014, 98 percent); 
‘‘(II) for 2016, 98 percent; and 
‘‘(III) for 2017 and each subse-
quent year, 97 percent. 
‘‘(iii) AUTHORITY TO DECREASE AP-
PLICABLE
PERCENTAGE
FOR
2018
AND 
SUBSEQUENT YEARS.—For 2018 and each 
subsequent year, if the Secretary finds that 
the proportion of eligible professionals who 
are meaningful EHR users (as determined 
under subsection (o)(2)) is less than 75 
percent, the applicable percent shall be de-
creased by 1 percentage point from the ap-
plicable percent in the preceding year, but 
in no case shall the applicable percent be 
less than 95 percent. 
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AMDT. NO. 98 
‘‘(B) 
SIGNIFICANT
HARDSHIP
EXCEP-
TION.—The Secretary may, on a case-by-case 
basis, exempt an eligible professional from the 
application of the payment adjustment under 
subparagraph (A) if the Secretary determines, 
subject to annual renewal, that compliance with 
the requirement for being a meaningful EHR 
user would result in a significant hardship, such 
as in the case of an eligible professional who 
practices in a rural area without sufficient 
Internet access. In no case may an eligible pro-
fessional be granted an exemption under this 
subparagraph for more than 5 years. 
‘‘(C) APPLICATION OF PHYSICIAN REPORT-
ING SYSTEM RULES.—Paragraphs (5), (6), and 
(8) of subsection (k) shall apply for purposes of 
this paragraph in the same manner as they 
apply for purposes of such subsection. 
‘‘(D) NON-APPLICATION
TO
HOSPITAL- 
BASED
ELIGIBLE
PROFESSIONALS.—No pay-
ment adjustment may be made under subpara-
graph (A) in the case of hospital-based eligible 
professionals 
(as 
defined 
in 
subsection 
(o)(1)(C)(ii)). 
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AMDT. NO. 98 
‘‘(E) DEFINITIONS.—For purposes of this 
paragraph: 
‘‘(i) COVERED
PROFESSIONAL
SERV-
ICES.—The 
term 
‘covered 
professional 
services’ has the meaning given such term 
in subsection (k)(3). 
‘‘(ii) ELIGIBLE PROFESSIONAL.—The 
term ‘eligible professional’ means a physi-
cian, as defined in section 1861(r). 
‘‘(iii) REPORTING PERIOD.—The term 
‘reporting period’ means, with respect to a 
year, a period specified by the Secretary.’’. 
(c) APPLICATION TO CERTAIN MA-AFFILIATED ELI-
GIBLE PROFESSIONALS.—Section 1853 of the Social Secu-
rity Act (42 U.S.C. 1395w–23) is amended by adding at 
the end the following new subsection: 
‘‘(l) APPLICATION OF ELIGIBLE PROFESSIONAL IN-
CENTIVES FOR CERTAIN MA ORGANIZATIONS FOR ADOP-
TION AND MEANINGFUL USE OF CERTIFIED EHR TECH-
NOLOGY.— 
‘‘(1) IN GENERAL.—Subject to paragraphs (3) 
and (4), in the case of a qualifying MA organization, 
the provisions of sections 1848(o) and 1848(a)(7) 
shall apply with respect to eligible professionals de-
scribed in paragraph (2) of the organization who the 
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AMDT. NO. 98 
organization attests under paragraph (6) to be 
meaningful EHR users in a similar manner as they 
apply to eligible professionals under such sections. 
Incentive payments under paragraph (3) shall be 
made to and payment adjustments under paragraph 
(4) shall apply to such qualifying organizations. 
‘‘(2) ELIGIBLE
PROFESSIONAL
DESCRIBED.— 
With respect to a qualifying MA organization, an eli-
gible professional described in this paragraph is an 
eligible professional (as defined for purposes of sec-
tion 1848(o)) who— 
‘‘(A)(i) is employed by the organization; or 
‘‘(ii)(I) is employed by, or is a partner of, 
an entity that through contract with the organi-
zation furnishes at least 80 percent of the enti-
ty’s patient care services to enrollees of such or-
ganization; and 
‘‘(II) furnishes at least 75 percent of the 
professional services of the eligible professional 
to enrollees of the organization; and 
‘‘(B) furnishes, on average, at least 20 
hours per week of patient care services. 
‘‘(3) ELIGIBLE PROFESSIONAL INCENTIVE PAY-
MENTS.— 
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AMDT. NO. 98 
‘‘(A) IN
GENERAL.—In applying section 
1848(o) under paragraph (1), instead of the ad-
ditional 
payment 
amount 
under 
section 
1848(o)(1)(A) and subject to subparagraph 
(B), the Secretary may substitute an amount 
determined by the Secretary to the extent fea-
sible and practical to be similar to the esti-
mated amount in the aggregate that would be 
payable if payment for services furnished by 
such professionals was payable under part B in-
stead of this part. 
‘‘(B) AVOIDING
DUPLICATION
OF
PAY-
MENTS.— 
‘‘(i) IN GENERAL.—If an eligible pro-
fessional described in paragraph (2) is eli-
gible for the maximum incentive payment 
under section 1848(o)(1)(A) for the same 
payment period, the payment incentive 
shall be made only under such section and 
not under this subsection. 
‘‘(ii) METHODS.—In the case of an el-
igible professional described in paragraph 
(2) who is eligible for an incentive payment 
under section 1848(o)(1)(A) but is not de-
scribed in clause (i) for the same payment 
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AMDT. NO. 98 
period, the Secretary shall develop a proc-
ess— 
‘‘(I) to ensure that duplicate pay-
ments are not made with respect to 
an eligible professional both under 
this subsection and under section 
1848(o)(1)(A); and 
‘‘(II) to collect data from Medi-
care Advantage organizations to en-
sure against such duplicate payments. 
‘‘(C) FIXED SCHEDULE FOR APPLICATION 
OF LIMITATION ON INCENTIVE PAYMENTS FOR 
ALL
ELIGIBLE
PROFESSIONALS.—In applying 
section 1848(o)(1)(B)(ii) under subparagraph 
(A), in accordance with rules specified by the 
Secretary, a qualifying MA organization shall 
specify a year (not earlier than 2011) that shall 
be treated as the first payment year for all eli-
gible professionals with respect to such organi-
zation. 
‘‘(D) CAP FOR ECONOMIES OF SCALE.—In 
no case may an incentive payment be made 
under this subsection, including under subpara-
graph (A), to a qualifying MA organization with 
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AMDT. NO. 98 
part, that are attributable to expenditures 
for physicians’ services. 
‘‘(C) APPLICATION OF PAYMENT ADJUST-
MENT.—In the case that a qualifying MA orga-
nization attests that not all eligible profes-
sionals of the organization are meaningful EHR 
users with respect to a year, the Secretary shall 
apply the payment adjustment under this para-
graph based on the proportion of all eligible 
professionals of the organization that are not 
meaningful EHR users for such year. If the 
number of eligible professionals of the organiza-
tion that are not meaningful EHR users for 
such year exceeds 5,000, such number shall be 
reduced to 5,000 for purposes of determining 
the proportion under the preceding sentence. 
‘‘(5) 
QUALIFYING
MA
ORGANIZATION
DE-
FINED.—In this subsection and subsection (m), the 
term ‘qualifying MA organization’ means a Medicare 
Advantage organization that is organized as a health 
maintenance organization (as defined in section 
2791(b)(3) of the Public Health Service Act). 
‘‘(6) MEANINGFUL EHR USER ATTESTATION.— 
For purposes of this subsection and subsection (m), 
a qualifying MA organization shall submit an attes-
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AMDT. NO. 98 
tation, in a form and manner specified by the Sec-
retary which may include the submission of such at-
testation as part of submission of the initial bid 
under section 1854(a)(1)(A)(iv), identifying— 
‘‘(A) whether each eligible professional de-
scribed in paragraph (2), with respect to such 
organization is a meaningful EHR user (as de-
fined in section 1848(o)(2)) for a year specified 
by the Secretary; and 
‘‘(B) whether each eligible hospital de-
scribed in subsection (m)(1), with respect to 
such organization, is a meaningful EHR user 
(as defined in section 1886(n)(3)) for an appli-
cable period specified by the Secretary. 
‘‘(7) POSTING
ON
WEBSITE.—The Secretary 
shall post on the Internet website of the Centers for 
Medicare & Medicaid Services, in an easily under-
standable format, a list of the names, business ad-
dresses, and business phone numbers of— 
‘‘(A) each qualifying MA organization re-
ceiving an incentive payment under this sub-
section for eligible professionals of the organiza-
tion; and 
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AMDT. NO. 98 
‘‘(B) the eligible professionals of such or-
ganization for which such incentive payment is 
based.’’. 
(d) CONFORMING AMENDMENTS.—Section 1853 of 
the Social Security Act (42 U.S.C. 1395w–23) is amend-
ed— 
(1) in subsection (a)(1)(A), by striking ‘‘and 
(i)’’ and inserting ‘‘(i), and (l)’’; 
(2) in subsection (c)— 
(A) in paragraph (1)(D)(i), by striking 
‘‘section 1886(h)’’ and inserting ‘‘sections 
1848(o) and 1886(h)’’; and 
(B) in paragraph (6)(A), by inserting after 
‘‘under part B,’’ the following: ‘‘excluding ex-
penditures attributable to subsections (a)(7) 
and (o) of section 1848,’’; and 
(3) in subsection (f), by inserting ‘‘and for pay-
ments under subsection (l)’’ after ‘‘with the organi-
zation’’. 
(e) 
CONFORMING
AMENDMENTS
TO
E-PRE-
SCRIBING.— 
(1) Section 1848(a)(5)(A) of the Social Security 
Act (42 U.S.C. 1395w–4(a)(5)(A)) is amended— 
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AMDT. NO. 98 
(A) in clause (i), by striking ‘‘or any sub-
sequent year’’ and inserting ‘‘, 2013, or 2014’’; 
and 
(B) in clause (ii), by striking ‘‘and each 
subsequent year’’. 
(2) Section 1848(m)(2) of such Act (42 U.S.C. 
1395w–4(m)(2)) is amended— 
(A) in subparagraph (A), by striking ‘‘For 
2009’’ and inserting ‘‘Subject to subparagraph 
(D), for 2009’’; and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(D) LIMITATION WITH RESPECT TO EHR 
INCENTIVE PAYMENTS.—The provisions of this 
paragraph shall not apply to an eligible profes-
sional (or, in the case of a group practice under 
paragraph (3)(C), to the group practice) if, for 
the reporting period the eligible professional (or 
group practice) receives an incentive payment 
under subsection (o)(1)(A) with respect to a 
certified EHR technology (as defined in sub-
section (o)(4)) that has the capability of elec-
tronic prescribing.’’. 
(f) PROVIDING ASSISTANCE TO ELIGIBLE PROFES-
SIONALS AND CERTAIN HOSPITALS.— 
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AMDT. NO. 98 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall provide assistance to eligible 
professionals (as defined in section 1848(o)(5), as 
added by subsection (a)), Medicaid providers (as de-
fined in section 1903(t)(2) of such Act, as added by 
section 4211(a)), and eligible hospitals (as defined in 
section 1886(n)(6)(A) of such Act, as added by sec-
tion 4202(a)) located in rural or other medically un-
derserved areas to successfully choose, implement, 
and use certified EHR technology (as defined in sec-
tion 1848(o)(4) of the Social Security Act, as added 
by section 4201(a)). 
(2) USE OF ENTITIES WITH EXPERTISE.—To 
the extent practicable, the Secretary shall provide 
such assistance through entities that have expertise 
in the choice, implementation, and use of such cer-
tified EHR technology. 
SEC. 4202. INCENTIVES FOR HOSPITALS. 
(a) INCENTIVE PAYMENT.—Section 1886 of the So-
cial Security Act (42 U.S.C. 1395ww) is amended by add-
ing at the end the following new subsection: 
‘‘(n) INCENTIVES FOR ADOPTION AND MEANINGFUL 
USE OF CERTIFIED EHR TECHNOLOGY.— 
‘‘(1) IN GENERAL.—Subject to the succeeding 
provisions of this subsection, with respect to inpa-
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AMDT. NO. 98 
tient hospital services furnished by an eligible hos-
pital during a payment year (as defined in para-
graph (2)(G)), if the eligible hospital is a meaningful 
EHR user (as determined under paragraph (3)) for 
the reporting period with respect to such year, in ad-
dition to the amount otherwise paid under this sec-
tion, there also shall be paid to the eligible hospital, 
from the Federal Hospital Insurance Trust Fund es-
tablished under section 1817, an amount equal to 
the applicable amount specified in paragraph (2)(A) 
for the hospital for such payment year. 
‘‘(2) PAYMENT AMOUNT.— 
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding subparagraphs of this paragraph, the 
applicable amount specified in this subpara-
graph for an eligible hospital for a payment 
year is equal to the product of the following: 
‘‘(i) INITIAL AMOUNT.—The sum of— 
‘‘(I) the base amount specified in 
subparagraph (B); plus 
‘‘(II) 
the 
discharge 
related 
amount specified in subparagraph (C) 
for a 12-month period selected by the 
Secretary with respect to such pay-
ment year. 
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AMDT. NO. 98 
‘‘(II) the total amount of the hos-
pital’s charges during such period, not 
including any charges that are attrib-
utable to charity care (as such term is 
used for purposes of hospital cost re-
porting under this title), divided by 
the total amount of the hospital’s 
charges during such period. 
Insofar as the Secretary determines that data 
are not available on charity care necessary to 
calculate the portion of the formula specified in 
clause (ii)(II), the Secretary shall use data on 
uncompensated care and may adjust such data 
so as to be an appropriate proxy for charity 
care including a downward adjustment to elimi-
nate bad debt data from uncompensated care 
data. In the absence of the data necessary, with 
respect to a hospital, for the Secretary to com-
pute the amount described in clause (ii)(II), the 
amount under such clause shall be deemed to 
be 1. In the absence of data, with respect to a 
hospital, necessary to compute the amount de-
scribed in clause (i)(II), the amount under such 
clause shall be deemed to be 0. 
‘‘(E) TRANSITION FACTOR SPECIFIED.— 
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AMDT. NO. 98 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), the transition factor specified in this 
subparagraph for an eligible hospital for a 
payment year is as follows: 
‘‘(I) For the first payment year 
for such hospital, 1. 
‘‘(II) For the second payment 
year for such hospital, 3⁄4. 
‘‘(III) For the third payment 
year for such hospital, 1⁄2. 
‘‘(IV) For the fourth payment 
year for such hospital, 1⁄4. 
‘‘(V) For any succeeding pay-
ment year for such hospital, 0. 
‘‘(ii) PHASE
DOWN
FOR
ELIGIBLE 
HOSPITALS FIRST ADOPTING EHR AFTER 
2013.—If the first payment year for an eli-
gible hospital is after 2013, then the tran-
sition factor specified in this subparagraph 
for a payment year for such hospital is the 
same as the amount specified in clause (i) 
for such payment year for an eligible hos-
pital for which the first payment year is 
2013. If the first payment year for an eli-
gible hospital is after 2015 then the transi-
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AMDT. NO. 98 
tion factor specified in this subparagraph 
for such hospital and for such year and 
any subsequent year shall be 0. 
‘‘(F) FORM OF PAYMENT.—The payment 
under this subsection for a payment year may 
be in the form of a single consolidated payment 
or in the form of such periodic installments as 
the Secretary may specify. 
‘‘(G) PAYMENT YEAR DEFINED.— 
‘‘(i) IN
GENERAL.—For purposes of 
this subsection, the term ‘payment year’ 
means a fiscal year beginning with fiscal 
year 2011. 
‘‘(ii) FIRST, SECOND, ETC. PAYMENT 
YEAR.—The term ‘first payment year’ 
means, with respect to inpatient hospital 
services furnished by an eligible hospital, 
the first fiscal year for which an incentive 
payment is made for such services under 
this subsection. The terms ‘second pay-
ment year’, ‘third payment year’, and 
‘fourth payment year’ mean, with respect 
to an eligible hospital, each successive year 
immediately following the first payment 
year for that hospital. 
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‘‘(3) MEANINGFUL EHR USER.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), an eligible hospital shall be treated 
as a meaningful EHR user for a reporting pe-
riod for a payment year (or, for purposes of 
subsection (b)(3)(B)(ix), for a reporting period 
under such subsection for a fiscal year) if each 
of the following requirements are met: 
‘‘(i) MEANINGFUL USE OF CERTIFIED 
EHR TECHNOLOGY.—The eligible hospital 
demonstrates to the satisfaction of the Sec-
retary, in accordance with subparagraph 
(C)(i), that during such period the hospital 
is using certified EHR technology in a 
meaningful manner. 
‘‘(ii) INFORMATION EXCHANGE.—The 
eligible hospital demonstrates to the satis-
faction of the Secretary, in accordance 
with subparagraph (C)(i), that during such 
period such certified EHR technology is 
connected in a manner that provides, in 
accordance with law and standards appli-
cable to the exchange of information, for 
the electronic exchange of health informa-
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AMDT. NO. 98 
tion to improve the quality of health care, 
such as promoting care coordination. 
‘‘(iii) 
REPORTING
ON
MEASURES 
USING
EHR.—Subject to subparagraph 
(B)(ii) and using such certified EHR tech-
nology, the eligible hospital submits infor-
mation for such period, in a form and 
manner specified by the Secretary, on such 
clinical quality measures and such other 
measures as selected by the Secretary 
under subparagraph (B)(i). 
The Secretary shall seek to improve the use of 
electronic health records and health care quality 
over time by requiring more stringent measures 
of meaningful use selected under this para-
graph. 
‘‘(B) REPORTING ON MEASURES.— 
‘‘(i) SELECTION.—The Secretary shall 
select measures for purposes of subpara-
graph (A)(iii) but only consistent with the 
following: 
‘‘(I) The Secretary shall provide 
preference to clinical quality measures 
that have been selected for purposes 
of applying subsection (b)(3)(B)(viii) 
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AMDT. NO. 98 
or that have been endorsed by the en-
tity with a contract with the Secretary 
under section 1890(a). 
‘‘(II) Prior to any measure (other 
than a clinical quality measure that 
has been selected for purposes of ap-
plying 
subsection 
(b)(3)(B)(viii)) 
being selected under this subpara-
graph, the Secretary shall publish in 
the Federal Register such measure 
and provide for a period of public 
comment on such measure. 
‘‘(ii) LIMITATIONS.—The Secretary 
may not require the electronic reporting of 
information on clinical quality measures 
under subparagraph (A)(iii) unless the 
Secretary has the capacity to accept the in-
formation electronically, which may be on 
a pilot basis. 
‘‘(iii) COORDINATION OF REPORTING 
OF
INFORMATION.—In 
selecting 
such 
measures, and in establishing the form and 
manner for reporting measures under sub-
paragraph (A)(iii), the Secretary shall seek 
to avoid redundant or duplicative reporting 
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AMDT. NO. 98 
with reporting otherwise required, includ-
ing 
reporting 
under 
subsection 
(b)(3)(B)(viii). 
‘‘(C) DEMONSTRATION
OF
MEANINGFUL 
USE OF CERTIFIED EHR TECHNOLOGY AND IN-
FORMATION EXCHANGE.— 
‘‘(i) IN
GENERAL.—A hospital may 
satisfy the demonstration requirement of 
clauses (i) and (ii) of subparagraph (A) 
through means specified by the Secretary, 
which may include— 
‘‘(I) an attestation; 
‘‘(II) the submission of claims 
with appropriate coding (such as a 
code indicating that inpatient care 
was documented using certified EHR 
technology); 
‘‘(III) a survey response; 
‘‘(IV) reporting under subpara-
graph (A)(iii); and 
‘‘(V) other means specified by the 
Secretary. 
‘‘(ii) USE
OF
PART
D
DATA.—Not-
withstanding sections 1860D–15(d)(2)(B) 
and 1860D–15(f)(2), the Secretary may 
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AMDT. NO. 98 
use data regarding drug claims submitted 
for purposes of section 1860D–15 that are 
necessary for purposes of subparagraph 
(A). 
‘‘(4) APPLICATION.— 
‘‘(A) LIMITATIONS
ON
REVIEW.—There 
shall be no administrative or judicial review 
under section 1869, section 1878, or otherwise 
of the determination of any incentive payment 
under this subsection and the payment adjust-
ment under subsection (b)(3)(B)(ix), including 
the determination of a meaningful EHR user 
under paragraph (3), determination of meas-
ures applicable to services furnished by eligible 
hospitals under this subsection, and the excep-
tion under subsection (b)(3)(B)(ix)(II). 
‘‘(B) POSTING
ON
WEBSITE.—The Sec-
retary shall post on the Internet website of the 
Centers for Medicare & Medicaid Services, in an 
easily understandable format, a list of the 
names of the eligible hospitals that are mean-
ingful EHR users under this subsection or sub-
section (b)(3)(B)(ix) and other relevant data as 
determined appropriate by the Secretary. The 
Secretary shall ensure that a hospital has the 
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AMDT. NO. 98 
opportunity to review the other relevant data 
that are to be made public with respect to the 
hospital prior to such data being made public. 
‘‘(5) CERTIFIED EHR TECHNOLOGY DEFINED.— 
The term ‘certified EHR technology’ has the mean-
ing given such term in section 1848(o)(4). 
‘‘(6) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) ELIGIBLE HOSPITAL.—The term ‘eli-
gible hospital’ means— 
‘‘(i) a subsection (d) hospital; and 
‘‘(ii) a critical access hospital (as de-
fined in section 1861(mm)(1)). 
‘‘(B) REPORTING PERIOD.—The term ‘re-
porting period’ means any period (or periods), 
with respect to a payment year, as specified by 
the Secretary.’’. 
(b) INCENTIVE MARKET BASKET ADJUSTMENT.— 
(1) IN
GENERAL.—Section 1886(b)(3)(B) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395ww(b)(3)(B)) is amended— 
(A) in clause (viii)(I), by inserting ‘‘(or, 
beginning with fiscal year 2016, by one-quar-
ter)’’ after ‘‘2.0 percentage points’’; and 
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AMDT. NO. 98 
(B) by adding at the end the following new 
clause: 
‘‘(ix)(I) For purposes of clause (i) for fiscal year 
2015 and each subsequent fiscal year, in the case of an 
eligible hospital (as defined in subsection (n)(6)(A)) that 
is not a meaningful EHR user (as defined in subsection 
(n)(3)) for the reporting period for such fiscal year, three- 
quarters of the applicable percentage increase otherwise 
applicable under clause (i) for such fiscal year shall be 
reduced by 331⁄3 percent for fiscal year 2015, 662⁄3 per-
cent for fiscal year 2016, and 100 percent for fiscal year 
2017 and each subsequent fiscal year. Such reduction 
shall apply only with respect to the fiscal year involved 
and the Secretary shall not take into account such reduc-
tion in computing the applicable percentage increase under 
clause (i) for a subsequent fiscal year. 
‘‘(II) The Secretary may, on a case-by-case basis, ex-
empt a subsection (d) hospital from the application of sub-
clause (I) with respect to a fiscal year if the Secretary 
determines, subject to annual renewal, that requiring such 
hospital to be a meaningful EHR user during such fiscal 
year would result in a significant hardship, such as in the 
case of a hospital in a rural area without sufficient Inter-
net access. In no case may a hospital be granted an ex-
emption under this subclause for more than 5 years. 
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AMDT. NO. 98 
‘‘(III) For fiscal year 2015 and each subsequent fis-
cal year, a State in which hospitals are paid for services 
under section 1814(b)(3) shall adjust the payments to 
each subsection (d) hospital in the State that is not a 
meaningful EHR user (as defined in subsection (n)(3)) 
in a manner that is designed to result in an aggregate 
reduction in payments to hospitals in the State that is 
equivalent to the aggregate reduction that would have oc-
curred if payments had been reduced to each subsection 
(d) hospital in the State in a manner comparable to the 
reduction under the previous provisions of this clause. The 
State shall report to the Secretary the methodology it will 
use to make the payment adjustment under the previous 
sentence. 
‘‘(IV) For purposes of this clause, the term ‘reporting 
period’ means, with respect to a fiscal year, any period 
(or periods), with respect to the fiscal year, as specified 
by the Secretary.’’. 
(2) CRITICAL
ACCESS
HOSPITALS.—Section 
1814(l) of the Social Security Act (42 U.S.C. 
1395f(l)) is amended— 
(A) in subparagraph (1), by striking 
‘‘paragraph (2)’’ and inserting ‘‘paragraphs (2) 
and (3)’’; and 
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AMDT. NO. 98 
(B) by adding at the end the following new 
paragraph: 
‘‘(3)(A) Subject to subparagraph (B), for fiscal year 
2015 and each subsequent fiscal year, in the case of a 
critical access hospital that is not a meaningful EHR user 
(as defined in section 1886(n)(3)) for the reporting period 
for such fiscal year, paragraph (1) shall be applied by sub-
stituting the applicable percent under subparagraph (C) 
for the percent described in such paragraph (1). 
‘‘(B) The Secretary may, on a case-by-case basis, ex-
empt a critical access hospital from the application of sub-
paragraph (A) with respect to a fiscal year if the Secretary 
determines, subject to annual renewal, that requiring such 
hospital to be a meaningful EHR user during such fiscal 
year would result in a significant hardship, such as in the 
case of a hospital in a rural area without sufficient Inter-
net access. In no case may a hospital be granted an ex-
emption under this subparagraph for more than 5 years. 
‘‘(C) The percent described in this subparagraph is— 
‘‘(i) for fiscal year 2015, 100.66 percent; 
‘‘(ii) for fiscal year 2016, 100.33 percent; and 
‘‘(iii) for fiscal year 2017 and each subsequent 
fiscal year, 100 percent.’’. 
(c) APPLICATION TO CERTAIN MA-AFFILIATED ELI-
GIBLE HOSPITALS.—Section 1853 of the Social Security 
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AMDT. NO. 98 
Act (42 U.S.C. 1395w-23), as amended by section 
4201(c), is further amended by adding at the end the fol-
lowing new subsection: 
‘‘(m) APPLICATION OF ELIGIBLE HOSPITAL INCEN-
TIVES FOR CERTAIN MA ORGANIZATIONS FOR ADOPTION 
AND MEANINGFUL USE
OF CERTIFIED EHR TECH-
NOLOGY.— 
‘‘(1) APPLICATION.—Subject to paragraphs (3) 
and (4), in the case of a qualifying MA organization, 
the provisions of sections 1814(l)(3), 1886(n), and 
1886(b)(3)(B)(ix) shall apply with respect to eligible 
hospitals described in paragraph (2) of the organiza-
tion which the organization attests under subsection 
(l)(6) to be meaningful EHR users in a similar man-
ner as they apply to eligible hospitals under such 
sections. Incentive payments under paragraph (3) 
shall be made to and payment adjustments under 
paragraph (4) shall apply to such qualifying organi-
zations. 
‘‘(2) ELIGIBLE
HOSPITAL
DESCRIBED.—With 
respect to a qualifying MA organization, an eligible 
hospital described in this paragraph is an eligible 
hospital (as defined in section 1886(n)(6)(A)) that is 
under common corporate governance with such orga-
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AMDT. NO. 98 
nization and serves individuals enrolled under an 
MA plan offered by such organization. 
‘‘(3) ELIGIBLE
HOSPITAL
INCENTIVE
PAY-
MENTS.— 
‘‘(A) IN
GENERAL.—In applying section 
1886(n)(2) under paragraph (1), instead of the 
additional payment amount under section 
1886(n)(2), there shall be substituted an 
amount determined by the Secretary to be simi-
lar to the estimated amount in the aggregate 
that would be payable if payment for services 
furnished by such hospitals was payable under 
part A instead of this part. In implementing the 
previous sentence, the Secretary— 
‘‘(i) shall, insofar as data to deter-
mine the discharge related amount under 
section 1886(n)(2)(C) for an eligible hos-
pital are not available to the Secretary, use 
such alternative data and methodology to 
estimate such discharge related amount as 
the Secretary determines appropriate; and 
‘‘(ii) shall, insofar as data to deter-
mine the medicare share described in sec-
tion 1886(n)(2)(D) for an eligible hospital 
are not available to the Secretary, use such 
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AMDT. NO. 98 
alternative data and methodology to esti-
mate such share, which data and method-
ology may include use of the inpatient bed 
days (or discharges) with respect to an eli-
gible hospital during the appropriate pe-
riod which are attributable to both individ-
uals for whom payment may be made 
under part A or individuals enrolled in an 
MA plan under a Medicare Advantage or-
ganization under this part as a proportion 
of the total number of patient-bed-days (or 
discharges) with respect to such hospital 
during such period. 
‘‘(B) AVOIDING
DUPLICATION
OF
PAY-
MENTS.— 
‘‘(i) IN GENERAL.—In the case of a 
hospital that for a payment year is an eli-
gible hospital described in paragraph (2) 
and for which at least one-third of their 
discharges (or bed-days) of Medicare pa-
tients for the year are covered under part 
A, payment for the payment year shall be 
made only under section 1886(n) and not 
under this subsection. 
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AMDT. NO. 98 
‘‘(ii) METHODS.—In the case of a 
hospital that is an eligible hospital de-
scribed in paragraph (2) and also is eligi-
ble for an incentive payment under section 
1886(n) but is not described in clause (i) 
for the same payment period, the Secretary 
shall develop a process— 
‘‘(I) to ensure that duplicate pay-
ments are not made with respect to 
an eligible hospital both under this 
subsection and under section 1886(n); 
and 
‘‘(II) to collect data from Medi-
care Advantage organizations to en-
sure against such duplicate payments. 
‘‘(4) PAYMENT ADJUSTMENT.— 
‘‘(A) Subject to paragraph (3), in the case 
of a qualifying MA organization (as defined in 
section 1853(l)(5)), if, according to the attesta-
tion of the organization submitted under sub-
section (l)(6) for an applicable period, one or 
more eligible hospitals (as defined in section 
1886(n)(6)(A)) that are under common cor-
porate governance with such organization and 
that serve individuals enrolled under a plan of-
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AMDT. NO. 98 
fered by such organization are not meaningful 
EHR users (as defined in section 1886(n)(3)) 
with respect to a period, the payment amount 
payable under this section for such organization 
for such period shall be the percent specified in 
subparagraph (B) for such period of the pay-
ment amount otherwise provided under this sec-
tion for such period. 
‘‘(B) SPECIFIED
PERCENT.—The percent 
specified under this subparagraph for a year is 
100 percent minus a number of percentage 
points equal to the product of— 
‘‘(i) the number of the percentage 
point reduction effected under section 
1886(b)(3)(B)(ix)(I) for the period; and 
‘‘(ii) the Medicare hospital expendi-
ture proportion specified in subparagraph 
(C) for the year. 
‘‘(C) MEDICARE HOSPITAL EXPENDITURE 
PROPORTION.—The Medicare hospital expendi-
ture proportion under this subparagraph for a 
year is the Secretary’s estimate of the propor-
tion, of the expenditures under parts A and B 
that are not attributable to this part, that are 
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AMDT. NO. 98 
attributable to expenditures for inpatient hos-
pital services. 
‘‘(D) APPLICATION OF PAYMENT ADJUST-
MENT.—In the case that a qualifying MA orga-
nization attests that not all eligible hospitals 
are meaningful EHR users with respect to an 
applicable period, the Secretary shall apply the 
payment adjustment under this paragraph 
based on a methodology specified by the Sec-
retary, taking into account the proportion of 
such eligible hospitals, or discharges from such 
hospitals, that are not meaningful EHR users 
for such period. 
‘‘(5) POSTING
ON
WEBSITE.—The Secretary 
shall post on the Internet website of the Centers for 
Medicare & Medicaid Services, in an easily under-
standable format, — 
‘‘(A) a list of the names, business address-
es, and business phone numbers of each quali-
fying MA organization receiving an incentive 
payment under this subsection for eligible hos-
pitals described in paragraph (2); and 
‘‘(B) a list of the names of the eligible hos-
pitals for which such incentive payment is 
based.’’. 
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AMDT. NO. 98 
(ii) in paragraph (6)(A), by inserting 
‘‘and subsections (b)(3)(B)(ix) and (n) of 
section 1886’’ after ‘‘section 1848’’; and 
(B) in subsection (f), by inserting ‘‘and 
subsection (m)’’ after ‘‘under subsection (l)’’. 
SEC. 4203. PREMIUM HOLD HARMLESS AND IMPLEMENTA-
TION FUNDING. 
(a) PREMIUM HOLD HARMLESS.— 
(1) IN GENERAL.—Section 1839(a)(1) of the 
Social Security Act (42 U.S.C. 1395r(a)(1)) is 
amended by adding at the end the following: ‘‘In ap-
plying this paragraph there shall not be taken into 
account additional payments under section 1848(o) 
and section 1853(l)(3) and the Government con-
tribution under section 1844(a)(3).’’. 
(2) PAYMENT.—Section 1844(a) of such Act 
(42 U.S.C. 1395w(a)) is amended— 
(A) in paragraph (2), by striking the pe-
riod at the end and inserting ‘‘; plus’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(3) a Government contribution equal to the 
amount of payment incentives payable under sec-
tions 1848(o) and 1853(l)(3).’’. 
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AMDT. NO. 98 
(b) IMPLEMENTATION FUNDING.—In addition to 
funds otherwise available, out of any funds in the Treas-
ury not otherwise appropriated, there are appropriated to 
the Secretary of Health and Human Services for the Cen-
ter for Medicare & Medicaid Services Program Manage-
ment Account, $100,000,000 for each of fiscal years 2009 
through 2015 and $45,000,000 for each succeeding fiscal 
year through fiscal year 2018, which shall be available for 
purposes of carrying out the provisions of (and amend-
ments made by) this part. Amounts appropriated under 
this subsection for a fiscal year shall be available until ex-
pended. 
SEC. 4204. NON-APPLICATION OF PHASED-OUT INDIRECT 
MEDICAL EDUCATION (IME) ADJUSTMENT 
FACTOR FOR FISCAL YEAR 2009. 
(a) IN GENERAL.—Section 412.322 of title 42, Code 
of Federal Regulations, shall be applied without regard to 
paragraph (c) of such section, and the Secretary of Health 
and Human Services shall recompute payments for dis-
charges occurring on or after October 1, 2008, as if such 
paragraph had never been in effect. 
(b) NO EFFECT ON SUBSEQUENT YEARS.—Nothing 
in subsection (a) shall be construed as having any effect 
on the application of paragraph (d) of section 412.322 of 
title 42, Code of Federal Regulations. 
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AMDT. NO. 98 
SEC. 4205. STUDY ON APPLICATION OF EHR PAYMENT IN-
CENTIVES FOR PROVIDERS NOT RECEIVING 
OTHER INCENTIVE PAYMENTS. 
(a) STUDY.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall conduct a study to determine 
the extent to which and manner in which payment 
incentives (such as under title XVIII or XIX of the 
Social Security Act) and other funding for purposes 
of implementing and using certified EHR technology 
(as defined in section 1848(o)(4) of the Social Secu-
rity Act, as added by section 4311(a)) should be 
made available to health care providers who are re-
ceiving minimal or no payment incentives or other 
funding under this Act, under title XVIII or XIX of 
such Act, or otherwise, for such purposes. 
(2) DETAILS OF STUDY.—Such study shall in-
clude an examination of— 
(A) the adoption rates of certified EHR 
technology (as so defined) by such health care 
providers; 
(B) the clinical utility of such technology 
by such health care providers; 
(C) whether the services furnished by such 
health care providers are appropriate for or 
would benefit from the use of such technology; 
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AMDT. NO. 98 
(D) the extent to which such health care 
providers work in settings that might otherwise 
receive an incentive payment or other funding 
under this Act, title XVIII or XIX of the Social 
Security Act, or otherwise; 
(E) the potential costs and the potential 
benefits of making payment incentives and 
other funding available to such health care pro-
viders; and 
(F) any other issues the Secretary deems 
to be appropriate. 
(b) REPORT.—Not later than June 30, 2010, the 
Secretary shall submit to Congress a report on the find-
ings and conclusions of the study conducted under sub-
section (a). 
SEC. 4206. STUDY ON AVAILABILITY OF OPEN SOURCE 
HEALTH INFORMATION TECHNOLOGY SYS-
TEMS. 
(a) IN GENERAL.— 
(1) STUDY.—The Secretary of Health and 
Human Services shall, in consultation with the 
Under Secretary for Health of the Veterans Health 
Administration, the Director of the Indian Health 
Service, the Secretary of Defense, the Director of 
the Agency for Healthcare Research and Quality, 
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AMDT. NO. 98 
the Administrator of the Health Resources and Serv-
ices Administration, and the Chairman of the Fed-
eral Communications Commission, conduct a study 
on— 
(A) the current availability of open source 
health information technology systems to Fed-
eral safety net providers (including small, rural 
providers); 
(B) the total cost of ownership of such sys-
tems in comparison to the cost of proprietary 
commercial products available; 
(C) the ability of such systems to respond 
to the needs of, and be applied to, various pop-
ulations (including children and disabled indi-
viduals); and 
(D) the capacity of such systems to facili-
tate interoperability. 
(2) CONSIDERATIONS.—In conducting the study 
under paragraph (1), the Secretary of Health and 
Human Services shall take into account the cir-
cumstances of smaller health care providers, health 
care providers located in rural or other medically un-
derserved areas, and safety net providers that deliver 
a significant level of health care to uninsured indi-
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AMDT. NO. 98 
viduals, Medicaid beneficiaries, SCHIP beneficiaries, 
and other vulnerable individuals. 
(b) REPORT.—Not later than October 1, 2010, the 
Secretary of Health and Human Services shall submit to 
Congress a report on the findings and the conclusions of 
the study conducted under subsection (a), together with 
recommendations for such legislation and administrative 
action as the Secretary determines appropriate. 
Subtitle B—Medicaid Funding 
SEC. 4211. MEDICAID PROVIDER EHR ADOPTION AND OPER-
ATION PAYMENTS; IMPLEMENTATION FUND-
ING. 
(a) IN GENERAL.—Section 1903 of the Social Secu-
rity Act (42 U.S.C. 1396b) is amended— 
(1) in subsection (a)(3)— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (D); 
(B) by striking ‘‘plus’’ at the end of sub-
paragraph (E) and inserting ‘‘and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(F)(i) 100 percent of so much of the 
sums expended during such quarter as are at-
tributable to payments for certified EHR tech-
nology (and support services including mainte-
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AMDT. NO. 98 
nance and training that is for, or is necessary 
for the adoption and operation of, such tech-
nology) by Medicaid providers described in sub-
section (t)(1); and 
‘‘(ii) 90 percent of so much of the sums ex-
pended during such quarter as are attributable 
to payments for reasonable administrative ex-
penses related to the administration of pay-
ments described in clause (i) if the State meets 
the condition described in subsection (t)(9); 
plus’’; and 
(2) by inserting after subsection (s) the fol-
lowing new subsection: 
‘‘(t)(1)(A) For purposes of subsection (a)(3)(F), the 
payments for certified EHR technology (and support serv-
ices including maintenance that is for, or is necessary for 
the operation of, such technology) by Medicaid providers 
described in this paragraph are payments made by the 
State in accordance with this subsection of the applicable 
percent of the net allowable costs of Medicaid providers 
(as defined in paragraph (2)) for such technology (and 
support services). 
‘‘(B) For purposes of subparagraph (A), the term 
‘applicable percent’ means— 
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AMDT. NO. 98 
‘‘(i) in the case of a Medicaid provider de-
scribed in paragraph (2)(A), 85 percent; 
‘‘(ii) in the case of a Medicaid provider de-
scribed in clause (i) or (ii) of paragraph (2)(B), 100 
percent; and 
‘‘(iii) in the case of a Medicaid provider de-
scribed in clause (iii) of paragraph (2)(B), a percent 
specified by the Secretary, but not less than 85 per-
cent. 
‘‘(2) In this subsection and subsection (a)(3)(F), the 
term ‘Medicaid provider’ means— 
‘‘(A) an eligible professional (as defined in 
paragraph (3)(B)) who is not hospital-based and has 
at least 30 percent of the professional’s patient vol-
ume (as estimated in accordance with standards es-
tablished by the Secretary) attributable to individ-
uals who are receiving medical assistance under this 
title; and 
‘‘(B)(i) a children’s hospital, (ii) an acute-care 
hospital that is not described in clause (i) and that 
has at least 10 percent of the hospital’s patient vol-
ume (as estimated in accordance with standards es-
tablished by the Secretary) attributable to individ-
uals who are receiving medical assistance under this 
title, or (iii) a Federally-qualified health center or 
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AMDT. NO. 98 
rural health clinic that has at least 30 percent of the 
center’s or clinic’s patient volume (as estimated in 
accordance with standards established by the Sec-
retary) attributable to individuals who are receiving 
medical assistance under this title. 
An eligible professional shall not qualify as a Medicaid 
provider under this subsection unless the professional has 
waived, in a manner specified by the Secretary, any right 
to payment under section 1848(o) with respect to the 
adoption or support of certified EHR technology by the 
eligible professional. In applying clauses (ii) and (iii) of 
subparagraph (B), the standards established by the Sec-
retary for patient volume shall include individuals enrolled 
in a Medicaid managed care plan (under section 1903(m) 
or section 1932). 
‘‘(3) In this subsection and subsection (a)(3)(F): 
‘‘(A) The term ‘certified EHR technology’ 
means a qualified electronic health record (as de-
fined in 3000(13) of the Public Health Service Act) 
that is certified pursuant to section 3001(c)(5) of 
such Act as meeting standards adopted under sec-
tion 3004 of such Act that are applicable to the type 
of record involved (as determined by the Secretary, 
such as an ambulatory electronic health record for 
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AMDT. NO. 98 
office-based physicians or an inpatient hospital elec-
tronic health record for hospitals). 
‘‘(B) The term ‘eligible professional’ means a 
physician as defined in paragraphs (1) and (2) of 
section 1861(r), and includes a nurse mid-wife and 
a nurse practitioner. 
‘‘(C) The term ‘hospital-based’ means, with re-
spect to an eligible professional, a professional (such 
as a pathologist, anesthesiologist, or emergency phy-
sician) who furnishes substantially all of the individ-
ual’s professional services in a hospital setting 
(whether inpatient or outpatient) and through the 
use of the facilities and equipment, including quali-
fied electronic health records, of the hospital. 
‘‘(4)(A) The term ‘allowable costs’ means, with re-
spect to certified EHR technology of a Medicaid provider, 
costs of such technology (and support services including 
maintenance and training that is for, or is necessary for 
the adoption and operation of, such technology) as deter-
mined by the Secretary to be reasonable. 
‘‘(B) The term ‘net allowable costs’ means allowable 
costs reduced by any payment that is made to the Med-
icaid provider involved from any other source that is di-
rectly attributable to payment for certified EHR tech-
nology or services described in subparagraph (A). 
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AMDT. NO. 98 
‘‘(C) In no case shall— 
‘‘(i) the aggregate allowable costs under this 
subsection (covering one or more years) with respect 
to a Medicaid provider described in paragraph 
(2)(A) for purchase and initial implementation of 
certified EHR technology (and services described in 
subparagraph (A)) exceed $25,000 or include costs 
over a period of longer than 5 years; 
‘‘(ii) for costs not described in clause (i) relat-
ing to the operation, maintenance, or use of certified 
EHR technology, the annual allowable costs under 
this subsection with respect to such a Medicaid pro-
vider for costs not described in clause (i) for any 
year exceed $10,000; 
‘‘(iii) payment described in paragraph (1) for 
costs described in clause (ii) be made with respect 
to such a Medicaid provider over a period of more 
than 5 years; 
‘‘(iv) the aggregate allowable costs under this 
subsection with respect to such a Medicaid provider 
for all costs exceed $75,000; or 
‘‘(v) the allowable costs, whether for purchase 
and initial implementation, maintenance, or other-
wise, for a Medicaid provider described in paragraph 
(2)(B)(iii) exceed such aggregate or annual limita-
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AMDT. NO. 98 
tion as the Secretary shall establish, based on an 
amount determined by the Secretary as being ade-
quate to adopt and maintain certified EHR tech-
nology, consistent with paragraph (6). 
‘‘(5) Payments described in paragraph (1) are not in 
accordance with this subsection unless the following re-
quirements are met: 
‘‘(A) The State provides assurances satisfactory 
to the Secretary that amounts received under sub-
section (a)(3)(F) with respect to costs of a Medicaid 
provider are paid directly to such provider without 
any deduction or rebate. 
‘‘(B) Such Medicaid provider is responsible for 
payment of the costs described in such paragraph 
that are not provided under this title. 
‘‘(C) With respect to payments to such Med-
icaid provider for costs other than costs related to 
the initial adoption of certified EHR technology, the 
Medicaid provider demonstrates meaningful use of 
certified EHR technology through a means that is 
approved by the State and acceptable to the Sec-
retary, and that may be based upon the methodolo-
gies applied under section 1848(o) or 1886(n). In 
establishing such means, which may include the re-
porting of clinical quality measures to the State, the 
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AMDT. NO. 98 
State shall ensure that populations with unique 
needs, such as children, are appropriately addressed. 
‘‘(D) To the extent specified by the Secretary, 
the certified EHR technology is compatible with 
State or Federal administrative management sys-
tems. 
‘‘(6)(A) In no case shall the payments described in 
paragraph (1), with respect to a hospital, exceed in the 
aggregate the product of— 
‘‘(i) the overall hospital EHR amount for the 
hospital computed under subparagraph (B); and 
‘‘(ii) the Medicaid share for such hospital com-
puted under subparagraph (C). 
‘‘(B) For purposes of this paragraph, the overall hos-
pital EHR amount, with respect to a hospital, is the sum 
of 
the 
applicable 
amounts 
specified 
in 
section 
1886(n)(2)(A) for such hospital for the first 4 payment 
years (as estimated by the Secretary) determined as if the 
Medicare share specified in clause (ii) of such section were 
1. The Secretary shall publish in the Federal Register the 
overall hospital EHR amount for each hospital eligible for 
payments under this subsection. In computing amounts 
under clause (ii) for payment years after the first payment 
year, the Secretary shall assume that in subsequent pay-
ment years discharges increase at the average annual rate 
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AMDT. NO. 98 
of growth of the most recent three years for which dis-
charge data are available. 
‘‘(C) The Medicaid share computed under this sub-
paragraph, for a hospital for a period specified by the Sec-
retary, shall be calculated in the same manner as the 
Medicare share under section 1886(n)(2)(D) for such a 
hospital and period, except that there shall be substituted 
for the numerator under clause (i) of such section the 
amount that is equal to the number of inpatient-bed-days 
(as established by the Secretary) which are attributable 
to individuals who are receiving medical assistance under 
this title and who are not described in section 
1886(n)(2)(D)(i). In computing inpatient-bed-days under 
the previous sentence, the Secretary shall take into ac-
count inpatient-bed-days attributable to inpatient-bed- 
days that are paid for individuals enrolled in a Medicaid 
managed care plan (under section 1903(m) or section 
1932). 
‘‘(7) With respect to health care providers other than 
hospitals, the Secretary shall establish and implement a 
detailed process to ensure coordination of the different 
programs for payment of such health care providers for 
adoption or use of health information technology (includ-
ing certified EHR technology), as well as payments for 
such health care providers provided under this title or title 
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AMDT. NO. 98 
XVIII, to assure no duplication of funding. The Secretary 
shall promulgate regulations to carry out the preceding 
sentence. 
‘‘(8) In carrying out paragraph (5)(C), the State and 
Secretary shall seek, to the maximum extent practicable, 
to avoid duplicative requirements from Federal and State 
Governments to demonstrate meaningful use of certified 
EHR technology under this title and title XVIII. In doing 
so, the Secretary may deem satisfaction of requirements 
for such meaningful use for a payment year under title 
XVIII to be sufficient to qualify as meaningful use under 
this subsection. The Secretary may also specify the report-
ing periods under this subsection in order to carry out this 
paragraph. 
‘‘(9) In order to be provided Federal financial partici-
pation under subsection (a)(3)(F)(ii), a State must dem-
onstrate to the satisfaction of the Secretary, that the 
State— 
‘‘(A) is using the funds provided for the pur-
poses of administering payments under this sub-
section, including tracking of meaningful use by 
Medicaid providers; 
‘‘(B) is conducting adequate oversight of the 
program under this subsection, including routine 
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AMDT. NO. 98 
tracking of meaningful use attestations and report-
ing mechanisms; and 
‘‘(C) is pursuing initiatives to encourage the 
adoption of certified EHR technology to promote 
health care quality and the exchange of health care 
information under this title, subject to applicable 
laws and regulations governing such exchange. 
‘‘(10) The Secretary shall periodically submit reports 
to the Committee on Energy and Commerce of the House 
of Representatives and the Committee on Finance of the 
Senate on status, progress, and oversight of payments 
under paragraph (1).’’. 
(b) IMPLEMENTATION FUNDING.—In addition to 
funds otherwise available, out of any funds in the Treas-
ury not otherwise appropriated, there are appropriated to 
the Secretary of Health and Human Services for the Cen-
ter for Medicare & Medicaid Services Program Manage-
ment Account, $40,000,000 for each of fiscal years 2009 
through 2015 and $20,000,000 for each succeeding fiscal 
year through fiscal year 2018, which shall be available for 
purposes of carrying out the provisions of (and the amend-
ments made by) this part. Amounts appropriated under 
this subsection for a fiscal year shall be available until ex-
pended. 
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AMDT. NO. 98 
(c) HHS REPORT
ON IMPLEMENTATION
OF DE-
TAILED PROCESS TO ASSURE NO DUPLICATION OF FUND-
ING.—Not later than July 1, 2012, the Secretary of 
Health and Human Services shall submit to Congress a 
report on the establishment and implementation of the de-
tailed process under section 1903(t)(7) of the Social Secu-
rity Act, as added by subsection (a), together with rec-
ommendations for such legislation and administrative ac-
tion as the Secretary determines appropriate. 
TITLE V—STATE FISCAL RELIEF 
SEC. 5000. PURPOSES; TABLE OF CONTENTS. 
(a) PURPOSES.—The purposes of this title are as fol-
lows: 
(1) To provide fiscal relief to States in a period 
of economic downturn. 
(2) To protect and maintain State Medicaid 
programs during a period of economic downturn, in-
cluding by helping to avert cuts to provider payment 
rates and benefits or services, and to prevent con-
strictions of income eligibility requirements for such 
programs, but not to promote increases in such re-
quirements. 
(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. 
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AMDT. NO. 98 
Sec. 5001. Temporary increase of Medicaid FMAP. 
Sec. 5002. Extension and update of special rule for increase of Medicaid DSH 
allotments for low DSH States. 
Sec. 5003. Payment of Medicare liability to States as a result of the Special 
Disability Workload Project. 
Sec. 5004. Funding for the Department of Health and Human Services Office 
of the Inspector General. 
Sec. 5005. GAO study and report regarding State needs during periods of na-
tional economic downturn. 
SEC. 5001. TEMPORARY INCREASE OF MEDICAID FMAP. 
(a) PERMITTING MAINTENANCE OF FMAP.—Subject 
to subsections (e), (f), and (g), if the FMAP determined 
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 for the 
State’s FMAP for fiscal year 2010, before the appli-
cation 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 
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AMDT. NO. 98 
year 2008, fiscal year 2009, or fiscal year 2010 shall 
be substituted for the State’s FMAP for fiscal year 
2011, before the application of this section, but only 
for the first calendar quarter in fiscal year 2011. 
(b) GENERAL 7.6 PERCENTAGE POINT INCREASE.— 
Subject to subsections (e), (f), and (g), for each State for 
calendar quarters during the recession adjustment period 
(as defined in subsection (h)(2)) , the FMAP (after the 
application of subsection (a)) shall be increased (without 
regard to any limitation otherwise specified in section 
1905(b) of the Social Security Act) by 7.6 percentage 
points. 
(c) ADDITIONAL RELIEF BASED ON INCREASE IN 
UNEMPLOYMENT.— 
(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 dur-
ing the recession adjustment period, the FMAP for 
the State shall be further increased by the number 
of percentage points equal to the product of the 
State percentage applicable for the State under sec-
tion 1905(b) of the Social Security Act (42 U.S.C. 
1396d(b)) after the application of subsections (a) 
and (b) and the applicable percent determined in 
paragraph (3) for the calendar quarter (or, if great-
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AMDT. NO. 98 
er, for a previous such calendar quarter, subject to 
paragraph (4)) . 
(2) QUALIFYING CRITERIA.— 
(A) IN GENERAL.—For purposes of para-
graph (1), a State qualifies for additional relief 
under this subsection for a calendar quarter oc-
curring during the recession adjustment period 
if the State is 1 of the 50 States or the District 
of Columbia and the State satisfies any of the 
following criteria for the quarter: 
(i) An increase of at least 1.5 percent-
age points, but less than 2.5 percentage 
points, in the average monthly unemploy-
ment rate, seasonally adjusted, for the 
State or District, as determined by com-
paring months in the most recent previous 
3-consecutive month period for which data 
are available for the State or District to 
the lowest average monthly unemployment 
rate, seasonally adjusted, for the State or 
District for any 3-consecutive-month pe-
riod preceding that period and beginning 
on or after January 1, 2006 (based on the 
most recently available monthly publica-
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AMDT. NO. 98 
tions of the Bureau of Labor Statistics of 
the Department of Labor). 
(ii) An increase of at least 2.5 per-
centage points, but less than 3.5 percent-
age points, in the average monthly unem-
ployment rate, seasonally adjusted, for the 
State or District (as so determined). 
(iii) An increase of at least 3.5 per-
centage points for the State or District, in 
the average monthly unemployment rate, 
seasonally adjusted, for the State or Dis-
trict (as so determined). 
(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.—For purposes of 
paragraph (1), the applicable percent is— 
(A) 2.5 percent, if the State satisfies the 
criteria described in paragraph (2)(A)(i) for the 
calendar quarter; 
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AMDT. NO. 98 
(B) 4.5 percent if the State satisfies the 
criteria described in paragraph (2)(A)(ii) for 
the calendar quarter; and 
(C) 6.5 percent if the State satisfies the 
criteria described in paragraph (2)(A)(iii) for 
the calendar quarter. 
(4) MAINTENANCE
OF
HIGHER
PERCENTAGE 
REDUCTION FOR PERIOD AFTER LOWER PERCENT-
AGE
DEDUCTION
WOULD
OTHERWISE
TAKE
EF-
FECT.— 
(A) HOLD HARMLESS PERIOD.—If the per-
centage reduction applied to a State under 
paragraph (3) 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 
paragraph) is less than the percentage reduc-
tion applied for the preceding quarter (as so de-
termined), the higher percentage reduction shall 
continue in effect for each subsequent calendar 
quarter ending before July 1, 2010. 
(B) NOTICE OF DECREASE IN PERCENT-
AGE REDUCTION.—The Secretary shall notify a 
State at least 3 months prior to applying any 
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AMDT. NO. 98 
lower percentage reduction to the State under 
paragraph (3). 
(d) INCREASE IN CAP ON MEDICAID PAYMENTS TO 
TERRITORIES.—Subject to subsections (f) and (g), with 
respect to entire fiscal years occurring during the reces-
sion 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 Mar-
iana Islands, and American Samoa under subsections (f) 
and (g) of section 1108 of the Social Security Act (42 
6 U.S.C. 1308) shall each be increased by 15.2 percent. 
(e) SCOPE OF APPLICATION.—The increases in the 
FMAP for a State under this section shall apply for pur-
poses of title XIX of the Social Security Act and shall 
not apply with respect to— 
(1) disproportionate share hospital payments 
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.)); 
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AMDT. NO. 98 
(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 as-
sistance provided to individuals made eligible under 
a State plan under title XIX of the Social Security 
Act (including under any waiver under such title or 
under section 1115 of such Act (42 U.S.C. 1315)) 
because of income standards (expressed as a per-
centage of the poverty line) for eligibility for medical 
assistance that are higher than the income stand-
ards (as so expressed) for such eligibility as in effect 
on July 1, 2008. 
(f) STATE INELIGIBILITY.— 
(1) MAINTENANCE
OF
ELIGIBILITY
REQUIRE-
MENTS.— 
(A) IN
GENERAL.—Subject to subpara-
graphs (B) and (C), a State is not eligible for 
an increase in its FMAP under subsection (a), 
(b), or (c), or an increase in a cap amount 
under subsection (d), if eligibility standards, 
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AMDT. NO. 98 
(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, methodolo-
gies, or procedures that are no more re-
strictive than the eligibility standards, 
methodologies, or procedures, respectively, 
under such plan (or waiver) as in effect on 
July 1, 2008; or 
(ii) on the basis of a restriction that 
was directed to be made under State law 
as of July 1, 2008, and would have been 
in effect as of such date, but for a delay 
in the request for, and approval of, a waiv-
er under section 1115 of such Act with re-
spect to such restriction. 
(2) COMPLIANCE WITH PROMPT PAY REQUIRE-
MENTS.—No State shall be eligible for an increased 
FMAP rate as provided under this section for any 
claim submitted by a provider subject to the terms 
of section 1902(a)(37)(A) of the Social Security Act 
(42 U.S.C. 1396a(a)(37)(A)) during any period in 
which that State has failed to pay claims in accord-
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AMDT. NO. 98 
ance with section 1902(a)(37)(A) of such Act. Each 
State shall report to the Secretary, no later than 30 
days following the 1st day of the month, its compli-
ance 
with 
the 
requirements 
of 
section 
1902(a)(37)(A) of the Social Security Act as they 
pertain to claims made for covered services during 
the preceding month. 
(3) NO
WAIVER
AUTHORITY.—The Secretary 
may not waive the application of this subsection or 
subsection (g) under section 1115 of the Social Se-
curity Act or otherwise. 
(g) REQUIREMENTS.— 
(1) IN GENERAL.—A State may not deposit or 
credit the additional Federal funds paid to the State 
as a result of this section to any reserve or rainy day 
fund maintained by the State. 
(2) STATE REPORTS.—Each State that is paid 
additional Federal funds as a result of this section 
shall, not later than September 30, 2011, submit a 
report to the Secretary, in such form and such man-
ner as the Secretary shall determine, regarding how 
the additional Federal funds were expended. 
(3) ADDITIONAL REQUIREMENT FOR CERTAIN 
STATES.—In the case of a State that requires polit-
ical subdivisions within the State to contribute to-
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AMDT. NO. 98 
ward the non-Federal share of expenditures under 
the State Medicaid plan required under section 
1902(a)(2) of the Social Security Act (42 U.S.C. 
1396a(a)(2)), the State is not eligible for an in-
crease 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 pay for 
quarters during the recession adjustment period a 
greater percentage of the non-Federal share of such 
expenditures, or a greater percentage of the non- 
Federal share of payments under section 1923, than 
the respective percentage that would have been re-
quired by the State under such plan on September 
30, 2008, prior to application of this section. 
(h) DEFINITIONS.—In this section, except as other-
wise 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 
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AMDT. NO. 98 
U.S.C. 9902(2)), including any revision required by 
such section. 
(3) RECESSION
ADJUSTMENT
PERIOD.—The 
term ‘‘recession adjustment period’’ means the pe-
riod 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 mean-
ing given such term 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 ad-
justment period. 
SEC. 5002. EXTENSION AND UPDATE OF SPECIAL RULE FOR 
INCREASE OF MEDICAID DSH ALLOTMENTS 
FOR LOW DSH STATES. 
Section 1923(f)(5) of the Social Security Act (42 
U.S.C. 1396r–4(f)(5)) is amended— 
(1) in subparagraph (B)— 
(A) in the subparagraph heading, by strik-
ing ‘‘YEAR
2004
AND
SUBSEQUENT
FISCAL 
YEARS’’ and inserting ‘‘YEARS 2004 THROUGH 
2008’’; 
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AMDT. NO. 98 
(B) in clause (i), by inserting ‘‘and’’ after 
the semicolon; 
(C) in clause (ii), by striking ‘‘; and’’ and 
inserting a period; and 
(D) by striking clause (iii); and 
(2) by adding at the end the following subpara-
graph: 
‘‘(C) FOR FISCAL YEAR 2009 AND SUBSE-
QUENT FISCAL YEARS.—In the case of a State 
in which the total expenditures under the State 
plan (including Federal and State shares) for 
disproportionate share hospital adjustments 
under this section for fiscal year 2006, as re-
ported to the Administrator of the Centers for 
Medicare & Medicaid Services as of August 31, 
2009, is greater than 0 but less than 3 percent 
of the State’s total amount of expenditures 
under the State plan for medical assistance 
during the fiscal year, the DSH allotment for 
the State with respect to— 
‘‘(i) fiscal year 2009, shall be the 
DSH allotment for the State for fiscal year 
2008 increased by 16 percent; 
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AMDT. NO. 98 
‘‘(ii) fiscal year 2010, shall be the 
DSH allotment for the State for fiscal year 
2009 increased by 16 percent; 
‘‘(iii) fiscal year 2011 for the period 
ending on December 31, 2010, shall be 1⁄4 
of the DSH allotment for the State for fis-
cal year 2010 increased by 16 percent; 
‘‘(iv) fiscal year 2011 for the period 
beginning on January 1, 2011, and ending 
on September 30, 2011, shall be 3⁄4 of the 
DSH allotment that would have been de-
termined under this subsection for the 
State for fiscal year 2011 if this subpara-
graph had not been enacted; 
‘‘(v) fiscal year 2012, shall be the 
DSH allotment that would have been de-
termined under this subsection for the 
State for fiscal year 2012 if this subpara-
graph had not been enacted; and 
‘‘(vi) fiscal year 2013 and any subse-
quent fiscal year, shall be the DSH allot-
ment for the State for the previous fiscal 
year subject to an increase for inflation as 
provided in paragraph (3)(A).’’. 
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AMDT. NO. 98 
SEC. 5003. PAYMENT OF MEDICARE LIABILITY TO STATES 
AS A RESULT OF THE SPECIAL DISABILITY 
WORKLOAD PROJECT. 
(a) IN GENERAL.—The Secretary, in consultation 
with the Commissioner, shall work with each State to 
reach an agreement, not later than 3 months after the 
date of enactment of this Act, on the amount of a payment 
for the State related to the Medicare program liability as 
a result of the Special Disability Workload project, subject 
to the requirements of subsection (c). 
(b) PAYMENTS.— 
(1) DEADLINE FOR MAKING PAYMENTS.—Not 
later than 30 days after reaching an agreement with 
a State under subsection (a), the Secretary shall pay 
the State, from the amounts appropriated under 
paragraph (2), the payment agreed to for the State. 
(2) APPROPRIATION.—Out of any money in the 
Treasury not otherwise appropriated, there is appro-
priated $3,000,000,000 for fiscal year 2009 for 
making payments to States under paragraph (1). 
(3) LIMITATIONS.—In no case may— 
(A) the aggregate amount of payments 
made by the Secretary to States under para-
graph (1) exceed $3,000,000,000; or 
(B) any payments be provided by the Sec-
retary under this section after the first day of 
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AMDT. NO. 98 
the first month that begins 4 months after the 
date of enactment of this Act. 
(c) REQUIREMENTS.—The requirements of this sub-
section are the following: 
(1) FEDERAL
DATA
USED
TO
DETERMINE 
AMOUNT OF PAYMENTS.—The amount of the pay-
ment under subsection (a) for each State is deter-
mined on the basis of the most recent Federal data 
available, including the use of proxies and reasonable 
estimates as necessary, for determining expeditiously 
the amount of the payment that shall be made to 
each State that enters into an agreement under this 
section. The payment methodology shall consider the 
following factors: 
(A) The number of SDW cases found to 
have been eligible for benefits under the Medi-
care program and the month of the initial 
Medicare program eligibility for such cases. 
(B) The applicable non-Federal share of 
expenditures made by a State under the Med-
icaid program during the time period for SDW 
cases. 
(C) Such other factors as the Secretary 
and the Commissioner, in consultation with the 
States, determine appropriate. 
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AMDT. NO. 98 
(2) CONDITIONS
FOR
PAYMENTS.—A State 
shall not receive a payment under this section unless 
the State— 
(A) waives the right to file a civil action 
(or to be a party to any action) in any Federal 
or State court in which the relief sought in-
cludes a payment from the United States to the 
State related to the Medicare liability under 
title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.) as a result of the Special 
Disability Workload project; and 
(B) releases the United States from any 
further claims for reimbursement of State ex-
penditures as a result of the Special Disability 
Workload project. 
(3) NO INDIVIDUAL STATE CLAIMS DATA RE-
QUIRED.—No State shall be required to submit indi-
vidual claims evidencing payment under the Med-
icaid program as a condition for receiving a payment 
under this section. 
(4) INELIGIBLE STATES.—No State that is a 
party to a civil action in any Federal or State court 
in which the relief sought includes a payment from 
the United States to the State related to the Medi-
care liability under title XVIII of the Social Security 
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AMDT. NO. 98 
Act (42 U.S.C. 1395 et seq.) as a result of the Spe-
cial Disability Workload project shall be eligible to 
receive a payment under this section while such an 
action is pending or if such an action is resolved in 
favor of the State. 
(d) DEFINITIONS.—In this section: 
(1) 
COMMISSIONER.—The 
term 
‘‘Commis-
sioner’’ means the Commissioner of Social Security. 
(2) MEDICAID PROGRAM.—The term ‘‘Medicaid 
program’’ means the program of medical assistance 
established under title XIX of the Social Security 
Act (42 U.S.C. 1396a et seq.) and includes medical 
assistance provided under any waiver of that pro-
gram approved under section 1115 or 1915 of such 
Act (42 U.S.C. 1315, 1396n) or otherwise. 
(3) MEDICARE PROGRAM.—The term ‘‘Medicare 
program’’ means the program established under title 
XVIII of the Social Security Act (42 U.S.C. 1395 et 
seq.). 
(4) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(5) SDW CASE.—The term ‘‘SDW case’’ means 
a case in the Special Disability Workload project in-
volving an individual determined by the Commis-
sioner to have been eligible for benefits under title 
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AMDT. NO. 98 
II of the Social Security Act (42 U.S.C. 401 et seq.) 
for a period during which such benefits were not 
provided to the individual and who was, during all 
or part of such period, enrolled in a State Medicaid 
program. 
(6) 
SPECIAL
DISABILITY
WORKLOAD 
PROJECT.—The term ‘‘Special Disability Workload 
project’’ means the project described in the 2008 
Annual Report of the Board of Trustees of the Fed-
eral Old-Age and Survivors Insurance and Federal 
Disability Insurance Trust Funds, H.R. Doc. No. 
110-104, 110th Cong. (2008). 
(7) STATE.—The term ‘‘State’’ means each of 
the 50 States and the District of Columbia. 
SEC. 5004. FUNDING FOR THE DEPARTMENT OF HEALTH 
AND HUMAN SERVICES OFFICE OF THE IN-
SPECTOR GENERAL. 
For purposes of ensuring the proper expenditure of 
Federal funds under title XIX of the Social Security Act 
(42 U.S.C. 1396 et seq.), there is appropriated to the Of-
fice of the Inspector General of the Department of Health 
and Human Services, out of any money in the Treasury 
not otherwise appropriated and without further appropria-
tion, $31,250,000 for the recession adjustment period (as 
defined in section 5001(h)(3)). Amounts appropriated 
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AMDT. NO. 98 
under this section shall remain available for expenditure 
until expended and shall be in addition to any other 
amounts appropriated or made available to such Office for 
such purposes. 
SEC. 5005. GAO STUDY AND REPORT REGARDING STATE 
NEEDS DURING PERIODS OF NATIONAL ECO-
NOMIC 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 developing recommenda-
tions for addressing the needs of States during such peri-
ods. As part of such analysis, the Comptroller General 
shall study the past and projected effects of temporary in-
creases 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 appropriate 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 
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AMDT. NO. 98 
temporary adjustment of the Federal medical assist-
ance 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 recommendations for— 
(A) improvements to the factors that would 
begin and end the application of such percent-
age; 
(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 cov-
erage; 
(B) declines in State revenues; and 
(C) caseload maintenance and growth 
under Medicaid, the State Children’s Health In-
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AMDT. NO. 98 
surance Program, or any other publicly-funded 
programs to provide health benefits coverage 
for State residents. 
(3) Identification of, and recommendations for 
addressing, the effects on States of any other spe-
cific economic indicators that the Comptroller Gen-
eral determines appropriate. 
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Amendment No. 98 
H.R. 1 
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