Sec. 424.  

(e)^[513]  (1) The Secretary may not make a payment to a State under this subpart for a period in fiscal year 2008, unless the State has provided to the Secretary data which shows, for fiscal year 2007—

(A)  the percentage of children in foster care under the responsibility of the State who were visited on a monthly basis by the caseworker handling the case of the child; and

(B)  the percentage of the visits that occurred in the residence of the child.

(2)(A)  Based on the data provided by a State pursuant to paragraph (1), the Secretary, in consultation with the State, shall establish, not later than June 30, 2008, an outline of the steps to be taken to ensure, by October 1, 2011, that at least 90 percent of the children in foster care under the responsibility of the State are visited by their caseworkers on a monthly basis, and that the majority of the visits occur in the residence of the child. The outline shall include target percentages to be reached each fiscal year, and should include a description of how the steps will be implemented. The steps may include activities designed to improve caseworker retention, recruitment, training, and ability to access the benefits of technology.

(B)  Beginning October 1, 2008, if the Secretary determines that a State has not made the requisite progress in meeting the goal described in subparagraph (A) of this paragraph, then the percentage that shall apply for purposes of subsection (a) of this section for the period involved shall be the percentage set forth in such subsection (a) reduced by—

(i)  1, if the number of full percentage points by which the State fell short of the target percentage established for the State for the period pursuant to such subparagraph is less than 10;

(ii)  3, if the number of full percentage points by which the State fell short, as described in clause (i), is not less than 10 and less than 20; or

(iii)  5, if the number of full percentage points by which the State fell short, as described in clause (i), is not less than 20.

(a) 

(2)  Family support services.—The term “family support services” means community-based services to promote the safety and well-being of children and families designed to increase the strength and stability of families (including adoptive, foster, and extended families), to increase parents’ confidence and competence in their parenting abilities, to afford children a safe, stable, and supportive family environment, to strengthen parental relationships and promote healthy marriages, and otherwise to enhance child development.

(5)  Tribal organization.—The term “tribal organization” means the recognized governing body of any Indian tribe.

(6)  Indian tribe.—The term “Indian tribe” means any Indian tribe (as defined in section 482(i)(5), as in effect before August 22, 1996) and any Alaska Native organization (as defined in section 482(i)(7)(A), as so in effect).

Sec. 437. 

(f) 

(3) 

(B)  Required minimum period of approval.—A grant shall be awarded under this subsection for a period of not less than 2, and not more than 5, fiscal years.

(7) 

(B)  after taking such factors into consideration, give greater weight to awarding grants to regional partnerships that propose to address methamphetamine abuse and addiction in the partnership region (alone or in combination with other drug abuse and addiction) and which demonstrate that methamphetamine abuse and addiction (alone or in combination with other drug abuse and addiction) is adversely affecting child welfare in the partnership region.

Sec. 438. 

(b) 

(2)  Separate applications.—A highest State court desiring grants under this section for 2 or more purposes shall submit separate applications for the following grants:

(A)  A grant for the purposes described in paragraphs (1) and (2) of subsection (a).

(B)  A grant for the purpose described in subsection (a)(3).

(C)  A grant for the purpose described in subsection (a)(4).

(c)  Allotments.—

(1)  Grants to assess and improve handling of court proceedings relating to foster care and adoption.—

(A)  In General.—Each highest State court which has an application approved under subsection (b) of this section for a grant described in subsection (b)(2)(A) of this section, and is conducting assessment and improvement activities in accordance with this section, shall be entitled to payment, for each of fiscal years 2002 through 2011, from the amount reserved pursuant to section 436(b)(2) (and the amount, if any, reserved pursuant to section 437(b)(2)), of an amount equal to the sum of $85,000 plus the amount described in subparagraph (B) of this paragraph for the fiscal year.

(B)  Formula.—The amount described in this subparagraph for any fiscal year is the amount that bears the same ratio to the amount reserved pursuant to section 436(b)(2) (and the amount, if any, reserved pursuant to section 437(b)(2)) for the fiscal year (reduced by the dollar amount specified in subparagraph (A) of this paragraph for the fiscal year) as the number of individuals in the State who have not attained 21 years of age bears to the total number of such individuals in all States the highest State courts of which have approved applications under subsection (b) for such grant.

(A)  In general.—Each highest State court which has an application approved under subsection (b) of this section for a grant referred to in subparagraph (B) or (C) of subsection (b)(2) shall be entitled to payment, for each of fiscal years 2006 through 2011, from the amount made available under whichever of paragraph (1) or (2) of subsection (e) applies with respect to the grant, of an amount equal to the sum of $85,000 plus the amount described in subparagraph (B) of this paragraph for the fiscal year with respect to the grant.

(B)  Formula.—The amount described in this subparagraph for any fiscal year with respect to a grant referred to in subparagraph (B) or (C) of subsection (b)(2) is the amount that bears the same ratio to the amount made available under subsection (e) for such a grant (reduced by the dollar amount specified in subparagraph (A) of this paragraph) as the number of individuals in the State who have not attained 21 years of age bears to the total number of such individuals in all States the highest State courts of which have approved applications under subsection (b) for such a grant.

Sec. 1130. (a) 

(2)  Limitation.—The Secretary may authorize not more than 10 demonstration projects under paragraph (1) in each of fiscal years 1998 through 2003.

(3)  Certain types of proposals required to be considered.—

(A)  If an appropriate application therefor is submitted, the Secretary shall consider authorizing a demonstration project which is designed to identify and address barriers that result in delays to adoptive placements for children in foster care.

(B)  If an appropriate application therefor is submitted, the Secretary shall consider authorizing a demonstration project which is designed to identify and address parental substance abuse problems that endanger children and result in the placement of children in foster care, including through the placement of children with their parents in residential treatment facilities (including residential treatment facilities for post-partum depression) that are specifically designed to serve parents and children together in order to promote family reunification and that can ensure the health and safety of the children in such placements.

(C)  If an appropriate application therefor is submitted, the Secretary shall consider authorizing a demonstration project which is designed to address kinship care.

(d)  Duration of Demonstration.—A demonstration project under this section may be conducted for not more than 5 years, unless in the judgment of the Secretary, the demonstration project should be allowed to continue.

(f)  Evaluations; Report.—Each State authorized to conduct a demonstration project under this section shall—

(1)  obtain an evaluation by an independent contractor of the effectiveness of the project, using an evaluation design approved by the Secretary which provides for—

(A)  comparison of methods of service delivery under the project, and such methods under a State plan or plans, with respect to efficiency, economy, and any other appropriate measures of program management;

(B)  comparison of outcomes for children and families (and groups of children and families) under the project, and such outcomes under a State plan or plans, for purposes of assessing the effectiveness of the project in achieving program goals; and

(C)  any other information that the Secretary may require; and

(2)  provide interim and final evaluation reports to the Secretary, at such times and in such manner as the Secretary may require.

DEFINITION OF UTILIZATION AND QUALITY CONTROL PEER REVIEW ORGANIZATION

SEC. 1152.  The term “utilization and quality control peer review organization” means an entity which—

(1)(A)  is composed of a substantial number of the licensed doctors of medicine and osteopathy engaged in the practice of medicine or surgery in the area and who are representative of the practicing physicians in the area, designated by the Secretary under section 1153, with respect to which the entity shall perform services under this part, or (B) has available to it, by arrangement or otherwise, the services of a sufficient number of licensed doctors of medicine or osteopathy engaged in the practice of medicine or surgery in such area to assure that adequate peer review of the services provided by the various medical specialties and subspecialties can be assured;

(2)  is able, in the judgment of the Secretary, to perform review functions required under section 1154 in a manner consistent with the efficient and effective administration of this part and to perform reviews of the pattern of quality of care in an area of medical practice where actual performance is measured against objective criteria which define acceptable and adequate practice; and

Sec. 1153. 

(a)  (1) The Secretary shall establish throughout the United States geographic areas with respect to which contracts under this part will be made. In establishing such areas, the Secretary shall use the same areas as established under section 1152 of this Act as in effect immediately prior to the date of the enactment of the Peer Review Improvement Act of 1982^[514], but subject to the provisions of paragraph (2).

(2)  As soon as practicable after the date of the enactment of the Peer Review Improvement Act of 1982, the Secretary shall consolidate such geographic areas, taking into account the following criteria:

(A)  Each State shall generally be designated as a geographic area for purposes of paragraph (1).

(B)  The Secretary shall establish local or regional areas rather than State areas only where the volume of review activity or other relevant factors (as determined by the Secretary) warrant such an establishment, and the Secretary determines that review activity can be carried out with equal or greater efficiency by establishing such local or regional areas. In applying this subparagraph the Secretary shall take into account the number of hospital admissions within each State for which payment may be made under title XVIII or a State plan approved under title XIX, with any State having fewer than 180,000 such admissions annually being established as a single statewide area, and no local or regional area being established which has fewer than 60,000 total hospital admissions (including public and private pay patients) under review annually, unless the Secretary determines that other relevant factors warrant otherwise.

(C)  No local or regional area shall be designated which is not a self-contained medical service area, having a full spectrum of services, including medical specialists’ services.

Sec. 1153. (c) 

(4)  if the Secretary intends not to renew a contract, he shall notify the organization of his decision at least 90 days prior to the expiration of the contract term, and shall provide the organization an opportunity to present data, interpretations of data, and other information pertinent to its performance under the contract, which shall be reviewed in a timely manner by the Secretary;

(5)  the organization may terminate the contract upon 90 days notice to the Secretary;

reimbursement shall be made to the organization on a monthly basis, with payments for any month being made not later than 15 days after the close of such month.

(6)  the Secretary may terminate the contract prior to the expiration of the contract term upon 90 days notice to the organization if the Secretary determines that—

(A)  the organization does not substantially meet the requirements of section 1152; or

(B)  the organization has failed substantially to carry out the contract or is carrying out the contract in a manner inconsistent with the efficient and effective administration of this part, but only after such organization has had an opportunity to submit data and have such data reviewed by the panel established under subsection (d);

(d) (1)  Prior to making any termination under subsection (c)(6)(B), the Secretary must provide the organization with an opportunity to provide data, interpretations of data, and other information pertinent to its performance under the contract. Such data and other information shall be reviewed in a timely manner by a panel appointed by the Secretary, and the panel shall submit a report of its findings to the Secretary in a timely manner. The Secretary shall make a copy of the report available to the organization.

(2)  The Secretary may accept or not accept the findings of the panel. After the panel has submitted a report with respect to an organization, the Secretary may, with the concurrence of the organization, amend the contract to modify the scope of the functions to be carried out by the organization, or in any other manner. The Secretary may terminate a contract under the authority of subsection (c)(6)(B) upon 90 days notice after the panel has submitted a report, or earlier if the organization so agrees.

(3)  A panel appointed by the Secretary under this subsection shall consist of not more than five individuals, each of whom shall be a member of a quality improvement organization having a contract with the Secretary under this part. While serving on such panel individuals shall be paid at a per diem rate not to exceed the current per diem equivalent at the time that service on the panel is rendered for grade GS-18 under section 5332 of title 5, United States Code. Appointments shall be made without regard to title 5, United States Code.

(4)  During the period after the Secretary has given notice of intent to terminate a contract, and prior to the time that the Secretary enters into a contract with another quality improvement^[516] organization, the Secretary may transfer review responsibilities of the organization under the contract being terminated to another quality improvement^[517] organization, or to an intermediary or carrier having an agreement under section 1816 or a contract under section 1842.

(i) (1)  Notwithstanding any other provision of this section, the Secretary shall not renew a contract with any organization that is not an in-State organization (as defined in paragraph (3)) unless the Secretary has first complied with the requirements of paragraph (2).

(2) (A)  Not later than six months before the date on which a contract period ends with respect to an organization that is not an in-State organization, the Secretary shall publish in the Federal Register—

(i)  the date on which such period ends; and

(ii)  the period of time in which an in-State organization may submit a proposal for the contract ending on such date.

(B)  If one or more qualified in-State organizations submits a proposal within the period of time specified under subparagraph (A)(ii), the Secretary shall not automatically renew the current contract on a noncompetitive basis, but shall provide for competition for the contract in the same manner as a new contract under subsection (b).

(3)  For purposes of this subsection, an in-State organization is an organization that has its primary place of business in the State in which review will be conducted (or, which is owned by a parent corporation the headquarters of which is located in such State).

Sec. 1154.  FUNCTIONS OF QUALITY IMPROVEMENT ORGANIZATIONS.

(a) 

(4) 

(C)  The Secretary may provide, by contract under competitive procurement procedures on a State-by-State basis in up to 25 States, for the review described in subparagraph (B) by an appropriate entity (which may be a quality improvement^[518] organization described in that subparagraph). In selecting among States in which to conduct such competitive procurement procedures, the Secretary may not select States which, as a group, have more than 50 percent of the total number of individuals enrolled with eligible organizations under section 1876. Under a contract with an entity under this subparagraph—

(i)  the entity must be, or must meet all the requirements under section 1152 to be, a quality improvement^[519] organization (other than the ability to perform review functions under this section that are not described in subparagraph (B)),

(ii)  the contract must meet the requirement of section 1153(b)(3), and

(iii)  the level of effort expended under the contract shall be, to the extent practicable, not less than the level of effort that would otherwise be required under the third sentence of subparagraph (B) if this subparagraph did not apply.

(d)  Each contract under this part shall require that the quality improvement^[520] organization’s review responsibility pursuant to subsection (a)(1) will include review of all ambulatory surgical procedures specified pursuant to section 1833(i)(1)(A) which are performed in the area, or, at the discretion of the Secretary a sample of such procedures.

(b) 

(4)  Promotion of the development of electronic health records.—The entity shall promote the development and use of electronic health records that contain the functionality for automated collection, aggregation, and transmission of performance measurement information.

(b) 

(A)  fiscal year 2014, $0;

(B)  fiscal year 2015, $275,000,000.

(C)  fiscal year 2020 and each subsequent fiscal year, the Secretary’s estimate, as of July 1 of the fiscal year, of the aggregate reduction in expenditures under this title during the preceding fiscal year directly resulting from the reduction in payment amounts under sections 1848(a)(7), 1848(l)(4), 1853(m)(4), and 1886(b)(3)(B)(ix).

(a) 

(81)  provide that the State will comply with such regulations regarding the application of primary and secondary payor rules with respect to individuals who are eligible for medical assistance under this title and are eligible beneficiaries under the CLASS program established under title XXXII of the Public Health Service Act as the Secretary shall establish; and

(82)  provide that, not later than 2 years after the date of enactment of the Community Living Assistance Services and Supports Act, each State shall—

(A)  assess the extent to which entities such as providers of home care, home health services, home and community service providers, public authorities created to provide personal care services to individuals eligible for medical assistance under the State plan, and nonprofit organizations, are serving or have the capacity to serve as fiscal agents for, employers of, and providers of employment- related benefits for, personal care attendant workers who provide personal care services to individuals receiving benefits under the CLASS program established under title XXXII of the Public Health Service Act, including in rural and underserved areas;

(B)  designate or create such entities to serve as fiscal agents for, employers of, and providers of employment related benefits for, such workers to ensure an adequate supply of the workers for individuals receiving benefits under the CLASS program, including in rural and underserved areas; and

(C)  ensure that the designation or creation of such entities will not negatively alter or impede existing programs, models, methods, or administration of service delivery that provide for consumer controlled or self directed home and community services and further ensure that such entities will not impede the ability of individuals to direct and control their home and community services, including the ability to select, manage, dismiss, co-employ, or employ such workers or inhibit such individuals from relying on family members for the provision of personal care services.

(f) 

(8)  Rebasing of state dsh allotments for fiscal year 2021.—With respect to fiscal year 2021, for purposes of applying paragraph (3)(A) to determine the DSH allotment for a State, the amount of the DSH allotment for the State under paragraph (3) for fiscal year 2020 shall be equal to the DSH allotment as reduced under paragraph (7).

Sec. 403. (a) 

(1) 

(B)  State family assistance grant defined.—As used in this part, the term “State family assistance grant” means the greatest of—

(i)  1/3 of the total amount required to be paid to the State under former section 403 (as in effect on September 30, 1995) for fiscal years 1992, 1993, and 1994 (other than with respect to amounts expended by the State for child care under subsection (g) or (i) of former section 402 (as so in effect)); plus

(ii)(I)  the total amount required to be paid to the State under former section 403 for fiscal year 1994 (other than with respect to amounts expended by the State for child care under subsection (g) or (i) of former section 402 (as so in effect)); plus

(II)  an amount equal to 85 percent of the amount (if any) by which the total amount required to be paid to the State under former section 403(a)(5) for emergency assistance for fiscal year 1995 exceeds the total amount required to be paid to the State under former section 403(a)(5) for fiscal year 1994, if, during fiscal year 1994 or 1995, the Secretary approved under former section 402 an amendment to the former State plan with respect to the provision of emergency assistance; or

(iii)  4/3 of the total amount required to be paid to the State under former section 403 (as in effect on September 30, 1995) for the 1st 3 quarters of fiscal year 1995 (other than with respect to amounts expended by the State under the State plan approved under part F (as so in effect) or for child care under subsection (g) or (i) of former section 402 (as so in effect)), plus the total amount required to be paid to the State for fiscal year 1995 under former section 403(1) (as so in effect).

(C)  Total amount required to be paid to the state under former section 403 defined.—As used in this part, the term “total amount required to be paid to the State under former section 403” means, with respect to a fiscal year—

(i)  in the case of a State to which section 1108 does not apply, the sum of—

(I)  the Federal share of maintenance assistance expenditures for the fiscal year, before reduction pursuant to subparagraph (B) or (C) of section 403(b)(2) (as in effect on September 30, 1995), as reported by the State on ACF Form 231;

(II)  the Federal share of administrative expenditures (including administrative expenditures for the development of management information systems) for the fiscal year, as reported by the State on ACF Form 231;

(III)  the Federal share of emergency assistance expenditures for the fiscal year, as reported by the State on ACF Form 231;

(IV)  the Federal share of expenditures for the fiscal year with respect to child care pursuant to subsections (g) and (i) of former section 402 (as in effect on September 30, 1995), as reported by the State on ACF Form 231; and

(V)  the Federal obligations made to the State under section 403 for the fiscal year with respect to the State program operated under part F (as in effect on September 30, 1995), as determined by the Secretary, including additional obligations or reductions in obligations made after the close of the fiscal year; and

(ii)  in the case of a State to which section 1108 applies, the lesser of—

(I)  the sum described in clause (i); or

(II)  the total amount certified by the Secretary under former section 403 (as in effect during the fiscal year) with respect to the territory.

(D)  Information to be used in determining amounts.—

(i)  For fiscal years 1992 and 1993.—

(I)  In determining the amounts described in subclauses (I) through (IV) of subparagraph (C)(i) for any State for each of fiscal years 1992 and 1993, the Secretary shall use information available as of April 28, 1995.

(II)  In determining the amount described in subparagraph (C)(i)(V) for any State for each of fiscal years 1992 and 1993, the Secretary shall use information available as of January 6, 1995.

(ii)  For fiscal year 1994.—In determining the amounts described in subparagraph (C)(i) for any State for fiscal year 1994, the Secretary shall use information available as of April 28, 1995.

(iii)  For fiscal year 1995.—

(I)  In determining the amount described in subparagraph (B)(ii)(II) for any State for fiscal year 1995, the Secretary shall use the information which was reported by the States and estimates made by the States with respect to emergency assistance expenditures and was available as of August 11, 1995.

(II)  In determining the amounts described in subclauses (I) through (III) of subparagraph (C)(i) for any State for fiscal year 1995, the Secretary shall use information available as of October 2, 1995.

(III)  In determining the amount described in subparagraph (C)(i)(IV) for any State for fiscal year 1995, the Secretary shall use information available as of February 28, 1996.

(IV)  In determining the amount described in subparagraph (C)(i)(V) for any State for fiscal year 1995, the Secretary shall use information available as of October 5, 1995.

(E)  Appropriation.—Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated for fiscal years 1996, 1997, 1998, 1999, 2000, 2001, and 2002 such sums as are necessary for grants under this paragraph.

Sec. 1902. (a) 

(10) 

(E) 

(iv) 

(II)  for the portion of medicare cost-sharing described in section 1905(p)(3)(A)(ii) that is attributable to the operation of the amendments made by (and subsection (e)(3) of) section 4611 of the Balanced Budget Act of 1997 for individuals who would be described in subclause (I) of “135 percent” and “175 percent” were substituted for “120 percent” and “135 percent” respectively; and

Sec. 473A. 

(b) 

(2)  the number of foster child adoptions in the State during the fiscal year exceeds the base number of foster child adoptions for the State for the fiscal year;

(c) 

(2)  Determination of numbers of adoptions.—

(A)  Determinations based on afcars data.—Except as provided in subparagraph (B), the Secretary shall determine the numbers of foster child adoptions and of special needs adoptions in a State during each of fiscal years 1995 through 2002, for purposes of this section, on the basis of data meeting the requirements of the system established pursuant to section 479, as reported by the State and approved by the Secretary by August 1 of the succeeding fiscal year.

(B)  Alternative data sources permitted for fiscal years 1995 through 1997.—For purposes of the determination described in subparagraph (A) for fiscal years 1995 through 1997, the Secretary may use data from a source or sources other than that specified in subparagraph (A) that the Secretary finds to be of equivalent completeness and reliability, as reported by a State by April 30, 1998, and approved by the Secretary by July 1, 1998.

(g)  Definitions.—

(3) (A)  with respect to fiscal year 1998, the average number of foster child adoptions in the State in fiscal years 1995, 1996, and 1997; and

(B)  with respect to any subsequent fiscal year, the number of foster child adoptions in the State in the fiscal year for which the number is the greatest in the period that begins with fiscal year 1997 and ends with the fiscal year preceding such subsequent fiscal year.

(4) (A)  with respect to fiscal year 1998, the average number of special needs adoptions in the State in fiscal years 1995,1996, and 1997; and

(B)  with respect to any subsequent fiscal year, the number of special needs adoptions in the State in the fiscal year for which the number is the greatest in the period that begins with fiscal year 1997 and ends with the fiscal year preceding such subsequent fiscal year.

(j)  Supplemental grants.—

(1)  In general.—Subject to the availability of such amounts as may be provided in advance in appropriations Acts, in addition to any amount otherwise payable under this section to any State that is an incentive-eligible State for fiscal year 1998, the Secretary shall make a grant to the State in an amount equal to the lesser of—

(A)  the amount by which—

(i)  the amount that would have been payable to the State under this section during fiscal year 1999 (on the basis of adoptions in fiscal year 1998) in the absence of subsection (d)(2) of this section if sufficient funds had been available for the payment; exceeds

(ii)  the amount that, before December 14, 1999, was payable to the State under this section during fiscal year 1999 (on such basis); or

(B)  the amount that bears the same ratio to the dollar amount specified in paragraph (2) as the amount described by subparagraph (A) for the State bears to the aggregate of the amounts described by subparagraph (A) for all States that are incentive-eligible States for fiscal year 1998.

(2)  Funding.—$23,000,000 of the amounts appropriated under subsection (h)(1) of this section for fiscal year 2000 may be used for grants under paragraph (1) of this subsection.

Sec. 1117.  [Heading was amended]

APPOINTMENT OF ADMINISTRATOR AND CHIEF ACTUARY OF HEALTH CARE FINANCING ADMINISTRATION

Sec. 1128. (c) 

(3) 

(B)  [First sentence was replaced] Subject to subparagraph (G), in the case of an exclusion under subsection (a) of this section, the minimum period exclusion shall be not less than five years, except that, upon the request of a State, the Secretary may waive the exclusion under subsection (a)(1) of this section in the case of an individual or entity that is the sole community physician or sole source of essential specialized services in a community.

Sec. 1814. (a)  [ Seventh sentence was stricken.] The certification regarding terminal illness of an individual under paragraph (7) shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.

USE OF PUBLIC AGENCIES OR PRIVATE ORGANIZATIONS TO FACILITATE PAYMENT TO PROVIDERS OF SERVICES

Sec. 1816.  (a) If any group or association of providers of services wishes to have payments under this part to such providers made through a national, State, or other public or private agency or organization and nominates such agency or organization for this purpose, the Secretary is authorized to enter into an agreement with such agency or organization providing for the determination by such agency or organization (subject to the provisions of section 1878 and to such review by the Secretary as may be provided by the agreement) of the amount of the amount of the payments required pursuant to this part to be made to such providers (and to providers assigned to such agency or organization under subsection (E)), and for the making of such payments by such agency or organization to such providers (and to providers assigned to such agency or organization under subsection (E)). Such agreement may also include provision for the agency or organization to do all or any part of the following: (1) to provide consultative services to institutions or agencies to enable them to establish and maintain fiscal records necessary for purposes of this part and otherwise to qualify as hospitals, extended care facilities, or home health agencies, and (2) with respect to the providers of services which are to receive payments through it (A) to serve as a center for, and communicate to providers, any information or instructions furnished to it by the Secretary, and serve as a channel of communication from providers to the Secretary; (B) to make such audits of the records of providers as may be necessary to insure that proper payments are made under this part; and (C) to perform such other functions as are necessary to carry this subsection. As used in this title and part and part B of title XI, the term “fiscal intermediary” means an agency or organization with a contract under this section.

(b)  The Secretary shall not enter into or renew an agreement with any agency or organization under this section unless—

(1)  he finds—

(A)  after applying the standards, criteria, and procedures developed under subsection (f) of this section, that to do so is consistent with the effective and efficient administration of this part, and

(B)  that such agency or organization is willing and able to assist the providers to which payments are made through it under this part in the application of safeguards against unnecessary utilization of services furnished by them to individuals entitled to hospital insurance benefits under section 426 of this title, and the agreement provides for such assistance; and

(2)  such agency or organization agrees—

(A)  to furnish to the Secretary such of the information acquired by it in carrying out its agreement under this section, and

(B)  to provide the Secretary with access to all such data, information, and claims processing operations, as the Secretary may find necessary in performing his functions under this part.

(c)(1)  An agreement with any agency or organization under this section may contain such terms and conditions as the Secretary finds necessary or appropriate, may provide for advances of funds to the agency or organization for the making of payments by it under subsection (a), and shall provide for payment of so much of the cost of administration of the agency or organization as is determined by the Secretary to be necessary and proper for carrying out the functions covered by the agreement. The Secretary shall provide that in determining the necessary and proper cost of administration, the Secretary shall, with respect to each agreement, take into account the amount that is reasonable and adequate to meet the costs which must be incurred by an efficiently and economically operated agency or organization in carrying out the terms of its agreement. The Secretary shall cause to have published in the Federal Register, by not later than September 1 before each fiscal year, data, standards, and methodology to be used to establish budgets for fiscal intermediaries under this section for that fiscal year, and shall cause to be published in the Federal Register for public comment, at least 90 days before such data, standards, and methodology are published, the data, standards, and methodology proposed to be used. The Secretary may not require, as a condition of entering into or renewing an agreement under this section or under section 1871, that a fiscal intermediary match data obtained other than in its activities under this part with data used in the administration of this part for purposes of identifying situations in which the provisions of section 1862(b) may apply.

(d)  If the nomination of an agency or organization as provided in this section is made by a group or association of providers of services, it shall not be binding on members of the group or association which notify the Secretary of their election to that effect. Any provider may, upon such notice as may be specified in the agreement under this section with an agency or organization, withdraw its nomination to receive payments through such agency or organization. Any provider which has withdrawn its nomination, and any provider which has not made a nomination, may elect to receive payments from any agency or organization which has entered into an agreement with the Secretary under this section if the Secretary and such agency or organization agree to it.

(e)(1)  Notwithstanding subsections (a) and (d), the Secretary, after taking into consideration any preferences of providers of services, may assign or reassign any provider of services to any agency or organization which has entered into an agreement with him under this section, if he determines, after applying the standards, criteria, and procedures developed under subsection (f), that such assignment or reassignment would result in the more effective and efficient administration of this part.

(2)  Notwithstanding subsections (a) and (d), the Secretary may (subject to the provisions of paragraph (4)) designate a national or regional agency or organization which has entered into an agreement with him under this section to perform functions under the agreement with respect to a class of providers of services in the Nation or region (as the case may be), if he determines, after applying the standards, criteria, and procedures developed under subsection (f), that such designation would result in more effective and efficient administration of this part.

(3)(A)  Before the Secretary makes an assignment or reassignment under paragraph (1) of a provider of services to other than the agency or organization nominated by the provider, he shall furnish (i) the provider and such agency or organization with a full explanation of the reasons for his determination as to the efficiency and effectiveness of the agency or organization to perform the functions required under this part with respect to the provider, and (ii) such agency or organization with opportunity for a hearing, and such determination shall be subject to judicial review in accordance with chapter 7 of title 5, United States Code.

(B)  Before the Secretary makes a designation under paragraph (2) with respect to a class of providers of services, he shall furnish (i) such providers and the agencies and organizations adversely affected by such designation with a full explanation of the reasons for his determination as to the efficiency and effectiveness of such agencies and organizations to perform the functions required under this part with respect to such providers, and (ii) the agencies and organizations adversely affected by such designation with opportunity for a hearing, and such determination shall be subject to judicial review in accordance with chapter 7 of title 5, United States Code.

(4)  Notwithstanding subsections (a) and (d) and paragraphs (1), (2), and (3) of this subsection, the Secretary shall designate regional agencies or organizations which have entered into an agreement with him under this section to perform functions under such agreement with respect to home health agencies (as defined in section 1861(o)) in the region, except that in assigning such agencies to such designated regional agencies or organizations the Secretary shall assign a home health agency which is a subdivision of a hospital (and such agency and hospital are affiliated or under common control) only if, after applying such criteria relating to administrative efficiency and effectiveness as he shall promulgate, he determines that such assignment would result in the more effective and efficient administration of this title. By not later than July 1, 1987, the Secretary shall limit the number of such regional agencies or organizations to not more than ten.

(5)  Notwithstanding any other provision of this subchapter, the Secretary shall designate the agency or organization which has entered into an agreement under this section to perform functions under such an agreement with respect to each hospice program, except that with respect to a hospice program which is a subdivision of a provider of services (and such hospice program and provider of services are under common control) due regard shall be given to the agency or organization which performs the functions under this section for the provider of services.

(f)(1)  In order to determine whether the Secretary should enter into, renew, or terminate an agreement under this section with an agency or organization, whether the Secretary should assign or reassign a provider of services to an agency or organization, and whether the Secretary should designate an agency or organization to perform services with respect to a class of providers of services, the Secretary shall develop standards, criteria, and procedures to evaluate such agency’s or organization’s (A) overall performance of claims processing (including the agency’s or organization’s success in recovering payments made under this title for services for which payment has been or could be made under a primary plan (as defined in section 1862(b)(2)(A))) and other related functions required to be performed by such an agency or organization under an agreement entered into under this section, and (B) performance of such functions with respect to specific providers of services, and the Secretary shall establish standards and criteria with respect to the efficient and effective administration of this part. No agency or organization shall be found under such standards and criteria not to be efficient or effective or to be less efficient or effective solely on the ground that the agency or organization serves only providers located in a single State.

(2)  The standards and criteria established under paragraph (1) shall include—

(A)  with respect to claims for services furnished under this part by any provider of services other than a hospital—

(i)  whether such agency or organization is able to process 75 percent of reconsiderations within 60 days (except in the case of fiscal year 1989, 66 percent of reconsiderations) and 90 percent of reconsiderations within 90 days, and

(ii)  the extent to which such agency’s or organization’s determinations are reversed on appeal; and

(B)  with respect to applications for an exemption from or exception or adjustment to the target amount applicable under section 1886(b) to a hospital that is not a subsection (d) hospital (as defined in section 1886(d)(1)(B))—

(i)  if such agency or organization receives a completed application, whether such agency or organization is able to process such application not later than 75 days after the application is filed, and

(ii)  if such agency or organization receives an incomplete application, whether such agency or organization is able to return the application with instructions on how to complete the application not later than 60 days after the application is filed.

(g)  An agreement with the Secretary under this section may be terminated—

(1)  by the agency or organization which entered into such agreement at such time and upon such notice to the Secretary, to the public, and to the providers as may be provided in regulations, or

(2)  by the Secretary at such time and upon such notice to the agency or organization, to the providers which have nominated it for purposes of this section, and to the public, as may be provided in regulations, but only if he finds, after applying the standards, criteria, and procedures developed under subsection (f) and after reasonable notice and opportunity for hearing to the agency or organization, that (A) the agency or organization has failed substantially to carry out the agreement, or (B) the continuation of some or all of the functions provided for in the agreement with the agency or organization is disadvantageous or is inconsistent with the efficient administration of this part.

(h)  An agreement with an agency or organization under this section may require any of its officers or employees certifying payments or disbursing funds pursuant to the agreement, or otherwise participating in carrying out the agreement, to give surety bond to the United States in such amount as the Secretary may deem appropriate.

(i)(1)  No individual designated pursuant to an agreement under this section as a certifying officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payments certified by him under this section.

(2)  No disbursing officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payment by him under this section if it was based upon a voucher signed by a certifying officer designated as provided in paragraph (1) of this subsection.

(3)  No such agency or organization shall be liable to the United States for any payments referred to in paragraph (1) or (2).

(l)  No agency or organization may carry out (or receive payment for carrying out) any activity pursuant to an agreement under this section to the extent that the activity is carried out pursuant to a contract under the Medicare Integrity Program under section 1893.

Sec. 1833. (a) 

(3)  in the case of services described in section 1832(a)(2)(D), the costs which are reasonable and related to the cost of furnishing such services or which are based on such other tests of reasonableness as the Secretary may prescribe in regulations, including those authorized under section 1861(v)(1)(A), less the amount a provider may charge as described in clause (ii) of section 1866(a)(2)(A), but in no case may the payment for such services (other than for items and services described in section 1861(s)(10)(A)) exceed 80 percent of such costs;

(i) 

(2) 

(C)  Notwithstanding the second sentence of subparagraph (A) or the second sentence of subparagraph (B), if the Secretary has not updated amounts established under such subparagraphs with respect to facility services furnished during a fiscal year (beginning with fiscal year 1996), such amounts shall be increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) as estimated by the Secretary for the 12-month period ending with the midpoint of the year involved. In each of the fiscal years 1998 through 2002, the increase under this subparagraph shall be reduced (but not below zero) by 2.0 percentage points.

(o) 

(2)(A)  Except as provided by the Secretary under subparagraphs (B) and (C), the limits established under this paragraph—

(i)  for the furnishing of —

(I)  one pair of custom molded shoes (including any inserts that are provided initially with the shoes) is $300, and

(II)  any additional pair of inserts with respect to such shoes is $50; and

(ii)  for the furnishing of extra-depth shoes and inserts is—

(I)  $100 for the pair of shoes itself, and

(II)  $50 for any pairs of inserts for a pair of shoes.

USE OF CARRIERS FOR ADMINISTRATION OF BENEFITS

Sec. 1842.  (a) In order to provide for the administration of the benefits under this part with maximum efficiency and convenience for individuals entitled to benefits under this part and for providers of services and other persons furnishing services to such individuals, and with a view to furthering coordination of the administration of the benefits under part A of this subchapter and under this part, the Secretary is authorized to enter into contracts with carriers, including carriers with which agreements under section 1816 are in effect, which will perform some or all of the following functions (or, to the extent provided in such contracts, will secure performance thereof by other organizations); and, with respect to any of the following functions which involve payments for physicians’ services on a reasonable charge basis, the Secretary shall to the extent possible enter into such contracts:

(1)(A)  make determinations of the rates and amounts of payments required pursuant to this part to be made to providers of services and other persons on a reasonable cost or reasonable charge basis (as may be applicable);

(B)  receive, disburse, and account for funds in making such payments; and

(C)  make such audits of the records of providers of services as may be necessary to assure that proper payments are made under this part;

(2)(A)  determine compliance with the requirements of section 1861(k) of this title as to utilization review; and

(B)  assist providers of services and other persons who furnish services for which payment may be made under this part in the development of procedures relating to utilization practices, make studies of the effectiveness of such procedures and methods for their improvement, assist in the application of safeguards against unnecessary utilization of services furnished by providers of services and other persons to individuals entitled to benefits under this part, and provide procedures for and assist in arranging, where necessary, the establishment of groups outside hospitals (meeting the requirements of section 1861(k)(2)) to make reviews of utilization;

(3)  serve as a channel of communication of information relating to the administration of this part; and

(4)  otherwise assist, in such manner as the contract may provide, in discharging administrative duties necessary to carry out the purposes of this part.

(b)(1)  Contracts with carriers under subsection (a) of this section may be entered into without regard to section 3709 of the Revised Statutes of the United States or any other provision of law requiring competitive bidding.

(2)(A)  No such contract shall be entered into with any carrier unless the Secretary finds that such carrier will perform its obligations under the contract efficiently and effectively and will meet such requirements as to financial responsibility, legal authority, and other matters as he finds pertinent. The Secretary shall publish in the Federal Register standards and criteria for the efficient and effective performance of contract obligations under this section, and opportunity shall be provided for public comment prior to implementation. In establishing such standards and criteria, the Secretary shall provide a system to measure a carrier’s performance of responsibilities described in paragraph (3)(H), subsection (h) of this section, and section 1845(e)(2). The Secretary may not require, as a condition of entering into or renewing a contract under this section or under section 1871, that a carrier match data obtained other than in its activities under this part with data used in the administration of this part for purposes of identifying situations in which section 1862(b) may apply.

(B)  The Secretary shall establish standards for evaluating carriers’ performance of reviews of initial carrier determinations and of fair hearings under paragraph (3)(C), under which a carrier is expected—

(i)  to complete such reviews, within 45 days after the date of a request by an individual enrolled under this part for such a review, in 95 percent of such requests, and

(ii)  to make a final determination, within 120 days after the date of receipt of a request by an individual enrolled under this part for a fair hearing under paragraph (3)(C), in 90 percent of such cases.

(D)  In addition to any other standards and criteria established by the Secretary for evaluating carrier performance under this paragraph relating to avoiding erroneous payments, the carrier shall be subject to standards and criteria relating to the carrier’s success in recovering payments made under this part for items or services for which payment has been or could be made under a primary plan (as defined in section 1862(b)(2)(A)).

(E)  With respect to the payment of claims for home health services under this part that, but for the amendments made by section 4611 of the Balanced Budget Act of 1997, would be payable under part A of this subchapter instead of under this part, the Secretary shall continue administration of such claims through fiscal intermediaries under section 1816.

(3) 

(C)  will establish and maintain procedures pursuant to which an individual enrolled under this part will be granted an opportunity for a fair hearing by the carrier, in any case where the amount in controversy is at least $100, but less than $500, when requests for payment under this part with respect to services furnished him are denied or are not acted upon with reasonable promptness or when the amount of such payment is in controversy;

(D)  will furnish to the Secretary such timely information and reports as he may find necessary in performing his functions under this part;

(E)  will maintain such records and afford such access thereto as the Secretary finds necessary to assure the correctness and verification of the information and reports under subparagraph (D) and otherwise to carry out the purposes of this part;

(I)  will submit annual reports to the Secretary describing the steps taken to recover payments made under this part for items or services for which payment has been or could be made under a primary plan (as defined in section 1862(b)(2)(A)); and

(5)  Each contract under this section shall be for a term of at least one year, and may be made automatically renewable from term to term in the absence of notice by either party of intention to terminate at the end of the current term; except that the Secretary may terminate any such contract at any time (after such reasonable notice and opportunity for hearing to the carrier involved as he may provide in regulations) if he finds that the carrier has failed substantially to carry out the contract or is carrying out the contract in a manner inconsistent with the efficient and effective administration of the insurance program established by this part.

(6) 

(A)  or (ii) (where the service was provided in a hospital, critical access hospital, clinic, or other facility) to the facility in which the service was provided if there is a contractual arrangement between such physician or other person and such facility under which such facility submits the bill for such service,

(c)(1)  Any contract entered into with a carrier under this section shall provide for advances of funds to the carrier for the making of payments by it under this part, and shall provide for payment of the cost of administration of the carrier, as determined by the Secretary to be necessary and proper for carrying out the functions covered by the contract. The Secretary shall provide that in determining a carrier’s necessary and proper cost of administration, the Secretary shall, with respect to each contract, take into account the amount that is reasonable and adequate to meet the costs which must be incurred by an efficiently and economically operated carrier in carrying out the terms of its contract. The Secretary shall cause to have published in the Federal Register, by not later than September 1 before each fiscal year, data, standards, and methodology to be used to establish budgets for carriers under this section for that fiscal year, and shall cause to be published in the Federal Register for public comment, at least 90 days before such data, standards, and methodology are published, the data, standards, and methodology proposed to be used.

(5)  Each contract under this section which provides for the disbursement of funds, as described in subsection (a)(1)(B), shall require the carrier to meet criteria developed by the Secretary to measure the timeliness of carrier responses to requests for payment of items described in section 1834(a)(15)(C).

(6)  No carrier may carry out (or receive payment for carrying out) any activity pursuant to a contract under this subsection to the extent that the activity is carried out pursuant to a contract under the Medicare Integrity Program under section 1893. The previous sentence shall not apply with respect to the activity described in section 1893(b)(5) of this title (relating to prior authorization of certain items of durable medical equipment under section 1834(a)(15)).

(d)  Any contract with a carrier under this section may require such carrier or any of its officers or employees certifying payments or disbursing funds pursuant to the contract, or otherwise participating in carrying out the contract, to give surety bond to the United States in such amount as the Secretary may deem appropriate.

(e)(1)  No individual designated pursuant to a contract under this section as a certifying officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payments certified by him under this section.

(2)  No disbursing officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payment by him under this section if it was based upon a voucher signed by a certifying officer designated as provided in paragraph (1) of this subsection.

(3)  No such carrier shall be liable to the United States for any payments referred to in paragraph (1) or (2).

(f)  For purposes of this part, the term “carrier” means—

(1)  with respect to providers of services and other persons, a voluntary association, corporation, partnership, or other nongovernmental organization which is lawfully engaged in providing, paying for, or reimbursing the cost of, health services under group insurance policies or contracts, medical or hospital service agreements, membership or subscription contracts, or similar group arrangements, in consideration of premiums or other periodic charges payable to the carrier, including a health benefits plan duly sponsored or underwritten by an employee organization; and

(2)  with respect to providers of services only, any agency or organization (not described in paragraph (1)) with which an agreement is in effect under section 1816.

(3)  No such agency or organization shall be liable to the United States for any payments referred to in paragraph (1) or (2).

(o) 

(1) 

(G)  The provisions of subparagraphs (A) through (F) of this paragraph shall not apply to an inhalation drug or biological furnished through durable medical equipment covered under section 1861(n).

DEMONSTRATION PROJECTS FOR COMPETITIVE ACQUISITION OF ITEMS AND SERVICES

Sec. 1847.  (a) Establishment of demonstration project bidding areas.—

(1)  In general.—The Secretary shall implement not more than 5 demonstration projects under which competitive acquisition areas are established for contract award purposes for the furnishing under this part of the items and services described in subsection (d) of this section.

(2)  Project requirements.—Each demonstration project under paragraph (1)—

(A)  shall include such group of items and services as the Secretary may prescribe,

(B)  shall be conducted in not more than 3 competitive acquisition areas, and

(C)  shall be operated over a 3-year period.

(3)  Criteria for establishment of competitive acquisition areas.—Each competitive acquisition area established under a demonstration project implemented under paragraph (1)—

(A)  shall be, or shall be within, a metropolitan statistical area (as defined by the Secretary of Commerce), and

(B)  shall be chosen based on the availability and accessibility of entities able to furnish items and services, and the probable savings to be realized by the use of competitive bidding in the furnishing of items and services in such area.

(b)  Awarding of contracts in areas.—

(1)  In general.—The Secretary shall conduct a competition among individuals and entities supplying items and services described in subsection (c) of this section for each competitive acquisition area established under a demonstration project implemented under subsection (a) of this section.

(2)  Conditions for awarding contract.—The Secretary may not award a contract to any entity under the competition conducted pursuant to paragraph (1) to furnish an item or service unless the Secretary finds that the entity meets quality standards specified by the Secretary and that the total amounts to be paid under the contract are expected to be less than the total amounts that would otherwise be paid.

(3)  Contents of contract.—A contract entered into with an entity under the competition conducted pursuant to paragraph (1) is subject to terms and conditions that the Secretary may specify.

(4)  Limit on number of contractors.—The Secretary may limit the number of contractors in a competitive acquisition area to the number needed to meet projected demand for items and services covered under the contracts.

(c)  Expansion of projects.—

(1)  Evaluations.—The Secretary shall evaluate the impact of the implementation of the demonstration projects on medicare program payments, access, diversity of product selection, and quality. The Secretary shall make annual reports to the Committees on Ways and Means and Commerce of the House of Representatives and the Committee on Finance of the Senate on the results of the evaluation described in the preceding sentence and a final report not later than 6 months after the termination date specified in subsection (e) of this section.

(2)  Expansion.—If the Secretary determines from the evaluations under paragraph (1) that there is clear evidence that any demonstration project—

(A)  results in a decrease in Federal expenditures under this subchapter, and

(B)  does not reduce program access, diversity of product selection, and quality under this subchapter, the Secretary may expand the project to additional competitive acquisition areas.

(d)  Services described.—The items and services to which this section applies are all items and services covered under this part (except for physicians’ services as defined in section 1861(s)(1) of this Act) that the Secretary may specify. At least one demonstration project shall include oxygen and oxygen equipment.

(e)  Termination.—Notwithstanding any other provision of this section, all projects under this section shall terminate not later than December 31, 2002.

Sec. 1851. (b) 

(4) 

(A)  [First sentence was stricken] An individual is not eligible to enroll in an MSA plan under this part.

(i)  on or after January 1, 2003, unless the enrollment is the continuation of such an enrollment in effect as of such date; or

(ii)  as of any date if the number of such individuals so enrolled as of such date has reached 390,000

(C)  [Second sentence was stricken] The Secretary shall submit such a report, by not later than March 1, 2002, on whether the time limitation under subparagraph (A)(i) should be extended or removed and whether to change the numerical limitation under subparagraph (A)(ii).

(d) 

(4) 

(E)  Supplemental benefits.—Whether the organization offering the plan includes mandatory supplemental benefits in its base benefit package or offers optional supplemental benefits and the terms and conditions (including premiums) for such coverage.

(e) 

(3) 

(B)  Annual, coordinated election period.—For purposes of this section, the term “annual, coordinated election period” means, with respect to a year before 2003 and after 2005, the month of November before such year and with respect to 2003, 2004, and 2005, the period beginning on November 15 and ending on December 31 of the year before such year.

title XI—

(A)  those items and services (other than hospice care) for which benefits are available under parts A and B to individuals residing in the area served by the plan, and

(B)  additional benefits required under section 1854(f)(1)(A).

(c) 

(1) 

(I)  Quality Assurance program.—A description of the organization’s quality assurance program under subsection (e).

(e) 

(1)  In general.—Each Medicare+Choice organization must have arrangements, consistent with any regulation, for an ongoing quality assurance program for health care services it provides to individuals enrolled with Medicare+Choice plans of the organization.

(2)  Elements of program.—

(A)  In general.—The quality assurance program of an organization with respect to a Medicare+Choice plan (other than a Medicare+Choice private fee-for-service plan, a non-network MSA plan, or a preferred provider organization plan) it offers shall—

(i)  stress health outcomes and provide for the collection, analysis, and reporting of data (in accordance with a quality measurement system that the Secretary recognizes) that will permit measurement of outcomes and other indices of the quality of Medicare+Choice plans and organizations;

(ii)  monitor and evaluate high volume and high risk services and the care of acute and chronic conditions;

(iii)  evaluate the continuity and coordination of care that enrollees receive;

(iv)  be evaluated on an ongoing basis as to its effectiveness;

(v)  include measures of consumer satisfaction;

(vi)  provide the Secretary with such access to information collected as may be appropriate to monitor and ensure the quality of care provided under this part;

(vii)  provide review by physicians and other health care professionals of the process followed in the provision of such health care services;

(viii)  provide for the establishment of written protocols for utilization review, based on current standards of medical practice;

(ix)  have mechanisms to detect both underutilization and overutilization of services;

(x)  after identifying areas for improvement, establish or alter practice parameters;

(xi)  take action to improve quality and assesses the effectiveness of such action through systematic followup; and

(xii)  make available information on quality and outcomes measures to facilitate beneficiary comparison and choice of health coverage options (in such form and on such quality and outcomes measures as the Secretary determines to be appropriate). Such program shall include a separate focus (with respect to all the elements described in this subparagraph) on racial and ethnic minorities.

(B)  Elements of program for organizations offering.—Medicare+Choice private fee-for-service plans, non-network MSA plans, and preferred provider organization plans The quality assurance program of an organization with respect to a Medicare+Choice private fee-for-service plan, a non-network MSA plan, or a preferred provider organization plan it offers shall—

(i)  meet the requirements of clauses (i) through (vi) of subparagraph (A);

(ii)  insofar as it provides for the establishment of written protocols for utilization review, base such protocols on current standards of medical practice; and

(iii)  have mechanisms to evaluate utilization of services and inform providers and enrollees of the results of such evaluation. Such program shall include a separate focus (with respect to all the elements described in this subparagraph) on racial and ethnic minorities.

(C)  “Non-network msa plan” defined.—In this subsection, the term “non-network MSA plan” means an MSA plan offered by a Medicare+Choice organization that does not provide benefits required to be provided by this part, in whole or in part, through a defined set of providers under contract, or under another arrangement, with the organization.

(D)  Definition of preferred provider organization plan.—In this paragraph, the term “preferred provider organization plan” means a Medicare+Choice plan that—

(i)  has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan;

(ii)  provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and

(iii)  is offered by an organization that is not licensed or organized under State law as a health maintenance organization.

(3)  External review.—

(A)  In general.—Each Medicare+Choice organization shall, for each Medicare+Choice plan it operates, have an agreement with an independent quality review and improvement organization approved by the Secretary to perform functions of the type described in sections 1320c-3(a)(4)(B) and 1320c-3(a)(14) of this title with respect to services furnished by Medicare+Choice plans for which payment is made under this subchapter. The previous sentence shall not apply to a Medicare+Choice private fee-for-service plan or a non-network MSA plan that does not employ utilization review.

(B)  Nonduplication of accreditation.—Except in the case of the review of quality complaints, and consistent with subparagraph (C), the Secretary shall ensure that the external review activities conducted under subparagraph (A) are not duplicative of review activities conducted as part of the accreditation process.

(C)  Waiver authority.—The Secretary may waive the requirement described in subparagraph (A) in the case of an organization if the Secretary determines that the organization has consistently maintained an excellent record of quality assurance and compliance with other requirements under this part.

(j) 

(4) 

(A) 

(ii) 

(II)  conducts periodic surveys of both individuals enrolled and individuals previously enrolled with the organization to determine the degree of access of such individuals to services provided by the organization and satisfaction with the quality of such services.

(iii)  The organization provides the Secretary with descriptive information regarding the plan, sufficient to permit the Secretary to determine whether the plan is in compliance with the requirements of this subparagraph.

Sec. 1853. (b) 

(1)  Annual announcement.—The Secretary shall annually determine, and shall announce (in a manner intended to provide notice to interested parties) for years before 2004 and after 2005 not later than March 1 before the calendar year concerned and for 2004 and 2005 not later than the second Monday in May before the respective calendar year—

(A)  the annual Medicare+Choice capitation rate for each Medicare+Choice payment area for the year, and

(B)  the risk and other factors to be used in adjusting such rates under subsection (a)(1)(A) of this section for payments for months in that year.

(d)  [Heading was amended in its entirety.] Medicare+Choice Payment Area Defined.— Medicare+Choice payment area defined

(1)  In general.—In this part, except as provided in paragraph (3), the term Medicare+Choice payment area means a county, or equivalent area specified by the Secretary.

Sec. 1854. (a) 

(1)  In general.—Not later than the second Monday in September of 2002, 2003, and 2004 (or July 1 of each other year), each Medicare+Choice organization shall submit to the Secretary, in a form and manner specified by the Secretary and for each Medicare+Choice plan for the service area (or segment of such an area if permitted under subsection (h)) in which it intends to be offered in the following year—

(A)  the information described in paragraph (2), (3), or (4) for the type of plan involved; and

(B)  the enrollment capacity (if any) in relation to the plan and area.

(b) 

(2) 

(A)  The Medicare+Choice monthly basic beneficiary premium.—The term “Medicare+Choice monthly basic beneficiary premium” means, with respect to a Medicare+Choice plan, the amount authorized to be charged under subsection (e)(1) of this section for the plan, or, in the case of a Medicare+Choice private fee-for-service plan, the amount filed under subsection (a)(4)(A)(ii).

(B)  Medicare+Choice monthly supplemental beneficiary premium.—The term Medicare+Choice monthly supplemental beneficiary premium means, with respect to a Medicare+Choice plan, the amount authorized to be charged under subsection (e)(2) for the plan or, in the case of a MSA plan or Medicare+Choice private fee-for-service plan, the amount filed under paragraph (3)(B) or (4)(B) of subsection (a).

(c)  Uniform Premium and Bid Amounts.—Except as permitted under section 1857(i), the MA monthly bid amount submitted under subsection (a)(6), the amounts of the MA monthly basic, prescription drug, and supplemental beneficiary premiums, and the MA monthly MSA premium charged under subsection (b) of an MA organization under this part may not vary among individuals enrolled in the plan.

Sec. 1856. (b) 

(3)  Relation to state laws.—

(A)  In general.—The standards established under this subsection shall supersede any State law or regulation (including standards described in subparagraph (B)) with respect to Medicare+Choice plans which are offered by Medicare+Choice organizations under this part to the extent such law or regulation is inconsistent with such standards.

(B)  Standards specifically superseded State standards relating to the following are superseded under this paragraph:

(i)  Benefit requirements (including cost-sharing requirements).

(ii)  Requirements relating to inclusion or treatment of providers.

(iii)  Coverage determinations (including related appeals and grievance processes).

(iv)  Requirements relating to marketing materials and summaries and schedules of benefits regarding a Medicare+Choice plan.

Sec. 1869. (c) 

(3) 

(D)  Limitation on individual reviewing determinations.—

(i)  Physicians and health care professional No physician or health care professional under the employ of a qualified independent contractor may review—

(I)  determinations regarding health care services furnished to a patient if the physician or health care professional was directly responsible for furnishing such services; or

(II)  determinations regarding health care services provided in or by an institution, organization, or agency, if the physician or any member of the family of the physician or health care professional has, directly or indirectly, a significant financial interest in such institution, organization, or agency.

(ii)  Family described.—For purposes of this paragraph, the family of a physician or health care professional includes the spouse (other than a spouse who is legally separated from the physician or health care professional under a decree of divorce or separate maintenance), children (including stepchildren and legally adopted children), grandchildren, parents, and grandparents of the physician or health care professional.

Sec. 1876. (h) 

(5) 

(C)  The Secretary may not extend or renew a reasonable cost reimbursement contract under this subsection for any period beyond December 31, 2004.

Sec. 1886. (b) 

(3) 

(B) 

(i) 

(XIX)  for fiscal year 2004 and each subsequent fiscal year, the market basket percentage increase for hospitals in all areas.

(d) 

(9) 

(A) 

(ii)  for discharges beginning in a fiscal year beginning on or after October 1, 1997, 50 percent (and for discharges between October 1, 1987, and September 30, 1997, 25 percent) of the discharge-weighted average of—

(I)  the national adjusted DRG prospective payment rate (determined under paragraph (3)(D)) for hospitals located in a large urban area,

(II)  such rate for hospitals located in other urban areas, and

(III)  such rate for hospitals located in a rural area, for such discharges, adjusted in the manner provided in paragraph (3)(E) for different area wage levels. As used in this section, the term “subsection (d) Puerto Rico hospital” means a hospital that is located in Puerto Rico and that would be a subsection (d) hospital (as defined in paragraph (1)(B)) if it were located in one of the fifty States.

Sec. 1888. (e) 

(12)  Payment rule for certain facilities.—

(A)  In general.—In the case of a qualified acute skilled nursing facility described in subparagraph (B), the per diem amount of payment shall be determined by applying the non-Federal percentage and Federal percentage specified in paragraph (2)(C)(ii).

(B)  Facility described.—For purposes of subparagraph (A), a qualified acute skilled nursing facility is a facility that—

(i)  was certified by the Secretary as a skilled nursing facility eligible to furnish services under this subchapter before July 1, 1992;

(ii)  is a hospital-based facility; and

(iii)  for the cost reporting period beginning in fiscal year 1998, the facility had more than 60 percent of total patient days comprised of patients who are described in subparagraph (C).

(C)  Description of patients.—For purposes of subparagraph (B), a patient described in this subparagraph is an individual who—

(i)  is entitled to benefits under part A of this subchapter; and

(ii)  is immuno-compromised secondary to an infectious disease, with specific diagnoses as specified by the Secretary.

Sec. 1927. (g) 

(1) 

(B) 

(i) 

(IV)  American Medical Association Drug Evaluations; and

OLD-AGE AND SURVIVORS INSURANCE BENEFIT PAYMENTS

Sec. 202. (b) 

(4)(A)  The amount of a wife’s insurance benefit for each month (as determined after application of the provisions of subsections (q) and (k) of this section) shall be reduced (but not below zero) by an amount equal to two-thirds of the amount of any monthly periodic benefit payable to the wife (or divorced wife) for such month which is based upon her earnings while in the service of the Federal Government or any State (or political subdivision thereof, as defined in section 418(b)(2) of this title) if, on the last day she was employed by such entity—

(i)  such service did not constitute “employment” as defined in section 410 of this title, or

(ii)  such service was being performed while in the service of the Federal Government, and constituted “employment” as so defined solely by reason of—

(I)  clause (ii) or (iii) of subparagraph (G) of section 410(a)(5) of this title, where the lump-sum payment described in such clause (ii) or the cessation of coverage described in such clause (iii) (whichever is applicable) was received or occurred on or after January 1, 1988, or

(II)  an election to become subject to the Federal Employees’ Retirement System provided in chapter 84 of title 5 or the Foreign Service Pension System provided in subchapter II of chapter 8 of title I of the Foreign Service Act of 1980 (22 U.S.C. 4071 et seq.) made pursuant to law after December 31, 1987, unless subparagraph (B) applies. The amount of the reduction in any benefit under this subparagraph, if not a multiple of $0.10, shall be rounded to the next higher multiple of $0.10.

(B)(i)  Subparagraph (A)(i) shall not apply with respect to monthly periodic benefits based wholly on service as a member of a uniformed service (as defined in section 410(m) of this title).

(ii)  Subparagraph (A)(ii) shall not apply with respect to monthly periodic benefits based in whole or in part on service which constituted “employment” as defined in section 410 of this title if such service was performed for at least 60 months in the aggregate during the period beginning January 1, 1988, and ending with the close of the first calendar month as of the end of which the wife (or divorced wife) is eligible for benefits under this subsection and has made a valid application for such benefits.

(C)  For purposes of this paragraph, any periodic benefit which otherwise meets the requirements of subparagraph (A), but which is paid on other than a monthly basis, shall be allocated on a basis equivalent to a monthly benefit (as determined by the Commissioner of Social Security) and such equivalent monthly benefit shall constitute a monthly periodic benefit for purposes of subparagraph (A). For purposes of this subparagraph, the term “periodic benefit” includes a benefit payable in a lump sum if it is a commutation of, or a substitute for, periodic payments.

(c) 

(2)(A)  The amount of a husband’s insurance benefit for each month (as determined after application of the provisions of subsections (q) and (k) of this section) shall be reduced (but not below zero) by an amount equal to two-thirds of the amount of any monthly periodic benefit payable to the husband (or divorced husband) for such month which is based upon his earnings while in the service of the Federal Government or any State (or political subdivision thereof, as defined in section 418(b)(2) of this title) if, on the last day he was employed by such entity —

(i)  such service did not constitute “employment” as defined in section 410 of this title, or

(ii)  such service was being performed while in the service of the Federal Government, and constituted “employment” as so defined solely by reason of—

(I)  clause (ii) or (iii) of subparagraph (G) of section 410(a)(5) of this title, where the lump-sum payment described in such clause (ii) or the cessation of coverage described in such clause (iii) (whichever is applicable) was received or occurred on or after January 1, 1988, or

(II)  the Foreign Service Act of 1980 (22 U.S.C. 4071 et seq.) made pursuant to law after December 31, 1987, unless subparagraph (B) applies. The amount of the reduction in any benefit under this subparagraph, if not a multiple of $0.10, shall be rounded to the next higher multiple of $0.10.

(B)(i)  Subparagraph (A)(i) shall not apply with respect to monthly periodic benefits based wholly on service as a member of a uniformed service (as defined in section 410(m) of this title).

(ii)  Subparagraph (A)(ii) shall not apply with respect to monthly periodic benefits based in whole or in part on service which constituted “employment” as defined in section 410 of this title if such service was performed for at least 60 months in the aggregate during the period beginning January 1, 1988, and ending with the close of the first calendar month as of the end of which the husband (or divorced husband) is eligible for benefits under this subsection and has made a valid application for such benefits.

(C)  For purposes of this paragraph, any periodic benefit which otherwise meets the requirements of subparagraph (A), but which is paid on other than a monthly basis, shall be allocated on a basis equivalent to a monthly benefit (as determined by the Commissioner of Social Security) and such equivalent monthly benefit shall constitute a monthly periodic benefit for purposes of subparagraph (A). For purposes of this subparagraph, the term “periodic benefit” includes a benefit payable in a lump sum if it is a commutation of, or a substitute for, periodic payments.

(e) 

(7)(A)  The amount of a widow’s insurance benefit for each month (as determined after application of the provisions of subsections (q) and (k) of this section, paragraph (2)(D), and paragraph (3)) shall be reduced (but not below zero) by an amount equal to two-thirds of the amount of any monthly periodic benefit payable to the widow (or surviving divorced wife) for such month which is based upon her earnings while in the service of the Federal Government or any State (or political subdivision thereof, as defined in section 418(b)(2) of this title) if, on the last day she was employed by such entity—

(i)  such service did not constitute “employment” as defined in section 410 of this title, or

(ii)  such service was being performed while in the service of the Federal Government, and constituted “employment” as so defined solely by reason of—

(I)  clause (ii) or (iii) of subparagraph (G) of section 410(a)(5) of this title, where the lump-sum payment described in such clause (ii) or the cessation of coverage described in such clause (iii) (whichever is applicable) was received or occurred on or after January 1, 1988, or

(II)  an election to become subject to the Federal Employees’ Retirement System provided in chapter 84 of title 5 or the Foreign Service Pension System provided in subchapter II of chapter 8 of title I of the Foreign Service Act of 1980 (22 U.S.C. 4071 et seq.) made pursuant to law after December 31, 1987, unless subparagraph (B) applies. The amount of the reduction in any benefit under this subparagraph, if not a multiple of $0.10, shall be rounded to the next higher multiple of $0.10.

(B)(i)  Subparagraph (A)(i) shall not apply with respect to monthly periodic benefits based wholly on service as a member of a uniformed service (as defined in section 410(m) of this title).

(ii)  Subparagraph (A)(ii) shall not apply with respect to monthly periodic benefits based in whole or in part on service which constituted “employment” as defined in section 410 of this title if such service was performed for at least 60 months in the aggregate during the period beginning January 1, 1988, and ending with the close of the first calendar month as of the end of which the widow (or surviving divorced wife) is eligible for benefits under this subsection and has made a valid application for such benefits.

(C)  For purposes of this paragraph, any periodic benefit which otherwise meets the requirements of subparagraph (A), but which is paid on other than a monthly basis, shall be allocated on a basis equivalent to a monthly benefit (as determined by the Commissioner of Social Security) and such equivalent monthly benefit shall constitute a monthly periodic benefit for purposes of subparagraph (A). For purposes of this subparagraph, the term “periodic benefit” includes a benefit payable in a lump sum if it is a commutation of, or a substitute for, periodic payments.

(f) 

(2)(A)  The amount of a widower’s insurance benefit for each month (as determined after application of the provisions of subsections (q) and (k) of this section, paragraph (3)(D), and paragraph (4)) shall be reduced (but not below zero) by an amount equal to two-thirds of the amount of any monthly periodic benefit payable to the widower (or surviving divorced husband) for such month which is based upon his earnings while in the service of the Federal Government or any State (or political subdivision thereof, as defined in section 418(b)(2) of this title) if, on the last day he was employed by such entity—

(i)  such service did not constitute “employment” as defined in section 410 of this title, or

(ii)  such service was being performed while in the service of the Federal Government, and constituted “employment” as so defined solely by reason of—

(I)  clause (ii) or (iii) of subparagraph (G) of section 410(a)(5) of this title, where the lump-sum payment described in such clause (ii) or the cessation of coverage described in such clause (iii) (whichever is applicable) was received or occurred on or after January 1, 1988, or

(II)  an election to become subject to the Federal Employees’ Retirement System provided in chapter 84 of title 5 or the Foreign Service Pension System provided in subchapter II of chapter 8 of title I of the Foreign Service Act of 1980 (22 U.S.C. 4071 et seq.) made pursuant to law after December 31, 1987, unless subparagraph (B) applies. The amount of the reduction in any benefit under this subparagraph, if not a multiple of $0.10, shall be rounded to the next higher multiple of $0.10.

(B)(i)  Subparagraph (A)(i) shall not apply with respect to monthly periodic benefits based wholly on service as a member of a uniformed service (as defined in section 410(m) of this title).

(ii)  Subparagraph (A)(ii) shall not apply with respect to monthly periodic benefits based in whole or in part on service which constituted “employment” as defined in section 410 of this title if such service was performed for at least 60 months in the aggregate during the period beginning January 1, 1988, and ending with the close of the first calendar month as of the end of which the widower (or surviving divorced husband) is eligible for benefits under this subsection and has made a valid application for such benefits.

(C)  For purposes of this paragraph, any periodic benefit which otherwise meets the requirements of subparagraph (A), but which is paid on other than a monthly basis, shall be allocated on a basis equivalent to a monthly benefit (as determined by the Commissioner of Social Security) and such equivalent monthly benefit shall constitute a monthly periodic benefit for purposes of subparagraph (A). For purposes of this subparagraph, the term “periodic benefit” includes a benefit payable in a lump sum if it is a commutation of, or a substitute for, periodic payments.

(g) 

(4)(A)  The amount of a mother’s or father’s insurance benefit for each month (as determined after application of the provisions of subsection (k) of this section) shall be reduced (but not below zero) by an amount equal to two-thirds of the amount of any monthly periodic benefit payable to the individual for such month which is based upon the individual’s earnings while in the service of the Federal Government or any State (or political subdivision thereof, as defined in section 418(b)(2) of this title) if, on the last day the individual was employed by such entity—

(i)  such service did not constitute “employment” as defined in section 410 of this title,

(ii)  such service was being performed while in the service of the Federal Government, and constituted “employment” as so defined solely by reason of—

(I)  clause (ii) or (iii) of subparagraph (G) of section 410(a)(5) of this title, where the lump-sum payment described in such clause (ii) or the cessation of coverage described in such clause (iii) (whichever is applicable) was received or occurred on or after January 1, 1988, or

(II)  an election to become subject to the Federal Employees’ Retirement System provided in chapter 84 of title 5 or the Foreign Service Pension System provided in subchapter II of chapter 8 of title I of the Foreign Service Act of 1980 (22 U.S.C. 4071 et seq.) made pursuant to law after December 31, 1987, unless subparagraph (B) applies. The amount of the reduction in any benefit under this subparagraph, if not a multiple of $0.10, shall be rounded to the next higher multiple of $0.10.

(B)(i)  Subparagraph (A)(i) shall not apply with respect to monthly periodic benefits based wholly on service as a member of a uniformed service (as defined in section 410(m) of this title).

(ii)  Subparagraph (A)(ii) shall not apply with respect to monthly periodic benefits based in whole or in part on service which constituted “employment” as defined in section 410 of this title if such service was performed for at least 60 months in the aggregate during the period beginning January 1, 1988, and ending with the close of the first calendar month as of the end of which the individual is eligible for benefits under this subsection and has made a valid application for such benefits.

(C)  For purposes of this paragraph, any periodic benefit which otherwise meets the requirements of subparagraph (A), but which is paid on other than a monthly basis, shall be allocated on a basis equivalent to a monthly benefit (as determined by the Commissioner of Social Security) and such equivalent monthly benefit shall constitute a monthly periodic benefit for purposes of subparagraph (A). For purposes of this subparagraph, the term “periodic benefit” includes a benefit payable in a lump sum if it is a commutation of, or a substitute for, periodic payments.

Sec. 204. (g)  For payments which are adjusted or withheld to recover an overpayment of supplemental security income benefits paid under Title XVI of this Act (including State supplementary payments paid under an agreement pursuant to section 1616(a) of this Act or section 212(b) of Public Law 93-66), see section 1147.

Sec. 205. (j) 

(6)  The Commissioner of Social Security shall include as a part of the annual report required under section 704 information with respect to the implementation of the preceding provisions of this subsection, including the number of cases in which the representative payee was changed, the number of cases discovered where there has been a misuse of funds, how any such cases were dealt with by the Commissioner of Social Security, the final disposition of such cases, including any criminal penalties imposed, and such other information as the Commissioner of Social Security determines to be appropriate.

Sec. 208. (c)  In the case of any violation described in the preceding sentence, including a first such violation, if the court determines that such violation includes a willful misuse of funds by such person or entity, the court may also require that full or partial restitution of such funds be made to the individual for whom such person or entity was the certified payee.

There are authorized to be appropriated to each of the Trust Funds, consisting of the Federal Old-Age and Survivors Insurance Trust Fund, the Federal Disability Insurance Trust Fund, and the Federal Hospital Insurance Trust Fund, for transfer on July 1 of each calendar year to such Trust Fund from amounts in the general fund in the Treasury not otherwise appropriated, an amount equal to the total of the additional amounts which would be appropriated to such Trust Fund for the fiscal year ending September 30 of such calendar year under section 201 or 1817 of this Act if the amounts of the additional wages deemed to have been paid for such calendar year by reason of subsection (a) of this section constituted remuneration for employment (as defined in section 3121(b) of the Internal Revenue Code of 1986) for purposes of the taxes imposed by sections 3101 and 3111 of the Internal Revenue Code of 1986. Amounts authorized to be appropriated under this subsection for transfer on July 1 of each calendar year shall be determined on the basis of estimates of the Commissioner of Social Security of the wages deemed to be paid for such calendar year under subsection (a) of this section; and proper adjustments shall be made in amounts authorized to be appropriated for subsequent transfer to the extent prior estimates were in excess of or were less than such wages so deemed to be paid. Additional adjustments may be made in the amounts so authorized to be appropriated to the extent that the amounts transferred in accordance with clauses (i) and (ii) of section 151(b)(3)(B) of the Social Security Amendments of 1983 with respect to wages deemed to have been paid in 1983 were in excess of or were less than the amount which the Commissioner of Social Security, on the basis of appropriate data, determines should have been so transferred.

Sec. 234. (d) 

(2)  The authority under the preceding provisions of this section (including any waiver granted pursuant to subsection (c) of this section) shall terminate 5 years after December 17, 1999.

Sec. 703. 

EXPENSES AND PER DIEM

(f)  Members of the Board shall serve without compensation, except that, while serving on business of the Board away from their homes or regular places of business, members may be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5703 of title 5, United States Code, for persons in the Government employed intermittently.

Sec. 808. (a) 

(1) 

(B)  under title II to recover the amount in excess of the correct amount, if the person is not currently eligible for payment under this title.

Sec. 811. (b)  Restitution by representative payee.—If a person or organization violates subsection (a) in the person’s or organization’s role as, or in applying to become, a representative payee under section 807 of this Act on behalf of a qualified individual, and the violation includes a willful misuse of funds by the person or entity, the court may also require that full or partial restitution of funds be made to the qualified individual.

Sec. 1129. (a)  who makes, or causes to be made, a statement or representation of a material fact for use in determining any initial or continuing right to or the amount of—

(A)  monthly insurance benefits under subchapter II of this chapter,

(B)  benefits or payments under subchapter VIII of this chapter, or

(C)  benefits or payments under subchapter XVI of this chapter, that the person knows or should know is false or misleading or knows or should know omits a material fact or makes such a statement with knowing disregard for the truth shall be subject to,

RECOVERY OF SSI OVERPAYMENTS FROM OTHER BENEFITS

Sec. 1147.  (a) In General.—(1) Whenever the Commissioner of Social Security determines that more than the correct amount of any payment has been made under the supplemental security income program under title XVI of this Act (including, for purposes of this section, under section 1616(a) of this Act or section 212(b) of Public Law 93–66) to a person who is not currently eligible for cash benefits under the program, the Commissioner, notwithstanding section 207 of this Act but subject to paragraph (2) of this subsection, may recover the amount incorrectly paid by decreasing any amount which is payable to the person under title II or VIII of this Act in any month by not more than 10 percent of the amount payable under such title

(2)  The 10 percent limitation set forth in paragraph (1) shall not apply to an overpayment made to a person if—

(A)  the person or the spouse of the person was involved in willful misrepresentation or concealment of material information in connection with the overpayment; or

(B)  the person so requests.

(b)  No Effect on SSI Eligibility or Benefit Amount.—In any case in which the Commissioner of Social Security takes action in accordance with subsection (a) to recover an amount incorrectly paid to any person, neither that person, nor any individual whose eligibility for benefits under the supplemental security income program under title XVI, or whose amount of such benefits, is determined by considering any part of that person’s income, shall, as a result of such action—

(1)  become eligible for benefits under such program; or

(2)  if such person or individual is otherwise so eligible, become eligible for increased benefits under such program.

RECOVERY OF SOCIAL SECURITY BENEFIT OVERPAYMENTS FROM TITLE VIII BENEFITS

Sec. 1147A. [42 U.S.C. 1320b-18]  Whenever the Commissioner of Social Security determines that more than the correct amount of any payment has been made under title II to an individual who is not currently receiving benefits under that title but who is receiving benefits under title VIII, the Commissioner may recover the amount incorrectly paid under title II by decreasing any amount which is payable to the individual under title VIII.

Sec. 1149. (c) 

(2)  Disabled beneficiary.—The term “disabled beneficiary” has the meaning given that term in section 1148(k)(2).

Sec. 1150. (g) 

(2)  Disabled beneficiary.—The term “disabled beneficiary” has the meaning given that term in section 1148(k)(2).

Sec. 1611. (c) 

(2) 

(B)  in the case of the month in which an application becomes effective or the first month following a period of ineligibility, if such application becomes effective, or eligibility is restored, after the first day of such month, bear the same ratio to the amount of the benefit which would have been payable to such individual if such application had become effective, or eligibility had been restored, on the first day of such month as the number of days in such month including and following the effective date of such application or restoration of eligibility bears to the total number of days in such month.

Sec. 1612. (b) 

(3)(A)  the total unearned income of such individual (and such spouse, if any) in a month which, as determined in accordance with criteria prescribed by the Commissioner of Social Security, is received too infrequently or irregularly to be included, if such income so received does not exceed $20 in such month, and (B) the total earned income of such individual (and such spouse, if any) in a month which, as determined in accordance with such criteria, is received too infrequently or irregularly to be included, if such income so received does not exceed $10 in such month;

Sec. 1613. (a) 

(11)  for the month of receipt and the following month, any refund of Federal income taxes made to such individual (or such spouse) by reason of section 32 of the Internal Revenue Code of 1986 (relating to earned income tax credit), and any payment made to such individual (or such spouse) by an employer under section 3507 of such Code (relating to advance payment of earned income credit);

Sec. 1631. (a) 

(2) 

(G)  The Commissioner of Social Security shall include as a part of the annual report required under section 704 information with respect to the implementation of the preceding provisions of this paragraph, including—

(i)  the number of cases in which the representative payee was changed;

(ii)  the number of cases discovered where there has been a misuse of funds;

(iii)  how any such cases were dealt with by the Commissioner of Social Security;

(iv)  the final disposition of such cases (including any criminal penalties imposed); and

(v)  such other information as the Commissioner of Social Security determines to be appropriate.

(H)  The Commissioner of Social Security shall make an initial report to each House of the Congress on the implementation of subparagraphs (B) and (C) within 270 days after October 9, 1984. The Commissioner of Social Security shall include in the annual report required under section 704, information with respect to the implementation of subparagraphs (B) and (C), including the same factors as are required to be included in the Commissioner’s report under section 205(j)(4)(B).

(b) 

(6)  For provisions relating to the recovery of benefits incorrectly paid under this subchapter from benefits payable under subchapter II of this chapter, see section 1147.

(d) 

(2) 

(A) 

(ii)  by substituting “section 1631(a)(7)(A) of this title or the requirements of due process of law” for “subsection (g) or (h) of section 423 of this title”.

Sec. 1135. (b) 

(3)  sanctions under section 1867 (relating to examination and treatment for emergency medical conditions and women in labor) for a transfer of an individual who has not been stabilized in violation of subsection (c) of such section if the transfer arises out of the circumstances of the emergency;

Sec. 1933. (g)  Special Rule.— With respect to the period that begins on January 1, 2004, and ends on September 30, 2004, a State shall select qualifying individuals, and provide such individuals with assistance, in accordance with the provisions of this section as in effect with respect to calendar year 2003, except that for such purpose—

(1)  references in the preceding subsections of this section to “fiscal year” and “calendar year” shall be deemed to be references to such period; and

(2)  the total allocation amount under subsection (c) for such period shall be $300,000,000.

Sec. 403. (a) 

(2)  Bonus to reward decrease in illegitimacy ratio.—

(A)  In general.—Each eligible State shall be entitled to receive from the Secretary a grant for each bonus year.

(B)  Amount of grant.—

(i)  In general.—If, for a bonus year, none of the eligible States is Guam, the Virgin Islands, or American Samoa, then the amount of the grant shall be—

(I)  $20,000,000 if there are 5 eligible States; or

(II)  $25,000,000 if there are fewer than 5 eligible States.

(ii)  Amount if certain territories are eligible.—If, for a bonus year, Guam, the Virgin Islands, or American Samoa is an eligible State, then the amount of the grant shall be—

(I)  in the case of such a territory, 25 percent of the mandatory ceiling amount (as defined in section 1108(c)(4)) with respect to the territory; and

(II)  in the case of a State that is not such a territory—

(aa)  if there are 5 eligible States other than such territories, $20,000,000, minus 1/5 of the total amount of the grants payable under this paragraph to such territories for the bonus year; or

(bb)  if there are fewer than 5 such eligible States, $25,000,000, or such lesser amount as may be necessary to ensure that the total amount of grants payable under this paragraph for the bonus year does not exceed $100,000,000.

(C)  Definitions.—As used in this paragraph:

(i)  Eligible state.—

(I)  In general.—The term “eligible State” means a State that the Secretary determines meets the following requirements:

(aa)  The State demonstrates that the illegitimacy ratio of the State for the most recent 2-year period for which such information is available decreased as compared to the illegitimacy ratio of the State for the previous 2-year period, and the magnitude of the decrease for the State for the period is not exceeded by the magnitude of the corresponding decrease for 5 or more other States for the period. In the case of a State that is not a territory specified in subparagraph (B), the comparative magnitude of the decrease for the State shall be determined without regard to the magnitude of the corresponding decrease for any such territory.

(bb)  The rate of induced pregnancy terminations in the State for the calendar year for which the most recent data are available is less than the rate of induced pregnancy terminations in the State for the calendar year 1995.

(II)  Disregard of changes in data due to changed reporting methods.—In making the determination required by subclause (I), the Secretary shall disregard—

(aa)  any difference between the illegitimacy ratio of a State for a calendar year and the number of out-of-wedlock births that occurred in a State for fiscal year 1995 which is attributable to a change in State methods of reporting data used to calculate the illegitimacy ratio; and

(bb)  any difference between the rate of induced pregnancy terminations in a State for a calendar year and such rate for calendar year 1995 which is attributable to a change in State methods of reporting data used to calculate such rate.

(ii)  Bonus year.—The term “bonus year” means calendar years 1999, 2000, 2001, 2002, and 2003.

(iii)  Illegitimacy ratio.—The term “illegitimacy ratio” means, with respect to a State and a period—

(I)  the number of out-of-wedlock births to mothers residing in the State that occurred during the period; divided by

(II)  the number of births to mothers residing in the State that occurred during the period.

(D)  Appropriation.—Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated for fiscal years 1999 through 2003, such sums as are necessary for grants under this paragraph.

Sec. 407. (a)  Review of Implementation of State Work Programs.—During fiscal year 1999, the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate shall hold hearings and engage in other appropriate activities to review the implementation of this section by the States, and shall invite the Governors of the States to testify before them regarding such implementation. Based on such hearings, such Committees may introduce such legislation as may be appropriate to remedy any problems with the State programs operated pursuant to this section.

Sec. 408. (a) 

(3)  No assistance for families not assigning certain support rights to the state.—

(A)  In general.—A State to which a grant is made under section 403 shall require, as a condition of providing assistance to a family under the State program funded under this part, that a member of the family assign to the State any rights the family member may have (on behalf of the family member or of any other person for whom the family member has applied for or is receiving such assistance) to support from any other person, not exceeding the total amount of assistance so provided to the family, which accrue (or have accrued) before the date the family ceases to receive assistance under the program, which assignment, on and after such date, shall not apply with respect to any support (other than support collected pursuant to section 464) which accrued before the family received such assistance and which the State has not collected by—

(i) 

(I)  September 30, 2000, if the assignment is executed on or after October 1, 1997, and before October 1, 2000; or

(II)  the date the family ceases to receive assistance under the program, if the assignment is executed on or after October 1, 2000; or

(ii)  If the State elects to distribute collections under section 457(a)(6), the date the family ceases to receive assistance under the program, if the assignment is executed on or after October 1, 1998.

(B)  Limitation.—A State to which a grant is made under section 403 shall not require, as a condition of providing assistance to any family under the State program funded under this part, that a member of the family assign to the State any rights to support described in subparagraph (A) which accrue after the date the family ceases to receive assistance under the program.

Sec. 436. (a)  Authorization.—There are authorized to be appropriated to carry out the provisions of this subpart $305,000,000 for each of fiscal years 2002 through 2006.

Sec. 457. (a)  In General.—Subject to subsections (d) and (e), an amount collected on behalf of a family as support by a State pursuant to a plan approved under this part shall be distributed as follows:

(1)  Families receiving assistance.—In the case of a family receiving assistance from the State, the State shall—

(A)  pay to the Federal Government the Federal share of the amount so collected; and

(B)  retain, or distribute to the family, the State share of the amount so collected.

In no event shall the total of the amounts paid to the Federal Government and retained by the State exceed the total of the amounts that have been paid to the family as assistance by the State.

(2)  Families that formerly received assistance.—In the case of a family that formerly received assistance from the State:

(A)  Current support payments.—To the extent that the amount so collected does not exceed the amount required to be paid to the family for the month in which collected, the State shall distribute the amount so collected to the family.

(B)  Payment of arrearages.—To the extent that the amount so collected exceeds the amount required to be paid to the family for the month in which collected, the State shall distribute the amount so collected as follows:

(i)  Distribution of arrearages that accrued after the family ceased to receive assistance.—

(I)  Pre-october 1997.—Except as provided in subclause (II), the provisions of this section as in effect and applied on the day before the date of the enactment of section 302 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (other than subsection (b)(1) (as so in effect)) shall apply with respect to the distribution of support arrearages—

(aa)  accrued after the family ceased to receive assistance, and

(bb)  are collected before October 1, 1997.

(II)  Post-september 1997.—With respect to the amount so collected on or after October 1, 1997 (or before such date, at the option of the State)—

(aa)  In general.—The State shall first distribute the amount so collected (other than any amount described in clause (iv)) to the family to the extent necessary to satisfy any support arrearages with respect to the family that accrued after the family ceased to receive assistance from the State.

(bb)  Reimbursement of governments for assistance provided to the family.—After the application of division (aa) and clause (ii)(II)(aa) with respect to the amount so collected, the State shall retain the State share of the amount so collected, and pay to the Federal Government the Federal share (as defined in subsection (c)(2)) of the amount so collected, but only to the extent necessary to reimburse amounts paid to the family as assistance by the State.

(cc)  Distribution of the remainder to the family.—To the extent that neither division (aa) nor division (bb) applies to the amount so collected, the State shall distribute the amount to the family.

(ii)  Distribution of arrearages that accrued before the family received assistance.—

(I)  Pre-october 2000.—Except as provided in subclause (II), the provisions of this section as in effect and applied on the day before the date of enactment of section 302 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, or earlier at the State’s option.(other than subsection (b)(1) (as so in effect)) shall apply with respect to the distribution of support arrearages that—

(aa)  accrued before the family received assistance, and

(bb)  are collected before October 1, 2000.

(II)  Post-september 2000.—Unless, based on the report required by paragraph (5), the Congress determines otherwise, with respect to the amount so collected on or after October 1, 2000 (or before such date, at the option of the State—

(aa)  In general.—The State shall first distribute the amount so collected (other than any amount described in clause (iv)) to the family to the extent necessary to satisfy any support arrearages with respect to the family that accrued before the family received assistance from the State.

(bb)  Reimbursement of governments for assistance provided to the family.—After the application of clause (i)(II)(aa) and division (aa) with respect to the amount so collected, the State shall retain the State share of the amount so collected, and pay to the Federal Government the Federal share (as defined in subsection (c)(2)) of the amount so collected, but only to the extent necessary to reimburse amounts paid to the family as assistance by the State.

(cc)  Distribution of the remainder to the family.—To the extent that neither division (aa) nor division (bb) applies to the amount so collected, the State shall distribute the amount to the family.

(iii)  Distribution of arrearages that accrued while the family received assistance.—In the case of a family described in this subparagraph, the provisions of paragraph (1) shall apply with respect to the distribution of support arrearages that accrued while the family received assistance.

(iv)  Amounts collected pursuant to section 464.—Notwithstanding any other provision of this section, any amount of support collected pursuant to section 464 shall be retained by the State to the extent past-due support has been assigned to the State as a condition of receiving assistance from the State, up to the amount necessary to reimburse the State for amounts paid to the family as assistance by the State. The State shall pay to the Federal Government the Federal share of the amounts so retained. To the extent the amount collected pursuant to section 464 exceeds the amount so retained, the State shall distribute the excess to the family.

(v)  Ordering rules for distribution.—For purposes of this subparagraph, unless an earlier effective date is required by this section, effective October 1, 2000, the State shall treat any support arrearages collected, except for amounts collected pursuant to section 464, as accruing in the following order:

(I)  To the period after the family ceased to receive assistance.

(II)  To the period before the family received assistance.

(III)  To the period while the family was receiving assistance.

(3)  Families that never received assistance.—In the case of any other family, the State shall distribute the amount so collected to the family.

(3)  Families that never received assistance.—In the case of any other family, the State shall distribute to the family the portion of the amount so collected that remains after withholding any fee pursuant to section 464(6)((B)(ii).

(4)  Families under certain agreements.—In the case of an amount collected for a family in accordance with a cooperative agreement under section 454(33) distribute the amount so collected pursuant to the terms of the agreement.

(5)  Study and report.—Not later than October 1, 1999, the Secretary shall report to the Congress the Secretary’s findings with respect to—

(A)  whether the distribution of post-assistance arrearages to families has been effective in moving people off of welfare and keeping them off of welfare;

(B)  whether early implementation of a pre-assistance arrearage program by some States has been effective in moving people off of welfare and keeping them off of welfare;

(C)  what the overall impact has been of the amendments made by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 with respect to child support enforcement in moving people off of welfare and keeping them off of welfare; and

(D)  based on the information and data the Secretary has obtained, what changes, if any, should be made in the policies related to the distribution of child support arrearages.

(6)  State option for applicability.—Notwithstanding any other provision of this subsection, a State may elect to apply the rules described in clauses (i)(II), (ii)(II), and (v) of paragraph (2)(B) to support arrearages collected on and after October 1, 1998, and, if the State makes such an election, shall apply the provisions of this section, as in effect and applied on the day before the date of enactment of section 302 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, other than subsection (b)(1) (as so in effect), to amounts collected before October 1, 1998.

(b)  Continuance of Assignments.—Any rights to support obligations, assigned to a State as a condition of receiving assistance from the State under part A and in effect on September 30, 1997 (or such earlier date, on or after August 22, 1996, as the State may choose), shall remain assigned after such date.

Sec. 464. (c) 

(2)  For purposes of subsection (a)(2), the term “past-due support” means only past-due support owed to or on behalf of a qualified child (or a qualified child and the parent with whom the child is living if the same support order includes support for the child and the parent).

(3)  For purposes of paragraph (2), the term “qualified child” means a child—

(A)  who is a minor; or

(B)(i)  who, while a minor, was determined to be disabled under Title II or XVI; and

(ii)  for whom an order of support is in force.

Sec. 472. (a)  Each State with a plan approved under this part shall make foster care maintenance payments (as defined in section 475(4)) under this part with respect to a child who would have met the requirements of section 406(a) or of section 407 (as such sections were in effect on July 16, 1996) but for his removal from the home of a relative (specified in section 406(a) (as so in effect)), if—

(1)  the removal from the home occurred pursuant to a voluntary placement agreement entered into by the child’s parent or legal guardian, or was the result of a judicial determination to the effect that continuation therein would be contrary to the welfare of such child and (effective October 1, 1983) that reasonable efforts of the type described in section 471(a)(15) for a child have been made;

(2)  such child’s placement and care are the responsibility of (A) the State agency administering the State plan approved under section 471, or (B) any other public agency with whom the State agency administering or supervising the administration of the State plan approved under section 471 has made an agreement which is still in effect;

(3)  such child has been placed in a foster family home or child-care institution as a result of the voluntary placement agreement or judicial determination referred to in paragraph (1); and

(4)  such child—

(A)  would have received aid under the State plan approved under section 402 (as in effect on July 16, 1996) in or for the month in which such agreement was entered into or court proceedings leading to the removal of such child from the home were initiated, or

(B)(i)  would have received such aid in or for such month if application had been made therefor, or (ii) had been living with a relative specified in section 406(a) (as in effect on July 16, 1996) within six months prior to the month in which such agreement was entered into or such proceedings were initiated, and would have received such aid in or for such month if in such month he had been living with such a relative and application therefor had been made.

In any case where the child is an alien disqualified under section 245A(h), 210(f), or 210A(d)(7) of the Immigration and Nationality Act from receiving aid under the State plan approved under section 402 in or for the month in which such agreement was entered into or court proceedings leading to the removal of the child from the home were instituted, such child shall be considered to satisfy the requirements of paragraph (4) (and the corresponding requirements of section 473(a)(2)(B)), with respect to that month, if he or she would have satisfied such requirements but for such disqualification. In determining whether a child would have received aid under a State plan approved under section 402 (as in effect on July 16, 1996), a child whose resources (determined pursuant to section 402(a)(7)(B), as so in effect) have a combined value of not more than $10,000 shall be considered to be a child whose resources have a combined value of not more than $1,000 (or such lower amount as the State may determine for purposes of such section 402(a)(7)(B)).

Sec. 473. (a) 

(2)  For purposes of paragraph (1)(B)(ii), a child meets the requirements of this paragraph if such child—

(A)(i)  at the time adoption proceedings were initiated, met the requirements of section 406(a) or section 407 (as such sections were in effect on July 16, 1996) or would have met such requirements except for his removal from the home of a relative (specified in section 406(a) (as so in effect)), either pursuant to a voluntary placement agreement with respect to which Federal payments are provided under section 474 (or 403 (as such section was in effect on July 16, 1996)) or as a result of a judicial determination to the effect that continuation therein would be contrary to the welfare of such child,

(ii)  meets all of the requirements of title XVI with respect to eligibility for supplemental security income benefits, or

(iii)  is a child whose costs in a foster family home or child-care institution are covered by the foster care maintenance payments being made with respect to his or her minor parent as provided in section 475(4)(B),

(B)(i)  would have received aid under the State plan approved under section 402 (as in effect on July 16, 1996) in or for the month in which such agreement was entered into or court proceedings leading to the removal of such child from the home were initiated, or

(ii)(I)  would have received such aid in or for such month if application had been made therefor, or (II) had been living with a relative specified in section 406(a) (as in effect on July 16, 1996) within six months prior to the month in which such agreement was entered into or such proceedings were initiated, and would have received such aid in or for such month if in such month he had been living with such a relative and application therefor had been made, or

(iii)  is a child described in subparagraph (A)(ii) or (A)(iii), and

(C)  has been determined by the State, pursuant to subsection (c) of this section, to be a child with special needs.

The last sentence of section 472(a) shall apply, for purposes of subparagraph (B), in any case where the child is an alien described in that sentence. Any child who meets the requirements of subparagraph (C), who was determined eligible for adoption assistance payments under this part with respect to a prior adoption, who is available for adoption because the prior adoption has been dissolved and the parental rights of the adoptive parents have been terminated or because the child’s adoptive parents have died, and who fails to meet the requirements of subparagraphs (A) and (B) but would meet such requirements if the child were treated as if the child were in the same financial and other circumstances the child was in the last time the child was determined eligible for adoption assistance payments under this part and the prior adoption were treated as never having occurred, shall be treated as meeting the requirements of this paragraph for purposes of paragraph (1)(B)(ii).

Sec. 1834. (a) 

(7) 

(A)  In general.—In the case of an item of durable medical equipment not described in paragraphs (2) through (6)—

(i)  payment shall be made on a monthly basis for the rental of such item during the period of medical need (but payments under this clause may not extend over a period of continuous use of longer than 15 months, or, in the case of an item for which a purchase agreement has been entered into under clause (iii), a period of continuous use of longer than 13 months), and, subject to subparagraph (B), the amount recognized for each of the first 3 months of such period is 10 percent of the purchase price recognized under paragraph (8) with respect to the item, and for each of the remaining months of such period is 7.5 percent of such purchase price;

(ii)  in the case of a power-driven wheelchair, at the time the supplier furnishes the item, the supplier shall offer the individual patient the option to purchase the item, and payment for such item shall be made on a lump-sum basis if the patient exercises such option;

(iii)  during the 10th continuous month during which payment is made for the rental of an item under clause (i), the supplier of such item shall offer the individual patient the option to enter into a purchase agreement under which, if the patient notifies the supplier not later than 1 month after the supplier makes such offer that the patient agrees to accept such offer and exercise such option—

(I)  the supplier shall transfer title to the item to the individual patient on the first day that begins after the 13th continuous month during which payment is made for the rental of the item under clause (i),

(II)  after the supplier transfers title to the item under subclause (I), maintenance and servicing payments shall be made in accordance with clause (vi);

(iv)  in the case of an item for which a purchase agreement has not been entered into under clause (ii) or clause (iii), during the first 6-month period of medical need that follows the period of medical need during which payment is made under clause (i), no payment shall be made for rental or maintenance and servicing of the item;

(v)  in the case of an item for which a purchase agreement has not been entered into under clause (ii) or clause (iii), during the first month of each succeeding 6-month period of medical need, a maintenance and servicing payment may be made (for parts and labor not covered by the supplier’s or manufacturer’s warranty, as determined by the Secretary to be appropriate for the particular type of durable medical equipment) and the amount recognized for each such 6-month period is the lower of (I) a reasonable and necessary maintenance and servicing fee or fees established by the Secretary, or (II) 10 percent of the total of the purchase price recognized under paragraph (8) with respect to the item; and

(vi)  in the case of an item for which a purchase agreement has been entered into under clause (ii) or clause (iii), maintenance and servicing payments may be made (for parts and labor not covered by the supplier’s or manufacturer’s warranty, as determined by the Secretary to be appropriate for the particular type of durable medical equipment), and such payments shall be in an amount established by the Secretary on the basis of reasonable charges in the locality for maintenance and servicing.

The Secretary shall determine the meaning of the term “continuous” in subparagraph (A).

Sec. 1839. (i) 

(3) 

(B) 

(iii)  For 2009, 60 percent.

(iv)  for 2010, 80 percent.

Sec. 1903. (w) 

(7) 

(A) 

(viii)  Services of a medicaid managed care organization with a contract under section 1903(m).

Sec. 1915. (g) 

(2)  For purposes of this subsection, the term “case management services” means services which will assist individuals eligible under the plan in gaining access to needed medical, social, educational, and other services.

Sec. 1927. (b) 

(3) 

(A) 

(i)  not later than 30 days after the last day of each rebate period under the agreement (beginning on or after January 1, 1991), on the average manufacturer price (as defined in subsection (k)(1), customary prompt pay discounts extended to wholesalers) and, (for single source drugs and innovator multiple source drugs), the manufacturer’s best price (as defined in subsection (c)(2)(B)) for covered outpatient drugs for the rebate period under the agreement;

Sec. 473B. [42 U.S.C. 673c note] (a)  Grant Authority.—The Secretary shall make a grant to each State that is a home study incentive-eligible State for a fiscal year in an amount equal to the timely interstate home study incentive payment payable to the State under this section for the fiscal year, which shall be payable in the immediately succeeding fiscal year.

(b)  Home Study Incentive-Eligible State.—A State is a home study incentive-eligible State for a fiscal year if—

(1)  the State has a plan approved under this part for the fiscal year;

(2)  the State is in compliance with subsection (c) for the fiscal year; and

(3)  based on data submitted and verified pursuant to subsection (c), the State has completed a timely interstate home study during the fiscal year.

(c)  Data Requirements.—

(1)  In general.—A State is in compliance with this subsection for a fiscal year if the State has provided to the Secretary a written report, covering the preceding fiscal year, that specifies—

(A)  the total number of interstate home studies requested by the State with respect to children in foster care under the responsibility of the State, and with respect to each such study, the identity of the other State involved;

(B)  the total number of timely interstate home studies completed by the State with respect to children in foster care under the responsibility of other States, and with respect to each such study, the identity of the other State involved; and

(C)  such other information as the Secretary may require in order to determine whether the State is a home study incentive-eligible State.

(2)  Verification of data.—In determining the number of timely interstate home studies to be attributed to a State under this section, the Secretary shall check the data provided by the State under paragraph (1) against complementary data so provided by other States.

(d)  Timely Interstate Home Study Incentive Payments.—

(1)  In general.—The timely interstate home study incentive payment payable to a State for a fiscal year shall be $1,500, multiplied by the number of timely interstate home studies attributed to the State under this section during the fiscal year, subject to paragraph (2).

(2)  Pro rata adjustment if insufficient funds available.—If the total amount of timely interstate home study incentive payments otherwise payable under this section for a fiscal year exceeds the total of the amounts made available pursuant to subsection (h) for the fiscal year (reduced (but not below zero) by the total of the amounts (if any) payable under paragraph (3) of this subsection with respect to the preceding fiscal year), the amount of each such otherwise payable incentive payment shall be reduced by a percentage equal to—

(A)  the total of the amounts so made available (as so reduced); divided by

(B)  the total of such otherwise payable incentive payments.

(3)  Appropriations available for unpaid incentive payments for prior fiscal years.—

(A)  In general.—If payments under this section are reduced under paragraph (2) or subparagraph (B) of this paragraph for a fiscal year, then, before making any other payment under this section for the next fiscal year, the Secretary shall pay each State whose payment was so reduced an amount equal to the total amount of the reductions which applied to the State, subject to subparagraph (B) of this paragraph.

(B)  Pro rata adjustment if insufficient funds available.—If the total amount of payments otherwise payable under subparagraph (A) of this paragraph for a fiscal year exceeds the total of the amounts made available pursuant to subsection (h) for the fiscal year, the amount of each such payment shall be reduced by a percentage equal to—

(i)  the total of the amounts so made available; divided by.

(ii)  the total of such otherwise payable payments.

(e)  Two-Year Availability of Incentive Payments.—Payments to a State under this section in a fiscal year shall remain available for use by the State through the end of the next fiscal year.

(f)  Limitations on Use of Incentive Payments.—A State shall not expend an amount paid to the State under this section except to provide to children or families any service (including post-adoption services) that may be provided under part B or E. Amounts expended by a State in accordance with the preceding sentence shall be disregarded in determining State expenditures for purposes of Federal matching payments under sections 423, 434, and 474.

(g)  Definitions.—In this section:

(1)  Home study.—The term “home study” means an evaluation of a home environment conducted in accordance with applicable requirements of the State in which the home is located, to determine whether a proposed placement of a child would meet the individual needs of the child, including the child’s safety, permanency, health, well-being, and mental, emotional, and physical development.

(2)  Interstate home study.—The term “interstate home study” means a home study conducted by a State at the request of another State, to facilitate an adoptive or foster placement in the State of a child in foster care under the responsibility of the State.

(3)  Timely interstate home study.—The term “timely interstate home study” means an interstate home study completed by a State if the State provides to the State that requested the study, within 30 days after receipt of the request, a report on the results of the study. The preceding sentence shall not be construed to require the State to have completed, within the 30-day period, the parts of the home study involving the education and training of the prospective foster or adoptive parents.

(h)  Limitations on Authorization of Appropriations.—

(1)  In general.—For payments under this section, there are authorized to be appropriated to the Secretary—

(A)  $10,000,000 for fiscal year 2007;

(B)  $10,000,000 for fiscal year 2008;

(C)  $10,000,000 for fiscal year 2009; and

(D)  $10,000,000 for fiscal year 2010.

(2)  Availability.—Amounts appropriated under paragraph (1) are authorized to remain available until expended.

Sec. 1135. (b) 

(3) 

(B)  the direction or relocation of an individual to receive medical screening in an alternate location pursuant to an appropriate State emergency preparedness plan;

Sec. 1847B. (a) 

(3) 

(A) 

(iii)  *  *  *and biologicals—

(I)  shall be made only to such contractor; and

(II)  shall be conditioned upon the administration of such drugs and biologicals.

Sec. 1886. (d) 

C)

(iv)  The Secretary shall include recommendations with respect to adjustments to weighting factors under clause (i) in the annual report to Congress required under subsection (e)(3)(B).

(e) 

(3)  The Secretary, not later than April 1, 1987, for fiscal year 1988 and not later than March 1 before the beginning of each fiscal year (beginning with fiscal year 1989), shall report to the Congress the Secretary’s initial estimate of the percentage change that the Secretary will recommend under paragraph (4) with respect to that fiscal year.

Sec. 1903. (x) 

(2) 

(B)  on the basis of receiving supplemental security income benefits under title XVI; or

Sec. 1916A. (e) 

(2) 

(A)  Heading was amended For poorest beneficiaries.—

Sec. 1923. (f) 

(6)  Allotment adjustment.—Only with respect to fiscal year 2004 or 2005, if a statewide waiver under section 1115 is revoked or terminated before the end of either such fiscal year and there is no DSH allotment for the State, the Secretary shall—

(A)  permit the State whose waiver was revoked or terminated to submit an amendment to its State plan that would describe the methodology to be used by the State (after the effective date of such revocation or termination) to identify and make payments to disproportionate share hospitals, including children’s hospitals and institutions for mental diseases or other mental health facilities (other than State-owned institutions or facilities), on the basis of the proportion of patients served by such hospitals that are low-income patients with special needs; and

(B)  provide for purposes of this subsection for computation of an appropriate DSH allotment for the State for fiscal year 2004 or 2005 (or both) that would not exceed the amount allowed under paragraph (3)(B)(ii) and that does not result in greater expenditures under this title than would have been made if such waiver had not been revoked or terminated.

In determining the amount of an appropriate DSH allotment under subparagraph (B) for a State, the Secretary shall take into account the level of DSH expenditures for the State for the fiscal year preceding the fiscal year in which the waiver commenced.

Sec. 2104. (h) 

(4)  Special rules.—

(A)  Expenditures limited to coverage for populations eligible on october 1, 2006.—A State shall use amounts redistributed under this subsection only for expenditures for providing child health assistance or other health benefits coverage for populations eligible for such assistance or benefits under the State child health plan (including under a waiver of such plan) on October 1, 2006.

(B)  Regular fmap for expenditures for coverage of nonchild populations.—To the extent a State uses amounts redistributed under this subsection for expenditures for providing child health assistance or other health benefits coverage to an individual who is not a child or a pregnant woman, the Federal medical assistance percentage (as defined in the first sentence of section 1905(b)) applicable to the State for the fiscal year shall apply to such expenditures for purposes of making payments to the State under subsection (a) of section 2105 from such amounts.

Sec. 1858. (e) 

(2) 

(A) 

(i)  *  *  *the Fund—

(I)  during 2012, $1,600,000,000; and

(II)  during 2013, $1,790,000,000.

Sec. 1848. (l) 

(2) 

(A)  Amount available.—There shall be available to the Fund for expenditures an amount equal to $1,350,000,000. In addition, there shall be available to the Fund for expenditures during 2009 an amount equal to $320,000,000 and for expenditures during or after 2013 an amount equal to $60,000,000.

Sec. 403. (a) 

(3) 

(H) 

(ii)  Subparagraph (G) shall be applied as if “fiscal year 2008” were substituted for “fiscal year 2001”; and

Sec. 1833. (a) 

(1) 

(D) 

(iii)  on the basis of a rate established under a demonstration project under section 1847(e), the amount paid shall be equal to 100 percent of such rate

(c)  Notwithstanding any other provision of this part, with respect to expenses incurred in any calendar year in connection with the treatment of mental, psychoneurotic, and personality disorders of an individual who is not an inpatient of a hospital at the time such expenses are incurred, there shall be considered as incurred expenses for purposes of subsections (a) and (b) only 621/2 percent of such expenses. For purposes of this subsection, the term “treatment” does not include brief office visits (as defined by the Secretary) for the sole purpose of monitoring or changing drug prescriptions used in the treatment of such disorders or partial hospitalization services that are not directly provided by a physician.

(t) 

(7) 

(D) 

(i) 

(II)  last sentence was stricken For purposes of the previous sentence, with respect to covered OPD services furnished during 2006, 2007, or 2008, the applicable percentage shall be 95 percent, 90 percent, and 85 percent, respectively.

Sec. 1834. (a) 

(5) 

(F)  Ownership of equipment.—

(ii)  Ownership.—

(I)  Transfer of title.—On the first day that begins after the 36th continuous month during which payment is made for the equipment under this paragraph, the supplier of the equipment shall transfer title to the equipment to the individual.

(II)  Payment for oxygen and maintenance and servicing.—After the supplier transfers title to the equipment under subclause (I)—

(aa)  payments for oxygen shall continue to be made in the amount recognized for oxygen under paragraph (9) for the period of medical need; and

(bb)  maintenance and servicing payments shall, if the Secretary determines such payments are reasonable and necessary, be made (for parts and labor not covered by the supplier’s or manufacturer’s warranty, as determined by the Secretary to be appropriate for the equipment), and such payments shall be in an amount determined to be appropriate by the Secretary.

Sec. 1847. (e)  Demonstration Project for Clinical Laboratory Services.—

(1)  In general.—The Secretary shall conduct a demonstration project on the application of competitive acquisition under this section to clinical diagnostic laboratory tests—

(A)  for which payment would otherwise be made under section 1833(h) (other than for pap smear laboratory tests under paragraph (7) of such section) or section 1834(d)(1) (relating to colorectal cancer screening tests); and

(B)  which are furnished by entities that did not have a face-to-face encounter with the individual.

(2)  Terms and conditions.—

(A)  In general.—Except as provided in subparagraph (B), such project shall be under the same conditions as are applicable to items and services described in subsection (a)(2), excluding subsection (b)(5)(B) and other conditions as the Secretary determines to be appropriate.

(B)  Application of clia quality standards.—The quality standards established by the Secretary under section 353 of the Public Health Service Act for clinical diagnostic laboratory tests shall apply to such tests under the demonstration project under this section in lieu of quality standards described in subsection (b)(2)(A)(i).

(3)  Reports.—The Secretary shall submit to Congress—

(A)  an initial report on the project not later than December 31, 2005; and

(B)  such progress and final reports on the project after such date as the Secretary determines appropriate.

Sec. 1848. (l) 

(2) 

(A) 

(i) 

(III)  For expenditures during 2013, an amount equal to $4,960,000,00).

(IV)  For expenditures during 2014, an amount equal to $290,000,000.

(ii) 

(III)  2013—The amount available for expenditures during 2013 shall only be available for an adjustment to the update of the conversion factor under subsection (d) for that year

(IV)  2014—The amount available for expenditures during 2014 shall only be available for an adjustment to the update of the conversion factor under subsection (d) for that year.

(B) 

(iii)  2013 for payment with respect to physicians’ services furnished during 2013; and

(iv)  2014 for payment with respect to physicians’ services furnished during 2014.

(m)  [Heading was amended in its entirety] Transitional Bonus Incentive Payments for Quality Reporting in 2007 and 2008.—Transitional Bonus Incentive Payments for Quality Reporting in 2007 and 2008

(1)  In general.—With respect to covered professional services furnished during a reporting period (as defined in paragraph (6)(C)) by an eligible professional, if—

(A)  there are any quality measures that have been established under the physician reporting system that are applicable to any such services furnished by such professional for such period, and

(B)  the eligible professional satisfactorily submits (as determined under paragraph (2)) to the Secretary data on such quality measures in accordance with such reporting system for such reporting period,

in addition to the amount otherwise paid under part B of title XVIII of the Social Security Act, subject to paragraph (3), there also shall be paid to the eligible professional (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6) of the Social Security Act (42 U.S.C. 1395u(b)(6))) from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 of such Act (42 U.S.C. 1395t) an amount equal to 1.5 percent of the Secretary’s estimate (based on claims submitted not later than two months after the end of the reporting period) of the allowed charges under such part for all such covered professional services furnished during the reporting period.

(3)  Payment limitation.—

(A)  In general.—In no case shall the total payment made under this subsection to an eligible professional (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6) of the Social Security Act) exceed the product of—

(i)  the total number of quality measures for which data are submitted under the physician reporting system for covered professional services of such professional that are furnished during the reporting period; and

(ii)  300 percent of the average per measure payment amount specified in subparagraph (B).

(B)  Average payment amount specified.—The average per measure payment amount specified in this subparagraph is an amount, estimated by the Secretary (based on claims submitted not later than two months after the end of the reporting period), equal to—

(i)  the total of the amount of allowed charges under part B of title XVIII of the Social Security Act for all covered professional services furnished during the reporting period on claims for which quality measures are reported under the physician reporting system; divided by

(ii)  the total number of quality measures for which data are reported under such system for covered professional services furnished during the reporting period.

(5) 

(E) 

(ii)  Treatment of determinations.—A determination under this subsection shall not be treated as a determination for purposes of section 1869 of the Social Security Act.

(iii)  the determination of the payment limitation under paragraph (3); and

(6) 

(C)  Reporting period.—The term “reporting period” means—

(i)  for 2007, the period beginning on July 1, 2007, and ending on December 31, 2007; and

(ii)  for 2008, all of 2008.

(D)  Secretary.—The term “Secretary” means the Secretary of Health and Human Services.

Sec. 1852. (e) 

(3) 

(A) 

(ii)  Applicable to ma regional plans.—The Secretary shall establish as appropriate by regulation requirements for the collection, analysis, and reporting of data that permits the measurement of health outcomes and other indices of quality for MA organizations with respect to MA regional plans. Such requirements may not exceed the requirements under this subparagraph with respect to MA local plans that are preferred provider organization plans.

Sec. 1859. (f)  Restriction on Enrollment for Specialized MA Plans for Special Needs Individuals.—

Sec. 1860D-14. (a) 

(1) 

(A)  *  *  *equal to—

(i)  100 percent of the amount described in subsection (b)(1), but not to exceed the premium amount specified in subsection (b)(2)(B); plus

(ii)  80 percent of any late enrollment penalties imposed under section 1860D-13(b) for the first 60 months in which such penalties are imposed for that individual, and 100 percent of any such penalties for any subsequent month.

Sec. 1865. (a)  Except as provided in subsection (b) and the second sentence of section 1863, if—

(1)  an institution is accredited as a hospital by the Joint Commission on Accreditation of Hospitals, and

(2)(A)  such institution authorizes the Commission to release to the Secretary upon his request (or such State agency as the Secretary may designate) a copy of the most current accreditation survey of such institution made by such Commission, together with any other information directly related to the survey as the Secretary may require (including corrective action plans),

then, such institution shall be deemed to meet the requirements of the numbered paragraphs of section 1861(e); except—

(3)  paragraph (6) thereof,and

(4)  any standard, promulgated by the Secretary pursuant to paragraph (9) thereof, which is higher than the requirements prescribed for accreditation by such Commission.

If such Commission, as a condition for accreditation of a hospital, requires a utilization review plan (or imposes another requirement which serves substantially the same purpose), requires a discharge planning process (or imposes another requirement which serves substantially the same purpose), or imposes a standard which the Secretary determines is at least equivalent to the standard promulgated by the Secretary as described in paragraph (4) of this subsection, the Secretary is authorized to find that all institutions so accredited by such Commission comply also with clause (A) or (B) of section 1861(e)(6) or the standard described in such paragraph (4), as the case may be.

Sec. 1881. (b) 

(13) 

(B) 

(ii)  Nothing in this paragraph, section 1842, section 1947A, or section 1847B shall be construed as requiring or authorizing the bundling of payment for drugs and biologicals into the basic case-mix adjusted payment system under this paragraph.

Sec. 1923. (f) 

(6) 

(B) 

(i)  *  *  *Only with respect to fiscal year 2008 for the period ending on June 30, 2008, the DSH allotment for Hawaii for such portion of the fiscal year, notwithstanding the table set forth in paragraph (2), shall be $7,500, 000.

Sec. 1936. (e) 

(2) 

(A)  Availability.—Amounts appropriated pursuant to paragraph (1) shall remain available until expended.

Sec. 1139. [42 U.S.C. 1320b-9] (a)(1)  ^[521] There is hereby established a commission to be known as the National Commission on Children (in this section referred to as the “Commission”).

(b)(1)  The Commission shall consist of—

(A)  12 members to be appointed by the President,

(B)  12 members to be appointed by the Speaker of the House of Representatives, and

(C)  12 members to be appointed by the President pro tempore of the Senate.

(2)  The President, the Speaker, and the President pro tempore shall each appoint as members of the Commission—

(A)  4 individuals who—

(i)  are representatives of organizations providing services to children,

(ii)  are involved in activities on behalf of children, or

(iii)  have engaged in academic research with respect to the problems and needs of children,

(B)  4 individuals who are elected or appointed public officials (at the Federal, State, or local level) involved in issues and programs relating to children, and

(C)  4 individuals who are parents or representatives of parents or parents’ organizations.

(3)  The appointments made pursuant to subparagraphs (B) and (C) of paragraph (1) shall be made in consultation with the chairmen of committees of the House of Representatives and the Senate, respectively, having jurisdiction over relevant Federal programs.

(c)(1)  It shall be the duty and function of the Commission to serve as a forum on behalf of the children of the Nation and to conduct the studies and issue the report required by subsection (d).

(2)  The Commission (and any committees that it may form) shall conduct public hearings in different geographic areas of the country, both urban and rural, in order to receive the views of a broad spectrum of the public on the status of the Nation’s children and on ways to safeguard and enhance the physical, mental, and emotional well-being of all of the children of the Nation, including those with physical or mental disabilities, and others whose circumstances deny them a full share of the opportunities that parents of the Nation may rightfully expect for their children.

(3)  The Commission shall receive testimony from individuals, and from representatives of public and private organizations and institutions with an interest in the welfare of children, including educators, health care professionals, religious leaders, providers of social services, representatives of organizations with children as members, elected and appointed public officials, and from parents and children speaking in their own behalf.

(d)  The Commission shall submit to the President, and to the Committees on Finance and Labor and Human Resources of the Senate and the Committees on Ways and Means, Education and Labor, and Energy and Commerce of the House of Representatives, an interim report no later than March 31, 1990, and a final report no later than March 31, 1991, setting forth recommendations with respect to the following subjects:

(1)  Questions relating to the health of children that the Commission shall address include—

(A)  how to reduce infant mortality,

(B)  how to reduce the number of low-birth-weight babies,

(C)  how to reduce the number of children with chronic illnesses and disabilities,

(D)  how to improve the nutrition of children,

(E)  how to promote the physical fitness of children,

(F)  how to ensure that pregnant women receive adequate prenatal care,

(G)  how to ensure that all children have access to both preventive and acute care health services, and

(H)  how to improve the quality and availability of health care for children.

(2)  Questions relating to social and support services for children and their parents that the Commission shall address include—

(A)  how to prevent and treat child neglect and abuse,

(B)  how to provide help to parents who seek assistance in meeting the problems of their children,

(C)  how to provide counseling services for children,

(D)  how to strengthen the family unit,

(E)  how children can be assured of adequate care while their parents are working or participating in education or training programs,

(F)  how to improve foster care and adoption services,

(G)  how to reduce drug and alcohol abuse by children and youths, and

(H)  how to reduce the incidence of teenage pregnancy.

(3)  Questions relating to education that the Commission shall address include—

(A)  how to encourage academic excellence for all children at all levels of education,

(B)  how to use preschool experiences to enhance educational achievement,

(C)  how to improve the qualifications of teachers,

(D)  how schools can better prepare the Nation’s youth to compete in the labor market,

(E)  how parents and schools can work together to help children achieve success at each step of the academic ladder,

(F)  how to encourage teenagers to complete high school and remain in school to fulfill their academic potential,

(G)  how to address the problems of drug and alcohol abuse by young people,

(H)  how schools might lend support to efforts aimed at reducing the incidence of teenage pregnancy, and

(I)  how schools might better meet the special needs of children who have physical or mental handicaps.

(4)  Questions relating to income security that the Commission shall address include—

(A)  how to reduce poverty among children,

(B)  how to ensure that parents support their children to the fullest extent possible through improved child support collection services, including services on behalf of children whose parents are unmarried, and

(C)  how to ensure that cash assistance to needy children is adequate.

(5)  Questions relating to tax policy that the Commission shall address include—

(A)  how to assure the equitable tax treatment of families with children,

(B)  the effect of existing tax provisions, including the dependent care tax credit, the earned income tax credit, and the targeted jobs tax credit, on children living in poverty,

(C)  whether the dependent care tax credit should be refundable and the effect of such a policy,

(D)  whether the earned income tax credit should be adjusted for family size and the effect of such a policy, and

(E)  whether there are other tax-related policies which would reduce poverty among children.

(6)  In addition to addressing the questions specified in paragraphs (1) through (5), the Commission shall—

(A)  seek to identify ways in which public and private organizations and institutions can work together at the community level to identify deficiencies in existing services for families and children and to develop recommendations to ensure that the needs of families and children are met, using all available resources, in a coordinated and comprehensive manner, and

(B)  assess the existing capacities of agencies to collect and analyze data on the status of children and on relevant programs, identify gaps in the data collection system, and recommend ways to improve the collection of data and the coordination among agencies in the collection and utilization of data.

The reports required by this subsection shall be based upon the testimony received in the hearings conducted pursuant to subsection (c), and upon other data and findings developed by the Commission.

(e)(1)(A)  Members of the Commission shall first be appointed not later than 60 days after the date of the enactment of this section^[522], for terms ending on March 31, 1991.

(B)  A vacancy in the Commission shall not affect its powers, but shall be filled in the same manner as the vacant position was first filled.

(2)  The Commission shall elect one of its members to serve as Chairman of the Commission. The Chairman shall be a nonvoting member of the Commission.

(3)  A majority of the members of the Commission shall constitute a quorum for the transaction of business.

(4)(A)  The Commission shall meet at the call of the Chairman, or at the call of a majority of the members of the Commission.

(B)  The Commission shall meet not less than 4 times during the period beginning with the date of the enactment of this section and ending with September 30, 1990.

(5)  Decisions of the Commission shall be according to the vote of a simple majority of those present and voting at a properly called meeting.

(6)  Members of the Commission shall serve without compensation, but shall be reimbursed for travel, subsistence, and other necessary expenses incurred in the performance of their duties as members of the Commission.

(f)(1)  The Commission shall appoint an Executive Director of the Commission. In addition to the Executive Director, the Commission may appoint and fix the compensation of such personnel as it deems advisable. Such appointments and compensation may be made without regard to title 5, United States Code, that govern appointments in the competitive services, and the provisions of chapter 51 and subchapter III of chapter 53 of such title that relate to classifications and the General Schedule pay rates.

(2)  The Commission may procure such temporary and intermittent services of consultants under section 3109(b) of title 5, United States Code, as the Commission determines to be necessary to carry out the duties of the Commission.

(g)  In carrying out its duties, the Commission, or any duly organized committee thereof, is authorized to hold such hearings, sit and act at such times and places, and take such testimony, with respect to matters for which it has a responsibility under this section, as the Commission or committee may deem advisable.

(h)(1)  The Commission may secure directly from any department or agency of the United States such data and information as may be necessary to carry out its responsibilities.

(2)  Upon request of the Commission, any such department or agency shall furnish any such data or information.

(i)  The General Services Administration shall provide to the Commission, on a reimbursable basis, such administrative support services as the Commission may request.

(j)  There are authorized to be appropriated through fiscal year 1991, such sums as may be necessary to carry out this section for each of fiscal years 1989 and 1990.

(k)(1)  The Commission is authorized to accept donations of money, property, or personal services. Funds received from donations shall be deposited in the Treasury in a separate fund created for this purpose. Funds appropriated for the Commission and donated funds may be expended for such purposes as official reception and representation expenses, public surveys, public service announcements, preparation of special papers, analyses, and documentaries, and for such other purposes as determined by the Commission to be in furtherance of its mission to review national issues affecting children.

(2)  For purposes of Federal income, estate, and gift taxation, money and other property accepted under paragraph (1) of this subsection shall be considered as a gift or bequest to or for the use of the United States.

(3)  Expenditure of appropriated and donated funds shall be subject to such rules and regulations as may be adopted by the Commission and shall not be subject to Federal procurement requirements.

(l)  The Commission is authorized to conduct such public surveys as it deems necessary in support of its review of national issues affecting children and, in conducting such surveys, the Commission shall not be deemed to be an “agency” for the purpose of section 3502 of title 44, United States Code.

Sec. 1937. (a) 

(1) 

(ii)  for any child under 19 years of age who is covered under the State plan under section 1902(a)(10)(a). wrap-around benefits to the benchmark coverage or benchmark equivalent coverage consisting of early and periodic screening, diagnostic and treatment services defined in section 1905(r).

Sec. 2103. (c) 

(2) 

(B)  Mental health services.

Sec. 2104. (e)  3-year Availability of Amounts Allotted.—Amounts allotted to a State pursuant to this section for a fiscal year shall remain available for expenditure by the State through the end of the second succeeding fiscal year; except that amounts reallotted to a State under subsection (f) shall be available for expenditure by the State through the end of the fiscal year in which they are reallotted.

Sec. 2105. (a) 

(1) 

(B)  for the provision of medical assistance on behalf of a child during a presumptive eligibility period under section 1920A;

Sec. 2107. (f)  [Last sentence] For purposes of the preceding sentence, a caretaker relative (as such term is defined for purposes of carrying out section 1931 shall not be considered a childless adult.

Sec. 2108. (c) 

(5)  Funding.—Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated $10,000,000 for fiscal year 2000 for the purpose of conducting an evaluation authorized under this subsection. Amounts appropriated under this paragraph shall remain available for expenditure through fiscal year 2002.

(d)  General Audit.—

(1)  Audit.—Beginning with fiscal year 2000, and every third fiscal year thereafter, the Secretary, through the Inspector General of the Department of Health and Human Services, shall audit a sample from among the States described in paragraph (2) in order to—

(A)  determine the number, if any, of enrollees under the plan under this title who are eligible for medical assistance under title XIX (other than as optional targeted low-income children under section 1902(a)(10)(A)(ii)(XIV)); and

(B)  assess the progress made in reducing the number of uncovered low-income children, including the progress made to achieve the strategic objectives and performance goals included in the State child health plan under section 2107(a).

(2)  described.—A State described in this paragraph is a State with an approved State child health plan under this title that does not, as part of such plan, provide health benefits coverage under the State’s medicaid program under title XIX.

(3)  Monitoring and report from gao.—The Comptroller General of the United States shall monitor the audits conducted under this subsection and, not later than March 1 of each fiscal year after a fiscal year in which an audit is conducted under this subsection, shall submit a report to Congress on the results of the audit conducted during the prior fiscal year.

Sec. 403. (a) 

(3) 

(H) 

(ii)  subparagraph (G) shall be applied as if “fiscal year 2009” were substituted for “fiscal year 2001”; and

(c)  Emergency Fund.—

(1)  Establishment.—There is established in the Treasury of the United States a fund which shall be known as the “Emergency Contingency Fund for State Temporary Assistance for Needy Families Programs” (in this subsection referred to as the “Emergency Fund”).

(2)  Deposits into fund.—

(A)  In general.—Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated for fiscal year 2009, $5,000,000,000 for payment to the Emergency Fund.

(B)  Availability and use of funds.—The amounts appropriated to the Emergency Fund under subparagraph (A) shall remain available through fiscal year 2010 and shall be used to make grants to States in each of fiscal years 2009 and 2010 in accordance with the requirements of paragraph (3).

(C)  Limitation.—In no case may the Secretary make a grant from the Emergency Fund for a fiscal year after fiscal year 2010.

(3)  Grants.—

(A)  Grant related to caseload increases.—

(i)   In general.—For each calendar quarter in fiscal year 2009 or 2010, the Secretary shall make a grant from the Emergency Fund to each State that—

(I)  requests a grant under this subparagraph for the quarter; and

(II)  meets the requirement of clause (ii) for the quarter.

(ii)  Non-recurrent short term expenditure requirement.—A State meets the requirement of this clause for a quarter if the total expenditures of the State for non-recurrent short term benefits in the quarter, whether under the State program funded under this part or as qualified State expenditures, exceeds the total expenditures of the State for non-recurrent short term benefits in the corresponding quarter in the emergency fund base year of the State.

(iii)  Amount of grant.—Subject to paragraph (5), the amount of the grant to be made to a State under this subparagraph for a quarter shall be an amount equal to 80 percent of the excess described in clause (ii).

(C)  Grant related to increased expenditures for subsidized employment.—

(i)  In general.—For each calendar quarter in fiscal year 2009 or 2010, the Secretary shall make a grant from the Emergency Fund to each State that—

(I)  requests a grant under this subparagraph for the quarter; and

(II)  meets the requirement of clause (ii) for the quarter.

(ii)  Non-recurrent short term expenditure requirement.—A State meets the requirement of this clause for a quarter if the total expenditures of the State for non-recurrent short term benefits in the quarter, whether under the State program funded under this part or as qualified State expenditures, exceeds the total expenditures of the State for non-recurrent short term benefits in the corresponding quarter in the emergency fund base year of the State.

(iii)  Amount of grant.—Subject to paragraph (5), the amount of the grant to be made to a State under this subparagraph for a quarter shall be an amount equal to 80 percent of the excess described in clause (ii).

(C)  Grant related to increased expenditures for subsidized employment.—

(i)  In general.—For each calendar quarter in fiscal year 2009 or 2010, the Secretary shall make a grant from the Emergency Fund to each State that—

(I)  requests a grant under this subparagraph for the quarter; and

(II)  meets the requirement of clause (ii) for the quarter.

(ii)  Subsidized employment expenditure requirement.—A State meets the requirement of this clause for a quarter if the total expenditures of the State for subsidized employment in the quarter, whether under the State program funded under this part or as qualified State expenditures, exceeds the total such expenditures of the State in the corresponding quarter in the emergency fund base year of the State.

(iii)  Amount of grant.—Subject to paragraph (5), the amount of the grant to be made to a State under this subparagraph for a quarter shall be an amount equal to 80 percent of the excess described in clause (ii).

(4)  Authority to make necessary adjustments to data and collect needed data.—In determining the size of the caseload of a State and the expenditures of a State for basic assistance, non-recurrent short-term benefits, and subsidized employment, during any period for which the State requests funds under this subsection, and during the emergency fund base year of the State, the Secretary may make appropriate adjustments to the data, on a State-by-State basis, to ensure that the data are comparable with respect to the groups of families served and the types of aid provided. The Secretary may develop a mechanism for collecting expenditure data, including procedures which allow States to make reasonable estimates, and may set deadlines for making revisions to the data.

(5)  Limitation.—The total amount payable to a single State under subsection (b) and this subsection for fiscal years 2009 and 2010 combined shall not exceed 50 percent of the annual State family assistance grant.

(6)  Limitations on use of funds.—A State to which an amount is paid under this subsection may use the amount only as authorized by section 404.

(7)  Timing of implementation.—The Secretary shall implement this subsection as quickly as reasonably possible, pursuant to appropriate guidance to States.

(8)  Application to indian tribes.—This subsection shall apply to an Indian tribe with an approved tribal family assistance plan under section 412 in the same manner as this subsection applies to a State.

(9)  Definitions.—In this subsection:

(A)  Average monthly assistance caseload defined.—The term “average monthly assistance caseload” means, with respect to a State and a quarter, the number of families receiving assistance during the quarter under the State program funded under this part or as qualified State expenditures, subject to adjustment under paragraph (4).

(B)   Emergency fund base year.—

(i)  In general.—The term “emergency fund base year” means, with respect to a State and a category described in clause (ii), whichever of fiscal year 2007 or 2008 is the fiscal year in which the amount described by the category with respect to the State is the lesser.

(ii)  Categories described.—The categories described in this clause are the following:

(I)  The average monthly assistance caseload of the State.

(II)  The total expenditures of the State for non-recurrent short term benefits, whether under the State program funded under this part or as qualified State expenditures.

(III)  The total expenditures of the State for subsidized employment, whether under the State program funded under this part or as qualified State expenditures.

(C)  Qualified state expenditures.—The term “qualified State expenditures” has the meaning given the term in section 409(a)(7).

Sec. 404. (e)  Authority to Reserve Certain Amounts for Assistance.—A State or tribe may reserve amounts paid to the State or tribe under this part for any fiscal year for the purpose of providing, without fiscal year limitation, assistance under the State or tribal program funded under this part.

Sec. 1176. (b) 

(2)  Noncompliance not discovered.— A penalty may not be imposed under subsection (a) with respect to a provision of this part if it is established to the satisfaction of the Secretary that the person liable for the penalty did not know, and by exercising reasonable diligence would not have known, that such person violated the provision.

Sec. 1858. (e) 

(7)  Biennial GAO reports.—Not later than January 1 of 2009, 2011, 2013, and 2015, the Comptroller General of the United States shall submit to the Secretary and Congress a report on the application of additional payments under this subsection. Each report shall include—

(A)  an evaluation of—

(i)  the quality of care provided to individuals enrolled in MA regional plans for which additional payments were made under this subsection;

(ii)  the satisfaction of such individuals with benefits under such a plan;

(iii)  the costs to the medicare program for payments made to such plans; and

(iv)  any improvements in the delivery of health care services under such a plan;

(B)  a comparative analysis of the performance of MA regional plans receiving payments under this subsection with MA regional plans not receiving such payments; and

(C)  recommendations for such legislation or administrative action as the Comptroller General determines to be appropriate.

Sec. 2108. (d)  Inspector General Audit.—

(3)  Monitoring and report from GAO.—The Comptroller General of the United States shall monitor the audits conducted under this subsection and, not later than March 1 of each fiscal year after a fiscal year in which an audit is conducted under this subsection, shall submit a report to Congress on the results of the audit conducted during the prior fiscal year.

Sec. 1936. (f) 

(3) 

(B) 

(i)  Domestic violence, verified by such reasonable and confidential documentation as the State law may require, which causes the individual reasonably to believe that such individual’s continued employment would jeopardize the safety of the individual or of any member of the individual’s immediate family (as defined by the Secretary of Labor).

Sec. 513. (b) 

(2) 

(C) 

(i)  Healthy relationships, such as positive self-esteem and relationship dynamics, friendships, dating, romantic involvement, marriage, and family interactions.

Sec. 1128E. (g) .—

(iv)  Exclusion from participation in Federal or State health care programs (as defined in sections 1128B(f) and 1128(h), respectively).

(A)  for 2009 section 1834(a)(14)(J)(i) shall apply under this paragraph instead of the percentage increase otherwise applicable; and

(B)  for 2014, if subparagraph (A) is applied to the items and services and there has not been a payment adjustment under paragraph (3)(B) for the items and services for any previous year, the percentage increase computed under section 1834(a)(14)(L)(i) shall apply instead of the percentage increase otherwise applicable.

(g) (3) 

(D)  State law enforcement agencies.

(E)  State medicaid fraud control units.

Sec. 1139A. (e) .—

(8)  Appropriation.— There is authorized to be appropriated to carry out this subsection, $25,000,000 for the period of fiscal years 2009 through 2013.

Sec. 1181. (d) 

(2) 

(B) 

(iv)  Requirements for publication of research.—Any research published under clause (ii)(IV) shall be within the bounds of and entirely consistent with the evidence and findings produced under the contract with the Institute under this subparagraph. If the Institute determines that those requirements are not met, the Institute shall not enter into another contract with the agency, instrumentality, or entity which managed or conducted such research for a period determined appropriate by the Institute (but not less than 5 years).

(f) 

(1) 

(C) 

(ii)  5 members representing physicians and providers, including at least 1 surgeon, nurse, State licensed integrative health care practitioner, and representative of a hospital.

Sec. 1817. (k) 

(3) 

(A) 

(i) 

(V)  for each fiscal year after fiscal year 2010, the limit under this clause for fiscal year 2010.

(X)  for each fiscal year after fiscal year 2010, not less than the amount required under this clause for fiscal year 2010.

(ix)  for each fiscal year after fiscal year 2010, the amount to be appropriated under this subparagraph for fiscal year 2010.

Sec. 1819. (d) 

(1) 

(B)  Required notices.—If a change occurs in—

(i)  the persons with an ownership or control interest (as defined in section 1124(a)(3) in the facility,

(ii)  the persons who are officers, directors, agents, or managing employees (as defined in section 1126(b) of the facility,

(iii)  the corporation, association, or other company responsible for the management of the facility, or

(iv)  the individual who is the administrator or director of nursing of the facility,

the skilled nursing facility must provide notice to the State agency responsible for the licensing of the facility, at the time of the change, of the change and of the identity of each new person, company, or individual described in the respective clause.

Sec. 1834. (a) 

(14) 

(L)  For 2014.—If a change occurs in—

(i)  in the case of items and services described in subparagraph (J)(i) for which a payment adjustment has not been made under subsection (a)(1)(F)(ii) in any previous year, the percentage increase in the consumer price index for all urban consumers (U.S. urban average) for the 12-month period ending with June 2013, plus 2.0 percentage points; or,

(ii)  in the case of other items and services, the percentage increase in the consumer price index for all urban consumers (U.S. urban average) for the 12-month period ending with June 2013; and,

(M)  for a subsequent year, the percentage increase in the consumer price index for all urban consumers (U.S. urban average) for the 12-month period ending with June of the previous year.

Sec. 1842. (s) 

(1) 

***Any fee schedule established under this paragraph for such item or service shall be updated each year by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, except that for all items and services described in paragraph (2)(D)—

(A)  for 2009 section 1834(a)(14)(J)(i) shall apply under this paragraph instead of the percentage increase otherwise applicable; and

(B)  for 2014, if subparagraph (A) is applied to the items and services and there has not been a payment adjustment under paragraph (3)(B) for the items and services for any previous year, the percentage increase computed under section 1834(a)(14)(L)(i) shall apply instead of the percentage increase otherwise applicable.

Sec. 1851. (e) 

(2) 

(C)  Continuous open enrollment and disenrollment for first 3 months in subsequent years.—

(i)  In general.— Subject to clause (ii), at any time during the first 6 months of 2006, or, if the individual first becomes a Medicare+Choice eligible individual during 2006, during the first 6 months during 2006 in which the individual is a Medicare+Choice eligible individual, a Medicare+Choice eligible individual may change the election under subsection (a)(1).

(ii)  Limitation of one change.— An individual may exercise the right under clause (i) only once. The limitation under this clause shall not apply to changes in elections effected during an annual, coordinated election period under paragraph (3) or during a special enrollment period under the first sentence of paragraph (4).

Sec. 1858. (e)  Stabilization fund.—

(1)  Establishment.—The Secretary shall establish under this subsection an MA Regional Plan Stabilization Fund (in this subsection referred to as the “Fund”) which shall be available for two purposes:

(A)  To provide incentives to have MA regional plans offered in each MA region under paragraph (3).

(B)  To provide incentives to retain MA regional plans in certain MA regions with below-national-average MA market penetration under paragraph (4).

(2)  Funding.—

(i)  In general.—There shall also be made available to the Fund, 50 percent of savings described in clause (ii).

(ii)  Payment from trust funds.—Such amount shall be available to the Fund, as expenditures are made from the Fund, from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund in the proportion specified in section 1853(f).

(B)  Additional funding from savings.—

(i)  In general.—There shall also be made available to the Fund, 50 percent of savings described in clause (ii).

(ii)  Savings.—The savings described in this clause are 25 percent of the average per capita savings described in section 1854(b)(4)(C) for which monthly rebates are provided under section 1854(b)(1)(C) in the fiscal year involved that are attributable to MA regional plans.

(iii)  Availability.—Funds made available under this subparagraph shall be transferred into a special account in the Treasury from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund in the proportion specified in section 1853(f) on a monthly basis.

(C)  Obligations.—Amounts in the Fund shall be available in advance of appropriations to MA regional plans in qualifying MA regions only in accordance with paragraph (5).

(D)  Ordering.—Expenditures from the Fund shall first be made from amounts made available under subparagraph (A)

(3)  Plan entry funding.—

(A)  In general.—Funding is available under this paragraph for a year only as follows:

(i)  National plan.—For a national bonus payment described in subparagraph (B) for the offering by a single MA organization of an MA regional plan in each MA region in the year, but only if there was not such a plan offered in each such region in the previous year. Funding under this clause is only available with respect to any individual MA organization for a single year, but may be made available to more than one such organization in the same year.

(ii)  Regional plans.—Subject to clause (iii), for an increased amount under subparagraph (C) for an MA regional plan offered in an MA region which did not have any MA regional plan offered in the prior year.

(iii)  Limitation on regional plan funding in case of national plan.—In no case shall there be any payment adjustment under subparagraph (C) for a year for which a national payment adjustment is made under subparagraph (B).

(B)  National bonus payment.—The national bonus payment under this subparagraph shall—

(i)  be available to an MA organization only if the organization offers MA regional plans in every MA region;

(ii)  be available with respect to all MA regional plans of the organization regardless of whether any other MA regional plan is offered in any region; and

(iii)  subject to amounts available under paragraph (5) for a year, be equal to 3 percent of the benchmark amount otherwise applicable for each MA regional plan offered by the organization.

(C)  Regional payment adjustment.—

(i)  In general.—The increased amount under this subparagraph for an MA regional plan in an MA region for a year shall be an amount, determined by the Secretary, based on the bid submitted for such plan (or plans) and shall be available to all MA regional plans offered in such region and year. Such amount may be based on the mean, mode, or median, or other measure of such bids and may vary from region to region. The Secretary may not limit the number of plans or bids in a region.

(ii)  Multi-year funding.—

(I)  In general.—Subject to amounts available under paragraph (5), funding under this subparagraph shall be available for a period determined by the Secretary.

(II)  Report.—If the Secretary determines that funding will be provided for a second consecutive year with respect to an MA region, the Secretary shall submit to the Congress a report that describes the underlying market dynamics in the region and that includes recommendations concerning changes in the payment methodology otherwise provided for MA regional plans under this part.

(iii)  Application to all plans in a region.—Funding under this subparagraph with respect to an MA region shall be made available with respect to all MA regional plans offered in the region.

(iv)  Limitation on availability of a plan retention funding in next year.—If an increased amount is made available under this subparagraph with respect to an MA region for a period determined by the Secretary under clause (ii)(I), in no case shall funding be available under paragraph (4) with respect to MA regional plans offered in the region in the year following such period.

(D)  Application.—Any additional payment under this paragraph provided for an MA regional plan for a year shall be treated as if it were an addition to the benchmark amount otherwise applicable to such plan and year, but shall not be taken into account in the computation of any benchmark amount for any subsequent year.

(4)  Plan retention funding.—

(A)  In general.—Funding is available under this paragraph for a year with respect to MA regional plans offered in an MA region for the increased amount specified in subparagraph (B) but only if the region meets the requirements of subparagraphs (C) and (E).

(B)  Payment increase.—The increased amount under this subparagraph for an MA regional plan in an MA region for a year shall be an amount, determined by the Secretary, that does not exceed the greater of—

(i)  3 percent of the benchmark amount applicable in the region; or

(ii)  such amount as (when added to the benchmark amount applicable to the region) will result in the ratio of—

(I)  such additional amount plus the benchmark amount computed under section 1854(b)(4)(B)(i) for the region and year, to the adjusted average per capita cost for the region and year, as estimated by the Secretary under section 1876(a)(4) and adjusted as appropriate for the purpose of risk adjustment; being equal to

(II)  the weighted average of such benchmark amounts for all the regions and such year, to the average per capita cost for the United States and such year, as estimated by the Secretary under section 1876(a)(4) and adjusted as appropriate for the purpose of risk adjustment.

(C)  Regional requirements.—The requirements of this subparagraph for an MA region for a year are as follows:

(i)  Notification of plan exit.—The Secretary has received notice (in such form and manner as the Secretary specifies) before a year that one or more MA regional plans that were offered in the region in the previous year will not be offered in the succeeding year.

(ii)  Regional plans available from fewer than 2 ma organizations in the region.—The Secretary determines that if the plans referred to in clause (i) are not offered in the year, fewer than 2 MA organizations will be offering MA regional plans in the region in the year involved.

(iii)  Percentage enrollment in ma regional plans below national average.—For the previous year, the Secretary determines that the average percentage of MA eligible individuals residing in the region who are enrolled in MA regional plans is less than the average percentage of such individuals in the United States enrolled in such plans.

(D)  Application.—Any additional payment under this paragraph provided for an MA regional plan for a year shall be treated as if it were an addition to the benchmark amount otherwise applicable to such plan and year, but shall not be taken into account in the computation of any benchmark amount for any subsequent year.

(E)  2–consecutive-year limitation.—

(i)  In general.—In no case shall any funding be available under this paragraph in an MA region in a period of consecutive years that exceeds 2 years.

(ii)  Report.—If the Secretary determines that funding will be provided under this paragraph for a second consecutive year with respect to an MA region, the Secretary shall submit to the Congress a report that describes the underlying market dynamics in the region and that includes recommendations concerning changes in the payment methodology otherwise provided for MA regional plans under this part.

(5)  Funding limitation.—

(A)  In general.—The total amount expended from the Fund as a result of the application of this subsection through the end of a calendar year may not exceed the amount available to the Fund as of the first day of such year. For purposes of this subsection, amounts that are expended under this title insofar as such amounts would not have been expended but for the application of this subsection shall be counted as amounts expended as a result of such application.

(B)  Application of limitation.—The Secretary may obligate funds from the Fund for a year only if the Secretary determines (and the Chief Actuary of the Centers for Medicare and Medicaid Services and the appropriate budget officer certify) that there are available in the Fund at the beginning of the year sufficient amounts to cover all such obligations incurred during the year consistent with subparagraph (A). The Secretary shall take such steps, in connection with computing additional payment amounts under paragraphs (3) and (4) and including limitations on enrollment in MA regional plans receiving such payments, as will ensure that sufficient funds are available to make such payments for the entire year. Funds shall only be made available from the Fund pursuant to an apportionment made in accordance with applicable procedures.

(6)  Secretary reports.—Not later than April 1 of each year (beginning in 2008), the Secretary shall submit a report to Congress and the Comptroller General of the United States that includes—

(A)  a detailed description of—

(i)  the total amount expended as a result of the application of this subsection in the previous year compared to the total amount that would have been expended under this title in the year if this subsection had not been enacted;

(ii)  the projections of the total amount that will be expended as a result of the application of this subsection in the year in which the report is submitted compared to the total amount that would have been expended under this title in the year if this subsection had not been enacted;

(iii)  amounts remaining within the funding limitation specified in paragraph (5); and

(iv)  the steps that the Secretary will take under paragraph (5)(B) to ensure that the application of this subsection will not cause expenditures to exceed the amount available in the Fund; and

(B)  a certification from the Chief Actuary of the Centers for Medicare and Medicaid Services that the description provided under subparagraph (A) is reasonable, accurate, and based on generally accepted actuarial principles and methodologies.

(7)^[523]  Repealed.

Sec. 1861. (aa) 

(3) 

(A)  services of the type described in subparagraphs (A) through (C) of paragraph (1) and services described in subsections (qq) and (vv); and

Sec. 1866D. (a) 

(2) 

(B)  Extension.—The Secretary may extend the duration of the pilot program for providers of services and suppliers participating in the pilot program as of the day before the end of the 5-year period described in subparagraph (A), for a period determined appropriate by the Secretary, if the Secretary determines that such extension will result in improving or not reducing the quality of patient care and reducing spending under this title.

(g)  Implementation Plan.— In the case of an individual that receives health care items or services under a demonstration program carried out under this section, the Secretary shall ensure that such individual is notified of any waivers of coverage or payment rules that are applicable to such individual under this title as a result of the participation of the individual in such program.

(1)  In general.—Not later than January 1, 2016, the Secretary shall submit a plan for the implementation of an expansion of the pilot program if the Secretary determines that such expansion will result in improving or not reducing the quality of patient care and reducing spending under this title.

Sec. 1868. (a)  Practicing Physicians Advisory Council.—

(1)  The Secretary shall appoint, based upon nominations submitted by medical organizations representing physicians, a Practicing Physicians Advisory Council (in this subsection referred to as the “Council”) to be composed of 15 physicians, each of whom has submitted at least 250 claims for physicians’ services under this title in the previous year. At least 11 of the members of the Council shall be physicians described in section 1861(r)(1) and the members of the Council shall include both participating and nonparticipating physicians and physicians practicing in rural areas and underserved urban areas.

(2)  The Council shall meet once during each calendar quarter to discuss certain proposed changes in regulations and carrier manual instructions related to physician services identified by the Secretary. To the extent feasible and consistent with statutory deadlines, such consultation shall occur before the publication of such proposed changes.

(3)  Members of the Council shall be entitled to receive reimbursement of expenses and per diem in lieu of subsistence in the same manner as other members of advisory councils appointed by the Secretary are provided such reimbursement and per diem under this title.

Sec. 1899A. (c) 

(3) 

(A) 

(III)  for proposal year 2019 and subsequent proposal years, a year in which the Chief Actuary of the Centers for Medicare & Medicaid Services makes a determination in the determination year that the growth rate described in paragraph (8) exceeds the growth rate described in paragraph (6)(A)(i).

Sec. 1900. (c) 

(2) 

(A)  In general.— The membership of MACPAC shall include individuals who have had direct experience as enrollees or parents of enrollees in Medicaid or CHIP and individuals with national recognition for their expertise in Federal safety net health programs, health finance and economics, actuarial science, health facility management, health plans and integrated delivery systems, reimbursement of health facilities, health information technology, pediatric physicians, dentists, and other providers of health services, and other related fields, who provide a mix of different professionals, broad geographic representation, and a balance between urban and rural representatives.

(B)  Inclusion.—The membership of MACPAC shall include (but not be limited to) physicians and other health professionals, employers, third-party payers, and individuals with expertise in the delivery of health services. Such membership shall also include consumers representing children, pregnant women, the elderly, and individuals with disabilities, current or former representatives of State agencies responsible for administering Medicaid, and current or former representatives of State agencies responsible for administering CHIP.

(f)  [ Heading was amended in its entirety.] Authorization of Appropriations

Sec. 1902. (a) 

(78)  provide that the State agency described in paragraph (9) exclude, with respect to a period, any individual or entity from participation in the program under the State plan if such individual or entity owns, controls, or manages an entity that (or if such entity is owned, controlled, or managed by an individual or entity that)—

(A)  has unpaid overpayments (as defined by the Secretary) under this title during such period determined by the Secretary or the State agency to be delinquent;

(B)  is suspended or excluded from participation under or whose participation is terminated under this title during such period; or

(C)  is affiliated with an individual or entity that has been suspended or excluded from participation under this title or whose participation is terminated under this title during such period.

Sec. 1905. (a) 

(13)  other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level;

Sec. 1915. (i) 

(1) 

(C)  Protection of number of individuals to be provided home and community-based services.—

(i)  In general.—The State submits to the Secretary, in such form and manner, and upon such frequency as the Secretary shall specify, the projected number of individuals to be provided home and community-based services.

(ii)  Authority to limit number of eligible individuals.—A State may limit the number of individuals who are eligible for such services and may establish waiting lists for the receipt of such services.

Sec. 1923. (f) 

(6)  [Heading was amended] Allotment Adjustments for Fiscal Years 2007 Through 2011 and the First Calendar Year of Fiscal Year 2012

(I)  if the State is a low DSH State described in paragraph (5)(B), the applicable percentage is equal to 25 percent; and

(II)  if the State is any other State, the applicable percentage is 50 percent.

(I)  if the State is a low DSH State described in paragraph (5)(B), the applicable percentage is equal to the product of the percentage reduction in uncovered individuals for the fiscal year from the preceding fiscal year and 25 percent;

(II)  and if the State is any other State, the applicable percentage is equal to the product of the percentage reduction in uncovered individuals for the fiscal year from the preceding fiscal year and 50 percent.

(8)  Rebasing of state dsh allotments for fiscal year 2021.—With respect to fiscal year 2021, for purposes of applying paragraph (3)(A) to determine the DSH allotment for a State, the amount of the DSH allotment for the State under paragraph (3) for fiscal year 2020 shall be equal to the DSH allotment as reduced under paragraph (7).

(5)  Use of amp in upper payment limits.— The Secretary shall calculate the Federal upper reimbursement limit established under paragraph (4) as no less than 175 percent of the weighted average (determined on the basis of utilization) of the most recently reported monthly average manufacturer prices for pharmaceutically and therapeutically equivalent multiple source drug products that are available for purchase by retail community pharmacies on a nationwide basis. The Secretary shall implement a smoothing process for average manufacturer prices. Such process shall be similar to the smoothing process used in determining the average sales price of a drug or biological under section 1847A.

(1)  Covered outpatient drugs dispensed by health maintenance organizations, including medicaid managed care organizations that contract under section 1903(m), are not subject to the requirements of this section.

(k) (1) 

(B)  Exclusion of customary prompt pay discounts extended to wholesalers.—The average manufacturer price for a covered outpatient drug shall be determined without regard to customary prompt pay discounts extended to wholesalers.

(7) 

(C) 

(iii)  a drug product is considered to be sold or marketed in a State if it appears in a published national listing of average wholesale prices selected by the Secretary, provided that the listed product is generally available to the public through retail pharmacies in that State.

Sec. 1937. (b) 

(2) 

(C) 

(i)  Coverage of prescription drugs.

(ii)  Mental health services.

Sec. 2104. (a) 

(16)  for fiscal year 2013, for purposes of making 2 semiannual allotments—

(A)  $2,850,000,000 for the period beginning on October 1, 2012, and ending on March 31, 2013, and

(B)  $2,850,000,000 for the period beginning on April 1, 2013, and ending on September 30, 2013.

Sec. 2105. (c) 

(10) 

(M)  Coordination with medicaid.—In the case of a targeted low-income child who receives child health assistance through a State plan under title XIX and who voluntarily elects to receive a premium assistance subsidy under this section, the provisions of section 1906A shall apply and shall supersede any other provisions of this paragraph that are inconsistent with such section.

Sec. 1108. (g) 

(5)  Fiscal year 2011 and thereafter.—The amounts otherwise determined under this subsection for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa for the second, third, and fourth quarters of fiscal year 2011, and for each fiscal year after fiscal year 2011 (after the application of subsection (f) and the preceding paragraphs of this subsection), shall be increased by 30 percent.

Sec. 1848. (b) 

(4) 

(C)  Adjustment in practice expense to reflect higher presumed utilization.—Consistent with the methodology for computing the number of practice expense relative value units under subsection (c)(2)(C)(ii) with respect to advanced diagnostic imaging services (as defined in section 1834(e)(1)(B)) furnished on or after January 1, 2010, the Secretary shall adjust such number of units so it reflects—

(i)  in the case of services furnished on or after January 1, 2010, and before January 1, 2013, a 65 percent (rather than 50 percent) presumed rate of utilization of imaging equipment;

(ii)  in the case of services furnished on or after January 1, 2013, and before January 1, 2014, a 70 percent (rather than 50 percent) presumed rate of utilization of imaging equipment; and

(iii)  in the case of services furnished on or after January 1, 2014, a 75 percent (rather than 50 percent) presumed rate of utilization of imaging equipment.

(III)  Change in presumed utilization level of certain advanced diagnostic imaging services for 2010 through 2012.—Effective for fee schedules established beginning with 2010 and ending with 2012, reduced expenditures attributable to the presumed rate of utilization of imaging equipment of 65 percent under subsection (b)(4)(C)(i) instead of a presumed rate of utilization of such equipment of 50 percent.

(IV)  Change in presumed utilization level of certain advanced diagnostic imaging services for 2013.—Effective for fee schedules established for 2013, reduced expenditures attributable to the presumed rate of utilization of imaging equipment of 70 percent under subsection (b)(4)(C)(ii) instead of a presumed rate of utilization of such equipment of 50 percent.

(V)  Change in presumed utilization level of certain advanced diagnostic imaging services for 2014 and subsequent years.—Effective for fee schedules established beginning with 2014, reduced expenditures attributable to the presumed rate of utilization of imaging equipment of 75 percent under subsection (b)(4)(C)(iii) instead of a presumed rate of utilization of such equipment of 50 percent.

Sec. 1854. (b) 

(1) 

(C) 

(iii)  Form of rebate for plan year 2012 and subsequent plan years.—For plan years beginning on or after January 1, 2012, a rebate required under this subparagraph may not be used for the purpose described in clause (ii)(III) and shall be provided through the application of the amount of the rebate in the following priority order:

(I)  First, to use the most significant share to meaningfully reduce cost-sharing otherwise applicable for benefits under the original medicare fee-for-service program under parts A and B and for qualified prescription drug coverage under part D, including the reduction of any deductibles, copayments, and maximum limitations on out-of-pocket expenses otherwise applicable. Any reduction of maximum limitations on out-of-pocket expenses under the preceding sentence shall apply to all benefits under the original medicare fee-for-service program option. The Secretary may provide guidance on meaningfully reducing cost-sharing under this subclause, except that such guidance may not require a particular amount of cost-sharing or reduction in cost-sharing.

(II)  Second, to use the next most significant share to meaningfully provide coverage of preventive and wellness health care benefits (as defined by the Secretary) which are not benefits under the original medicare fee-for-service program, such as smoking cessation, a free flu shot, and an annual physical examination.

(III)  Third, to use the remaining share to meaningfully provide coverage of other health care benefits which are not benefits under the original medicare fee-for-service program, such as eye examinations and dental coverage, and are not benefits described in subclause (II).

Sec. 403. (a) 

(3) 

(H) 

(ii)  subparagraph (G) shall be applied as if “fiscal year 2011” were substituted for “fiscal year 2001”; and

Sec. 403. (a) 

(2) 

(III)  Marriage education, marriage skills, and relationship skills programs, that may include parenting skills, financial management, conflict resolution, and job and career advancement, for non-married pregnant women and non-married expectant fathers.

(D)  Appropriation.—Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated $150,000,000 for each of fiscal years 2006 through 2010, for expenditure in accordance with this paragraph.

(3) 

(H) 

(ii)  subparagraph (G) shall be applied as if “the date specified in section 106(3) of the Continuing Appropriations Act, 2011” were substituted for “fiscal year 2001”;and