131 
be limited to contract changes resulting from inflation, 
market fluctuation, rate adjustments, and other necessary 
contract actions to complete existing projects, and associ-
ated supervision and administration costs and costs for de-
sign during construction: Provided further, That the Sec-
retary may not use more than $50,000,000 under the au-
thority provided in this section: Provided further, That the 
Secretary shall notify in advance such contract changes and 
adjustments in annual reports to the congressional defense 
committees: Provided further, That the authority to provide 
assistance under this heading is in addition to any other 
authority to provide assistance to foreign nations: Provided 
further, That contributions of funds for the purposes pro-
vided herein from any person, foreign government, or inter-
national organization may be credited to this Fund, to re-
main available until expended, and used for such purposes: 
Provided further, That the Secretary of Defense shall notify 
the congressional defense committees in writing upon the 
receipt and upon the obligation of any contribution, delin-
eating the sources and amounts of the funds received and 
the specific use of such contributions: Provided further, That 
the Secretary of Defense shall, not fewer than 15 days prior 
to obligating from this appropriation account, notify the 
congressional defense committees in writing of the details 
of any such obligation: Provided further, That the Secretary
132 
of Defense shall notify the congressional defense committees 
of any proposed new projects or transfer of funds between 
budget sub-activity groups in excess of $20,000,000: Pro-
vided further, That the United States may accept equip-
ment procured using funds provided under this heading in 
this or prior Acts that was transferred to the security forces 
of Afghanistan and returned by such forces to the United 
States: Provided further, That equipment procured using 
funds provided under this heading in this or prior Acts, 
and not yet transferred to the security forces of Afghanistan 
or transferred to the security forces of Afghanistan and re-
turned by such forces to the United States, may be treated 
as stocks of the Department of Defense upon written notifi-
cation to the congressional defense committees: Provided 
further, That of the funds provided under this heading, not 
less than $10,000,000 shall be for recruitment and retention 
of women in the Afghanistan National Security Forces, and 
the recruitment and training of female security personnel: 
Provided further, That such amount is designated by the 
Congress for Overseas Contingency Operations/Global War 
on Terrorism pursuant to section 251(b)(2)(A)(ii) of the 
Balanced Budget and Emergency Deficit Control Act of 
1985.
133 
COUNTER-ISIL TRAIN AND EQUIP FUND 
For the ‘‘Counter-Islamic State of Iraq and the Levant 
Train and Equip Fund’’, $1,769,000,000, to remain avail-
able until September 30, 2019: Provided, That such funds 
shall be available to the Secretary of Defense in coordina-
tion with the Secretary of State, to provide assistance, in-
cluding training; equipment; logistics support, supplies, 
and services; stipends; infrastructure repair and renova-
tion; and sustainment, to foreign security forces, irregular 
forces, groups, or individuals participating, or preparing 
to participate in activities to counter the Islamic State of 
Iraq and the Levant, and their affiliated or associated 
groups: Provided further, That these funds may be used in 
such amounts as the Secretary of Defense may determine 
to enhance the border security of nations adjacent to conflict 
areas including Jordan, Lebanon, Egypt, and Tunisia re-
sulting from actions of the Islamic State of Iraq and the 
Levant: Provided further, That amounts made available 
under this heading shall be available to provide assistance 
only for activities in a country designated by the Secretary 
of Defense, in coordination with the Secretary of State, as 
having a security mission to counter the Islamic State of 
Iraq and the Levant, and following written notification to 
the congressional defense committees of such designation: 
Provided further, That the Secretary of Defense shall ensure
134 
that prior to providing assistance to elements of any forces 
or individuals, such elements or individuals are appro-
priately vetted, including at a minimum, assessing such ele-
ments for associations with terrorist groups or groups asso-
ciated with the Government of Iran; and receiving commit-
ments from such elements to promote respect for human 
rights and the rule of law: Provided further, That the Sec-
retary of Defense shall, not fewer than 15 days prior to obli-
gating from this appropriation account, notify the congres-
sional defense committees in writing of the details of any 
such obligation: Provided further, That the Secretary of De-
fense may accept and retain contributions, including assist-
ance in-kind, from foreign governments, including the Gov-
ernment of Iraq and other entities, to carry out assistance 
authorized under this heading: Provided further, That con-
tributions of funds for the purposes provided herein from 
any foreign government or other entity may be credited to 
this Fund, to remain available until expended, and used 
for such purposes: Provided further, That the Secretary of 
Defense may waive a provision of law relating to the acqui-
sition of items and support services or sections 40 and 40A 
of the Arms Export Control Act (22 U.S.C. 2780 and 2785) 
if the Secretary determines that such provision of law would 
prohibit, restrict, delay or otherwise limit the provision of 
such assistance and a notice of and justification for such
135 
waiver is submitted to the congressional defense committees, 
the Committees on Appropriations and Foreign Relations 
of the Senate and the Committees on Appropriations and 
Foreign Affairs of the House of Representatives: Provided 
further, That the United States may accept equipment pro-
cured using funds provided under this heading, or under 
the heading, ‘‘Iraq Train and Equip Fund’’ in prior Acts, 
that was transferred to security forces, irregular forces, or 
groups participating, or preparing to participate in activi-
ties to counter the Islamic State of Iraq and the Levant 
and returned by such forces or groups to the United States, 
may be treated as stocks of the Department of Defense upon 
written notification to the congressional defense committees: 
Provided further, That equipment procured using funds 
provided under this heading, or under the heading, ‘‘Iraq 
Train and Equip Fund’’ in prior Acts, and not yet trans-
ferred to security forces, irregular forces, or groups partici-
pating, or preparing to participate in activities to counter 
the Islamic State of Iraq and the Levant may be treated 
as stocks of the Department of Defense when determined by 
the Secretary to no longer be required for transfer to such 
forces or groups and upon written notification to the con-
gressional defense committees: Provided further, That the 
Secretary of Defense shall provide quarterly reports to the 
congressional defense committees on the use of funds pro-
136 
vided under this heading, including, but not limited to, the 
number of individuals trained, the nature and scope of sup-
port and sustainment provided to each group or individual, 
the area of operations for each group, and the contributions 
of other countries, groups, or individuals: Provided further, 
That such amount is designated by the Congress for Over-
seas Contingency Operations/ Global War on Terrorism 
pursuant to section 251(b)(2)(A)(ii) of the Balanced Budget 
and Emergency Deficit Control Act of 1985. 
PROCUREMENT 
AIRCRAFT PROCUREMENT, ARMY 
For an additional amount for ‘‘Aircraft Procurement, 
Army’’, $424,686,000, to remain available until September 
30, 2020: Provided, That such amount is designated by the 
Congress for Overseas Contingency Operations/Global War 
on Terrorism pursuant to section 251(b)(2)(A)(ii) of the 
Balanced Budget and Emergency Deficit Control Act of 
1985. 
MISSILE PROCUREMENT, ARMY 
For an additional amount for ‘‘Missile Procurement, 
Army’’, $557,583,000, to remain available until September 
30, 2020: Provided, That such amount is designated by the 
Congress for Overseas Contingency Operations/Global War 
on Terrorism pursuant to section 251(b)(2)(A)(ii) of the
137 
Balanced Budget and Emergency Deficit Control Act of 
1985. 
PROCUREMENT OF WEAPONS AND TRACKED COMBAT 
VEHICLES, ARMY 
For an additional amount for ‘‘Procurement of Weap-
ons and Tracked Combat Vehicles, Army’’, $1,191,139,000, 
to remain available until September 30, 2020: Provided, 
That such amount is designated by the Congress for Over-
seas Contingency Operations/Global War on Terrorism pur-
suant to section 251(b)(2)(A)(ii) of the Balanced Budget 
and Emergency Deficit Control Act of 1985. 
PROCUREMENT OF AMMUNITION, ARMY 
For an additional amount for ‘‘Procurement of Am-
munition, Army’’, $193,436,000, to remain available until 
September 30, 2020: Provided, That such amount is des-
ignated by the Congress for Overseas Contingency Oper-
ations/Global War on Terrorism pursuant to section 
251(b)(2)(A)(ii) of the Balanced Budget and Emergency 
Deficit Control Act of 1985. 
OTHER PROCUREMENT, ARMY 
For an additional amount for ‘‘Other Procurement, 
Army’’, $405,575,000, to remain available until September 
30, 2020: Provided, That such amount is designated by the 
Congress for Overseas Contingency Operations/Global War 
on Terrorism pursuant to section 251(b)(2)(A)(ii) of the
138 
Balanced Budget and Emergency Deficit Control Act of 
1985. 
AIRCRAFT PROCUREMENT, NAVY 
For an additional amount for ‘‘Aircraft Procurement, 
Navy’’, $157,300,000, to remain available until September 
30, 2020: Provided, That such amount is designated by the 
Congress for Overseas Contingency Operations/Global War 
on Terrorism pursuant to section 251(b)(2)(A)(ii) of the 
Balanced Budget and Emergency Deficit Control Act of 
1985. 
WEAPONS PROCUREMENT, NAVY 
For an additional amount for ‘‘Weapons Procurement, 
Navy’’, $130,994,000, to remain available until September 
30, 2020: Provided, That such amount is designated by the 
Congress for Overseas Contingency Operations/Global War 
on Terrorism pursuant to section 251(b)(2)(A)(ii) of the 
Balanced Budget and Emergency Deficit Control Act of 
1985. 
PROCUREMENT OF AMMUNITION, NAVY AND MARINE 
CORPS 
For an additional amount for ‘‘Procurement of Am-
munition, Navy and Marine Corps’’, $223,843,000, to re-
main available until September 30, 2020: Provided, That 
such amount is designated by the Congress for Overseas 
Contingency Operations/Global War on Terrorism pursu-
139 
ant to section 251(b)(2)(A)(ii) of the Balanced Budget and 
Emergency Deficit Control Act of 1985. 
OTHER PROCUREMENT, NAVY 
For an additional amount for ‘‘Other Procurement, 
Navy’’, $207,984,000, to remain available until September 
30, 2020: Provided, That such amount is designated by the 
Congress for Overseas Contingency Operations/Global War 
on Terrorism pursuant to section 251(b)(2)(A)(ii) of the 
Balanced Budget and Emergency Deficit Control Act of 
1985. 
PROCUREMENT, MARINE CORPS 
For an additional amount for ‘‘Procurement, Marine 
Corps’’, $64,071,000, to remain available until September 
30, 2020: Provided, That such amount is designated by the 
Congress for Overseas Contingency Operations/Global War 
on Terrorism pursuant to section 251(b)(2)(A)(ii) of the 
Balanced Budget and Emergency Deficit Control Act of 
1985. 
AIRCRAFT PROCUREMENT, AIR FORCE 
For an additional amount for ‘‘Aircraft Procurement, 
Air Force’’, $510,836,000, to remain available until Sep-
tember 30, 2020: Provided, That such amount is designated 
by the Congress for Overseas Contingency Operations/Glob-
al War on Terrorism pursuant to section 251(b)(2)(A)(ii)
140 
of the Balanced Budget and Emergency Deficit Control Act 
of 1985. 
MISSILE PROCUREMENT, AIR FORCE 
For an additional amount for ‘‘Missile Procurement, 
Air Force’’, $381,700,000, to remain available until Sep-
tember 30, 2020: Provided, That such amount is designated 
by the Congress for Overseas Contingency Operations/Glob-
al War on Terrorism pursuant to section 251(b)(2)(A)(ii) 
of the Balanced Budget and Emergency Deficit Control Act 
of 1985. 
SPACE PROCUREMENT, AIR FORCE 
For an additional amount for ‘‘Space Procurement, 
Air Force’’, $2,256,000, to remain available until Sep-
tember 30, 2020: Provided, That such amount is designated 
by the Congress for Overseas Contingency Operations/Glob-
al War on Terrorism pursuant to section 251(b)(2)(A)(ii) 
of the Balanced Budget and Emergency Deficit Control Act 
of 1985. 
PROCUREMENT OF AMMUNITION, AIR FORCE 
For an additional amount for ‘‘Procurement of Am-
munition, Air Force’’, $501,509,000, to remain available 
until September 30, 2020: Provided, That such amount is 
designated by the Congress for Overseas Contingency Oper-
ations/Global War on Terrorism pursuant to section
142 
30 days after enactment of this Act, individually submit 
to the congressional defense committees the modernization 
priority assessment for their respective National Guard or 
Reserve component: Provided further, That none of the 
funds made available by this paragraph may be used to 
procure manned fixed wing aircraft, or procure or modify 
missiles, munitions, or ammunition: Provided further, That 
such amount is designated by the Congress for Overseas 
Contingency Operations/Global War on Terrorism pursu-
ant to section 251(b)(2)(A)(ii) of the Balanced Budget and 
Emergency Deficit Control Act of 1985. 
PROCUREMENT, NATIONAL DEFENSE RESTORATION FUND 
(INCLUDING TRANSFER OF FUNDS) 
In addition to amounts provided elsewhere in this Act, 
there is appropriated $6,000,000,000, for the ‘‘Procurement, 
National Defense Restoration Fund’’: Provided, That such 
funds provided under this heading shall only be available 
for programs, projects and activities necessary to implement 
the 2018 National Defense Strategy: Provided further, That 
such funds shall not be available for transfer until 30 days 
after the Secretary has submitted, and the congressional de-
fense committees have approved, the proposed allocation 
plan for the use of such funds to implement such strategy: 
Provided further, That such allocation plan shall include 
a detailed justification for the use of such funds and a de-
143 
scription of how such investments are necessary to imple-
ment the strategy: Provided further, That the Secretary of 
Defense may transfer these funds only to procurement ac-
counts: Provided further, That the funds transferred shall 
be merged with and shall be available for the same purposes 
and for the same time period, as the appropriation to which 
transferred: Provided further, That none of the funds made 
available under this heading may be transferred to any pro-
gram, project, or activity specifically limited or denied by 
this Act: Provided further, That the transfer authority pro-
vided under this heading is in addition to any other trans-
fer authority available to the Department of Defense: Pro-
vided further, That such amount is designated by the Con-
gress for Overseas Contingency Operations/Global War on 
Terrorism pursuant to section 251(b)(2)(A)(ii) of the Bal-
anced Budget and Emergency Deficit Control Act of 1985. 
RESEARCH, DEVELOPMENT, TEST AND 
EVALUATION 
RESEARCH, DEVELOPMENT, TEST AND EVALUATION, ARMY 
For an additional amount for ‘‘Research, Develop-
ment, Test and Evaluation, Army’’, $119,368,000 (in-
creased by $6,000,000), to remain available until September 
30, 2019: Provided, That such amount is designated by the 
Congress for Overseas Contingency Operations/Global War 
on Terrorism pursuant to section 251(b)(2)(A)(ii) of the
144 
Balanced Budget and Emergency Deficit Control Act of 
1985. 
RESEARCH, DEVELOPMENT, TEST AND EVALUATION, NAVY 
For an additional amount for ‘‘Research, Develop-
ment, Test and Evaluation, Navy’’, $124,865,000, to re-
main available until September 30, 2019: Provided, That 
such amount is designated by the Congress for Overseas 
Contingency Operations/Global War on Terrorism pursu-
ant to section 251(b)(2)(A)(ii) of the Balanced Budget and 
Emergency Deficit Control Act of 1985. 
RESEARCH, DEVELOPMENT, TEST AND EVALUATION, AIR 
FORCE 
For an additional amount for ‘‘Research, Develop-
ment, Test and Evaluation, Air Force’’, $144,508,000, to 
remain available until September 30, 2019: Provided, That 
such amount is designated by the Congress for Overseas 
Contingency Operations/Global War on Terrorism pursu-
ant to section 251(b)(2)(A)(ii) of the Balanced Budget and 
Emergency Deficit Control Act of 1985. 
RESEARCH, DEVELOPMENT, TEST AND EVALUATION, 
DEFENSE-WIDE 
For an additional amount for ‘‘Research, Develop-
ment, Test and Evaluation, Defense-Wide’’, $226,096,000, 
to remain available until September 30, 2019: Provided, 
That such amount is designated by the Congress for Over-
145 
seas Contingency Operations/Global War on Terrorism pur-
suant to section 251(b)(2)(A)(ii) of the Balanced Budget 
and Emergency Deficit Control Act of 1985. 
RESEARCH, DEVELOPMENT, TEST AND EVALUATION, 
NATIONAL DEFENSE RESTORATION FUND 
(INCLUDING TRANSFER OF FUNDS) 
In addition to amounts provided elsewhere in this Act, 
there is appropriated $1,000,000,000, for the ‘‘Research, De-
velopment, Test and Evaluation, National Defense Restora-
tion Fund’’: Provided, That such funds provided under this 
heading shall only be available for programs, projects and 
activities necessary to implement the 2018 National Defense 
Strategy: Provided further, That such funds shall not be 
available for transfer until 30 days after the Secretary has 
submitted, and the congressional defense committees have 
approved, the proposed allocation plan for the use of such 
funds to implement such strategy: Provided further, That 
such allocation plan shall include a detailed justification 
for the use of such funds and a description of how such 
investments are necessary to implement the strategy: Pro-
vided further, That the Secretary of Defense may transfer 
these funds only to research, development, test and evalua-
tion accounts: Provided further, That the funds transferred 
shall be merged with and shall be available for the same 
purposes and for the same time period, as the appropriation
146 
to which transferred: Provided further, That none of the 
funds made available under this heading may be trans-
ferred to any program, project, or activity specifically lim-
ited or denied by this Act: Provided further, That the trans-
fer authority provided under this heading is in addition 
to any other transfer authority available to the Department 
of Defense: Provided further, That such amount is des-
ignated by the Congress for Overseas Contingency Oper-
ations/Global War on Terrorism pursuant to section 
251(b)(2)(A)(ii) of the Balanced Budget and Emergency 
Deficit Control Act of 1985. 
REVOLVING AND MANAGEMENT FUNDS 
DEFENSE WORKING CAPITAL FUNDS 
For an additional amount for ‘‘Defense Working Cap-
ital Funds’’, $148,956,000: Provided, That such amount is 
designated by the Congress for Overseas Contingency Oper-
ations/Global War on Terrorism pursuant to section 
251(b)(2)(A)(ii) of the Balanced Budget and Emergency 
Deficit Control Act of 1985. 
OTHER DEPARTMENT OF DEFENSE PROGRAMS 
DEFENSE HEALTH PROGRAM 
For an additional amount for ‘‘Defense Health Pro-
gram’’, $395,805,000, which shall be for operation and 
maintenance: Provided, That such amount is designated by 
the Congress for Overseas Contingency Operations/Global
147 
War on Terrorism pursuant to section 251(b)(2)(A)(ii) of 
the Balanced Budget and Emergency Deficit Control Act 
of 1985. 
DRUG INTERDICTION AND COUNTER-DRUG ACTIVITIES, 
DEFENSE 
For an additional amount for ‘‘Drug Interdiction and 
Counter-Drug Activities, Defense’’, $196,300,000: Provided, 
That such amount is designated by the Congress for Over-
seas Contingency Operations/Global War on Terrorism pur-
suant to section 251(b)(2)(A)(ii) of the Balanced Budget 
and Emergency Deficit Control Act of 1985. 
JOINT IMPROVISED-THREAT DEFEAT FUND 
(INCLUDING TRANSFER OF FUNDS) 
For the ‘‘Joint Improvised-Threat Defeat Fund’’, 
$483,058,000, to remain available until September 30, 
2020: Provided, That such funds shall be available to the 
Secretary of Defense, notwithstanding any other provision 
of law, for the purpose of allowing the Director of the Joint 
Improvised-Threat Defeat Organization to investigate, de-
velop and provide equipment, supplies, services, training, 
facilities, personnel and funds to assist United States forces 
in the defeat of improvised explosive devices: Provided fur-
ther, That the Secretary of Defense may transfer funds pro-
vided herein to appropriations for military personnel; oper-
ation and maintenance; procurement; research, develop-
148 
ment, test and evaluation; and defense working capital 
funds to accomplish the purpose provided herein: Provided 
further, That this transfer authority is in addition to any 
other transfer authority available to the Department of De-
fense: Provided further, That the Secretary of Defense shall, 
not fewer than 5 days prior to making transfers from this 
appropriation, notify the congressional defense committees 
in writing of the details of any such transfer: Provided fur-
ther, That such amount is designated by the Congress for 
Overseas Contingency Operations/Global War on Terrorism 
pursuant to section 251(b)(2)(A)(ii) of the Balanced Budget 
and Emergency Deficit Control Act of 1985. 
OFFICE OF THE INSPECTOR GENERAL 
For an additional amount for the ‘‘Office of the Inspec-
tor General’’, $24,692,000: Provided, That such amount is 
designated by the Congress for Overseas Contingency Oper-
ations/Global War on Terrorism pursuant to section 
251(b)(2)(A)(ii) of the Balanced Budget and Emergency 
Deficit Control Act of 1985. 
GENERAL PROVISIONS—THIS TITLE 
SEC. 1301. Notwithstanding any other provision of 
law, funds made available in this title are in addition to 
amounts appropriated or otherwise made available for the 
Department of Defense for fiscal year 2018.
149 
(INCLUDING TRANSFER OF FUNDS) 
SEC. 1302. Upon the determination of the Secretary 
of Defense that such action is necessary in the national in-
terest, the Secretary may, with the approval of the Office 
of Management and Budget, transfer up to $2,500,000,000 
between the appropriations or funds made available to the 
Department of Defense in this title: Provided, That the Sec-
retary shall notify the Congress promptly of each transfer 
made pursuant to the authority in this section: Provided 
further, That the authority provided in this section is in 
addition to any other transfer authority available to the 
Department of Defense and is subject to the same terms and 
conditions as the authority provided in section 8005 of this 
Act. 
SEC. 1303. Supervision and administration costs and 
costs for design during construction associated with a con-
struction project funded with appropriations available for 
operation and maintenance or the ‘‘Afghanistan Security 
Forces Fund’’ provided in this Act and executed in direct 
support of overseas contingency operations in Afghanistan, 
may be obligated at the time a construction contract is 
awarded: Provided, That, for the purpose of this section, 
supervision and administration costs and costs for design 
during construction include all in-house Government costs.
150 
SEC. 1304. From funds made available in this title, 
the Secretary of Defense may purchase for use by military 
and civilian employees of the Department of Defense in the 
United States Central Command area of responsibility: 
(1) passenger motor vehicles up to a limit of 
$75,000 per vehicle; and 
(2) heavy and light armored vehicles for the 
physical security of personnel or for force protection 
purposes up to a limit of $450,000 per vehicle, not-
withstanding price or other limitations applicable to 
the purchase of passenger carrying vehicles. 
SEC. 1305. Not to exceed $5,000,000 of the amounts 
appropriated by this title under the heading ‘‘Operation 
and Maintenance, Army’’ may be used, notwithstanding 
any other provision of law, to fund the Commanders’ Emer-
gency Response Program (CERP), for the purpose of ena-
bling military commanders in Afghanistan to respond to 
urgent, small-scale, humanitarian relief and reconstruction 
requirements within their areas of responsibility: Provided, 
That each project (including any ancillary or related ele-
ments in connection with such project) executed under this 
authority shall not exceed $2,000,000: Provided further, 
That not later than 45 days after the end of each 6 months 
of the fiscal year, the Secretary of Defense shall submit to 
the congressional defense committees a report regarding the
151 
source of funds and the allocation and use of funds during 
that 6-month period that were made available pursuant to 
the authority provided in this section or under any other 
provision of law for the purposes described herein: Provided 
further, That, not later than 30 days after the end of each 
fiscal year quarter, the Army shall submit to the congres-
sional defense committees quarterly commitment, obliga-
tion, and expenditure data for the CERP in Afghanistan: 
Provided further, That, not less than 15 days before making 
funds available pursuant to the authority provided in this 
section or under any other provision of law for the purposes 
described herein for a project with a total anticipated cost 
for completion of $500,000 or more, the Secretary shall sub-
mit to the congressional defense committees a written notice 
containing each of the following: 
(1) The location, nature and purpose of the pro-
posed project, including how the project is intended to 
advance the military campaign plan for the country 
in which it is to be carried out. 
(2) The budget, implementation timeline with 
milestones, and completion date for the proposed 
project, including any other CERP funding that has 
been or is anticipated to be contributed to the comple-
tion of the project.
152 
(3) A plan for the sustainment of the proposed 
project, including the agreement with either the host 
nation, a non-Department of Defense agency of the 
United States Government or a third-party contrib-
utor to finance the sustainment of the activities and 
maintenance of any equipment or facilities to be pro-
vided through the proposed project. 
SEC. 1306. Funds available to the Department of De-
fense for operation and maintenance may be used, notwith-
standing any other provision of law, to provide supplies, 
services, transportation, including airlift and sealift, and 
other logistical support to allied forces participating in a 
combined operation with the armed forces of the United 
States and coalition forces supporting military and sta-
bility operations in Afghanistan and to counter the Islamic 
State of Iraq and the Levant: Provided, That the Secretary 
of Defense shall provide quarterly reports to the congres-
sional defense committees regarding support provided under 
this section. 
SEC. 1307. None of the funds appropriated or other-
wise made available by this or any other Act shall be obli-
gated or expended by the United States Government for a 
purpose as follows:
153 
(1) To establish any military installation or base 
for the purpose of providing for the permanent sta-
tioning of United States Armed Forces in Iraq. 
(2) To exercise United States control over any 
oil resource of Iraq. 
(3) To establish any military installation or base 
for the purpose of providing for the permanent sta-
tioning of United States Armed Forces in Afghani-
stan. 
SEC. 1308. None of the funds made available in this 
Act may be used in contravention of the following laws en-
acted or regulations promulgated to implement the United 
Nations Convention Against Torture and Other Cruel, In-
human or Degrading Treatment or Punishment (done at 
New York on December 10, 1984): 
(1) Section 2340A of title 18, United States 
Code. 
(2) Section 2242 of the Foreign Affairs Reform 
and Restructuring Act of 1998 (division G of Public 
Law 105–277; 112 Stat. 2681–822; 8 U.S.C. 1231 
note) and regulations prescribed thereto, including 
regulations under part 208 of title 8, Code of Federal 
Regulations, and part 95 of title 22, Code of Federal 
Regulations.
154 
(3) Sections 1002 and 1003 of the Department of 
Defense, Emergency Supplemental Appropriations to 
Address Hurricanes in the Gulf of Mexico, and Pan-
demic Influenza Act, 2006 (Public Law 109–148). 
SEC. 1309. None of the funds provided for the ‘‘Afghan-
istan Security Forces Fund’’ (ASFF) may be obligated 
prior to the approval of a financial and activity plan by 
the Afghanistan Resources Oversight Council (AROC) of the 
Department of Defense: Provided, That the AROC must ap-
prove the requirement and acquisition plan for any service 
requirements in excess of $50,000,000 annually and any 
non-standard 
equipment 
requirements 
in 
excess 
of 
$100,000,000 using ASFF: Provided further, That the De-
partment of Defense must certify to the congressional de-
fense committees that the AROC has convened and approved 
a process for ensuring compliance with the requirements in 
the preceding proviso and accompanying report language 
for the ASFF. 
SEC. 1310. Funds made available in this title to the 
Department of Defense for operation and maintenance may 
be used to purchase items having an investment unit cost 
of not more than $250,000: Provided, That, upon deter-
mination by the Secretary of Defense that such action is 
necessary to meet the operational requirements of a Com-
mander of a Combatant Command engaged in contingency
155 
operations overseas, such funds may be used to purchase 
items having an investment item unit cost of not more than 
$500,000. 
SEC. 1311. Up to $500,000,000 of funds appropriated 
by this Act for the Defense Security Cooperation Agency 
in ‘‘Operation and Maintenance, Defense-Wide’’ may be 
used to provide assistance to the Government of Jordan to 
support the armed forces of Jordan and to enhance security 
along its borders. 
SEC. 1312. None of the funds made available by this 
Act under the heading ‘‘Counter-ISIL Train and Equip 
Fund’’ may be used to procure or transfer man-portable air 
defense systems. 
SEC. 1313. For the ‘‘Ukraine Security Assistance Ini-
tiative’’, $150,000,000 is hereby appropriated, to remain 
available until September 30, 2018: Provided, That such 
funds shall be available to the Secretary of Defense, in co-
ordination with the Secretary of State, to provide assist-
ance, including training; equipment; lethal weapons of a 
defensive nature; logistics support, supplies and services; 
sustainment; and intelligence support to the military and 
national security forces of Ukraine, and for replacement of 
any weapons or defensive articles provided to the Govern-
ment of Ukraine from the inventory of the United States: 
Provided further, That the Secretary of Defense shall, not
156 
less than 15 days prior to obligating funds provided under 
this heading, notify the congressional defense committees in 
writing of the details of any such obligation: Provided fur-
ther, That the United States may accept equipment pro-
cured using funds provided under this heading in this or 
prior Acts that was transferred to the security forces of 
Ukraine and returned by such forces to the United States: 
Provided further, That equipment procured using funds 
provided under this heading in this or prior Acts, and not 
yet transferred to the military or National Security Forces 
of Ukraine or returned by such forces to the United States, 
may be treated as stocks of the Department of Defense upon 
written notification to the congressional defense committees: 
Provided further, That amounts made available by this sec-
tion are designated by the Congress for Overseas Contin-
gency Operations/Global War on Terrorism pursuant to sec-
tion 251(b)(2)(A)(ii) of the Balanced Budget and Emer-
gency Deficit Control Act of 1985. 
SEC. 1314. Funds appropriated in this title shall be 
available for replacement of funds for items provided to the 
Government of Ukraine from the inventory of the United 
States to the extent specifically provided for in section 9013 
of this Act. 
SEC. 1315. None of the funds made available by this 
Act under section 9013 for ‘‘Assistance and Sustainment
157 
to the Military and National Security Forces of Ukraine’’ 
may be used to procure or transfer man-portable air defense 
systems. 
SEC. 1316. (a) None of the funds appropriated or oth-
erwise made available by this Act under the heading ‘‘Oper-
ation and Maintenance, Defense-Wide’’ for payments under 
section 1233 of Public Law 110–181 for reimbursement to 
the Government of Pakistan may be made available unless 
the Secretary of Defense, in coordination with the Secretary 
of State, certifies to the congressional defense committees 
that the Government of Pakistan is— 
(1) cooperating with the United States in 
counterterrorism efforts against the Haqqani Network, 
the Quetta Shura Taliban, Lashkar e-Tayyiba, Jaish- 
e-Mohammed, Al Qaeda, and other domestic and for-
eign terrorist organizations, including taking steps to 
end support for such groups and prevent them from 
basing and operating in Pakistan and carrying out 
cross border attacks into neighboring countries; 
(2) not supporting terrorist activities against 
United States or coalition forces in Afghanistan, and 
Pakistan’s military and intelligence agencies are not 
intervening extra-judicially into political and judicial 
processes in Pakistan;
158 
(3) dismantling improvised explosive device 
(IED) networks and interdicting precursor chemicals 
used in the manufacture of IEDs; 
(4) preventing the proliferation of nuclear-re-
lated material and expertise; 
(5) implementing policies to protect judicial 
independence and due process of law; 
(6) issuing visas in a timely manner for United 
States visitors engaged in counterterrorism efforts and 
assistance programs in Pakistan; and 
(7) providing humanitarian organizations access 
to detainees, internally displaced persons, and other 
Pakistani civilians affected by the conflict. 
(b) The Secretary of Defense, in coordination with the 
Secretary of State, may waive the restriction in subsection 
(a) on a case-by-case basis by certifying in writing to the 
congressional defense committees that it is in the national 
security interest to do so: Provided, That if the Secretary 
of Defense, in coordination with the Secretary of State, ex-
ercises such waiver authority, the Secretaries shall report 
to the congressional defense committees on both the justifica-
tion for the waiver and on the requirements of this section 
that the Government of Pakistan was not able to meet: Pro-
vided further, That such report may be submitted in classi-
fied form if necessary.
159 
(INCLUDING TRANSFER OF FUNDS) 
SEC. 1317. In addition to amounts otherwise made 
available in this Act, $500,000,000 is hereby appropriated 
to the Department of Defense and made available for trans-
fer only to the operation and maintenance, military per-
sonnel, and procurement accounts, to improve the intel-
ligence, surveillance, and reconnaissance capabilities of the 
Department of Defense: Provided, That the transfer author-
ity provided in this section is in addition to any other 
transfer authority provided elsewhere in this Act: Provided 
further, That not later than 30 days prior to exercising the 
transfer authority provided in this section, the Secretary 
of Defense shall submit a report to the congressional defense 
committees on the proposed uses of these funds: Provided 
further, That the funds provided in this section may not 
be transferred to any program, project, or activity specifi-
cally limited or denied by this Act: Provided further, That 
amounts made available by this section are designated by 
the Congress for Overseas Contingency Operations/Global 
War on Terrorism pursuant to section 251(b)(2)(A)(ii) of 
the Balanced Budget and Emergency Deficit Control Act 
of 1985: Provided further, That the authority to provide 
funding under this section shall terminate on September 30, 
2018.
160 
SEC. 1318. None of the funds made available by this 
Act may be used with respect to Syria in contravention of 
the War Powers Resolution (50 U.S.C. 1541 et seq.), includ-
ing for the introduction of United States armed or military 
forces into hostilities in Syria, into situations in Syria 
where imminent involvement in hostilities is clearly indi-
cated by the circumstances, or into Syrian territory, air-
space, or waters while equipped for combat, in contraven-
tion of the congressional consultation and reporting require-
ments of sections 3 and 4 of that law (50 U.S.C. 1542 and 
1543). 
(RESCISSIONS) 
SEC. 1319. Of the funds appropriated in Department 
of Defense Appropriations Acts, the following funds are 
hereby rescinded from the following accounts and programs 
in the specified amounts: Provided, That such amounts are 
designated by the Congress for Overseas Contingency Oper-
ations/Global War on Terrorism pursuant to section 
251(b)(2)(A)(ii) of the Balanced Budget and Emergency 
Deficit Control Act of 1985: 
‘‘Other Procurement, Air Force’’, 2017/2019, 
$25,100,000; 
‘‘Afghanistan Security Forces Fund’’, 2017/2018, 
$100,000,000; and
161 
‘‘Counter-ISIL Train and Equip Fund’’, 2017/ 
2018, $112,513,000. 
‘‘Operation and Maintenance, Defense-Wide, 
DSCA 
Coalition 
Support 
Fund’’, 
2017/2018, 
$350,000,000. 
SEC. 1320. Each amount designated in this Act by the 
Congress for Overseas Contingency Operations/Global War 
on Terrorism pursuant to section 251(b)(2)(A)(ii) of the 
Balanced Budget and Emergency Deficit Control Act of 
1985 shall be available only if the President subsequently 
so designates all such amounts and transmits such designa-
tions to the Congress. 
SEC. 1321. (a) Not later than 30 days after the date 
of the enactment of this Act, the President shall submit to 
Congress a report on the United States strategy to defeat 
Al-Qaeda, the Taliban, the Islamic State of Iraq and Syria 
(ISIS), and their associated forces and co-belligerents. 
(b) The report required under subsection (a) shall in-
clude the following: 
(1) An analysis of the adequacy of the existing 
legal framework to accomplish the strategy described 
in subsection (a), particularly with respect to the Au-
thorization for Use of Military Force (Public Law 
107–40; 50 U.S.C. 1541 note) and the Authorization
162 
for Use of Military Force Against Iraq Resolution of 
2002 (Public Law 107–243; 50 U.S.C. 1541 note). 
(2) An analysis of the budgetary resources nec-
essary to accomplish the strategy described in sub-
section (a). 
(c) Not later than 30 days after the date on which the 
President submits to the appropriate congressional commit-
tees the report required by subsection (a), the Secretary of 
State and the Secretary of Defense shall testify at any hear-
ing held by any of the appropriate congressional committees 
on the report and to which the Secretary is invited. 
(d) In this section, the term ‘‘appropriate congres-
sional committees’’ means— 
(1) the Committee on Foreign Relations and the 
Committee on Armed Services of the Senate; and 
(2) the Committee on Foreign Affairs and the 
Committee on Armed Services of the House of Rep-
resentatives. 
SEC. 1322. (a) In addition to amounts provided else-
where 
in 
this 
Act, 
there 
is 
hereby 
appropriated 
$1,184,112,000, for the following accounts and programs in 
the specified amounts for costs associated with Operation 
Freedom’s Sentinel: 
(1) ‘‘Military Personnel, Army’’, $48,377,000;
163 
(2) 
‘‘Military 
Personnel, 
Marine 
Corps’’, 
$179,000; 
(3) ‘‘Military Personnel, Air Force’’, $1,340,000; 
(4) 
‘‘Operation 
and 
Maintenance, 
Army’’, 
$872,491,000; 
(5) 
‘‘Operation 
and 
Maintenance, 
Navy’’, 
$76,274,000; 
(6) 
‘‘Operation 
and 
Maintenance, 
Marine 
Corps’’, $24,734,000; 
(7) ‘‘Operation and Maintenance, Defense-Wide’’, 
$81,164,000; 
(8) ‘‘Procurement of Ammunition, Navy and 
Marine Corps’’, $10,853,000, to remain available 
until September 30, 2020; 
(9) ‘‘Other Procurement, Navy’’, $31,500,000, to 
remain available until September 30, 2020; and 
(10) ‘‘Research, Development, Test and Evalua-
tion, Navy’’, $37,200,000, to remain available until 
September 30, 2019. 
(b) Amounts provided pursuant to this section are 
hereby designated by the Congress for Overseas Contingency 
Operations/Global War on Terrorism pursuant to section 
251(b)(2)(A)(ii) of the Balanced Budget and Emergency 
Deficit Control Act of 1985.
164 
TITLE X—ADDITIONAL GENERAL PROVISIONS 
REFERENCES TO REPORT 
SEC. 1401. Any reference to a ‘‘report accompanying 
this Act’’ contained in this Act shall be treated as a ref-
erence to House Report 115–219. Such report shall apply 
for purposes of determining the allocation of funds provided 
by, and the implementation of, this Act. 
SPENDING REDUCTION ACCOUNT 
SEC. 1402. $0. 
SEC. 1403. None of the funds appropriated or other-
wise made available under the heading ‘‘Afghanistan Secu-
rity Forces Fund’’ may be used to procure uniforms for the 
Afghan National Army. 
SEC. 1404. None of the funds made available in this 
Act may be used for the closure of a biosafety level 4 labora-
tory. 
SEC. 1405. None of the funds made available by this 
Act may be used to provide arms, training, or other assist-
ance to the Azov Battalion. 
SEC. 1406. None of the finds made available by this 
Act may be used to purchase heavy water from Iran. 
SEC. 1407. None of the funds appropriated by this Act 
may be used to plan for, begin, continue, complete, process, 
or approve a public-private competition under the Office 
of Management and Budget Circular A-76.
165 
SEC. 1408. Notwithstanding any other provision of 
law, with respect to the revised security category (as that 
term is defined in section 250(c)(4)(D) of the Balanced 
Budget and Emergency Deficit Control Act of 1985), any 
sequestration order issued under such Act for fiscal year 
2018 shall have no force or effect. 
This division may be cited as the ‘‘Department of De-
fense Appropriations Act, 2018’’. 
DIVISION D—MISCELLANEOUS 
SEC. 1501. (a) Section 1240B of the Food Security Act 
of 1985 (16 U.S.C. 3839aa-2) is amended by striking sub-
section (a) and inserting the following: 
‘‘(a) ESTABLISHMENT.—During each of the 2002 
through 2019 fiscal years, the Secretary shall provide pay-
ments to producers that enter into contracts with the Sec-
retary under the program.’’. 
(b) Section 1241 of the Food Security Act of 1985 (16 
U.S.C. 3841) is amended— 
(1) in subsection (a)— 
(A) in the matter preceding paragraph (1), 
by striking ‘‘2018’’ and inserting ‘‘2018 (and fis-
cal year 2019 in the case of the program speci-
fied in paragraph (5))’’; and
166 
(B) in paragraph (5)(E), by striking ‘‘fiscal 
year 2018’’ and inserting ‘‘each of fiscal years 
2018 through 2019’’; and 
(2) in subsection (b), by striking ‘‘2018’’ and in-
serting ‘‘2018 (and fiscal year 2019 in the case of the 
program specified in subsection (a)(5))’’. 
DIVISION E—TAX MATTERS 
SEC. 1601. REPEAL OF SHIFT IN TIME OF PAYMENT OF COR-
PORATE ESTIMATED TAXES. 
The Trade Preferences Extension Act of 2015 is 
amended by striking section 803 (relating to time for pay-
ment of corporate estimated taxes). 
DIVISION F—HEALTH 
PROVISIONS 
SEC. 2100. SHORT TITLE. 
This division may be cited as the ‘‘Strengthening and 
Underpinning the Safety-net to Aid Individuals Needing 
Care Act of 2018’’ or the ‘‘SUSTAIN Care Act of 2018’’. 
TITLE I—MEDICARE EXTENDERS 
AND RELATED POLICIES 
Subtitle A—Medicare Part A 
SEC. 2101. EXTENSION OF THE MEDICARE-DEPENDENT 
HOSPITAL (MDH) PROGRAM. 
(a) IN GENERAL.—Section 1886(d)(5)(G) of the Social 
Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amended—
167 
(1) in clause (i), by striking ‘‘October 1, 2017’’ 
and inserting ‘‘October 1, 2019’’; 
(2) in clause (ii)(II), by striking ‘‘October 1, 
2017’’ and inserting ‘‘October 1, 2019’’; and 
(3) in clause (iv)— 
(A) by amending subclause (I) to read as 
follows: 
‘‘(I) that— 
‘‘(aa) is located in a rural 
area; or 
‘‘(bb) for discharges occur-
ring on or after October 1, 2017, 
is located in a State with no 
rural area (as defined in para-
graph (2)(D)) and satisfies any of 
the criteria in subclause (I), (II), 
(III), 
or 
(IV) 
of 
paragraph 
(8)(E)(ii),’’; and 
(B) by adding at the end, after and below 
subclause (IV), the following flush sentence: 
‘‘For purposes of applying subclause (II) of paragraph 
(8)(E)(ii) under subclause (I)(bb), such subclause (II) shall 
be applied by inserting ‘as of January 1, 2018,’ after ‘such 
State’ each place it appears.’’. 
(b) CONFORMING AMENDMENTS.—
168 
(1) EXTENSION
OF
TARGET
AMOUNT.—Section 
1886(b)(3)(D) of the Social Security Act (42 U.S.C. 
1395ww(b)(3)(D)) is amended— 
(A) in the matter preceding clause (i), by 
striking ‘‘October 1, 2017’’ and inserting ‘‘Octo-
ber 1, 2019’’; and 
(B) in clause (iv), by striking ‘‘through fis-
cal year 2017’’ and inserting ‘‘through fiscal 
year 2019’’. 
(2) PERMITTING
HOSPITALS
TO
DECLINE
RE-
CLASSIFICATION.—Section 13501(e)(2) of the Omni-
bus Budget Reconciliation Act of 1993 (42 U.S.C. 
1395ww note) is amended by striking ‘‘through fiscal 
year 2017’’ and inserting ‘‘through fiscal year 2019’’. 
SEC. 2102. EXTENSION OF INCREASED INPATIENT HOS-
PITAL PAYMENT ADJUSTMENT FOR CERTAIN 
LOW-VOLUME HOSPITALS. 
Section 1886(d)(12) of the Social Security Act (42 
U.S.C. 1395ww(d)(12)) is amended— 
(1) in subparagraph (B), in the matter pre-
ceding clause (i), by striking ‘‘fiscal year 2018’’ and 
inserting ‘‘fiscal year 2020’’; 
(2) in subparagraph (C)(i), by striking ‘‘fiscal 
years 2011 through 2017’’ and inserting ‘‘fiscal years 
2011 through 2019’’ each place it appears; and
169 
(3) in subparagraph (D), by striking ‘‘fiscal 
years 2011 through 2017’’ and inserting ‘‘fiscal years 
2011 through 2019’’. 
SEC. 2103. STUDIES RELATING TO HOSPITAL PROGRAMS 
PAID OUTSIDE OF PROSPECTIVE PAYMENT 
SYSTEMS. 
(a) MEDPAC REPORT.—Using data from hospital 
programs with respect to which hospitals receive payment 
outside of the prospective payment systems under sections 
1833 and 1886 of the Social Security Act (42 U.S.C. 1395l; 
42 U.S.C. 1395ww) (such programs referred to in this sub-
section as ‘‘PPS carve-out programs’’) or other data, as 
available, not later than June 30, 2019, the Medicare Pay-
ment Advisory Commission shall submit to Congress a re-
port that evaluates and recommends changes to PPS carve- 
out programs, including with respect to amendments made 
by sections 2101 and 2102 of this Act, sections 1814, 1820, 
1886(d)(5)(D)(iii), and 1115(A) of the Social Security Act, 
and such other sections of title XVIII of the Social Security 
Act deemed appropriate. To the extent feasible, such report 
shall make recommendations on a payment methodology 
under the Medicare program for hospital payments, includ-
ing with respect to PPS carve-out programs, that differs 
from the payment methodology applicable to such programs 
as of September 30, 2017.
170 
(b) MEDPAC RECOMMENDATIONS FOR POSSIBLE AL-
TERNATIVE PAYMENTS.—Not later than 2 years after the 
date by which the Secretary of Health and Human Services 
has collected 2 years of data under sections 1886(d)(5)(G) 
and 1886(d)(12) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(G); 42 U.S.C. 1395ww(d)(12)), as extended 
pursuant to sections 2101 and 2102 of this Act, the Medi-
care Payment Advisory Commission shall submit to Con-
gress a report, including— 
(1) recommendations on payments, including a 
technical prototype for payments for PPS carve-out 
programs, if warranted; 
(2) recommendations, if any, on which Medicare 
fee-for-service regulations for hospital payments under 
title XVIII of the Social Security Act should be al-
tered (such as the critical access hospital 96-hour 
rule); 
(3) an analysis of the impact of the rec-
ommended payments described in paragraph (1) on 
Medicare beneficiary cost-sharing, access to care, and 
choice of setting; 
(4) a projection of any potential reduction in ex-
penditures under title XVIII of the Social Security 
Act that may be attributable to the application of the 
recommended payments described in paragraph (1);
171 
(5) a review of the value of hospitals partici-
pating in PPS carve-out programs collecting and re-
porting to the Secretary standardized patient assess-
ment data with respect to inpatient hospital services; 
(6) the types of rural hospital classifications and 
payment methodologies under the Medicare program, 
including information on each special payment struc-
ture such as eligibility criteria, and any areas of 
overlap between such special payment programs; 
(7) Medicare spending on each PPS carve-out 
program; 
(8) the financial aspects of hospitals partici-
pating in such PPS carve-out programs, such as the 
share of discharges under the Medicare and Medicaid 
programs; and 
(9) whether such payment programs are empiri-
cally justified to support Medicare beneficiary access 
to care. 
SEC. 2104. EXTENSION OF HOME HEALTH RURAL ADD-ON. 
(a) EXTENSION.— 
(1) IN GENERAL.—Section 421 of the Medicare 
Prescription Drug, Improvement, and Modernization 
Act of 2003 (Public Law 108–173; 117 Stat. 2283; 42 
U.S.C. 1395fff note), as amended by section 5201(b) 
of the Deficit Reduction Act of 2005 (Public Law
172 
109–171; 120 Stat. 46), section 3131(c) of the Patient 
Protection and Affordable Care Act (Public Law 111– 
148; 124 Stat. 428), and section 210 of the Medicare 
Access and CHIP Reauthorization Act of 2015 (Pub-
lic Law 114–10; 129 Stat. 151) is amended— 
(A) in subsection (a), by striking ‘‘January 
1, 2018’’ and inserting ‘‘January 1, 2019’’ each 
place it appears; 
(B) by redesignating subsections (b) and (c) 
as subsections (c) and (d), respectively; 
(C) in each of subsections (c) and (d), as so 
redesignated, by striking ‘‘subsection (a)’’ and 
inserting ‘‘subsection (a) or (b)’’; and 
(D) by inserting after subsection (a) the fol-
lowing new subsection: 
‘‘(b) SUBSEQUENT TEMPORARY INCREASE.— 
‘‘(1) IN GENERAL.—The Secretary shall increase 
the payment amount otherwise made under such sec-
tion 1895 for home health services furnished in a 
county (or equivalent area) in a rural area (as de-
fined in such section 1886(d)(2)(D)) that, as deter-
mined by the Secretary— 
‘‘(A) is in the highest quartile of all coun-
ties (or equivalent areas) based on the number of 
Medicare home health episodes furnished per 100
173 
individuals who are entitled to, or enrolled for, 
benefits under part A of title XVIII of the Social 
Security Act or enrolled for benefits under part 
B of such title (but not enrolled in a plan under 
part C of such title)— 
‘‘(i) in the case of episodes and visits 
ending during 2019, by 1.5 percent; and 
‘‘(ii) in the case of episodes and visits 
ending during 2020, by 0.5 percent; 
‘‘(B) has a population density of 6 individ-
uals or fewer per square mile of land area and 
is not described in subparagraph (A)— 
‘‘(i) in the case of episodes and visits 
ending during 2019, by 4 percent; 
‘‘(ii) in the case of episodes and visits 
ending during 2020, by 3 percent; 
‘‘(iii) in the case of episodes and visits 
ending during 2021, by 2 percent; and 
‘‘(iv) in the case of episodes and visits 
ending during 2022, by 1 percent; and 
‘‘(C) is not described in either subpara-
graph (A) or (B)— 
‘‘(i) in the case of episodes and visits 
ending during 2019, by 3 percent;
174 
‘‘(ii) in the case of episodes and visits 
ending during 2020, by 2 percent; and 
‘‘(iii) in the case of episodes and visits 
ending during 2021, by 1 percent. 
‘‘(2) RULES FOR DETERMINATIONS.— 
‘‘(A) NO SWITCHING.—For purposes of this 
subsection, the determination by the Secretary as 
to which subparagraph of paragraph (1) applies 
to a county (or equivalent area) shall be made 
a single time and shall apply for the duration 
of the period to which this subsection applies. 
‘‘(B) UTILIZATION.—In determining which 
counties (or equivalent areas) are in the highest 
quartile under paragraph (1)(A), the following 
rules shall apply: 
‘‘(i) The Secretary shall use data from 
2015. 
‘‘(ii) The Secretary shall exclude data 
from the territories (and the territories shall 
not be described in such paragraph). 
‘‘(iii) The Secretary may exclude data 
from counties (or equivalent areas) in rural 
areas with a low volume of home health epi-
sodes (and if data is so excluded with re-
spect to a county (or equivalent area), such
175 
county (or equivalent area) shall not be de-
scribed in such paragraph). 
‘‘(C) 
POPULATION
DENSITY.—In 
deter-
mining population density under paragraph 
(1)(B), the Secretary shall use data from the 
2010 decennial Census. 
‘‘(3) LIMITATIONS ON REVIEW.—There shall be 
no administrative or judicial review under section 
1869, section 1878, or otherwise of determinations 
under paragraph (1).’’. 
(2) REQUIREMENT TO SUBMIT COUNTY DATA ON 
CLAIM FORM.—Section 1895(c) of the Social Security 
Act (42 U.S.C. 1395fff(c)) is amended— 
(A) in paragraph (1), by striking ‘‘and’’ at 
the end; 
(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) in the case of home health services furnished 
on or after January 1, 2019, the claim contains the 
code for the county (or equivalent area) in which the 
home health service was furnished.’’. 
(b) OIG REVIEW.—The Office of the Inspector General 
shall submit to Congress, not later than January 1, 2020,
176 
and annually thereafter through January 1, 2024, a report 
containing— 
(1) an analysis of payments made under section 
1895 of the Social Security Act (42 U.S.C. 1395fff) 
increased under section 421 of the Medicare Prescrip-
tion Drug, Improvement, and Modernization Act of 
2003 (Public Law 108–173; 117 Stat. 2283; 42 
U.S.C. 1395fff note), as amended by section 5201(b) 
of the Deficit Reduction Act of 2005 (Public Law 
109–171; 120 Stat. 46), section 3131(c) of the Patient 
Protection and Affordable Care Act (Public Law 111– 
148; 124 Stat. 428), section 210 of the Medicare Ac-
cess and CHIP Reauthorization Act of 2015 (Public 
Law 114–10; 129 Stat. 151), and subsection (a); and 
(2) a recommendation on whether such payments 
should continue to be made based on county data. 
Subtitle B—Medicare Part B 
SEC. 2111. GROUND AMBULANCE SERVICES COST REPORT-
ING REQUIREMENT. 
(a) IN GENERAL.—Section 1121 of the Social Security 
Act (42 U.S.C. 1320a) is amended— 
(1) in subsection (a)— 
(A) by striking ‘‘For the purposes of’’ and 
inserting ‘‘Subject to subsection (d), for the pur-
poses of’’;
177 
(B) by inserting ‘‘suppliers of ground am-
bulance services,’’ after ‘‘health maintenance or-
ganizations,’’; and 
(C) in the matter following paragraph (5), 
by adding the following new sentence: ‘‘Not later 
than December 31, 2019, the Secretary shall 
modify the uniform reporting systems for pro-
viders of services with respect to ground ambu-
lance services to ensure that such systems con-
tain information similar (as determined by the 
Secretary) to information required under the 
uniform reporting system for suppliers of ground 
ambulance services.’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(d) In the case of a provider or supplier of ground 
ambulance services, the Secretary may modify the require-
ments for the inclusion of any data element specified in 
subsection (a) in reports made in accordance with the uni-
form reporting system established under this section with 
respect to such services for such provider or supplier.’’. 
(b) SUSPENSION OF PAYMENT FOR GROUND AMBU-
LANCE SERVICES; DEEMING CERTAIN PAYMENTS OVERPAY-
MENTS.—Section 1834(l) of the Social Security Act (42
178 
U.S.C. 1395m(l)) is amended by adding at the end the fol-
lowing new paragraph: 
‘‘(17) REQUIREMENT TO SUBMIT COST REPORT 
AND AUTHORITY TO SUSPEND PAYMENTS AND DEEM 
CERTAIN PAYMENTS OVERPAYMENTS FOR GROUND AM-
BULANCE SERVICES.— 
‘‘(A) IN GENERAL.—With respect to ground 
ambulance services furnished by a supplier of 
such services during cost reporting periods (as 
defined in subparagraph (I)) beginning on or 
after January 1, 2020, such supplier shall make 
reports to the Secretary of information described 
in section 1121(a) in accordance with the uni-
form reporting system established under such sec-
tion for such suppliers and, as may be required 
by the Secretary, of any of the information de-
scribed in subparagraph (B). 
‘‘(B) ADDITIONAL INFORMATION.—The Sec-
retary may, with respect to a supplier of ground 
ambulance services, require the following infor-
mation (to be reported to the extent practicable 
under the uniform reporting system established 
under section 1121(a) for such suppliers): 
‘‘(i) Whether the supplier is part of an 
emergency services department, a govern-
179 
mental organization, or another type of en-
tity (as described by the Secretary). 
‘‘(ii) The number of hours in a week 
during which the supplier is available for 
furnishing ground ambulance services. 
‘‘(iii) The average number of volunteer 
hours a week used by the supplier. 
‘‘(C) SUSPENSION OF PAYMENT.—Subject to 
subparagraph (E), in the case that the Secretary 
determines that a supplier of ground ambulance 
services has not made to the Secretary a timely 
report described in subparagraph (A) with re-
spect to a cost reporting period beginning on or 
after January 1, 2020, and before January 1, 
2022, the Secretary may suspend payments 
made under this subsection, in whole or in part, 
to such supplier until the Secretary determines 
that such supplier has made such a report. 
‘‘(D) DEEMING CERTAIN PAYMENTS OVER-
PAYMENTS.—Subject to subparagraphs (E) and 
(F), in the case that the Secretary determines 
that a supplier of ground ambulance services has 
not made to the Secretary a complete, accurate, 
and timely report described in subparagraph (A) 
with respect to a cost reporting period beginning
180 
on or after January 1, 2022, the Secretary may 
either— 
‘‘(i) deem payments made under this 
subsection to such supplier for such period 
to be overpayments and recoup such over-
payments; or 
‘‘(ii) suspend payments made under 
this subsection to such supplier for such pe-
riod. 
‘‘(E) HARDSHIP
DELAY.—The Secretary 
shall establish a process whereby a supplier of 
ground ambulance services may request a delay 
in making a report described in subparagraph 
(A) with respect to a cost reporting period for 
reason of significant hardship (as determined by 
the Secretary). 
‘‘(F) AUTHORITY TO MODIFY COST REPORT-
ING ELEMENTS AND ENFORCEMENT.—Not earlier 
than January 1, 2024, the Secretary may pro-
vide that subparagraph (D) no longer applies to 
suppliers of ground ambulance services or a cat-
egory of such suppliers after— 
‘‘(i) taking into account the rec-
ommendation of the Medicare Payment Ad-
visory Commission in the most recent report
181 
available to the Secretary submitted under 
section 2111(g) of the SUSTAIN Care Act 
of 2018 whether cost reports made by sup-
pliers or a category of suppliers (as speci-
fied for purposes of the report submitted 
under such section) of ground ambulance 
services should be required or modified; and 
‘‘(ii) undertaking notice and comment 
rulemaking. 
‘‘(G) AUDIT OF COST REPORTS.—The Sec-
retary shall audit reports described in subpara-
graph (A) made with respect to cost reporting 
periods beginning on or after January 1, 2021. 
‘‘(H) APPEALS.—The Secretary shall estab-
lish a process whereby a supplier of ground am-
bulance services may appeal a determination de-
scribed in subparagraph (C) or (D) made with 
respect to a cost report required to be made by 
such supplier under subparagraph (A). 
‘‘(I) DEFINITION.—In this paragraph, the 
term ‘cost reporting period’ means, with respect 
to a year, the 12-month period beginning on 
January 1 of such year.’’. 
(c) STAKEHOLDER FEEDBACK.—
182 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall implement the provisions of 
this section, including the amendments made by this 
section, through notice and comment rulemaking and 
seek input from stakeholders. 
(2) NONAPPLICATION OF PAPERWORK REDUCTION 
ACT.—Chapter 35 of title 44, United States Code, 
shall not apply with respect to— 
(A) the development and implementation of 
the uniform reporting system required under sec-
tion 1121(a) of the Social Security Act (42 
U.S.C. 1320a(a)) for suppliers of ground ambu-
lance services and reports required to be made 
under section 1834(l)(17) of such Act (42 U.S.C. 
1395m(l)(17)); and 
(B) the modification of the uniform report-
ing systems under such section 1121(a) of such 
Act for providers of such services and reports re-
quired to be made under section 1861(v)(1)(F) of 
such Act (42 U.S.C. 1395x(v)(1)(F)). 
(d) IMPLEMENTATION RESOURCES.—In addition to 
funds otherwise available, there are appropriated to the 
Centers for Medicare & Medicaid Services Program Man-
agement Account from the Federal Hospital Insurance 
Trust Fund under section 1817 of the Social Security Act
183 
(42 U.S.C. 1395i) $8,000,000 and from the Federal Supple-
mentary Medical Insurance Trust Fund under section 1841 
of such Act (42 U.S.C. 1395t) $137,000,000 (of which not 
less than $15,000,000 shall be used to fulfill the auditing 
requirement under section 1834(l)(17)(G) of such Act, as 
added by subsection (b) of this section) to carry out the pro-
visions of this section, including the amendments made by 
this section, to remain available through December 31, 
2022. Of the amounts appropriated under the previous sen-
tence, the Secretary shall use such sums as may be necessary 
to hire not less than 2 full-time employees for purposes of 
carrying out such provisions, including such amendments. 
(e) EXTENSION OF RURAL ADD-ON PAYMENTS.—Sec-
tion 1834(l) of the Social Security Act (42. U.S.C. 
1395m(l)) is amended— 
(1) in paragraph (12)(A), by striking ‘‘2018’’ 
and inserting ‘‘2023’’; and 
(2) in paragraph (13)(A), by striking ‘‘2018’’ 
each place it appears and inserting ‘‘2023’’. 
(f) SENSE OF CONGRESS.—It is the sense of Congress 
that— 
(1) a cost report made by a supplier of ground 
ambulance services with respect to a cost reporting 
period beginning before January 1, 2022, may not 
contain complete and accurate information on ground
230 
(3) REPORT.—Not later than April 1, 2019, the 
Secretary of Health and Human Services shall sub-
mit to the Committee on Ways and Means and the 
Committee on Energy and Commerce of the House of 
Representatives and the Committee on Finance of the 
Senate a report on the recommendations of such panel 
described in such paragraph. 
(4) NOTICE AND COMMENT RULEMAKING.—Not 
later than December 31, 2019, the Secretary of Health 
and Human Services shall pursue notice and com-
ment rulemaking on a case-mix system with respect 
to the prospective payment system for home health 
services under section 1895(b) of the Social Security 
Act (42 U.S.C. 1395fff(b)). 
(c) REPORTS.— 
(1) INTERIM REPORT.—Not later than March 15, 
2022, the Medicare Payment Advisory Commission 
shall submit to Congress an interim report on the ap-
plication of a 30-day unit of service as the unit of 
service applied under section 1895(b)(2) of the Social 
Security Act (42 U.S.C. 1395fff(b)(2)), as amended by 
subsection (a), including an analysis of the level of 
payments provided to home health agencies as com-
pared to the cost of delivering home health services,