Side-by-Side Comparison of Medicare, Medicaid, and SCHIP Provisions in the Deficit Reduction Act of 2005

CRS Report for Congress
Side-by-Side Comparison of Medicare,
Medicaid, and SCHIP Provisions
in the Deficit Reduction Act of 2005
January 30, 2006
Karen Tritz, Sibyl Tilson, Julie Stone, Chris L. Peterson, Jennifer
O’Sullivan, Paulette C. Morgan, Elicia J. Herz, Jean Hearne, Jim
Hahn, April Grady, Hinda Chaikind, and Evelyne P. Baumrucker
Analysts and Specialists in Health Insurance and Financing
Domestic Social Policy Division

Congressional Research Service ˜ The Library of Congress

Side-by-Side Comparison of Medicare, Medicaid, and
SCHIP Provisions in the Deficit Reduction Act of 2005
Summary
On December 19, 2005, the House agreed to a conference report on S. 1932.
However, the Senate amended the report, removing a few provisions as the result of
a point of order raised associated with the “Byrd Rule.” The amended agreement
passed the Senate on December 21, 2005, and was returned to the House for further
action. It is expected that the agreement will be taken up in the early part of the
session.
This report provides a comparison of Medicare, Medicaid and State Child
Health Insurance Program (SCHIP) provisions contained in the Deficit Reduction
Act of 2005 (S. 1932) as amended and passed by the Senate. The report compares
the bill’s provisions with current law.
This report will be updated.

Contents
Medicare’s update factor to increase operating payments
to acute-care hospitals as affected by submission
of quality data.........................................2
Value-based purchasing for acute care hospitals..................2
DRG Adjustment for Certain Hospital Acquired Infections.........3
Clarification of Inclusion of Medicaid Patient Days
in Medicare’s Computation of its Disproportionate
Share Hospital (DSH) Adjustment ........................4
Improvements to the Medicare-Dependent Hospital
(MDH) Program.......................................5
Reduction in Payments to Skilled Nursing Facilities (SNFs)
for Bad Debt..........................................5
Extend Phase-in of the Inpatient Rehabilitation Facility
(IRF) Compliance Thresholds............................6
Development of a Strategic Plan Regarding
Physician Investment in Specialty Hospitals.................6
Gainsharing Demonstration Project............................7
Post-acute Care Payment Reform Demonstration Program..........8
Beneficiary ownership of certain DME and Oxygen equipment......9
Adjustments in Payments for Imaging Services.................10
Limitation on Medicare Payments for Procedures
in Ambulatory Care Surgical Centers (ASCs)...............11
Update for Physicians’ Services for 2006......................12
Three Year Hold Harmless Transition for Small Rural Hospitals
Into the Outpatient Prospective Payment System (OPPS)......14
Update to the Composite Rate Component of the Basic Case-Mix
Adjusted Prospective Payment System for Dialysis Services...14
Revisions to Payments for Therapy Services....................15
Accelerated Implementation of Income-Related Reduction
in Part B Premium Subsidy.............................16
Medicare Coverage of Ultrasound Screening for
Abdominal Aortic Aneurysms...........................16
Improving Patient Access to, and Utilization of,
Colorectal Cancer Screening Under Medicare...............18
Delivery of Services at Federally Qualified Health Centers
(FQHC) ............................................18
Waiver of Part B Late Enrollment Penalty for
Certain International Volunteers.........................18
Home health payments.....................................19
Revision of period for providing payment for claims
that are submitted electronically.........................20
Time frame for part A and B payments........................20
Increase in Medicare Integrity Program (MIP) Funding...........21
Phase-out of risk adjustment budget neutrality in determining
the amount of payments to Medicare Advantage
organizations ........................................21
Establishment of PACE Provider Grant Program................24

Subtitle A. Medicaid..........................................26
Chapter 1. Payment for Prescription Drugs........................26
Modification of Federal Upper Payment Limit for
Multiple Source Drugs; Definition of Multiple Source Drugs..26
Disclosure of Price Information
to States and the Public................................27
Definition of Average Manufacturer Price.....................27
Exclusion of Sales at a Nominal Price from Determination
of Best Price.........................................28
Retail Survey Prices; State Payment and
Utilization Rates; and Performance Rankings...............29
Miscellaneous Amendments................................31
Effective Date for Prescription Drug Provisions.................31
Collection and Submission of Utilization Data for
Certain Physician Administered Drugs....................31
Collection and Submission of Utilization Data for
Certain Physician Administered Drugs....................32
Children’s Hospital Participation in Drug Discount Program.......33
Chapter 2. Asset Transfers.....................................34
Lengthening Look-Back Period..............................34
Change in Beginning Date for Period of Ineligibility.............35
Effective Date Section 6011................................35
Availability of Hardship Waivers; Additional Provisions
on Hardship Waivers..................................36
Disclosure and Treatment of Annuities........................36
Application of “Income-First” Rule in Applying
Community Spouse’s Income Before Assets in
Providing Support of Community Spouse..................39
Disqualification for Long-Term Care Assistance
for Individuals with Substantial Home Equity...............41
Enforceability of Continuing Care Retirement Communities
(CCRC) and Life Care Community Admission Contracts......42
Requirement to Impose Partial Months of Ineligibility............44
Authority for States to Accumulate Multiple Transfers into
One Penalty Period....................................45
Inclusion of Transfer of Certain Notes and Loans Assets..........46
Inclusion of Transfers to Purchase Life Estates..................47
Effective Date for Section 6016..............................47
Expansion of State Long-Term Care Partnership Program.........49
Chapter 3. Eliminating Fraud, Waste, and Abuse in Medicaid..........57
Encouraging the Enactment of State False Claims Acts...........57
Employee Education About False Claims Recovery..............57
Prohibition on Restocking and Double Billing of
Prescription Drugs....................................58
Medicaid Integrity Program.................................58
Enhancing Third Party Identification and Payment...............59
Improved Enforcement of Documentation Requirements..........60
Chapter 4. Flexibility in Cost Sharing and Benefits..................62
State Option for Alternative Premiums and Cost Sharing..........62
General Limitations.......................................62
Specified Groups Exempt from Premiums.....................63

Service-Related Cost Sharing...........................63
Construction .............................................64
Beneficiary Conditions For Continued Medicaid Enrollment
and Receipt of Services................................64
Indexing Nominal Cost Sharing and Conforming Amendment......65
Effective Date...........................................65
Special Rules for Cost Sharing for Prescription Drugs............65
Limitations on cost-sharing for non-preferred drugs..............66
Special conditions and applicable cost-sharing..................66
Flexibility regarding drugs excluded from cost sharing provisions...66
Effective Date...........................................66
Emergency Room Co-Payments for Non-Emergency Care.........66
Limitations ..............................................67
Provider Obligations Regarding Emergency Services.............67
Provider Liability.........................................68
Definitions ..............................................68
Grants to Establish Alternative Non-Emergency
Provider Networks....................................69
Effective Date...........................................69
Use of Benchmark Packages................................69
Full Benefit Eligible Individuals.............................70
Exempted Groups........................................71
Standard Benefits.........................................72
Wrap-Around Benefits for Children Only......................73
Treatment of Rural Health Clinics (RHCs) and
Federally Qualified Health Centers (FQHCs)...............73
Effective Date...........................................73
Chapter 5. State Financing.....................................74
Managed Care Organization Provider Tax.....................74
Reforms of Case Management and Targeted
Case Management (TCM)..............................75
Additional FMAP Adjustments..............................75
DSH Allotment for the District of Columbia....................76
Increase In Medicaid Payments to the Insular Areas..............76
Subchapter A — Family Opportunity Act......................78
Opportunity for Families of Disabled Children
to Purchase Medicaid Coverage for Such Children...........78
Interaction with Employer-Sponsored Family Coverage...........79
State Option to Impose Income-Related Premiums...............79
Conforming Amendments..................................80
Effective Date...........................................81
Demonstration Projects Regarding Home- and
Community-Based Alternatives to Psychiatric
Residential Treatment Facilities for Children...............81
State Demonstration.......................................81
Federal Evaluation and Report...............................82
Appropriation ............................................82
Family-to-Family Health Information Centers..................82
Restoration of Medicaid Eligibility for Certain SSI Beneficiaries...83
Subchapter B — Money Follows the Person
Rebalancing Demonstration.............................84

State Demonstrations......................................85
Eligible Individuals.......................................85
State Application.........................................86
Requirements for Self-Directed Services.......................87
Secretary’s Award of Competitive Grants and Waivers...........87
Conditional Approval of Out-Year Grants.....................87
Payments to States/ Carryover of Unused Grant Amounts.........88
Quality Assurance and Improvement; Technical Assistance
and Oversight........................................89
Research and Evaluation...................................89
Appropriations ...........................................89
Subchapter C — Miscellaneous..............................90
Medicaid Transformation Grants.............................90
Health Opportunity Accounts...............................91
Eligibility Rules for Demonstration Participants.................91
Benefits for Demonstration Participants.......................93
Cost Sharing for Demonstration Participants...................93
Provider Payments........................................94
Demonstration evaluation..................................94
Effective Date...........................................95
State Option to Establish Non-Emergency
Medical Transportation Program.........................95
Extension of Transitional Medical Assistance (TMA)
and Abstinence Education Program.......................95
Emergency Services Furnished by Non-Contract Providers
for Medicaid Managed Care Enrollees....................96
Expansion of home and community-based services..............97
Establishment of Needs-Based Criteria........................98
Projected Number of Enrollees in the Benefit and Modification
of Needs-Based Criteria................................99
Independent Evaluation of Eligibility.........................99
Independent Assessment Process............................100
Individualized Care Plan..................................100
State Option to Offer Self-Directed Services...................101
Quality Assurance and Conflict of Interest Standards............101
Redeterminations and Appeals.............................101
Presumptive Eligibility...................................102
No Effect on Other Waiver Authority........................102
Continued Federal Medicaid Funding for Certain Individuals.....102
Quality of care measures..................................102
Optional Choice of Self-Directed Personal Assistance Services
(Cash and Counseling)................................103
State Requirements......................................104
Reports and Evaluation...................................105
Limits to the Availability of Self-Directed Services.............105
Scope of Self-Directed Personal Assistance Services............106
Self-Directed Services Plan................................106
Self-Directed Services Budget..............................107
Application of Quality Assurance and Risk Management.........107
Financial Management Entity..............................108
Effective date...........................................108

Additional allotments to eliminate FY2006 funding shortfalls.....109
Use of Additional FY2006 Appropriation for Child Health
Assistance for Targeted Low-Income Children.............110
Prohibition against covering nonpregnant adults
with SCHIP funds...................................110
Continued authority for qualifying states to use certain funds
for Medicaid expenditures.............................111
Subtitle C — Katrina Relief....................................113
Additional Federal Payments Under Hurricane-Related
Multi-State Section 1115 Demonstrations.................113
List of Tables
Title V. Medicare.................................................2
Title VI. Medicaid and SCHIP......................................26
Subchapter A — Reform of Asset Transfer Rules........................34
Subchapter B — Expanded Access to Certain Benefits...................49
Chapter 6. Other Provisions........................................78
Subchapter A — Family Opportunity Act..........................78
Subchapter B — Money Follows the Person
Rebalancing Demonstration.....................................84
Subchapter C — Miscellaneous..................................90

Side-by-Side Comparison of Medicare,
Medicaid, and SCHIP Provisions
in the Deficit Reduction Act of 2005
On December 19, 2005, the House agreed to a conference report on S. 1932.
However, the Senate amended the report, removing a few provisions as the result of
a point of order raised associated with the “Byrd Rule.” ¹ The amended agreement
passed the Senate on December 21, 2005, and was returned to the House for further
action. Among the many provisions in the act, Title V proposes changes in the
Medicare program, and Title VI proposes changes in the Medicaid and State Child
Health Insurance Program (SCHIP) and provides some fiscal relief for Katrina
victims using Social Security Act section 1115 waiver authority. The House is slated
to act on the bill when it returns in 2006.
This report provides a side-by-side comparison of the provisions contained in
the Senate-passed version of the bill with current law. Additional information on
provisions in the House and Senate versions of the bill can be found in CRS Report
RL33131, Budget Reconciliation FY2006: Medicaid, Medicare, and State Child
Health Insurance Program (SCHIP) Provisions.
This report will be updated.

¹ See CRS Report RL33132, Budget Reconciliation Legislation in 2005, by Robert Keith.

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^s^econ^d^ary^diagⁿ^o^s^e^s^{are con}^s^id^{ered to be}^com^p^lication^s^or^DRG.^T^h^e^assigⁿ^m^en^{t o}^f^th^{e lo}^w^e^r^p^a^id^{DRG ap}^p^lies^to
^co^m^o^r^b^id^{ities (}^CC)^{. W}^h^en^p^r^es^eⁿ^{t as a seco}ⁿ^d^ar^y^dis^c^h^a^rg^es^{, w}^h^{ere, at th}^{e tim}^{e of}^th^{e pa}^tien^t^’^s^admⁱ^s^sⁱ^on^,
^con^dⁱ^tⁱ^on^(w^ith^{a s}^p^ecifⁱ^{c prin}^{cipal diag}ⁿ^o^sⁱ^s⁾^{, th}^es^e^t^h^{e ben}^e^fⁱ^ci^ary^h^a^{d n}^oⁿ^e^of^t^h^{e i}^d^en^tⁱ^fⁱ^e^d^di^agⁿ^o^sⁱ^s^codes^.
^diagⁿ^o^sⁱ^s^codes^{are con}^s^idered^toⁱⁿ^cr^{ease th}^{e len}^g^th^o^f^A^d^j^u^s^t^m^eⁿ^t^s^{to th}^{e relativ}^{e w}^e^ig^h^t^th^{at occu}^{r becau}^s^e^of
^s^t^ay^by^l^e^a^s^t^oⁿ^{e day}ⁱⁿ^{at leas}^{t 75% of}^th^{e patien}^t^s^.^In^th^{is actio}ⁿ^ar^{e n}^o^{t b}^u^d^g^{et n}^e^u^t^r^a^l^.^T^h^{e list o}^f^dⁱ^agⁿ^o^ses
^F^Y^2006,^{524 D}^R^G^s^{are u}^s^{ed f}^o^{r Medi}^{care pay}^m^en^t^m^a^y^{be rev}ⁱ^s^e^d^fr^o^m^tⁱ^m^{e to tim}^{e as}^lon^g^as^th^{ere are at}
^pu^rpos^es^{; 121 paired DR}^Gs^are^s^p^litⁱⁿ^to^hⁱ^g^h^e^r^an^{d low}^e^r^l^eas^t^t^w^{o di}^agⁿ^o^sⁱ^s^codes^s^e^l^ect^{ed f}^o^{r di}^s^c^ha^r^g^e^s
^{paid DR}^Gs^on^th^{e pres}^en^{ce or th}^{e abs}^eⁿ^{ce of}^{a C}^C^.^C^M^S^occu^rring^d^u^rin^g^an^y^fⁱ^s^{cal y}^{ear. T}^h^{e Secretary}^is
^h^a^s^added^an^d^del^e^t^e^{d codes}^f^r^om^t^h^{e s}^t^an^{dard l}ⁱ^s^t^of^C^C^s^,^r^e^q^u^ir^ed^to^coⁿ^s^u^l^t^w^ith^th^{e C}^eⁿ^t^ers^f^o^{r Dis}^eas^{e C}^oⁿ^t^rol
^b^u^t^ha^{s ne}^ve^r^c^o^nd^uc^t^e^d^a^c^o^m^p^r^e^h^eⁿ^sⁱ^v^e^r^e^vi^e^w^o^f^t^h^e^an^d^P^r^ev^en^tⁱ^oⁿ^an^d^o^t^h^e^r^ap^p^r^o^p^r^{iate en}^{tities w}^h^en

CRS-4
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^lis^t^.^I^t^{is p}^l^anⁿⁱⁿ^g^sy^stem^{atic r}^e^vⁱ^ew^o^f^th^{e CC list f}^o^r^selectin^g^an^d^r^e^vⁱ^sin^g^th^{e id}^en^tif^ied^dⁱ^agⁿ^o^{sis co}^d^e^{s. T}^h^e
^F^Y^{2007 Medi}^{care pay}^m^en^t^s^.^lⁱ^s^t^of^di^agⁿ^o^sⁱ^s^codes^an^{d D}^R^G^s^{are n}^o^t^s^u^bj^ect^t^o
^j^u^{dicial rev}ⁱ^ew^.
^C^l^a^rⁱ^fⁱ^c^a^tⁱ^oⁿ^o^f^Iⁿ^c^l^us^{ion of M}^e^dic^aⁱ^d^Pa^tⁱ^eⁿ^t^Hos^pⁱ^t^a^l^s^th^{at s}^e^rv^{e a certain}ⁿ^u^m^{ber of}^lowⁱⁿ^com^e^Se^c^tⁱ^oⁿ^5002.^T^h^{e Secretary}^canⁱⁿ^clu^d^{e in}^patie^nt
^y^s^{in M}^e^dⁱ^c^a^r^e^’^s^C^o^mputa^t^{ion of its}^Medⁱ^{care an}^d^Medⁱ^caid^b^eⁿ^e^fⁱ^{ciaries w}^{ill receiv}^e^{a DSH}^h^o^s^p^{ital day}^s^of^patien^t^s^eli^gⁱ^b^l^e^f^o^{r m}^e^{dical as}^sⁱ^s^t^an^ce
^p^r^opor^tiona^t^e^S^h^a^r^e^H^o^s^pⁱ^t^a^l^(DS^H⁾^adj^u^s^t^m^eⁿ^t^th^{at in}^creas^es^th^{eir Medicare IP}^P^S^pay^m^en^ts^.^und^e^r^{a S}^ectⁱ^oⁿ^{1115 dem}^oⁿ^s^t^r^atⁱ^oⁿ^w^aⁱ^v^{er i}ⁿ^t^h^e
^just^ment^.^Mo^{st h}^o^sp^{itals r}^eceⁱ^v^{e th}^{e ad}^d^itioⁿ^a^{l p}^a^y^m^en^{ts b}^a^sed^oⁿ^Medⁱ^car^{e DSH calcu}^latioⁿ^.^T^h^ese^d^a^y^s^w^{ill b}^e^co^uⁿ^t^ed^as
^th^eir^{DSH p}^a^tien^t^p^e^r^cen^tag^e^w^h^ich^{is calcu}^lated^u^sⁱⁿ^g^if^th^ey^w^e^r^e^p^r^o^v^id^ed^to^p^a^tien^t^{s w}^h^o^w^e^r^e^elig^ib^{le f}^o^r
^proportⁱ^oⁿ^of^t^h^{e h}^o^s^pⁱ^t^a^l^’^s^t^o^t^a^l^day^s^provⁱ^d^{ed t}^o^m^e^{dical as}^sⁱ^s^t^an^{ce u}ⁿ^d^er^an^a^pprov^{ed Medi}^cai^{d s}^t^at^{e pl}^an^.
ⁱ^{ki/CRS-RL33251}^Medi^cai^{d reci}^pi^en^t^s^{added t}^o^t^h^{e proport}ⁱ^oⁿ^of^t^h^e^h^o^s^pⁱ^t^a^l^’^s^Medi^{care i}ⁿ^patⁱ^eⁿ^t^day^s^provⁱ^d^{ed t}^o^poor^T^h^{e ex}^is^tin^g^reg^u^l^ation^s^an^{d th}^{eir effe}^c^t^iv^{e date are}^r^a^tif^ied^.^No^h^o^sp^ital^c^o^{st r}^e^p^o^r^{ts th}^{at ar}^{e clo}^s^ed^oⁿ^th^e
^g/w^{Medicare ben}^e^fⁱ^ciaries^(th^o^s^e^w^h^{o are elig}^ible^fo^{r P}^a^{rt A}^en^actm^eⁿ^t^d^a^{te w}^{ill b}^e^r^e^o^p^eⁿ^e^d^to^im^p^l^em^en^t^t^hⁱ^s
^s^.or^an^{d receiv}^e^Su^pplem^en^{tal Secu}^rity^In^com^e^.⁾^A^f^{ter a}^provⁱ^sⁱ^oⁿ

^le^ak^mⁱⁿⁱ^m^u^m^t^h^res^h^ol^{d of}^15%ⁱ^s^m^e^t^,^a^ho^s^pⁱ^t^a^l^’^s^D^S^H
^ad^j^u^stm^eⁿ^t^w^{ill v}^a^r^y^b^y^th^{e h}^o^sp^ital’^{s b}^e^d^{size o}^r^u^r^b^aⁿ^o^r
^://wiki^r^u^r^a^{l lo}^catioⁿ^.^T^h^{e p}^o^lⁱ^cy^o^f^w^h^eth^e^rⁱⁿ^p^a^tien^t^d^a^y^s
^h^ttp^p^r^o^v^id^ed^to^{a p}^a^tien^t^co^v^e^r^e^d^uⁿ^d^er^{a d}^e^m^oⁿ^s^tr^atioⁿ
^proj^ect^s^es^t^a^blⁱ^s^h^e^{d by}^S^ectⁱ^oⁿ^{1115 w}^aⁱ^v^ers^cou^l^{d be}
ⁱⁿ^clu^d^{ed in}^th^{e Medicare DSH calcu}^lation^ha^s^c^h^an^g^e^d
^ov^{er t}ⁱ^m^{e. S}^t^artⁱⁿ^g^Jan^u^a^ry²⁰^{, 2000, h}^o^s^pⁱ^t^a^l^s^w^e^re
^allo^w^e^d^toⁱⁿ^clu^d^e^t^h^{e in}^p^a^tien^t^h^o^sp^{ital d}^a^y^s^attr^ib^u^t^ab^le
^to^p^a^tien^t^{s m}^a^d^e^elig^ib^{le f}^o^r^Medⁱ^caid^p^u^r^s^u^aⁿ^t^to^{a state’}^s
^S^o^ci^al^S^ecu^ri^t^y^A^c^t^S^ectⁱ^oⁿ^{1115 w}^aⁱ^v^{er. Prev}ⁱ^o^u^s^l^y^,
^h^o^sp^{itals co}^u^l^dⁱⁿ^clu^d^{e d}^a^y^s^f^o^r^p^o^p^u^latioⁿ^s^uⁿ^d^er^th^e
^S^ectⁱ^oⁿ^{1115 w}^aⁱ^v^{er w}^h^{o w}^e^{re or cou}^l^d^ha^ve^been^m^a^de
^elig^{ible u}ⁿ^d^{er a s}^t^{ate Medicaid plan}^{. Start}ⁱ^ng^fo^r
^di^s^c^h^a^rg^es^on^O^c^t^{ober 1, 2003, h}^o^s^pⁱ^t^a^l^day^s^at^t^rⁱ^b^u^t^ed^t^o
^patien^t^s^w^h^{o do n}^o^{t receiv}^e^cov^e^rag^e^f^o^{r in}^patien^t^ben^e^f^its
^uⁿ^d^{er S}^ectⁱ^oⁿ^{1115 de}^m^oⁿ^s^t^r^atⁱ^oⁿ^proj^ect^s^canⁿ^o^t^be

CRS-5
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^couⁿ^t^{ed in}^th^{e Medicare DSH}^calcu^latioⁿ^.^T^h^{ese p}^o^licies
^w^e^{re es}^t^a^blⁱ^s^h^e^{d by}^reg^u^l^atⁱ^oⁿⁱⁿ^Jan^u^a^ry^{2000 an}^{d A}^ugust
^2003.
^Impr^ov^e^m^eⁿ^ts^{to the}^M^e^dic^a^r^e^-^De^pe^nde^nt^C^e^rt^aiⁿ^s^m^al^l^ru^ra^l^ho^spi^t^a^l^s^(wⁱ^t^h^{100 beds}^{or l}^e^s^s⁾^t^h^at^S^ecti^oⁿ^5003.^T^h^{e MDH s}^t^at^u^s^f^o^{r qu}^alⁱ^f^yⁱⁿ^g^ru^ral
^sp^it^{al (}^M^DH)^Pro^g^r^am.^h^a^v^e^at^l^eas^t^60%^ofⁱ^t^sⁱⁿ^patⁱ^eⁿ^t^day^s^{or di}^s^c^h^a^rg^es^du^riⁿ^g^ho^spⁱ^t^a^l^s^w^o^ul^d^b^e^e^x^t^e^nd^e^d^t^h^r^o^{ugh d}ⁱ^sc^ha^r^g^e^s^o^c^c^u^r^rⁱ^ng
^F^Y^{1987 or du}^rin^g^tw^{o of}^th^{e th}^{ree m}^o^st^r^ecen^tly^au^dited^bef^o^{re O}^c^t^obe^r^{1, 2011. S}^t^artⁱⁿ^g^f^o^{r di}^s^c^h^a^rg^es^on
^co^{st r}^e^p^o^r^tin^g^p^e^rⁱ^o^d^s⁽^f^o^r^w^hⁱ^c^h^th^er^{e is a settled}^co^st^O^c^t^{ober 1, 2006, a MD}^H^w^o^u^l^d^be^abl^e^t^o^el^ect^pay^m^en^t^s
^r^e^p^o^r^t)^attr^ib^u^t^ed^to^Medⁱ^car^e^p^a^tⁱ^en^{ts q}^u^alif^y^f^o^r^sp^ecial^bas^e^{d on}^50%^ofⁱ^t^s^F^Y^{2002 h}^o^s^pⁱ^t^a^l^-^s^p^eci^fⁱ^{c cos}^t^sⁱ^f^t^h^at
^tr^eatm^eⁿ^t^{as MDHs. MDH h}^o^sp^{itals ar}^{e p}^a^id^{at n}^a^tioⁿ^a^l^w^o^ul^d^r^e^sul^tⁱⁿ^hi^ghe^r^M^e^dⁱ^c^a^r^e^p^a^y^m^eⁿ^t^s^.^M^D^H^’^s
ⁱ^{ki/CRS-RL33251}^s^t^an^d^a^r^dⁱ^{zed rate or, if}^hⁱ^g^h^e^{r, 50% of}^th^{eir adj}^u^s^t^ed^F^Y^{1982 or F}^Y^{1987 h}^o^s^pⁱ^t^a^l^-^s^p^e^cⁱ^fⁱ^c^c^o^s^t^s^.^Thⁱ^s^s^p^e^cⁱ^a^l^pay^m^en^t^s^w^o^u^l^{d be bas}^e^{d on}^75%^of^t^h^ei^{r adj}^u^st^ed^ho^sp^ita^l-sp^e^cⁱ^fic^c^o^{sts sta}^r^{ting fo}^r^dⁱ^sc^ha^r^g^e^s^oⁿ^Oc^to^b^e^r
^g/w^tr^eatm^eⁿ^t^w^{ill lap}^s^{e f}^o^r^dⁱ^sch^a^r^g^{es star}^tin^g^oⁿ^Octo^b^e^r¹^,^1,^{2006. MD}^H^’^s^t^h^at^qu^alⁱ^f^y^f^o^{r a di}^s^p^roportⁱ^oⁿ^a^t^e^s^h^are
^s^.or²⁰^{06. C}^e^rt^aiⁿ^h^o^s^pⁱ^t^a^l^s^t^h^at^s^e^rv^{e a h}ⁱ^g^h^proportⁱ^oⁿ^of^ho^spⁱ^t^a^l⁽^D^SH⁾^a^d^j^u^st^m^e^nt^w^o^ul^d^no^t^ha^ve^t^h^e^a^d^j^u^st^m^e^nt
^le^ak^Medi^cai^{d pat}ⁱ^eⁿ^t^s^{or poor Medi}^{care ben}^e^fⁱ^cⁱ^a^rⁱ^e^s^qu^alⁱ^f^y^{capped at}^12%^.
^f^o^r^{a DSH ad}^j^u^stm^eⁿ^t^to^t^h^eⁱ^rⁱⁿ^p^a^tien^t^p^a^y^m^en^{ts. Sm}^all
^://wiki^u^r^ban^an^{d m}^o^s^t^ru^ral^h^o^s^pⁱ^t^a^l^s⁽^e^x^cept^f^o^{r ru}^ral^ref^e^rral
^h^ttp^cen^ters^{) h}^a^v^e^th^{eir DSH adj}^u^s^t^m^eⁿ^t^{capped at 12%.}
^Reductⁱ^{on in Pay}^m^eⁿ^t^s^t^o^{Skilled Nursing}^{Medicare pay}^s^th^{e cos}^t^s^of^certain^item^s^on^{a reas}^oⁿ^a^b^le^S^ecti^oⁿ^5004.^{Medicare pay}^m^en^ts^{to SNFS f}^o^{r allow}^a^ble
^{ies (}^S^NFs)^f^o^{r Bad Debt}^.^cos^t^basⁱ^s^(ou^t^sⁱ^{de of}^t^h^{e appl}ⁱ^cabl^e^pros^pectⁱ^v^e^pay^m^en^t^{bad debt}^s^w^o^u^l^{d be redu}^{ced t}^o^70%^f^o^{r ben}^e^fⁱ^ci^ari^e^s^w^h^o
^s^y^s^t^em⁾ⁱⁿ^clu^dⁱⁿ^g^th^{e u}ⁿ^p^{aid debt f}^o^{r ben}^e^fⁱ^ciaries^’^{are n}^o^{t eli}^g^{ible f}^o^{r both}^{Medicare an}^{d Medicare.}
^coin^s^u^ran^{ce an}^{d dedu}^{ctible am}^ouⁿ^t^s^.^C^M^{S h}^a^s^reim^bu^rs^ed^Medi^care’^s^pay^m^en^t^s^f^o^{r al}^l^o^w^a^bl^{e bad debt}^s^at^t^rⁱ^b^u^t^ed^t^o
^cert^aⁱⁿ^provⁱ^d^ers^f^o^{r 100%}^of^t^h^{e debt}^{. Ef}^f^ectⁱ^v^{e f}^o^{r cos}^t^du^al^elⁱ^gⁱ^b^l^e^ben^e^fⁱ^ci^ari^e^s^w^o^u^l^{d rem}^aⁱⁿ^at^100%^.

^report^s^s^t^artⁱⁿ^gⁱⁿ^FY^{2001, Medi}^{care beg}^aⁿ^rei^m^bu^rsⁱⁿ^g
^acu^{te care h}^o^s^p^itals^f^o^{r 70% of}^th^{e reas}^on^{able cos}^t^s
^as^s^o^{ciated w}^ith^ben^e^fⁱ^ciaries^’^allow^a^{ble bad debt. SNFs}
^{are s}^{till reim}^bu^rs^{ed 100% f}^o^{r th}^is^{bad debt.}

CRS-6
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^Ext^eⁿ^d^Ph^ase-ⁱⁿ^o^f^t^h^{e In}^p^a^tⁱ^en^t^I^R^{Fs ar}^{e eith}^er^f^r^eestan^dⁱⁿ^g^h^o^sp^{itals o}^r^dⁱ^stin^{ct p}^a^r^t^uⁿ^its^S^ecti^oⁿ^5005.^T^h^{e com}^p^lian^{ce th}^res^h^{old f}^o^{r IR}^Fs^is
^at^{ion Facilit}^y⁽^I^R^F⁾^C^o^m^p^lⁱ^a^nce^of^oth^e^{r h}^o^s^p^ital^s^t^h^a^t^{are ex}^em^{pt f}^r^om^Medicare’^s^IP^P^S^es^t^a^blⁱ^s^h^e^{d at}^60%^du^riⁿ^g^t^h^{e 12-}^m^oⁿ^t^h^peri^od^begⁱⁿⁿⁱⁿ^g
^r^e^s^holds^.^u^s^e^d^t^o^pay^acu^{te care h}^o^s^p^itals^{. T}^h^{e Medicare s}^t^atu^t^e^on^Ju^l^y^{1, 2006;}^at^65%^d^u^rⁱ^{ng t}^h^{e 12-}^m^oⁿ^t^h^peri^od
^gⁱ^v^e^s^th^{e Secretary}^dis^c^retion^t^o^es^tablis^h^th^{e criteria th}^at^begⁱⁿⁿⁱⁿ^g^on^Ju^l^y^{1, 2007;}^an^{d at}^75%^begⁱⁿⁿⁱⁿ^g^on^Ju^l^y
^f^{acilities m}^u^{st m}^{eet in}^o^r^d^e^r^to^b^e^coⁿ^s^id^er^ed^an^I^R^F.^{1, 2008 an}^{d s}^u^bs^equ^eⁿ^t^l^y^.
^Recen^tly^issu^ed^reg^u^l^atioⁿ^s^b^y^CMS^req^u^ire^th^at^{a f}^acility
^m^u^s^t^t^r^eat^{a cert}^aⁱⁿ^proportⁱ^oⁿ^of^patⁱ^eⁿ^t^s^wⁱ^t^h^s^p^eci^fⁱ^ed
^m^e^dⁱ^{cal co}ⁿ^d^itioⁿ^sⁱⁿ^o^r^d^e^r^to^q^u^alif^y^{as an}^I^R^{F an}^d
^receiv^e^hⁱ^g^h^e^{r Me}^dⁱ^c^a^{re pay}^m^en^ts^{. C}^M^S^{adopted a}
^tr^an^sitioⁿ^p^e^rⁱ^o^d^f^o^r^th^{e co}^m^p^lian^{ce th}^r^e^s^h^o^l^d^{as f}^o^llo^w^s^:
ⁱ^{ki/CRS-RL33251}^at^50%^f^r^om^Ju^l^y^{1, 2004 an}^{d bef}^o^re^Ju^l^y^1,^2005;^at^60%^f^r^om^Ju^l^y^{1, 2005 an}^{d bef}^o^r^e^J^u^l^y¹^,^2006;^at^{65 %}^f^r^om
^g/w^Ju^l^y^{1, 2006 an}^{d bef}^o^{re Ju}^l^y^{1, 2007;}^an^{d at}⁷⁵^%^f^r^om
^s^.or^Ju^l^y^{1, 2007 an}^{d t}^h^ereaf^t^e^r.
^le^ak
^De^v^e^lopmeⁿ^{t of a}^S^t^r^a^te^gic^P^l^aⁿ^Re^ga^r^d^ing^P^h^y^s^ician^s^ar^{e g}^eⁿ^e^r^a^lly^p^r^o^h^ib^ited^f^r^o^m^r^e^f^e^r^rⁱⁿ^g^S^ecti^oⁿ^5006.^T^h^{e Secretary}^is^requ^{ired to dev}^e^{lop a}
^://wiki^y^s^ician^In^v^est^men^tⁱⁿ^Sp^ecialt^y^Ho^sp^it^als.^Medⁱ^car^{e an}^d^Medⁱ^caid^p^a^tien^t^{s to}^f^acilitiesⁱⁿ^w^h^ich^th^ey^s^t^rat^e^gⁱ^{c an}^{d i}^m^pl^em^en^tⁱⁿ^g^pl^an^reg^a^rdi^ng^ph^y^sⁱ^cⁱ^aⁿ
^h^ttp^{(or th}^{eir im}^m^e^{diate f}^a^mⁱ^l^y^m^e^m^b^{er) h}^a^v^e^fⁱⁿ^aⁿ^c^ialⁱⁿ^v^e^stm^eⁿ^tⁱⁿ^sp^ecialty^h^o^s^p^{itals. T}^h^{e p}^l^an^w^{ill ad}^d^r^ess
ⁱⁿ^ter^e^{sts. T}^hⁱ^s^p^r^o^h^ib^itioⁿ^d^o^e^{s n}^o^{t ex}^ten^d^to^p^a^tien^t^th^{e proportion}^a^lity^ofⁱⁿ^v^e^s^t^m^eⁿ^t^retu^rn^{, bon}^{a f}ⁱ^de
^r^e^fe^r^r^a^l^{s t}^o^ho^spⁱ^t^a^l^s^w^h^e^r^e^p^h^y^sⁱ^cⁱ^a^{ns ha}^ve^o^w^ne^r^s^hi^p^o^rⁱ^nve^st^m^e^nt^s,^a^nnua^l^dⁱ^sc^l^o^sur^e^o^fⁱ^nve^st^m^e^ntⁱⁿ^c^o^m^e^,^t^h^e
ⁱⁿ^v^e^s^t^m^eⁿ^tⁱⁿ^ter^e^{st in}^th^{e w}^h^o^l^{e h}^o^sp^{ital itself}⁽^aⁿ^dⁿ^o^t^prov^is^ion^of^care^to^{Medicaid patien}^t^s^an^{d to ch}^arity^care
^m^e^rel^yⁱⁿ^{a s}^u^bdi^vⁱ^sⁱ^on^of^t^h^e^ho^spi^t^a^l⁾^{. S}^ectⁱ^oⁿ^{507 of}^p^a^tⁱ^eⁿ^t^s^b^y^s^p^e^cⁱ^a^l^t^y^h^o^s^pⁱ^t^a^l^s^,^an^d^approp^rⁱ^a^t^e
^MMA^estab^lish^e^d^th^{at th}^{e ex}^ce^p^t^ioⁿ^f^o^r^p^h^y^s^ician^eⁿ^f^o^r^cem^en^{t. A}ⁿⁱⁿ^terⁱ^m^r^e^p^o^r^{t is d}^u^{e w}^ithⁱⁿ^th^r^e^e
ⁱⁿ^v^e^stm^eⁿ^t^an^d^self^-^r^ef^er^r^a^{l w}^o^u^l^dⁿ^o^{t ex}^ten^d^to^sp^ecialty^m^oⁿ^t^h^s^an^d^th^{e f}ⁱⁿ^a^{l r}^e^p^o^r^{t is d}^u^{e n}^o^later^th^an^six^m^oⁿ^t^h^s
^h^o^s^pⁱ^t^a^l^s^f^o^{r a peri}^{od of}^18-^m^ont^h^s^f^r^om^en^act^m^eⁿ^t^(or^a^f^t^e^r^th^{e d}^a^{te o}^f^en^actm^eⁿ^t^{. T}^h^{e Secr}^etar^y^w^{ill co}ⁿ^tin^u^e
^uⁿ^{til J}^uⁿ^e⁸^,^2004).^Thⁱ^s^m^o^r^a^t^o^rⁱ^u^m^h^a^s^b^e^eⁿ^e^x^t^eⁿ^d^e^d^to^su^sp^en^d^th^{e en}^r^o^llm^en^{t o}^fⁿ^e^w^sp^ecialty^h^o^sp^{itals u}ⁿ^til
^a^d^mⁱⁿⁱ^st^r^a^tⁱ^v^e^l^{y b}^y^CM^{S w}^hⁱ^c^{h ha}^{s no}^tⁱ^ssue^d^p^r^o^vⁱ^d^e^r^t^h^{e earl}ⁱ^e^{r of}^t^h^{e dat}^e^of^s^u^bmⁱ^s^sⁱ^on^of^t^h^{e repo}^r^t^{or s}ⁱ^x
ⁿ^u^m^b^e^r^s^toⁿ^e^w^sp^ecialty^h^o^sp^{itals w}^hⁱ^l^eⁱ^t^ex^amⁱⁿ^{es th}^e^m^oⁿ^t^h^s^af^{ter th}^{e date of}^en^actm^eⁿ^t^{. If}^th^e^Secretary^does
^crit^{eria u}^s^{ed to aw}^{ard s}^u^chⁿ^u^m^bers^{. Gen}^e^rally^{, a}ⁿ^o^{t su}^b^m^{it th}^{e f}ⁱⁿ^a^{l r}^e^p^o^r^{t w}^ithⁱⁿ^th^{e six}^m^oⁿ^t^h^tim^e
^sp^ecialty^h^o^sp^{ital is p}^r^im^ar^ily^o^r^ex^clu^s^iv^ely^en^g^a^g^e^dⁱⁿ^p^e^rⁱ^o^d^,^th^en^th^{e en}^r^o^llm^en^{t su}^sp^en^sioⁿ^w^{ill b}^e^ex^ten^d^ed

CRS-7
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^th^{e care an}^{d treatm}^eⁿ^t^of^{cardiac or orth}^{opedic patien}^t^s^,^an^ad^d^itioⁿ^a^{l tw}^o^m^oⁿ^t^h^s^{. T}^h^{e Secr}^etar^y^w^ill^also^p^r^o^v^id^e
^b^u^{t d}^o^e^{s n}^o^{t in}^clu^d^{e th}^o^s^{e th}^{at ar}^{e in}^o^p^e^r^a^tioⁿ^o^r^uⁿ^d^er^an^ap^p^r^o^p^r^{iate cer}^tif^icatioⁿ^o^f^th^e^f^a^ilu^r^e^to^coⁿ^g^r^essioⁿ^al
^dev^e^l^opm^en^t^as^of^N^o^v^e^m^b^{er 18, 2003 (w}ⁱ^t^h^t^h^{e s}^a^m^e^com^m^ittees^of^j^u^ris^d^iction^.^T^h^{e Secretary}^m^a^y^w^a^iv^e
ⁿ^u^m^{ber of}^ph^y^sⁱ^cⁱ^aⁿⁱⁿ^v^e^st^o^r^s^as^of^s^u^ch^dat^e^t^h^at^m^eet^s^certain^requ^irem^en^ts^of^th^{e A}^d^mⁱⁿⁱ^s^t^rativ^e^P^r^ocedu^r^es^A^c^t
^oth^e^{r s}^p^ecifⁱ^{ed requ}^irem^en^ts^{). For}ⁱⁿ^s^t^an^ce,^anⁱⁿ^creas^{e in}^w^h^en^dev^e^l^opiⁿ^g^t^h^{e s}^t^rat^e^gi^c^an^{d i}^m^pl^em^en^tⁱⁿ^g^pl^an^.
^t^h^{e n}^u^m^{ber of}^beds^cou^l^{d on}^l^y^occ^u^{r on}^t^h^{e m}^aⁱⁿ^cam^pu^s^T^w^o^m^illioⁿ^d^o^llar^s^f^r^o^m^th^{e T}^r^easu^r^y^is^ap^p^r^o^p^r^iatedⁱⁿ
^of^th^{e h}^o^s^p^{ital an}^{d cou}^l^{d n}^o^{t ex}^{ceed th}^e^g^r^eater^of^{50% of}^F^Y^{2006 f}^o^{r t}^hⁱ^s^s^t^rat^e^gⁱ^{c pl}^an^.
^th^{e n}^u^m^b^e^r^o^f^b^e^d^sⁱⁿ^th^{e h}^o^sp^ital^a^s^o^f^No^v^e^m^b^er¹⁸^,
^2003,^or^fⁱ^v^e^beds^{. T}^h^{e S}^ecret^ary^w^a^s^di^rect^ed^t^o^con^sⁱ^d^er
^cer^tain^f^acto^r^{s in}^d^e^ter^mⁱⁿⁱⁿ^g^w^h^eth^e^r^a^h^o^s^p^{ital is u}ⁿ^d^er
ⁱ^{ki/CRS-RL33251}^dev^e^lopm^en^t,^s^u^ch^as^th^{e com}^p^letion^of^arch^itectu^r^al^plan^s^,^an^{d th}^{e s}^t^atu^s^of^fuⁿ^dⁱⁿ^g^,^zonⁱⁿ^g^requ^irem^en^ts^{, an}^d
^g/wⁿ^eces^s^a^ry^approv^als^f^r^om^{State ag}^en^cies^.
^s^.or
^le^ak^Ga^ins^h^a^r^{ing De}^mons^tr^a^t^{ion P}^r^oje^c^t^.^Antⁱ^-^ki^c^k^b^a^c^k^aⁿ^d^p^a^tⁱ^e^nt^r^e^ferral^law^s^areⁱⁿ^ten^d^ed^to^S^ecti^oⁿ^5007.^T^h^{e Secr}^etar^y^w^ill^estab^lish^{a g}^aⁱⁿ^sh^arⁱⁿ^g
^di^s^c^ou^rag^e^ph^y^sⁱ^cⁱ^aⁿ^s^an^{d ot}^h^e^{r h}^eal^t^h^{care prov}ⁱ^d^ers^f^r^om^dem^oⁿ^s^tration^proj^{ect to ev}^alu^a^{te arran}^g^e^m^eⁿ^t^s^betw^een
^://wikiⁱ^m^properl^y^profⁱ^tⁱⁿ^g^f^r^om^ref^e^rral^s^of^Medi^{care an}^d^I^P^P^S^h^o^sp^{itals an}^d^p^h^y^s^ician^s^an^d^p^r^actitioⁿ^e^r^s^{. Up}^to^six
^h^ttp^Medⁱ^caid^p^a^tien^t^{s. Ex}^cep^tioⁿ^s^to^th^o^s^e^law^s^p^e^r^m^{it cer}^tain^p^r^o^j^{ects (}^w^ith^{at least tw}^oⁱⁿ^r^u^r^a^l^ar^eas)^w^{ill b}^e^ap^p^r^o^v^ed
^p^h^y^s^ician^-^f^acility^ar^r^aⁿ^g^e^m^eⁿ^t^s^uⁿ^d^e^r^s^p^e^cⁱ^fⁱ^c^by^N^o^v^e^m^b^{er 1, 2006 an}^d^o^p^e^ratⁱ^oⁿ^a^lⁿ^o^l^a^t^e^{r t}^h^an
^ci^rcu^m^s^t^an^ces^{. In}^2004,^a^f^e^deral^di^s^t^ri^ct^cou^r^t^s^t^opped^J^aⁿ^u^a^ry^{1, 2007. T}^h^{e Secretary}^w^{ill s}^o^li^cⁱ^t^application^s
^{CMS f}^r^o^m^im^p^l^em^en^tin^g^an^eig^h^t^h^o^sp^ita^{l g}^aⁱⁿ^sh^arⁱⁿ^g⁹⁰^d^a^y^s^af^t^e^r^en^actm^eⁿ^t^{. T}^h^{e p}^r^o^j^{ects w}^{ill en}^d^oⁿ
^d^e^m^oⁿ^s^tr^atioⁿ^p^r^o^j^ect^b^e^c^a^u^s^{e o}^f^civ^{il m}^oⁿ^e^tar^y^p^eⁿ^a^lty^D^ece^m^b^{er 31, 2009. T}^h^{e proj}^ect^s^m^u^s^t^m^eet^cert^aⁱⁿ
^con^cer^ns.^In^March^{2005, MedPA}^C^recom^m^eⁿ^d^{ed t}^h^at^r^e^q^u^ir^em^en^{ts f}^o^r^m^aⁱⁿ^tainⁱⁿ^g^o^r^im^p^r^o^vⁱⁿ^g^q^u^ality^w^h^ile
^C^oⁿ^g^r^es^s^g^r^an^t^t^h^{e Secretary}^th^{e au}^th^ority^{to allow}^a^c^hⁱ^e^vⁱ^{ng c}^o^st^sa^vi^ngs.^Ce^r^t^aⁱ^{n e}^xⁱ^s^tⁱ^{ng r}^e^st^rⁱ^c^tⁱ^o^ns
^r^e^gul^a^t^e^d^gaⁱⁿ^sha^rⁱ^{ng a}^r^r^a^nge^m^e^nt^{s b}^e^t^w^e^eⁿ^p^h^y^sⁱ^cⁱ^a^ns^coⁿ^cerⁿⁱⁿ^gⁱⁿ^cen^tiv^{e p}^a^y^m^en^{ts w}^{ill b}^e^w^aⁱ^v^e^d^{. T}^h^e
^an^d^h^o^sp^itals.^Secr^etar^y^w^ill^m^{eet th}^{e f}^o^llo^wⁱⁿ^g^r^e^p^o^r^tin^g^r^e^q^u^ir^em^en^ts:
⁽¹⁾^a^r^e^p^o^r^t^to^Coⁿ^g^r^{ess o}ⁿ^th^{e n}^u^m^b^e^r^o^f^p^r^o^j^ects^w^ill^b^e
^du^{e n}^o^{later th}^an^Decem^{ber 1, 2006; (2) a proj}^{ect u}^pdate
^w^{ill be du}^{e n}^o^l^a^t^e^r^th^an^Decem^{ber 1, 2007; (3) a report}
^oⁿ^q^u^ality^im^p^r^o^v^em^en^{t an}^d^savⁱⁿ^g^s^w^ill^b^e^d^u^{e n}^o^later

CRS-8
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^th^an^Decem^{ber 1, 2008; an}^{d (4) a f}ⁱⁿ^a^{l report w}^ill^{be du}^e
ⁿ^o^{later th}^an^May^{1, 2010. Six}^m^illion^dollars^w^{ill be}
^appropri^a^t^e^{d f}^r^om^t^h^{e T}^r^eas^u^r^yⁱⁿ^F^Y²⁰⁰⁶^t^o^carry^ou^t^t^h^e
^p^r^o^j^{ects an}^d^w^ill^r^e^m^aⁱⁿ^av^ailab^l^e^f^o^r^ex^p^eⁿ^d^itu^r^e^th^r^o^u^g^h
^F^Y^2010.
^Po^st^-^acu^t^e^C^a^r^e^Pay^m^en^t^Ref^o^rm^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^5008.^T^h^{e Secretary}^is^req^uⁱ^r^e^d^t^o^e^s^tablis^h^a
^mons^tr^a^t^{ion P}^r^ogr^a^m^.^th^ree-^y^{ear dem}^oⁿ^s^tration^prog^ram^{to as}^s^e^s^s^th^e^cos^t^s^an^d
^ou^tcom^es^acros^s^dif^f^e^ren^t^pos^t-^acu^{te care s}^ites^by^J^aⁿ^u^a^ry
^{1, 20}^{08. U}ⁿ^{der t}^hⁱ^s^dem^oⁿ^s^t^r^atⁱ^oⁿ^,^anⁱⁿ^di^vⁱ^du^al
ⁱ^{ki/CRS-RL33251}^p^r^o^v^id^ed^tr^eatm^eⁿ^t^f^o^r^sp^ecifⁱ^{c d}ⁱ^agⁿ^o^{ses w}^{ill r}^eceⁱ^v^e^a^com^p^r^e^h^eⁿ^s^iv^{e as}^s^e^s^s^m^en^{t at dis}^c^h^a^rg^{e to determ}ⁱⁿ^{e th}^e
^g/w^approprⁱ^a^t^e^p^o^s^t^-^acu^{te care placem}^en^{t f}^o^{r th}^{e patien}^t^{. A}
^s^.or^stan^d^a^r^d^ized^p^a^tien^t^assessm^en^{t in}^str^u^m^eⁿ^t^w^{ill b}^e^u^s^ed
^le^ak^acros^s^{all pos}^t-^acu^{te car}^e^s^ites^{to m}^eas^u^r^{e th}^{e patien}^t^s^’
^f^uⁿ^c^tⁱ^oⁿ^a^{l s}^t^atu^s^an^{d oth}^e^{r f}^actors^.^P^a^rticipan^ts^are
^://wiki^r^e^q^u^ir^ed^to^p^r^o^v^id^eⁱⁿ^f^o^r^m^atioⁿ^oⁿ^th^{e f}ⁱ^x^e^d^an^d^v^a^rⁱ^ab^le
^h^ttp^co^{st f}^o^{r each}^p^a^tien^t^an^d^p^r^o^v^id^{e an}^ad^d^itioⁿ^a^l
^com^p^reh^eⁿ^s^iv^{e as}^s^e^s^s^m^en^t^a^t^th^{e en}^{d of}^th^{e pers}^on^’^s
^epi^s^{ode of}^{care. T}^h^{e dem}^oⁿ^s^t^r^a^tⁱ^oⁿ^prog^ramⁱ^s^requⁱ^r^ed
^to^coⁿ^s^{ist o}^f^su^f^fⁱ^cien^{t n}^u^m^b^e^r^s^to^d^e^ter^mⁱⁿ^{e sta}^tⁱ^s^tically
^r^e^liab^l^{e r}^e^su^{lts. T}^h^{e Sec}^r^etar^y^{is r}^e^q^u^ir^ed^to^su^b^m^{it a}
^r^e^p^o^r^t^t^o^Co^ngr^e^{ss no}^l^e^ss^t^h^aⁿ^si^{x m}^o^nt^{hs fr}^o^m^t^h^e^eⁿ^d^o^f
^t^h^e^p^r^o^j^{ect. Six}^m^illioⁿ^d^o^llar^s^w^{ill b}^e^tr^an^sf^er^r^e^d^f^r^o^m
^Medicare’^s^Hos^p^{ital In}^s^u^ran^ce^T^r^u^s^t^Fuⁿ^d^f^o^{r th}^{e cos}^t^s^of
^car^r^yⁱⁿ^g^o^u^{t th}^{e d}^e^m^oⁿ^s^tr^atioⁿ^p^r^o^g^r^a^m^.

CRS-9
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^Be^ne^ficⁱ^a^r^y^o^w^ne^r^s^{hip of c}^e^r^ta^{in DM}^E^aⁿ^d^Medicare^P^a^{rt B}^pay^s^f^o^{r certain}^item^s^of^du^rable^m^e^dical^S^e^c^tⁱ^oⁿ^5101.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t w}^o^u^l^{d requ}^ire
^y^g^eⁿ^e^quipmeⁿ^t.^equⁱ^pm^en^{t s}^u^ch^as^h^o^s^p^{ital beds}^,ⁿ^e^bu^lizers^an^{d pow}^er-^t^h^{e su}^p^p^lier^to^tr^an^sf^er^th^{e title o}^f^d^u^r^a^b^l^{e m}^e^dⁱ^c^a^l
^driv^en^w^h^eelch^airs^uⁿ^d^{er th}^{e capped ren}^t^{al categ}^ory^.^Mos^t^equⁱ^pm^en^{t in}^th^{e capped ren}^t^{al categ}^ory^to^th^e^ben^e^fⁱ^ciary
^item^sⁱⁿ^th^is^categ^ory^{are prov}^{ided on}^{a rent}^a^l^basⁱ^s^f^o^{r a}^af^{ter a 13-}^m^oⁿ^t^h^ren^t^{al pe}^rⁱ^o^d^.^T^h^{e option}^f^o^{r a 15-}
^{period th}^{at can}ⁿ^o^{t ex}^{ceed 15 m}^oⁿ^t^h^s^{. A}^f^{ter u}^sⁱⁿ^g^th^e^m^oⁿ^t^h^r^eⁿ^t^{al p}^e^rⁱ^o^d^w^ith^th^e^su^p^p^lier^r^e^tainⁱⁿ^g^o^wⁿ^e^r^s^hⁱ^p
^e^q^ui^p^m^eⁿ^t^fo^r¹⁰^m^o^nt^hs,^b^e^ne^fi^cⁱ^a^rⁱ^e^{s m}^u^st^b^e^gi^ve^{n t}^h^e^o^f^th^{e item}^w^o^u^l^d^b^e^elimⁱⁿ^ated^{. T}^h^{e o}^p^tioⁿ^f^o^r
^o^p^tioⁿ^o^f^p^u^r^c^h^a^sin^g^{it ef}^f^ectiv^e¹³^m^oⁿ^t^h^s^af^ter^th^{e star}^t^ben^e^fⁱ^ciaries^{to pu}^rch^a^s^e^pow^er-^d^riv^eⁿ^w^h^eelch^airs^w^h^en
^of^t^h^{e ren}^t^al^peri^{od. If}^t^h^ey^ch^oos^{e t}^h^{e pu}^rch^a^s^e^optⁱ^oⁿ^,ⁱⁿ^itially^f^u^rⁿ^ish^e^d^w^o^u^l^d^b^e^r^e^tain^ed^.
^th^e^{title to}^th^{e eq}^uⁱ^p^m^en^{t is tr}^an^sf^er^r^e^d^to^b^eⁿ^e^fⁱ^ciar^ies.^I^f
^th^e^p^u^r^c^h^a^{se o}^p^tioⁿ^{is n}^o^{t ch}^o^s^en^{, th}^{e su}^p^p^lier^r^e^tain^s^A^u^to^m^a^tic^p^a^y^m^en^t^to^th^{e su}^p^p^lier^s^ev^er^y^six^m^oⁿ^t^h^s^f^o^r
ⁱ^{ki/CRS-RL33251}^owⁿ^e^rs^hⁱ^{p of}^th^{e equ}ⁱ^pm^en^{t. B}^eⁿ^e^fⁱ^ciaries^can^con^tin^u^e^to^u^s^{e it, b}^u^{t Med}ⁱ^car^{e r}^eⁿ^t^{al p}^a^y^m^en^{ts to}^th^{e su}^p^p^lier^a^r^e^m^aⁱⁿ^ten^aⁿ^{ce an}^{d s}^e^rv^icⁱ^{ng w}^o^u^l^{d be elim}ⁱⁿ^{ated. Su}^ch^pay^m^en^t^s^(f^{or part}^s^an^{d l}^a^{bor n}^o^t^cov^e^{red by}^t^h^e
^g/w^termⁱⁿ^ated.^In^th^{e cas}^{e of}^{a pow}^er-^d^riv^eⁿ^w^h^eelch^{air, th}^e^sup^p^lⁱ^e^r^’^{s o}^r^m^a^nufa^c^t^ur^e^r^{’s w}^a^r^r^a^nt^y⁾^w^o^ul^d^oⁿ^l^y^b^e
^s^.or^s^u^p^p^lⁱ^e^r^m^u^s^t^of^f^e^{r th}^{e ben}^e^fⁱ^ciary^th^{e option}^of^m^a^{de if}^th^{e Secretary}^determⁱⁿ^{ed th}^em^{to be reas}^on^able
^le^ak^p^u^r^c^h^a^sin^g^th^{e eq}^uⁱ^p^m^en^{t w}^h^en^{it is f}ⁱ^r^s^{t f}^u^rⁿ^ish^e^d^.^an^{d n}^eces^s^a^ry^{. T}^h^is^am^en^dm^en^t^w^o^u^l^d^apply^{to item}^s^f^o^r
^://wiki^{Medicare pay}^m^en^ts^{to s}^u^ppliers^f^o^r^m^aⁱⁿ^ten^aⁿ^{ce an}^d^w^hⁱ^c^{h t}^h^e^fi^r^s^t^r^e^nt^a^l^m^o^nt^{h o}^c^c^u^r^r^e^d^oⁿ^o^r^a^f^t^e^r^J^a^nua^r^y^{1, 2006.}
^h^ttp^s^e^rvⁱ^cⁱⁿ^g^di^f^f^e^{r bas}^e^{d on}^w^h^et^h^e^{r t}^h^{e ben}^e^fⁱ^ci^ary^h^a^s
^pu^rch^a^s^e^{d th}^{e equ}ⁱ^pm^en^{t or w}^h^eth^e^{r th}^{e s}^u^pplier^con^tin^u^e^s^T^h^{e agr}^eem^en^{t f}^u^rth^e^{r prov}^ides^th^{at ren}^t^{al pay}^m^en^ts^f^o^r
^{to ow}ⁿ^{it. In}^th^{e cas}^e^o^f^{a pu}^rch^a^s^e^ag^reem^en^{t, pay}^m^en^t^ox^y^g^en^equⁱ^pm^en^t⁽ⁱⁿ^c^l^u^diⁿ^g^port^a^bl^{e ox}^y^g^en^equⁱ^pm^en^t⁾
^f^o^{r r}^e^p^a^irs^an^{d m}^aⁱⁿ^ten^aⁿ^{ce recom}^m^eⁿ^d^{ed by}^th^e^{are con}^v^e^{rted to ow}ⁿ^e^rs^hⁱ^{p at}^{36 m}^oⁿ^t^h^s^{. T}^h^{e s}^u^{pplier is}
^m^aⁿ^u^f^actu^r^{er is}^cov^e^{red. W}^h^en^th^{e equ}ⁱ^pm^en^{t rem}^aⁱⁿ^sⁱⁿ^r^e^q^u^ir^ed^to^tr^an^sf^er^th^{e title o}^f^th^{e eq}^uⁱ^p^m^en^t^t^o^t^h^e
^t^h^{e ow}ⁿ^e^rs^hⁱ^p^of^t^h^e^s^u^pplⁱ^e^r^an^{d con}^tⁱⁿ^u^e^s^t^o^{be u}^s^{ed by}^ben^e^fⁱ^ciary^af^{ter a 36-}^m^oⁿ^t^h^ren^t^al^period.^A^f^{ter tran}^s^f^er
^th^{e ben}^e^fⁱ^ciary^af^{ter th}^{e 15-}^m^oⁿ^t^h^ren^t^{al period, Medicare}^o^f^th^{e title, m}^oⁿ^t^h^l^y^p^a^y^m^en^{ts f}^o^r^o^x^y^g^en^coⁿ^t^en^{ts (}ⁱⁿ^th^e
^m^a^ke^{s a}^p^a^ymeⁿ^t^t^o^t^h^e^sup^p^lⁱ^e^r^e^v^e^r^y^si^{x m}^o^nt^{hs fo}^r^{case o}^f^g^a^seo^u^{s an}^d^liq^uⁱ^d^o^x^y^g^en⁾^w^{ill co}ⁿ^tin^u^e^to^b^e
^se^r^vⁱ^cⁱ^{ng a}ⁿ^d^maⁱⁿ^t^e^na^nc^e^r^e^ga^r^d^l^e^{ss o}^f^w^h^e^t^he^r^aⁿ^y^m^a^{de, as}^provⁱ^d^{ed f}^o^{r u}ⁿ^d^{er cu}^rren^t^l^a^w^,^f^o^{r t}^h^{e peri}^{od of}
^m^aⁱⁿ^ten^aⁿ^{ce an}^d^ser^v^icin^g^{is p}^e^r^f^o^r^m^e^d^.^m^e^{dical n}^{eed. P}^a^y^m^en^ts^f^o^r^m^aⁱⁿ^ten^aⁿ^{ce an}^{d s}^e^rv^icin^g
^(f^{or part}^s^an^d^l^a^b^o^r^not^cov^e^{red by}^t^h^{e s}^u^pplⁱ^e^r’^s^or
^m^aⁿ^u^f^ac^t^u^r^e^r^’^{s w}^a^r^r^aⁿ^t^y⁾^w^{ill b}^e^m^a^d^e^if^th^{e Secr}^etar^y

CRS-10
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^determⁱⁿ^es^the^m^t^o^{be reas}^on^{able an}^{d n}^eces^s^a^ry^{. T}^h^e
^ag^reem^en^{t s}^p^ecifⁱ^es^th^{at th}^{e prov}^is^ion^tak^e^s^eff^{ect on}
^Jan^u^a^ry^{1, 2006. In}^th^{e cas}^{e of}^an^indⁱ^vi^du^{al receiv}ⁱⁿ^g
^ox^y^g^en^equⁱ^pm^en^{t as}^o^f^Decem^{ber 31, 2005, th}^{e 36}
^m^oⁿ^t^h^peri^{od beg}ⁱⁿ^s^Jan^u^a^ry^{1, 2006.}
^A^d^ju^st^men^t^{s in}^Pay^m^en^t^s^f^o^{r Imag}ⁱⁿ^g^{Medicare h}^a^s^{a lon}^g^-^s^t^an^din^g^policy^of^redu^cin^g^pay^m^en^t^S^ecti^oⁿ⁵¹⁰²^.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t s}^p^ecifⁱ^es^th^at,
^ices.^f^o^r^m^u^ltip^{le su}^r^g^{ical p}^r^o^ced^u^r^{es p}^e^r^f^o^r^m^e^d^b^y^t^h^{e sam}^e^ef^f^e^c^tiv^{e f}^o^r^f^{ee sch}^e^d^u^{les estab}^lish^e^d^b^e^gⁱⁿⁿⁱⁿ^g^w^ith
^p^h^y^s^ician^,^oⁿ^th^{e sam}^e^p^a^tien^t^oⁿ^th^{e sam}^e^d^a^y^.^Fu^ll^{2007, th}^e^redu^{ced ex}^pen^d^itu^res^attribu^t^able^{to th}^{e m}^u^ltiple
^pay^m^en^{t is}^m^a^{de f}^o^r^th^{e h}ⁱ^g^h^e^s^t^{priced procedu}^r^{e, w}^ith^procedu^r^{e pay}^m^en^t^redu^ction^f^o^r^im^agⁱⁿ^g^(uⁿ^d^{er th}^{e f}ⁱⁿ^a^l
ⁱ^{ki/CRS-RL33251}^an^y^s^u^bs^equ^eⁿ^t^procedu^r^e^pai^d^at^50%^{. In}^{1995, t}^h^{e pol}ⁱ^c^y^w^a^s^ex^ten^d^{ed to certain}ⁿ^u^c^{lear m}^e^dicin^e^diagⁿ^o^s^tic^ru^{le pu}^blis^h^e^{d Nov}^e^m^b^{er 21, 2005) w}^{ill n}^o^t^be^tak^eⁿⁱⁿ^to^acco^uⁿ^t^f^o^{r p}^u^rp^o^s^{es o}^f^th^{e b}^u^d^g^{et n}^e^u^t^rality^calcu^latioⁿ
^g/w^procedu^r^es^.^f^o^{r f}^{ee s}^c^h^e^du^l^e^s^f^o^{r 2006 an}^{d 2007.}
^s^.or
^le^ak^Un^d^e^r^th^{e p}^h^y^s^ician^f^{ee sch}^e^d^u^{le, d}ⁱ^a^gⁿ^o^{stic im}^agⁱⁿ^g^T^h^{e ag}^reem^en^{t f}^u^rth^e^{r prov}^ides^th^{at f}^o^{r s}^p^ecifⁱ^ed
^proce^d^ures^{are priced as}^f^o^llow^s^{: (1) th}^{e prof}^es^sⁱ^on^alⁱ^m^agⁱⁿ^g^s^e^rvⁱ^ces^f^u^rnⁱ^s^h^e^{d on}^{or af}^t^e^r^Jan^u^a^ry^{1, 2007,}
^://wiki^co^m^p^oⁿ^en^{t (}^P^C)^r^e^p^r^esen^{ts th}^e^p^h^y^s^ician^w^o^r^k^{, th}^{at is th}^e^th^{e tech}ⁿⁱ^{cal com}^pon^en^{t (in}^c^lu^din^g^th^{e tech}ⁿⁱ^cal
^h^ttpⁱⁿ^ter^p^r^e^tatioⁿ^;⁽²⁾^th^{e tech}ⁿⁱ^{cal co}^m^p^oⁿ^en^{t (}^T^C)^r^e^p^r^esen^ts^co^m^p^oⁿ^en^{t o}^f^th^e^g^l^o^b^a^l^f^ee)^f^o^r^{a ser}^v^{ice w}^{ill b}^e^r^e^d^u^ced
^{practice ex}^pen^s^esⁱⁿ^clu^dⁱⁿ^g^clin^{ical s}^t^af^f^,^s^upplies^,^an^d^if^{it ex}^ceeds^(w^ith^ou^{t reg}^a^{rd to the g}^e^og^raph^{ic w}^a^g^e
^equⁱ^pm^en^{t; an}^{d (3) th}^{e g}^l^{obal s}^e^rv^{ice w}^h^ich^r^e^p^r^es^en^ts^adj^u^st^m^e^nt^f^act^{or) t}^h^{e ou}^t^p^atⁱ^eⁿ^t^depart^m^eⁿ^t^(O^PD^{) f}^e^e
^both^th^{e P}^C^an^{d T}^C^{. Diag}ⁿ^o^s^ticⁱ^m^a^gⁱⁿ^g^s^e^rv^ices^{, ev}^en^sch^e^d^u^{le am}^o^uⁿ^t^f^o^r^th^{e ser}^v^{ice estab}^lish^e^d^uⁿ^d^er^th^e
^t^h^os^{e perf}^orm^e^{d on}^contⁱ^guou^s^body^part^s^,^{are g}^eⁿ^e^ral^l^y^p^r^o^s^p^ectiv^{e p}^a^y^m^en^{t sy}^stem^f^o^r^h^o^sp^{ital o}^u^tp^atien^t
^{paid at 100%}^f^o^{r each}^procedu^r^e.^d^e^p^a^r^t^m^eⁿ^t^{s. I}ⁿ^su^ch^{cases, th}^{e Secr}^etar^y^w^{ill p}^r^o^v^id^{e f}^o^r
^th^{e us}^e^of^th^{at OP}^{D am}^ouⁿ^t^{, adj}^u^s^t^{ed by}^th^{e g}^e^og^raph^ic
^Oⁿ^N^o^v^e^m^b^{er 21, 2005}^,^CM^{S i}^s^s^u^{ed i}^t^s^fⁱⁿ^a^l^adj^u^s^t^m^eⁿ^t^f^{actor u}ⁿ^d^{er th}^{e phy}^sⁱ^cⁱ^aⁿ^f^{ee s}^c^h^e^du^{le. T}^h^e
^ph^y^sⁱ^cⁱ^aⁿ^f^{ee s}^c^h^e^du^l^e^reg^u^l^atⁱ^oⁿ^f^o^{r 2006 (}^Feder^a^l^ser^v^ices^th^is^p^o^licy^ap^p^{lies to}^ar^{e: im}^agⁱⁿ^g^an^d^co^m^p^u^t^er^-
^Regis^t^er^{, v}^o^l^.⁷⁰^{, pp. 70116-}^{70476). T}^hⁱ^s^reg^u^l^atⁱ^oⁿ^as^sⁱ^s^t^{ed im}^agⁱⁿ^g^s^e^r^v^ices^{, in}^clu^dⁱⁿ^g^X-^ray^,^u^ltras^ouⁿ^d
^p^r^o^v^id^ed^f^o^r^{a r}^e^d^u^ctioⁿⁱⁿ^th^{e T}^C^f^o^r^th^{e s}^u^b^s^e^q^u^eⁿ^t⁽ⁱ^nc^l^u^dⁱ^{ng ech}^ocardi^og^raph^y⁾^{, n}^u^c^l^{ear m}^e^dⁱ^cⁱ^ne
ⁱ^m^agⁱⁿ^g^procedu^r^{e perf}^orm^e^{d on}^con^tⁱ^g^u^o^u^s^body^part^s^.⁽ⁱ^nc^l^u^dⁱ^{ng p}^o^sⁱ^t^r^oⁿ^e^mⁱ^ssi^oⁿ^t^o^m^o^gr^a^p^hy⁾^,^m^a^gne^tⁱ^c
^T^h^{e m}^u^ltip^{le p}^r^o^ced^u^r^{e r}^e^d^u^ctioⁿⁱ^sⁿ^o^{t ap}^p^lied^to^P^C^res^oⁿ^aⁿ^ce^im^agⁱⁿ^g^,^c^o^m^p^u^t^e^d^t^o^m^o^g^r^a^p^h^y^,^an^d

CRS-11
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^ser^v^{ices. W}^h^en^{a g}^l^o^b^a^{l ser}^v^ice^c^o^d^e^{is b}^illed^,^th^{e T}^C^f^l^u^o^ros^c^op^y^.^{Not in}^clu^d^{ed are diag}ⁿ^o^s^{tic an}^{d s}^c^reenⁱⁿ^g
^p^o^r^tⁱ^oⁿ^{, b}^u^{t n}^o^{t th}^{e P}^C^p^o^r^tioⁿ^,^{is r}^e^d^u^ced^.^C^M^S^ma^mmo^gr^a^p^hy^.^T^hⁱ^s^c^h^a^ngeⁱ^s^no^t^t^o^b^e^t^a^ke^{n i}ⁿ^t^o
^id^en^tif^ied¹¹^f^a^m^{ilies o}^f^im^agⁱⁿ^g^p^r^o^ced^u^r^{es b}^y^im^agⁱⁿ^g^acco^uⁿ^t^f^o^{r p}^u^rp^o^s^{es o}^f^th^{e b}^u^d^g^{et n}^e^u^t^rality^calcu^latioⁿ
^m^o^d^a^li^ty^{. T}^h^{e m}^u^ltip^{le p}^r^o^ced^u^r^{e T}^C^p^a^y^m^en^{t r}^e^d^u^ctioⁿ^begⁱⁿⁿⁱⁿ^gⁱⁿ^2007.
^{is to}^b^e^ap^p^lied^oⁿ^ly^to^p^r^o^ced^u^r^{es in}^v^o^lvⁱⁿ^g^coⁿ^tig^u^o^u^s
^body^parts^w^ithⁱⁿ^{a f}^a^m^ily^o^f^codes^,ⁿ^o^{t acros}^s^f^a^m^ilies^.
^T^h^{e p}^a^y^m^eⁿ^{t r}^e^d^u^ctioⁿ^{is to}^b^e^p^h^ased^-ⁱⁿ^w^ith^{a 2}⁵^%
^redu^ctⁱ^oⁿⁱⁿ^{2006 an}^{d a 50%}^redu^ctⁱ^oⁿⁱⁿ^{2007. F}^u^rt^h^e^r,
^th^{e b}^u^d^g^{et n}^e^u^t^r^a^lity^ad^j^u^s^t^m^eⁿ^t^{is to}^b^e^ap^p^lied^oⁿ^ly^to
^p^r^acti^c^e^ex^p^eⁿ^s^{e r}^e^lativ^{e v}^a^lu^{e u}ⁿ^{its r}^a^th^er^th^an^to^b^o^t^h
ⁱ^{ki/CRS-RL33251}^w^o^rk^an^{d practice ex}^pen^s^{e relativ}^{e v}^a^lu^{e u}ⁿ^its^.
^g/w^Limita^{tion on M}^e^dic^a^r^e^P^a^y^m^eⁿ^ts^for^Medⁱ^c^a^r^e^u^s^{es a f}^{ee sch}^e^d^u^{le to}^p^a^y^f^o^r^th^{e f}^acility^S^ecti^oⁿ^5103.^Sta^r^tin^g^f^o^{r s}^u^rg^{ical procedu}^r^es^on
^s^.or^ced^u^r^{es in}^A^m^b^u^l^at^o^r^y^Care^Su^rg^{ical Cen}^t^ers^ser^v^{ices r}^e^lated^t^o^a^s^u^r^g^er^y^p^r^o^v^id^edⁱⁿ^an^A^S^{C. T}^h^e^J^aⁿ^u^a^ry^{1, 2007, w}^h^en^th^e^A^S^C^f^acility^pay^m^en^{t (w}^ith^ou^t
^le^ak^S^C^s⁾^.^as^s^o^{ciated ph}^y^s^ician^s^e^rv^ices^(s^u^r^g^e^ry^an^{d an}^es^th^es^{ia) are}^application^of^an^y^g^e^og^raph^{ic price dif}^f^e^ren^ces^{) is}^g^r^eater
^r^e^im^b^u^r^s^ed^uⁿ^d^er^th^{e p}^h^y^s^ician^f^{ee sch}^e^d^u^{le. CMS}^th^an^th^{e Medicare OP}^{D f}^{ee s}^c^h^e^dul^{e am}^ouⁿ^t^es^tablis^h^e^d
^://wiki^m^aⁱⁿ^tain^{s a list o}^f^a^p^p^r^o^v^ed^A^S^{C p}^r^o^ced^u^r^{es w}^h^ich^is^uⁿ^d^er^OP^P^S⁽^w^ith^o^u^{t ap}^p^licatioⁿ^o^f^an^y^g^e^o^g^r^a^p^h^ic
^h^ttp^requⁱ^r^{ed t}^o^b^e^u^pdat^e^{d ev}^ery^t^w^{o y}^ears^.^T^h^{e approv}^ed^ad^j^u^stm^eⁿ^t⁾^f^o^r^th^{e sam}^e^ser^v^ice,^th^{e A}^S^{C w}^{ill b}^e^p^a^id^th^e
^A^S^C^procedu^r^es^are^categ^orizedⁱⁿ^to^on^{e of}ⁿⁱⁿ^e^pay^m^en^t^OP^{D f}^{ee sch}^e^d^u^{le am}^o^uⁿ^t^{. T}^h^{is ad}^j^u^s^t^m^eⁿ^t^ap^p^{lies to}
^g^r^o^u^p^s^th^a^t^c^o^m^p^rⁱ^{se th}^{e A}^S^{C f}^acility^f^{ee sch}^e^d^u^{le. T}^h^e^A^S^{C p}^a^y^m^en^{ts u}ⁿ^{til th}^{e r}^e^vⁱ^s^e^d^A^S^{C p}^a^y^m^en^{t sy}^stem^is
ⁿⁱⁿ^e^p^a^y^m^en^{t r}^a^{tes r}^e^f^l^{ect th}^{e n}^a^tioⁿ^a^{l m}^e^dⁱ^an^co^{st o}^f^im^p^l^em^en^ted^.^T^o^{tal p}^a^y^m^en^ts^to^A^S^Cs^uⁿ^d^er^th^{e r}^e^vⁱ^sed
^procedu^r^esⁱⁿ^th^{at g}^r^o^{up adj}^u^s^t^{ed to ref}^l^{ect g}^e^og^raph^ic^pay^m^en^{t s}^y^s^t^em^can^{be n}^o^m^o^{re th}^an^th^os^{e u}ⁿ^d^{er th}^e
^p^r^{ice v}^a^rⁱ^atioⁿ^.^P^a^y^m^en^{ts ar}^e^also^ad^j^u^sted^w^h^en^m^u^ltip^le^ex^is^tin^g^A^S^C^pay^m^en^{t s}^y^s^t^em^{, in}^clu^dⁱⁿ^g^th^{e redu}^ced
^s^u^rg^{ical procedu}^r^es^{are perf}^orm^e^{d at th}^{e s}^a^m^e^tim^e.^T^h^e^ex^p^eⁿ^d^itu^r^e^{s th}^{at r}^e^su^{lt f}^r^o^m^th^{e ap}^p^licatioⁿ^o^f^th^is
^Secretary^is^requ^{ired to im}^plem^en^{t a n}^e^w^A^S^C^p^a^y^m^en^t^provⁱ^sⁱ^oⁿ^.

^s^y^s^t^e^m^{no l}^a^t^e^{r t}^h^an^Jan^u^a^ry^{2008. Medi}^care
^r^e^im^b^u^r^s^em^en^{t f}^o^r^h^o^sp^{ital o}^u^tp^atien^t^d^e^p^a^r^t^m^eⁿ^t⁽^O^P^D⁾
^s^e^rv^ices^is^bas^e^d^oⁿ^{a f}^{ee s}^c^h^e^du^{le es}^tablis^h^e^{d by}^a
^s^e^pa^r^a^t^e^pros^pectⁱ^v^{e pay}^m^en^t^s^y^s^t^em^(O^PPS^{). U}ⁿ^der
^OP^P^S^{, th}^{e u}ⁿ^{it o}^f^p^a^y^m^eⁿ^{t is th}^{e in}^dⁱ^vⁱ^d^u^{al ser}^v^{ice o}^r

CRS-12
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^procedu^r^{e as}^as^sⁱ^gⁿ^e^{d to a am}^bu^latory^pay^m^en^t
^clas^sⁱ^fⁱ^cation^(A^P^C^{). T}^h^{e pay}^m^en^{t rate f}^o^{r eac}^h^s^e^r^vⁱ^c^e
^{is d}^e^ter^mⁱⁿ^ed^b^y^m^u^ltip^lyⁱⁿ^g^th^{e r}^e^lativ^{e w}^e^ig^h^t^f^o^r^th^e
^s^e^rv^ice’^s^A^P^C^by^th^{e con}^v^e^rs^ion^f^actor.
^Up^d^a^t^e^f^o^{r Ph}^y^s^ician^s^{’ Serv}^{ices f}^o^{r 2006.}^Medⁱ^car^e^p^a^y^m^en^ts^f^o^r^ser^v^{ices o}^f^p^h^y^s^ician^s^aⁿ^d^c^e^r^tain^S^ecti^oⁿ^5104.^T^h^e^c^o^nf^eren^{ce ag}^reem^en^{t ov}^errides
ⁿ^oⁿ^p^h^y^sician^p^r^actitioⁿ^e^r^s^ar^{e m}^a^d^e^oⁿ^th^{e b}^a^{sis o}^f^{a f}^e^e^application^of^th^{e f}^o^rm^u^l^{a f}^o^{r 2006 by}^s^e^ttin^g^th^e^u^pdate
^sch^e^d^u^{le. T}^h^{e f}^{ee sch}^e^d^u^{le assig}ⁿ^s^r^e^lativ^e^v^a^l^u^{es to}^at^{zero. In}^ef^f^ect^{, t}^hⁱ^s^m^ean^s^t^h^at^t^h^{e 2006 c}^o^nve^r^sⁱ^oⁿ
^ser^v^{ices th}^at^r^e^f^l^{ect p}^h^y^s^ician^w^o^r^k⁽ⁱ^{.e., th}^{e tim}^{e, sk}^ill,^f^act^{or i}^s^t^h^{e s}^a^m^e^as^t^h^{e 2005 con}^v^e^rsⁱ^oⁿ^f^act^or.
^an^dⁱⁿ^ten^s^ity^it^t^a^k^e^{s to}^p^r^o^v^id^{e th}^{e ser}^v^ice)^{, p}^r^actice
ⁱ^{ki/CRS-RL33251}^ex^pen^s^es^{, an}^{d m}^a^{lpractice cos}^t^s^.^T^h^{e relativ}^{e v}^a^lu^es^are^adj^u^s^t^{ed f}^o^{r g}^e^og^raph^{ic v}^a^riation^sⁱⁿ^cos^t^s^.^T^h^{e adj}^u^s^t^ed^T^h^e^ag^reem^en^{t als}^o^requ^ires^th^{e Medicare P}^a^y^m^en^t^A^d^vⁱ^so^r^y^Co^m^mⁱ^ssioⁿ⁽^M^ed^P^A^C)^to^su^b^m^{it a r}^e^p^o^r^{t to}
^g/w^relativ^{e v}^a^lu^es^are^t^h^eⁿ^con^v^e^{rted in}^{to a dollar pay}^m^en^t^C^oⁿ^g^r^es^s^by^March^{1, 2007 on}^m^ech^anⁱ^s^m^s^t^h^at^cou^l^d^be
^s^.or^am^ouⁿ^t^by^{a con}^v^e^rs^ion^f^{actor. T}^h^e^con^v^e^rs^ion^f^{actor f}^o^r^u^s^{ed to replace th}^{e s}^u^s^t^ain^a^{ble g}^r^ow^th^{rate s}^y^s^t^em^{. T}^h^e
^le^ak^{2005 i}^s^$37.8975.^r^e^p^o^r^{t is to}^{: (}¹⁾^id^en^tif^y^an^d^ex^amⁱⁿ^{e alter}ⁿ^ativ^{e m}^e^th^o^d^s
^fo^r^a^sse^ssi^ng^vo^l^u^m^e^gr^o^w^t^h^;⁽²⁾^r^e^vi^e^w^o^p^tⁱ^o^{ns t}^o^c^o^nt^r^o^l
^://wiki^T^h^{e con}^v^e^rs^ion^f^{actor is}^th^{e s}^a^m^e^f^o^{r all s}^e^rv^ices^{. It}^th^{e v}^o^lu^m^e^o^f^p^h^y^s^ician^s^ser^v^{ices u}ⁿ^d^er^Medⁱ^ca^r^e^w^h^ile
^h^ttp^is^u^{pdated each}^y^{ear accordin}^g^{to a f}^o^rm^u^l^a^s^p^ecifⁱ^{ed in}^m^aⁱⁿ^tainⁱ^{ng acces}^s^f^o^{r ben}^e^fⁱ^ciaries^;^{(3) ex}^amⁱⁿ^{e th}^e
^law^.^T^h^{e in}^ten^t^of^th^{e f}^o^rm^u^l^{a is}^{to place a res}^t^rain^{t on}^ap^p^licatioⁿ^o^f^v^o^lu^m^e^coⁿ^t^r^o^{ls u}ⁿ^d^er^th^{e f}^ee^sch^e^d^u^le;⁽⁴⁾
^ov^{erall s}^p^en^din^g^f^o^{r ph}^y^s^ician^s^’^s^e^rv^ices^{. Sev}^e^{ral f}^actors^id^en^tif^y^lev^e^{ls o}^f^ap^p^licatioⁿ^o^f^v^o^lu^m^e^c^oⁿ^t^r^o^{ls su}^ch^as
^en^{ter in}^{to th}^{e calcu}^lation^of^th^{e f}^o^rm^u^l^a.^T^h^es^{e in}^clu^d^{e (1)}^g^r^ou^{p practice, h}^o^s^p^{ital m}^e^{dical s}^t^af^f^,^ty^pe^o^f^s^e^rv^ice,
^th^{e su}^stain^a^b^l^{e g}^r^o^w^th^r^a^{te (}^S^G^R⁾^w^h^ich^{is essen}^tially^a^g^e^og^raph^{ic area, an}^{d ou}^tli^e^r^s^;^{(5) ex}^amⁱⁿ^{e th}^e
^cu^m^u^lativ^{e targ}^{et f}^o^{r Medicare s}^p^en^din^g^g^r^ow^th^ov^{er tim}^e^ad^mⁱⁿⁱ^str^a^tiv^{e f}^easib^ility^o^f^im^p^l^em^en^tin^g^o^p^tioⁿ^s^uⁿ^d^er
⁽^wⁱ^t^h^{1996 s}^e^rvⁱⁿ^g^as^t^h^{e bas}^e^peri^od);^{(2) t}^h^{e Med}ⁱ^c^a^r^e⁽²⁾^,ⁱⁿ^clu^dⁱⁿ^g^th^{e av}^ailab^ility^o^f^d^a^{ta an}^d^tim^{e lag}^s^;⁽⁶⁾
^ecoⁿ^o^mⁱ^{c in}^d^e^x⁽^M^EI⁾^w^h^ich^m^easu^r^{es in}^f^l^atioⁿⁱⁿ^th^e^ex^amⁱⁿ^{e th}^{e ex}^ten^t^to^w^h^ich^th^e^alterⁿ^ativ^{e m}^e^th^o^d^s
ⁱⁿ^p^u^{ts n}^eed^ed^to^p^r^o^d^u^c^e^p^h^y^s^ician^s^ser^v^{ices; an}^d⁽³⁾^th^e^iden^tif^{ied an}^{d ex}^amⁱⁿ^{ed u}ⁿ^d^{er (1}⁾^s^h^ou^{ld be s}^p^ecifⁱ^ed;
^u^pdat^e^adj^u^s^t^m^eⁿ^t^f^act^{or w}^hⁱ^c^h^m^odi^fⁱ^es^t^h^{e u}^pdat^e^{, w}^hⁱ^c^h^an^d⁽⁷⁾^id^en^tif^y^th^{e ap}^p^r^o^p^r^{iate lev}^e^{ls o}^f^dⁱ^scr^e^tioⁿ^f^o^r^th^e
^w^o^u^l^{d ot}^h^e^rwⁱ^s^{e be al}^l^o^w^e^{d by}^t^h^e^MEI,^t^o^briⁿ^g^s^p^en^diⁿ^g^Secre^t^a^r^y^of^{HHS to ch}^an^g^e^pay^m^en^{t rates}^uⁿ^d^{er th}^{e f}^e^e
ⁱⁿ^lin^{e w}^ith^th^e^SGR^targ^et.^Inⁿ^o^cas^{e can}^th^{e adj}^u^s^t^m^eⁿ^t^sch^e^d^u^{le o}^r^to^o^t^h^e^r^w^{ise tak}^e^step^{s t}^h^{at af}^f^{ect p}^h^y^s^ician
^f^act^{or be l}^e^s^s^t^h^an^mⁱⁿ^u^s^7%^{or m}^o^{re t}^h^an^pl^u^s^3%^.^b^e^h^a^vⁱ^o^r^{. T}^h^{e r}^e^p^o^r^{t is to}ⁱⁿ^cl^u^d^{e r}^eco^m^m^eⁿ^d^atioⁿ^s^oⁿ

CRS-13
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^T^h^{e law}^s^p^ecifⁱ^es^{a f}^o^rm^u^l^a^f^o^r^calcu^latin^g^th^{e SGR}^.^altern^ative^m^ech^an^is^m^s^{to replace th}^{e SGR}^.^T^h^{e s}^ection
^{It is}^bas^e^{d on}^ch^an^g^e^sⁱⁿ^f^o^u^r^f^a^ctors^:^{(1) es}^tim^ated^appropri^a^t^e^s^{$550,000 f}^r^om^t^h^e^T^r^eas^u^r^y^,^ou^t^of^am^ouⁿ^t^s
^ch^an^g^e^sⁱⁿ^f^ees^{; (2) es}^tim^{ated ch}^an^g^eⁱⁿ^th^{e av}^erag^eⁿ^o^{t o}^t^h^e^r^w^{ise ap}^p^r^o^p^r^iated^,^to^Med^P^AC^to^car^r^y^o^u^{t th}^e
^num^b^e^r^o^f^P^a^r^t^B^eⁿ^r^o^l^l^e^e^s⁽^e^xc^l^u^dⁱ^{ng M}^e^dⁱ^c^a^r^e^stud^y^.
^A^d^v^aⁿ^t^a^g^e^ben^e^fⁱ^ciaries⁾^{; (3) es}^tim^{ated proj}^{ected g}^r^ow^th
ⁱⁿ^real^g^r^os^s^dom^es^tⁱ^c^produ^ct^(G^D^P^{) g}^r^ow^t^h^{per capi}^t^a^;
^an^{d (4)}^es^tim^ated^ch^an^g^eⁱⁿ^ex^pen^d^itu^res^du^{e to ch}^an^g^e^sⁱⁿ
^law^o^r^r^e^g^u^l^atioⁿ^s^.^Iⁿ^o^r^d^e^r^to^ev^en^o^u^t^lar^g^e^f^l^u^c^tu^atioⁿ^s^,
^M^M^A^c^h^a^nge^d^t^h^e^G^D^P^c^a^l^c^u^l^a^tⁱ^o^{n fr}^o^m^aⁿ^a^nnua^l
^{change to}^{an annual aver}^age^{change o}^v^er^{the p}^r^eced^{ing 1}⁰
ⁱ^{ki/CRS-RL33251}^y^ears^{(a “}^10-^y^{ear rollin}^g^av^erag^e”).
^g/w^T^h^{e SGR tar}^g^{et is n}^o^{t a lim}^{it o}ⁿ^e^x^p^eⁿ^d^itu^r^e^s.
^s^.or^R^a^th^{er, th}^{e f}^{ee s}^c^h^e^du^{le u}^{pdate ref}^l^ects^th^{e s}^u^cces^s^o^r
^le^ak^f^a^ilu^r^eⁱⁿ^m^eetin^g^th^{e tar}^g^{et. I}^f^ex^p^eⁿ^d^itu^r^e^{s ex}^c^eed^th^e
^://wiki^tar^g^{et, th}^{e u}^p^d^a^{te f}^o^r^{a f}^u^tu^r^e^y^ear^{is r}^e^d^u^ced^{. T}^h^{is is w}^h^at^occu^{rred f}^o^{r 2002. It}^w^a^s^al^s^o^s^l^at^{ed t}^o^occu^{r i}ⁿ^{2003 an}^d
^h^ttp²⁰⁰⁴^;^h^o^w^e^v^e^r^,^legⁱ^slatioⁿ^p^r^ev^en^ted^th^{is f}^r^o^m^o^ccu^r^rⁱⁿ^g
^t^h^r^o^ugh^2005.^Uⁿ^{der t}^h^{e f}^o^rm^u^l^{a, a n}^e^g^a^tⁱ^v^{e 4.4 %}^u^pdat^e
^g^o^esⁱⁿ^t^o^ef^f^ectⁱⁿ^2006.
^T^h^{ree Y}^{ear Ho}^ld^{Harmless T}^r^an^sitⁱ^oⁿ^f^o^r^T^h^{e OP}^P^S^f^o^r^ser^vⁱ^c^e^s^p^r^o^v^id^ed^b^y^h^o^sp^{ital o}^u^tp^atien^t^S^ecti^oⁿ^5105.^Cer^t^ain^sm^{all r}^u^r^a^{l h}^o^sp^{itals (}^w^ithⁿ^o^m^o^r^e
^{ral Ho}^sp^it^{als I}ⁿ^t^o^t^h^{e O}^u^t^p^at^ien^t^d^e^p^a^r^t^m^e^nt^{s (}^O^P^D⁾^w^a^{s i}^m^p^l^e^m^eⁿ^t^e^dⁱⁿ^A^ugust^{2000 f}^o^r^th^an^{100 beds}^th^{at are n}^o^{t SC}^Hs^{) can}^re^ceiv^e^addition^a^l
^s^p^ect^iv^{e Pay}^m^en^t^Sy^st^{em (}^O^PPS)^.^m^o^st^acu^te^car^{e h}^o^sp^{itals. Un}^d^e^r^h^o^ld^h^a^r^m^{less p}^r^o^v^isioⁿ^s^,^{Medicare pay}^m^en^ts^if^th^{eir ou}^tpatien^t^p^a^y^m^en^ts^uⁿ^d^er
^{as m}^o^dⁱ^fⁱ^ed^b^y^th^{e MMA}^{, r}^u^r^a^{l h}^o^sp^{itals w}^ithⁿ^o^m^o^r^e^OP^P^S^{are les}^s^th^an^uⁿ^d^{er th}^{e old pa}^y^m^eⁿ^t^s^y^s^t^em^{. For}
^t^h^an^{100 beds}^an^{d s}^o^l^e^com^m^uⁿⁱ^t^y^h^o^s^pⁱ^t^a^l^s^(S^C^H⁾^l^o^cat^ed^calen^{dar y}^{ear (C}^{Y) 2006,}^th^es^{e h}^o^s^p^itals^w^{ill receiv}^e^95%
ⁱⁿ^ru^{ral areas}^{are paid n}^o^les^s^uⁿ^d^{er OP}^P^S^th^an^th^ey^w^o^u^l^d^o^f^an^y^dⁱ^f^f^e^ren^ce.^T^h^e^h^o^s^p^{itals w}^{ill receiv}^e⁹⁰^%^o^f^th^e
^h^a^v^e^receiv^e^{d u}ⁿ^d^{er th}^{e prior reim}^bu^rs^em^en^{t s}^y^s^t^e^m^f^o^r^di^f^f^e^ren^{ce i}ⁿ^C^Y^{2007 an}^{d 85%}^of^t^h^{e di}^f^f^e^r^en^{ce i}ⁿ
^cov^e^red^O^P^D^s^e^rv^ices^prov^{ided u}ⁿ^{til J}^aⁿ^u^a^ry^{1, 2006.}^C^Y^2008.

^Un^d^e^r^its^ad^mⁱⁿⁱ^str^a^tiv^{e au}^th^o^r^ity^{, star}^tin^g^f^o^r^ser^v^{ices o}ⁿ

CRS-14
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^Jan^u^a^ry^{1, 2006, C}^M^S^h^a^sⁱⁿ^creas^{ed O}^PPS^pay^m^en^t^s^t^o
^ru^ral^S^C^H^s^by^7.1%^.
^Upda^te^{to the}^Compos^ite^Ra^t^e^Compone^nt^T^h^{e Medic}^a^r^{e P}^r^es^cription^Dru^g^,^Im^prov^em^en^{t, an}^d^S^ecti^oⁿ⁵¹⁰^6.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t in}^creas^es^th^e
^t^h^{e Basic Case-}^Mⁱ^{x A}^d^ju^st^ed^Pro^s^p^ect^iv^e^Modernⁱ^zatⁱ^oⁿ^A^c^t^of^{2003 (MMA}^{) requ}ⁱ^r^ed^t^h^{e S}^ecret^ary^com^pos^{ite rate}^com^pon^en^t^of^th^{e bas}ⁱ^{c cas}^e-^mⁱ^x^adj^u^s^t^ed
^m^en^t^Sy^st^{em f}^o^{r Dialy}^s^{is Serv}^ices.^to^es^tablis^h^{a bas}ⁱ^{c cas}^e-^mⁱ^x^adj^u^s^t^{ed pros}^pectiv^e^pay^m^en^t^s^y^s^t^em^by^1.6%^f^o^{r s}^e^rvⁱ^ces^begⁱⁿⁿⁱⁿ^g^Jan^u^a^ry^{1, 2006.}
^sy^stem^f^o^r^dⁱ^aly^s^{is ser}^v^{ices f}^u^rⁿ^ish^e^d^eith^er^at^{a f}^acility^o^r
ⁱⁿ^a^p^a^tⁱ^e^nt^{’s ho}^m^e^,^fo^r^se^r^vⁱ^c^e^s^furⁿⁱ^s^he^d^b^e^giⁿⁿⁱ^{ng o}ⁿ
^Jan^u^a^ry^{1, 2005. T}^h^e^basⁱ^{c cas}^e-^mⁱ^x^adj^u^s^t^{ed s}^y^s^t^em^h^a^s
^t^w^o^co^m^p^oⁿ^en^{ts: (}¹⁾^th^{e co}^m^p^o^s^{ite r}^a^{te, w}^h^ich^co^v^e^r^s
ⁱ^{ki/CRS-RL33251}^s^e^rv^ices^{, in}^clu^dⁱⁿ^g^dialy^s^is^{; an}^{d (2) a dru}^g^add-^on^adj^u^s^t^m^eⁿ^t^f^o^{r th}^{e dif}^f^e^ren^{ce betw}^een^th^{e pa}^y^m^en^t
^g/w^am^o^uⁿ^t^{s f}^o^r^sep^a^r^a^tely^b^illab^l^{e d}^r^u^g^s^an^d^bⁱ^o^l^o^g^{icals an}^d
^s^.or^th^eir^acq^uⁱ^sitioⁿ^co^{sts, as d}^e^ter^mⁱⁿ^ed^b^y^Iⁿ^sp^ecto^r^Gen^e^r^a^l
^le^ak^R^e^port^s^.
^://wiki^T^h^{e Secretary}^is^requ^{ired to u}^{pdate th}^{e bas}ⁱ^{c cas}^e-^mⁱ^x
^h^ttp^a^d^j^u^st^e^d^p^a^y^m^eⁿ^t^a^m^o^unt^{s a}^nnua^l^l^y^b^e^giⁿⁿⁱ^{ng w}ⁱ^t^h^2006,
^bu^{t on}^ly^f^o^{r th}^{at portion}^of^th^{e cas}^e-^mⁱ^x^ad^j^u^s^t^{ed s}^y^s^t^em
^th^{at is}^r^e^p^r^e^s^en^{ted by}^th^{e add-}^on^adj^u^s^t^m^eⁿ^t^an^{d n}^o^{t f}^o^r
^th^{e p}^o^r^tioⁿ^r^e^p^r^esen^ted^b^y^th^{e co}^m^p^o^s^{ite r}^a^te.
^Revⁱ^sioⁿ^s^t^o^Pay^m^en^t^s^f^o^{r T}^h^e^r^ap^y^T^h^{e Bal}^aⁿ^{ced Bu}^dg^et^A^c^t^of^{1997 (BBA}^{97) es}^t^a^blⁱ^s^he^d^S^ecti^oⁿ^5107.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t does}ⁿ^o^t^ex^ten^d
^ices.^a^nnua^l^p^e^r^b^e^ne^fi^cⁱ^a^r^y^p^a^y^m^eⁿ^t^lⁱ^mⁱ^t^s^fo^r^a^l^l^o^u^t^p^a^tⁱ^e^nt^th^{e m}^o^r^a^to^rⁱ^u^m^{. Ho}^w^e^v^e^r^,^th^{e Secretary}^is^requ^{ired to}
^th^er^ap^y^ser^v^{ices p}^r^o^v^id^ed^b^yⁿ^oⁿ^-^h^o^sp^ital^p^r^o^v^id^er^s.^T^h^e^im^plem^en^{t an}^ex^ception^s^proces^s^f^o^{r ex}^pen^s^esⁱⁿ^cu^{rred in}
^lim^it^s^ap^p^lied^to^ser^v^{ices p}^r^o^v^id^ed^b^yⁱⁿ^d^e^p^eⁿ^d^en^t^{2006. U}ⁿ^{der t}^h^{e proces}^s^,^{a Part}^B^en^rol^l^{ee, or a pers}^on
^th^er^ap^{ists as w}^e^{ll as to}^th^o^s^{e p}^r^o^v^id^ed^b^y^co^m^p^r^e^h^eⁿ^s^iv^e^actin^g^on^beh^a^lf^of^th^{e en}^{rollee, m}^a^y^requ^es^{t an}^ex^ception
^o^u^tp^atien^t^r^e^h^a^b^ilitatioⁿ^f^aci^l^{ities (}^C^ORFs)^an^d^o^t^h^e^r^f^r^om^th^{e ph}^y^s^{ical th}^erapy^an^{d occu}^pation^a^{l th}^erapy^caps^.
^r^e^h^a^b^ilitatioⁿ^ag^en^{cies. T}^h^{e lim}^{its d}ⁱ^dⁿ^o^{t ap}^p^l^y^to^T^h^eⁱⁿ^divⁱ^du^{al m}^a^y^obtain^s^u^ch^ex^ception^if^th^{e prov}^is^ion
^o^u^tp^atien^t^ser^v^{ices p}^r^o^v^id^ed^b^y^h^o^sp^itals.^of^s^e^rv^ices^is^de^t^e^r^mⁱⁿ^{ed m}^e^dicallyⁿ^eces^s^a^ry^{. If}^th^e

CRS-15
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^Begⁱⁿⁿⁱⁿ^gⁱⁿ^{1999, t}^h^{ere w}^e^{re t}^w^{o ben}^e^fⁱ^ci^ary^Secretary^doesⁿ^o^{t m}^a^k^e^{a decis}ⁱ^on^on^{a requ}^es^{t w}^ithⁱⁿ¹⁰
^lⁱ^mⁱ^t^s^{. T}^h^{e f}ⁱ^rs^t^w^a^s^{a $1,500 per benef}ⁱ^ci^ary^a^nnua^l^c^a^p^bu^sⁱⁿ^e^s^s^day^s^of^receipt,^th^{e Secretary}^is^deem^{ed to h}^a^v^e
^f^o^r^a^l^{l ou}^tpatien^t^ph^y^s^{ical th}^erapy^s^e^rv^ices^an^{d s}^p^eech^f^o^uⁿ^d^th^{e s}^e^rv^ices^m^e^dicallyⁿ^eces^s^a^ry^.^T^h^{e Secretary}^is
^l^a^ngua^ge^p^a^t^h^o^l^o^g^y^se^r^vⁱ^c^e^s^.^T^h^e^se^c^o^nd^w^a^s^a^$¹^,^{500 per}^r^e^q^u^ir^ed^to^w^a^iv^{e su}^ch^p^r^o^v^isioⁿ^s^o^f^law^an^d^r^e^g^u^l^atioⁿ^s
^b^e^ne^fi^cⁱ^a^r^y^a^nnua^l^c^a^p^fo^r^a^l^l^o^u^t^p^a^tⁱ^e^nt^o^c^c^u^p^a^tⁱ^oⁿ^a^l⁽ⁱⁿ^c^lu^dⁱⁿ^g^th^o^s^{e r}^e^lated^to^th^{e P}^a^p^e^r^w^o^r^k^Red^u^ctioⁿ^A^c^t)
^t^h^erapy^s^e^rvⁱ^ces^{. Beg}ⁱⁿⁿⁱⁿ^gⁱⁿ²^{002, t}^h^{e am}^ouⁿ^t^w^o^u^l^d^as^{are n}^eces^s^a^ry^{to im}^plem^en^{t th}^es^e^am^en^dm^en^ts^on^a
ⁱⁿ^creas^{e by}^th^{e Medicare econ}^o^mⁱ^{c in}^dex^{(MEI) rou}ⁿ^d^ed^ti^m^e^l^y^basⁱ^s^.^T^h^{e am}^en^dm^en^ts^m^a^y^{be im}^plem^en^{ted by}
^{to th}^{e n}^eares^{t m}^u^{ltiple of}^$10.^prog^ramⁱⁿ^s^t^ru^ction^{or oth}^e^rw^is^{e. T}^h^{e ag}^reem^en^{t s}^p^ecifⁱ^es
^th^{at th}^{ere can}^{be n}^o^admⁱⁿⁱ^s^t^rativ^{e or j}^u^di^{cial rev}ⁱ^ew^of
^T^h^e^B^a^l^aⁿ^{ced Bu}^dg^et^R^e^fⁱⁿ^e^m^eⁿ^t^A^c^t^of¹⁹⁹⁹^th^{e ex}^cep^tioⁿ^s^p^r^o^{cess (}ⁱⁿ^c^lu^dⁱⁿ^g^estab^lish^m^en^t^o^f^th^e
ⁱ^{ki/CRS-RL33251}^(BBR^A⁾^s^u^s^p^en^{ded appl}ⁱ^catⁱ^oⁿ^of^t^h^{e l}ⁱ^mⁱ^t^s^f^o^r²⁰⁰⁰^an^d^{2001. T}^h^e^Medi^{care, Medi}^cai^{d, an}^{d S}^C^H^I^{P Ben}^e^fⁱ^t^s^proces^s⁾^.
^g/w^Im^prov^em^en^t^an^d^Prot^ectⁱ^oⁿ^A^c^t^of^{2000 (BIPA}⁾^ex^t^eⁿ^d^ed^T^h^{e ag}^reem^en^{t als}^o^r^e^qu^ires^th^{e Secretary}^,^by^J^u^ly
^s^.or^t^h^e^susp^eⁿ^si^oⁿ^t^h^r^o^ugh^{2002. Im}^pl^em^en^t^a^tⁱ^oⁿ^of^t^h^e^{1, 2006, t}^oⁱ^m^pl^em^en^t^clⁱⁿⁱ^cal^l^y^appropri^a^t^e^{code edi}^t^s^f^o^r
^le^ak^prov^is^ion^w^a^s^delay^e^{d u}ⁿ^{til Septem}^{ber 2003. T}^h^{e caps}^ph^y^s^{ical th}^erapy^s^e^rv^ices^{, o}^ccu^pation^a^{l th}^erapy^s^e^rv^ices^,
^://wiki^w^e^{re i}^m^pl^em^en^t^e^{d f}^r^om^S^e^pt^em^{ber 1, 2003 t}^h^rou^g^h^Decem^{ber 7, 2003.}^MMA^rein^s^t^{ated th}^{e m}^o^ratoriu^m^f^r^om^and^sp^{eech language p}^a^tho^l^o^g^y^ser^v^ices.^T^h^{e ed}^{its ar}^{e to}^id^en^tif^y^an^d^elimⁱⁿ^{ate im}^p^r^o^p^e^r^p^a^y^m^en^{ts. T}^h^{e ed}^its^ar^e
^h^ttp^Decem^{ber 8, 2003 th}^ro^{ugh Decem}^b^e^r³¹^,^{2005. T}^h^{e caps}^toⁱⁿ^clu^d^{e ed}^{its o}^f^clin^ically^illo^gⁱ^{cal co}^m^bⁱⁿ^atioⁿ^s^o^f
^g^oⁱⁿ^t^o^ef^f^ect^ag^aiⁿ^begⁱⁿⁿⁱ^ng^J^aⁿ^u^a^ry^{1, 2006. In}^t^h^e^procedu^r^{e codes}^an^{d ot}^h^e^{r edi}^t^s^t^o^cont^rolⁱⁿ^appropri^a^t^e
^N^o^v^e^m^b^e^r²^{005, f}ⁱⁿ^a^l^ph^y^sⁱ^cⁱ^aⁿ^f^{ee s}^c^h^e^du^l^e^reg^u^l^atⁱ^oⁿ^b^illin^g^s^.
^f^o^r²⁰⁰⁶^C^M^S^anⁿ^o^uⁿ^{ced t}^h^at^t^h^{e cap w}^o^u^l^{d be $1,740 i}ⁿ
^2006.
^A^ccelerat^ed^Imp^l^emen^t^a^tⁱ^oⁿ^o^f^In^co^me-^Sin^{ce th}^{e in}^ception^of^{Medicare, all}^P^a^rt^B^en^rollees^h^a^v^e^S^ecti^oⁿ^5111.^T^h^{e ag}^reem^en^{t accelerates}^th^{e p}^h^a^s^e-ⁱⁿ
^la^te^{d Re}^duc^{tion in P}^a^r^t^{B P}^r^e^m^{ium S}^ubs^idy^.^p^a^id^th^{e sam}^e^P^a^r^t^B^p^r^em^iu^m^,^r^e^g^a^r^d^{less o}^f^th^eirⁱⁿ^co^m^e^p^e^rⁱ^o^d^f^r^o^m^fⁱ^v^e^y^ear^{s to}^th^r^{ee y}^ear^{s, w}^ith^th^{e p}^r^o^v^isioⁿ
^lev^e^{l. MMA}ⁱⁿ^cr^eased^th^{e P}^a^r^t^B^p^r^e^m^iu^m^s^f^o^r^hⁱ^g^h^e^r^f^u^l^l^y^ef^f^ectⁱ^v^{e i}ⁿ^{2009. In}^{2007, h}ⁱ^g^h^e^{r i}ⁿ^com^e^en^rol^l^ees
ⁱⁿ^com^e^en^rol^l^ees^begⁱⁿⁿⁱⁿ^gⁱⁿ^{2007. In}^{2007, i}ⁿ^di^vⁱ^du^al^s^w^{ill p}^a^y^to^{tal p}^r^em^iu^m^s^r^aⁿ^gⁱⁿ^g^f^r^o^m²⁸^.³^%^to⁴³^.¹⁵^%^o^f
^w^h^os^{e m}^o^dⁱ^fⁱ^{ed adj}^u^s^t^{ed g}^r^os^sⁱⁿ^com^e^(A^{GI) ex}^ceeds^th^{e total v}^a^lu^{e of}^P^a^rt^B^.^In^{2010, en}^rollees^w^{ill pay}^total
^{$80,000 and}^c^o^u^p^les^w^h^os^{e m}^odifⁱ^{ed A}^G^{I ex}^ceeds^premⁱ^u^m^s^ran^gⁱⁿ^g^f^r^om^31.7%^t^o^61.85%^of^t^h^{e t}^o^t^a^l
^{$160,000 w}^{ill be s}^u^bj^{ect to h}ⁱ^g^h^e^{r prem}^iu^m^am^ouⁿ^t^s^.^T^h^e^v^a^l^u^{e of}^Part^{B. Wh}^en^f^u^l^l^y^ph^as^ed-ⁱⁿⁱⁿ^{2009, h}ⁱ^g^h^e^r

CRS-16
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
ⁱⁿ^creas^{e is}^{to be ph}^as^ed-ⁱⁿ^ov^{er f}ⁱ^v^e^y^ears^.^Du^rin^g^th^{e f}ⁱ^rs^tⁱⁿ^co^m^eⁱⁿ^dⁱ^vⁱ^d^u^als^w^{ill p}^a^y^to^{tal p}^r^em^iu^m^s^r^aⁿ^gⁱⁿ^g^f^r^o^m
^y^ear^{, h}ⁱ^g^h^e^rⁱⁿ^co^m^e^en^r^o^{llees w}^{ill p}^a^y^p^r^em^iu^m^s^r^aⁿ^gⁱⁿ^g³⁵^%^to⁸⁰^%^o^f^th^{e to}^{tal v}^a^lu^{e o}^f^P^a^r^t^B^.
^f^r^om^27%^t^o^36%^of^t^h^{e v}^a^l^u^{e of}^Par^t^{B. Wh}^en^f^u^l^l^y
^p^h^ased^-ⁱⁿ^,^hⁱ^g^h^e^rⁱⁿ^co^m^eⁱⁿ^dⁱ^vⁱ^d^u^{als w}^{ill p}^a^y^p^r^em^iu^m^s
^ran^gⁱⁿ^g^f^r^om^35%^t^o^80%^of^t^h^{e v}^a^l^u^{e of}^Part^{B. T}^h^{e t}^e^rm
^m^odifⁱ^{ed A}^G^I^m^e^an^s^adj^u^s^t^{ed g}^r^os^sⁱⁿ^com^e^as^defⁱⁿ^e^d
^uⁿ^d^er^th^{e In}^tern^{al R}^e^v^eⁿ^u^e^C^{ode (determ}ⁱⁿ^e^{d w}^ith^ou^t
^reg^a^{rd to}^s^p^ecifⁱ^{ed ex}^clu^s^ion^s^{), in}^creas^{ed by}^tax^-^ex^em^pt
ⁱⁿ^ter^e^s^t^{. I}ⁿ^g^eⁿ^e^r^a^{l, th}^{e tax}^a^b^l^{e y}^ear^to^b^e^u^s^ed^{is th}^at
^begⁱⁿⁿⁱⁿ^gⁱⁿ^th^{e s}^econ^d^calen^da^r^y^e^a^r^precedin^g^th^{e y}^ear
ⁱ^{ki/CRS-RL33251}ⁱⁿ^v^o^lv^ed.^Un^{der certain}^circu^m^s^t^an^ces^{, an}ⁱⁿ^divⁱ^du^al^m^a^y^req^u^e^s^t^t^o^h^a^v^e^t^h^e^d^e^t^e^r^mⁱⁿ^a^tⁱ^oⁿ^m^a^d^e^f^o^r^a^m^o^r^e^r^ecen^t
^g/w^y^{ear. T}^h^{e c}^u^r^r^eⁿ^t^law^prov^is^ion^w^h^ich^s^p^ecifⁱ^es^th^{at a}
^s^.or^ben^e^fⁱ^ciary^’^s^ch^eck^canⁿ^o^{t g}^o^dowⁿ^f^r^om^on^{e y}^{ear to th}^e
^le^akⁿ^e^x^t^a^s^{a r}^e^su^{lt o}^f^th^{e P}^a^r^t^B^p^r^em^iu^mⁱⁿ^cr^{ease w}^{ill n}^o^t
^://wiki^app^l^y^t^o^pers^on^s^s^u^bj^{ect to an}ⁱⁿ^com^e^-^r^{elated in}^creas^{e in}^t^h^ei^{r P}^a^rt^{B prem}ⁱ^u^m^s^.
^h^ttp
^M^e^dic^a^r^e^Cov^e^r^a^g^e^o^f^U^l^t^r^a^s^{ound S}^c^r^e^eⁿ^ing^{Medicare prov}^ides^co^verag^e^f^o^{r s}^e^rv^ices^w^h^ich^are^S^ecti^oⁿ^5112.^T^h^{e ag}^reem^en^{t aut}^h^o^r^izes^Medicare
^A^bdomina^l^A^o^r^t^ic^Aⁿ^e^u^r^y^s^m^s^.^reas^on^{able an}^{d n}^eces^s^a^ry^f^o^{r th}^{e diag}ⁿ^o^sⁱ^s^{or treatm}^eⁿ^t^of^c^o^v^e^r^a^g^e^o^f^u^l^t^r^a^s^o^uⁿ^d^s^c^r^e^eⁿⁱⁿ^g^f^o^r^a^bdomⁱⁿ^a^l^a^o^r^tⁱ^c
^illn^{ess o}^rⁱⁿ^j^u^r^y^o^r^to^im^p^r^o^v^e^t^h^e^f^uⁿ^c^tioⁿⁱⁿ^g^o^f^a^an^eu^ry^s^m^s^f^o^{r in}^divⁱ^dua^l^s^w^h^{o: (1) receiv}^e^ref^e^rrals^f^o^r
^m^a^lf^orm^e^{d body}^m^e^m^b^er.^In^addition^,^{Medicare cov}^e^rs^su^ch^scr^eenⁱⁿ^g^s^{as a r}^e^su^lt^o^f^anⁱⁿ^{itial p}^r^ev^en^tiv^{e p}^h^y^s^ical
^certain^prev^en^tiv^{e s}^e^rv^ices^s^p^ecifⁱ^{ed in}^law^.^e^x^am^perf^orm^e^{d f}^o^{r n}^e^w^{Medicare en}^rollees^{; (2) w}^h^o
^h^a^v^eⁿ^o^{t prev}^iou^s^ly^h^a^{d s}^u^ch^{a tes}^t^cov^e^{red by}^Medicare;
^aⁿ^d⁽³⁾^w^h^o^ha^ve^a^fa^mⁱ^l^y^hi^st^o^r^y^o^f^a^b^d^o^mⁱ^na^l^a^o^r^tⁱ^c
^an^eu^ry^s^m^{or w}^h^{o m}^aⁿⁱ^f^e^s^t^ris^k^f^actorsⁱⁿ^clu^d^{ed in}^a
^ben^e^fⁱ^ciary^categ^ory^iden^tif^{ied by}^th^{e Un}^{ited States}
^P^r^ev^en^tiv^{e Serv}^ices^T^a^s^k^Force.
^Aⁿ^u^l^t^r^as^ouⁿ^d^s^c^re^eⁿⁱⁿ^g^f^o^{r abdom}ⁱⁿ^al^aortⁱ^c

CRS-17
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^aⁿ^e^u^r^y^{sm i}^s^d^e^fi^ne^d^a^s^a^p^r^o^c^e^d^ur^e^usi^{ng so}^und^w^a^ve^s
^pro^vⁱ^d^e^d^f^o^{r t}^h^{e earl}^y^det^ectⁱ^oⁿ^of^abdomⁱⁿ^al^aortⁱ^c
^an^eu^ry^s^m^{. T}^h^e^Secretary^cou^l^{d s}^p^ecif^y^oth^e^{r procedu}^r^es
^usi^{ng a}^l^t^e^rⁿ^a^tⁱ^v^e^t^e^c^hno^l^o^gi^e^s^w^hⁱ^c^{h a}^r^e^o^f^c^o^m^m^e^nsur^a^t^e
^accu^racy^an^{d co}^s^t^.^T^h^{e term}ⁱⁿ^clu^d^es^th^{e ph}^y^s^ician^’^s
ⁱⁿ^ter^p^r^e^tatioⁿ^o^f^th^{e r}^e^su^{lts o}^f^th^{e p}^r^o^ced^u^r^{e. Ultr}^aso^uⁿ^d
^s^c^reenⁱⁿ^g^f^o^{r abdom}ⁱⁿ^al^aortⁱ^c^an^eu^ry^s^mⁱ^s^t^o^{be i}ⁿ^cl^u^d^ed
ⁱⁿ^t^h^e^p^a^c^k^a^g^e^o^f^s^e^r^vⁱ^c^e^s^p^r^o^vⁱ^d^e^dⁱⁿ^t^h^eⁱⁿ^itial
^prev^en^ti^ve^s^e^rv^{ice ex}^am^of^f^e^{red to n}^e^w^Medicare
^en^rollees^.
ⁱ^{ki/CRS-RL33251}^P^a^y^m^en^ts^{are m}^a^de^uⁿ^d^{er th}^{e ph}^y^s^ician^f^e^e
^g/w^s^c^h^e^du^l^e^f^o^{r s}^c^reenⁱⁿ^g^s^perf^orm^e^d^oⁿ^{or af}^t^e^{r Jan}^u^a^ry^1,
^s^.or^{2007. T}^h^{e Part}^{B dedu}^ctⁱ^b^l^e^doesⁿ^o^t^appl^y^t^o^t^h^es^e
^le^ak^s^e^rv^ices^.
^://wiki^Improv^{ing Pat}ⁱ^ent^A^{ccess t}^o^{, and Ut}^iliz^at^ion^Medicare^cov^e^rs^certain^color^ectal^can^{cer s}^c^reenⁱⁿ^g^tes^t^s^,^S^ecti^oⁿ^5113.^T^h^{e agr}^eem^en^{t prov}^ides^th^{at th}^{e P}^a^{rt B}
^h^ttp^{, Co}^lo^rect^al^Can^{cer Screen}ⁱⁿ^g^Un^d^e^{r M}^e^dⁱ^care.^su^b^j^ec^t^t^o^co^v^e^r^a^g^e^lim^itatioⁿ^s^b^a^sed^oⁿ^th^{e ty}^p^e^o^f^test^dedu^ctⁱ^b^l^e^doesⁿ^o^t^appl^y^t^o^{colorectal c}^aⁿ^cer^s^c^reenⁱⁿ^g
^aⁿ^d^t^h^eⁱⁿ^divⁱ^du^al’^s^lev^e^{l of}^ris^k^{. C}^o^v^e^{red tes}^t^s^{are f}^eca^l^t^e^s^t^s^,^ef^f^ectⁱ^v^{e Jan}^u^a^ry^{1, 2007}
^occu^l^t^bl^{ood t}^e^s^t^{, f}^l^exⁱ^b^l^e^sⁱ^g^m^oi^dos^copy^{, s}^c^reenⁱⁿ^g
^colon^o^s^c^opy^{, an}^{d bariu}^m^en^em^a.^P^a^y^m^en^ts^f^o^{r s}^e^rv^ices
^{are m}^a^{de u}ⁿ^d^{er th}^{e ph}^y^s^ician^f^{ee s}^c^h^e^du^le,^s^ubj^{ect to th}^e
^P^a^{rt B}^dedu^{ctible an}^{d coin}^s^u^ran^ce.
^Deliv^ery^o^f^Serv^{ices at}^F^e^d^e^rally^Q^u^alif^ied^A^ccordin^g^{to s}^t^atu^t^{e, an}^F^Q^H^Cⁱ^s^r^e^quⁱ^r^{ed t}^o^provⁱ^d^e^S^ecti^oⁿ^5114.^Medi^c^a^r^{e cov}^e^{red diabetes}^s^e^lf^-
^h^Cen^t^{ers (}^F^Q^HC)^.^certain^prim^ary^care^s^e^rv^ices^by^ph^y^s^ician^s^an^{d appropriate}^m^aⁿ^a^g^e^m^eⁿ^t^tr^ainⁱⁿ^g^an^d^m^e^dⁱ^calⁿ^u^t^r^itioⁿ^th^er^ap^y
^mⁱ^d^-^lev^e^{l p}^r^actitioⁿ^e^r^s^{as w}^e^{ll as o}^t^h^e^r^p^r^ev^en^tiv^e^h^e^alth^ser^v^{ices (}^p^r^o^vⁱ^d^e^d^b^y^r^e^gⁱ^ster^ed^dⁱ^etitian^o^rⁿ^u^t^r^itioⁿ
^s^e^rv^icesⁱⁿ^clu^dⁱⁿ^g^th^os^{e requ}^{ired u}ⁿ^d^er^certain^s^ection^s^of^prof^es^sⁱ^on^{al) are added as}^FQHC^s^e^rv^ices^{. S}^e^r^vⁱ^c^es
^th^{e P}^u^b^{lic Health}^Ser^v^{ice (}^P^HS)^A^c^t⁽^s^p^ecifⁱ^cally^Sectioⁿ^s^f^u^rn^is^h^e^{d by}^{a h}^ealth^{care pr}^o^f^e^s^sⁱ^on^{al w}^h^{o is}^uⁿ^d^er
^329,^330,^an^{d 340 of}^t^h^{e PH}^S⁾^{. Pri}^o^r^t^o^t^h^e^en^act^m^eⁿ^t^of^con^t^{ract w}^ith^{a FQHC}^w^o^u^l^{d be m}^a^{de directly}^t^o^th^e

CRS-18
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^MMA^{, FQHC ser}^v^{ices w}^e^r^e^co^v^e^r^e^d^b^y^{a sk}^illedⁿ^u^r^sin^g^FQHC^.
^f^a^c^ility^’^s⁽^S^NF)^coⁿ^s^o^lid^ated^b^illin^g^r^e^q^u^ir^em^en^{t. FQHC}
^ser^v^{ices w}^e^r^e^b^uⁿ^d^ledⁱⁿ^to^th^{e SNF’}^{s co}^m^p^r^e^h^eⁿ^s^iv^{e p}^e^r
^dⁱ^e^m^pay^m^en^{t f}^o^{r th}^{e cov}^e^{red s}^t^ay^an^{d n}^o^{t s}^e^parately
^b^illab^l^{e. MMA}^sp^ecifⁱ^ed^t^h^a^t^{a SNF P}^a^r^t^A^r^e^sid^eⁿ^t^w^h^o
^receiv^e^s^FQHC^s^e^rv^ices^f^r^om^{a ph}^y^sⁱ^cⁱ^aⁿ^{or appropriate}
^p^r^actitioⁿ^e^r^w^o^u^l^d^b^e^ex^clu^d^ed^f^r^o^m^{SNF co}ⁿ^s^o^lid^ated
^b^illin^g^an^d^b^e^p^a^id^sep^a^r^a^tely^.
^W^a^iv^{er of}^Part^B^Lat^e^Enrollment^Penalt^y^f^o^r^{Medicare P}^a^{rt B}^is^{a v}^o^luⁿ^t^ary^prog^ram^.^P^e^ople^g^eⁿ^e^rally^S^ecti^oⁿ^5115.^T^h^{e ag}^reem^en^t^perm^its^certainⁱⁿ^divⁱ^du^als
ⁱ^{ki/CRS-RL33251}^ain^In^t^e^rn^at^ioⁿ^a^{l Vo}^luⁿ^t^{eers .}^en^rol^lⁱⁿ^P^a^r^t^{B w}^h^en^t^h^ey^t^u^rn^{65. Pers}^on^s^w^h^{o del}^a^y^en^r^o^llm^en^{t in}^th^{e p}^r^o^g^r^a^m^af^ter^th^eirⁱⁿ^{itial en}^r^o^llm^en^t^to^d^e^lay^en^r^o^llm^en^{t in}^P^a^r^t^B^w^ith^o^u^{t a d}^e^l^a^y^e^d^en^r^o^llm^en^{t p}^eⁿ^a^lty^{. T}^h^o^s^{e in}^dⁱ^vⁱ^d^u^als^p^e^r^m^itted^to^d^e^lay
^g/w^p^e^rⁱ^o^d^ar^{e su}^b^j^ect^to^a^p^r^em^iu^m^p^eⁿ^a^lty^.^T^h^{is p}^eⁿ^a^lty^{is a}^en^r^o^llm^en^{t w}^o^u^l^d^b^e^th^o^s^{e w}^h^o^v^o^luⁿ^t^eer^ed^o^u^tsid^{e o}^f^th^e
^s^.or^s^u^rc^ha^r^g^{e equ}^a^{l to 10% of}^th^{e prem}^iu^m^am^ouⁿ^t^f^o^{r each}^Uⁿⁱ^t^e^d^St^a^t^e^s^fo^r^a^t^l^e^a^s^t¹²^m^oⁿ^t^{hs t}^h^r^o^{ugh a}^p^r^o^g^r^a^m
^le^ak¹²^m^oⁿ^t^h^s^o^f^d^e^lay^e^d^en^r^o^llm^en^{t. T}^h^er^{e is n}^o^u^p^p^e^r^lim^it^s^pon^s^o^{red by}^{a t}^a^x^-^exe^m^pt^org^aⁿⁱ^zatⁱ^oⁿ^defⁱⁿ^e^{d u}ⁿ^d^er
^on^th^{e am}^ouⁿ^t^of^th^{e s}^u^r^c^ha^rg^{e th}^{at m}^a^y^apply^.^Fu^rth^e^r,^S^ectⁱ^oⁿ⁵⁰¹⁽^c⁾⁽³^{) of}^t^h^{e In}^t^e^rn^al^R^e^v^eⁿ^u^e^C^{ode. T}^h^e
^://wiki^th^{e p}^eⁿ^a^lty^coⁿ^tin^u^e^{s to}^ap^p^l^y^f^o^r^t^h^e^en^tir^{e tim}^{e th}^eⁱⁿ^divⁱ^du^als^m^u^s^t^dem^oⁿ^s^{trate th}^ey^h^a^{d h}^ealthⁱⁿ^s^u^ran^c^e
^h^ttpⁱⁿ^dⁱ^vⁱ^d^u^{al is en}^r^o^l^l^e^dⁱⁿ^P^a^r^t^B^.^T^h^{e law}^estab^lish^e^s^co^v^e^r^a^g^e^w^h^{ile ser}^vⁱⁿ^gⁱⁿ^th^{e in}^terⁿ^atioⁿ^a^{l p}^r^o^g^r^a^m^.
^cer^tain^ex^cep^tioⁿ^s^to^th^{e d}^e^lay^e^d^en^r^o^llm^en^{t p}^eⁿ^a^lty^{. On}^e
^ex^cep^tioⁿ^ap^p^lie^{s to}^th^{e “}^w^o^r^ki^{ng a}^g^e^d^.^”^D^e^l^a^y^e^d^Iⁿ^dⁱ^vⁱ^d^u^als^p^e^r^m^itted^to^d^e^lay^en^r^o^llm^en^t^w^ill^h^a^v^e
^en^r^o^l^l^m^en^{t is also}^p^e^r^m^itted^f^o^r^cer^tain^dⁱ^sab^l^ed^p^e^r^s^oⁿ^s^{a sp}^{ecial P}^a^r^t^B^en^r^o^l^l^m^eⁿ^t^p^e^rⁱ^o^d^w^h^ich^w^{ill b}^e^th^{e six}^-
^w^h^o^ha^ve^gr^o^u^p^he^a^l^t^hⁱⁿ^sur^a^nc^e^c^o^ve^r^a^ge^b^a^se^d^oⁿ^t^h^eⁱ^r^m^o^nt^h^p^e^rⁱ^o^d^b^e^giⁿⁿⁱ^ng^oⁿ^t^h^e^fi^r^s^t^d^a^y^o^f^t^h^e^m^o^nt^{h t}^h^e
^owⁿ^{or a f}^a^m^ily^m^e^m^b^er’^s^cu^rren^t^em^pl^o^y^m^e^{nt w}^ith^aⁱⁿ^dⁱ^vⁱ^d^u^{al is n}^o^loⁿ^g^erⁱⁿ^th^{e p}^r^o^g^r^a^m^.^Co^v^e^r^a^g^e^w^ill
^l^a^rg^{e g}^r^ou^{p h}^eal^t^h^pl^an^.^b^e^gⁱⁿ^th^e^m^oⁿ^t^h^af^ter^th^{e in}^dⁱ^vⁱ^d^u^{al en}^r^o^{lls. T}^h^{is sectio}ⁿ
^applies^{to m}^oⁿ^t^h^s^an^{d s}^p^{ecial en}^rollm^en^{t periods}
^Iⁿ^dⁱ^vⁱ^d^u^{als w}^h^o^ar^{e p}^e^r^m^itted^to^d^e^lay^en^r^o^l^l^m^en^t^begⁱⁿⁿⁱⁿ^g^Jan^u^a^ry^2007.

^h^a^v^e^th^eir^o^wⁿ^s^p^e^c^{ial en}^r^o^llm^en^{t p}^e^rⁱ^o^d^s^{. A}^sp^ecial
^enr^o^l^l^m^en^{t period beg}ⁱⁿ^s^w^h^en^cu^rren^{t em}^ploy^m^eⁿ^t^en^ds
^{or w}^h^en^cov^e^rag^e^uⁿ^d^{er th}^{e plan}^en^ds^{. T}^h^{e s}^p^ecial
^en^rol^l^m^eⁿ^t^peri^{od en}^ds^ei^g^h^t^m^oⁿ^t^h^s^l^a^t^e^{r. In}^di^vⁱ^du^al^s

CRS-19
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^w^h^o^f^a^{il to}^en^r^o^{ll in}^th^{is p}^e^rⁱ^o^d^ar^{e co}ⁿ^s^id^er^ed^to^h^a^v^e
^delay^e^{d en}^rollm^ent^an^{d cou}^l^{d becom}^e^s^u^bj^{ect to th}^e
^p^eⁿ^a^lty^.
^Ho^{me h}^ealt^h^p^a^y^m^en^t^s^.^T^h^{e M}^e^dⁱ^c^a^r^e^ho^m^e^he^al^t^h^pros^pectⁱ^v^e^pay^m^en^t^s^y^s^t^em^,^S^ecti^oⁿ^5201.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t elim}^inates^th^e
^w^hⁱ^c^h^w^a^sⁱ^m^pl^em^ent^e^{d on}^O^c^t^{ober 1, 2000, prov}ⁱ^d^es^a^u^pdat^e^f^o^r^h^o^m^e^h^eal^t^h^pay^m^en^t^sⁱⁿ^{2006. It}^al^s^o^ex^t^eⁿ^d^s
^s^t^an^dardized^p^a^y^m^en^{t f}^o^{r a 60-}^day^epis^{ode of}^care^th^e⁵^%^ad^d^itioⁿ^a^{l p}^a^y^m^en^{t f}^o^r^r^u^r^a^{l h}^o^m^e^h^ealth^ep^iso^d^e^s
^f^u^rn^is^h^e^{d to a Medicare ben}^e^fⁱ^ciary^.^Medicare’^s^pay^m^en^t^or^vⁱ^sⁱ^t^s^begⁱⁿⁿⁱⁿ^g^on^{or af}^t^e^{r Jan}^u^a^ry^{1, 2006 an}^{d bef}^o^re
^{is ad}^j^u^st^e^d^t^o^r^e^f^l^{ect th}^{e ty}^p^e^an^dⁱⁿ^ten^s^ity^o^f^car^e^Jan^u^a^ry^{1, 2007.}
^f^u^rn^is^h^e^{d an}^{d area w}^a^g^e^s^as^m^eas^u^r^{ed by}^th^{e h}^o^s^p^ital
ⁱ^{ki/CRS-RL33251}^w^a^geⁱⁿ^d^e^x.^S^t^artⁱ^ngⁱⁿ^{2007, t}^h^{e con}^f^eren^{ce ag}^reem^en^t^di^rect^s^h^o^m^e^h^ealt^h^a^g^en^cies^{to s}^u^bm^{it to th}^{e Secretary}^h^ealth^care
^g/w^Each^y^{ear Medicare’}^s^pay^m^en^t^to^h^o^m^e^h^ealth^ag^en^cies^is^q^u^ality^d^a^{ta in}^{a f}^o^r^m^{, m}^aⁿⁿ^e^r^,^an^d^tim^{e p}^e^rⁱ^o^d^sp^ecifⁱ^ed
^s^.or^up^d^a^t^e^d^b^y^t^h^e^p^r^o^j^e^c^t^e^d^a^nnua^l^c^h^a^ngeⁱⁿ^t^h^e^ho^m^e^he^a^l^t^h^by^t^h^{e S}^ecret^ary^.^In^{2007 an}^{d s}^u^bs^equ^eⁿ^t^y^ears^,^{a h}^o^m^e
^le^ak^m^a^rk^{et bas}^k^{et (HHMB}⁾^,^w^ith^s^p^ecifⁱ^ed^redu^ction^sⁱⁿ^s^o^m^e^he^a^l^th^ag^en^cy^th^{at does}ⁿ^o^{t s}^u^bm^{it th}^{e requ}^{ired qu}^ali^t^y
^y^ears^.^F^o^{r t}^h^{e l}^a^s^t^t^h^{ree cal}^en^{dar qu}^art^e^rs^of^2004-^2006,^d^a^ta^w^{ill receiv}^e^an^u^p^d^a^{te o}^f^th^{e m}^a^rk^{et b}^a^sk^{et m}ⁱⁿ^u^s
^://wiki^th^{e h}^o^m^e^h^ealth^u^p^d^a^{te is}^th^e^HHMB^mⁱⁿ^u^s⁰^.⁸^p^e^r^cen^tag^e^t^w^{o percen}^t^a^g^e^poiⁿ^t^s^.^T^hⁱ^s^redu^ctⁱ^oⁿ^w^o^u^l^{d on}^l^y^appl^y
^h^ttp^poiⁿ^t^s^.^In^{2007 an}^{d s}^u^bs^equ^eⁿ^t^y^ears^,^t^h^{e pay}^m^en^t^u^pdat^e^{to th}^{e f}ⁱ^s^{cal y}^earⁱⁿ^qu^es^tion^.^T^h^{e con}^f^eren^{ce ag}^reem^en^t
^f^o^{r h}^o^m^e^h^ealth^ag^en^cies^is^equ^a^{l to th}^{e f}^u^{ll HHMB}^.^directs^th^{e Secretary}^{to des}ⁱ^gⁿ^procedu^r^es^f^o^{r m}^a^kⁱⁿ^g^th^e
^d^a^{ta av}^ailab^l^{e to}^th^{e p}^u^b^lic.
^T^h^{e Medicare P}^r^es^cription^Dru^g^Im^pro^v^e^m^en^{t an}^d
^M^o^d^e^rⁿⁱ^z^a^tⁱ^oⁿ^A^c^t^o^f²⁰⁰³^p^r^o^vⁱ^d^e^d^f^o^r^a^oⁿ^e^-^y^e^a^r⁵^%^T^h^{e con}^f^eren^ce^ag^reem^en^t^directs^th^{e Medicare P}^a^y^m^en^t
^ad^d^itioⁿ^a^{l p}^a^y^m^en^{t f}^o^r^h^o^m^e^h^ealth^ser^v^{ices f}^u^rⁿ^ish^e^dⁱⁿ^A^d^vⁱ^s^o^r^y^C^o^m^mⁱ^ssioⁿ^to^su^b^m^{it a r}^e^p^o^r^{t to}^Coⁿ^g^r^{ess n}^o
^ru^{ral areas}^{. T}^h^{e tem}^porary^pay^m^en^{t beg}^aⁿ^f^o^r^e^p^is^odes^l^a^t^e^{r t}^h^an^Juⁿ^e^{1, 2007 on}^{a v}^a^l^u^e-^bas^e^{d pu}^rch^a^sⁱⁿ^g
^an^{d v}ⁱ^sⁱ^t^s^en^diⁿ^g^on^{or af}^t^e^{r A}^p^ri^l^{1, 2004}^an^d^bef^o^{re A}^p^ri^l^p^r^o^g^r^a^m^f^o^r^h^o^m^e^h^ealth^ser^v^{ices. T}^h^{e r}^e^p^o^r^{t is to}
^{1, 2005. It}^w^a^s^m^a^{de w}ⁱ^t^h^ou^t^reg^a^{rd t}^o^cert^aⁱⁿ^bu^dg^etⁱⁿ^clu^d^{e recom}^m^eⁿ^d^ation^s^on^th^{e s}^t^ru^ctu^r^e^of^th^{e prog}^ram^,
ⁿ^e^u^t^r^a^lit^y^p^r^o^v^isioⁿ^s^an^d^w^a^{s n}^o^{t in}^clu^d^edⁱⁿ^th^{e b}^a^{se f}^o^r^det^e^rmⁱⁿⁱⁿ^g^t^h^res^h^ol^ds^{, t}^h^{e s}ⁱ^{ze of}^v^a^l^u^e-^bas^e^{d pay}^m^en^t^s^,
^d^e^ter^mⁱⁿ^atioⁿ^o^f^p^a^y^m^en^{t u}^p^d^a^tes.^s^o^u^r^c^e^s^of^f^uⁿ^d^s^,^an^{d t}^h^{e rel}^a^tⁱ^oⁿ^s^hⁱ^{p of}^pay^m^en^t^s^an^d
^im^p^r^o^v^em^en^{ts in}^h^ealth^car^{e q}^u^ality^{. T}^h^{e co}ⁿ^f^er^en^ce
^ag^reem^en^t^di^rect^s^{$550,000 t}^o^{be appropri}^a^t^e^t^o^t^h^e

CRS-20
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^Medⁱ^car^{e P}^a^y^m^en^{t A}^d^vⁱ^so^r^y^Co^m^mⁱ^ssioⁿ^t^o^w^r^{ite th}^is
^report^.
^Re^vⁱ^sⁱ^{on of pe}^rⁱ^o^d^for^pr^ov^{iding pa}^y^m^eⁿ^{t for}^Man^d^atory^electronⁱ^{c claim}^s^s^u^bm^is^sⁱ^on^w^eⁿ^tⁱⁿ^{to ef}^f^ect^S^ecti^oⁿ^5202.^T^h^{e C}^oⁿ^f^eren^{ce ag}^reem^eⁿ^{t directs}
^h^at^{are su}^b^m^it^t^e^d^elect^roⁿⁱ^cally^.^on^Ju^l^y^{1, 2005 f}^o^{r al}^l^provⁱ^d^er^s,^wⁱ^t^h^{a f}^e^w^ex^ceptⁱ^oⁿ^s^.^{Medicare con}^t^ractors^{to delay}^th^{e pay}^m^en^{t of}^claim^s^th^at
^T^h^{e ex}^ception^sⁱⁿ^clu^d^{e (1) s}^m^a^ll^p^r^o^v^id^er^{s w}^ith^f^e^w^e^r^th^an^ar^{e n}^o^{t su}^b^m^itted^electr^oⁿⁱ^cally^{. T}^h^{e co}ⁿ^t^r^acto^r^{s ar}^e
²⁵^f^u^ll-^tim^{e eq}^uⁱ^v^a^len^t⁽^F^T^E^s)^em^p^l^o^y^ees^an^d^p^h^y^s^ician^s^,^{directed to pay}^95%^of^{all “}^c^lean^{” claim}^s^w^ithⁱⁿ^29-³⁰
^p^r^actitioⁿ^e^r^s^{, o}^r^su^p^p^lier^s^w^ith^f^e^w^e^r^th^an¹⁰^FT^Es^,⁽²⁾^day^s^of^{receipt f}^o^{r paper claim}^s^.
^den^tis^ts^{, an}^d⁽³⁾^oth^e^r^prov^iders^as^s^p^ecifⁱ^{ed by}^th^{e C}^eⁿ^t^ers
^f^o^{r Medicare an}^{d Medicaid Se}^rv^ices^(C^{MS). Medicare}
ⁱ^{ki/CRS-RL33251}^con^t^ractors^m^u^s^t^pay⁹⁵^%^o^f^{all “}^c^lean^{” paper claim}^s^w^ithⁱⁿ^27-^{30 day}^s^of^receipt.
^g/w
^s^.or^Tⁱ^me^fr^a^m^e^for^pa^r^t^A^a^{nd B pa}^y^m^eⁿ^ts^.^M^e^dⁱ^c^a^r^{e con}^t^ractors^{accept, proces}^s^,^an^{d pay}^c^l^aⁱ^m^s^S^ecti^oⁿ^5203.^T^h^{e C}^oⁿ^f^eren^{ce ag}^reem^eⁿ^{t delay}^s
^le^ak^su^b^m^itted^b^y^p^r^o^v^id^er^{s f}^o^r^Medⁱ^c^a^r^e-^co^v^e^r^e^d^ser^v^ices.^Medi^ca^r^e^P^a^r^t^A^an^{d B pay}^m^en^t^s^byⁿⁱⁿ^e^day^s^{. C}^l^ai^m^s
^{Medicare con}^t^ractors^m^u^s^t^payⁱⁿ^t^e^res^t^on^claim^s^th^{at are}^t^h^at^w^o^u^l^{d ot}^h^e^rwⁱ^s^{e be pai}^d^on^Sept^em^{ber 22, 2006,}
^://wikiⁿ^o^t^pai^d^prom^pt^l^y^.^t^h^rou^gh^Se^pt^em^{ber 30, 2006 w}^o^u^l^{d be pai}^d^on^t^h^{e f}ⁱ^rs^t
^h^ttp^bu^sⁱⁿ^e^s^s^day^of^O^c^t^{ober 2006. N}^oⁱⁿ^t^e^res^t^or^l^a^t^e^pen^a^l^t^y
^T^h^{e con}^t^ractors^m^u^s^t^pay^95%^of^all^“^c^lean^{” claim}^s^w^ithⁱⁿ^w^o^u^l^d^b^e^p^a^id^to^an^en^tity^o^rⁱⁿ^dⁱ^vⁱ^d^u^{al f}^o^r^aⁿ^y^d^e^layⁱⁿ
¹⁴^-³⁰^d^a^y^s^o^f^receip^t^f^o^{r el}^e^c^t^r^oⁿⁱ^cally^su^b^m^itted^claim^s^,^{a pay}^m^en^t^du^riⁿ^g^t^h^{e peri}^od.
^an^{d w}ⁱ^t^hⁱⁿ^27-^{30 day}^s^of^receipt^f^o^{r paper claim}^s^{. If}^th^e
^p^a^y^m^en^{t is n}^o^{t m}^a^d^e^w^ithⁱⁿ^th^{at tim}^{e, in}^ter^e^{st b}^e^gⁱⁿ^s
^accruⁱⁿ^g^on^th^{e day}^af^{ter th}^{e requ}^{ired pay}^m^en^t^d^a^t^e^aⁿ^d
^en^d^s^oⁿ^th^{e d}^a^{te o}ⁿ^w^h^ich^th^{e p}^a^y^m^en^{t is m}^a^d^e^{. T}^h^e
ⁱⁿ^ter^e^{st r}^a^{te is set at th}^{e h}ⁱ^g^h^e^r^o^f^th^{e “}^p^rⁱ^v^a^{te c}^oⁿ^s^u^m^er
^r^a^t^e^”^,^o^r^t^h^e^“c^ur^r^e^nt^va^l^u^e^o^f^fund^s.^”
^In^{crease in}^M^e^dⁱ^c^a^r^e^In^t^e^g^r^it^y^Pro^g^r^{am (}^M^IP)^A^s^p^a^r^t^o^f^th^{e Health}^Iⁿ^su^r^aⁿ^c^{e P}^o^r^t^ab^ility^an^d^S^ecti^oⁿ^5204.^MIP^f^uⁿ^dⁱⁿ^g^isⁱⁿ^creas^{ed by}^{$100 m}^illion
^A^ccouⁿ^t^ability^Ac^{t of}^{1996 (HIP}^A^A⁾^{, C}^oⁿ^g^r^es^s^{acted to}^f^o^{r F}^Y^2006.

^inc^r^eas^{e an}^{d s}^t^{abilize f}^e^{deral f}^uⁿ^dⁱⁿ^g^f^o^{r an}^ti-^f^r^au^d

CRS-21
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^activ^ities^.^A^s^requ^{ired by}^Section^1817(k⁾^of^th^{e Medicare}
^law^,^an^ex^pen^d^itu^{re accou}ⁿ^t^w^a^s^e^s^tablis^h^e^{d w}^ithⁱⁿ^th^e
^Fed^e^r^a^{l Ho}^sp^{ital I}ⁿ^su^r^aⁿ^c^e^T^r^u^s^{t Fu}ⁿ^d⁽^t^h^e^HCFA^C
^accouⁿ^t^{). C}^e^rtain^am^ouⁿ^t^s^w^e^{re appropriated f}^r^om^th^e
^T^r^u^s^{t Fu}ⁿ^d^f^o^r^sp^ecifⁱ^{c activ}^itie^s^,ⁱⁿ^clu^dⁱⁿ^g^th^{e Med}ⁱ^car^e
^In^t^e^g^rⁱ^t^y^P^r^og^ram^(MIP^{). T}^h^es^e^a^m^ouⁿ^t^s^h^a^v^e^been
^es^tablis^h^e^d^asⁿ^o^{t les}^s^th^an^{$710 m}^illion^an^{d n}^o^{t m}^o^re^th^an
^{$720 m}^illioⁿ^f^o^{r FY2002 an}^{d s}^u^bs^equ^eⁿ^tly^.
^P^h^{ase-out of risk}^a^d^{justment budget}^M^e^dⁱ^{care A}^d^v^aⁿ^t^ag^{e pay}^m^en^{t rates}^{are ris}^k^adj^u^s^t^ed^t^o^S^ecti^oⁿ^5301.^Begⁱⁿⁿⁱⁿ^gⁱⁿ^{2007, t}^hⁱ^s^s^ectⁱ^oⁿ⁽¹⁾^w^o^u^l^d
ⁱ^{ki/CRS-RL33251}^utr^a^lity^{in de}^te^r^m^{ining the}^a^m^{ount of pa}^y^m^eⁿ^ts^e^dic^a^r^e^A^d^v^a^nta^g^e^or^ga^niza^tions^.^coⁿ^t^r^o^{l f}^o^r^th^{e v}^a^rⁱ^atioⁿⁱⁿ^th^{e co}^{st o}^f^p^r^o^v^idⁱⁿ^g^h^ealth^car^e^am^on^g^ben^e^fⁱ^cⁱ^aries^.^R^a^tes^{are adj}^u^s^t^{ed by}^dem^o^g^r^aphⁱ^c^ch^an^g^e^th^{e w}^a^y^MA^area-^s^p^ecifⁱ^{c n}^oⁿ^-^dru^g^m^o^nt^h^l^y^ben^c^h^m^ark^s^{(or MA}^ben^c^h^m^ark^s⁾^{are calcu}^{lated, an}^{d (2)}
^g/w^aⁿ^d^he^a^l^t^h^st^a^t^{us i}ⁿ^dⁱ^c^a^t^o^r^s.^Iⁿ^t^h^e^r^e^p^o^r^t^l^a^ngua^ge^t^o^t^h^e^w^o^u^l^d^s^p^ecif^y^an^adj^u^s^t^m^eⁿ^t^{to th}^{e ben}^c^h^m^ark^s^to^ph^as^e-
^s^.or^{Medicare, Medicaid, an}^{d SC}^HIP^B^a^lan^c^e^d^B^u^dg^et^o^u^t^o^v^er^{all in}^cr^{eases in}^MA^r^a^{tes th}^{at ar}^{e th}^{e r}^e^su^lt^o^f^th^e
^le^ak^R^e^fⁱⁿ^e^m^eⁿ^t^A^c^t^of^{1999, C}^oⁿ^g^r^es^s^u^r^g^e^{d t}^h^{e S}^ecret^ary^t^o^b^u^d^g^{et n}^e^u^t^r^a^{l im}^p^l^em^en^tatioⁿ^o^f^rⁱ^sk^ad^j^u^stm^eⁿ^t^.
^im^plem^en^{t a m}^o^{re clin}^ically^-^b^a^s^{ed ris}^k^adj^u^s^t^m^eⁿ^t
^://wiki^m^e^t^h^odol^og^y^wⁱ^t^h^ou^t^redu^ciⁿ^g^ov^eral^l^pay^m^en^t^s^t^o^pl^an^s^.^C^h^aⁿ^g^e^s^t^o^t^h^{e ben}^c^h^m^ar^k:^In^{2007, i}^f^t^h^{e S}^ecret^ary
^h^ttp^T^o^k^{eep pay}^m^en^ts^f^r^om^bein^g^redu^{ced ov}^{erall, th}^e^doesⁿ^o^t^rebas^e^rat^e^s^t^o^100%^of^{per capi}^t^a^f^ee-^f^o^r-^s^e^rvⁱ^c^e
^Secr^etar^y^ap^p^lied^{a b}^u^d^g^{et n}^e^u^t^r^a^lity^ad^j^u^stm^eⁿ^t^to^th^{e r}ⁱ^sk^cos^t^s^,^t^h^{e MA}^ben^c^h^m^ark^s^w^o^ul^d^b^e^equ^a^l^t^o^t^h^{e 2006}
^a^d^j^u^s^t^{ed rat}^e^s^.^H^o^w^e^v^e^{r, t}^h^{e S}^ecret^ary^h^a^s^propos^ed^t^o^rat^e^s^as^anⁿ^o^uⁿ^ced^by^t^h^{e S}^ecret^ary^on^A^p^ri^l^{4, 2005, w}ⁱ^t^h
^p^h^ase^-^o^u^{t th}^{e b}^u^d^g^{et n}^e^u^t^r^a^lity^ad^j^u^stm^eⁿ^t^citin^g^stu^d^ies^fo^ur^a^d^j^u^st^m^e^nt^{s —}⁽¹⁾^e^x^c^l^u^sⁱ^o^{n o}^f^aⁿ^y^na^tⁱ^o^na^l
^t^h^at^s^h^ow^{a di}^f^f^e^ren^c^eⁱⁿ^t^h^{e report}^e^{d h}^eal^t^h^s^t^at^u^s^of^a^d^j^u^s^t^m^e^nt^{s fo}^r^c^o^dⁱ^{ng i}ⁿ^t^e^nsi^t^y^,⁽²⁾^e^x^c^l^usi^o^{n o}^f^rⁱ^s^k
^Medicar^e^Adv^aⁿ^t^ag^e^en^rollees^com^p^{ared to th}^{e reported}^ad^j^u^stm^eⁿ^t^b^u^d^g^{et n}^e^u^t^r^a^lity^{, (}³⁾ⁱⁿ^cr^e^a^{se b}^a^sed^oⁿ^th^e
^h^ealth^statu^s^o^f^b^eⁿ^e^fⁱ^ciar^{ies in}^tr^ad^itioⁿ^a^{l Med}ⁱ^car^e.ⁿ^a^tioⁿ^a^{l p}^e^r^cap^{ita MA}^g^r^o^w^th^p^e^r^cen^tag^e^{, an}^d⁽⁴⁾
^om^is^sⁱ^on^of^an^y^adj^u^s^t^m^eⁿ^t^s^to^accouⁿ^t^f^o^{r errors}ⁱⁿ
^p^r^ev^io^u^s^y^ear^s’^p^r^o^j^ectioⁿ^s^o^f^th^{e n}^a^tioⁿ^a^{l p}^e^r^cap^{ita MA}
^g^r^ow^th^percen^tag^e^{. If}^th^{e Secretary}^does^rebas^e^th^e^rates
ⁱⁿ^{2007, t}^h^{e MA}^ben^c^h^m^ark^w^o^u^l^d^{be s}^e^t^at^t^h^{e g}^r^eat^{er of}
^ei^t^h^{er t}^h^{e rat}^e^cal^cu^l^a^t^e^{d abov}^{e, or}^100%^of^{per capi}^t^a^f^ee-
^f^o^r-^s^e^rvⁱ^{ce s}^p^en^diⁿ^gⁱⁿ^t^h^{e ar}^e^a^.^A^f^t^e^{r 2007, i}^f^t^h^e

CRS-22
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^Secretary^doesⁿ^o^{t rebas}^e^rates^,^the^M^A^ben^c^h^m^ark^s
^w^oul^d^{be t}^h^{e prev}ⁱ^o^u^s^y^ear’^s^ben^c^h^m^ark^(pri^{or t}^o^t^h^e
^applⁱ^catⁱ^oⁿ^of^t^h^{e ph}^as^e-^ou^t^percen^t^a^g^e^di^s^c^u^s^s^e^{d bel}^o^w⁾
ⁱⁿ^creas^{ed by}^th^{e n}^a^tion^a^{l per capita MA}^g^r^o^w^t^h
^p^e^r^cen^t^a^g^e^w^ith^o^u^{t ad}^j^u^stin^g^f^o^r^er^r^o^r^sⁱⁿ^th^{e estim}^atioⁿ
^of^t^h^{e g}^r^ow^t^h^percen^t^a^g^e^f^o^{r a y}^{ear bef}^o^re²^{004. A}^f^t^e^r
^{2007, i}^f^t^h^{e S}^ecret^ary^rebas^e^s^rat^e^s^,^t^h^e^ben^c^h^m^ark^w^o^u^l^d
^{be equ}^a^{l to th}^{e g}^r^eater^of^eith^{er th}^{e rate calcu}^{lated abov}^e,
^{or 100%}^of^{per capi}^t^a^f^ee-^f^o^r-^s^e^rvⁱ^{ce s}^p^en^diⁿ^g^.
ⁱ^{ki/CRS-RL33251}^Pha^s^ing^o^u^{t Bud}^g^e^{t Neutra}^{lity f}^o^{r Risk}^Ad^justm^eⁿ^{t: T}^h^eⁿ^e^w^ben^c^h^m^ark^s^des^c^ri^{bed abov}^{e w}^o^u^l^{d be fr}^{ee of}^t^h^e
^g/w^b^u^d^g^e^t^ne^u^t^r^a^l^rⁱ^{sk a}^d^j^u^st^m^e^nt^.^H^o^w^e^ve^r^,^t^h^e^ne^w
^s^.or^b^eⁿ^c^h^m^ar^k^s^w^o^u^l^d^b^e^ad^j^u^sted^so^th^{at b}^u^d^g^{et n}^e^u^t^r^a^lity
^le^ak^w^o^u^l^{d be ph}^as^ed-^o^u^t^ov^{er f}^o^u^r^y^ears^.^T^h^{e applicable}
^://wiki^ph^as^e-^ou^t^f^act^ors^w^o^u^l^{d be equ}^a^l^t^o^{.55 i}ⁿ^{2007, .40}ⁱⁿ^{2008, .}²^{5 i}ⁿ^{2009 an}^{d .05 i}ⁿ^{2010. T}^hⁱ^s^m^ean^s^t^h^atⁱⁿ
^h^ttp^2007,^55%^of^t^h^{e pay}^m^en^t^t^o^pl^an^s^w^o^u^l^{d be bas}^e^d^on^t^h^e
^bu^dg^{et n}^e^u^t^{ral ris}^k^adj^u^s^t^m^eⁿ^t^{, and}⁴⁵^%^of^th^{e pay}^m^en^t
^t^o^pl^an^s^w^o^u^l^{d be bas}^e^{d on}^{a rat}^e^wⁱ^t^h^ou^t^t^h^{e bu}^dg^et
ⁿ^e^u^t^r^a^l^a^d^j^u^stm^eⁿ^t^{. A}^d^d^itioⁿ^a^lly^{, th}^{e b}^eⁿ^c^h^m^ar^k^w^o^u^l^d
^b^e^m^u^ltip^lied^b^y^a^c^o^m^p^l^e^x^f^o^r^m^u^l^{a th}^{at eq}^u^a^{ls th}^e
^Secretary^’^s^es^tim^{ate of}^th^{e total am}^ouⁿ^t^of^pay^m^en^ts^th^at
^w^o^u^l^d^h^a^v^e^b^een^m^a^d^e^to^p^l^an^{s w}^ith^b^u^d^g^{et n}^e^u^t^r^a^lity^,
^divⁱ^{ded by}^th^{e Secretary}^’^s^es^tim^ate^of^th^{e total am}^ouⁿ^t^of
^p^a^y^m^en^{ts th}^{at w}^o^u^l^d^b^e^m^a^d^e^w^ith^o^u^{t b}^u^d^g^{et n}^e^u^t^r^a^lity^.
^W^h^en^m^a^kⁱⁿ^g^th^is^calcu^lation^,^th^{e Secretary}^w^o^u^l^{d (a) u}^s^e
^{a com}^p^{lete s}^e^{t of}^th^{e m}^o^s^t^rece^nt^aⁿ^{d repres}^en^tativ^{e MA}
^ris^k^s^c^ores^av^{ailable, (b) adj}^u^s^t^th^{e ris}^k^s^c^ores^{to ref}^l^ect

CRS-23
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^ch^an^g^e^sⁱⁿ^treatm^eⁿ^t^an^{d codin}^g^practicesⁱⁿ^f^ee-^f^o^r-
^s^e^rv^{ice, an}^{d (c) adj}^u^s^t^t^h^{e ris}^k^s^c^ores^f^o^{r dif}^f^e^ren^cesⁱⁿ
^codin^g^pattern^s^uⁿ^d^{er Medicare P}^a^{rt A}^an^d^B^com^p^ared^to
^M^A^plan^s^{to th}^{e ex}^ten^t^th^{e Secretary}^h^a^s^iden^tif^ie^d
^dif^f^e^ren^ces^an^{d (d) as}ⁿ^eces^s^a^ry^{, adj}^u^s^t^f^o^{r late data}
^s^u^b^m^issioⁿ^s,^la^gge^d^c^o^ho^r^t^s,^aⁿ^d^c^h^a^nge^{s in M}^A
^enr^o^l^l^m^en^{t. T}^h^{e Secretar}^y^cou^l^{d tak}^eⁱⁿ^{to accou}ⁿ^t
^es^tim^a^t^e^d^health^ris^k^of^en^rolleesⁱⁿ^pref^{erred prov}^ider
^o^r^gaⁿⁱ^z^a^tⁱ^o^{ns (}ⁱ^nc^l^u^dⁱ^{ng M}^A^r^e^gi^oⁿ^a^l^p^l^aⁿ^s)^fo^r^t^h^e^y^e^a^r^.
^T^h^{e Secretary}^w^o^u^l^{d be requ}^ired^{to con}^d^u^c^{t a s}^t^u^d^y^of^th^e
ⁱ^{ki/CRS-RL33251}^dif^f^e^ren^{ce betw}^een^treatm^eⁿ^t^an^d^codin^g^pattern^s^betw^een^MA^pl^an^s^an^{d prov}ⁱ^d^ers^uⁿ^d^{er Part}^s^A^an^{d B of}^Medi^care
^g/w^u^sⁱⁿ^g^dat^a^s^t^artⁱⁿ^gⁱⁿ^{2004. T}^h^e^fi^ndⁱⁿ^g^s^w^o^u^l^{d be}
^s^.orⁱⁿ^corporat^{ed i}ⁿ^t^o^cal^cu^l^a^tⁱ^oⁿ^s^of^MA^ben^c^h^m^ark^sⁱⁿ^2008,
^le^ak²⁰⁰⁹^{, an}^{d 2010. N}^o^adj^u^s^t^m^eⁿ^t^s^w^o^u^l^{d be m}^a^{de i}^f
^://wiki^pay^m^en^tsⁱⁿ^creas^{ed relativ}^{e to cu}^rren^{t law}^.
^h^ttp^T^h^{e Secretary}^cou^l^{d n}^o^{t m}^a^k^e^an^y^adj^u^s^t^m^eⁿ^t^s^{to MA}
^ben^c^h^m^ark^s^{, oth}^e^{r th}^an^th^os^{e s}^p^ecifⁱ^{ed abov}^{e. T}^h^e
^Secretary^’^s^au^th^ority^to^ris^k^adj^u^s^t^MA^ben^c^h^m^ark^s^bas^e^d
^on^100%^of^{per capi}^t^a^f^ee-^f^o^r-^s^e^rvⁱ^{ce s}^p^en^diⁿ^g^w^o^u^l^{d n}^o^t
^b^e^lim^ited^b^y^th^{ese ch}^an^g^e^s.
^Est^a^b^lⁱ^s^h^m^en^t^o^f^PA^C^E^Pro^v^id^{er G}^r^an^t^PA^C^Eⁱ^s^{a prog}^ram^provⁱ^dⁱⁿ^g^com^p^reh^eⁿ^sⁱ^v^{e Medi}^care^S^ecti^oⁿ^5302.^T^h^{is p}^r^o^v^isioⁿ^cr^{eates site d}^e^v^e^lo^p^m^en^t
^ogr^a^m^.^an^{d Medicaid s}^e^rv^ices^uⁿ^d^{er a}^m^aⁿ^a^g^e^{d care arran}^g^e^m^eⁿ^t^g^r^an^ts^{, prov}^ides^techⁿⁱ^{cal as}^sⁱ^s^t^aⁿ^{ce to es}^tablis^h^e^{d ru}^ral
^toⁱⁿ^dⁱ^vⁱ^d^u^{als o}^v^er^a^g^e⁵⁵^w^h^o^ar^{e elig}^ib^{le f}^o^r^{a n}^u^r^sin^g^P^A^{CE p}^r^o^v^id^er^{s, an}^d^estab^lish^e^{s an}^o^u^tlier^f^uⁿ^d^f^o^r^r^u^r^a^l
^ho^m^e^l^e^ve^l^o^f^c^a^r^e^.^P^A^CE^o^r^gaⁿⁱ^z^a^tⁱ^o^ns,^w^hⁱ^c^h^a^r^e^p^u^b^lⁱ^c^P^A^C^E^prov^iders^.^A^ru^{ral area w}^o^ul^d^b^e^{a cou}ⁿ^t^y^th^{at is}
^o^r^p^r^iv^{ate n}^oⁿ^-^p^r^o^f^{it en}^{tities, receiv}^e^{a f}ⁱ^x^e^d^m^oⁿ^t^h^l^yⁿ^o^{t p}^a^r^t^o^f^a^Metr^o^p^o^litan^{Statistical A}^r^{eas (}^a^{s d}^e^fⁱⁿ^e^d^b^y
^{Medicare an}^{d Medicaid pay}^m^en^{t to cov}^e^{r a com}^p^reh^eⁿ^s^iv^e^th^{e Of}^fⁱ^{ce of}^Man^a^g^e^m^eⁿ^t^an^{d B}^u^dg^{et) as}^es^tablis^h^e^{d f}^o^r
^{set o}^f^ser^v^{ices f}^o^r^P^A^{CE p}^a^r^ticip^an^{ts. T}^h^{e P}^A^{CE ser}^v^ice^{Medicare IP}^P^S^pay^m^en^ts^{to acu}^{te ca}^{re h}^o^s^p^itals^{. T}^h^e

CRS-24
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^pack^ag^{e m}^u^s^tⁱⁿ^clu^d^{e all Medicare an}^{d Medicaid cov}^e^red^Secr^etar^y^w^{ill estab}^lⁱ^s^h^{a p}^r^o^ced^u^r^{es to}^aw^ar^d^site
^s^e^rv^ices^{, an}^{d oth}^e^{r s}^e^rv^ices^determⁱⁿ^{ed n}^eces^s^a^ry^by^th^e^dev^e^l^opm^en^t^g^r^an^t^s^t^o^u^p^t^o¹⁵^qu^alⁱ^fⁱ^e^{d PA}^C^E^provⁱ^d^ers
^m^u^ltid^iscip^lin^ar^y^team^f^o^r^th^{e car}^{e o}^f^th^{e P}^A^CE^th^{at s}^e^rv^{e a ru}^{ral area. T}^h^es^{e prov}^iders^are^r^u^r^a^l^P^A^C^E
^p^a^r^ticip^an^t.^{pilot s}^ites^.^T^h^e^P^A^C^E^g^r^an^ts^w^o^u^l^{d n}^o^{t ex}^{ceed $750,000.}
^T^h^e^Secretary^is^{appropriated $7.5 m}^illionⁱⁿ^{FY2006 ou}^t
^of^th^{e T}^r^eas^u^r^y^f^o^{r th}^es^{e dev}^e^lopm^en^{t g}^r^ants^an^{d rem}^aⁱⁿ
^av^{ailable f}^o^{r ex}^pen^d^itu^re^uⁿ^{til FY2008. T}^h^{e Secretary}
^w^{ill estab}^lish^{a tech}ⁿⁱ^{cal assistan}^ce^p^r^o^g^r^a^m^to^p^r^o^v^id^{e (}¹⁾
^o^u^treach^an^d^ed^u^catioⁿ^to^sp^ecifⁱ^ed^en^{tities in}^terestedⁱⁿ
^s^t^artin^g^ru^{ral P}^A^C^E^prog^ram^s^{, an}^{d (2)}^techⁿⁱ^cal^as^sⁱ^s^t^an^ce
ⁱ^{ki/CRS-RL33251}ⁿ^eces^s^a^ry^t^o^s^u^{pport ru}^{ral P}^A^C^E^{pilot s}^ites^.^Aⁿ^ou^tlier^f^uⁿ^d^f^o^rⁱⁿ^p^a^tien^t^an^d^r^e^lated^p^h^y^s^ician^an^d^an^cillar^y
^g/w^co^{sts in}^cu^r^r^e^d^f^o^r^an^e^lⁱ^g^ib^{le p}^a^r^ticip^an^{t w}^ithⁱⁿ^{a g}ⁱ^v^eⁿ
^s^.or¹²^-^m^oⁿ^t^h^p^e^rⁱ^o^dⁱ^s^r^e^q^u^ir^ed^{. Ou}^tlier^co^{sts ar}^{e th}^o^s^e
^le^akⁱⁿ^patⁱ^eⁿ^t^an^d^ot^h^e^{r cos}^t^sⁱⁿ^ex^ces^s^of^{$50,000 i}ⁿ^cu^rred
^://wiki^w^ithⁱⁿ^{a g}ⁱ^v^eⁿ¹²^-^m^oⁿ^t^h^p^e^rⁱ^o^d^f^o^r^an^elig^ib^{le p}^a^r^ticip^an^t^w^h^{o res}ⁱ^desⁱⁿ^{a ru}^{ral area. For th}^{e f}ⁱ^rs^{t th}^{ree y}^ears^of^its
^h^ttp^o^p^e^rati^oⁿ^,^a^r^u^{ral P}^A^{CE site w}^{ill receiv}^e⁸⁰^%^o^f^th^e
^ou^{tlier cos}^t^sⁱⁿ^ex^ces^s^of^{$50,000 f}^o^{r th}^{at period. T}^o^tal
^o^u^tlier^p^a^y^m^en^{ts f}^o^r^aⁿ^elig^ib^{le p}^a^r^ticip^an^{t co}^u^l^dⁿ^o^t
^ex^{ceed $100,00}⁰^f^o^{r th}^{e 12 m}^oⁿ^t^h^{period u}^s^{ed to}
^calcu^{late th}^{e pay}^m^en^{t. No s}^{ite m}^a^y^receiv^e^m^o^{re th}^an
^{$500,000 in}^{total ou}^tlier^ex^pen^s^e^pay^m^en^tsⁱⁿ^{a period. A}
^ru^ral^P^A^C^E^{pilot s}^{ite is}^requ^{ired to acces}^s^an^d^ex^h^a^u^s^t^ris^k
^res^e^rv^es^h^e^{ld or arran}^g^e^{d f}^o^{r th}^{e prov}^{ider an}^{d an}^y
^w^o^rkⁱⁿ^g^{capital am}^ouⁿ^t^s^{prior to receiv}ⁱⁿ^g^an^y^pay^m^en^t
^f^r^o^m^th^{e o}^u^tlier^f^uⁿ^d^{. T}^h^{e Secr}^etar^y^is^ap^p^r^o^p^r^iated^$¹⁰
^m^illioⁿ^f^o^{r FY2006 f}^o^{r th}^{e ou}^{tlier f}^uⁿ^d^w^h^ich^are
^a^v^aⁱ^l^a^b^l^e^fo^r^e^x^p^e^ndⁱ^t^u^r^e^t^h^r^o^{ugh FY}^{2010. T}^h^{e S}^ecret^ary

CRS-25
^Provisⁱ^on^{Current L}^a^w^{Conference Agreem}^{ent as}^pas^s^{ed by the Senate}
^is^r^e^q^u^ir^ed^to^su^b^m^{it a r}^e^p^o^r^{t to}^Coⁿ^g^r^{ess o}ⁿ^th^e
^ev^alu^a^ti^oⁿ^o^f^th^{e r}^u^r^a^{l P}^A^{CE p}^ilo^{t sites n}^o^later^th^an⁶⁰
^m^oⁿ^t^h^s^fr^o^m^t^h^{e date of}^en^actm^eⁿ^t^{. A}ⁿ^y^am^ouⁿ^t^paid
^uⁿ^d^er^th^{is au}^th^o^r^ity^w^o^u^l^d^b^eⁱⁿ^ad^d^itioⁿ^to^Medⁱ^car^e
^PA^C^E^f^uⁿ^d^s^pai^d^uⁿ^d^e^r^Sectⁱ^oⁿ^{1894 of}^t^h^{e S}^o^ci^al
^S^ecu^ri^t^y^A^c^t^{or Medi}^cai^{d PA}^C^E^f^uⁿ^d^s^pai^d^f^o^{r u}ⁿ^d^er
^S^ectⁱ^oⁿ^{1934 of}^t^h^{e s}^a^m^e^act^.
ⁱ^{ki/CRS-RL33251}
^g/w
^s^.or
^le^ak
^://wikiTitle VI. Medicaid and SCHIP
^h^ttp
. MedicaidChapter 1. Payment for Prescription Drugs
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent as}^pas^s^{ed by the Senate}
^M^odific^a^t^{ion of Fe}^de^r^a^{l Uppe}^r^P^a^y^m^eⁿ^t^States^s^e^{t th}^{e am}^ouⁿ^t^s^{to pay}^ph^arm^acies^f^o^{r ou}^tpatien^t^S^ecti^oⁿ^6001.(a).^T^h^{e con}^f^eren^{ce ag}^reem^en^{t applies}
^M^u^ltiple^S^our^c^e^Dr^ugs^{; De}^{finition of}^p^r^escr^ip^tioⁿ^d^r^u^g^s^p^r^o^v^id^ed^to^{Medicaid en}^rollees^{. States}^FUL^s^to^m^u^ltip^{le so}^u^r^{ce d}^r^u^g^s^f^o^r^w^h^ich^th^e^FDA^h^a^s
^u^lt^{iple Source Drugs.}^pay^th^os^{e am}^ouⁿ^t^s^to^p^h^a^r^m^acies^an^{d th}^en^s^eek^rat^e^{d t}^w^{o or m}^o^{re produ}^ct^s^t^o^{be t}^h^e^r^a^p^e^u^tⁱ^cal^l^y^an^d
^rei^m^burs^e^m^eⁿ^t^of^t^h^{e f}^e^deral^s^h^{are of}^t^h^os^{e pay}^m^en^t^s^.^ph^arm^aceu^tically^equⁱ^v^a^len^t^{. For t}^hos^{e dru}^g^s^{, th}^{e FUL}
^{Federal reim}^bu^rs^em^en^ts^{to s}^t^ates^f^o^r^s^t^{ate s}^p^en^din^g^f^o^r^w^o^u^l^{d be equ}^a^l^t^o^250%^of^t^h^{e av}^erag^{e m}^aⁿ^u^f^act^u^r^{er pri}^c^e
^cer^tain^o^u^t^p^atien^t^p^r^escr^ip^tioⁿ^dru^g^s^{are s}^u^bj^{ect to ceilin}^g^s^com^p^u^t^{ed w}ⁱ^t^h^ou^t^reg^a^{rd t}^o^p^r^om^pt^pay^di^s^c^ouⁿ^t^s^.
^called^f^e^d^e^r^a^{l u}^p^p^e^r^lim^its⁽^F^UL^s)^.^T^h^{e FUL}^ap^p^{lies, in}^th^e^Ef^f^ectⁱ^v^{e Jan}^u^a^ry^{1, 2007.}

CRS-26
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent as}^pas^s^{ed by the Senate}
^ag^g^r^eg^{ate, to}^p^a^y^m^en^{ts f}^o^r^m^u^ltip^{le so}^u^r^{ce d}^r^u^g^s^{— th}^o^s^e^T^h^{e ag}^r^eem^en^{t m}^o^dⁱ^fⁱ^es^th^{e d}^e^fⁱⁿ^itioⁿ^o^f^m^u^ltip^{le so}^u^r^ce
^th^{at h}^a^v^e^{at leas}^{t th}^{ree th}^erapeu^tically^e^q^ui^v^a^len^t^dru^g^d^r^u^g^so^th^{at a d}^r^u^g^q^u^a^lif^{ies as a m}^u^ltip^{le so}^u^r^{ce d}^r^u^g^if
^v^e^rs^ion^s^.^T^h^e^C^eⁿ^t^ers^f^o^{r Medicare an}^{d Medicaid Serv}^ices^th^{ere is}^{at leas}^{t on}^{e oth}^e^{r dru}^g^s^o^{ld an}^{d m}^a^rk^e^t^{ed du}^rin^g
^(C^MS)^c^a^l^c^u^l^a^t^e^s^t^h^{e F}^U^L^t^o^{be equ}^a^l^t^o^150%^of^t^h^e^th^{e period th}^{at is}^{rated as}^th^erapeu^ti^c^a^l^l^y^equⁱ^v^a^len^t^an^d
^p^ublis^h^e^{d price f}^o^{r th}^{e leas}^{t co}^stly^th^er^ap^eu^{tic eq}^uⁱ^v^a^l^eⁿ^t^.^bⁱ^o^e^q^u^iv^alen^{t to}^it.
^T^h^{e pu}^blis^h^e^{d prices}^th^{at C}^M^{S u}^s^es^as^a^basⁱ^s^f^o^r^calcu^latin^g
^th^{e FUL}^s^{are th}^{e low}^e^s^t^of^th^{e av}^erag^{e w}^h^oles^{ale prices}
^(A^W^P^{) f}^o^{r each}^gr^o^{up of}^dru^g^equⁱ^v^a^len^t^s^.^B^r^an^{d n}^a^m^e
^d^r^u^g^s^ar^{e su}^b^j^e^c^t^t^o^an^u^p^p^e^r^lim^{it eq}^u^a^{l to}^th^{e am}^o^uⁿ^t^th^at
^p^h^ar^m^{acists m}^u^{st p}^a^y^to^acq^uⁱ^r^e^th^{e d}^r^u^g⁽^t^h^e^a^c^q^uⁱ^sitioⁿ
ⁱ^{ki/CRS-RL33251}^cos^t^{) as}^es^tim^{ated by}^th^{e s}^t^ates^.
^g/w
^s^.or^P^h^arm^aceu^{tical m}^aⁿ^u^f^actu^r^ers^w^h^os^{e dru}^g^s^{are av}^{ailable to}^{Medicaid ben}^e^fⁱ^ciaries^m^u^s^t^p^r^ov^{ide s}^t^{ate Medicaid}
^le^ak^prog^ram^s^wⁱ^t^h^rebat^e^s^.^R^e^bat^e^s^{are cal}^cu^l^a^t^e^d^bas^e^{d on}^t^h^e
^://wiki^av^erag^{e m}^aⁿ^u^f^actu^r^er’^s^price^(A^MP^{) of}^each^produ^{ct, an}^{d f}^o^r^certain^oth^e^{r produ}^cts^,^th^{e bes}^t^{price at w}^h^ich^th^e
^h^ttp^m^aⁿ^u^f^actu^r^ers^s^e^{ll th}^{e dr}^{ug. T}^h^{e A}^M^P^is^defⁱⁿ^e^{d as}^th^e
^av^erag^{e p}^rⁱ^c^{e paid to a m}^aⁿ^u^f^actu^r^{er by}^w^h^oles^alers^f^o^r
^dru^g^s^di^s^t^ri^bu^t^e^{d t}^o^ret^aⁱ^l^ph^arm^aci^es^{. C}^e^rt^aiⁿ^f^e^deral^dru^g
^p^u^r^c^ha^se^{s a}^s^w^e^{ll a}^s^se^ve^r^a^{l o}^t^he^r^sp^e^cⁱ^fic^kind^s^o^f^sa^le^s^a^r^e
^ex^em^{pt f}^r^om^th^{e A}^M^P^an^{d f}^r^o^m^th^{e bes}^t^{price calcu}^lation^.
^Sales^{at prices}^th^at^{are “}ⁿ^omⁱⁿ^{al” in}^am^ouⁿ^t^{are ex}^clu^d^ed
^f^r^om^t^h^{e com}^p^u^t^atⁱ^oⁿ^of^bes^t^pri^{ce. C}^M^S^defⁱⁿ^e^s^no^mⁱⁿ^a^l
^pri^ces^t^o^{be t}^h^os^{e t}^h^at^{are bel}^o^w^10%^of^t^h^{e A}^M^P.
^Discl^o^s^u^r^{e o}^f^{Price In}^f^o^rmat^ioⁿ^t^o^St^at^es^A^M^{P an}^{d bes}^t^pri^{ce dat}^a^{are requ}ⁱ^r^{ed t}^o^{be report}^e^{d by}^S^ecti^oⁿ^6001(b⁾^{. T}^h^{e con}^f^eren^{ce ag}^reem^en^{t w}^o^u^l^d
^P^ublic^.^m^aⁿ^u^f^actu^r^er^{s to}^{CMS n}^o^later^th^an³⁰^d^a^y^s^af^ter^th^e^d^a^{te o}^fⁱⁿ^creas^{e th}^{e requ}ⁱ^r^e^d^reportin^g^of^A^M^P^an^{d bes}^t^prices^.
^en^teringⁱⁿ^{to a rebate ag}^reem^en^{t an}^{d th}^enⁿ^o^{later th}^an³⁰^A^M^{P w}^o^u^l^{d be report}^e^{d an}^{d cal}^cu^l^a^t^e^{d o}ⁿ^{a m}^oⁿ^t^h^l^y

CRS-27
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent as}^pas^s^{ed by the Senate}
^day^s^af^{ter th}^{e las}^t^day^of^each^{rebate period.}^T^h^os^e^prices^are^b^a^{sis. I}ⁿ^ad^d^itioⁿ^,^t^h^{e ag}^r^eem^en^{t allo}^w^s^{states to}^h^a^v^e
^r^e^q^u^ir^ed^to^b^e^k^e^p^t^coⁿ^f^id^en^{tial ex}^cep^{t f}^o^r^th^{e p}^u^r^p^o^s^{e o}^f^{access to}^rep^o^r^ted^A^M^P^d^a^{ta f}^o^{r m}^u^ltip^{le so}^u^r^{ce d}^r^u^g^s^f^o^r
^carryⁱⁿ^g^ou^t^t^h^{e requ}ⁱ^r^e^m^en^t^s^of^Medi^cai^{d rebat}^e^s^,^{or t}^o^th^{e pu}^rpos^{e of}^carryⁱⁿ^g^ou^{t th}^{e Medicai}^d^p^r^og^ram^s^an^d
^p^e^r^m^{it th}^{e Co}^m^p^tr^o^ller^Gen^e^r^a^{l an}^d^th^{e D}ⁱ^r^e^c^t^o^r^o^f^th^e^w^o^u^l^d^r^e^q^u^ir^{e th}^{e Secr}^e^t^ar^y^to^dⁱ^sclo^{se su}^chⁱⁿ^f^o^r^m^atioⁿ
^C^oⁿ^g^r^es^sⁱ^on^{al B}^u^dg^{et Of}^fⁱ^{ce to rev}ⁱ^ew^th^{e in}^f^o^rm^ation^.^thr^o^{ugh a w}^e^b^s^{ite accessib}^l^e^to^{the p}^u^b^lic.^Iⁿ^ad^d^itio^n,^the
^prov^is^ion^requ^ires^th^e^Secretar^y^to^p^r^o^v^id^{e A}^M^P^s^to^states
^oⁿ^{a m}^oⁿ^t^h^l^y^b^a^{sis an}^d^to^u^p^d^a^{te in}^f^o^r^m^atioⁿ^p^o^s^ted^to^th^e
^w^e^bs^{ite on}^{at leas}^{t a qu}^arterly^basⁱ^s^.
^Defⁱⁿⁱ^tⁱ^oⁿ^o^f^A^v^erag^{e M}^aⁿ^u^f^act^u^r^{er Price.}^T^h^{e A}^M^P^is^d^e^fⁱⁿ^e^d^a^s^t^h^{e av}^erag^e^price^paid^to^a^S^ecti^oⁿ^6001(c).^T^h^{e con}^f^eren^{ce ag}^reem^en^{t am}^en^ds^th^e
ⁱ^{ki/CRS-RL33251}^m^aⁿ^u^f^act^u^r^{er by}^w^h^ol^es^al^ers^f^o^{r dru}^g^s^di^s^t^ri^bu^t^e^{d t}^o^ret^aⁱ^l^ph^arm^acies^{. C}^M^Sⁱⁿ^s^t^ru^cts^m^aⁿ^u^f^actu^r^ers^{to ex}^clu^d^{e certain}^d^e^fⁱⁿ^itioⁿ^o^f^A^M^P^to^ex^clu^d^{e cu}^sto^m^ar^y^p^r^o^m^p^t^p^a^y^dis^c^ouⁿ^t^s^ex^ten^d^{ed to w}^h^oles^alers^f^r^om^th^os^{e am}^ouⁿ^t^s^.^In
^g/w^f^e^deral^dru^g^pu^rch^a^s^e^s^as^w^e^l^l^as^f^r^{ee g}^oods^f^r^o^m^t^h^e^ad^d^itioⁿ^,^th^{e ag}^r^eem^en^{t m}^o^dⁱ^fⁱ^{es th}^{e p}^r^ic^e^r^e^p^o^r^tin^g
^s^.or^com^p^u^t^ation^of^A^M^P^.^Sales^{at n}^o^mⁱⁿ^a^{l prices}^{are ex}^clu^d^ed^requ^irem^en^ts^s^o^th^{at m}^aⁿ^u^f^actu^r^ers^w^o^u^l^{d be requ}^{ired to}
^le^ak^f^r^om^th^{e bes}^t^{price com}^p^u^t^ation^.^Man^u^f^actu^r^ers^{are requ}^ired^s^u^bm^{it, n}^o^{t later th}^an³⁰^d^a^y^s^a^f^{ter th}^{e las}^t^day^of^each
^://wiki^{to report, f}^o^{r each}^rebate^p^e^rⁱ^o^d^,^th^{e A}^M^P^f^o^{r all Medicaid}^cov^e^red^ou^t^p^atⁱ^eⁿ^t^dru^g^produ^ct^s^an^{d t}^h^{e bes}^t^pri^{ce f}^o^r^sⁱⁿ^g^l^e^rebat^e^peri^{od, t}^h^{e cu}^s^t^om^ary^prom^pt^p^a^y^di^s^c^ouⁿ^t^s^ex^ten^d^ed^to^w^h^o^l^esaler^sⁱⁿ^ad^d^itioⁿ^to^th^{e A}^M^P^an^d^b^e^st
^h^ttp^so^u^r^{ce an}^dⁱⁿⁿ^o^v^a^to^r^m^u^ltip^{le so}^u^r^{ce d}^r^u^g^s^to^CMS.^{price reportin}^g^requ^{ired u}ⁿ^d^{er cu}^rren^t^law^.
^T^h^{e con}^f^eren^{ce ag}^reem^en^{t requ}^ires^th^{e In}^s^p^{ector Gen}^e^ral
^of^th^{e Departm}^eⁿ^t^of^Health^an^{d Hu}^m^aⁿ^Serv^ices^(HHS)
^t^o^{, n}^o^l^a^t^e^{r t}^h^an^Juⁿ^e^{1, 2006, rev}ⁱ^ew^t^h^{e requ}ⁱ^r^em^en^t^s^f^o^r,
^an^d^th^{e m}^aⁿⁿ^e^rⁱⁿ^w^h^ich^A^M^Pⁱ^s^d^e^ter^mⁱⁿ^ed^an^d^to
^su^b^m^{it to}^th^{e Se}^c^r^e^t^a^r^y^an^d^Coⁿ^g^r^{ess an}^y
^r^e^c^o^m^m^eⁿ^d^atioⁿ^s^f^o^r^ch^an^g^e^{s as d}^e^ter^mⁱⁿ^ed^to^b^e
^appropri^a^t^e^.
^T^h^{e ag}^reem^eⁿ^t^a^l^s^o^requ^ires^th^{e Secretary}^of^{HHS to}
^pr^o^m^u^l^g^a^{te a reg}^u^l^ation^clarif^yⁱⁿ^g^th^{e requ}^irem^en^ts^f^o^r

CRS-28
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent as}^pas^s^{ed by the Senate}
^an^d^th^{e m}^aⁿⁿ^e^rⁱⁿ^w^h^ich^A^M^P^s^ar^{e to}^b^e^d^e^ter^mⁱⁿ^ed^,
^takⁱⁿ^gⁱⁿ^to^coⁿ^s^id^er^atioⁿ^th^{e r}^eco^m^m^eⁿ^d^atioⁿ^s^o^f^th^e
^In^s^p^ect^{or Gen}^e^ral^.
^Exc^l^u^sⁱ^oⁿ^o^f^{Sales at}^{a No}^min^a^{l Price}^Iⁿ^ad^d^itioⁿ^to^th^{e A}^M^P^,^p^h^ar^m^a^c^e^u^{tical m}^aⁿ^u^f^actu^r^er^{s ar}^e^S^ecti^oⁿ^{6001 (d}^).^T^h^{e con}^f^eren^{ce ag}^reem^en^{t m}^odifⁱ^es^th^e
^m^Det^e^rmin^at^ioⁿ^o^f^Best^Price.^requ^{ired to report to th}^{e Secr}^etary^of^{HHS th}^e^“^b^es^t^{price” at}^m^aⁿ^u^f^actu^r^{er price reportin}^g^requ^irem^en^ts^s^o^th^{at f}^o^r
^w^h^ich^th^{e m}^aⁿ^u^f^actu^r^{er s}^e^lls^each^of^its^dru^g^produ^cts^to^cal^en^{dar q}^u^a^r^t^e^rs^begⁱⁿⁿⁱⁿ^g^on^{or af}^t^e^{r Jan}^u^a^ry^{1, 2007,}
^certain^pu^rch^a^s^e^rs^f^o^{r th}^{e pu}^rpos^{e of}^calcu^latin^g^th^{e rebate}^m^aⁿ^u^f^actu^r^er^{s w}^o^u^l^d^b^e^r^e^q^u^ir^ed^to^r^e^p^o^r^tⁱⁿ^f^o^r^m^atioⁿ^oⁿ
^am^ouⁿ^t^s^.^P^r^ice^s^t^h^{at are n}^o^mⁱⁿ^a^{l in}^am^ouⁿ^t^{are ex}^clu^d^ed^s^a^les^of^{Medicaid cov}^e^{red dru}^g^s^th^{at are m}^a^{de at a}
^f^r^om^bes^t^pri^{ce report}ⁱⁿ^g^.^N^o^mⁱⁿ^a^l^pri^ces^{are def}ⁱⁿ^e^{d by}^no^mⁱ^na^l^p^rⁱ^c^e^.
ⁱ^{ki/CRS-RL33251}^C^M^{S to be th}^os^{e th}^{at a}^r^e^b^e^low^{10% of}^th^{e av}^erag^e^m^aⁿ^u^f^actu^r^er’^s^price.^Iⁿ^ad^d^itioⁿ^,^th^{e ag}^r^eem^en^t^d^e^fⁱⁿ^e^{s th}^{e sales th}^{at ar}^{e to}^b^e
^g/w^c^o^nsi^d^e^r^e^d^no^mⁱ^na^l^fo^r^t^h^e^p^u^r^p^o^s^e^o^f^r^e^p^o^r^tⁱ^{ng no}^mⁱ^na^l
^s^.or^{price s}^a^les^an^{d f}^o^{r com}^p^u^tin^g^an^d^reportin^g^th^{e bes}^t^price.
^le^ak⁽^T^h^e^ag^reem^en^{t does}ⁿ^o^{t am}^en^{d th}^{e A}^M^P^vⁱ^s^-^a-vi^s
^://wiki^no^mⁱⁿ^a^l^pri^ces^{.) N}^o^mⁱⁿ^a^l^s^a^l^e^s^{are t}^h^os^{e m}^a^{de by}^a^m^a^nufa^c^t^ur^e^r^o^f^c^o^ve^r^e^d^d^r^{ugs a}^t^no^mⁱ^na^l^p^rⁱ^c^e^s^t^o⁽^a⁾
^h^ttp^en^{tities elig}^ib^{le f}^o^r^dⁱ^s^c^o^uⁿ^t^ed^p^r^escr^ip^tioⁿ^d^r^u^g^p^r^ices
^uⁿ^d^{er S}^ectⁱ^oⁿ^340(B)^of^t^h^e^Pu^blⁱ^c^H^eal^t^h^S^e^rvⁱ^{ce A}^c^t^;^(b)
ⁱⁿ^ter^m^ed^{iate car}^{e f}^{acilities f}^o^r^th^{e m}^eⁿ^t^ally^r^e^tar^d^ed^{, (}^c⁾
^state-^o^wⁿ^e^d^o^r^o^p^e^r^a^tedⁿ^u^r^sin^g^f^{acilities, d}⁾^an^y^o^t^h^e^r
^f^acility^o^r^en^ti^t^y^t^h^{at th}^{e Secr}^etar^y^d^e^ter^mⁱⁿ^{es is a saf}^e^ty
ⁿ^e^t^p^r^o^v^id^er^to^w^h^ich^{sales o}^f^su^ch^d^r^u^g^s^{at n}^o^mⁱⁿ^a^l^p^r^ices
^w^o^u^l^d^b^e^ap^p^r^o^p^r^{iate b}^a^se^d^oⁿ^th^{e ty}^p^e^o^f^f^acility^{, th}^e
^ser^v^{ices it}^p^r^o^v^id^{es, th}^{e p}^a^tien^t^{s ser}^v^ed^an^d^th^{e n}^u^m^b^e^r^o^f
^o^t^h^e^r^su^ch^f^{acilities elig}^ib^{le f}^o^rⁿ^o^mⁱⁿ^a^l^p^r^icin^gⁱⁿ^th^e
^ar^{ea. T}^h^{e n}^o^mⁱⁿ^a^{l p}^r^{ice lim}^itatioⁿ^s^d^oⁿ^o^{t ap}^p^l^y^to
^no^miⁿ^a^l^d^r^{ug p}^u^r^c^ha^se^{s p}^u^r^s^ua^nt^t^o^a^m^a^st^e^r^a^g^r^e^e^m^eⁿ^t
^f^o^{r procu}^r^em^en^t^of^dru^g^s^on^t^h^{e F}^e^deral^S^u^ppl^y^S^c^h^e^du^l^e^.

CRS-29
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent as}^pas^s^{ed by the Senate}
^Ret^a^{il Su}^rv^ey^Prices;^St^at^{e Paym}^eⁿ^t^an^d^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ⁶⁰⁰¹⁽^e⁾^.^T^h^e^ag^reem^en^{t allow}^s^th^{e Secretary}^to
^iliz^at^{ion Rat}^es;^{and Perf}^{ormance Rankings.}^coⁿ^t^r^act^f^o^r^ser^v^{ices f}^o^r^th^{e d}^e^ter^mⁱⁿ^atioⁿ^o^f^r^e^{tail su}^r^v^ey
^prices^f^o^{r cov}^e^{red ou}^tpatien^t^dru^g^s^th^{at repres}^en^{t a}
ⁿ^a^tion^w^{ide av}^erag^{e of}^con^s^u^m^{er pu}^rch^a^s^e^prices^f^o^r^s^u^ch
^dru^g^s^{, ne}^t^of^al^l^di^s^c^ouⁿ^t^s^an^{d rebat}^e^s^.^S^u^ch^{a con}^t^ract
^w^o^u^l^{d be aw}^{arded f}^o^{r a t}^e^rm^of^t^w^{o y}^ears^.
^T^h^e^Secr^etar^y^w^o^u^l^d^b^e^r^e^q^u^ir^ed^to^co^m^p^etitiv^ely^bⁱ^d^f^o^r
^an^o^u^tsid^{e v}^eⁿ^d^o^r^w^ith^{a d}^e^m^oⁿ^s^tr^ated^hⁱ^sto^r^yⁱⁿ
^su^r^v^eyⁱⁿ^g^an^d^d^e^ter^mⁱⁿⁱⁿ^g^oⁿ^a^r^e^p^r^esen^tativ^eⁿ^a^tioⁿ^w^id^e
ⁱ^{ki/CRS-RL33251}^b^a^sis^,^r^e^{tail p}^r^{ices f}^o^rⁱⁿ^g^r^ed^ien^t^co^{sts o}^f^p^r^escr^ip^tioⁿ
^g/w^d^r^u^g^s^{; w}^o^r^kⁱⁿ^g^w^ith^r^e^{tail p}^h^ar^m^{acies, co}^m^m^e^r^c^{ial p}^a^y^e^r^s^,
^s^.or^an^{d s}^t^at^esⁱⁿ^obt^aiⁿⁱⁿ^g^an^{d di}^s^s^e^mⁱⁿ^a^tⁱⁿ^g^pri^c^eⁱⁿ^f^o^r^m^a^tⁱ^oⁿ^;^an^{d collectin}^g^an^{d reportin}^g^p^rⁱ^c^e
^le^akⁱⁿ^f^o^rm^ation^on^{at leas}^{t a m}^oⁿ^t^h^l^y^b^a^sⁱ^s^.^T^h^{e con}^t^ract
^://wiki^w^o^u^l^dⁱⁿ^clu^d^{e th}^{e ter}^m^{s an}^d^coⁿ^d^itioⁿ^s^sp^ecifⁱ^ed^b^y^th^e^Secretary^an^{d w}^o^u^l^{d in}^clu^d^{e a requ}^irem^en^t^th^at^th^e^v^eⁿ^dor
^h^ttp^m^oⁿⁱ^t^o^{r th}^{e m}^a^rk^{etplace an}^{d report to th}^{e Secretary}^each
^tim^{e th}^er^{e is a n}^e^w^co^v^e^r^e^d^o^u^tp^atien^t^d^r^u^g^av^ailab^l^e
ⁿ^a^tion^w^{ide; an}^{d u}^{pdate th}^{e Secretary}ⁿ^o^les^s^oft^eⁿ^th^an
^m^oⁿ^t^h^l^y^oⁿ^th^{e r}^e^{tail su}^r^v^ey^p^r^{ices f}^o^r^m^u^ltip^{le so}^u^r^ce
^dru^g^s^an^{d on}^t^h^e^com^p^u^t^ed^u^pper^pay^m^en^t^lⁱ^mⁱ^t^f^o^{r t}^h^os^e
^d^r^u^g^s^{. I}ⁿ^f^o^r^m^atioⁿ^oⁿ^th^{e r}^e^{tail su}^r^v^ey^p^r^{ices o}^b^t^ain^e^d
^t^h^r^o^{ugh t}^hⁱ^s^p^r^o^c^e^ss,ⁱⁿ^c^l^udⁱ^{ng i}ⁿ^fo^r^m^a^tⁱ^o^{n o}ⁿ^si^ngl^e
^s^o^u^r^ce^dru^g^s^w^o^u^l^d^{be requ}ⁱ^r^{ed t}^o^{be prov}ⁱ^d^{ed t}^o^s^t^at^es^on
^an^on^g^oⁱⁿ^g^an^{d tim}^ely^basⁱ^s^.^T^h^{e Sec}^r^etary^w^o^u^l^{d be}
^requⁱ^r^{ed t}^o^devⁱ^s^e^an^{d i}^m^pl^em^en^t^a^m^e^aⁿ^{s f}^o^{r prov}ⁱ^dⁱⁿ^g
^acces^s^{to each}^s^t^{ate Medicaid ag}^eⁿ^cy^of^{collected price}
ⁱⁿ^f^o^r^m^atioⁿ^an^d^t^o^p^r^o^v^id^{e in}^f^o^r^m^atioⁿ^oⁿ^r^e^{tail su}^r^v^ey

CRS-30
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent as}^pas^s^{ed by the Senate}
^p^rⁱ^c^e^s^,ⁱⁿ^c^l^udⁱ^ngⁱⁿ^fo^r^m^a^tⁱ^o^{n o}ⁿ^si^ngl^e^so^ur^c^e^d^r^ugs,^t^o
^s^t^ates^{at leas}^{t m}^oⁿ^t^h^l^y^.
^T^h^{e ag}^r^e^e^m^eⁿ^{t allow}^s^s^u^ch^{a con}^t^{ract to in}^clu^d^e
ⁿ^o^tif^ica^tion^of^th^{e Secretary}^w^h^en^{a dru}^g^produ^{ct th}^{at is}
^th^erapeu^tically^an^{d ph}^arm^aceu^tically^e^q^uⁱ^v^a^len^t^an^d
^bio^e^qu^iv^alen^{t becom}^e^s^g^eⁿ^e^rally^av^{ailable. If}^th^e
^Secretary^w^e^{re to be n}^o^tif^{ied th}^at^s^u^c^h^{a produ}^{ct h}^a^s
^becom^e^g^eⁿ^e^rally^av^{ailable, th}^{e Secretary}^w^o^u^l^{d be}
^r^e^q^u^ir^ed^to^m^a^k^e^{a d}^e^ter^mⁱⁿ^atⁱ^oⁿ^w^ithⁱⁿ^sev^eⁿ^d^a^y^s^{as to}
ⁱ^{ki/CRS-RL33251}^w^h^eth^e^r^th^{e d}^r^u^g^m^{eets th}^{e d}^e^fⁱⁿ^itioⁿ^o^f^a^m^u^ltip^le^so^u^r^ce
^g/w^dru^g^s^u^bj^{ect to th}^{e application}^of^th^e^FUL^.^T^h^e^ag^reem^en^t
^s^.or^allo^w^s^th^{e Secr}^etar^y^t^o^w^a^iv^{e th}^o^s^{e p}^r^o^v^isioⁿ^s^th^e^Secretary^determⁱⁿ^e^s^{are appropriate to w}^a^iv^{e, of}^th^e
^le^ak^Fed^e^r^a^{l A}^c^q^u^isitioⁿ^Reg^u^l^atioⁿ^,^f^o^r^th^{e ef}^fⁱ^cien^t
^://wiki^im^plem^en^tation^of^th^{e con}^t^ract.^T^h^{e agr}^eem^{ent r}^e^q^u^ir^es^an^{annual r}^e^p^o^r^{t f}^r^o^m^each
^h^ttp^s^t^{ate ag}^eⁿ^c^y^.^States^{are re}^q^u^ir^ed^to^p^r^o^v^id^{e to}^th^e
^Secretary^,^th^{e pay}^m^en^{t rates}^f^o^{r all cov}^e^r^e^d^dru^g^s^,
^dⁱ^sp^en^sin^g^f^{ees an}^d^u^tⁱ^lizatioⁿ^o^f^m^u^ltip^{le so}^u^r^{ce d}^r^u^g^s
^uⁿ^d^{er th}^{e s}^t^{ate Medicaid plan}^{. T}^h^{e Se}^c^r^e^t^ary^is^requ^ired
^t^o^c^o^m^p^a^r^e^,^oⁿ^aⁿ^a^nnua^l^b^a^si^s,^fo^r^t^h^e⁵⁰^m^o^st^wⁱ^d^e^l^y
^p^r^escr^ib^ed^d^r^u^g^s^{, th}^{e n}^a^tioⁿ^a^{l r}^e^taⁱ^l^{sales p}^r^{ice d}^a^{ta f}^o^r
^each^state.^In^ad^d^itioⁿ^,^th^{e Secretary}^{is req}^u^ired^to^su^b^m^it
^ful^lⁱⁿ^fo^r^m^a^tⁱ^o^{n r}^e^ga^r^dⁱ^{ng t}^h^e^a^nnua^l^r^a^nki^{ngs t}^o
^C^oⁿ^g^r^es^s^.^T^h^{e prov}^is^ion^becom^e^s^ef^f^ectiv^{e on}^J^aⁿ^u^a^ry^1,
^2007.
^Mⁱ^s^c^e^lla^ne^ous^A^m^e^ndmeⁿ^ts^.^States^{are requ}^{ired to h}^a^v^eⁱⁿ^{place a prog}^ram^of^pros^pectiv^e^S^ecti^oⁿ^6001(f).^T^h^{e con}^f^eren^{ce ag}^reem^en^{t clarif}^ies^th^at

CRS-31
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent as}^pas^s^{ed by the Senate}
^d^r^u^g^revⁱ^ew^w^h^erein^b^e^f^o^{re each}^p^r^escrip^tioⁿ^{is f}^illed^,^th^e^th^{e r}^e^q^u^ir^em^en^t^to^p^r^o^v^id^{e p}^r^o^s^p^ectiv^{e d}^r^u^g^r^e^vⁱ^ew^{s is n}^o^t
^u^s^{e o}^f^th^{e p}^r^escr^ip^tioⁿ^is^scr^een^{ed f}^o^{r poten}^tial^dru^g^th^erapyⁱⁿ^ten^d^ed^t^o^r^e^q^u^ir^{e v}^e^rⁱ^fⁱ^catioⁿ^s^th^{at co}ⁿ^s^u^ltatioⁿ^s^w^e^r^e
^p^r^o^b^l^e^m^s.^T^h^e^r^e^q^uⁱ^r^e^m^eⁿ^tⁱⁿ^c^l^ud^e^s^l^a^ngua^ge^c^l^a^rⁱ^f^yⁱ^{ng t}^h^a^t^of^f^e^{red or ref}^u^s^e^{d. Ef}^f^ectⁱ^v^{e on}^t^h^{e dat}^e^of^en^act^m^eⁿ^t^.
ⁿ^o^thⁱⁿ^gⁱⁿ^th^{e p}^r^o^v^isi^oⁿⁱ^sⁱⁿ^ten^d^ed^to^r^e^q^u^ir^{e a p}^h^ar^m^acist
^to^p^r^o^v^id^e^th^is^coⁿ^s^u^ltatioⁿ^w^h^en^{a b}^eⁿ^e^fⁱ^ciar^y^r^e^f^u^{ses su}^ch
^{a co}ⁿ^s^u^ltatioⁿ^.
^Ef^f^ect^iv^{e Dat}^e^f^o^{r Prescrip}^tⁱ^oⁿ^Dru^g^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^6001(g)^{. Un}^les^s^oth^e^r^wⁱ^s^{e s}^p^ecifⁱ^ed,^th^e
^ov^is^ions^.^provⁱ^sⁱ^oⁿ^sⁱⁿ^S^ectⁱ^oⁿ^{6001 t}^a^k^e^ef^f^ect^on^Jan^u^a^ry^1,^2007,
^w^ith^o^u^t^r^e^g^a^r^d^to^w^h^eth^e^r^o^rⁿ^o^{t f}ⁱⁿ^a^l^r^e^g^u^l^atioⁿ^s^to^car^r^y
ⁱ^{ki/CRS-RL33251}^ou^t^su^ch^am^en^dm^en^t^s^h^a^v^e^been^prom^u^l^g^a^t^e^{d by}^s^u^ch^dat^e^.
^g/w
^s^.or^Collect^{ion and Submission}^of^Ut^iliz^at^ion^Man^u^f^actu^r^ers^are^requ^ired^to^prov^{ide rebates}^{to s}^t^ates^f^o^{r all}^S^ecti^oⁿ^6002.^{For adm}ⁱⁿⁱ^s^t^{ered dru}^g^s^admⁱⁿⁱ^s^t^{ered on}^or
^le^ak^t^a^f^o^{r Cert}^ain^Ph^y^s^ician^A^d^minⁱ^st^ered^Dr^u^g^s^.^o^u^tp^atien^t^p^r^escr^ip^tioⁿ^d^r^u^g^s^w^ith^so^m^e^ex^ce^p^tⁱ^oⁿ^s^.^af^t^e^r^Jan^u^a^ry^{1, 2006, s}^t^at^es^{are requ}ⁱ^r^{ed t}^o^provⁱ^d^e^f^o^r^t^h^e
^O^u^t^p^a^tⁱ^e^nt^pres^cri^p^tⁱ^o^{n d}^r^{ugs p}^r^o^vⁱ^d^e^d^t^h^r^o^{ugh m}^a^na^ge^d^c^a^r^e^co^llectioⁿ^an^d^su^b^m^issioⁿ^o^f^u^tilizatioⁿ^an^d^co^dⁱⁿ^g
^://wiki^o^r^g^aⁿⁱ^zatioⁿ^s^ar^{e ex}^p^licitly^ex^em^p^t^ed^f^r^o^m^th^{e r}^e^b^a^teⁱⁿ^f^o^rm^ation^f^o^{r each}^{Medicaid s}ⁱⁿ^g^l^{e s}^o^u^r^ce^dru^g^th^{at is}
^h^ttp^r^e^q^u^ir^em^en^{t. I}ⁿ^ad^d^itioⁿ^,^o^u^tp^atien^t^d^r^u^g^s^dⁱ^sp^en^sed^b^y^a^ph^y^s^ician^admⁱⁿⁱ^s^t^{ered. For dru}^g^s^admⁱⁿⁱ^s^t^{ered o}ⁿ^or
^h^o^sp^{ital an}^d^b^illed^atⁿ^o^m^o^r^e^th^an^th^{e h}^o^sp^ital’^{s p}^u^r^c^h^a^sin^g^af^t^e^{r Jan}^u^a^ry^{1, 2008, s}^t^at^es^{are requ}ⁱ^r^ed^t^o^provⁱ^d^e^f^o^{r t}^h^e
^cos^t^s^{are ex}^em^{pt f}^r^om^th^{e rebate requ}^irem^en^{t. C}^e^rtain^dru^g^s^co^llectioⁿ^an^d^su^b^m^issioⁿ^o^f^u^tilizatioⁿ^an^d^co^dⁱⁿ^g
^admⁱⁿⁱ^s^t^{ered by}^ph^y^s^ician^sⁱⁿ^th^{eir of}^fⁱ^ces^{or in}^an^oth^e^rⁱⁿ^fo^rm^atioⁿ^f^o^{r each}^Medⁱ^caid^m^u^ltip^{le so}^u^r^{ce d}^r^u^g^th^at
^o^u^t^p^a^tⁱ^e^nt^s^e^t^tⁱ^ng,^suc^h^a^s^c^h^e^m^o^t^he^r^a^p^y^,^ha^ve^o^f^t^e^{n b}^e^eⁿ^{is p}^h^y^s^ician^ad^mⁱⁿⁱ^ster^ed^.^Su^b^m^issioⁿ^{s f}^r^o^m^{states w}^{ill b}^e
^e^x^c^l^ud^e^d^fr^o^m^t^h^e^d^r^ug^r^e^b^a^t^e^p^r^o^g^r^a^m^a^l^t^h^o^{ugh t}^h^e^r^eⁱ^s^no^bas^e^{d on}^Nation^a^{l Dru}^g^C^odes^uⁿ^l^es^s^th^{e Secretary}
^s^p^ecifⁱ^{c s}^t^atu^t^ory^ex^c^l^us^ion^.^T^h^is^is^becau^s^e^prov^iders^u^s^e^s^p^ecifⁱ^{ed an}^altern^ativ^{e coding s}^y^s^t^em^{. A}^{ll oth}^e^r
^Health^c^a^r^e^C^o^m^m^oⁿ^P^r^ocedu^r^{e C}^odin^g^Sy^s^t^em^(HC^P^C^S⁾^p^r^o^v^isioⁿ^s^ar^{e id}^en^{tical to}^th^{e Ho}^u^s^{e b}^ill.

^J-^c^o^d^e^s^t^o^b^{ill t}^h^e^M^e^dⁱ^c^aⁱ^d^p^r^o^g^r^a^m^f^o^rⁱⁿ^je^c^tⁱ^b^l^e
^pres^cription^dru^g^s^{, in}^c^l^udⁱⁿ^g^can^{cer dru}^g^s^{. T}^h^{e HC}^P^C^S
^J^-^codes^{do n}^o^{t, h}^o^w^e^v^e^{r, prov}^{ide States}^w^ith^th^{e s}^p^ecifⁱ^c
^m^aⁿ^u^f^actu^r^{er in}^f^o^rm^ationⁿ^eces^s^a^ry^{to en}^able^t^h^em^{to s}^eek
^rebates^.^T^h^{e NDC}ⁿ^u^m^{ber is}ⁿ^eces^s^a^ry^fo^r^t^h^{e s}^t^{ate to bill}

CRS-32
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent as}^pas^s^{ed by the Senate}
^m^aⁿ^u^f^actu^r^ers^f^o^{r rebates}^.^C^M^{S h}^a^s^requ^es^{ted th}^at^s^t^ates
ⁱ^d^eⁿ^tif^y^{Medicaid dru}^g^s^{, s}^p^ecifⁱ^cally^th^os^{e u}^sⁱⁿ^g^HC^P^C^S
^J^-^codes^,^by^th^{eir NDC}^codes^s^o^th^at^rebates^can^{be collected}
^f^o^{r the}^s^e^dru^g^s^(L^{etter to State Medicaid Director, SMDL}
^#03-⁰⁰^{2, dat}^e^{d March}^{14, 2003). C}^M^S^h^a^s^con^c^l^u^{ded t}^h^at
^becau^s^e^of^th^is^codin^g^,^m^aⁿ^y^s^t^{ate Medicaid prog}^ram^s^h^a^v^e
ⁿ^o^{t co}^llected^r^e^b^a^{tes o}ⁿ^th^ese^d^r^u^g^s^,^r^e^su^ltin^gⁱⁿ^m^illioⁿ^s^o^f
^d^o^llar^sⁱⁿ^uⁿ^c^o^llected^r^e^b^a^tes.
^Collect^{ion and Submiss}ⁱ^{on of}^Ut^iliz^at^ion^Man^u^f^actu^r^ers^{are requ}^{ired to prov}^{ide rebates}^to^s^t^ates^f^o^r^all^S^ecti^oⁿ^6002.^{For adm}ⁱⁿⁱ^s^t^{ered dru}^g^s^admⁱⁿⁱ^s^t^{ered on}^or
ⁱ^{ki/CRS-RL33251}^t^a^f^o^r^Ce^r^t^aⁱ^{n P}^h^y^s^ic^ia^{n A}^d^minis^t^e^r^e^d^Dr^ugs^.^o^u^tp^atien^t^p^r^escr^ip^tioⁿ^d^r^u^g^s^w^ith^so^m^e^e^x^cep^tioⁿ^s^.^O^u^t^p^atⁱ^eⁿ^t^p^r^e^s^c^rⁱ^p^tⁱ^o^{n d}^r^{ugs p}^r^o^vⁱ^d^e^d^t^h^r^o^{ugh m}^a^na^ge^d^c^a^r^e^af^t^e^{r Jan}^u^a^ry^{1, 2006, s}^t^at^es^are^requⁱ^r^ed^t^o^provⁱ^d^{e f}^o^{r t}^h^e^co^llectioⁿ^an^d^su^b^m^issioⁿ^o^f^u^tilizatioⁿ^an^d^co^dⁱⁿ^g
^g/w^o^r^g^aⁿⁱ^zatioⁿ^s^ar^{e ex}^p^licitly^ex^em^p^t^ed^f^r^o^m^th^e^r^e^b^a^teⁱⁿ^f^o^rm^ation^f^o^{r e}^ach^{Medicaid s}ⁱⁿ^g^l^{e s}^o^u^r^{ce dru}^g^th^{at is}
^s^.or^r^e^q^u^ir^em^en^{t. I}ⁿ^ad^d^itioⁿ^,^o^u^tp^atien^t^d^r^u^g^s^dⁱ^sp^en^sed^b^y^a^ph^y^sⁱ^c^ian^admⁱⁿⁱ^s^t^{ered. For dru}^g^s^admⁱⁿⁱ^s^t^{ered on}^or
^le^ak^h^o^sp^ital^an^d^b^illed^{at n}^o^m^o^r^e^th^an^th^e^h^o^sp^ital’^s^p^u^r^c^h^a^sin^g^af^t^e^{r Jan}^u^a^ry^{1, 2008,}^s^t^at^es^are^requⁱ^r^{ed t}^o^provⁱ^d^{e f}^o^{r t}^h^e
^://wiki^cos^t^s^{are ex}^em^{pt f}^r^om^th^{e rebate}^requ^irem^en^{t. C}^e^rtain^dru^g^s^admⁱⁿⁱ^s^t^e^r^{ed by}^ph^y^s^ician^sⁱⁿ^th^{eir of}^fⁱ^ces^{or in}^an^oth^e^r^co^llectioⁿ^an^d^su^b^m^issioⁿ^o^f^u^tilizatioⁿ^an^d^co^dⁱⁿ^gⁱⁿ^f^o^rm^atioⁿ^f^o^{r each}^Me^dⁱ^caid^m^u^ltip^{le so}^u^r^{ce d}^r^u^g^th^at
^h^ttp^o^u^t^p^a^tⁱ^e^nt^se^t^tⁱ^ng,^suc^h^a^s^c^h^e^m^o^t^he^r^a^p^y^,^ha^ve^o^f^t^e^{n b}^e^eⁿ^is^ph^y^s^ician^admⁱⁿⁱ^s^t^{ered. Su}^bm^is^sⁱ^on^s^f^r^om^s^t^ates^w^ill
^e^x^c^l^ud^e^d^fr^o^m^t^h^e^d^r^{ug r}^e^b^a^t^e^p^r^o^g^r^a^m^a^l^t^h^o^{ugh t}^h^e^r^eⁱ^s^no^{be bas}^e^{d on}^N^a^tⁱ^oⁿ^a^l^D^r^u^g^C^odes^uⁿ^l^es^s^t^h^{e S}^ecret^ary
^s^p^ecifⁱ^{c s}^t^atu^t^ory^e^x^c^l^u^s^ion^.^T^h^is^is^becau^s^e^prov^iders^u^s^e^s^p^ecifⁱ^{ed an}^alte^rⁿ^ativ^{e codin}^g^s^y^s^t^em^{. A}^{ll oth}^e^r
^Health^{care C}^o^m^m^oⁿ^P^r^ocedu^r^{e C}^odin^g^S^y^s^t^em^(HC^P^C^S⁾^p^r^o^v^isioⁿ^s^ar^{e id}^en^{tical to}^th^{e Ho}^u^s^{e b}^ill.

^J^-^co^d^e^s^t^o^b^{ill th}^{e Med}ⁱ^caid^p^r^o^g^r^a^m^f^o^rⁱⁿ^j^ectib^le
^pres^cription^dru^g^s^{, in}^clu^dⁱⁿ^g^can^{cer d}^r^ugs^.^T^h^{e HC}^P^C^S
^J-^codes^{do n}^o^t^,^h^o^w^e^v^e^{r, prov}ⁱ^d^{e s}^t^at^es^wⁱ^t^h^t^h^e^s^p^eci^fⁱ^c
^m^aⁿ^u^f^actu^r^{er in}^f^o^rm^atioⁿ^neces^s^a^ry^{to en}^{able th}^em^{to s}^eek
^r^e^b^a^{tes. T}^h^{e NDC n}^u^m^b^e^r^isⁿ^e^c^e^s^s^a^r^y^f^o^r^th^{e state to}^b^ill
^m^aⁿ^u^f^actu^r^ers^f^o^{r rebates}^.^C^M^{S h}^a^s^requ^e^s^{ted th}^{at s}^t^ates
^iden^tif^y^{Medicaid dr}^ugs^,^s^p^ecifⁱ^cally^th^os^{e u}^sⁱⁿ^g^HC^P^C^S
^J^-^codes^,^by^th^{eir NDC}^codes^s^o^th^{at rebates}^can^{be collected}

CRS-33
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent as}^pas^s^{ed by the Senate}
^f^o^r^th^es^{e dru}^g^s⁽^L^e^t^t^e^r^t^o^St^at^{e M}^e^di^cai^d^Dⁱ^r^ect^or^{, SMDL}
^#03-^{002, dat}^e^{d March}^{14, 2003). C}^M^S^h^a^s^con^c^l^u^{ded t}^h^at
^becau^s^e^of^th^is^codin^g^,^m^aⁿ^y^s^t^ate^{Medicaid prog}^ram^s^h^a^v^e
ⁿ^o^t^co^llected^r^e^b^a^tes^oⁿ^th^{ese d}^r^u^g^s^{, r}^e^su^ltin^gⁱⁿ^m^illioⁿ^s^o^f
^d^o^llar^sⁱⁿ^uⁿ^c^o^llected^r^e^b^a^tes.
^C^hⁱ^l^{dren’s Hospit}^{al Part}^icipat^{ion in Drug}^S^ectⁱ^oⁿ^{340(B) of}^t^h^{e Pu}^blⁱ^c^H^eal^t^h^S^e^r^vⁱ^{ce A}^c^t^al^l^o^w^s^S^ecti^oⁿ^6004.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t in}^clu^d^es^a
^c^{ount P}^r^ogr^a^m^.^certain^h^ealth^{care prov}^iders^,ⁱⁿ^clu^dⁱⁿ^g^co^m^m^uⁿ^ity^h^ealth^p^r^o^v^isioⁿ^ad^dⁱⁿ^g^Ch^ild^r^eⁿ^’^{s Ho}^sp^itals^t^o^th^{e list o}^f
^cen^ters^an^{d dis}^p^roportion^a^{te s}^h^{are h}^o^s^p^itals^{, acces}^s^to^p^r^ov^iders^th^{at m}^a^y^h^a^v^e^acces^s^{to 340(B) dis}^c^ouⁿ^t^e^d
^pres^cription^dru^g^prices^th^at^are^sim^ilar^to^th^{e p}^r^{ices p}^a^id^b^y^pri^ces^{. T}^h^{e prov}ⁱ^sⁱ^on^w^o^u^l^{d becom}^e^ef^f^ectⁱ^v^{e f}^o^{r dru}^g^s
ⁱ^{ki/CRS-RL33251}^{Medicaid ag}^en^cies^af^{ter bein}^g^redu^{ced by}^m^aⁿ^u^f^actu^r^er^rebat^e^s^.^pu^rch^a^s^e^{d on}^{or af}^t^e^{r t}^h^{e dat}^e^of^en^act^m^eⁿ^t^.

^g/w
^s^.or
^le^ak
^://wiki
^h^ttp

CRS-34
sset Transfers
Subchapter A — Reform of Asset Transfer Rules
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^{Lengthening Look-Back P}^e^riod.^Cu^r^r^en^{t law}^r^e^q^u^ir^{es states to}^im^p^o^s^{e p}^eⁿ^a^lties^oⁿⁱⁿ^dⁱ^vⁱ^d^u^als^S^ecti^oⁿ^6011(a).^T^h^{e C}^oⁿ^f^eren^{ce ag}^re^e^m^en^{t w}^o^u^l^d
^w^h^o^tr^an^sf^er^{assets (}^a^{ll in}^c^o^m^e^aⁿ^d^r^e^so^u^r^{ces o}^f^th^e^am^en^{d s}^ectⁱ^oⁿ^{1917(c)(1)(B)(i}^{) of}^t^h^{e S}^o^ci^al^S^ecu^ri^t^y
ⁱⁿ^di^vⁱ^du^al^aⁿ^d^of^t^h^{e i}ⁿ^di^vⁱ^du^al^’^s^s^pou^s^e^{) f}^o^{r l}^e^s^s^t^h^an^f^aⁱ^r^A^c^t^t^o^l^e^ngt^he^{n t}^h^e^l^o^o^k^-b^a^c^k^d^a^t^e^t^o^fi^ve^y^e^a^r^s,^o^r⁶⁰
^m^a^rk^{et v}^a^lu^{e (an}^es^tim^{ate of}^th^{e v}^a^lu^{e of}^an^a^s^s^e^t^if^s^o^{ld at}^m^oⁿ^t^h^s^{, f}^o^{r al}^lⁱⁿ^com^e^an^{d ass}^e^t^s^di^s^pos^{ed of}^by^t^h^e
^th^{e p}^r^e^v^a^ilin^g^p^r^{ice at th}^{e tim}^{e it w}^a^{s actu}^a^lly^tr^an^sf^er^r^e^d⁾^.ⁱⁿ^divⁱ^du^{al af}^{ter en}^actm^eⁿ^t^{. For in}^com^e^an^{d as}^s^e^ts
^Specifⁱ^cally^{, th}^{e ru}^les^requ^{ire s}^t^ates^{to delay}^Medicaid^di^s^pos^{ed of}^pri^o^{r t}^o^t^h^e^eⁿ^act^m^eⁿ^t^dat^e^{, t}^h^{e l}^ook^back
ⁱ^{ki/CRS-RL33251}^elig^ib^ility^f^o^r^cer^tain^Medⁱ^caid^loⁿ^g^-^te^r^m^car^{e ser}^v^{ices f}^o^rⁱⁿ^divⁱ^du^als^applyⁱⁿ^g^f^o^r^careⁱⁿ^{a n}^u^r^sⁱⁿ^g^h^o^m^e^{, an}^{d, at s}^t^ate^peri^ods^of^{36 m}^oⁿ^t^h^s^f^o^{r i}ⁿ^com^e^an^{d as}^s^e^t^s^an^d⁶⁰^m^oⁿ^t^h^s^f^o^r^cer^tain^tr^u^s^{ts w}^o^u^l^d^ap^p^l^y^.

^g/w^option^,^f^o^{r certain}^{people receiv}ⁱⁿ^g^{care in}^com^m^uⁿ^ity^-^b^as^ed
^s^.or^settin^g^s^{, w}^h^o^h^a^v^e^tr^an^sf^er^r^e^d^{assets f}^o^r^{less th}^an^f^a^ir^m^a^r^k^et
^le^ak^v^a^lu^{e on}^{or af}^{ter a “}^l^ook^-^b^ack^{date.” T}^h^{e “}^l^ook^-^b^ack^date”
^://wiki^{is 3}⁶^m^oⁿ^t^h^s^p^r^io^r^to^ap^p^licatioⁿ^f^o^r^Medⁱ^caid^f^o^rⁱⁿ^co^m^e^an^d^m^o^s^t^as^s^e^t^s^di^s^pos^{ed of}^by^t^h^{e i}ⁿ^di^vi^d^u^a^l^{, an}^{d 60 m}^oⁿ^t^h^sⁱⁿ
^h^ttp^th^{e cas}^{e of}^certain^tru^s^ts^.
^Iⁿ^elig^ib^ility^f^o^r^Medⁱ^caid^co^v^e^r^a^g^e^{is lim}^ited^to^oⁿ^ly^cer^tain
^l^o^ng-term^{care s}^e^rv^ices^{, n}^o^{t all s}^e^rv^ices^cov^e^{red u}ⁿ^d^{er th}^e
^p^r^o^g^r^a^m^.^T^h^{e ser}^v^{ices f}^o^r^w^h^ich^th^{e p}^eⁿ^a^lty^ap^p^{lies in}^clu^d^e
ⁿ^u^r^sin^g^f^acility^car^{e; ser}^vⁱ^c^e^s^p^r^o^v^id^edⁱⁿ^an^yⁱⁿ^stitu^tioⁿⁱⁿ
^w^h^ich^th^e^l^e^v^e^l^o^f^car^{e is eq}^uⁱ^v^a^len^t^to^th^o^s^{e p}^r^o^v^id^ed^b^y^a
ⁿ^u^r^sⁱⁿ^g^f^acility^{; Sec}^tion^{1915(c) h}^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^ed
^w^a^iv^{er s}^e^rv^ices^{; h}^o^m^e^h^ealth^s^e^r^v^ices^{; an}^{d pers}^on^{al care}
^f^u^rn^is^h^e^dⁱⁿ^{a h}^o^m^e^{or oth}^e^{r location}^s^{. States}^m^a^y^ch^oos^{e to}
^ap^p^l^y^th^{is in}^elig^ib^ility^p^e^rⁱ^o^d^to^o^t^h^e^r^stat^e^p^l^an^loⁿ^g^-^ter^m
^{care s}^e^rv^ices^{. (T}^h^e^y^als^o^cu^rren^tly^apply^t^o^h^o^m^e^an^d
^com^m^uⁿ^ity^care^f^o^{r f}^uⁿ^c^tion^a^lly^dis^a^{bled elderly}ⁱⁿ^divⁱ^du^als

CRS-35
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^uⁿ^d^e^r^Se^c^tⁱ^oⁿ^{1929 of}^t^h^{e act}^{. T}^hⁱ^sⁱ^s^an^optⁱ^oⁿ^a^l^cov^e^rag^e
^g^r^ou^{p w}^hⁱ^c^h^operat^e^s^on^l^yⁱⁿ^T^e^x^a^s^.^{) In}^ge^ne^r^a^l^,^s^t^at^es^do
ⁿ^o^{t ex}^ten^d^th^{e pen}^a^lty^{to Medicaid’}^s^acu^{te care s}^e^rv^ices^.
^Cha^ngeⁱⁿ^Be^{ginning Da}^te^for^P^e^rⁱ^{od of}^T^h^e^p^e^rⁱ^o^d^o^fⁱⁿ^elig^ib^ility^{, o}^r^p^eⁿ^a^lty^p^e^rⁱ^o^d^,^b^e^gⁱⁿ^s^oⁿ^th^e^S^ecti^oⁿ^6011(b⁾^{. T}^h^{e C}^oⁿ^f^eren^{ce ag}^reem^en^{t am}^en^ds
^y^.^fⁱ^r^s^{t d}^a^y^o^f^th^{e f}ⁱ^r^s^{t m}^oⁿ^t^h^d^u^rⁱⁿ^g^o^r^af^ter^w^h^ich^{assets h}^a^v^e^S^e^c^tⁱ^oⁿ¹⁹¹⁷⁽^c⁾⁽¹⁾⁽^D⁾^o^f^t^h^e^S^o^cⁱ^a^l^S^e^c^u^rⁱ^t^y^A^c^t^b^y
^beenⁱ^m^properl^y^t^r^an^s^f^{erred an}^{d w}^hⁱ^c^h^doesⁿ^o^t^occu^{r i}ⁿ^an^y^ch^an^gⁱⁿ^g^th^{e star}^{t d}^a^{te o}^f^th^{e in}^elig^ib^ility^p^e^rⁱ^o^d^f^o^r^all
^o^t^h^e^r^p^e^rⁱ^o^d^o^fⁱⁿ^elig^ib^ility^.^T^h^er^{e is n}^o^lim^{it to}^th^{e len}^g^t^h^o^f^tran^s^f^ers^m^a^{de on}^{or af}^{ter th}^e^date^of^en^actm^eⁿ^t^{, to beg}ⁱⁿ
^t^h^{e pen}^a^l^t^y^peri^od.^oⁿ^t^h^e^fi^r^s^t^d^a^y^o^f^a^m^o^nt^{h d}^u^rⁱ^{ng o}^r^a^f^t^e^r^w^hⁱ^c^{h a}^sse^t^s
^h^a^v^e^b^een^tr^an^sf^er^r^e^d^f^o^r^{less th}^an^f^a^ir^m^a^r^k^e^t^v^a^lu^{e, o}^r
ⁱ^{ki/CRS-RL33251}^th^e^d^a^te^oⁿ^w^h^ich^th^{e in}^dⁱ^vⁱ^d^u^{al is elig}^ib^{le f}^o^r^Medⁱ^caid^an^d^w^o^u^l^d^o^t^h^e^rw^{ise b}^e^receivⁱⁿ^gⁱⁿ^stitu^tioⁿ^a^l^lev^e^l^care
^g/w^bas^e^{d on}^an^approv^{ed appl}ⁱ^catⁱ^o^{n f}^o^{r s}^u^ch^{care bu}^t^f^o^r
^s^.or^th^e^ap^p^licatioⁿ^o^f^th^{e p}^eⁿ^a^lty^p^e^rⁱ^o^d^,^w^h^ich^e^v^e^r^is^later^,
^le^ak^an^{d w}^hⁱ^c^h^doesⁿ^o^t^oc^c^u^r^du^riⁿ^g^an^y^peri^{od of}
ⁱⁿ^elig^ib^ility^{as a r}^e^su^{lt o}^f^an^{asset tr}^an^sf^er^p^o^licy^.^Fo^r
^://wiki^tran^s^f^ers^m^a^{de prior to th}^is^act’^s^en^actm^eⁿ^t^{, cu}^rren^t^law
^h^ttp^ap^p^lies.
^Ef^f^ect^iv^{e Dat}^e^Sect^ioⁿ^6011.^C^u^rren^tly^ef^f^ectiv^e.^S^ecti^oⁿ^6011(c)^.^T^h^{e C}^oⁿ^f^eren^{ce ag}^reem^en^{t m}^a^k^e^s^th^e
^p^r^o^v^isioⁿ^sⁱⁿ^th^{is sectio}ⁿ^ef^f^ectiv^{e o}ⁿ^o^r^af^ter^th^{e d}^a^te^o^f
^en^actm^eⁿ^t^.
^A^v^ailabilit^y^of^H^a^r^d^s^hⁱ^p^W^aⁱ^v^ers;^A^dditⁱ^onal^T^o^{protect ben}^e^fⁱ^ciaries^f^r^om^uⁿⁱⁿ^t^en^{ded con}^s^equ^eⁿ^c^e^s^a^s^a^S^ecti^oⁿ^s^6011(d⁾^an^d^(e).^T^h^{e C}^oⁿ^f^eren^{ce ag}^re^e^m^en^t
^{isions on Hardship W}^a^iv^ers.^r^e^su^{lt o}^f^asset^tr^an^sf^er^p^eⁿ^a^lties,^cu^r^r^en^{t law}^r^e^q^u^ir^{es states to}^am^en^ds^S^ectⁱ^oⁿ^1917(c)(2(D⁾⁾^of^t^h^e^S^o^ci^al^S^ecu^ri^t^y^A^c^t
^estab^lis^h^p^r^o^ced^u^r^{es f}^o^rⁿ^o^{t im}^p^o^sⁱⁿ^g^p^eⁿ^a^{lties o}ⁿ^p^e^r^s^oⁿ^s^by^addin^g^requ^irem^en^ts^th^at^s^t^ates^approv^{e u}ⁿ^d^u^e
^w^h^{o, accordin}^g^{to criteria es}^ta^blis^h^e^{d by}^th^{e Secretary}^,^can^h^a^r^d^sh^ip^r^e^q^u^ests^w^h^en^th^{e asset tr}^an^sf^er^p^eⁿ^a^lty^w^o^u^l^d
^sho^w^t^h^a^t^a^p^e^na^l^t^y^w^o^ul^dⁱ^m^p^o^s^e^aⁿ^und^ue^ha^r^d^shi^p^.^CM^S^depriv^{e th}^{e in}^divⁱ^du^{al of}^(A^{) m}^e^{dical car}^e^s^u^ch^th^{at th}^e
^g^uⁱ^dan^{ce s}^p^ecifⁱ^es^th^{at u}ⁿ^d^u^e^h^a^rds^h^{ip can}^occu^{r w}^h^enⁱⁿ^di^vⁱ^du^a^l^’s^heal^t^h^{or l}ⁱ^f^{e w}^o^u^l^{d be en}^dan^g^e^red;^{or (b)}
^applⁱ^catⁱ^oⁿ^of^t^h^{e pen}^a^l^t^y^w^o^u^l^{d depri}^v^e^t^h^eⁱⁿ^di^vⁱ^du^al^of^f^{ood, cloth}ⁱⁿ^g^,^s^h^{elter, or}^oth^e^rⁿ^eces^s^ities^of^lif^{e. States}

CRS-36
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^m^e^{dical care s}^o^th^{at h}ⁱ^s^{or h}^e^{r h}^ealth^{or lif}^{e w}^o^u^l^{d be}^{are requ}^{ired to}^prov^ide^f^o^r:^{(1) n}^o^{tice to recipien}^ts^th^at
^en^dan^g^e^red,^or^w^h^enⁱ^t^w^o^u^l^{d depri}^v^{e t}^h^{e i}ⁿ^di^vⁱ^du^al^of^f^ood,^an^uⁿ^d^u^e^h^a^rds^h^ip^ex^ception^ex^is^ts^{; a (2) a tim}^ely
^clo^t^hⁱⁿ^g^,^s^h^e^lter^,^o^r^o^t^h^e^rⁿ^{ecessities o}^f^lif^{e. T}^h^{e g}^uⁱ^d^aⁿ^c^e^proces^s^f^o^{r det}^e^rmⁱⁿⁱⁿ^g^w^h^et^h^e^{r an}^un^du^{e h}^a^rds^hⁱ^p
^ex^p^l^ain^s^th^{at u}ⁿ^d^u^e^h^a^r^d^sh^ip^d^o^e^{s n}^o^t^ex^ist^w^h^en^ap^p^licatioⁿ^w^a^iv^er^w^{ill b}^e^g^r^an^ted^f^o^r^t^h^{e in}^dⁱ^vⁱ^d^u^{al; an}^d⁽³⁾^a
^o^f^th^{e p}^eⁿ^a^lty^w^o^u^l^d^m^e^r^e^ly^cau^{se th}^{e in}^dⁱ^vⁱ^d^u^al^proces^s^uⁿ^d^{er w}^h^ich^an^adv^e^rs^e^determⁱⁿ^ation^can^be
ⁱⁿ^con^v^eⁿⁱ^en^ce^or^w^h^en^it^mⁱ^g^h^t^res^t^{rict h}ⁱ^s^{or h}^e^{r lif}^es^ty^{le bu}^t^appealed.
^w^o^u^l^{d n}^o^t^pu^t^hⁱ^m^{or h}^e^{r at}^ri^s^k^of^s^e^ri^ou^s^depri^v^atⁱ^oⁿ^.
^T^h^{e C}^oⁿ^f^eren^{ce a}^g^r^e^em^en^{t als}^o^am^en^ds^Section
^C^M^{S g}^uⁱ^dan^{ce requ}^ires^th^{at s}^t^{ate procedu}^r^es^{, at a m}ⁱⁿⁱ^m^u^m^,^{1917(c)(2) of}^th^{e Social Secu}^rity^A^c^{t to perm}^{it f}^acilities
^prov^{ide f}^o^{r a}ⁿ^d^dⁱ^s^c^u^s^s^:^{(1) a n}^o^{tice to recipien}^ts^th^{at an}ⁱⁿ^w^h^ichⁱⁿ^stitu^tioⁿ^a^lizedⁱⁿ^dⁱ^vⁱ^d^u^{als r}^e^sid^e^to^f^ile^uⁿ^d^u^e
ⁱ^{ki/CRS-RL33251}^uⁿ^d^u^{e h}^a^r^d^sh^ip^ex^cep^tioⁿ^ex^{ists; (}²⁾^{a tim}^ely^p^r^o^c^e^s^s^f^o^r^d^e^ter^mⁱⁿⁱⁿ^g^w^h^eth^e^r^an^uⁿ^d^u^e^h^a^r^d^sh^ip^w^a^iv^er^w^{ill b}^e^h^a^r^d^sh^ip^w^a^iv^er^ap^p^licatioⁿ^s^oⁿ^b^e^h^a^lf^o^f^th^{e in}^dⁱ^vⁱ^d^u^al,^w^ith^th^{e in}^stitu^ti^oⁿ^a^l^izedⁱⁿ^dⁱ^vⁱ^d^u^al’^s^coⁿ^s^en^{t o}^r^th^{at o}^f
^g/w^g^r^an^te^d^;^a^{nd (3) a proces}^s^uⁿ^d^{er w}^h^ich^an^adv^e^rs^e^th^{e pers}^on^al^repres^en^tativ^e.^If^th^{e application}^f^o^{r u}ⁿ^d^u^e
^s^.or^determⁱⁿ^ation^can^{be appealed.}^h^a^r^d^s^h^ip^o^fⁿ^u^r^sin^g^f^acility^r^e^sid^eⁿ^t^{s m}^{eets cr}^iterⁱ^a
^le^ak^s^p^ecifⁱ^{ed by}^th^{e Secre}^t^a^r^y^,^th^{e s}^t^{ate w}^o^u^l^{d h}^a^v^e^th^e
^://wiki^o^p^tioⁿ^o^f^p^r^o^v^idⁱⁿ^g^p^a^y^m^en^{ts f}^o^rⁿ^u^r^sⁱⁿ^g^f^acility^ser^v^{ices to}^h^o^ld^th^e^b^e^d^f^o^r^th^{ese in}^dⁱ^vⁱ^d^u^{als at a f}^acility
^h^ttp^w^h^{ile an}^a^p^p^licatioⁿ^{is p}^eⁿ^dⁱⁿ^g^.^Su^ch^p^a^y^m^en^{ts co}^u^l^d
ⁿ^o^t^{be m}^a^{de f}^o^{r l}^oⁿ^g^e^{r t}^h^an^{30 day}^s^.
^Dis^c^l^os^ur^e^a^{nd T}^r^e^a^t^me^{nt of A}^nnuitie^s^.^C^u^rren^t^l^a^w^provⁱ^d^es^t^h^at^t^h^e^t^e^r^m^“^t^r^u^s^t^,^”^f^o^r^pu^rpos^es^of^S^ecti^oⁿ⁶⁰¹²^{. T}^h^{e C}^oⁿ^f^eren^{ce ag}^reem^en^{t am}^en^ds
^{asset tr}^an^sf^er^{s an}^d^th^{e lo}^o^k^-^b^ack^p^e^rⁱ^o^d^,ⁱⁿ^clu^d^{es a}ⁿⁿ^u^ities^S^ectⁱ^oⁿ^{1917 of}^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t^an^d^requⁱ^r^es
^oⁿ^ly^to^th^{e ex}^ten^t^th^{at th}^{e Secretary}^o^f^DHHS^d^e^fⁱⁿ^e^s^th^em^asⁱⁿ^dⁱ^vi^d^u^a^l^{s a}^p^p^l^yⁱ^{ng f}^o^{r Medi}^cai^d-^cov^e^r^e^d^LT^{C se}^r^vⁱ^c^e^s^,
^su^ch^{. CMS g}^uⁱ^d^aⁿ^{ce (}^T^r^aⁿ^s^m^{ittal L}^e^tter⁶⁴⁾^ask^s^{states to}^u^pon^Medicaid^a^p^plication^an^{d recertif}^ication^of
^d^e^ter^mⁱⁿ^{e th}^{e u}^ltim^{ate p}^u^r^p^o^s^{e o}^f^an^anⁿ^u^ityⁱⁿ^o^r^d^e^r^to^e^lig^ib^ility^{, to}^dⁱ^sclo^{se to}^th^{e state, a d}^e^scrⁱ^p^tioⁿ^o^f^aⁿ^y
^dⁱ^stⁱ^ngui^{sh t}^h^o^s^e^t^h^a^t^a^r^e^v^a^lⁱ^d^l^y^p^u^r^c^ha^se^d^a^s^p^a^r^t^o^f^aⁱⁿ^ter^e^{st th}^{e in}^dⁱ^vⁱ^d^u^{al o}^r^co^m^m^uⁿ^ity^sp^o^u^{se h}^a^{s in}^an
^r^e^ti^r^e^m^eⁿ^t^p^l^an^f^r^o^m^th^o^s^{e th}^{at ab}^u^s^iv^ely^sh^elter^{assets. T}^o^aⁿⁿ^u^ity⁽^o^r^sim^ilar^fⁱⁿ^aⁿ^c^{ial in}^str^u^m^eⁿ^t^{, as sp}^ecifⁱ^ed^b^y
^b^e^d^eem^ed^v^a^lidⁱⁿ^th^{is r}^e^sp^{ect, th}^e^lⁱ^f^e^o^f^th^{e an}ⁿ^u^ity^m^u^st^th^{e Secretary}⁾^{, reg}^a^rdles^s^of^w^h^eth^e^{r t}^h^e^aⁿⁿ^u^ity^is
^coin^cide^w^ith^th^{e av}^erag^{e n}^u^m^{ber of}^y^ears^of^lif^e^ex^pectan^cy^irrev^o^{cable or is}^treated^as^an^{asset. Su}^ch^ap^p^licatioⁿ^o^r
^f^o^{r t}^h^{e i}ⁿ^di^vⁱ^du^al^(accordiⁿ^g^t^o^t^a^bl^esⁱⁿ^t^h^e^tr^aⁿ^sm^ittal⁾^{. If}^recertif^ication^f^o^rmⁱⁿ^clu^d^es^{a s}^t^atem^en^{t n}^a^mⁱⁿ^g^th^{e s}^t^ate

CRS-37
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^theⁱⁿ^dⁱ^vⁱ^du^{al is}ⁿ^o^{t reas}^on^ab^ly^ex^p^ected^to^liv^{e lo}ⁿ^g^e^r^th^an^as^th^{e rem}^aⁱⁿ^{der ben}^e^fⁱ^ciary^.^In^th^{e cas}^{e of}^dis^c^los^u^re
^th^{e g}^u^a^r^aⁿ^t^{ee p}^e^rⁱ^o^d^o^f^th^{e an}ⁿ^u^ity^,^t^h^eⁱⁿ^dⁱ^vⁱ^d^u^{al w}^{ill n}^o^t^con^cernⁱⁿ^g^an^anⁿ^u^ity^{, th}^{e s}^t^ate^no^tⁱ^f^ies^th^{e an}ⁿ^u^ity^’^s
^r^{eceive f}^a^ir^m^a^r^k^{et valu}^e^f^o^r^{the annuity}^b^a^sed^oⁿ^the^is^s^u^{er of}^th^{e s}^t^ate’^s^rig^h^t^as^a^p^r^ef^{erred rem}^aⁱⁿ^der
^p^r^o^j^ected^r^e^tu^rⁿ^{; in}^th^{is case, th}^{e a}ⁿⁿ^u^ity^{is n}^o^{t “}^actu^a^rⁱ^ally^ben^e^fⁱ^ciary^f^o^{r Medica}ⁱ^d^a^s^sⁱ^s^t^an^{ce f}^u^rn^is^h^e^{d to th}^e
^s^o^uⁿ^d^{” an}^{d a tran}^s^f^{er of}^as^s^e^ts^f^o^{r les}^s^th^an^f^a^ir^m^a^rk^{et v}^a^lu^eⁱⁿ^di^vⁱ^du^al^{. Is}^s^u^ers^m^a^yⁿ^o^tⁱ^f^y^pers^on^s^wⁱ^t^h^aⁿ^y^o^t^h^e^r
^h^a^s^tak^eⁿ^{place. T}^h^{e s}^t^{ate Medica}ⁱ^d^M^aⁿ^u^a^{l prov}^ides^lif^e^r^e^m^aⁱⁿ^d^e^rⁱⁿ^ter^e^{st o}^f^th^{e state’}^{s r}^e^m^aⁱⁿ^d^e^rⁱⁿ^ter^e^st.
^ex^pectan^cy^tables^{to be u}^s^{ed by}^s^t^ates^f^o^{r determ}ⁱⁿⁱⁿ^g
^w^h^e^t^he^r^aⁿ^a^nnui^t^yⁱ^s^a^c^t^ua^rⁱ^a^l^l^y^so^und^.^States^m^a^y^requ^ire^aⁿⁱ^s^s^u^{er to n}^o^tif^y^th^{e s}^t^{ate w}^h^en
^th^{ere is}^{a ch}^an^g^eⁱⁿ^th^{e am}^ouⁿ^t^ofⁱⁿ^com^e^or^p^rⁱⁿ^cⁱ^p^a^l
^w^ith^drawⁿ^f^r^om^th^{e am}^ouⁿ^t^w^ith^drawⁿ^{at th}^e^p^oⁱ^nt^of
ⁱ^{ki/CRS-RL33251}^{Medicaid application}^{or recertif}^ication^.^States^tak^e^th^isⁱⁿ^form^ationⁱⁿ^{to accou}ⁿ^t^w^h^en^determⁱⁿⁱⁿ^g^th^{e am}^ount
^g/w^o^f^th^{e s}^t^ate’^s^fⁱⁿ^aⁿ^c^{ial s}^h^{are of}^cos^t^s^{or in}^the
^s^.orⁱⁿ^dⁱ^vⁱ^d^u^al’^s^elig^ib^ility^f^o^r^Medⁱ^caid^.
^le^ak
^://wiki^T^h^e^Secretary^m^a^y^prov^{ide g}^uⁱ^dan^{ce to s}^t^ates^on^categ^ories^of^tran^s^action^s^th^{at m}^a^y^{be tre}^a^t^e^d^as^a
^h^ttp^tran^s^f^{er of}^as^s^e^{t f}^o^{r les}^s^th^an^f^a^{ir m}^a^rk^{et v}^a^lu^{e. States}
^m^a^y^d^eⁿ^y^elig^ib^ility^f^o^r^m^e^dⁱ^{cal assistan}^{ce f}^o^r^an
ⁱⁿ^di^vⁱ^du^al^bas^e^{d on}^t^h^{e i}ⁿ^com^e^{or res}^o^u^r^ces^deri^v^e^d
^f^r^om^an^anⁿ^u^ity^.
^T^h^{e C}^oⁿ^f^eren^{ce agr}^e^e^m^en^{t als}^o^am^en^ds^Section
^{1917(c)(1) of}^t^h^e^S^o^ci^al^S^ecu^ri^t^y^A^c^t^by^addiⁿ^g^t^h^at^t^h^e
^pu^rch^a^s^e^of^an^anⁿ^u^ity^{be treated as}^{a dis}^pos^{al of}^an
^a^s^s^e^t^fo^{r les}^s^th^an^f^a^{ir m}^a^rk^{et v}^a^lu^{e u}ⁿ^l^es^s^th^{e s}^t^{ate is}
ⁿ^a^m^e^d^{as th}^{e r}^e^m^aⁱⁿ^d^e^r^b^eⁿ^e^fⁱ^ciar^yⁱⁿ^th^{e f}ⁱ^r^s^{t p}^o^s^itioⁿ
^f^o^{r at leas}^{t th}^{e total am}^ouⁿ^t^o^f^M^e^{dicaid ex}^pen^d^itu^res
^p^a^id^oⁿ^b^e^h^a^lf^o^f^th^{e an}ⁿ^u^itan^t^o^r^{is n}^a^m^e^dⁱⁿ^th^{e seco}ⁿ^d

CRS-38
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^p^o^s^itioⁿ^af^ter^th^{e co}^m^m^uⁿ^ity^sp^o^u^se^o^r^mⁱⁿ^o^r^o^r^dⁱ^sab^l^ed
^ch^{ild an}^{d s}^u^ch^s^pou^s^e^{or a repres}^eⁿ^t^a^tⁱ^v^e^of^th^{e s}^u^ch
^chⁱ^l^d^doesⁿ^o^t^di^s^pos^e^of^an^y^s^u^ch^rem^aⁱⁿ^{der f}^o^{r l}^e^s^s
^th^an^f^a^ir^m^a^r^k^{et v}^a^lu^e.
^Iⁿ^clu^d^{es an}ⁿ^u^{ities p}^u^r^c^h^a^sed^b^y^o^r^oⁿ^b^e^h^a^lf^o^f^an
^a^nnui^t^a^nt^w^h^o^ha^{s a}^p^p^lⁱ^e^d^fo^r^M^e^dⁱ^c^aⁱ^d^-^c^o^ve^r^e^d^nur^si^ng
^f^acility^o^r^o^t^h^e^r^loⁿ^g^-^ter^m^car^e^ser^v^{ices in}^th^{e d}^e^fⁱⁿ^itioⁿ
^o^f^anⁿ^u^{ities th}^{at ar}^{e su}^b^j^{ect to}^{asset tr}^an^sf^er^r^u^les.
ⁱ^{ki/CRS-RL33251}^T^h^{e Co}ⁿ^f^er^en^{ce ag}^r^eem^en^{t ex}^clu^d^{es f}^r^o^m^th^{e d}^e^fⁱⁿ^itioⁿ^of^an^as^s^e^t,^th^os^{e th}^{at are des}^c^{ribed in}^s^u^bs^ection^{(b) an}^d
^g/w^{(q) of}^S^ectⁱ^oⁿ^{408 of}^t^h^e^In^t^e^rn^al^R^e^v^eⁿ^u^e^C^{ode (IR}^C⁾^of
^s^.or^1986,^or^pu^rch^a^s^e^d^w^ith^proceeds^f^r^om^{: (1) an}^accouⁿ^t
^le^ak^{or t}^r^u^s^t^des^c^ri^bedⁱⁿ^s^u^bs^ectⁱ^oⁿ^s^{(a), (c), an}^{d (p) of}
^://wiki^S^ectⁱ^oⁿ^{408 of}^t^h^{e IR}^C^;^{(2) a s}ⁱ^m^p^lⁱ^fⁱ^e^{d em}^pl^oy^ee^pen^sⁱ^oⁿ^as^defⁱⁿ^e^{d i}ⁿ^Se^c^tⁱ^oⁿ^408(k⁾^of^t^h^{e IR}^C^;^{or (3)}
^h^ttp^{a R}^o^t^h^IR^A^defⁱⁿ^e^{d i}ⁿ^Se^ctⁱ^oⁿ^408A^of^t^h^{e IR}^C^.
^Aⁿⁿ^u^{ities w}^o^u^l^d^also^b^e^ex^clu^d^ed^f^r^o^m^p^eⁿ^a^{lties if}^th^ey
^{are irrev}^o^cable^an^dⁿ^oⁿ^-^as^sⁱ^gⁿ^a^{ble, actu}^a^rially^s^o^uⁿ^d^(as
^determⁱⁿ^{ed by}^actu^a^{rial pu}^blication^s^of^th^{e Of}^fⁱ^{ce of}^th^e
^Ch^ief^A^c^tu^ar^y^o^f^th^{e So}^{cial Secu}^r^ity^A^d^mⁱⁿⁱ^str^a^tioⁿ⁾^,
^aⁿ^d^p^r^o^v^id^{e f}^o^r^p^a^y^m^en^{ts in}^eq^u^a^{l am}^o^uⁿ^t^{s d}^u^rⁱⁿ^g^t^h^e
^ter^m^o^f^th^{e an}ⁿ^u^ity^{, w}^ithⁿ^o^d^e^f^e^r^r^{al an}^dⁿ^o^b^a^llo^oⁿ
^pay^m^en^t^s^.
^T^h^{e C}^oⁿ^f^eren^ce^a^g^r^eem^en^t^am^en^ds^S^ectⁱ^oⁿ^1917(b)(4)
^o^f^th^{e So}^{cial Secu}^r^ity^A^c^{t to}ⁱⁿ^clu^d^{e an}^anⁿ^u^ityⁱⁿ^th^e
^d^e^fⁱⁿ^itioⁿ^o^f^{estate th}^{at is su}^b^j^{ect to}^e^s^t^a^t^e^r^eco^v^e^r^y
^uⁿ^l^{ess th}^{e an}ⁿ^u^ity^isⁱ^s^s^u^e^d^b^y^{a f}ⁱⁿ^aⁿ^c^{ial in}^stitu^tioⁿ^o^r

CRS-39
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^o^t^h^e^r^b^u^sin^e^{ss th}^{at sells an}ⁿ^u^{ities in}^th^e^s^t^{ate as p}^a^r^t^o^f
ⁱ^t^s^r^e^gul^a^r^b^u^si^ne^ss.
^T^h^{e am}^en^dm^en^ts^apply^t^o^tran^s^action^s^{, in}^clu^dⁱⁿ^g^th^e
^pu^rch^a^s^e^of^anⁿ^uⁱ^t^y^{, occu}^rriⁿ^g^on^or^af^t^e^r^t^h^{e dat}^e^of^t^hⁱ^s
^act’^s^en^actm^eⁿ^t^.
^A^pplic^a^t^{ion of “Inc}^ome^-^Fir^s^{t” Rule}ⁱⁿ^Reg^a^r^dⁱⁿ^gⁱⁿ^co^m^e^{, cu}^r^r^en^{t law}^ex^em^p^t^{s all in}^co^m^e⁽^e^.g^.,^S^ecti^oⁿ^6013.^T^h^{e C}^oⁿ^f^eren^{ce ag}^reem^en^{t am}^en^ds
ⁱ^{ng Community}^S^pous^e^’^s^Inc^o^me^Be^f^o^r^e^pen^s^ion^{or Social Secu}^rit^y⁾^o^f^th^{e com}^m^uⁿ^ity^s^pou^s^e^(th^e^S^ectⁱ^oⁿ^{1924(d), an}^{d t}^h^ereiⁿ^s^ectⁱ^oⁿ^s^{(c) an}^{d (e),}^o^f^t^h^e
^r^ov^{iding S}^{upport of}^C^o^mmunity^sp^o^u^{se o}^f^{a Med}ⁱ^caid^b^eⁿ^e^fⁱ^ciary^receivⁱⁿ^gⁱⁿ^stitu^tioⁿ^a^l,^o^r^at^So^{cial Secu}^r^ity^A^c^{t to}^r^e^q^u^ir^e^s^t^ates^{to con}^s^{ider th}^{at all}
ⁱ^{ki/CRS-RL33251}^e^.^s^t^{ate option}^,^h^o^m^e^an^{d com}^m^uni^t^y^-^b^as^{ed lon}^g^-^term^care^s^e^rv^ices^{) f}^r^om^bein^g^con^s^{idered av}^{ailable to th}^{e oth}^e^{r s}^pou^s^eⁱⁿ^co^m^e^o^f^th^eⁱⁿ^stitu^tioⁿ^a^lized^sp^o^u^{se th}^{at co}^u^l^d^b^e^m^a^d^e^av^{ailable to th}^{e com}^m^uⁿ^ity^s^pou^s^e^{, in}^accordan^ce^wⁱ^t^h
^g/w^f^o^r^p^u^r^p^o^s^{es o}^f^Medⁱ^caid^elig^ib^ility^{. Fo}^r^co^m^m^uⁿ^ity^sp^o^u^ses^th^{e calcu}^latioⁿ^o^f^th^{e p}^o^s^t-^elig^ib^ili^ty^allo^catioⁿ^o^f
^s^.or^wⁱ^t^h^m^o^{re l}ⁱ^mⁱ^t^e^{d i}ⁿ^com^e^,^Se^c^tⁱ^oⁿ^{1924(d) of}^t^h^{e S}^o^ci^alⁱⁿ^co^m^e^o^r^ad^d^itioⁿ^a^{l in}^co^m^e^allo^w^aⁿ^{ce allo}^cated^{at a f}^a^ir
^le^ak^Secu^r^ity^A^c^{t p}^r^o^v^id^{es f}^o^r^th^{e es}^t^a^b^lish^m^en^{t o}^f^{a m}ⁱⁿⁱ^m^u^m^h^earin^g^,^h^a^s^been^m^a^{de bef}^o^{re s}^t^ates^allocat^{e to th}^e
^m^oⁿ^t^h^l^y^m^aⁱⁿ^ten^aⁿ^{ce n}^eeds^allow^aⁿ^c^e^f^o^{r each}^com^m^uⁿ^ity^co^m^m^uⁿ^ity^sp^o^u^{se r}^e^so^u^r^{ces f}^r^o^m^th^{e in}^stitu^tioⁿ^a^lized
^://wiki^sp^o^u^{se to}^t^r^y^t^o^en^su^r^e^th^{at th}^{e co}^m^m^uⁿ^ity^sp^o^u^{se h}^a^s^s^pou^s^e^{to prov}^{ide th}^{e dif}^f^e^ren^{ce betw}^een^th^e^mⁱⁿⁱ^m^u^m
^h^ttp^s^u^ffi^cien^{t in}^com^e^{to m}^{eet h}ⁱ^s^{or h}^e^{r bas}ⁱ^{c m}^oⁿ^t^h^l^yⁿ^eed^s^.^m^o^nth^l^y^m^aⁱⁿ^ten^aⁿ^{ce n}^eeds^allow^aⁿ^{ce an}^{d all in}^com^e
⁽^T^he^c^o^m^m^uni^t^y^sp^o^u^se^{’s m}ⁱⁿⁱ^m^u^m^m^o^nt^hl^y^m^aⁱⁿ^t^e^na^nc^e^av^{ailable to th}^{e com}^m^uⁿ^ity^s^pou^s^e^.^T^h^es^{e am}^en^dm^en^ts
ⁿ^eeds^allow^aⁿ^{ce is}^s^e^t^at^a^lev^e^l^th^at^is^hⁱ^g^h^e^{r th}^an^th^{e of}^fⁱ^cial^a^p^p^l^y^to^tr^an^sf^er^{s an}^d^allo^catioⁿ^s^m^a^d^e^oⁿ^o^r^af^ter^t^h^e
^f^e^{deral pov}^erty^lev^e^{l.) On}^{ce inc}^o^m^eⁱ^s^attribu^t^{ed to each}^of^dat^e^of^t^hⁱ^s^ac^t^’^s^en^act^m^eⁿ^t^byⁱⁿ^di^vⁱ^du^al^s^w^h^{o becom}^e
^th^{e s}^p^o^u^s^e^s^accordin^g^{to th}^{eir ow}ⁿ^e^rs^hⁱ^{p in}^teres^t^{, th}^eⁱⁿ^stitu^tioⁿ^a^lized^sp^o^u^{ses o}ⁿ^o^r^af^ter^su^ch^d^a^te.
^com^m^uⁿ^ity^s^pou^s^e^’^s^m^oⁿ^t^h^l^yⁱⁿ^com^e^is^com^p^{ared ag}^ain^s^{t th}^e
^mⁱⁿⁱ^m^u^m^m^o^nt^hl^y^m^aⁱⁿ^t^e^na^nc^e^ne^e^d^{s a}^l^l^o^w^a^nc^e^.
^Reg^a^r^dⁱⁿ^g^{assets, f}^e^d^e^r^a^{l law}^allo^w^s^{states to}^{select t}^h^e
^am^o^uⁿ^t^o^f^{assets a co}^m^m^uⁿ^ity^sp^o^u^{se m}^a^y^b^e^allo^w^e^d^to
^r^e^tain^{. T}^h^{is am}^o^uⁿ^t^{is r}^e^f^e^r^r^ed^t^o^{as th}^{e co}^m^m^uⁿ^ity^sp^o^u^se
^res^o^u^r^{ce allow}^aⁿ^{ce (C}^SR^A⁾^{. Federal requ}^irem^en^ts^s^p^e^cⁱ^f^y
^t^h^at^t^hⁱ^s^am^ouⁿ^t^m^a^y^beⁿ^o^g^r^eat^er^t^h^an^{$95,100 an}^{d n}^o^l^e^s^s

CRS-40
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^t^h^an^$19,020ⁱⁿ^t^o^t^a^l^couⁿ^t^abl^e^as^s^e^t^sⁱⁿ^{2005. Wh}^en
^d^e^ter^mⁱⁿⁱⁿ^g^elig^ib^ility^,^all^{assets o}^f^th^{e co}^u^p^{le ar}^{e co}^m^bⁱⁿ^ed^,
^co^uⁿ^t^ed^,^aⁿ^d^sp^{lit in}^h^a^lf^{, r}^e^g^a^r^d^{less o}^f^o^wⁿ^e^r^s^hⁱ^p^.^I^f^th^e
^com^m^uⁿ^ity^s^pou^s^e^’^s^s^h^are^of^th^e^as^s^e^ts^is^les^s^th^an^th^{e s}^t^ate-
^s^p^ecifⁱ^{ed m}^a^xⁱ^m^u^m^,^t^h^en^th^{e Medicaid ben}^e^fⁱ^ciary^m^u^s^t
^tran^s^f^{er h}ⁱ^s^{or h}^e^r^s^h^are^of^th^e^as^s^e^ts^{to th}^{e com}^m^uⁿ^ity^s^pou^s^e
^uⁿ^{til th}^{e co}^m^m^uⁿ^ity^-^s^p^o^u^se’^s^sh^{are reach}^{es th}^{e m}^a^xⁱ^m^u^m^.
^A^l^l^ot^h^e^{r n}^oⁿ^-^ex^em^pt^as^s^e^t^s^m^u^s^t^{be dep}^l^e^t^e^d^bef^o^{re t}^h^e
^applican^{t can}^qu^alif^y^f^o^{r Medicaid.}
ⁱ^{ki/CRS-RL33251}^I^f^t^h^e^c^o^m^m^uni^t^y^sp^o^u^se^{’s m}^o^nt^hl^yⁱⁿ^c^o^m^e^a^m^o^untⁱ^s^l^e^ss^th^an^th^{e m}ⁱⁿⁱ^m^u^m^m^oⁿ^t^h^l^y^m^aⁱⁿ^ten^aⁿ^{ce n}^eeds^allow^aⁿ^{ce, th}^e
^g/wⁱⁿ^stitu^tioⁿ^a^lized^sp^o^u^se^m^a^y^ch^o^o^s^e^to^tr^an^sf^er^an^am^o^uⁿ^t^o^f
^s^.or^hⁱ^{s o}^r^h^e^rⁱⁿ^co^m^e^o^r^a^s^s^e^t^s^to^m^a^k^e^u^p^f^o^r^th^{e sh}^o^r^tf^{all (}ⁱ^.e.,
^le^ak^th^{e dif}^f^e^ren^{ce betw}^een^th^{e com}^m^uⁿ^ity^s^pou^s^e^’^s^m^ont^hl^y
ⁱⁿ^com^e^an^{d th}^{e s}^t^at^e^-^s^p^ecifⁱ^{ed m}ⁱⁿⁱ^m^u^m^m^oⁿ^t^h^l^y
^://wiki^m^aⁱⁿ^ten^aⁿ^{ce n}^eeds^allow^aⁿ^ce).^T^h^{is tr}^an^sf^er^allo^w^s^m^o^r^e
^h^ttpⁱⁿ^co^m^e^to^b^e^a^v^ailab^l^{e to}^th^{e co}^m^m^uⁿ^ity^sp^o^u^{se, w}^h^ile
^Medⁱ^caid^p^a^y^s^{a lar}^g^er^sh^ar^{e o}^f^th^eⁱⁿ^stitu^tioⁿ^a^lized^sp^o^u^se’^s
^car^{e co}^{sts. W}^ithⁱⁿ^f^e^d^e^r^a^{l lim}^{its, states set th}^{e m}^a^xⁱ^m^u^m
^m^oⁿ^t^h^l^yⁱⁿ^co^m^e^lev^e^{l th}^{at co}^m^m^uⁿ^ity^sp^o^u^ses^m^a^y^r^e^tain^.
^Fed^e^r^a^{l r}^e^q^u^ir^em^en^{ts sp}^ecif^y^th^{at th}^{is am}^o^uⁿ^t^m^a^y^b^eⁿ^o
^g^r^eat^{er t}^h^an^{$2,377.50 per m}^oⁿ^t^h^,^an^dⁿ^o^l^e^s^s^t^h^an^$1,561.25
^{per m}^oⁿ^t^hⁱⁿ^2005.
^T^h^{e Med}ⁱ^caid^b^eⁿ^e^fⁱ^ciar^y^o^r^co^m^m^uⁿ^ity^sp^o^u^se^{is en}^titled^to
^{a f}^a^ir^h^earⁱⁿ^g^if^eith^er^{is d}ⁱ^ssatisfⁱ^ed^w^ith^:⁽¹⁾^a^d^e^ter^mⁱⁿ^atioⁿ
^o^f^th^{e co}^m^m^uⁿ^ity^sp^o^u^se^m^oⁿ^t^h^l^yⁱⁿ^co^m^e^allo^w^aⁿ^{ce; (}²⁾^th^e
^a^m^o^unt^o^f^m^o^nt^hl^yⁱⁿ^c^o^m^e^o^t^he^r^wⁱ^s^e^a^v^aⁱ^l^a^b^l^e^;⁽³⁾^t^h^e
^co^m^p^u^t^atioⁿ^o^r^attr^ib^u^tioⁿ^o^f^th^{e sp}^o^u^{sal sh}^ar^{e o}^f^r^e^so^u^r^ces;

CRS-41
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^o^r⁽⁴⁾^th^{e d}^e^ter^mⁱⁿ^a^t^ioⁿ^o^f^th^{e co}^m^m^uⁿ^ity^sp^o^u^{se r}^e^so^u^r^ce
^allo^w^aⁿ^{ce. I}^f^eith^er^sp^o^u^{se estab}^lish^e^s^th^{at th}^{e co}^m^m^uⁿ^ity
^s^pou^s^eⁿ^eedsⁱⁿ^com^e^abov^{e t}^h^{e am}^ouⁿ^t^s^provⁱ^d^e^d^by^t^h^e
^mⁱⁿⁱ^m^u^m^m^oⁿ^t^h^l^yⁿ^eeds^allow^a^nc^{e, du}^{e to ex}^ception^a^l
^cir^c^u^m^staⁿ^c^e^s^r^e^su^ltin^gⁱⁿ^sigⁿⁱ^fⁱ^can^{t f}ⁱⁿ^aⁿ^c^{ial d}^u^r^e^{ss, th}^er^e
^sh^{all b}^e^su^b^s^titu^ted^f^o^r^th^{e m}ⁱⁿⁱ^m^u^m^m^oⁿ^t^h^l^y^m^aⁱⁿ^teⁿ^aⁿ^c^e
ⁿ^eed^{s allo}^w^aⁿ^{ce am}^o^uⁿ^t^s^a^d^eq^u^a^{te to}^p^r^o^v^id^{e ad}^d^itioⁿ^a^l
ⁿ^ecessar^yⁱⁿ^co^m^e^{. Fed}^e^r^a^{l law}^allo^w^s^eith^erⁱⁿ^co^m^e^o^r
^res^o^u^r^ces^f^r^om^t^h^{e s}^pou^s^e^rec^eⁱ^viⁿ^g^Medi^cai^{d t}^o^be
^tr^an^sf^er^r^e^d^to^th^{e co}^m^m^uⁿ^ity^sp^o^u^{se to}^m^{eet th}^{is n}^eed^.
ⁱ^{ki/CRS-RL33251}^Dis^qua^lific^a^t^{ion for}^Long-T^e^r^m^Ca^r^e^W^ithⁱⁿ^f^e^d^e^r^a^{l law}^,^{states set asse}^t^s^t^an^d^a^r^d^{s th}^{at ap}^p^lican^ts^S^ecti^oⁿ^6014.^T^h^{e C}^oⁿ^f^eren^{ce ag}^reem^en^{t am}^en^ds
^g/w^sⁱ^s^t^aⁿ^c^e^for^Indivⁱ^dua^ls^wⁱ^{th S}^ubs^ta^ntia^l^m^u^st^m^e^e^t^t^o^q^u^a^lⁱ^f^y^fo^r^M^e^dⁱ^c^aⁱ^d^c^o^ve^r^a^ge^.^A^m^o^{ng o}^t^he^r^S^ectⁱ^oⁿ^{1917 of}^t^h^e^S^o^ci^al^S^ecu^ri^t^y^A^c^t^t^o^ex^cl^u^d^{e f}^r^om
^s^.or^E^quity^.^thⁱⁿ^g^s^,^t^h^e^s^{e s}^t^an^dards^s^p^ecif^y^{a lim}^{it on}^th^{e am}^ouⁿ^t^of^Medⁱ^caid^elig^ib^ility^f^o^rⁿ^u^r^sin^g^f^a^c^ility^o^r^o^t^h^e^r^l^oⁿ^g^-
^le^ak^couⁿ^t^{able as}^s^e^t^s^{a pers}^on^m^a^y^h^a^v^e^{to qu}^alif^y^,^as^w^e^{ll as}^ter^m^c^a^r^e^ser^v^{ices, cer}^tainⁱⁿ^dⁱ^vⁱ^d^u^{als w}^ith^an^eq^u^ity
^defⁱⁿ^e^w^h^ich^ty^pes^of^as^s^e^ts^are^couⁿ^t^ed^an^dⁿ^o^t^couⁿ^t^{ed. In}ⁱⁿ^t^e^res^tⁱⁿ^t^h^ei^r^h^o^m^e^of^g^r^eat^{er t}^h^an^{$500,000. A}^s^t^at^e
^://wiki^g^eⁿ^e^{ral, cou}ⁿ^t^{able as}^s^e^ts^c^aⁿⁿ^o^{t ex}^{ceed $2,000 f}^o^{r an}^m^a^y^{elect, w}^ith^ou^{t reg}^a^{rd to Medicaid’}^s^r^e^q^u^irem^en^ts
^h^ttpⁱⁿ^dⁱ^vⁱ^d^u^{al ap}^p^lican^{t. States g}^eⁿ^e^r^a^lly^f^o^llo^w^SSI^r^u^{les f}^o^r^coⁿ^cerⁿⁱⁿ^g^s^t^a^t^e^wⁱ^d^eⁿ^e^s^s^aⁿ^d^c^o^m^p^ar^ab^ility^,^to
^c^o^m^p^utⁱ^{ng b}^o^t^{h c}^o^unt^a^b^l^e^aⁿ^d^no^n-c^o^unt^a^b^l^e^a^sse^t^s^.^s^u^bs^titu^{te an}^am^ouⁿ^t^th^at^ex^{ceed $500,000 bu}^{t does}ⁿ^o^t
^ex^{ceed $750,000. T}^h^es^e^d^o^l^l^a^{r am}^ouⁿ^t^s^{are in}^creas^ed,
^C^u^rren^{t Medicaid an}^{d SSI as}^s^e^t^couⁿ^tin^g^practices^g^eⁿ^e^rally^begⁱⁿⁿⁱ^ngⁱⁿ^{2011, f}^r^om^y^{ear t}^o^y^{ear bas}^e^{d on}^t^h^e
^ex^clu^d^{e th}^{e en}^{tire v}^a^lu^{e of}^aⁿ^a^p^p^l^ican^t’^s^h^o^m^e^{. A}^h^o^m^e^is^percen^tag^eⁱⁿ^creas^{e in}^th^{e con}^s^u^m^{er p}^r^{ice in}^dex^f^o^{r all}
^defⁱ^ne^{d as}^an^y^propert^yⁱⁿ^w^hⁱ^c^h^anⁱⁿ^di^vⁱ^du^al^(an^d^s^pou^s^e^,^u^r^ban^con^s^u^m^ers^{(all item}^s^{, Un}^ited^States^city^av^erag^e),
^if^an^y⁾^h^a^s^an^owⁿ^e^rs^hⁱ^{p in}^teres^t^an^{d w}^h^ich^s^e^rv^es^as^th^e^rouⁿ^d^{ed t}^o^t^h^eⁿ^eares^t^{$1,000. T}^h^{e S}^ecret^ary^es^t^a^blⁱ^s^h^e^s
ⁱⁿ^divⁱ^du^al’^s^prin^{cipal place of}^resⁱ^den^{ce. T}^h^is^p^r^o^p^erty^{a p}^r^o^{cess f}^o^r^w^a^ivⁱⁿ^g^t^h^{is p}^r^o^v^isioⁿⁱⁿ^th^{e case o}^f^a
ⁱⁿ^clu^d^{es th}^{e sh}^elterⁱⁿ^w^h^ich^aⁿⁱⁿ^dⁱ^vⁱ^d^u^{al r}^e^sid^e^{s, th}^{e lan}^d^dem^oⁿ^s^{trated h}^a^rds^h^ip.
^oⁿ^w^h^ich^th^{e sh}^elter^is^lo^cated^an^d^r^e^lated^o^u^tb^u^ildⁱⁿ^g^s^{. I}^f^an
ⁱⁿ^di^vⁱ^du^al^(an^d^s^pou^s^e^{, i}^f^an^y⁾^m^o^v^e^s^ou^t^of^hⁱ^s^{or h}^e^r^h^o^m^e^In^divⁱ^du^als^w^h^os^{e s}^pou^s^e^{, ch}^{ild u}ⁿ^d^{er ag}^{e 2}¹^{, or ch}^ild
^w^ith^o^u^{t th}^{e in}^ten^t^to^r^e^tu^rⁿ^{, th}^e^h^o^m^e^b^eco^m^e^{s a co}^uⁿ^t^ab^le^w^h^{o i}^s^blⁱⁿ^{d or}^di^s^a^bl^{ed (as}^defⁱⁿ^e^{d by}^t^h^{e S}^ectⁱ^oⁿ¹⁶¹⁴
^res^o^u^r^{ce becau}^s^eⁱ^t^isⁿ^o^lon^g^e^{r th}^{e in}^divⁱ^du^al’^s^prin^cipal^o^f^th^{e So}^{cial Secu}^r^ity^A^c^t)^law^f^u^l^l^y^r^e^sid^e^{s in}^th^e

CRS-42
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^p^l^ace^of^resⁱ^d^eⁿ^c^e^.^H^o^w^e^v^e^r^,ⁱ^f^aⁿⁱⁿ^dⁱ^vⁱ^d^u^a^l^l^e^a^v^e^s^hⁱ^s^o^rⁱⁿ^dⁱ^vi^d^u^a^l^{’s ho}^m^e^w^o^ul^d^no^t^b^e^e^x^c^l^ud^e^d^fr^o^m
^h^e^r^h^o^m^e^to^liv^{e in}^anⁱⁿ^stitu^tioⁿ^,^th^{e h}^o^m^e^is^{still co}ⁿ^s^id^er^ed^elig^ib^ility^.^T^hⁱ^s^p^r^o^v^isioⁿ^w^o^u^l^dⁿ^o^{t p}^r^ev^en^{t an}
^{to be th}^{e indiv}ⁱ^du^al’^s^prin^{cipal place of}^resⁱ^den^ce,ⁱⁿ^dⁱ^vi^d^u^a^l^fr^o^m^usi^{ng a}^r^e^ve^r^s^e^m^o^r^t^ga^ge^o^r^ho^m^e^e^q^ui^t^y
^ir^r^e^sp^ectiv^{e o}^f^th^{e in}^dⁱ^vⁱ^d^u^al’^sⁱⁿ^teⁿ^t^to^r^e^tu^rⁿ^{, as lo}ⁿ^g^{as a}^lo^an^to^r^e^d^u^{ce th}^eⁱⁿ^dⁱ^vⁱ^d^u^al’^s^to^{tal eq}^u^ityⁱⁿ^ter^e^{st in}^th^e
^sp^o^u^{se o}^r^d^e^p^eⁿ^d^en^{t r}^e^lativ^{e o}^f^th^{e elig}^ib^{le in}^dⁱ^vⁱ^d^u^al^ho^m^e^.
^coⁿ^tin^u^e^{s to}^liv^{e th}^er^e.^T^h^eⁱⁿ^dⁱ^vⁱ^d^u^al’^s^eq^u^ityⁱⁿ^th^{e f}^o^r^m^er
^h^o^m^e^becom^e^s^{a cou}ⁿ^t^{able res}^o^u^r^{ce ef}^f^ectiv^{e w}^ith^th^{e f}ⁱ^r^s^t^T^h^{e C}^oⁿ^f^eren^ce^a^g^reem^en^{t w}^o^u^l^{d apply}^{to in}^divⁱ^du^als
^d^a^y^o^f^t^h^e^m^o^nt^{h f}^o^l^l^o^wⁱⁿ^g^t^h^e^m^o^nt^{h i}^tⁱ^s^no^l^o^nge^r^hi^{s o}^r^w^h^o^ar^{e d}^e^ter^mⁱⁿ^e^d^elig^ib^{le f}^o^r^Medⁱ^caidⁿ^u^r^sin^g
^h^e^{r prin}^{cipal place of}^resⁱ^den^ce.^f^acilit^y^o^r^o^t^h^e^r^loⁿ^g^-^ter^m^car^{e ser}^v^{ices b}^a^sed^oⁿ^an
^applⁱ^catⁱ^oⁿ^fⁱ^l^e^{d on}^{or af}^t^e^{r Jan}^u^a^ry^{1, 2006.}
ⁱ^{ki/CRS-RL33251}^Enf^o^rceabilit^y^o^f^C^oⁿ^tⁱⁿ^uing^Care^Co^{ntinuing Car}^e^Retir^em^{ent Co}^m^m^{unities (}^CCRCs)^o^f^f^e^r^a^S^ecti^oⁿ^6015.^T^h^{e C}^oⁿ^f^eren^{ce ag}^reem^en^{t am}^en^ds
^g/w^{(CCRC) and Life Care}^r^a^nge^o^f^ho^usi^{ng a}ⁿ^d^he^a^l^t^h^c^a^r^e^se^r^vⁱ^c^e^s^t^o^se^r^v^e^o^l^d^e^r^S^ectⁱ^oⁿ^{1919(c)(5) of}^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t^t^o^provⁱ^d^e
^s^.or^A^d^mis^sⁱ^{on Contr}^a^c^t^s^.^pers^on^s^as^th^ey^ag^{e an}^d^as^th^eir^h^ealth^{care n}^eeds^ch^an^g^e^ov^er^an^ex^ception^f^o^{r s}^t^ate-^licen^s^e^{d, reg}ⁱ^s^t^{ered, certif}^{ied, or}
^le^ak^tⁱ^m^e^.^C^CRCs^g^eⁿ^e^ra^l^l^y^of^f^e^{r i}ⁿ^de^peⁿ^d^eⁿ^t^lⁱ^vⁱⁿ^g^uⁿⁱ^t^s^,^eq^uⁱ^v^a^len^t^coⁿ^tin^uⁱⁿ^g^car^{e r}^e^tir^em^en^{t co}^m^m^uⁿ^ities
^assisted^livⁱⁿ^g^,^an^dⁿ^u^r^sin^g^f^acility^car^{e f}^o^r^p^e^r^s^oⁿ^{s w}^h^o^can⁽^CCRCs)^o^r^a^lⁱ^f^e^c^a^r^e^c^o^m^m^uni^t^y⁽ⁱ^nc^l^u^dⁱ^{ng nur}^si^ng
^://wiki^af^f^o^{rd to pa}^y^eⁿ^tran^{ce f}^ees^an^{d w}^h^{o of}^ten^resⁱ^{de in}^s^u^ch^f^acility^ser^v^{ices p}^r^o^v^id^ed^{as p}^a^r^t^o^f^th^a^t^co^m^m^uⁿ^ity⁾^to
^h^ttp^CCRCs^thr^o^ugho^{ut the}ⁱ^r^o^l^d^e^r^y^e^a^r^s.^T^h^e^se^r^v^ic^e^s^ge^ne^r^a^lly^allo^w^th^em^to^r^e^q^u^ir^eⁱⁿ^th^{eir adm}ⁱ^s^s^ion^s^con^t^racts^th^at
^of^f^e^{red in}^clu^d^{e m}^eals^,^tran^s^portation^,^em^erg^eⁿ^c^y^re^s^p^on^s^e^resⁱ^den^t^s^s^p^en^{d th}^{eir res}^o^u^r^ces^(s^u^b^j^{ect to Medicaid’}^s
^sy^ste^m^s,^aⁿ^d^oⁿ^-site^nur^{sing a}ⁿ^d^p^h^y^s^ic^ia^{n se}^r^v^ic^e^s^.^M^a^ny^ru^les^con^cernⁱⁿ^g^th^{e res}^o^u^r^ces^allow^aⁿ^{ce f}^o^{r com}^m^uⁿ^ity
^a^l^so^o^ffe^r^ho^m^e^c^a^r^e^,^m^a^id^se^r^v^ic^e^s^aⁿ^d^la^uⁿ^d^r^y^.^CCRCs^spou^s^e^s^,^des^c^ri^{bed abov}^{e), decl}^{ared f}^o^{r t}^h^{e pu}^rpos^es^o^f
^w^e^{re dev}^e^l^{oped, i}ⁿ^l^a^rg^{e part}^{, i}ⁿ^res^pon^s^e^t^o^anⁱⁿ^t^e^res^t^admⁱ^s^sⁱ^on^,^on^th^{eir care bef}^o^{re th}^ey^apply^f^o^r^Medicaid.
^am^on^g^m^aⁿ^y^elderly^pers^on^s^{to ag}^e-ⁱⁿ^-^p^{lace. C}^C^R^C^s^can^be^Fo^r^ap^p^lican^{ts w}^ith^co^m^m^uⁿ^ity^sp^o^u^ses,^oⁿ^ly^th^{at p}^a^r^t^o^f
^eith^er^f^o^r^-^p^r^o^f^{it o}^rⁿ^o^t-^f^o^r^-^p^r^o^f^{its. T}^h^ey^ar^{e p}^a^id^p^rⁱ^m^a^r^ily^th^{e en}^tran^{ce f}^{ee th}^{at is}ⁿ^o^{t protected f}^o^r^b^y^t^h^e
^wⁱ^t^h^p^rⁱ^v^a^t^e^f^uⁿ^d^s^,^b^u^t^aⁿ^u^m^b^e^r^a^l^s^o^a^ccep^t^M^e^dⁱ^c^aⁱ^d^com^m^uⁿ^ity^s^pou^s^e^’^s^res^o^u^r^{ce allow}^aⁿ^{ce w}^o^u^l^{d be}
^p^a^y^m^eⁿ^{t fo}^r^nur^sing^fa^c^ility^se^r^v^ic^e^s^.^A^ltho^{ugh the}^m^a^j^o^r^ity^con^s^{idered in}^th^{e co}^m^p^u^t^ation^of^th^{e s}^pou^s^a^{l s}^h^are
^o^f^CC^{RC r}^e^sid^eⁿ^t^{s d}^oⁿ^o^{t m}^{eet th}^{e f}ⁱⁿ^aⁿ^c^{ial cr}^iterⁱ^{a f}^o^r^av^{ailable to Medicaid.}
^Medi^cai^{d, s}^o^m^e^do.
^T^h^{e C}^oⁿ^f^eren^{ce ag}^reem^en^t^am^en^ds^S^ectⁱ^{on 1917 of}^t^h^e
^{Social Secu}^rity^A^c^{t to}^con^s^id^{er certain}^en^tran^{ce f}^ees^f^o^r

CRS-43
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^{CCRCs o}^r^life^c^a^r^e^c^o^m^m^unitⁱ^e^{s to}^b^e^c^o^unta^b^le
^r^e^s^o^urces^{, an}^{d th}^u^s^av^{ailable to th}^{e applican}^{t, f}^o^r
^p^u^r^p^o^s^{es o}^f^th^e^Medⁱ^caid^elig^ib^ility^d^e^ter^mⁱⁿ^atioⁿ^to^th^e
^ex^ten^t^th^at:
⁽^A⁾^th^eⁱⁿ^dⁱ^vⁱ^d^u^{al h}^a^{s th}^{e ab}^ility^to^u^s^{e th}^{e en}^tr^an^ce^f^ee,
^{or th}^{e con}^t^ract^prov^ides^th^{at th}^{e en}^tran^{ce f}^{ee m}^a^y^be
^u^s^{ed, to pay}^f^o^{r care s}^h^ou^{ld oth}^e^{r res}^o^u^r^ces^orⁱⁿ^com^e^of
^th^{e in}^divⁱ^du^{al be in}^s^u^f^fⁱ^cien^{t to pay}^f^o^{r care;}
⁽^B⁾^th^eⁱⁿ^dⁱ^vⁱ^d^u^{al is elig}^ib^{le f}^o^r^{a r}^e^f^uⁿ^d^o^f^an^y
ⁱ^{ki/CRS-RL33251}^rem^aⁱⁿⁱⁿ^g^en^tran^{ce f}^{ee w}^h^en^th^{e in}^divⁱ^du^{al dies}^or^termⁱⁿ^ates^th^{e C}^C^R^C^{or lif}^{e care co}^m^m^uⁿ^ity^con^t^racts
^g/w^an^{d leav}^es^th^{e com}^m^uⁿ^ity^{; an}^d
^s^.or^(C^{) th}^{e en}^tran^{ce f}^{ee does}ⁿ^o^t^c^oⁿ^f^{er an}^owⁿ^e^rs^hⁱ^p
^le^akⁱⁿ^ter^e^{st in}^th^{e co}ⁿ^tin^uⁱⁿ^g^car^{e r}^e^ti^r^e^m^eⁿ^t^co^m^m^uⁿ^ity^o^r
^lif^{e care com}^m^uⁿ^ity^.

^://wiki
^h^ttp

CRS-44
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^Re^quir^e^me^{nt to Imp}^o^s^e^P^a^r^t^ia^{l M}^onths^of^Cu^r^r^en^{t law}^r^e^q^u^ir^es^{states to}^im^p^o^s^{e p}^eⁿ^a^{lties o}ⁿⁱⁿ^dⁱ^vⁱ^d^u^als^S^ecti^oⁿ^6016(a).^T^h^{e C}^oⁿ^f^eren^{ce ag}^reem^ent^a^m^en^ds
^y^.^a^p^p^l^yⁱⁿ^g^f^o^{r Medicaid w}^h^{o tran}^s^f^{er as}^s^e^ts^{(all in}^com^e^aⁿ^d^Sectⁱ^oⁿ^{1917(c)(1)(E) of}^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t^by
^res^o^u^r^ces^of^t^h^{e i}ⁿ^di^vⁱ^du^al^an^{d of}^t^h^{e i}ⁿ^di^vⁱ^du^al^’^s^s^pou^s^e^{) f}^o^r^a^d^dⁱ^{ng t}^h^a^t^a^st^a^t^e^s^h^a^l^l^no^t^r^o^und^d^o^w^n,^o^r^o^t^he^r^wⁱ^s^e
^les^s^th^an^f^a^{ir m}^a^rk^{et v}^a^lu^{e (an}^es^tim^{ate of}^th^{e v}^a^lu^e^o^f^an^dⁱ^sr^eg^ar^d^aⁿ^y^f^r^actioⁿ^a^{l p}^e^rⁱ^o^d^o^fⁱⁿ^elig^ib^ility^w^h^en
^{asset if}^so^ld^at^th^e^p^r^ev^ailin^g^p^r^ice^at^th^{e tim}^{e it w}^a^{s actu}^a^lly^d^e^ter^mⁱⁿⁱⁿ^g^th^{e in}^elig^ib^ility^p^e^rⁱ^o^d^w^ith^r^e^sp^{ect to}^th^e
^tran^s^f^{erred). Specif}ⁱ^cally^{, th}^{e ru}^les^re^qu^{ire s}^t^ates^{to delay}^di^s^pos^al^of^as^s^e^t^s^.

^Medⁱ^caid^elig^ib^ility^f^o^{r in}^dⁱ^vⁱ^d^u^a^l^{s receiv}ⁱⁿ^g^{care in}^a
ⁿ^u^r^sⁱ^ng^h^o^m^e^{, an}^{d, at s}^t^{ate option}^,^certain^{people receiv}ⁱⁿ^g
^{care in}^com^m^uⁿ^ity^-^b^as^{ed s}^e^ttin^g^s^{, w}^h^{o h}^a^v^e^tran^s^f^er^red
^as^s^e^ts^f^o^{r les}^s^th^an^f^a^{ir m}^a^rk^et^v^a^lu^e^on^{or af}^{ter a “}^l^ook^-^b^ack
ⁱ^{ki/CRS-RL33251}^dat^e^{.” T}^h^{e “}^l^ook^-^b^ack^dat^{e” i}^s^{36 m}^oⁿ^t^h^s^pri^o^{r t}^o^applⁱ^catⁱ^oⁿ^f^o^{r Me}^di^cai^{d f}^o^{r i}ⁿ^com^e^an^{d m}^o^s^t^as^s^e^t^s^di^s^pos^{ed of}^by^t^h^e
^g/wⁱⁿ^divⁱ^du^{al, an}^{d 60 m}^oⁿ^t^h^sⁱⁿ^th^{e cas}^{e of}^certain^tru^s^ts^.
^s^.or
^le^ak^T^h^{e len}^g^t^h^o^f^th^{e d}^e^lay^{is d}^e^ter^mⁱⁿ^ed^b^y^dⁱ^vⁱ^dⁱⁿ^g^th^{e to}^tal
^://wiki^cu^m^u^lativ^e^uⁿ^c^om^pen^s^{ated v}^a^lu^{e of}^{all as}^s^e^ts^tran^s^f^{erred by}^t^h^{e i}ⁿ^di^vⁱ^du^al^{(or i}ⁿ^di^vⁱ^du^al^’^s^s^pou^s^e^{) on}^{or af}^t^e^{r t}^h^{e l}^ook^-
^h^ttp^back^{date by}^th^{e av}^erag^e^m^oⁿ^t^h^l^y^cos^t^{to a priv}^{ate patien}^t^of
^aⁿ^u^r^sin^g^f^acilityⁱⁿ^th^{e state (}^o^r^,^{at th}^{e o}^p^tioⁿ^o^f^th^e^state,ⁱⁿ
^th^e^co^m^m^uⁿ^ityⁱⁿ^w^h^ich^th^{e in}^dⁱ^vⁱ^d^u^al^isⁱⁿ^stitu^tioⁿ^a^lized⁾^at
^th^{e tim}^{e of}^application^.^{For ex}^am^{ple, a trans}^f^{erred as}^s^e^t
^w^o^rt^h^{$60,000, di}^vⁱ^{ded by}^{a $5,000 av}^erag^{e m}^oⁿ^t^h^l^y^pri^v^at^e
^pay^rat^eⁱⁿ^{a n}^u^r^sⁱ^ng^ho^m^e^,^res^u^l^t^sⁱⁿ^{a 12-}^m^oⁿ^t^h^peri^{od of}
ⁱⁿ^elig^ib^ility^f^o^r^Medⁱ^caid^loⁿ^g^-^ter^m^car^e^ser^v^ices.^T^h^{e p}^e^rⁱ^o^d
^o^fⁱⁿ^e^lⁱ^gⁱ^bⁱ^l^ity^b^e^gⁱⁿ^s^th^{e f}ⁱ^r^s^{t d}^a^y^o^f^th^{e f}ⁱ^r^s^{t m}^oⁿ^t^h^d^u^rⁱⁿ^g
^{or af}^{ter w}^h^ich^as^s^e^ts^h^a^v^e^been^im^properly^tran^s^f^{erred an}^d
^w^h^ich^d^o^e^{s n}^o^{t o}^ccu^rⁱⁿ^an^y^o^t^h^e^r^p^e^rⁱ^o^d^o^fⁱⁿ^elig^ib^ility^.
^T^h^er^{e is n}^o^lim^{it to}^th^{e len}^g^t^h^o^f^th^{e p}^eⁿ^a^lty^p^e^rⁱ^o^d^.

CRS-45
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^W^h^en^calcu^latin^g^th^{e len}^g^t^h^o^f^th^{e p}^eⁿ^a^lty^p^e^rⁱ^o^d^w^h^en^assets
^{are tran}^s^f^{erred f}^o^{r les}^s^th^an^f^a^{ir m}^a^r^k^e^t^va^lu^{e, cu}^rren^{t law}
^allo^w^s^state^s^to^“^r^o^uⁿ^d^d^o^wⁿ^,^{” o}^rⁿ^o^{t in}^clu^d^{e in}^th^e
ⁱⁿ^elig^ib^ility^p^e^rⁱ^o^d^th^{e q}^u^o^tien^t^am^o^uⁿ^t^s⁽^r^esu^ltin^g^f^r^o^m^th^e
^divⁱ^sⁱ^on^of^the^v^a^lu^{e of}^th^{e tran}^s^f^{erred as}^s^e^{t by}^th^{e av}^erag^e
^m^oⁿ^t^h^l^y^priv^ate^pay^{rate in}^{a n}^u^r^sⁱⁿ^g^h^o^m^e^{) th}^{at are les}^s^th^an
^on^{e m}^oⁿ^t^h^.^{For ex}^am^{ple, in}^{a s}^t^{ate w}^ith^aⁿ^av^erag^{e priv}^ate
^s^t^ayⁱⁿ^{a n}^u^r^sⁱⁿ^g^h^o^m^e^of^{$4,100, an}ⁱⁿ^elig^ibility^pe^rⁱ^{od f}^o^r
^anⁱ^m^proper^t^r^an^s^f^{er of}^{$53,000 cou}^l^{d be 12.92}^m^oⁿ^t^h^s⁽ⁱ^.e.,
^$53,000/^{$4,100=12.92). A}^l^t^h^o^{ugh so}^m^e^st^a^t^e^s^w^o^ul^dⁱ^m^p^o^s^e
ⁱ^{ki/CRS-RL33251}^anⁱⁿ^elig^ib^ility^p^e^rⁱ^o^d^o^f¹²^m^oⁿ^t^h^s^an^d²⁸^d^a^y^s⁽^o^f^{a 3}¹^d^a^y^m^o^nt^h)^,^o^t^h^e^r^st^a^t^e^s^m^a^y^r^o^und^d^o^w^{n t}^h^e^q^u^o^tⁱ^e^nt^t^o^aⁿ
^g/wⁱⁿ^elig^ib^ility^p^e^rⁱ^o^d^o^f¹²^m^oⁿ^t^h^s^oⁿ^ly^.
^s^.or
^le^ak^A^u^t^h^o^r^it^y^f^o^{r St}^at^{es t}^o^A^ccu^m^u^l^a^t^e^M^u^lt^ip^le^Cu^r^r^en^{t law}^an^d^ad^d^itioⁿ^a^{l CMS}^g^uⁱ^d^aⁿ^ce^p^r^o^v^id^{es th}^{at w}^h^en^S^ecti^oⁿ^6016(b⁾^T^h^{e C}^oⁿ^f^er^eⁿ^{ce ag}^reem^en^{t am}^en^ds
^an^sf^{ers in}^t^o^Oⁿ^{e Pen}^a^lt^y^Perio^d^.^{a n}^u^m^{ber of}^as^s^e^ts^{are tran}^s^f^{erred f}^o^{r les}^s^th^an^f^a^{ir m}^a^rk^et^S^ectⁱ^oⁿ^{1917(c)(1) of}^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t^by^addiⁿ^g
^://wiki^v^a^l^u^{e on}^{or af}^t^e^{r t}^h^{e l}^ook^-^b^a^c^k^dat^e^du^riⁿ^g^t^h^e^sa^m^e^m^o^nt^h,^t^h^at^f^o^{r an}ⁱⁿ^di^vⁱ^du^al^{or an}ⁱⁿ^di^vⁱ^du^al^’s^s^pou^s^e^w^h^o
^h^ttp^th^e^p^eⁿ^a^lty^p^e^rⁱ^o^d^{is calcu}^lated^u^sⁱⁿ^g^th^{e to}^{tal cu}^m^u^lativ^e^dⁱ^sp^o^s^{es o}^f^m^u^ltip^{le f}^r^actioⁿ^a^{l assets in}^m^o^r^e^th^an^oⁿ^e
^uⁿ^c^om^pen^s^at^{ed v}^a^l^u^{e of}^al^l^as^s^e^t^s^t^r^an^s^f^{erred du}^ri^{ng t}^h^at^m^oⁿ^t^h^f^o^r^{less th}^an^f^a^ir^m^a^r^k^{et v}^a^lu^e^oⁿ^o^r^af^ter^th^e
^m^oⁿ^t^h^by^t^h^{e i}ⁿ^di^vⁱ^du^al^{(or i}ⁿ^di^vⁱ^du^al^’^s^s^pou^s^e^{) di}^vⁱ^{ded by}^appl^{icable look}^-^b^ack^{date, s}^t^ates^m^a^y^determⁱⁿ^{e th}^e
^th^{e av}^erag^{e m}^oⁿ^t^h^l^y^cos^t^{to a}^p^r^iv^{ate patien}^t^of^{a n}^u^r^sⁱⁿ^g^p^eⁿ^a^lty^p^e^rⁱ^o^d^b^y^t^r^eatin^g^th^{e to}^{tal, cu}^m^u^lativ^e
^f^acilityⁱⁿ^th^{e sta}^t^e⁽^o^r^,^{at th}^{e o}^p^tioⁿ^o^f^th^{e state, in}^th^e^uⁿ^c^om^pen^s^{ated v}^a^lu^{e of}^{all as}^s^e^ts^tran^s^f^erre^d^by^th^e
^co^m^m^uⁿ^ityⁱⁿ^w^h^ich^th^{e in}^dⁱ^vⁱ^d^u^{al is in}^stitu^tioⁿ^a^lized⁾^at^th^eⁱⁿ^di^vⁱ^du^al^{(or i}ⁿ^di^vⁱ^du^al^’^s^s^pou^s^e^{) du}^riⁿ^g^al^l^m^oⁿ^t^h^s^as
^tim^{e of}^application^.^W^h^en^{a n}^u^m^{ber of}^as^s^e^ts^are^tran^s^f^erred^on^{e tran}^s^f^{er. States}^w^oul^d^b^e^allow^e^{d to beg}ⁱⁿ^s^u^ch
^d^u^rⁱ^ng^d^ifferen^t^m^o^nt^hs,^t^h^eⁿ^t^h^e^r^u^l^e^s^va^r^y^b^a^se^d^up^oⁿ^pen^a^l^t^y^peri^ods^on^t^h^{e earl}ⁱ^e^s^t^dat^e^w^hⁱ^c^h^w^o^u^l^{d appl}^y^t^o
^w^h^et^h^e^{r t}^h^{e pen}^a^l^t^y^peri^ods^ov^e^r^l^a^p^.^If^{a pen}^a^l^t^y^peri^{od f}^o^r^s^u^ch^tran^s^f^ers^.

^each^tran^s^f^{er ov}^erlaps^w^ith^th^{e beg}ⁱⁿⁿⁱⁿ^g^of^{a n}^e^w^pen^a^lty
^{period, th}^en^s^t^ates^m^a^y^e^ith^{er add tog}^e^th^{er th}^{e v}^a^lu^{e of}^th^e
^tran^s^f^{erred as}^s^e^ts^an^{d calcu}^{late a s}ⁱⁿ^g^l^e^p^e^na^l^t^y^{period or}
ⁱ^m^p^o^s^e^each^p^eⁿ^a^l^t^y^p^e^rⁱ^o^d^s^e^q^u^eⁿ^tⁱ^a^l^l^y^.^I^f^t^h^e^p^eⁿ^a^l^t^y

CRS-46
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^period^fo^r^e^a^c^h^tran^s^f^{er does}ⁿ^o^{t ov}^{erlap, th}^en^s^t^ates^m^u^s^t
^{treat each}^tran^s^f^{er as}^{a s}^e^{parate ev}^en^{t an}^{d im}^pos^{e each}
^p^eⁿ^a^lty^p^e^rⁱ^o^d^star^tin^g^oⁿ^th^{e f}ⁱ^r^s^{t d}^a^y^o^f^th^e^m^oⁿ^t^hⁱⁿ^w^h^ich
^each^tran^s^f^{er w}^a^s^m^a^de.
^In^clu^s^ioⁿ^o^f^T^r^an^sf^{er o}^f^Cert^ain^No^t^es^an^d^Uⁿ^d^e^r^cu^r^r^en^{t law}^,^{states set stan}^d^a^r^d^{s, w}^ithⁱⁿ^f^e^d^e^r^a^l^{Section 6}⁰^16(c)^{. T}^h^{e C}^oⁿ^f^eren^{ce ag}^reem^en^{t am}^en^ds
^aⁿ^s^A^sset^s.^p^a^r^a^m^e^ter^s^,^f^o^r^th^e^am^o^uⁿ^t^an^d^ty^p^e^o^f^{assets th}^at^ap^p^lican^ts^S^ectⁱ^oⁿ^1917(c)⁽¹^{) of}^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t^t^o^m^a^k^e
^ma^y^ha^ve^t^o^q^u^a^lⁱ^f^y^fo^r^M^e^dⁱ^c^aⁱ^d^.^Iⁿ^ge^ne^r^a^l^,^c^o^unt^a^b^l^e^ad^d^itioⁿ^a^{l assets su}^b^j^{ect to}^th^{e lo}^o^k^-^b^ack^p^e^rⁱ^o^d^,^an^d
^as^s^e^ts^canⁿ^o^{t ex}^{ceed $2,000 f}^o^{r an}ⁱⁿ^divⁱ^du^{al. How}^e^v^e^{r, n}^o^t^th^u^s^{a p}^eⁿ^a^lty^,^if^estab^lish^e^d^o^r^tr^an^sf^er^r^e^d^f^o^r^{less th}^an
^{all assets ar}^{e co}^uⁿ^t^ed^f^o^r^elig^ib^ility^p^u^r^p^o^s^{es. T}^h^{e stan}^d^a^r^d^s^f^a^{ir m}^a^rk^{et v}^a^lu^{e. Su}^ch^as^s^e^ts^w^o^u^l^{d in}^clu^d^{e f}^uⁿ^d^s^u^s^ed
ⁱ^{ki/CRS-RL33251}^s^t^ates^s^e^t^als^oⁱⁿ^clu^d^e^{criteria f}^o^{r def}ⁱⁿⁱⁿ^gⁿ^oⁿ^-^couⁿ^t^{able, or}^ex^em^p^t^{, assets. States g}^eⁿ^e^r^a^lly^f^o^llo^w^r^u^{les f}^o^r^th^e^t^o^p^u^r^c^ha^se^a^p^r^o^mⁱ^sso^r^y^no^t^e^,^l^o^aⁿ^o^r^m^o^r^t^ga^ge^,^unl^e^s^s^th^{e repay}^m^en^{t term}^s^{are actu}^a^rially^s^o^uⁿ^d^{, prov}^{ide f}^o^r
^g/w^Su^pplem^en^{tal Secu}^rity^In^com^e^{(SSI) prog}^ram^f^o^{r com}^p^u^tin^g^pay^m^en^t^s^t^o^{be m}^a^{de i}ⁿ^equa^l^a^m^ouⁿ^t^s^du^riⁿ^g^t^h^{e t}^e^rm
^s^.or^b^o^t^{h c}^o^unt^a^b^l^e^aⁿ^d^no^n-c^o^unt^a^b^l^e^a^sse^t^s^.^of^t^h^{e l}^o^an^an^d^wⁱ^t^h^no^def^e^rralⁿ^o^{r bal}^l^oon^pay^m^en^t^s^,
^le^ak^an^d^p^r^o^h^ib^{it th}^{e can}^cellatioⁿ^o^f^th^{e b}^a^lan^{ce u}^p^oⁿ^th^e
^Un^{der s}^t^{ate Medicaid an}^{d SSI}^r^u^l^e^s^,^couⁿ^t^{able as}^s^e^ts^m^a^y^death^of^th^{e len}^d^er.
^://wikiⁱⁿ^clu^d^{e, b}^u^{t ar}^{e n}^o^{t lim}^ited^to^{, f}^uⁿ^d^{s in}^{a sav}ⁱⁿ^g^s^o^r^m^oⁿ^e^y
^h^ttp^m^a^rk^et^acco^uⁿ^t^{, sto}^c^k^s^o^r^o^t^h^e^{r ty}^p^e^{s o}^f^eq^u^ities,^accelerated^In^th^{e cas}^{e of}^{a prom}ⁱ^s^s^o^r^yⁿ^o^{te, loan}^{, or m}^o^rtg^a^g^e^th^at
^cash^b^eⁿ^e^f^{its f}^r^o^m^cer^tain^ty^p^e^{s o}^fⁱⁿ^su^r^aⁿ^c^{e p}^o^{licies, an}^d^d^o^e^{s n}^o^{t satisf}^y^th^{ese r}^e^q^u^ir^em^en^{ts, th}^eir^v^a^lu^{e sh}^{all b}^e
^f^uⁿ^d^s^f^r^om^cert^aⁱⁿ^t^y^pes^of^t^r^u^s^t^s^t^h^at^can^{be obt}^aiⁿ^e^{d by}^t^h^e^th^{e o}^u^tstan^dⁱⁿ^g^b^a^lan^{ce d}^u^{e as o}^f^th^{e d}^a^{te o}^f^th^e
ⁱⁿ^di^vⁱ^du^al^{, t}^h^{e i}ⁿ^di^vⁱ^du^al^’^s^s^pou^s^e^{, or an}^y^oⁿ^e^actⁱⁿ^g^f^o^{r t}^h^eⁱⁿ^dⁱ^vⁱ^d^u^al’^s^ap^p^licatioⁿ^f^o^r^cer^tain^Medⁱ^caid^loⁿ^g^-^te^r^m
ⁱⁿ^di^vⁱ^du^al^{or t}^h^{e i}ⁿ^dⁱ^vi^d^u^al^’^s^s^pou^s^e^{, t}^o^pay^f^o^{r t}^h^e^{care s}^e^rv^ices^.

ⁱⁿ^dⁱ^vⁱ^d^u^al’^s^m^e^dⁱ^{cal o}^rⁿ^u^r^sin^g^f^acility^car^{e, ev}^en^if^th^e^f^uⁿ^d^s
^o^r^p^a^y^m^en^t^s^{are n}^o^t^di^s^t^ri^bu^t^e^{d. U}ⁿ^{der Medi}^cai^{d an}^{d S}^S^I
^ru^les^,ⁿ^oⁿ^-^couⁿ^t^a^b^l^e^as^s^e^tsⁱⁿ^clu^d^{e an}ⁱⁿ^divⁱ^du^al’^s^prim^ary
^{place of}^resⁱ^den^ce,^on^{e au}^tom^{obile, h}^o^u^s^eh^{old g}^oods^an^d
^pers^oⁿ^a^l^ef^f^ect^s^,^propert^y^es^s^eⁿ^tⁱ^a^l^t^oⁱⁿ^com^e^-^p^rodu^ciⁿ^g
^activ^ity^{, u}^p^to^$¹^,⁵⁰⁰ⁱⁿ^b^u^rⁱ^{al f}^uⁿ^d^{s, lif}^{e in}^su^r^aⁿ^{ce p}^o^licies
^w^h^os^{e total f}^{ace v}^a^lu^{e is}ⁿ^o^{t g}^r^eate^r^t^h^an^{$1,500, an}^d
^mⁱ^scellan^e^o^u^{s o}^t^h^e^r^item^s^.

CRS-47
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^O^t^he^r^r^u^l^e^{s d}^e^fiⁿⁱ^{ng c}^o^unt^a^b^l^e^aⁿ^d^noⁿ^-^c^o^unt^a^b^l^e^a^sse^t^s
^apply^on^lyⁱⁿ^particu^l^{ar s}^t^ates^{. T}^h^{eir r}^u^l^e^s^a^r^{e g}^eⁿ^e^rally
ⁱⁿ^ten^d^ed^t^o^r^e^strⁱ^{ct th}^{e u}^s^{e o}^f^cer^tain^fⁱⁿ^aⁿ^c^{ial in}^str^u^m^eⁿ^t^s
⁽^e^.g^{. an}ⁿ^u^{ities, p}^r^o^m^isso^r^yⁿ^o^{tes, o}^r^t^r^u^s^ts)^to^p^r^o^t^{ect assets}
^s^o^th^{at applic}^aⁿ^ts^can^qu^alif^y^f^o^{r Medicaid earlier th}^an^th^ey
^mⁱ^ght^o^t^he^r^wⁱ^s^e^.
^Iⁿ^clu^s^ioⁿ^o^f^T^r^an^sf^{ers t}^o^Pu^rch^{ase L}ⁱ^f^e^Cu^r^r^eⁿ^t^law^d^o^e^{s n}^o^{t sp}^ecif^y^w^h^eth^e^r^lif^{e estates sh}^o^u^ld^b^e^S^ecti^oⁿ^6016(d⁾^.^T^h^{e C}^oⁿ^f^eren^{ce ag}^ree^m^en^{t am}^en^ds
^ta^te^s^.^{treated as}^couⁿ^t^{able or n}^oⁿ^c^ouⁿ^t^{able as}^s^e^ts^f^o^{r pu}^rpos^es^of^S^ectⁱ^oⁿ^1917(c)(1)^of^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t^by^addiⁿ^g
^applyⁱⁿ^g^th^{e Medicaid as}^s^e^{t tran}^s^f^{er ru}^les^.^In^C^M^{S g}^uⁱ^dan^ce,^a^p^r^o^v^isioⁿ^th^{at w}^o^u^l^d^r^e^d^e^fⁱⁿ^e^th^{e ter}^m^‘^a^ssets,^’^wⁱ^t^h
ⁱ^{ki/CRS-RL33251}^h^o^w^e^v^e^{r, th}^{e Secretary}^s^p^ecifⁱ^es^t^h^a^t^th^{e es}^tablis^h^m^en^{t of}^a^lif^{e estate co}ⁿ^s^titu^{tes a tr}^an^sf^er^o^f^assets.^T^h^{e g}^uⁱ^d^aⁿ^{ce also}^res^p^{ect to}^th^{e Medicaid as}^s^e^{t tran}^s^f^{er ru}^les^,^{to in}^clu^d^{e th}^e^p^u^r^c^h^a^s^e^o^f^{a lif}^{e estate in}^ter^e^{st in}^an^o^t^h^e^rⁱⁿ^dⁱ^vⁱ^d^u^al’^s
^g/w^ex^plain^s^th^at^a^tran^s^f^er^f^o^{r les}^s^th^an^f^a^{ir m}^a^rk^{et v}^a^lu^{e occu}^rs^ho^m^e^unl^e^{ss t}^h^e^p^u^r^c^ha^se^r^r^e^sⁱ^d^e^{s i}ⁿ^t^h^e^ho^m^e^fo^r^a^t
^s^.or^w^h^en^ev^{er th}^{e v}^a^lu^{e of}^th^{e tran}^s^f^{erred as}^s^e^{t is}^g^r^{eater th}^an^th^e^leas^{t on}^{e y}^{ear af}^{ter th}^{e date of}^pu^rch^a^s^e^.
^le^ak^v^a^lu^{e of}^th^{e rig}^h^t^s^con^f^erred^by^th^e^lif^e^es^{tate. A}^ccordin^g^to
^{CMS, a lif}^e^estate^{is in}^v^o^lv^ed^w^h^en^anⁱⁿ^dⁱ^vⁱ^d^u^{al w}^h^o^o^wⁿ^s
^://wiki^propert^y^t^r^aⁿ^sfe^r^s^owⁿ^e^rs^hⁱ^{p t}^o^an^ot^h^e^{r i}ⁿ^di^vⁱ^du^al^w^hⁱ^l^e
^h^ttp^r^e^tainⁱⁿ^g^,^f^o^r^th^{e r}^e^{st o}^f^hⁱ^{s o}^r^h^e^r^lif^{e (}^o^r^th^{e lif}^{e o}^f^an^o^t^h^e^r
^p^e^r^s^oⁿ⁾^,^c^e^r^t^aⁱⁿ^rⁱ^g^h^t^{s to}^th^{at p}^r^o^p^e^r^t^y^.^Gen^e^r^a^lly^{, a lif}^e
^{estate en}^{titles th}^{e g}^r^aⁿ^t^o^r^to^p^o^{ssess, u}^s^{e, an}^d^o^b^t^ain^p^r^o^f^its
^f^r^om^th^{e property}^as^lon^g^as^h^e^{or s}^h^{e liv}^es^{, ev}^en^th^ou^g^h
^act^u^a^l^owⁿ^e^rs^hⁱ^{p of}^t^h^{e propert}^y^h^a^s^pas^s^e^{d t}^o^an^ot^h^e^r
ⁱⁿ^di^vⁱ^du^al^.
^Ef^f^ect^iv^{e Dat}^e^f^o^{r Sect}^ioⁿ^6016.^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^6016(f)^.^T^h^{is p}^r^o^vⁱ^sⁱ^oⁿ^ap^p^{lies to}^p^a^y^m^en^t
^m^a^de^uⁿ^d^{er t}^h^{e Medi}^cai^{d prog}^ram^f^o^{r cal}^en^dar^qu^art^e^rs
^begⁱⁿⁿⁱⁿ^g^on^{or af}^{ter th}^{e date of}^th^is^act’^s^en^actm^eⁿ^t^,
^w^ith^o^u^{t r}^e^g^a^r^d^to^w^h^eth^e^r^o^rⁿ^o^{t f}ⁱⁿ^a^{l r}^e^g^u^l^atioⁿ^s^to
^carry^ou^{t s}^u^ch^am^en^dm^en^ts^h^a^v^e^been^pro^m^ul^g^a^{ted by}
^s^u^ch^dat^e^{. A}^m^en^dm^en^t^s^m^a^{de by}^t^hⁱ^s^provⁱ^sⁱ^oⁿ^{do n}^o^t

CRS-48
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^apply^{to Medicaid as}^sⁱ^s^t^an^{ce prov}^{ided f}^o^{r s}^e^rv^ices
^bef^o^{re t}^h^{e dat}^e^of^en^act^m^eⁿ^t^{, as}^s^e^t^s^di^s^pos^{ed of}^on^or
^bef^o^{re t}^h^{e dat}^e^of^en^act^m^eⁿ^t^{, or t}^r^u^s^t^s^es^t^a^blⁱ^s^h^e^d^on^or
^bef^o^{re th}^{e date of}^en^actm^eⁿ^t^.
^In^th^{e cas}^{e of}^{a s}^t^{ate that th}^{e Secretary}^of^Health^an^d
^Hu^m^aⁿ^Ser^vⁱ^{ces d}^e^ter^mⁱⁿ^{es r}^e^q^u^ir^{es state leg}ⁱ^slatioⁿ^to
^m^{eet th}^{e ad}^d^itioⁿ^a^{l r}^e^q^u^ir^em^en^{ts o}^f^th^{is p}^r^o^v^isioⁿ^,^th^e
^s^t^{ate Medicaid plan}^w^o^u^l^{d n}^o^{t be r}^e^g^a^{rded as}^f^a^ilin^g^to
^co^m^p^ly^w^ith^th^{e r}^e^q^uⁱ^r^e^m^en^{ts so}^lely^oⁿ^th^{e b}^a^{sis o}^f^its
ⁱ^{ki/CRS-RL33251}^f^a^ilu^r^e^to^m^{eet th}^{ese ad}^d^itioⁿ^a^{l r}^e^q^u^ir^em^en^{ts b}^e^f^o^r^e^th^e^fⁱ^r^s^t^d^a^y^o^f^th^{e f}ⁱ^r^s^{t calen}^d^a^r^q^u^ar^ter^b^e^gⁱⁿⁿⁱⁿ^g^af^ter^th^e
^g/w^clos^{e of}^th^{e f}ⁱ^rs^{t reg}^u^l^{ar s}^e^s^sⁱ^on^of^th^{e s}^t^{ate leg}ⁱ^s^l^atu^r^e
^s^.or^th^{at beg}ⁱⁿ^s^af^{ter th}^{e date of}^en^actm^eⁿ^t^of^th^is^act.^In^th^e
^le^ak^cas^{e of}^{a s}^t^{ate th}^{at h}^a^s^{a tw}^o-^y^e^a^r^l^e^gi^s^l^ativ^{e s}^e^s^sⁱ^on^,
^://wiki^each^y^{ear of}^th^{e s}^e^s^sⁱ^on^w^o^u^l^{d be con}^s^{idered to be a}^s^e^{parate reg}^u^l^{ar s}^e^s^sⁱ^on^of^th^{e s}^t^{ate leg}ⁱ^s^l^atu^r^{e. T}^hⁱ^s
^h^ttp^am^en^dm^en^t^applⁱ^e^s^t^o^provⁱ^sⁱ^oⁿ^uⁿ^d^{er S}^ectⁱ^oⁿ^{6016 of}
^th^{e C}^oⁿ^f^eren^{ce ag}^reem^en^t.

CRS-49
Subchapter B — Expanded Access to Certain Benefits
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^E^x^pa^ns^{ion of S}^t^a^t^e^Long-T^e^r^m^Ca^r^e^Un^{der Medica}ⁱ^d^’s^lon^g^-^term^{care (L}^T^C^{) in}^s^u^ran^c^e^S^ecti^oⁿ^6021.^T^h^{e con}^f^e^r^eⁿ^{ce ag}^reem^en^{t am}^en^ds^Section
^r^t^ne^r^s^{hip P}^r^ogr^a^m^.^part^ners^hⁱ^{p prog}^ram^,^cert^aⁱⁿ^pers^on^s^w^h^{o h}^a^v^e¹⁹¹⁷⁽^b⁾⁽¹^)(C⁾⁽ⁱⁱ⁾^of^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t^t^o^:^{(1) requ}ⁱ^r^e
^ex^h^a^u^s^{ted (or u}^s^{ed at leas}^{t s}^o^m^e^of^{) th}^{e ben}^e^fi^t^s^o^f^a^t^h^a^t^e^xⁱ^s^tⁱ^{ng p}^a^r^t^ne^r^s^hi^p^p^r^o^g^r^a^m^s^no^t^a^l^l^o^w^c^o^nsum^e^r
^priv^{ate lon}^g^-^term^{care in}^s^u^ran^{ce policy}^m^a^y^a^cces^s^prot^ectⁱ^oⁿ^s^t^aⁿ^d^a^r^d^s^t^o^{be l}^e^s^s^s^t^riⁿ^g^eⁿ^t^(det^ermⁱⁿ^e^{d by}^t^h^e
^Medⁱ^caid^w^ith^o^u^{t m}^eetin^g^th^{e sam}^e^m^ean^s-^testin^g^Secretary⁾^th^an^t^h^o^s^{e apply}ⁱⁿ^g^uⁿ^d^{er th}^{e s}^t^{ate plan}
^requⁱ^r^em^en^t^s^as^ot^h^e^{r g}^r^ou^ps^of^Medi^cai^{d el}ⁱ^gⁱ^b^l^e^s^.^F^o^r^am^en^dm^en^{t as}^of^Decem^{ber 31, 2005; an}^{d (2)}^allow^s^certain
^th^es^{e in}^divⁱ^du^als^,^m^ean^s^-^t^e^s^tin^g^requ^irem^en^ts^{are relax}^e^dⁱⁿ^divⁱ^du^alsⁱⁿ^s^t^ates^w^ith^s^t^{ate plan}^am^en^dm^en^ts^approv^ed
^a^t⁽¹⁾^th^{e tim}^{e o}^f^ap^p^licatioⁿ^to^Medⁱ^caid^;^an^d⁽²⁾^th^e^af^t^e^{r May}^{14, 1993}^t^o^{be ex}^em^pt^f^r^om^es^t^a^t^e^recov^e^ry
ⁱ^{ki/CRS-RL33251}^tim^{e of}^th^{e ben}^e^fⁱ^ciary^’^s^death^w^h^en^M^e^{dicaid es}^tate^requ^irem^en^ts^if^th^{e am}^en^dm^en^{t prov}^ides^f^o^{r th}^{e dis}^r^eg^{ard of}
^g/w^r^eco^v^e^r^y^{is g}^eⁿ^e^r^a^lly^ap^p^lied^.^an^y^as^s^e^ts^{or res}^o^u^r^cesⁱⁿ^th^{e am}^ouⁿ^t^equ^a^{l to th}^{e am}^ouⁿ^t^of
^s^.orⁱⁿ^s^u^ran^{ce ben}^e^fⁱ^t^s^m^a^de^t^o^{or on}^beh^a^l^f^of^anⁱⁿ^di^vⁱ^du^al^w^h^o
^le^ak^Iⁿ^g^eⁿ^e^r^a^{l, states allo}^wⁱⁿ^dⁱ^vⁱ^d^u^als^to^r^e^tainⁿ^o^m^o^r^e^th^an^is^{a ben}^e^fⁱ^ciary^uⁿ^d^{er a L}^T^C^policy⁽ⁱⁿ^c^lu^din^g^a^c^e^r^tif^icate
^{$2,000 i}ⁿ^couⁿ^t^abl^e^as^s^e^t^s^an^{d ex}^em^pt^cert^aⁱⁿ^noⁿ^-^is^s^u^{ed u}ⁿ^d^{er a g}^r^ou^{p in}^s^u^r^a^nc^{e con}^t^{ract), if}^th^{e f}^o^llowⁱⁿ^g
^://wiki^couⁿ^t^{able as}^s^e^ts^s^u^ch^as^anⁱⁿ^divⁱ^du^al’^s^prim^ary^{place of}^requ^irem^en^ts^{are m}^e^t:
^h^ttp^resⁱ^den^{ce, on}^{e au}^t^o^m^obi^l^e^{, h}^o^u^s^eh^ol^{d g}^o^ods^an^d
^pers^on^al^ef^f^ect^s^.^Uⁿ^d^e^r^S^ectⁱ^oⁿ^{1902 of}^t^h^{e S}^o^ci^al^{(I) T}^h^{e pol}ⁱ^c^y^c^o^ve^r^s^anⁱⁿ^s^u^{red w}^h^{o w}^a^s^{a res}ⁱ^den^t^of^s^u^ch
^Secu^rity^A^c^{t, a s}^t^{ate m}^a^y^requ^es^t^th^{e Secretary}^’^s^s^t^{ate w}^h^en^cov^e^rag^e^fⁱ^rs^{t becam}^{e ef}^f^ectiv^e^uⁿ^d^{er th}^{e policy}^.
^p^e^rm^is^sⁱ^on^{to am}^en^{d its}^{Medicaid s}^t^{ate plan}^s^{to allow}^In^th^{e cas}^{e of}^{a L}^T^Cⁱⁿ^s^u^ran^{ce policy}^ex^ch^an^g^e^{d f}^o^{r an}^oth^e^r
^cer^tain^ap^p^lican^{ts to}^r^e^tain^g^r^{eater am}^ouⁿ^t^s^of^couⁿ^t^able^su^ch^p^o^licy^,^th^{is r}^e^q^u^ir^em^en^{t ap}^p^{lies b}^a^sed^oⁿ^th^{e co}^v^e^r^a^g^e
^asset^s^t^h^aⁿ^o^t^h^e^r^ap^p^lican^{ts an}^d^{still q}^u^alif^y^f^o^r^of^th^{e f}ⁱ^rs^{t s}^u^ch^policy^th^{at w}^a^s^ex^ch^an^g^e^d;
^{Medicaid. Specif}ⁱ^cally^{, s}^t^ates^th^{at obtain}^th^{e Secretary}^’^s
^approv^al^m^a^y^di^s^r^eg^{ard s}^o^m^e^o^r^a^l^l^of^t^h^{e as}^s^e^t^s^of^(II)^T^h^{e pol}ⁱ^c^yⁱ^s^{a qu}^alⁱ^fⁱ^e^{d L}^T^Cⁱⁿ^s^u^ran^{ce pol}ⁱ^c^y^(m^eetⁱⁿ^g
^pers^on^s^appl^yⁱⁿ^g^f^o^{r Medi}^cai^{d w}^h^{o h}^a^v^e^p^u^rch^a^s^e^d^s^p^eci^fⁱ^catⁱ^oⁿ^s^defⁱⁿ^e^{d i}ⁿ^S^ectⁱ^oⁿ^7702B(b)^of^t^h^{e In}^t^e^rn^al
^loⁿ^g^-^ter^m^car^{e in}^su^r^aⁿ^{ce p}^o^licies.^Re^veⁿ^u^e^C^{ode of}^{1986) i}^s^s^u^{ed n}^o^t^earlⁱ^e^{r t}^h^an^t^h^{e ef}^f^ectⁱ^v^e
^{date of}^th^{e Medicaid s}^t^{ate plan}^am^en^dm^en^t;
^S^ectⁱ^oⁿ^{1917 of}^t^h^e^S^o^ci^al^S^ecu^ri^t^y^A^c^t^(am^eⁿ^d^{ed by}^t^h^e
^Omⁿⁱ^bu^s^B^u^dg^{et R}^econ^c^iliation^A^c^{t of}^{1993, P}^.^L^.^103-^{(III) T}^h^{e pol}ⁱ^c^y^m^eet^s^t^h^{e f}^o^l^l^o^wⁱⁿ^g^requⁱ^r^em^en^t^s^s^p^eci^fⁱ^ed

CRS-50
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^{66) allow}^s^on^ly^th^os^{e s}^t^ates^w^ith^an^approv^{ed s}^t^{ate plan}ⁱⁿ^th^{e N}^a^tⁱ^oⁿ^a^{l A}^s^s^o^ciation^of^In^s^u^ran^{ce C}^o^m^mⁱ^s^sⁱ^on^er’^s
^am^en^dm^en^t^as^of^M^a^y^{14, 1993 t}^o^ex^em^ptⁱⁿ^di^vⁱ^du^al^s⁽^N^A^I^C)^Lo^ng-T^e^r^m^Ca^r^e^Iⁿ^sur^a^nc^e^M^o^d^e^l^Re^gul^a^tⁱ^o^{ns a}ⁿ^d
^f^r^om^{Medicaid es}^{tate recov}^e^ry^w^h^{o ap}^p^l^y^{to Medicaid}^L^oⁿ^g^-^Te^r^m^C^a^r^e^Iⁿ^s^u^r^aⁿ^c^e^M^o^d^e^l^A^c^t⁽^a^s^adopt^e^d^a^s^o^f
^af^{ter ex}^h^a^u^s^tin^g^th^{eir priv}^{ate lon}^g^-^term^careⁱⁿ^s^u^ran^c^e^O^c^t^{ober 2000).}
^b^eⁿ^e^f^{its. B}^y^th^{at d}^a^{te, f}ⁱ^v^e^{states (}^C^alif^o^rⁿⁱ^a,
^C^oⁿⁿ^ecticu^t^{, In}^dian^a,^Iow^a^{, an}^{d New}^York^{) h}^a^{d receiv}^e^d
^C^M^{S approv}^{al. A}^{ll of}^th^es^e^s^t^a^t^es^{, ex}^{cept Iow}^a^{, h}^a^v^e
ⁱ^m^pl^em^en^t^e^{d part}ⁿ^e^rs^hⁱ^{p prog}^ram^s^.
^T^h^{e f}^o^u^r^partn^e^rs^hⁱ^{p s}^t^ates^w^ith^activ^{e prog}^ram^s^h^a^v^e^Mo^d^e^{l Reg}^u^l^atioⁿ^s^r^e^latin^g^to^:
ⁱ^{ki/CRS-RL33251}^di^f^f^e^ren^t^m^odel^s^f^o^{r det}^e^rmⁱⁿⁱⁿ^g^t^h^{e am}^ou^nt^of^as^s^e^t^s^th^at^an^elig^ib^{le p}^a^r^ticip^an^{t m}^a^y^p^r^o^t^{ect. Co}ⁿⁿ^ecticu^t^an^d^-^Gu^ar^an^teed^r^eⁿ^e^w^a^{l o}^rⁿ^oⁿ^can^cellab^ility⁽ⁱⁿ^c^lu^dⁱⁿ^g^so^m^e^sectioⁿ^s^o^f^th^{e Mo}^d^e^{l A}^c^t)^;
^g/w^Calif^o^rⁿⁱ^{a u}^s^{e a d}^o^llar^-^f^o^r^-^d^o^llar^m^o^d^e^{l, in}^w^h^ich^th^e^-^P^r^o^h^ib^itioⁿ^s^oⁿ^lim^itatioⁿ^s^an^d^ex^clu^s^ioⁿ^s^;
^s^.or^am^ouⁿ^t^of^th^e^as^s^e^ts^{protected is}^equⁱ^v^a^len^t^{to th}^e^v^a^lu^e^-^Ex^ten^s^ioⁿ^o^f^b^eⁿ^e^f^its;
^le^ak^of^t^h^{e ben}^e^fⁱ^t^pack^ag^{e pai}^d^by^t^h^e^polⁱ^c^y^pu^rch^a^s^e^{d (e.g}^.,^{- Co}^ntⁱ^nua^tⁱ^o^{n o}^r^c^o^nve^r^sⁱ^o^{n o}^f^c^o^ve^r^a^ge^;
^{$100,000 of}ⁿ^u^r^sⁱⁿ^g^h^o^m^e^or^as^sⁱ^s^t^ed^lⁱ^vⁱⁿ^g^ben^e^fⁱ^t^s^pai^d^-^Dis^c^on^tin^u^aⁿ^{ce an}^{d replacem}^en^{t of}^policies^;
^://wiki^en^abl^e^s^t^h^atⁱⁿ^di^vⁱ^du^al^t^o^ret^aⁱⁿ^u^p^t^o^{$100,000 i}ⁿ^as^s^e^t^s^-^Unⁱⁿ^ten^tioⁿ^a^{l lap}^s^e;
^h^ttp^an^d^{still q}^u^alif^y^f^o^r^Medⁱ^caid^co^v^e^r^a^g^eⁱⁿ^th^{at state)}^.^{- Disc}^lo^sur^e^;
^New^Yo^r^k^u^s^{es a to}^{tal asset p}^r^o^t^ectioⁿ^m^o^d^e^{l in}^w^h^ich^-^R^e^qu^{ired dis}^c^los^u^{re of}^ratin^g^practices^{to con}^s^u^m^er;
^pers^on^s^w^h^{o pu}^rch^a^s^e^cert^aⁱⁿ^s^t^at^e-^approv^{ed pol}ⁱ^cⁱ^e^s^-^P^r^o^h^ib^itioⁿ^s^ag^ain^s^{t p}^o^s^t-^claim^s^uⁿ^d^er^w^r^itin^g^;
^m^a^y^q^u^alif^y^f^o^r^Medⁱ^caid^w^ith^o^u^{t h}^a^vⁱⁿ^g^to^m^{eet an}^y^o^f^-^Mⁱⁿⁱ^mu^{m s}^t^aⁿ^d^a^r^d^s^;
^Medicaid’^s^as^s^e^{t criteria.}^Iⁿ^dⁱ^an^{a u}^s^es^{a h}^y^{brid m}^odel,^-^A^pplication^f^o^rm^s^an^{d replacem}^en^{t cov}^e^rag^e^;
^o^f^f^e^rⁱⁿ^g^b^o^t^h^d^o^llar^-^f^o^r^-^d^o^llar^an^d^to^{tal asset p}^r^o^t^ectioⁿ^-^Rep^o^r^tin^g^r^e^q^u^ir^em^en^ts;
⁽^Iⁿ^dⁱ^an^{a sw}^itch^e^d^f^r^o^m^th^{e d}^o^llar^-^f^o^r^-^d^o^llar^m^o^d^e^{l to}^th^e^-^Filin^g^r^e^q^u^ir^em^en^{ts f}^o^r^m^a^r^k^etin^g^;
^h^y^bri^d^m^odelⁱⁿ^1998).^-^Stan^dards^f^o^{r m}^a^r^k^e^tⁱⁿ^g^,ⁱⁿ^clu^dⁱⁿ^gⁱⁿ^accu^{rate com}^p^letion
^of^m^e^di^cal^hⁱ^s^t^ori^e^s^;
^Fed^e^r^a^{l o}^v^er^sig^h^t^o^f^L^T^{C in}^su^r^aⁿ^ce^is^lar^g^ely^lim^ited^to^-^Su^itab^ility^;
^p^r^o^vⁱ^s^ioⁿ^s^estab^lish^e^d^b^y^th^{e Health}^Iⁿ^su^r^aⁿ^c^e^-^P^r^o^h^ib^itioⁿ^ag^ain^s^{t p}^r^eex^istin^g^coⁿ^d^itioⁿ^s^an^d^p^r^o^b^a^tioⁿ^a^r^y
^P^o^rtability^an^{d A}^ccouⁿ^t^ability^A^c^{t of}^{1996 (HIP}^A^A^,^P^.^L^.^periodsⁱⁿ^replacem^en^{t policies}^{or certif}^icates^;
¹^04-^{191). H}^I^PA^A^es^t^a^blⁱ^s^h^e^{d n}^e^w^ru^l^e^s^reg^a^rdiⁿ^g^t^h^e^-^Coⁿ^tin^g^eⁿ^tⁿ^oⁿ^f^o^r^f^e^itu^r^e^b^eⁿ^e^f^{its if}^th^{e p}^o^licy^h^o^l^d^e^r

CRS-51
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^tax^treatm^eⁿ^t^of^L^T^Cⁱⁿ^s^u^ra^nc^e^an^{d ex}^pen^s^es^{, an}^d^d^eclin^{es th}^{e o}^f^f^e^r^o^f^{a n}^oⁿ^f^o^r^f^e^itu^r^e^p^r^o^v^isioⁿ^;
^d^e^fⁱⁿ^e^d^th^{e r}^e^q^u^ir^em^en^{ts f}^o^r^{a tax}^-^q^u^alif^ied^L^T^C^-^Stan^d^a^r^d^f^o^r^m^{at o}^u^tlin^{e o}^f^co^v^e^r^a^g^e^{; an}^d
ⁱⁿ^s^u^ran^{ce po}^lⁱ^c^y^.^L^T^Cⁱⁿ^s^u^ran^{ce produ}^cts^{are larg}^ely^-^D^e^lⁱ^v^ery^of^s^h^opper’^s^g^uⁱ^de.
^reg^u^l^{ated by}^s^t^ates^{. Ev}^ery^s^t^a^t^e^a^{nd th}^{e Dis}^t^{rict of}
^Co^l^u^m^bⁱ^a^ha^s^so^m^e^l^a^w^s^go^ve^rⁿⁱ^{ng LT}^{C i}ⁿ^sur^a^nc^e^.
^Man^y^of^th^es^e^l^a^w^s^ref^l^{ect g}^uⁱ^dan^{ce prov}^{ided by}^th^e
^Natioⁿ^a^{l A}^sso^ciatioⁿ^o^f^Iⁿ^su^r^aⁿ^{ce Co}^m^mⁱ^ssioⁿ^er^s
^(NA^I^C⁾^{, an org}^aⁿⁱ^zation^of^s^t^{ate in}^s^u^ran^{ce reg}^u^l^ators^.
^T^h^is^g^uⁱ^d^aⁿ^{ce, p}^r^o^v^id^edⁱⁿ^th^{e f}^o^r^m^o^f^{a Mo}^d^e^l^A^c^t^an^d
^{Model R}^e^g^u^l^at^ion^s^f^o^{r L}^T^Cⁱⁿ^s^u^ran^{ce, addres}^s^e^s^a
ⁱ^{ki/CRS-RL33251}^num^b^e^r^o^f^a^r^e^a^s^,ⁱⁿ^c^l^udⁱ^{ng t}^h^e^fo^l^l^o^wⁱ^ng.
^g/w^Mo^d^e^{l r}^e^g^u^l^atioⁿ^s^:^Mo^d^e^{l A}^c^{t r}^e^latin^g^to^:
^s^.or^-^A^pplication^f^o^rm^s^an^{d replacem}^en^{t cov}^e^rag^e^;^-^P^r^eex^istin^g^coⁿ^d^itioⁿ^s^;
^le^ak^-^Rep^o^r^tin^g^r^e^q^u^ir^em^en^ts;^-^P^r^io^r^h^o^sp^italizatioⁿ^;
^-^Filin^g^r^e^q^u^ir^em^en^{ts f}^o^r^m^a^r^k^etin^g^;^{- Co}^ntⁱ^nge^nt^no^nfo^r^feⁱ^t^u^r^e^b^e^ne^fi^t^s^;
^://wiki^-^S^t^an^dards^f^o^{r m}^a^rk^etⁱⁿ^g^;^{- Ri}^ght^o^f^r^e^t^u^rⁿ^;
^h^ttp^-^A^ppropri^a^t^eⁿ^e^s^s^of^recom^m^eⁿ^d^{ed pu}^rch^a^s^e^;^-^Ou^tlin^{e o}^f^co^v^e^r^a^g^e^;
^-^Stan^d^a^r^d^f^o^r^m^{at o}^u^tlin^{e o}^f^co^v^e^r^a^g^e^{; an}^d^-^R^e^qu^irem^en^ts^f^o^{r certif}^icates^uⁿ^d^{er g}^r^ou^{p plan}^s^;
^-^R^e^quⁱ^r^em^en^t^s^t^o^delⁱ^v^{er s}^h^opper’^s^g^uⁱ^de.^-^P^o^licy^su^m^m^a^r^y^;
^-^Mon^t^h^l^y^reports^on^{accelerated death}^ben^e^f^its^{; an}^d
^Mo^d^e^{l A}^c^t:^Iⁿ^coⁿ^t^estab^ility^p^e^rⁱ^o^d^.
^-^Ou^tlin^{e o}^f^co^v^e^r^a^g^e^;
^-^R^e^qu^irem^en^ts^f^o^{r certif}^icates^uⁿ^d^er^g^r^ou^p^plan^s^;^policy^T^h^e^s^{e prov}ⁱ^sⁱ^oⁿ^s^of^t^h^{e L}^oⁿ^g^-^T^e^rm^C^a^{re In}^s^u^ran^{ce Model}
^s^u^mma^r^y^;^Re^gul^a^tⁱ^o^{n a}ⁿ^d^Lo^ng-T^e^r^m^Ca^r^e^Iⁿ^sur^a^nc^e^M^o^d^e^l^A^c^t^a^r^e
^-^A^{ccelerated death}^ben^e^f^its^{; an}^d^{treated as}ⁱⁿ^clu^dⁱⁿ^g^an^y^oth^e^{r prov}^is^ion^th^{e R}^e^g^u^l^ation^or^A^c^t
^-^Iⁿ^coⁿ^t^estab^ility^p^e^rⁱ^o^d^.ⁿ^eces^s^a^r^y^t^o^im^plem^en^{t th}^{e prov}^is^ion^.^L^oⁿ^g^-^term^care
ⁱⁿ^s^u^ran^{ce poli}^cⁱ^e^s^is^s^u^{ed in}^{a s}^t^{ate s}^h^{all be deem}^{ed as}
^HI^P^P^A^alsoⁱⁿ^clu^d^{es r}^e^q^u^ir^em^en^{ts th}^{at tax}^-^q^u^alif^ied^m^e^e^tⁱⁿ^g^th^{e r}^e^q^u^ir^em^en^{ts o}^f^th^{e m}^o^d^e^{l r}^e^g^u^l^atioⁿ^o^r^th^e
^p^o^{licies co}^m^p^ly^w^ith^coⁿ^s^u^m^er^p^r^o^t^ectioⁿ^s^r^e^g^a^r^dⁱⁿ^g^th^e^{Model A}^c^{t if}^th^{e s}^t^{ate plan}^am^en^dm^en^{t prov}^ides^th^{at th}^{e s}^t^ate

CRS-52
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^d^e^liv^er^y^o^f^p^o^{licies, in}^f^o^r^m^atioⁿ^oⁿ^d^eⁿⁱ^{als o}^f^claim^s^,ⁱⁿ^s^u^ran^c^e^c^o^m^mⁱ^s^sⁱ^on^{er f}^o^{r th}^{e s}^t^{ate certif}^ies⁽ⁱⁿ^{a m}^aⁿⁿ^e^r
^an^d^dⁱ^sclo^su^r^e^{. W}^h^{ile m}^aⁿ^y^{state law}^s^aⁿ^d^r^e^g^u^l^atioⁿ^s^s^a^tis^f^acto^r^y^{to th}^{e Secretary}⁾^th^{at th}^{e policy}^m^eets^s^u^ch
^{are bas}^e^{d la}^rg^ely^on^th^{e NA}^IC^s^t^an^dards^,^oth^e^rs^h^a^v^e^requ^irem^en^ts^.
^adopt^{ed on}^l^y^s^o^m^e^of^t^h^es^e^s^t^an^dards^.^A^s^{a res}^u^l^t^,^t^h^ere⁽^I^V⁾^I^f^a^t^t^h^e^d^a^t^e^o^f^p^u^r^c^ha^se^t^h^e^p^u^r^c^h^a^se^rⁱ^s^y^o^unge^r^t^h^aⁿ
^is^sⁱ^gⁿⁱ^fⁱ^can^{t v}^a^riationⁱⁿ^regul^a^t^ory^practices^acros^s^ag^e⁶¹^,^th^e^p^o^licy^m^u^{st p}^r^o^v^id^{e f}^o^r^co^m^p^o^uⁿ^dⁱⁿ^f^l^atioⁿ^;^if^th^e
^s^t^ates^.^pu^rch^a^s^e^rⁱ^s^{at leas}^{t ag}^{e 61 bu}^{t n}^o^{t older th}^an^ag^{e 76, th}^e
^p^o^licy^m^u^st^p^r^o^v^id^{e so}^m^e^lev^e^{l o}^fⁱⁿ^f^l^atioⁿ^p^r^o^t^ectioⁿ^;^an^d^if
^t^h^{e pu}^rch^a^s^e^{r i}^s^ag^{e 76 or ol}^der,^t^h^e^p^o^lⁱ^c^y^m^a^y^,^bu^tⁱ^sⁿ^o^t
^r^e^q^u^ir^ed^to^{, p}^r^o^v^id^{e so}^m^e^lev^e^{l o}^fⁱⁿ^f^l^atioⁿ^p^r^o^t^ectioⁿ^.
ⁱ^{ki/CRS-RL33251}^N^a^tⁱ^o^na^l^Cl^e^a^rⁱ^ngh^o^u^se^fo^r^Lo^ng-T^e^r^m^Ca^r^e^.^N^o^p^r^o^v^isioⁿⁱⁿ^cu^r^r^eⁿ^t^law^r^e^q^u^ir^{es th}^{e estab}^lⁱ^s^h^m^en^{t o}^f^a^{(V) T}^h^{e s}^t^{ate M}^e^dⁱ^c^a^{id ag}^en^cy^prov^idesⁱⁿ^f^o^rm^ation^an^d^techⁿⁱ^{cal as}^sⁱ^s^t^an^{ce to th}^{e s}^t^{ate in}^s^u^ran^{ce depa}^r^t^m^eⁿ^t^on^th^e
^g/w^LT^{C c}^o^nsum^e^r^c^l^e^a^rⁱ^ngho^use^.ⁱⁿ^s^u^ranc^e^depart^m^eⁿ^t^’^s^rol^e^of^as^s^u^riⁿ^g^t^h^at^an^yⁱⁿ^di^vⁱ^du^al
^s^.or^w^h^{o s}^e^lls^{a L}^T^Cⁱⁿ^s^u^ran^{ce po}^lⁱ^cy^uⁿ^d^{er th}^{e partn}^e^rs^hⁱ^p
^le^ak^Iⁿ^related^activ^{ities, DHHS h}^a^{s f}^uⁿ^d^ed^so^m^e^state^s^t^o^receiv^e^s^trainⁱⁿ^g^or^d^e^m^o^ns^t^r^a^t^e^s^e^vⁱ^d^en^{ce of}^an
^es^tablis^h^s^t^ate-^bas^e^{d con}^s^u^m^e^r^-^f^r^ien^d^ly^acces^s^to^uⁿ^d^er^stan^dⁱⁿ^g^o^f^su^ch^p^o^{licies an}^d^h^o^w^th^ey^r^e^{late to}^o^t^h^e^r
^://wikiⁱⁿ^f^o^rm^atⁱ^oⁿ^abou^t^L^T^C^se^rvⁱ^ces^{. In}^F^Y^{2003 an}^d^pu^blⁱ^c^an^{d pri}^v^at^{e cov}^e^rag^e^of^L^T^C^;
^h^ttp^F^Y^2004,^t^h^e^C^eⁿ^t^ers^f^o^{r Medi}^{care an}^{d Medi}^cai^{d (C}^MS⁾
^an^d^Ao^A^aw^{arded approx}^im^ately^{$19 m}^illionⁱⁿ^g^r^an^ts^(V^{I) T}^h^{e i}^s^s^u^{er of}^t^h^{e pol}ⁱ^c^y^provⁱ^d^es^r^e^gul^{ar report}^s^t^o^t^h^e
^{to s}^t^ates^f^o^{r t}^h^e^pu^rpos^{e of}^as^sⁱ^s^tin^g^th^{eir ef}^f^o^rts^to^Secretary^th^{at in}^clu^d^{e, in}^a^c^c^o^rdan^{ce w}^ith^th^{e Secretary}^’^s
^{create a s}ⁱⁿ^g^l^{e, coordin}^a^{ted s}^y^s^t^em^ofⁱⁿ^f^o^rm^ation^an^d^r^e^g^u^l^atioⁿ^s⁽^a^f^t^er^coⁿ^s^u^ltatioⁿ^w^ith^th^{e Natio}ⁿ^a^l^A^sso^ciatioⁿ
^acces^s^f^o^{r all pers}^on^s^s^eekⁱⁿ^g^lon^g^term^{care to m}ⁱⁿⁱ^mⁱ^ze^o^f^Iⁿ^sur^a^nc^e^Co^m^mⁱ^ssioⁿ^e^r^s,^issue^r^{s o}^f^L^T^{C insur}^aⁿ^c^e
^con^f^usi^oⁿ^,^en^h^aⁿ^{ce i}ⁿ^di^vⁱ^du^al^ch^oi^{ce, an}^{d s}^u^pport^policies^,^s^t^ates^w^ith^ex^perien^{ce w}ⁱ^t^h^LT^Cⁱⁿ^s^u^ran^c^e
ⁱⁿ^f^o^rm^{ed decis}ⁱ^on^-^m^akⁱⁿ^g^.^In^{FY2005, $15}^m^illion^w^a^s^partn^e^rs^hⁱ^{p plan}^s^,^ot^h^e^{r s}^t^ates^{, an}^{d repres}^en^tativ^es^of
^a^w^a^r^d^e^d^.^A^t^o^t^a^l^o^f⁴³^s^t^a^t^e^s^h^a^v^e^receiv^e^d^g^r^aⁿ^t^s^f^o^r^coⁿ^s^u^m^er^s^o^f^L^T^{C in}^su^r^aⁿ^{ce p}^o^licies)ⁿ^o^tif^icatioⁿ^r^e^g^a^r^dⁱⁿ^g
^th^{is p}^u^r^p^o^s^{e. So}^m^e^o^f^th^e^co^m^m^oⁿ^activ^{ities u}ⁿ^d^er^th^is^w^h^eⁿ^a^l^l^b^e^ne^fi^t^s^aⁿ^d^t^h^eⁱ^r^a^m^o^unt^{s und}^e^r^t^h^e^p^o^lⁱ^c^y^ha^ve
^g^r^an^{ts p}^r^o^g^r^a^mⁱⁿ^clu^d^eⁱⁿ^f^o^r^m^atioⁿ^an^d^r^e^f^e^r^r^a^l,^been^{paid, w}^h^en^th^{e policy}^oth^e^rw^is^{e term}ⁱⁿ^ates^{, an}^{d oth}^e^r
^ou^treach^,^couⁿ^s^elin^g^abou^{t pu}^{blic ben}^e^f^its^an^{d L}^T^Cⁱⁿ^f^o^r^m^atioⁿ^th^{at th}^{e Secr}^etar^y^d^e^ter^mⁱⁿ^{es is}^ap^p^r^o^p^r^iate^to^th^e
^opti^o^ns^,^an^{d cas}^{e m}^aⁿ^a^g^e^m^eⁿ^t^{. States}^’^m^e^th^ods^f^o^r^admⁱⁿⁱ^s^t^ratⁱ^oⁿ^of^t^h^{e part}ⁿ^e^rs^hⁱ^{p prog}^ram^s^{. T}^h^es^e
^im^plem^en^tin^g^th^{e g}^r^an^{t m}^a^y^v^a^r^y^;^s^o^m^e^s^t^ates^h^a^v^e^r^e^g^u^l^atioⁿ^s^sh^{all sp}^ecif^y^th^{e ty}^p^e^an^d^f^o^r^m^a^t^o^f^th^{e d}^a^{ta an}^d

CRS-53
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^es^tablis^h^e^{d an}^act^ua^l^ph^y^s^{ical location}^,^an^{d oth}^e^{r s}^t^atesⁱⁿ^f^o^r^m^atioⁿ^to^b^e^r^e^p^o^r^ted^,^an^d^th^{e f}^r^eq^u^eⁿ^c^y^w^ith^w^h^ich
^ha^ve^e^s^t^a^b^lⁱ^s^he^d^a^st^a^t^e^wⁱ^d^e^c^l^e^a^rⁱ^ngho^use^t^h^r^o^{ugh a}^s^u^ch^reports^{are to be m}^a^{de. T}^h^{e Secretary}^,^a^s^appropriate,
^to^ll-^f^r^{ee n}^u^m^b^e^r^o^r^{a w}^e^b^-^b^a^sedⁱⁿ^f^o^r^m^atioⁿ^site.^prov^ides^copies^of^th^{e reports}^{to th}^{e s}^t^{ate in}^v^o^lv^ed;
^Iⁿ^ad^d^itioⁿ^,^{CMS h}^a^{s m}^a^d^e^av^ailab^l^{e to}^th^{e p}^u^b^{lic, v}ⁱ^{a its}
^w^e^bs^{ite, a c}^o^m^p^aris^on^of^{Medicare an}^{d Medicaid-}
^certif^{ied n}^u^r^sⁱⁿ^g^h^o^m^e^s^an^{d h}^o^m^e^h^ealth^ag^en^cies^{. T}^h^e
ⁱⁿ^f^o^r^m^atioⁿ^p^r^o^v^id^{es d}^e^t^a^iled^f^acility^an^d^ag^en^cy
ⁱⁿ^f^o^rm^ation^an^{d ch}^aracteris^tⁱ^c^s^,^an^{d con}^t^ain^s^s^e^v^e^ral
^m^easu^r^{es o}^f^q^u^ality⁽^e^.g^{., im}^p^r^o^v^em^en^{t in}^m^o^b^ilit^y⁾^.
ⁱ^{ki/CRS-RL33251}^Thⁱ^s^w^e^b^sⁱ^t^e^d^o^e^sⁿ^o^t^c^o^v^e^r^a^s^sⁱ^s^t^e^d^lⁱ^vⁱⁿ^g^f^a^c^ilitie^s^,^g^r^o^u^p^h^o^m^e^{s an}^d^o^t^h^e^r^r^e^sid^eⁿ^tⁱ^a^l^f^{acilities th}^{at ar}^{e n}^o^t
^g/wⁿ^u^r^sin^g^f^acilitie^s^;ⁿ^o^r^d^o^e^{s it co}^v^e^rⁿ^oⁿ^-^m^e^dⁱ^{cal, n}^oⁿ^-
^s^.or^certif^{ied, h}^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed L}^T^C^s^e^rv^ices^.
^le^ak
^{(VII) T}^h^{e s}^t^{ate does}ⁿ^o^{t im}^pos^{e an}^y^requ^irem^en^{t af}^f^ectin^g^th^e
^://wiki^term^s^{or ben}^e^f^its^of^s^u^ch^{a pol}^icy^uⁿ^l^es^s^th^{e s}^t^{ate im}^pos^es
^h^ttp^su^ch^r^e^q^u^ir^em^en^{t o}ⁿ^L^T^{C i}ⁿ^su^r^aⁿ^{ce p}^o^{licies w}^ith^o^u^{t r}^e^g^a^r^d
^t^o^w^h^e^t^he^r^t^h^e^p^o^lⁱ^c^yⁱ^s^c^o^ve^r^e^d^und^e^r^t^h^e^p^a^r^t^ne^r^s^hi^p^o^rⁱ^s
^o^f^f^e^r^e^dⁱⁿ^coⁿⁿ^ectioⁿ^w^ith^su^ch^{a p}^a^r^tⁿ^e^r^s^hⁱ^p^.
^Iⁿ^coⁿ^s^u^ltatioⁿ^w^ith^o^t^h^e^r^a^p^p^r^o^p^r^{iate f}^e^d^e^r^a^{l ag}^en^cies,
^is^s^u^ers^of^L^T^Cⁱⁿ^s^u^ran^{ce, an}^{d th}^{e Nation}^a^l^As^s^o^ciation^of
^In^s^u^ran^{ce C}^o^m^mⁱ^s^sⁱ^on^e^r^s^,^s^t^{ate in}^s^u^ran^{ce com}^mⁱ^s^sⁱ^on^ers^,
^s^t^ates^w^ith^ex^perien^{ce w}^ith^L^T^Cⁱⁿ^s^u^ran^ce^partn^e^rs^hⁱ^p^plan^s^,
^oth^e^{r s}^t^ates^{, an}^d^repres^en^tativ^es^of^con^s^u^m^ers^of^L^T^C
ⁱⁿ^s^u^ran^{ce policies}^,^th^{e Secretary}^dev^e^lops^recom^m^eⁿ^d^ation^s
^fo^r^Co^ngr^e^ss^t^o^a^u^t^h^o^rⁱ^z^e^aⁿ^d^fund^a^uni^fo^r^m^mⁱⁿⁱ^m^u^m^d^a^t^a
^s^e^t^to^b^e^r^e^p^o^r^ted^electr^oⁿⁱ^cally^b^y^{all issu}^er^{s o}^f^L^T^C
ⁱⁿ^su^r^aⁿ^{ce p}^o^{licies u}ⁿ^d^er^q^u^a^l^if^ied^{state L}^T^{C in}^su^r^aⁿ^c^e

CRS-54
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^partn^e^rs^hⁱ^ps^{to a s}^ecu^{re, cen}^{tralized electron}ⁱ^c^q^u^e^r^y^an^d
^{report g}^eⁿ^e^ratin^g^m^ech^anⁱ^s^m^th^{at s}^t^{ate, th}^{e Secretary}^,^an^d
^oth^e^{r f}^e^{deral ag}^en^cies^can^acces^s^.
^No^{t later}^th^an¹²^m^oⁿ^t^h^s^a^f^ter^th^{e Natio}ⁿ^a^{l A}^sso^ciatioⁿ^o^f
^Iⁿ^s^u^ran^{ce C}^o^m^mⁱ^s^sⁱ^on^ersⁱ^s^s^u^es^{a rev}ⁱ^sⁱ^on^{, u}^pdat^e^{or ot}^he^r
^m^odi^fⁱ^catⁱ^oⁿ^of^{a m}^odel^reg^u^l^atⁱ^oⁿ^{or m}^odel^act^provⁱ^sⁱ^oⁿ
^listed^ab^o^v^{e o}^r^su^b^s^tan^tially^r^e^lated^th^o^s^{e listed}^a^b^o^v^e^,^th^e
^Sec^r^etary^revⁱ^ew^s^th^es^{e ch}^an^g^e^s^,^determⁱⁿ^es^w^h^eth^e^r
ⁱⁿ^corporatin^g^s^u^ch^ch^an^g^e^sⁱⁿ^t^o^t^h^{e corres}^pon^diⁿ^g^provⁱ^sⁱ^oⁿ
ⁱ^{ki/CRS-RL33251}^w^o^u^l^dⁱ^m^prov^{e qu}^alⁱ^fⁱ^e^{d s}^t^at^{e L}^T^Cⁱⁿ^s^u^ran^{ce part}ⁿ^e^rs^hⁱ^ps^,^an^d^,^if^so^{, in}^co^r^p^o^r^{ate th}^{e ch}^an^g^e^{s in}^to^th^{e p}^r^o^v^isioⁿ^.
^g/w
^s^.or^{States m}^a^y^r^e^q^u^ir^{e issu}^er^{s o}^f^L^T^Cⁱⁿ^su^r^aⁿ^{ce p}^o^{licies so}^ldⁱⁿ
^le^ak^th^{at s}^t^{ate (reg}^ardles^s^of^w^h^eth^e^{r th}^{e policy}^is^is^s^u^e^d^und^e^r^a
^://wiki^q^u^alif^ied^{state L}^T^{C in}^su^r^aⁿ^{ce p}^a^r^tⁿ^e^r^s^hⁱ^p⁾^to^r^e^p^o^r^{t ad}^d^itioⁿ^a^lⁱⁿ^f^o^r^m^atioⁿ^o^r^d^a^{ta to}^th^{e state.}
^h^ttp
^Ou^{t o}^f^an^y^f^uⁿ^dⁱⁿ^th^{e T}^r^easu^r^yⁿ^o^{t o}^t^h^e^r^w^{ise ap}^p^r^o^p^r^iated^,
^th^er^{e is ap}^p^r^o^p^r^iated^to^th^e^Secr^etar^y^$¹^m^illioⁿ^f^o^r^th^{e p}^e^rⁱ^o^d
^of^F^Y^s^2006-^2010.
^T^o^p^e^r^m^{it p}^o^r^tab^ilityⁱⁿ^L^T^{C in}^su^r^aⁿ^{ce p}^o^{licies p}^u^r^c^h^a^sed
^uⁿ^d^{er s}^t^{ate L}^T^Cⁱⁿ^s^u^ran^{ce partn}^e^rs^hⁱ^ps^,^t^h^{e Secretary}
^dev^e^l^o^psⁿ^o^l^a^t^e^{r t}^h^an^Jan^u^a^ry^{1, 2007, i}ⁿ^con^s^u^l^t^a^tⁱ^oⁿ^wⁱ^t^h
^th^{e Nation}^a^{l A}^s^s^o^ciation^of^In^s^u^ran^{ce C}^o^m^mⁱ^s^sⁱ^on^ers^,^s^t^ates
^w^ith^ex^perien^{ce w}^ith^L^T^Cⁱⁿ^s^u^ran^{ce partn}^e^rs^hⁱ^{p plan}^s^,^oth^e^r
^s^t^{ate, an}^{d repres}^en^tativ^es^of^cons^um^e^r^s^of^L^T^Cⁱⁿ^s^u^ran^c^e
^p^o^{licies, stan}^d^a^r^d^{s f}^o^r^uⁿⁱ^f^o^r^m^r^ecip^r^o^{cal r}^eco^gⁿ^itioⁿ^o^f^su^ch
^p^o^{licies am}^oⁿ^g^{states w}^ith^q^u^alif^ied^{state L}^T^{C in}^su^r^aⁿ^c^e

CRS-55
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^p^a^r^t^ne^r^s^hi^p^s^w^hⁱ^c^{h ha}^ve^b^e^ne^fi^t^s^p^aⁱ^d^und^e^r^suc^h^p^o^lⁱ^cⁱ^e^s^wⁱ^l^l
^{be trea}^t^e^d^t^h^{e s}^a^m^e^by^{all s}^u^ch^s^t^ates^{, an}^{d s}^t^ates^w^ith^s^u^ch
^partn^e^rs^hⁱ^ps^s^h^{all be}^s^u^bj^{ect to s}^u^ch^s^t^an^dards^uⁿ^l^es^s^th^{e s}^t^ate
^no^tif^ies^th^{e Secretary}^of^th^{e State’}^s^election^{to be ex}^e^m^p^t
^fr^o^m^suc^h^staⁿ^d^a^r^d^s.
^T^h^e^Se^c^r^e^t^a^r^y^a^nnua^l^l^y^r^e^p^o^r^t^s^t^o^Co^ngr^e^{ss o}ⁿ^t^h^e^LT^C
ⁱⁿ^s^u^ran^ce^partn^e^rs^hⁱ^ps^{. Su}^ch^reports^w^o^u^l^dⁱⁿ^clu^d^e^an^aly^s^es
^o^f^t^h^{e ex}^t^eⁿ^t^t^o^w^hⁱ^c^h^partⁿ^e^rs^hⁱ^{p prog}^ram^s^ex^pan^d^{or l}ⁱ^mⁱ^t
^acces^s^ofⁱⁿ^divⁱ^du^als^{to L}^T^C^an^{d th}^{e im}^{pact of}^s^u^ch
ⁱ^{ki/CRS-RL33251}^partⁿ^e^rs^hⁱ^ps^on^f^e^deral^an^{d s}^t^a^t^e^ex^pen^dⁱ^t^u^res^uⁿ^d^{er Medi}^care^an^d^Medⁱ^caid^.^No^thⁱⁿ^gⁱⁿ^th^{is p}^r^o^v^isioⁿ^s^h^a^l^{l r}^e^q^u^ir^{e th}^e
^g/w^Sec^r^etary^{to con}^d^u^c^{t an}ⁱⁿ^depen^d^en^{t rev}ⁱ^ew^of^each^L^T^C
^s^.orⁱⁿ^s^u^r^a^nc^{e policy}^of^f^e^{red u}ⁿ^d^{er or in}^conⁿ^ection^w^ith^{a s}^t^ate
^le^ak^partⁿ^e^rs^hⁱ^{p prog}^ram^.
^://wiki^A^s^t^{ate plan}^am^en^dm^en^{t th}^{at prov}^ides^f^o^{r a qu}^alif^{ied s}^t^ate
^h^ttp^L^T^Cⁱⁿ^s^u^ran^{ce partn}^e^rs^hⁱ^{p m}^a^y^prov^{ide th}^at^th^{e am}^en^dm^en^t
^b^e^ef^f^ectiv^{e f}^o^r^L^T^{C in}^su^r^aⁿ^{ce p}^o^{licies issu}^ed^oⁿ^o^r^a^f^t^e^r^a
^d^a^{te th}^{at is n}^o^{t ear}^lier^th^an^th^{e f}ⁱ^r^s^{t d}^a^y^o^f^th^{e f}ⁱ^r^s^{t c}^a^l^eⁿ^d^a^r
^q^u^a^r^terⁱⁿ^w^h^ich^th^{e p}^l^an^am^en^d^m^en^{t w}^a^{s su}^b^m^itted^to^th^e
^Secretary^.
^N^a^tⁱ^o^na^l^Cl^e^a^rⁱ^ngho^use^fo^r^LT^C.^T^h^e^Se^c^r^e^t^a^r^y^e^s^t^a^b^lⁱ^s^he^s
^a^N^a^tⁱ^o^na^l^Cl^e^a^rⁱ^ngho^use^fo^r^LT^{C I}ⁿ^fo^r^m^a^tⁱ^o^{n (}^t^hi^{s m}^a^y^b^e
^d^oⁿ^e^t^h^r^o^{ugh a}^c^o^nt^r^a^c^t^o^rⁱⁿ^t^e^r^a^ge^nc^y^a^g^r^e^e^m^eⁿ^t⁾^.^T^h^e
^N^a^tⁱ^o^na^l^Cl^e^a^rⁱ^ngho^use^fo^r^LT^C:⁽¹⁾^e^d^uc^a^t^e^s^c^o^nsum^e^r^s
^w^ith^r^e^sp^{ect to}^th^{e av}^ailab^ility^an^d^lim^itatioⁿ^s^o^f^Medⁱ^caid
^LT^C^c^o^ve^r^a^ge⁽^a^nd^p^r^o^vⁱ^d^e^s^c^o^nt^a^c^tⁱⁿ^fo^r^m^a^tⁱ^o^{n fo}^r
^obtainⁱⁿ^g^s^p^ecifⁱ^{c s}^t^{ate in}^fo^r^m^ation^on^L^T^C^cov^e^rag^e^),

CRS-56
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
ⁱⁿ^clu^dⁱⁿ^g^{state M}^e^dⁱ^caid^elig^ib^ility^an^d^{estate r}^eco^v^e^r^y
^r^e^q^u^ir^em^en^{ts; (}²⁾^p^r^o^v^id^e^s^o^b^j^ectiv^{e in}^f^o^r^m^atioⁿ^to^assist
^con^s^u^m^ers^w^ith^th^{e decis}ⁱ^on^-^m^akⁱⁿ^g^proces^s^f^o^r^determⁱⁿⁱⁿ^g
^w^h^et^h^e^{r t}^o^pu^rch^a^s^e^L^T^Cⁱⁿ^s^u^ran^{ce or t}^o^pu^rs^u^e^ot^h^e^{r pri}^v^at^e
^m^a^rk^{et altern}^ativ^es^{for pu}^rch^a^sⁱⁿ^g^L^T^C^an^{d prov}^{ide con}^t^act
ⁱⁿ^f^o^r^m^atioⁿ^f^o^r^ad^d^itioⁿ^a^{l o}^b^j^ectiv^{e r}^e^so^u^r^{ces o}ⁿ^p^l^anⁿⁱⁿ^g^f^o^r
^L^T^Cⁿ^eeds^;^an^{d (3) m}^aⁱⁿ^tain^{a lis}^{t of}^s^t^ates^wⁱ^t^h^s^t^{ate L}^T^C
ⁱⁿ^sur^a^nc^e^p^a^r^t^ne^r^s^hi^p^s^.
^Iⁿ^p^r^o^v^idⁱⁿ^gⁱⁿ^f^o^r^m^atioⁿ^to^coⁿ^s^u^m^er^{s o}ⁿ^L^T^{C, th}^{e Natio}ⁿ^a^l
ⁱ^{ki/CRS-RL33251}^Cl^e^a^rⁱ^ngho^use^fo^r^L^T^C^Iⁿ^fo^r^m^a^tⁱ^o^{n sha}^l^l^no^t^a^d^vo^c^a^t^eⁱⁿ^f^a^v^o^r^of^{a s}^p^ecifⁱ^{c L}^T^Cⁱⁿ^s^u^ran^{ce prov}^{ider or a s}^p^ecifⁱ^c^L^T^C
^g/wⁱⁿ^su^r^aⁿ^{ce p}^o^licy^.
^s^.or
^le^ak^Ou^t^o^f^an^y^f^uⁿ^d^{s in}^th^{e T}^r^easu^r^yⁿ^o^t^o^t^h^e^r^w^ise^ap^p^r^o^p^r^iated^,
^://wiki^t^h^e^r^{e is ap}^p^r^o^p^r^iated^to^car^r^y^o^u^{t f}^o^r^th^{e Natio}ⁿ^a^l^Clear^ingho^{use f}^o^r^L^T^{C $}³^m^illio^{n f}^o^r^each^o^f^FY^2006-^2010.

^h^ttp

CRS-57
apter 3. Eliminating Fraud, Waste, and Abuse in Medicaid
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^En^co^u^r^agⁱⁿ^g^t^h^{e En}^act^men^t^o^f^St^at^e^F^a^lse^Uⁿ^{der t}^h^{e f}^e^deral^F^a^l^s^{e C}^l^ai^m^s^A^c^t^,^an^y^oⁿ^e^w^h^{o k}ⁿ^o^wⁱ^ngl^y^Se^c^tⁱ^oⁿ^6031.^Un^{der th}^{e con}^f^eren^{ce ag}^reem^en^{t, if}^a
^c^ts.^su^b^m^{its a f}^a^{lse claim}^to^th^{e f}^e^d^e^r^a^{l g}^o^v^e^rⁿ^m^eⁿ^t^{is liab}^l^{e f}^o^r^s^t^{ate h}^a^sⁱⁿ^e^f^f^{ect a law}^relatin^g^{to f}^a^ls^{e or f}^r^au^du^len^t
^d^a^m^a^ge^{s up}^t^o^t^h^r^e^e^tⁱ^m^e^s^t^h^e^a^m^o^unt^o^f^t^h^e^go^ve^rⁿ^m^e^nt^’s^claim^s^th^{at m}^eets^requ^irem^en^ts^s^p^ecifⁱ^{ed in}^the^bⁱ^{ll, th}^e
^dam^a^g^e^s^plu^s^m^aⁿ^d^atory^pen^a^lties^of^$⁵^,⁵^{00 to $11,000 f}^o^r^FMA^P^{, w}^ith^res^p^{ect to an}^y^am^o^unt^s^recov^e^{red u}ⁿ^d^{er a}
^each^f^a^l^s^e^c^l^aⁱ^m^s^u^b^m^itted^.^Un^d^e^r^qui^t^a^m^(w^hⁱ^s^t^l^e^bl^ow^e^r⁾^st^a^t^e^a^c^tⁱ^o^{n b}^r^o^ught^und^e^r^suc^h^a^l^a^w^,ⁱ^s^d^e^c^r^e^a^s^e^d^b^y¹⁰
^p^r^o^v^isioⁿ^s^o^f^th^{e act, p}^r^iv^{ate citizen}^{s w}^ith^kⁿ^o^w^l^ed^g^e^o^f^percen^t^a^g^e^poiⁿ^t^s^.
^p^o^t^en^{tial v}ⁱ^o^l^atioⁿ^s⁽^“^r^e^lato^r^s^”)^m^a^y^f^{ile su}^{it o}ⁿ^b^e^h^a^lf^o^f^th^e
^g^o^v^e^rn^m^eⁿ^t^an^d^{are en}^titled^to^receiv^e^{a sh}^{are o}^f^th^e^p^r^o^ceed^s^T^h^{e prov}ⁱ^sⁱ^oⁿⁱ^s^ef^f^ectⁱ^v^{e Jan}^u^a^ry^{1, 2007, ex}^ceptⁱⁿ^t^h^e
ⁱ^{ki/CRS-RL33251}^o^f^th^{e actio}ⁿ^o^r^settlem^eⁿ^t^o^f^th^e^claim⁽^r^aⁿ^gⁱⁿ^g^f^r^o^m¹⁵^%^to^cas^{e of}^{a s}^t^{ate w}^h^ich^th^{e Secretary}^of^HHS^d^e^termⁱⁿ^es
^g/w³⁰^%^,^d^e^p^e^ndⁱ^{ng o}ⁿ^w^h^e^t^he^r^o^r^no^t^t^h^e^go^ve^rⁿ^m^e^nt^e^l^e^c^t^{s t}^o^th^{at state leg}ⁱ^slatioⁿ^{is r}^e^q^u^ir^ed^f^o^r^co^m^p^lian^ce.
^s^.or^{participate in}^th^{e cas}^e).
^le^ak
^{States m}^a^y^h^a^v^e^{a v}^a^riety^o^f^law^sⁱⁿ^p^l^{ace to}^f^acilitate
^://wiki^pros^ecu^tⁱ^oⁿ^of^Medi^cai^{d f}^r^au^{d, an}^{d s}^o^m^e^h^a^v^e^e^s^t^a^blⁱ^s^h^e^d
^h^ttp^th^{eir ow}ⁿ^v^e^r^sⁱ^o^ns^of^{a f}^a^ls^{e claim}^s^{act. W}^ith^lim^ited
^ex^ception^s^{, a s}^t^at^e^m^u^s^t^repay^th^{e f}^e^{deral s}^h^{are (g}^en^erally
^determⁱⁿ^{ed by}^th^{e f}^e^{deral m}^e^{dical as}^sⁱ^s^t^an^{ce percen}^{tage, or}
^F^M^A^P^{) of}^an^y^provi^d^e^{r ov}^erpay^m^en^t^wⁱ^t^hⁱⁿ^{60 day}^s^of
^di^s^c^ov^eriⁿ^g^t^h^{e ov}^erpay^m^en^t^,^reg^a^rdl^e^s^s^of^w^h^et^h^e^{r or n}^o^t^t^h^e
^s^t^{ate h}^a^s^recov^e^{red th}^{e ov}^erpay^m^en^{t to th}^{e prov}^ider.
^E^m^ploy^e^e^E^duc^a^t^{ion A}^{bout Fa}^ls^e^C^l^aⁱ^ms^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^6032.^Un^{der th}^{e con}^f^eren^{ce ag}^reem^en^{t, a s}^t^ate
^v^e^ry^.^{is r}^e^q^u^ir^ed^to^p^r^o^v^id^{e that}^any^entity^{that r}^{eceives annual}
^Medⁱ^caid^p^a^y^m^en^ts^o^f^at^least^$⁵^m^illioⁿ^,^{as a co}ⁿ^d^itioⁿ
^o^f^receivⁱⁿ^g^su^ch^p^a^y^m^en^{ts, m}^u^st:⁽¹⁾^e^s^tab^lish^w^r^itten
^policies^f^o^{r all}^em^ploy^ees^(an^d^an^y^con^t^{ractor or ag}^en^t)
^o^f^th^{e en}^tity^th^{at p}^r^o^v^id^{e d}^e^tailedⁱⁿ^f^o^r^m^atioⁿ^oⁿ^state

CRS-58
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^an^d^f^e^d^e^r^a^{l f}^a^l^s^e^claim^s^law^s^an^d^w^h^istle-^b^lo^w^e^r
^p^r^o^t^ectioⁿ^s^uⁿ^d^er^su^ch^law^s^{, (}²⁾ⁱⁿ^cl^u^d^{e in}^su^ch^w^r^itten
^p^o^{lices d}^e^tailed^p^r^o^v^isioⁿ^s^r^e^g^a^r^dⁱⁿ^g^th^e^en^tity^’^s^p^o^licies
^an^{d pr}^o^c^e^d^u^r^es^f^o^{r detectin}^g^an^{d prev}^en^tin^g^f^r^au^d,
^w^a^s^t^{e, an}^{d abu}^s^{e, an}^{d (3) i}ⁿ^c^l^u^d^{e in}^an^y^em^ploy^ee
^h^aⁿ^dbook^f^o^{r th}^{e en}^tity^{a s}^p^ecifⁱ^{c dis}^c^u^s^sⁱ^oⁿ^of^s^u^ch
^l^a^w^s^,^t^h^e^ri^g^h^t^s^of^em^pl^oy^ees^t^o^{be prot}^ect^{ed as}
^w^h^istleb^l^o^w^er^{s, an}^d^th^{e en}^tity^’^s^p^o^licies^an^d^p^r^o^ced^u^r^es
^f^o^{r detectin}^g^an^{d prev}^en^tin^g^f^r^au^{d, w}^a^s^t^{e, an}^{d abu}^s^e.
ⁱ^{ki/CRS-RL33251}^T^h^{e prov}ⁱ^sⁱ^oⁿⁱ^s^ef^f^ectⁱ^v^{e Jan}^u^a^ry^{1, 2007, ex}^ceptⁱⁿ^t^h^e^cas^{e of}^{a s}^t^{ate w}^h^ich^th^e^S^ecretary^of^{HHS determ}ⁱⁿ^es
^g/w^th^{at state leg}ⁱ^slatioⁿ^{is r}^e^q^u^ir^ed^f^o^r^co^m^p^lian^ce.
^s^.or
^le^ak^P^r^{ohibition on Re}^s^t^oc^kⁱ^{ng a}^{nd Double}^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^6033.^T^h^{e con}^f^eren^ce^ag^reem^en^t^w^o^u^l^d^proh^ibit
^Prescriptⁱ^{on Drugs.}^f^e^d^e^r^a^{l m}^a^tchⁱⁿ^g^p^a^y^m^en^{ts f}^o^r^th^{e in}^g^r^ed^ien^t^co^{st o}^f^a
^://wiki^cov^e^{red ou}^tpatien^t^d^r^ug^f^o^{r w}^h^ich^th^{e ph}^arm^acy^h^a^s
^h^ttp^already^receiv^e^{d pay}^m^en^{t (oth}^{er th}^an^{a reas}^on^able
^re-^s^tockⁱⁿ^g^f^{ee). It w}^o^u^l^{d becom}^e^ef^f^ectiv^{e on}^th^e^fⁱ^rs^t
^day^of^th^e^fⁱ^rs^t^fⁱ^s^cal^qu^{arter beg}ⁱⁿⁿⁱⁿ^g^af^{ter en}^actm^eⁿ^t^.
^M^e^dic^aⁱ^{d Inte}^gr^ity^P^r^ogr^a^m^.^States^an^d^th^{e f}^e^d^e^r^a^{l g}^o^v^e^rⁿ^m^eⁿ^t^sh^ar^{e in}^th^e^r^e^sp^oⁿ^sib^ility^S^ecti^oⁿ^6034.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t es}^tablis^h^e^s^a
^f^o^{r s}^a^f^e^g^u^a^rdi^ng^M^e^dⁱ^cai^{d prog}^ramⁱⁿ^t^e^g^rⁱ^t^y^{. S}^t^at^es^m^u^s^t^Medi^cai^{d In}^t^e^g^rⁱ^t^y^Prog^ram^,^{under w}^hⁱ^c^h^t^h^{e S}^ecret^ary
^co^m^p^ly^w^ith^f^e^d^e^r^a^{l r}^e^q^u^ir^em^en^{ts d}^e^sigⁿ^e^d^to^en^su^r^e^th^at^o^f^{HHS sh}^{all en}^terⁱⁿ^to^coⁿ^t^r^acts^w^ith^elig^ib^le^en^tities^to
^{Medicaid f}^uⁿ^d^s^{are proper}^l^y^s^p^en^{t (or recov}^e^{red, w}^h^en^car^r^y^o^u^t^its^activ^ities,ⁱⁿ^clu^dⁱⁿ^g^r^e^vⁱ^ew^o^f^th^{e actio}ⁿ^s^o^f
ⁿ^eces^s^a^ry^{). T}^h^{e C}^eⁿ^t^ers^f^o^{r Medicare an}^d^{Medicaid Serv}^icesⁱⁿ^dⁱ^vⁱ^d^u^{als o}^r^en^{tities, au}^d^{it o}^f^claim^s^f^o^r^p^a^y^m^en^t,
^(C^MS^{) i}^s^t^h^{e pri}^m^ary^f^e^deral^a^g^eⁿ^c^y^res^pon^sⁱ^bl^{e f}^o^rⁱ^d^en^tif^icatioⁿ^o^f^o^v^er^p^a^y^m^en^{ts, an}^d^ed^u^catioⁿ^w^ith
^p^r^o^vⁱ^dⁱⁿ^g^o^v^e^r^sⁱ^g^h^t^o^f^s^t^a^t^e^s^’^a^c^tⁱ^v^{ities a}ⁿ^d^f^a^c^ilitatin^g^th^eir^r^e^sp^{ect to}^p^a^y^m^eⁿ^{t in}^teg^r^ity^an^d^q^u^ality^o^f^car^e.
^prog^ramⁱⁿ^teg^rⁱ^t^y^ef^f^o^rts^.^T^h^{e HHS Of}^fⁱ^{ce of}^In^s^p^ector^A^p^p^r^o^p^r^iatioⁿ^s^f^o^r^th^{e p}^r^o^g^r^a^m^to^{tal $}⁵^mⁱ^llioⁿⁱⁿ
^Gen^e^ral^(OIG)^als^o^play^s^{a role in}^Medicaid^f^r^au^d^an^d^abu^s^e^FY2006,^{$50 m}^illionⁱⁿ^each^of^{FY2007 an}^{d FY2008,}

CRS-59
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^d^e^t^e^c^tⁱ^o^{n a}ⁿ^d^p^r^e^v^eⁿ^tⁱ^o^{n e}^ffo^r^t^{s t}^h^r^o^{ugh i}^t^sⁱ^nve^stⁱ^g^a^tⁱ^o^ns,^an^{d $75 m}^illionⁱⁿ^each^fⁱ^s^{cal y}^{ear th}^ereaf^te^r⁽^w^ith^a
^au^dits^{, ev}^alu^a^tion^s^{, is}^s^u^an^ces^of^prog^ram^recom^m^eⁿ^d^ation^s^,^m^aⁿ^d^at^{ed i}ⁿ^creas^{e of}^{100 em}^pl^oy^ees^w^h^os^{e du}^tⁱ^e^s
^an^d^o^t^h^e^r^activ^ities.^coⁿ^s^{ist so}^lely^o^f^p^r^o^t^ectin^g^th^{e in}^teg^r^ity^o^f^th^{e Med}ⁱ^caid
^prog^ram⁾^{. States}^{are requ}^ired^t^o^c^o^m^p^ly^w^ith^an^y
^A^s^p^a^r^t^o^f^{its p}^r^o^g^r^a^mⁱⁿ^teg^rⁱ^t^y^activ^{ities, CMS o}^p^e^r^a^{tes a}^requ^irem^en^ts^determⁱⁿ^{ed by}^th^{e Secret}^a^r^y^{to be}
^Medi^care^-^Medi^cai^{d (Medi}^-^Medi^{) dat}^a^m^a^t^c^h^proj^ect^t^h^atⁿ^eces^s^a^ry^f^o^{r carry}ⁱⁿ^g^o^u^{t th}^{e Medicaid In}^teg^r^ity
^aⁿ^a^l^y^zes^cl^ai^m^s^dat^a^f^r^om^bot^h^prog^ram^s^t^o^g^e^t^h^{er t}^o^det^e^c^t^Pr^og^r^a^m^.
^ab^er^r^aⁿ^t^p^a^tterⁿ^s^th^{at m}^a^yⁿ^o^{t b}^e^ev^id^en^{t w}^h^en^b^illin^g^s^ar^e
^vⁱ^ew^edⁱⁿ^iso^l^atioⁿ⁽^e^.g^{., p}^r^o^v^id^er^{s su}^b^m^ittin^g^claim^s^to^b^o^t^h^In^each^of^FY2006-^{2010, $25 m}^illion^is^appropriated^f^o^r
^prog^ram^s^f^o^{r procedu}^r^es^th^{at add u}^p^to^an^ex^ces^sⁱ^v^eⁿ^u^m^ber^Medⁱ^caid^activ^{ities o}^f^t^h^{e HHS Of}^fⁱ^{ce o}^f^Iⁿ^sp^ecto^r
ⁱ^{ki/CRS-RL33251}^o^f^h^o^u^r^s^of^patien^t^{care in}^{a s}ⁱⁿ^g^l^{e day}⁾^{. T}^h^{e Med}ⁱ^-M^e^dⁱ^proj^ec^t^b^e^g^aⁿ^wⁱ^t^h^on^{e s}^t^at^{e i}ⁿ^{2001, an}^{d w}^a^s^s^u^bs^equ^eⁿ^t^l^y^G^eⁿ^e^ral⁽ⁱⁿ^addi^tⁱ^oⁿ^t^o^an^y^ot^h^e^{r am}^ouⁿ^t^s^appropri^a^t^e^d^o^r^m^a^d^e^av^ailab^l^{e f}^o^r^{its Med}ⁱ^c^aⁱ^d^activ^{ities, to}^r^e^m^aⁱⁿ
^g/w^ex^pan^d^{ed t}^oⁱⁿ^cl^u^d^{e ei}^g^h^t^ot^h^e^rs^{. It}ⁱ^s^pri^m^ari^l^y^s^u^pport^e^{d by}^av^ailab^l^{e u}ⁿ^{til ex}^p^eⁿ^d^ed⁾^.
^s^.or^“w^e^d^{ge” f}^uⁿ^d^s^f^r^om^th^{e Health}^C^a^{re Frau}^{d an}^{d A}^b^u^s^e
^le^ak^C^oⁿ^t^{rol (HC}^F^A^C^{) accou}ⁿ^t^w^ithⁱⁿ^th^{e f}^e^{deral Hos}^pⁱ^t^a^l^T^h^{e con}^f^eren^{ce ag}^reem^eⁿ^t^a^l^s^o^es^tablis^h^e^s^{a n}^a^tion^a^l
^://wiki^In^s^u^ran^{ce (Medicare P}^a^{rt A}⁾^tru^s^{t f}^uⁿ^d^{. HC}^FA^C^w^e^dg^e^f^uⁿ^d^s^{are di}^vⁱ^{ded bet}^w^een^t^h^{e D}^e^part^m^eⁿ^t^of^Ju^s^tⁱ^{ce, t}^h^e^ex^pan^sⁱ^oⁿ^of^t^h^{e Medi}^care-^Medi^cai^{d dat}^a^m^a^t^c^h^proj^ect^(re^fe^r^r^e^{d to as}^th^{e Medi-}^M^{edi P}^r^og^ram⁾^as^{a requ}^ired
^h^ttp^H^H^S^O^f^fⁱ^{ce of}^In^s^p^ect^{or G}^e^neral^,^C^M^S^,^an^{d ot}^h^e^{r H}^H^S^activ^ity^o^f^th^{e Med}ⁱ^car^{e I}ⁿ^teg^r^ity^P^r^o^g^r^a^m^.^Iⁿ^ad^d^itioⁿ
^ag^en^cies^{. T}^h^{e H}^C^FA^C^accouⁿ^t^als^o^f^uⁿ^d^s^th^{e Medicare}^to^HCFA^{C ap}^p^r^o^p^r^iatioⁿ^s^f^o^r^th^{e Med}ⁱ^car^{e I}ⁿ^teg^r^ity
^Iⁿ^teg^r^ity^P^r^o^g^r^a^m^an^d^activ^{ities o}^f^th^{e Fed}^e^r^a^l^B^u^r^eau^o^f^Prog^ram^,^t^h^{e Medi}^-M^e^dⁱ^Prog^ramⁱ^s^appropri^a^t^e^{d $12}
^I^nve^stⁱ^g^a^tⁱ^o^{n r}^e^l^a^t^e^d^t^o^he^a^l^t^h^c^a^r^e^fr^a^u^d^.^A^nnua^l^mⁱⁿⁱ^m^u^m^m^illionⁱⁿ^{FY2006, $24 m}^illionⁱⁿ^{FY2007, $36 m}^illion
^an^{d m}^a^xⁱ^m^u^m^HC^FA^C^{appropriation}^s^{are s}^p^ecifⁱ^{ed in}^s^t^atu^t^e.ⁱⁿ^F^Y²^008,^{$48 m}^illionⁱⁿ^{FY2009, an}^{d $60 m}^illionⁱⁿ
^F^Y^{2010 an}^{d each}^fⁱ^s^{cal y}^{ear th}^ereaf^ter.
^E^nha^nc^{ing T}^h^ir^{d P}^a^r^t^y^Ideⁿ^tific^a^t^{ion a}ⁿ^d^T^h^ir^d^-^p^a^r^t^y^liab^ility⁽^T^P^L⁾^r^e^f^e^r^s^to^th^{e leg}^a^{l o}^b^lig^atioⁿ^o^f^S^ecti^oⁿ⁶⁰³⁵^.^T^h^e^coⁿ^f^er^en^{ce ag}^r^eem^en^{t su}^b^s^titu^{tes th}^e
^m^en^t^.^th^ir^d^p^a^r^ties^—ⁱⁿ^dⁱ^vⁱ^d^u^{als, en}^{tities, o}^r^p^r^o^g^r^a^m^s^{— to}^p^a^y^all^t^e^r^m^“^m^an^ag^ed^care^org^aⁿⁱ^zatio^n”^fo^r^“he^a^l^t^h
^{or part of}^th^{e ex}^pen^d^itu^res^f^o^{r m}^e^{dical as}^sⁱ^s^t^aⁿ^{ce f}^u^rn^is^h^e^d^m^aⁱⁿ^t^eⁿ^aⁿ^{ce o}^r^g^aⁿⁱ^zatioⁿ^”^an^d^am^en^d^s^th^{e list o}^f^th^ir^d
^uⁿ^d^{er a Medicaid s}^t^{ate plan}^{. In}^g^eⁿ^e^ral,^f^e^{deral law}^requ^ires^partⁱ^e^s^nam^e^{d i}ⁿ^S^ectⁱ^oⁿ^{1902(a)(25) of}^t^h^{e S}^o^ci^al
^Medⁱ^caid^to^b^e^th^{e p}^a^y^o^r^o^f^last^r^e^so^r^t^,^m^eanⁱⁿ^g^th^{at all o}^t^h^e^r^Secu^rity^A^c^{t f}^o^{r w}^h^ich^s^t^ates^m^u^s^t^t^a^k^e^{all reas}^on^able
^av^ailab^l^{e th}^ir^d^p^a^r^{ties m}^u^st^m^eet^th^eir^leg^a^{l o}^b^lig^atioⁿ^to^p^a^y^m^easu^r^{es to}^ascer^taiⁿ^t^h^{e leg}^a^{l liab}^ility^toⁱⁿ^clu^d^e

CRS-60
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^claim^s^bef^o^{re th}^{e Medicaid prog}^ram^pay^s^f^o^{r th}^{e care of}^an^se^l^f-i^nsur^e^d^p^l^aⁿ^s,^p^h^a^r^m^a^c^y^b^e^ne^fi^t^m^a^na^ge^r^s^,^aⁿ^d^o^t^he^r
ⁱⁿ^di^vⁱ^du^al^.^parties^th^{at are}^l^e^g^a^lly^res^pon^sⁱ^{ble (by}^s^t^atu^t^{e, con}^t^ract,
^{or ag}^reem^en^{t) f}^o^r^p^a^y^m^en^{t of}^{a claim}^f^o^{r a h}^ealth^care
^States^{are requ}^{ired to tak}^e^{all reas}^on^{able m}^eas^u^r^es^to^it^e^m^{or s}^e^rv^{ice. It als}^o^am^en^ds^th^{at s}^ection^{to in}^clu^d^e
^ascer^tain^th^{e leg}^a^{l liab}^ility^o^f^th^ir^d^p^a^r^{ties to}^p^a^y^f^o^r^car^{e an}^d^th^{ese en}^{tities in}^th^{e list o}^f^h^ealthⁱⁿ^su^r^e^r^s^th^at^states^m^u^st
^s^e^rv^ices^av^ailable^uⁿ^d^er^th^e^s^t^{ate Medicaid plan}^{. If}^th^{e s}^t^ate^prohⁱ^bⁱ^t^f^r^om^t^a^kⁱⁿ^g^anⁱⁿ^di^vⁱ^du^al^’^s^Medi^cai^d^s^t^at^u^sⁱⁿ^t^o
^h^a^{s d}^e^ter^mⁱⁿ^ed^th^{at p}^r^o^b^a^b^l^{e th}^ir^d^p^a^r^t^y^liab^ility^ex^ists^at^th^e^a^ccouⁿ^t^w^h^en^en^rollin^g^th^{e in}^divⁱ^du^{al or m}^a^kⁱ^ng
^tim^{e a claim}^f^o^r^r^e^im^b^u^r^s^em^en^{t is}^fⁱ^l^e^d^,^{it g}^eⁿ^e^r^a^lly^m^u^st^pay^m^en^t^s^f^o^{r ben}^e^fⁱ^t^s^t^o^{or on}^beh^a^l^f^of^t^h^{e i}ⁿ^di^vⁱ^du^al^.
^rej^ect^t^h^{e claim}^an^{d retu}^rn^{it to th}^{e prov}^{ider f}^o^{r a}
^d^e^ter^mⁱⁿ^atioⁿ^o^f^th^{e am}^o^uⁿ^t^o^f^th^ir^d^p^a^r^t^y^liabⁱ^lity⁽^r^ef^er^r^e^d^Iⁿ^ad^d^itioⁿ^,^{it r}^e^q^u^ir^{es a stat}^e^t^o^p^r^o^v^id^{e assu}^r^aⁿ^ces
ⁱ^{ki/CRS-RL33251}^to^{as “}^c^o^s^{t av}^oⁱ^d^aⁿ^{ce”). If}^p^r^o^b^a^b^l^{e liab}^ility^h^a^sⁿ^o^{t b}^een^estab^lⁱ^s^h^e^d^o^r^th^{e th}^ir^d^p^a^r^t^y^{is n}^o^{t av}^ailab^l^{e to}^p^a^y^th^e^satisf^acto^r^y^to^th^{e Secr}^etar^y^o^f^{HHS th}^{at it h}^a^s^law^sⁱⁿ^ef^f^ect^requⁱ^rⁱⁿ^g^t^hⁱ^r^d^partⁱ^e^s^t^o^provⁱ^d^{e, u}^pon^requ^es^t^of
^g/wⁱⁿ^divⁱ^du^al’^s^m^e^{dical ex}^pen^s^es^{, th}^{e s}^t^{ate m}^u^s^t^pay^th^{e claim}^th^{e state, in}^f^o^r^m^atioⁿ^to^d^e^ter^mⁱⁿ^{e h}^ealt^hⁱⁿ^su^r^aⁿ^c^e
^s^.or^aⁿ^d^th^en^attem^p^{t to}^r^eco^v^e^r^th^{e am}^o^uⁿ^t^p^a^id⁽^r^e^f^e^r^r^ed^t^o^a^s^cov^e^rag^e⁽ⁱⁿ^{a m}^aⁿⁿ^e^{r pres}^cribe^d^b^y^th^{e Secretary}⁾^an^d
^le^ak^“^p^ay^an^{d ch}^as^{e”). States}^are^g^eⁿ^e^rally^requ^ired^to^cos^t^av^oid^t^o^cooperat^e^wⁱ^t^h^pay^m^en^t^an^{d recov}^e^ry^effort^s^by
^://wiki^claim^s^uⁿ^l^es^s^th^ey^h^a^v^e^an^approv^ed^w^a^iv^er^th^at^allow^s^th^em^{to u}^s^{e th}^{e pay}^an^{d ch}^as^{e m}^e^th^od.^Medi^cai^d.
^h^ttp^T^h^{e prov}ⁱ^sⁱ^oⁿⁱ^s^ef^f^ectⁱ^v^{e Jan}^u^a^ry^{1, 2006, ex}^ceptⁱⁿ^t^h^e
^A^s^{a co}ⁿ^d^itioⁿ^o^f^elig^ib^ility^f^o^r^Medⁱ^caid^,ⁱⁿ^dⁱ^vⁱ^d^u^als^ar^e^c^a^s^e^of^{a s}^t^{ate w}^h^ich^th^{e Secretary}^of^{HHS determ}^ine^s
^requ^{ired to as}^sⁱ^gⁿ^{to th}^{e s}^t^{ate Medicaid ag}^en^cy^th^{eir rig}^h^t^s^to^th^{at state leg}ⁱ^slatioⁿ^{is r}^e^q^u^ir^ed^f^o^r^co^m^p^lian^ce.
^m^e^di^cal^s^u^pport^an^{d pay}^m^en^t^f^o^{r m}^e^di^cal^{care f}^r^om^an^y^t^hⁱ^r^d
^p^a^r^t^y^.^T^h^{is assig}ⁿ^m^en^{t o}^f^rⁱ^g^h^t^{s f}^{acilitates T}^P^L^r^eco^v^e^r^y^b^y
^allowⁱⁿ^g^th^{e s}^t^ate^to^collect,^on^beh^a^lf^of^{Medicaid en}^rollees^,
^am^ouⁿ^t^s^ow^{ed by}^t^hⁱ^r^{d part}ⁱ^e^s^f^o^{r cl}^ai^m^s^pai^d^by^Medi^cai^d.
^Imp^r^o^v^ed^En^f^o^rcemen^t^o^f^Do^cu^men^t^at^ioⁿ^T^o^b^e^elig^ib^{le f}^o^r^th^{e f}^u^{ll r}^aⁿ^g^e^o^f^b^eⁿ^e^f^{its o}^f^f^e^r^e^d^uⁿ^d^er^S^e^c^tⁱ^oⁿ^6036.^Un^{der th}^{e con}^f^eren^{ce ag}^reem^en^{t, s}^t^ates
^quir^e^me^nts^.^Medi^cai^{d, an}ⁱⁿ^di^vⁱ^du^al^m^u^s^t^{be a ci}^tⁱ^zen^or^na^tⁱ^o^nal^of^t^h^e^{are proh}^{ibited f}^r^om^receivⁱⁿ^g^{federal Medicaid}
^Un^ited^{States o}^r^{a q}^u^alif^ied^alien⁽^e^.g^{., a leg}^a^{l p}^e^r^m^an^en^t^rei^m^bu^rs^em^en^t^f^o^{r an}ⁱⁿ^di^vⁱ^du^al^w^h^{o h}^a^{s n}^o^t^provⁱ^d^ed
^r^e^sid^eⁿ^t^{, r}^e^f^u^g^{ee, alien}^g^r^an^ted^asy^l^u^m^o^r^r^e^lated^r^e^lief⁾^w^h^o^s^a^tis^f^actory^docu^m^en^tary^ev^iden^{ce of}^citizen^s^h^{ip or}
^m^{eets all o}^t^h^e^r^Medⁱ^caⁱ^d^p^r^o^g^r^a^m^elig^ib^ility^cr^iterⁱ^a.ⁿ^a^tioⁿ^a^lity^.^Su^ch^ev^id^en^{ce in}^clu^d^{es o}ⁿ^{e o}^f^th^{e f}^o^llo^wⁱⁿ^g

CRS-61
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^N^o^n-q^u^a^lⁱ^fⁱ^e^d^a^lⁱ^e^{ns (}^e^.^g^.^,^t^h^o^s^e^w^h^o^a^r^e^una^ut^ho^rⁱ^z^e^d^o^r^d^o^c^u^m^en^{ts: (}¹⁾^{a U.S. p}^a^s^s^p^o^r^{t; (}²⁾^Cer^tif^{icate o}^f
^illeg^a^lly^p^r^esen^{t, n}^oⁿ^-^im^mⁱ^g^r^an^{ts ad}^m^itted^f^o^r^{a tem}^p^o^r^ar^y^Natu^r^a^lizatioⁿ^;⁽³⁾^Cer^tif^{icate o}^f^{U.S. Citizen}^sh^ip^{; (}⁴⁾^a
^pu^rpos^{e) w}^h^{o w}^o^u^l^{d ot}^h^e^rwⁱ^s^{e be el}ⁱ^gⁱ^b^l^e^f^o^r^M^e^dⁱ^cai^d^v^a^lid^state-^issu^ed^d^r^iv^e^r^’^s^licen^{se o}^r^o^t^h^e^r^id^en^tity
^ex^{cept f}^o^{r th}^{eir im}^mⁱ^g^r^ation^s^t^atu^s^m^a^y^on^ly^receiv^e^docu^m^eⁿ^t^des^c^ri^{bed i}ⁿ^S^ectⁱ^oⁿ^274A^(b)(1)(D^{) of}^t^h^e
^{Medicaid care an}^{d s}^e^r^vⁱ^c^e^s^th^{at are n}^eces^s^a^ry^f^o^{r th}^e^I^m^mⁱ^g^r^atioⁿ^an^d^Natioⁿ^a^lity^A^c^{t, b}^u^{t o}ⁿ^ly^if^t^h^{e state}
^tr^eatm^eⁿ^t^o^f^an^e^m^er^g^eⁿ^c^y^m^e^dⁱ^{cal co}ⁿ^d^itioⁿ^an^d^ar^{e n}^o^tⁱ^s^s^uⁱⁿ^g^t^h^{e l}ⁱ^cen^s^e^{or docu}^m^en^t^requⁱ^r^es^proof^of^U^.^S^.
^r^e^lated^to^an^o^r^g^aⁿ^tr^an^sp^lan^t^p^r^o^ced^u^r^e.^citizen^s^hⁱ^p^{or a v}^e^rifⁱ^{ed Social Secu}^rityⁿ^u^m^{ber bef}^o^re
^is^s^u^an^ce;^{(5) s}^u^ch^oth^e^{r docu}^m^en^{t s}^p^ecifⁱ^edⁱⁿ^reg^u^l^ation
^A^s^{a co}ⁿ^d^itioⁿ^o^f^anⁱⁿ^dⁱ^vⁱ^d^u^al’^s^elig^ib^ility^f^o^r^Medⁱ^caid^by^th^{e Secretary}^th^{at prov}^ides^reliable^docu^m^en^tation^of
^ben^e^fⁱ^t^s^{, S}^ectⁱ^oⁿ^1137(d)^of^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t^requⁱ^r^es^id^en^tity^an^d^p^r^o^o^f^o^f^{U.S. citizen}^sh^ip^o^rⁿ^a^tioⁿ^a^lity^.
ⁱ^{ki/CRS-RL33251}^a^{state to}^o^b^t^ain^{a w}^r^itten^d^eclar^atioⁿ^,^uⁿ^d^er^p^eⁿ^a^l^t^y^o^f^p^e^r^j^u^r^y^,^statin^g^w^h^eth^e^r^th^eⁱⁿ^dⁱ^vⁱ^d^u^{al is a citizen}^o^rⁿ^a^tioⁿ^a^l^Satis^f^actory^ev^iden^{ce als}^oⁱⁿ^c^l^udes^{a docu}^m^en^{t f}^r^om
^g/w^of^th^{e Un}^{ited States}^{. If}^anⁱⁿ^divⁱ^du^al^declares^th^{at h}^e^{or s}^h^e^each^of^th^{e f}^o^llowⁱⁿ^g^lis^ts^{: (1)}^a^certif^{icate of}^birthⁱⁿ^th^e
^s^.or^is^{a citiz}^en^o^rⁿ^a^tioⁿ^a^{l, th}^{e state is n}^o^{t r}^e^q^u^ir^ed^to^o^b^t^ain^U.S^;^{(2) C}^e^rtⁱ^fⁱ^cat^{e of}^Bi^rt^h^Ab^r^o^a^d^;^{(3) U.S}^.^Cⁱ^tⁱ^zen
^le^ak^additi^oⁿ^a^l^docu^m^en^tary^ev^iden^{ce bu}^{t m}^a^y^ch^oos^{e to do s}^o^.^I^d^en^tif^icatioⁿ^Car^d^{; (}⁴⁾^Rep^o^r^{t o}^f^Bⁱ^r^t^h^A^b^r^o^ad^o^f^a
^://wiki^If^anⁱⁿ^divⁱ^du^{al declares}^th^{at h}^e^{or s}^h^eⁱ^s^not^{a citizen}^orⁿ^a^tion^a^{l, th}^{e in}^divⁱ^du^{al m}^u^s^t^{declare th}^{at h}^e^or^s^h^{e is}^a^C^itizen^of^th^e^{U.S.; or (5) s}^u^ch^oth^e^{r docu}^m^en^{t s}^p^ecifⁱ^ed^b^y^th^{e Secretary}^th^{at prov}^ides^proof^of^{U.S. citizen}^s^hⁱ^p
^h^ttp^q^u^alif^ied^alien^an^d^p^r^esen^{t Dep}^a^r^t^m^eⁿ^t^o^f^Ho^m^e^lan^d^Secu^r^ity^o^rⁿ^a^tioⁿ^a^lity^;^A^{ND (}¹⁾^an^y^id^en^tity^d^o^c^u^m^en^{t d}^e^scrⁱ^b^e^d
^Un^{ited St}^a^t^es^C^itizen^s^h^{ip an}^{d Im}^mⁱ^g^r^ation^Serv^ices^B^u^reauⁱⁿ^Se^ctⁱ^oⁿ^274A^(b)(1)(D^{) of}^t^h^{e Im}^mⁱ^g^r^atⁱ^oⁿ^an^d
⁽^DHS/USCI^S^{, f}^o^r^m^er^ly^th^{e I}^m^mⁱ^g^r^atioⁿ^an^d^Natu^r^a^lizatioⁿ^Natioⁿ^a^lity^A^c^{t; o}^r⁽²⁾^an^y^o^t^h^e^r^d^o^c^u^m^en^{t sp}^ecifⁱ^edⁱⁿ
^Ser^v^ice)^o^r^o^t^h^e^r^d^o^c^u^m^en^tatioⁿ^d^e^ter^mⁱⁿ^ed^b^y^th^{e state to}^reg^u^l^ation^by^t^h^{e Secretary}^th^{at prov}^ides^reliable
^coⁿ^s^titu^{te r}^easoⁿ^ab^{le ev}^id^en^{ce o}^f^satisf^acto^r^y^im^mⁱ^g^r^atioⁿ^d^o^c^u^m^en^tatioⁿ^o^f^id^en^tity^.
^s^t^atu^s^{. If}^anⁱⁿ^divⁱ^du^al^pres^en^ts^DHS/USC^{IS docu}^m^en^tation^,
^th^{e state m}^u^s^t^v^e^rⁱ^f^y^im^mⁱ^g^r^atioⁿ^statu^s^w^ith^DHS/USCI^S^T^h^{e r}^e^q^u^ir^em^en^ts^d^oⁿ^o^{t ap}^p^l^y^to^alien^s^w^h^o^ar^{e en}^titled
^t^h^r^o^{ugh t}^h^e^a^u^t^o^m^a^t^e^d^Sy^st^e^m^a^tⁱ^c^A^lⁱ^e^{n V}^e^rⁱ^fi^c^a^tⁱ^oⁿ^f^o^r^{to or e}ⁿ^{rolled f}^o^{r Medicare ben}^e^f^its^{, receiv}ⁱⁿ^g
^Eⁿ^title^m^e^{nts (}^S^A^V^E⁾^sy^ste^m^,^o^r^thr^o^{ugh a}ⁿ^a^l^te^rⁿ^a^tive^Su^p^p^l^em^en^tal^Secu^r^ity^Iⁿ^co^m^e⁽^SSI⁾^b^eⁿ^e^f^{its, o}^r^elig^ib^le
^s^y^s^t^em^approv^{ed by}^th^{e Secretary}^of^HHS.^f^o^{r Medicaid}^on^s^u^ch^oth^e^{r bas}ⁱ^s^as^th^{e Secretary}^m^a^y
^s^p^ecif^y^th^{at s}^a^tis^f^actory^ev^iden^{ce h}^a^{d been}^prev^iou^s^ly
^p^r^esen^ted^.^T^h^{e p}^r^o^vⁱ^sⁱ^oⁿ^w^o^u^l^d^ap^p^l^y^toⁱⁿ^itial

CRS-62
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^d^e^ter^mⁱⁿ^atioⁿ^s^an^d^to^r^e^d^e^ter^mⁱⁿ^atioⁿ^s^o^f^elig^ib^ility^f^o^r
^Medi^cai^{d m}^a^{de on}^{or af}^t^e^{r Ju}^l^y^{1, 2006.}
apter 4. Flexibility in Cost Sharing and Benefits
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
ⁱ^{ki/CRS-RL33251}^St^at^{e O}^p^tⁱ^oⁿ^f^o^r^A^l^t^e^rn^at^iv^{e Premiu}^{ms an}^d^st^Sh^arin^g^.^W^ith^s^o^m^e^ex^ception^s^{, prem}^iu^m^s^an^{d en}^rollm^en^{t f}^e^e^s^a^r^e^g^eⁿ^e^ral^l^y^prohⁱ^bⁱ^t^e^{d u}ⁿ^d^{er Medi}^cai^d.^W^h^en^applⁱ^cabl^e^,^S^ecti^oⁿ^6041(a)^{. T}^h^{e con}^f^eren^{ce ag}^reem^eⁿ^t^allow^s^s^t^ates^{to im}^pos^{e prem}^iu^m^s^an^{d cos}^t^-^s^h^a^rin^g^f^o^{r an}^y
^g/wⁿ^o^mⁱⁿ^a^{l am}^ouⁿ^t^s^f^o^{r s}^u^ch^ch^arg^e^s^{are betw}^een^{$1 an}^{d $19}^g^r^ou^{p of}ⁱⁿ^dⁱ^vⁱ^du^al^s^f^o^{r an}^y^t^y^{pe of}^s^e^rvⁱ^{ce (ex}^cept
^s^.or^{per m}^oⁿ^t^h^depen^dⁱⁿ^g^oⁿ^fa^mⁱ^l^yⁱⁿ^com^e^{. States}^{are allow}^e^d^pres^{cribed dru}^g^s^w^h^ich^ar^{e tr}^eated^sep^a^r^a^tely^{; see}
^le^ak^t^o^e^s^t^a^b^lishⁿ^o^mⁱⁿ^a^{l ser}^v^ice-^r^e^lated^co^st-^s^h^a^rⁱⁿ^g^r^e^q^u^ir^e^m^eⁿ^t^s^b^e^l^o^w⁾^,^t^h^r^o^ugh^M^e^dⁱ^c^aⁱ^d^st^a^t^e^p^l^aⁿ^a^m^eⁿ^d^m^eⁿ^t^s⁽^r^a^t^h^e^r
^t^h^at^{are g}^eⁿ^e^ral^l^y^bet^w^een^{$0.50 an}^{d $3}^,^d^e^pen^dⁱⁿ^g^on^t^h^e^th^an^w^a^iv^ers⁾^{, s}^u^bj^{ect to s}^p^ecifⁱ^{c res}^t^riction^s^{. P}^r^em^iu^m^s
^://wiki^cos^t^of^th^{e s}^e^rv^{ice prov}^ided.^Specifⁱ^c^s^e^rv^ices^an^d^g^r^ou^ps^are^aⁿ^d^c^o^st^-sha^rⁱ^ngⁱ^m^p^o^s^e^d^und^er^th^{is o}^p^tioⁿ^ar^{e allo}^w^e^d
^h^ttp^e^x^em^{pted f}^r^om^s^u^ch^cos^t^-^s^h^a^rin^g^.^W^a^iv^{er au}^th^ority^is^t^o^v^a^ry^am^on^g^cl^as^s^e^s^{or g}^r^ou^ps^ofⁱⁿ^di^vⁱ^du^al^s^,^{or t}^y^pes
^requ^{ired to ch}^an^g^e^th^es^{e ru}^les^.^of^s^e^rvi^c^e^.^Premⁱ^u^m^s^an^{d cos}^t^-^s^h^a^riⁿ^g^provⁱ^sⁱ^oⁿ^sⁱⁿ
^cu^r^r^eⁿ^t^law^f^o^r^w^o^r^k^er^{s w}^ith^dⁱ^sab^ilities^ar^eⁿ^o^t^af^f^ected^.
^Ge^ne^r^a^{l Limita}^tions^.^S^e^e^a^b^o^v^e^.^Iⁿ^g^eⁿ^e^r^a^{l, f}^o^rⁱⁿ^dⁱ^vⁱ^d^u^{als in}^f^a^m^ilies^wⁱ^t^hⁱⁿ^c^o^m^e
^bet^w^een^{100 an}^{d 15}⁰^%^FP^L:^{(1) n}^o^premⁱ^u^m^s^m^a^y^be
^im^pos^{ed, (2) cos}^t^s^h^arin^g^f^o^{r an}^y^item^or^s^e^rv^{ice can}ⁿ^o^t
^ex^{ceed 10% of}^th^{e cos}^t^of^th^e^item^or^s^e^rv^{ice, an}^{d (3) th}^e
^t^o^t^a^l^a^ggr^e^g^a^t^e^a^m^o^unt^o^f^a^l^l^c^o^st^-sha^rⁱ^{ng (}ⁱ^nc^l^u^dⁱ^{ng c}^o^st
^s^h^arin^g^f^o^r^p^r^es^{cribed dru}^g^s^an^{d em}^erg^eⁿ^c^y^room
^copay^m^en^ts^f^o^{r n}^oⁿ^-^em^erg^eⁿ^c^y^care;^s^{ee below}⁾^canⁿ^o^t
^ex^{ceed 5% of}^f^a^m^ilyⁱⁿ^com^e^as^{applied on}^{a qu}^arterly^or
^m^oⁿ^t^h^l^y^basⁱ^s^as^s^p^ecifⁱ^ed^b^y^th^{e s}^t^{ate. For in}^divⁱ^du^als

CRS-63
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
ⁱⁿ^f^a^m^ilies^w^ithⁱⁿ^com^e^abov^{e 150% FP}^L^:⁽¹⁾^t^h^e^t^o^tal
^ag^g^r^eg^{ate am}^ouⁿ^t^of^{all cos}^t^s^h^arin^g⁽ⁱⁿ^c^l^u^dⁱⁿ^g^cos^t
^s^h^arin^g^f^o^{r pres}^{cribed dru}^g^s^an^{d em}^erg^eⁿ^c^y^r^o^o^m
^copay^m^en^ts^f^o^{r n}^oⁿ^-^em^erg^eⁿ^c^y^care)^canⁿ^o^t^ex^ceed^5%
^o^f^f^a^m^ilyⁱⁿ^co^m^e^{as ap}^p^lied^oⁿ^{a q}^u^ar^ter^l^y^o^r^m^oⁿ^t^h^l^y
^basⁱ^s^as^s^p^ecifⁱ^{ed by}^th^e^s^t^a^t^{e, an}^{d (2) cos}^t^-^s^h^a^rin^g^f^o^r
^an^y^item^{or s}^e^rv^{ice can}ⁿ^o^{t ex}^ceed^20%^of^th^e^cos^t^of^th^e
^item^o^r^ser^v^ice.
^S^p^e^cⁱ^fie^d^Gr^oups^E^x^e^m^{pt fr}^{om P}^r^e^m^iums^.^Un^d^e^r^ce^r^t^aⁱⁿ^cⁱ^r^c^u^m^s^t^an^{ces, f}^a^m^{ilies q}^u^alif^yⁱⁿ^g^f^o^r^P^r^em^iu^m^s^ar^{e n}^o^{t p}^e^r^m^itted^f^o^r^:⁽¹⁾^m^aⁿ^d^ato^r^y^g^r^o^u^p^s
ⁱ^{ki/CRS-RL33251}^tr^an^sitioⁿ^a^{l Med}ⁱ^caid^,^p^r^egⁿ^aⁿ^t^w^o^m^eⁿ^an^dⁱⁿ^f^aⁿ^t^{s w}^ithⁱⁿ^com^e^ov^{er 150%}^F^P^L^,^m^e^di^cal^l^yⁿ^eedy^g^r^ou^p^s^,^an^d^of^ch^ildren^uⁿ^d^{er 18, in}^clu^dⁱⁿ^gⁱⁿ^divⁱ^du^alsⁱⁿ^f^o^s^t^{er care}^receivⁱⁿ^g^aid^o^r^a^ssistan^{ce u}ⁿ^d^{er P}^a^{rt B}^o^f^T^{itle IV an}^d
^g/w^w^o^r^k^e^r^s^wⁱ^t^h^dⁱ^s^a^b^ilities^m^a^y^b^e^c^h^a^r^g^e^d^p^r^e^mⁱ^u^m^s^f^o^r^pers^on^s^receivⁱⁿ^g^adoption^o^r^f^o^s^t^{er care as}^sⁱ^s^t^an^ce
^s^.or^{Medicaid cov}^e^rag^e^{. Oth}^e^rw^is^{e, in}^th^{e abs}^eⁿ^{ce of}^{a w}^a^iv^er,^uⁿ^d^er^T^{itle I}^V^-^E^{, r}^e^g^a^r^d^{less o}^f^ag^{e; (}²⁾^p^r^egⁿ^aⁿ^t^w^o^m^eⁿ^;
^le^ak^p^r^e^mⁱ^u^m^s^m^a^yⁿ^o^t^{be ch}^arg^e^{d f}^o^{r ot}^h^e^{r i}ⁿ^di^vⁱ^du^al^s^aⁿ^d⁽³⁾^ter^mⁱⁿ^ally^{ill p}^e^r^s^oⁿ^{s r}^eceivⁱⁿ^g^M^e^dⁱ^c^aⁱ^d^h^o^s^pⁱ^c^e
^g^r^ou^ps^.^car^{e; (}⁴⁾ⁱⁿ^dⁱ^vⁱ^d^u^a^l^sⁱⁿ^m^e^dⁱ^{cal in}^stitu^tioⁿ^s^w^h^o^ar^e
^://wiki^r^e^q^u^ir^ed^to^p^a^y^f^o^r^co^{sts o}^f^c^a^r^e^{all b}^u^{t a m}ⁱⁿⁱ^m^a^l
^h^ttp^am^ouⁿ^t^of^th^ei^rⁱⁿ^com^e^f^o^{r pers}^on^{al n}^eeds^,^an^{d (5)}
^w^o^m^eⁿ^w^h^{o qua}^lⁱ^f^y^f^o^{r Medicaid u}ⁿ^d^{er th}^{e breas}^{t an}^d
^cervⁱ^{cal can}^{cer elig}^ibil^ity^g^r^ou^{p. States}^m^a^y^ex^em^pt
^ad^d^itioⁿ^a^{l g}^r^o^u^p^s^f^r^o^m^p^r^em^iu^m^s^.
^S^p^{ecified Groups and S}^e^rv^{ices E}^xempt^A^{ll ser}^v^ice-^r^e^lated^co^st-^s^h^a^rⁱⁿ^g^{is p}^r^o^h^ib^ited^f^o^r^:⁽¹⁾^ch^ild^r^eⁿ^Ser^v^{ice r}^e^lated^co^st-^s^h^a^rⁱⁿ^g^{is n}^o^{t p}^e^r^m^itted^f^o^r^:⁽¹⁾
^m^Serv^ice-^Relat^e^d^Co^st^Sh^arin^g^.^uⁿ^d^{er 18}^y^e^a^r^s^of^ag^{e; (2) preg}ⁿ^aⁿ^t^w^o^m^eⁿ^f^o^{r an}^y^s^e^rv^ices^s^e^rvⁱ^ces^provⁱ^d^{ed t}^o^m^aⁿ^d^at^ory^g^r^ou^ps^of^chⁱ^l^d^ren^uⁿ^d^er
^th^{at r}^e^{late to}^th^e^p^r^egⁿ^aⁿ^c^y^o^r^to^an^y^o^t^h^e^r^m^e^dⁱ^{cal co}ⁿ^d^itioⁿ^{18, in}^clu^dⁱⁿ^gⁱⁿ^divⁱ^du^al^sⁱⁿ^f^o^s^t^{er care receiv}ⁱⁿ^g^{aid or}
^w^h^ich^m^a^y^com^p^lⁱ^c^{ate preg}ⁿ^aⁿ^c^y^;^{(3) s}^e^rv^ices^f^u^rn^is^h^e^{d to}^assistan^ce^uⁿ^d^er^P^a^{rt B}^o^f^T^{itle IV an}^d^p^e^rsoⁿ^{s receiv}ⁱⁿ^g
ⁱⁿ^dⁱ^vⁱ^d^u^{als w}^h^o^ar^{e in}^p^a^tien^t^{s in}^{a h}^o^sp^{ital, o}^r^ar^{e r}^e^sidⁱⁿ^gⁱⁿ^ad^o^p^tioⁿ^o^r^f^o^ster^car^{e assistan}^ce^uⁿ^d^er^T^{itle I}^V^-^E^,
^{a lo}ⁿ^g^ter^m^car^{e f}^acility^o^rⁱⁿ^an^o^t^h^e^r^m^e^dⁱ^c^a^lⁱⁿ^stitu^tioⁿ^if^reg^a^rdles^s^of^ag^{e; (2) prev}^eⁿ^tⁱ^v^{e s}^e^rv^ices^prov^{ided to}
^th^{e in}^dⁱ^vⁱ^d^u^{al is r}^e^q^u^ir^ed^to^sp^en^d^m^o^{st o}^f^th^eirⁱⁿ^co^m^e^f^o^r^ch^ild^r^eⁿ^uⁿ^d^er¹⁸^r^e^g^a^r^d^{less o}^f^f^a^m^ilyⁱⁿ^co^m^e^{; (}³⁾
^m^e^{dical care; (4) s}^e^rv^ices^furⁿ^is^h^e^{d to in}^divⁱ^du^als^receivⁱⁿ^g^ser^v^{ices p}^r^o^v^id^ed^to^p^r^egⁿ^aⁿ^t^w^o^m^eⁿ^th^{at r}^e^{late to}

CRS-64
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
^h^o^s^p^ice^care;^{(5) em}^erg^eⁿ^c^y^s^e^rv^ices^{; an}^{d (6) f}^a^m^ily^planⁿⁱⁿ^g^p^r^egⁿ^aⁿ^c^y^o^r^to^o^t^h^e^r^m^e^dⁱ^{cal co}ⁿ^d^itioⁿ^s^t^h^a^t^m^a^y
^s^e^rv^ices^an^{d s}^u^pplies^.^{For m}^o^s^t^oth^e^{r ben}^e^fⁱ^ciaries^an^d^com^p^{licate preg}ⁿ^aⁿ^c^y^;^{(4) s}^e^r^v^ices^prov^{ided to}
^s^e^rv^ices^{, s}^t^ates^m^a^y^im^pos^{e n}^o^mⁱⁿ^a^{l s}^e^rv^ice-^related^termⁱⁿ^ally^{ill in}^dⁱ^vⁱ^d^u^a^l^s^receivⁱⁿ^g^Medⁱ^caid^h^o^sp^ice
^co^st-^s^h^a^rⁱⁿ^g⁽^d^escr^ib^ed^ab^o^v^e)^{. Fo}^r^w^o^r^k^er^{s w}^ith^dⁱ^sab^ilities,^s^e^rv^ices^{; (5)}^s^e^rv^ices^prov^{ided to in}^divⁱ^du^alsⁱⁿ^m^e^dical
^s^e^rv^ice-^{related cos}^t^-^s^h^a^rin^g^m^a^y^{be requ}^{ired th}^{at ex}^ce^edsⁱⁿ^stitu^tioⁿ^s^w^h^o^ar^{e r}^e^q^u^ir^ed^to^sp^en^d^f^o^r^co^{sts o}^f^car^{e all}
ⁿ^o^mⁱⁿ^a^{l am}^ouⁿ^t^s^as^lon^g^as^th^ey^{are s}^e^{t on}^{a s}^lidin^g^s^cale^bu^{t a m}ⁱⁿⁱ^m^a^{l am}^ouⁿ^t^of^th^{eir in}^com^e^f^o^{r pers}^on^al
^bas^e^{d on}ⁱⁿ^com^e^.ⁿ^eeds^;^{(6) em}^erg^eⁿ^c^y^s^e^rv^ices^{; (7) f}^a^mⁱ^l^y^planⁿⁱⁿ^g
^se^r^v^ic^e^s^aⁿ^d^sup^p^lie^s,^aⁿ^d⁽⁸⁾^se^r^vⁱ^c^e^s^t^o^w^o^m^e^{n w}^h^o
^qu^alif^y^f^o^r^{Medicaid u}ⁿ^d^{er th}^{e breas}^{t an}^d^cervⁱ^cal^can^cer
^e^lⁱ^g^ib^ility^g^r^o^u^p^.^{States m}^a^y^ex^em^p^t^ad^d^itioⁿ^a^l
ⁱ^{ki/CRS-RL33251}ⁱⁿ^di^vⁱ^du^al^s^or^s^e^rvⁱ^ces^f^r^om^s^e^rvⁱ^ce-^rel^a^t^e^{d cos}^t^-^s^h^a^riⁿ^g^.
^g/w^Cons^tr^uc^tion.^No^prov^is^ion^.^T^h^{e ag}^reem^en^{t f}^u^rth^e^{r s}^p^ecifⁱ^e^s^t^h^a^t^t^h^e^s^e^p^r^o^vⁱ^s^ion^s
^s^.or^w^o^u^l^dⁿ^o^t^p^r^ev^en^{t states f}^r^o^m^f^u^r^t^h^e^r^lim^itin^g^p^r^em^iu^m^s
^le^ak^an^{d cos}^t^s^h^arin^g^,^af^f^{ect th}^{e au}^th^ority^of^th^{e Secretary}^to
^w^a^iv^{e lim}^{its o}ⁿ^p^r^em^iu^m^s^o^r^co^st-^s^h^a^rⁱⁿ^g^,ⁿ^o^r^af^f^e^ct
^://wiki^{related w}^a^iv^ersⁱⁿ^ef^f^{ect bef}^o^{re th}^{e date of}^en^actm^eⁿ^t^.
^h^ttp
^Be^ne^ficⁱ^a^r^y^Conditions^F^o^r^Continue^d^Un^{der th}^e^s^t^{ate Medicaid plan}^{, prov}^iders^m^u^s^tⁿ^o^{t den}^y^care^T^h^{e ag}^r^eem^en^{t allo}^w^s^states^to^coⁿ^d^itioⁿ^th^{e p}^r^o^v^isioⁿ^o^f
^e^dⁱ^caid^En^ro^llmen^t^an^d^Receip^t^o^f^Serv^ices.^{or s}^e^rv^ices^{to Medicaid ben}^e^fⁱ^ciaries^du^{e to th}^{e in}^divⁱ^du^al^’s^m^e^{dical a}^s^sⁱ^s^t^an^{ce on}^th^{e pay}^m^en^{t of}^prem^iu^m^s^{, an}^{d to}
ⁱⁿ^ab^ility^to^p^a^y^{a co}^s^t^-^s^h^a^rⁱⁿ^g^ch^ar^g^e^{. Ho}^w^e^v^e^r^,^th^is^ter^mⁱⁿ^{ate Med}ⁱ^caid^elig^ib^ility^oⁿ^th^{e b}^a^{sis o}^f^f^a^ilu^r^e^to
^r^e^q^u^ir^em^en^{t d}^o^e^{s n}^o^{t elim}ⁱⁿ^{ate th}^{e b}^eⁿ^e^fⁱ^ciar^y^’^{s liab}^ility^f^o^r^pay^{a prem}^iu^m^if^th^at^faⁱ^l^u^r^e^con^tin^u^e^s^f^o^{r at leas}^{t 60}
^pay^m^eⁿ^t^o^f^s^u^ch^ch^arg^e^s^.^F^o^{r cert}^aⁱⁿ^g^r^ou^ps^of^pregⁿ^aⁿ^t^day^s^{. S}^t^at^es^m^a^y^appl^y^t^hⁱ^s^provⁱ^sⁱ^oⁿ^t^o^s^o^m^e^{or al}^l
^w^o^m^e^{n a}ⁿ^dⁱⁿ^fa^nt^{s fo}^r^w^hⁱ^c^{h m}^o^nt^hl^y^p^r^e^mⁱ^u^m^s^m^a^y^b^e^g^r^ou^ps^o^f^ben^e^fⁱ^ci^ari^e^s^,^an^{d m}^a^y^w^aⁱ^v^{e prem}ⁱ^u^m
^ch^arg^e^{d, s}^t^ates^m^u^s^tⁿ^o^{t requ}^{ire prepay}^m^eⁿ^t^an^{d m}^u^s^tⁿ^o^t^pay^m^en^tsⁱⁿ^cas^es^w^h^{ere s}^u^ch^pay^m^en^ts^w^o^u^l^{d be an}
^ter^mⁱⁿ^a^t^e^M^e^dⁱ^caid^elig^ib^ility^f^o^r^f^a^ilu^r^e^to^p^a^y^su^ch^uⁿ^d^u^e^h^a^r^d^sh^ip^.^Iⁿ^ad^d^itioⁿ^,^th^{e p}^r^o^v^isioⁿ^w^o^u^l^d^allo^w
^p^r^em^iu^m^s^uⁿ^til^su^ch^f^a^ilu^r^e^coⁿ^tin^u^e^{s f}^o^r^{at least 6}⁰^d^a^y^s^.^s^t^{ates to}^p^e^r^m^{it p}^r^o^v^id^er^{s p}^a^r^ticip^atin^gⁱⁿ^Medⁱ^caid^to
^States^m^a^y^w^a^iv^{e th}^os^{e prem}^iu^m^s^w^h^en^s^u^ch^pa^y^m^eⁿ^ts^requ^{ire a Medicaid ben}^e^fⁱ^ciary^{to pay}^auth^orized
^w^o^ul^d^c^a^u^se^und^ue^ha^r^d^shi^p^.^co^st-^s^h^a^rin^g^{as a co}ⁿ^d^itioⁿ^o^f^receivⁱⁿ^g^{care o}^r^serv^ices.
^Provⁱ^d^ers^w^o^u^l^{d al}^s^o^{be al}^l^o^w^e^{d t}^o^redu^{ce or w}^aⁱ^v^e

CRS-65
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
^cos^t^-^s^h^a^rin^g^am^ouⁿ^t^s^on^{a cas}^e-^by^-^cas^{e bas}ⁱ^s^.
^In^d^exin^g^No^min^a^{l Co}^st^Sh^arin^g^an^d^T^h^{e regul}^ation^s^th^{at s}^p^ecif^yⁿ^o^mⁱⁿ^a^{l prem}^iu^m^an^d^S^ecti^oⁿ^6041(b⁾^.^Begⁱⁿⁿⁱⁿ^g^wⁱ^t^h^{2006, t}^h^{e S}^ecret^aryⁱ^s
^{ming A}^m^e^ndmeⁿ^t.^se^r^vⁱ^c^e^-^r^e^l^a^t^e^d^c^o^st^-sha^rⁱ^{ng a}^m^o^unt^{s w}^e^r^e^p^u^b^lⁱ^s^he^d^aⁿ^d^requ^ired^{to in}^creas^{e n}^o^mⁱⁿ^a^{l am}^ouⁿ^t^s^f^o^r^s^e^rv^ice-^related
^am^en^{ded i}ⁿ^t^h^{e l}^a^t^e^1970s^an^{d t}^h^{e earl}^y^1980s^{. T}^h^es^e^c^o^st^-sha^rⁱ^{ng b}^y^t^h^e^a^nnua^l^p^e^r^c^eⁿ^t^a^geⁱⁿ^c^r^e^a^s^eⁱⁿ^t^h^e
^am^ouⁿ^t^s^{are n}^o^{t adj}^u^s^t^{ed by}^an^y^f^actor.^m^e^{dical care com}^pon^en^{t of th}^{e con}^s^u^m^{er price in}^dex
^(C^P^I⁾^f^o^{r all u}^r^ban^con^s^u^m^ers^{(U.S. city}^av^erag^{e), as}
^r^o^und^e^d^upⁱⁿ^aⁿ^a^p^p^r^o^p^rⁱ^a^t^e^m^a^nne^r^.^T^h^e^s^e^c^h^a^nge^s
^ap^p^l^y^to^p^r^em^iu^m^an^d^co^st-^s^h^a^rⁱⁿ^g^p^r^o^v^isioⁿ^sⁱⁿ^v^o^lvⁱⁿ^g
ⁱ^{ki/CRS-RL33251}ⁿ^o^mⁱⁿ^a^l^am^ouⁿ^t^sⁱⁿ^exⁱ^s^tⁱⁿ^g^s^t^at^u^t^{e (S}^ectⁱ^oⁿ^{1916) as}^w^e^{ll as to}^th^{e n}^e^w^co^st-^s^h^a^rⁱⁿ^g^p^r^o^v^isioⁿ^s^sp^ecifⁱ^{c to}
^g/w^p^r^e^s^cription^dru^g^s^an^{d n}^oⁿ^-^em^erg^eⁿ^c^y^{care prov}^{ided i}ⁿ
^s^.or^an^em^erg^eⁿ^c^y^room^(des^{cribed below}⁾^.
^le^ak
^Ef^f^ect^iv^{e Dat}^e^.^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^6041(c)^T^h^es^{e prov}ⁱ^sⁱ^oⁿ^s^appl^y^t^o^cos^t^-^s^h^a^riⁿ^g
^://wiki^f^o^{r i}^t^e^m^s^an^{d se}^r^vⁱ^c^es^f^u^rnⁱ^s^h^e^{d on}^{or af}^t^e^{r March}^31,
^h^ttp^2006.
^Sp^{ecial Ru}^{les f}^o^{r Co}^s^t^Sh^arin^g^f^o^r^{States ar}^{e allo}^w^e^d^to^estab^lishⁿ^o^mⁱⁿ^a^{l ser}^v^ice-^r^e^lated^S^ecti^oⁿ^6042.^Un^{der th}^{e con}^f^eren^{ce ag}^reem^en^t,^s^t^a^t^es
^tⁱ^oⁿ^Dru^g^s^.^c^o^s^t^-^s^h^a^rⁱⁿ^g^r^e^q^u^ir^em^en^{ts (}^d^efⁱⁿ^edⁱⁿ^r^e^g^u^l^atioⁿ⁾^th^{at ar}^e^m^a^yⁱ^m^p^o^s^e^hi^ghe^r^c^o^st^-s^ha^rⁱ^{ng a}^m^o^unt^{s fo}^r^st^a^t^e^-
^g^eⁿ^e^ral^l^y^bet^w^een^{$0.50 an}^{d $3, depen}^dⁱⁿ^g^on^t^h^{e cos}^t^of^t^h^e^id^en^tifⁱ^e^dⁿ^oⁿ^-^p^r^e^f^e^r^r^e^d^d^r^u^g^s^w^ithⁱⁿ^{a class; w}^a^iv^{e o}^r
^s^e^rv^{ice prov}^ided.^Specifⁱ^c^s^e^rv^ices^an^{d g}^r^ou^ps^{are ex}^em^pted^redu^{ce th}^{e cos}^t^-^s^h^a^rin^g^oth^e^rw^is^e^{applicable f}^o^r
^f^r^o^m^su^ch^co^st-^s^h^a^rⁱⁿ^g^.^W^aⁱ^v^er^au^th^o^r^ity^{is r}^e^q^u^ir^ed^to^p^r^e^f^e^r^r^e^{d dru}^g^s^wⁱ^t^hⁱⁿ^s^u^ch^cl^as^s^;^an^{d m}^u^s^tⁿ^o^t^appl^y
^c^h^a^nge^t^h^e^s^e^r^u^l^e^s.^A^s^wⁱ^t^h^o^t^he^r^M^e^dⁱ^c^aⁱ^d^b^e^ne^fi^t^s^,^no^mⁱ^na^l^s^u^ch^cos^t^-^s^h^a^riⁿ^g^f^o^r^pref^{erred dru}^g^s^t^o^pers^on^s^ex^em^pt
^cos^t^-^s^h^a^rin^g^m^a^y^be^im^pos^{ed on}^pres^{cribed dru}^g^s^{, an}^d^s^t^ates^f^r^o^m^co^st-^s^h^a^rⁱⁿ^g⁽ⁱ^d^eⁿ^tif^ied^a^b^o^v^e)^{. W}^ithⁱⁿ^th^ese
^m^a^y^va^r^y^no^mⁱ^na^l^c^o^st^-sha^rⁱ^{ng a}^m^o^unt^{s fo}^r^p^r^e^f^e^r^r^e^d^aⁿ^d^param^e^t^e^rs^{, s}^t^at^esⁱ^d^en^tⁱ^f^y^t^h^e^g^r^ou^p(s⁾^of^ben^e^fⁱ^ci^ari^e^s
ⁿ^oⁿ^-^pref^{erred dru}^g^s^{. States}^m^a^y^als^o^im^plem^en^{t prior}^f^o^r^w^h^ich^th^{ese sp}^{ecial co}^st-^s^h^a^rⁱⁿ^g^r^u^{les w}^{ill ap}^p^l^y^.

^au^th^orization^f^o^{r pres}^{cribed dru}^g^s^.

CRS-66
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
^Limita^tioⁿ^s^{on c}^o^s^t^-s^ha^rⁱ^{ng for}^non-^See^abov^e.^C^o^s^t^-^s^h^a^rin^g^f^o^rⁿ^oⁿ^-^pref^{erred d}^r^ugs^m^a^y^no^t^ex^ceed:
^e^f^e^r^r^e^{d dr}^ugs^.⁽¹⁾ⁿ^o^mⁱⁿ^a^l^a^m^o^uⁿ^t^s^f^o^rⁱⁿ^dⁱ^vⁱ^d^u^a^l^sⁱⁿ^f^a^m^ilie^s^wⁱ^t^h
ⁱⁿ^com^e^bel^o^w^or^equ^a^l^t^o^150%^F^P^L^,^an^{d (2) 20%}^of^t^h^e
^co^s^t^o^f^th^{e d}^r^u^g^f^o^rⁱⁿ^dⁱ^vⁱ^d^u^{als in}^f^a^m^{ilies w}^ithⁱⁿ^co^m^e
^a^b^o^v^{e 150%}^F^P^L^.^F^o^{r pers}^on^s^g^eⁿ^e^ral^l^y^ex^em^pt^f^r^om
^c^o^st^-sha^rⁱ^ng⁽ⁱ^d^e^ntⁱ^fⁱ^e^d^a^b^o^v^e⁾^,^c^o^s^t^-sha^rⁱ^ng^fo^r
ⁿ^oⁿ^-^pref^{erred dru}^g^s^m^a^y^{be appl}ⁱ^e^{d. S}^u^ch^cos^t^-^s^h^a^riⁿ^g
^m^a^yⁿ^o^t^ex^ceedⁿ^o^mⁱⁿ^a^{l am}^ouⁿ^t^s^,^an^{d ag}^g^r^eg^{ate caps}^on
^co^st-^s^h^a^rⁱⁿ^g⁽ⁱ^d^eⁿ^tif^ied^ab^o^v^e)^w^o^u^l^d^{still ap}^p^l^y^.
ⁱ^{ki/CRS-RL33251}^Sp^{ecial co}ⁿ^dⁱ^t^ioⁿ^s^an^d^ap^p^licab^{le co}^st^-^arin^g^.^No^p^r^o^v^isioⁿ^.^Iⁿ^{cases in}^w^h^ich^{a p}^r^escr^ibⁱⁿ^g^p^h^y^s^ician^d^e^ter^mⁱⁿ^es^th^at^t^h^{e pref}^{erred dru}^g^w^o^u^l^{d n}^o^t^{be ef}^f^ectⁱ^v^e^{or w}^o^u^l^{d h}^a^v^e
^g/w^a^d^v^e^rs^{e h}^ealth^ef^f^ects^{or both}^,^th^{e s}^t^{ate m}^a^y^im^pos^{e t}^h^e
^s^.or^c^o^st^-sha^rⁱ^{ng a}^m^o^unt^fo^r^p^r^e^f^e^r^r^e^d^d^r^{ugs o}ⁿ^t^h^e
^le^ak^pres^cri^b^{ed n}^oⁿ^-^pref^{erred produ}^ct^.
^://wiki^Flexibilit^y^rega^{rding drugs excluded f}^r^om^No^prov^is^ion^.^T^h^{e a}^g^r^e^e^m^eⁿ^t^doesⁿ^o^{t prev}^en^{t s}^t^ates^f^r^om^ex^clu^dⁱⁿ^g
^h^ttp^s^t^s^h^a^r^{ing pr}^ov^is^ions^.^s^p^e^cⁱ^fⁱ^{ed dru}^g^s^{or clas}^s^e^s^of^dru^g^s^f^r^om^th^es^{e s}^p^ecial
^c^o^st^-sha^rⁱ^{ng r}^u^l^e^s.
^Ef^f^ect^iv^{e Dat}^e^.^No^prov^is^ion^.^T^h^es^{e prov}^is^ion^s^{are ef}^f^ectiv^{e f}^o^r^cos^t^-^s^h^a^rⁱⁿ^g^im^pos^ed
^f^o^{r i}^t^e^m^s^an^{d s}^e^rvⁱ^ces^f^u^rnⁱ^s^h^e^{d on}^{or a}^f^t^e^r^March^31,
^2006.
^E^m^e^r^ge^nc^y^{Room Co-P}^a^y^me^nts^for^Non-^W^a^iv^er^{s m}^a^y^b^e^u^s^ed^to^allo^w^{states to}^im^p^o^s^{e u}^p^to^tw^{ice th}^e^S^ecti^oⁿ⁶⁰⁴³^{. T}^h^{e con}^f^eren^{ce ag}^reem^en^{t w}^o^u^l^{d allow}
^e^r^ge^nc^y^Ca^r^e^.^o^t^he^r^wⁱ^s^e^a^p^p^lⁱ^c^a^b^l^e^no^mⁱ^na^l^c^o^st^-sh^a^rⁱ^{ng a}^m^o^unt^{s fo}^r^st^a^t^e^s^,^t^h^r^o^{ugh a}^st^a^t^e^p^l^aⁿ^a^m^eⁿ^d^m^eⁿ^t^,^t^oⁱ^m^p^o^s^e
ⁿ^oⁿ^-^em^erg^eⁿ^c^y^s^e^rv^ices^prov^{ided in}^{a h}^o^s^p^{ital em}^erg^eⁿ^c^yⁱⁿ^cr^e^a^s^e^{d cos}^t^-^s^h^a^rin^g^on^s^t^ate-^s^p^ecifⁱ^{ed g}^r^ou^ps^f^o^r
^room^(ER⁾^{. States}^m^a^y^im^pos^e^th^es^e^hⁱ^g^h^e^{r am}^ouⁿ^t^s^if^th^eyⁿ^oⁿ^-^em^erg^eⁿ^c^y^s^e^rv^ices^prov^{ided in}^an^ER^,^w^h^en^certain
^h^a^v^e^es^tablis^h^e^{d th}^{at Medicaid ben}^e^fⁱ^ciaries^h^a^v^e^av^ailable^coⁿ^d^itioⁿ^s^ar^{e m}^e^{t. Fir}^s^{t, alter}ⁿ^ativ^eⁿ^oⁿ^-^em^er^g^eⁿ^c^y
^an^{d acc}^e^s^sⁱ^{ble altern}^ativ^{e s}^o^u^r^ces^ofⁿ^oⁿ^-^em^erg^eⁿ^c^y^,^prov^iders^m^u^s^t^{be av}^{ailable an}^{d acces}^sⁱ^{ble to th}^{e pers}^on

CRS-67
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
^ou^tpatien^t^s^e^rv^ices^.^s^eekⁱⁿ^g^care.^S^e^c^o^nd^,^a^f^ter^a^m^e^dical^s^c^reenⁱⁿ^g^f^o^r
^em^er^g^eⁿ^c^y^m^e^dⁱ^{cal co}ⁿ^d^itioⁿ^s⁽^a^{s d}^e^fⁱⁿ^e^dⁱⁿ^Medⁱ^car^e
^law⁾^an^{d a determ}ⁱⁿ^ation^th^{at s}^u^c^h^an^em^erg^eⁿ^c^y^does
ⁿ^o^{t ex}^is^{t, bu}^{t bef}^o^{re th}^{e n}^oⁿ^-^em^erg^eⁿ^c^y^{care is}^prov^ided
^at^th^{e ER, th}^{e b}^eⁿ^e^fⁱ^ciar^y^m^u^{st b}^e^to^ld^:⁽¹⁾^th^e^h^o^sp^ital
^can^requ^{ire a copay}^m^en^{t, (2)}^th^eⁿ^a^m^e^an^{d location}^of^an
^altern^ativ^{e n}^oⁿ^-^em^erg^eⁿ^c^y^prov^{ider w}^h^{o i}^s^actu^a^lly
^av^{ailable an}^{d acces}^sⁱ^{ble an}^d^th^at^s^u^ch^{a prov}^{ider m}^a^yⁿ^o^t
^im^pos^{e th}^{e s}^a^m^e^cos^t^-^s^h^a^rin^g^,^an^{d (3) th}^{e h}^o^s^pⁱ^t^{al can}
^p^r^o^v^id^e^a^r^e^f^e^r^r^a^l.^W^h^en^th^{ese co}ⁿ^d^itioⁿ^s^ar^{e m}^e^t,^states
ⁱ^{ki/CRS-RL33251}^can^apply^{or w}^a^iv^{e cos}^t^-^s^h^a^rin^g^f^o^{r s}^e^rv^ices^deliv^ered^by^th^{e altern}^ativ^{e n}^oⁿ^-^em^erg^eⁿ^c^y^prov^ider.
^g/w
^s^.or^Limita^tions^.^S^e^e^a^b^o^v^e^.^F^o^{r pe}^r^s^oⁿ^s^wⁱ^t^hⁱⁿ^com^e^bet^w^een^100-^150%^F^P^L^,
^le^ak^cos^t^-^s^ha^rⁱⁿ^g^f^o^{r n}^oⁿ^-^em^erg^eⁿ^c^y^s^e^rv^icesⁱⁿ^an^ER^can
ⁿ^o^{t ex}^{ceed tw}^{ice th}^{e n}^o^mⁱ^na^l^am^ouⁿ^t^s^.^In^divⁱ^du^als
^://wiki^ex^em^{pt f}^r^om^prem^iu^m^s^{or s}^e^rv^ice-^{related cos}^t^-^s^h^a^rin^g
^h^ttp^uⁿ^d^{er ot}^h^e^{r prov}ⁱ^sⁱ^oⁿ^s^of^t^hⁱ^s^ag^reem^en^t^m^a^y^be^s^u^bj^ect
^t^o^no^mⁱ^na^l^c^o^p^a^y^m^eⁿ^t^s^fo^r^no^n-e^m^e^r^ge^nc^y^se^r^vⁱ^c^e^sⁱⁿ^aⁿ
^ER^{, on}^ly^w^h^eⁿ^no^cos^t^-^s^h^a^rin^g^is^im^pos^{ed f}^o^{r care in}
^hos^pi^t^a^l^ou^t^p^atⁱ^eⁿ^t^depart^m^eⁿ^t^s^{or by}^ot^h^e^{r al}^t^e^rn^atⁱ^v^e
^p^r^o^v^id^er^{s in}^th^e^ar^{ea ser}^v^ed^b^y^th^{e h}^o^sp^{ital ER.}
^A^g^g^r^eg^{ate cap}^{s o}ⁿ^co^st^-^s^h^a^rⁱⁿ^g⁽^d^escr^ib^ed^ab^o^v^e)^still
^appl^y^.
^P^r^ov^ide^r^Obliga^t^ions^Re^ga^r^dⁱⁿ^{g E}^m^e^r^ge^nc^y^C^oⁿ^t^racts^w^ith^m^aⁿ^a^g^e^{d care plan}^s^m^u^s^t^prov^{ide f}^o^{r cov}^e^rag^e^T^h^{ese p}^r^o^v^isioⁿ^s^h^a^v^eⁿ^o^im^p^{act o}ⁿ^{a h}^o^sp^ital’^s
^ices.^o^f^em^er^g^eⁿ^c^y^ser^v^{ices w}^ith^o^u^t^r^e^g^a^r^d^to^w^h^eth^e^r^th^e^o^b^lig^atioⁿ^s^w^ith^r^e^sp^{ect to}^scr^eenⁱⁿ^g^an^d^stab^ilizin^g^an
^em^erg^eⁿ^c^y^{care prov}^{ider h}^a^s^{a con}^t^ractu^a^{l relatio}^ns^hⁱ^{p w}^ith^em^er^g^eⁿ^c^y^m^e^dⁱ^{cal co}ⁿ^d^itioⁿ^,ⁿ^o^r^d^o^th^ey^m^o^dⁱ^f^y^th^e
^th^{e plan}^{or prior au}^t^h^o^rⁱ^zation^.^Aⁿ^em^erg^eⁿ^c^y^m^e^dical^ap^p^licatioⁿ^o^f^th^{e p}^r^u^d^en^t-^lay^p^er^soⁿ^stan^d^a^r^d^w^ith
^coⁿ^d^itioⁿ^{is o}ⁿ^{e m}^aⁿⁱ^f^e^stin^g^itself^b^y^acu^{te sy}^m^p^t^o^m^s^o^f^res^p^{ect to pay}^m^en^{t or cov}^e^rag^e^of^em^erg^eⁿ^c^y^s^e^rv^ices^by

CRS-68
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
^s^u^f^fⁱ^cien^t^s^e^v^e^rity⁽ⁱⁿ^c^lu^din^g^s^e^v^e^{re pain}^{) s}^u^ch^th^{at a}^pru^d^en^t^aⁿ^y^m^a^na^ge^d^c^a^r^e^o^r^gaⁿⁱ^z^a^tⁱ^o^n.
^lay^p^ers^oⁿ^,^w^h^o^pos^s^e^s^s^e^s^an^av^erag^{e k}ⁿ^o^w^l^edg^e^of^h^ealth^an^d
^m^e^dicin^e^{, cou}^l^{d reas}^on^ably^ex^p^{ect th}^e^abs^eⁿ^{ce of}^im^m^e^diate
^m^e^dⁱ^{cal atten}^tioⁿ^to^r^e^su^{lt in}^p^l^acin^g^th^{e h}^ealth^o^f^th^e
ⁱⁿ^di^vⁱ^du^alⁱⁿ^s^e^ri^ou^s^j^e^opardy^(an^dⁱⁿ^t^h^{e cas}^{e of}^{a preg}ⁿ^aⁿ^t
^w^o^m^a^n,^he^r^he^a^l^t^h^o^r^t^h^a^t^o^f^he^r^unb^o^r^{n c}^hⁱ^l^d⁾^,^se^rⁱ^o^u^s
^im^p^a^ir^m^eⁿ^t^to^b^o^d^ily^f^uⁿ^c^tioⁿ^s^{, o}^r^serⁱ^o^u^{s d}^y^sf^uⁿ^c^tioⁿ^o^f^an^y
^bodi^l^y^org^aⁿ^{or part}^.
^Prov^{ider Liabilit}^y^.^N^o^provⁱ^sⁱ^oⁿ^.⁽^Iⁿ^ge^ne^r^a^l^,^st^a^t^e^l^a^w^s^go^ve^rⁿ^provⁱ^d^er^Iⁿ^ad^dⁱ^tⁱ^oⁿ^,ⁿ^o^h^o^sp^{ital o}^r^p^h^y^s^ician^th^{at im}^p^o^s^es
ⁱ^{ki/CRS-RL33251}^liab^ility^.)^cos^t^-^s^h^a^rin^g^f^o^rⁿ^oⁿ^-^em^erg^eⁿ^c^y^{care in}^an^ER^is^{liable in}^an^y^civ^{il action}^{or proceedin}^g^,^abs^eⁿ^t^a^fⁱⁿ^dⁱⁿ^g^by^clear
^g/w^an^d^coⁿ^vⁱⁿ^cⁱⁿ^g^ev^id^en^{ce o}^f^g^r^o^ssⁿ^e^g^lig^en^ce.^Lⁱ^ab^ilities
^s^.or^r^e^l^a^t^e^{d t}^o^t^h^{e prov}ⁱ^sⁱ^oⁿ^of^em^erg^eⁿ^c^y^{care or ot}^he^r
^le^ak^{applicable s}^t^{ate law}^s^reg^a^rdin^g^deliv^ery^of^{care are n}^o^t
^a^f^f^{ected by}^th^es^{e prov}^is^ion^s^{. On}^Decem^{ber 21, 2}^005,
^://wiki^th^{e Sen}^a^{te pas}^s^e^{d a}ⁿ^a^m^en^{ded con}^f^eren^{ce ag}^reem^en^t
^h^ttp^t^h^a^t^,^t^h^r^o^{ugh a}^p^oⁱ^nt^o^f^o^r^d^e^r^,^st^r^u^c^k^t^hⁱ^s^p^r^o^vⁱ^sⁱ^o^n.
^De^finitions^.^No^prov^is^ion^.^“^N^on^-^e^m^e^rg^en^cy^s^e^rvi^c^e^s^”^m^e^an^s^an^y^{care or}^s^e^rv^ices
^f^u^rⁿ^ish^e^dⁱⁿ^an^{ER th}^{at th}^{e p}^h^y^s^ician^d^e^ter^mⁱⁿ^{es d}^o^es
ⁿ^o^{t co}ⁿ^s^titu^{te an}^ap^p^r^o^p^r^{iate m}^e^dⁱ^{cal scr}^eenⁱⁿ^g
^ex^amⁱⁿ^ation^{or s}^t^abi^lⁱ^zin^g^ex^amⁱⁿ^ation^an^{d treatm}^eⁿ^t
^s^c^reenⁱⁿ^g^requ^{ired f}^o^{r h}^o^s^p^itals^uⁿ^d^{er Medicare law}
^(reg^a^rdin^g^ex^amⁱⁿ^ation^an^{d treatm}^eⁿ^t^f^o^{r em}^erg^eⁿ^c^y
^m^e^dⁱ^{cal co}ⁿ^d^itioⁿ^s^an^d^w^o^m^eⁿⁱⁿ^lab^o^r⁾^.^“^A^lte^rⁿ^a^tⁱ^v^e
ⁿ^oⁿ^-^em^erg^e^nc^y^s^e^r^vⁱ^c^e^s^prov^{ider” m}^ean^s^a
^Medicaid-^participatin^g^h^ealth^{care prov}^{ider, s}^u^ch^as^a
^p^h^y^s^ician^’^{s o}^f^fⁱ^{ce, h}^ealth^car^{e clin}^ic,^co^m^m^uⁿ^ity^h^ealth
^cen^ter^,^h^o^sp^{ital o}^u^tp^atien^t^d^e^p^a^r^t^m^eⁿ^t^,^o^r^sim^ilar^h^ealth

CRS-69
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
^{care prov}^{ider th}^{at prov}^ides^clin^ically^ap^p^r^o^p^rⁱ^a^t^e^s^e^rv^ices
^f^o^r^t^h^e^dⁱ^a^gⁿ^o^sⁱ^s^o^r^t^r^e^a^t^m^eⁿ^t^o^f^t^h^e^c^oⁿ^d^itioⁿ
^con^t^em^poran^eou^s^ly^w^ith^th^{e prov}^is^ion^ofⁿ^oⁿ^-^em^erg^eⁿ^c^y
^ser^v^{ices th}^{at w}^o^u^l^d^o^t^h^e^r^w^{ise b}^e^p^r^o^v^id^edⁱⁿ^th^{e ER.}
^Gr^aⁿ^ts^{to E}^s^ta^blⁱ^s^{h A}^l^te^rⁿ^a^tⁱ^v^e^No^n-^No^prov^is^ion^.^T^h^{e Secretary}^is^req^uⁱ^r^e^d^t^o^p^r^o^vⁱ^d^e^f^o^{r pay}^m^en^ts^to
^e^r^ge^nc^y^P^r^ov^ide^r^Ne^tw^or^k^s^.^s^t^ates^f^o^{r th}^{e es}^tablis^h^m^en^{t of}^altern^{ate n}^oⁿ^-^em^er^geⁿ^c^y
^provⁱ^d^ers^,^{or n}^e^t^w^ork^s^of^s^u^c^h^provⁱ^d^ers^.^T^h^e
^con^f^eren^{ce ag}^reem^en^{t als}^o^au^th^orizes^an^{d appr}^o^p^r^iates
^$⁵⁰^m^illioⁿ^f^o^r^p^a^yⁱⁿ^g^su^ch^p^r^o^v^id^er^{s f}^o^r^th^{e f}^o^u^r^-^y^ear
ⁱ^{ki/CRS-RL33251}^perⁱ^o^d^begⁱⁿⁿⁱⁿ^g^wⁱ^t^h^{2006. T}^h^{e S}^ecret^aryⁱ^s^requⁱ^r^ed^{to g}ⁱ^v^e^{a pref}^eren^{ce to s}^t^ates^th^{at estab}^lish^o^r^p^r^o^v^id^{e f}^o^r
^g/w^altern^{ate n}^oⁿ^-^em^erg^eⁿ^c^y^s^e^rv^ices^p^r^o^vⁱ^d^e^r^s^(or
^s^.orⁿ^e^tw^ork^s^{) th}^{at s}^e^rv^{e ru}^{ral or u}ⁿ^d^ers^e^rv^e^d^a^r^e^a^s^w^h^ere
^le^ak^ben^e^fⁱ^ciaries^m^a^y^h^a^v^e^lim^ite^d^acces^s^{to prim}^ary^care
^provⁱ^d^ers^,^{or i}ⁿ^part^ne^rs^hⁱ^{p w}ⁱ^t^h^l^o^cal^com^m^uⁿⁱ^t^y
^://wiki^h^o^s^p^itals^{. T}^o^acces^s^th^es^{e f}^uⁿ^d^s^,^s^t^ates^{are requ}^{ired to}
^h^ttp^f^{ile an}^ap^p^licatioⁿ^m^e^e^tin^g^r^e^q^u^ir^em^en^{ts set b}^y^th^e
^Secretary^.
^Ef^f^ect^iv^{e Dat}^e^.^N^o^p^r^o^vⁱ^sⁱ^oⁿ^.^T^h^es^{e am}^en^dm^en^ts^apply^toⁿ^oⁿ^-^e^m^e^rg^en^cy^s^e^rv^ices
^f^u^rnⁱ^s^h^e^{d on}^{or af}^t^e^{r Jan}^u^a^ry^{1, 2007.}
^{Use o}^f^Ben^c^h^m^{ark Packag}^es.^Categ^o^rⁱ^callyⁿ^eed^y⁽^C^N)^elig^ib^ility^g^r^o^u^p^sⁱⁿ^clu^d^e^f^a^m^ilies^S^ecti^oⁿ⁶⁰⁴⁴^{. T}^h^e^ag^reem^en^t^gⁱ^v^e^s^s^t^ates^th^{e option}^to
^w^ith^ch^ild^r^eⁿ^,^th^{e eld}^e^r^l^y^,^cer^tain^p^e^r^s^oⁿ^{s w}^ith^dⁱ^sabⁱ^l^ities,^prov^{ide Medicaid to s}^t^ate-^s^p^ecifⁱ^{ed g}^r^ou^ps^th^r^o^ug^h
^an^{d certain}^oth^e^{r preg}ⁿ^aⁿ^t^w^o^m^eⁿ^an^{d ch}^ildren^w^{ho m}^eet^eⁿ^r^o^l^l^m^eⁿ^tⁱⁿ^b^e^nc^hm^a^r^{k a}ⁿ^d^b^e^nc^hm^a^r^k-e^q^ui^va^l^e^nt
^ap^p^licab^{le f}ⁱⁿ^aⁿ^c^{ial stan}^d^a^r^d^{s. Med}ⁱ^callyⁿ^eed^y⁽^M^N)^g^r^o^u^p^s^cov^e^rag^e^(des^cribed^b^e^low⁾^.^States^can^on^ly^ex^ercis^e
ⁱⁿ^clu^d^{e th}^{e sam}^e^ty^p^e^s^o^fⁱⁿ^dⁱ^vⁱ^d^u^{als, b}^u^{t d}ⁱ^f^f^e^r^eⁿ^t^{, ty}^pⁱ^cally^th^{is o}^p^tioⁿ^f^o^r^elig^ib^ility^g^r^o^u^p^s^th^{at w}^e^r^e^estab^lish^e^d
^hi^ghe^r^fi^na^ncⁱ^a^l^st^aⁿ^d^a^r^d^{s a}^p^p^l^y.^So^m^e^b^e^ne^fi^t^s^a^r^e^uⁿ^d^er^th^e^s^t^{ate plan}^on^{or bef}^o^{re th}^{e date}^of^en^actm^eⁿ^t^of
^m^aⁿ^d^ato^r^y^f^o^r^th^{e CN (}^e^.g^{., in}^p^a^tien^t^an^d^o^u^tp^atien^t^h^o^sp^ital^th^{is o}^p^tioⁿ^.^{States m}^a^y^c^h^o^o^s^{e to}^p^r^o^v^id^{e o}^t^h^e^r

CRS-70
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
^{care, lab an}^{d x}^-^ra^y^s^e^rv^ices^{, ph}^y^s^ician^s^e^rv^ices^{, n}^u^r^sⁱⁿ^g^w^r^ap^-^a^r^o^uⁿ^d^an^d^ad^d^itioⁿ^a^{l b}^eⁿ^e^f^{its (}^s^{ee b}^e^lo^w⁾^.
^f^acility^car^{e f}^o^r^p^e^r^s^oⁿ^{s ag}^{e 2}¹^an^d^o^v^er⁾^.^Oth^e^r^b^eⁿ^e^f^its^ar^e
^o^p^tioⁿ^a^{l f}^o^r^th^{e CN (}^e^.g^{., o}^t^h^e^r^p^r^actitioⁿ^e^r^ser^v^ices,^r^o^u^tin^e
^den^t^al^{care, ph}^y^s^{ical th}^erapy⁾^{. B}^eⁿ^e^f^its^of^f^e^{red to C}^N^g^r^ou^ps
^m^u^s^t^{be th}^{e s}^a^m^e^s^t^atew^{ide, an}^dⁱⁿ^am^ouⁿ^t^{, du}^ration^an^d
^s^c^ope.^States^m^a^y^of^f^e^{r a m}^o^{re res}^t^rictiv^{e ben}^e^f^{it pack}^ag^{e to}
^th^{e MN, bu}^{t m}^u^s^t^of^f^e^{r p}^r^eⁿ^{atal an}^{d deliv}^ery^s^e^rv^ices^,
^am^b^u^lato^r^y^ser^v^ice^s^f^o^r^p^e^r^s^oⁿ^{s u}ⁿ^d^er²¹^an^d^th^o^s^{e en}^titled
^toⁱⁿ^stitu^tioⁿ^a^{l ser}^v^{ices, an}^d^h^o^m^e^h^ealth^ser^v^{ices f}^o^r^th^o^s^e
^en^titled^toⁿ^u^r^sin^g^f^acility^car^{e. B}^eⁿ^e^f^{its o}^f^f^e^r^e^d^t^o^MN
ⁱ^{ki/CRS-RL33251}^g^r^ou^ps^m^u^s^t^{be t}^h^{e s}^a^m^e^s^t^at^e^wⁱ^d^e^,^an^{d i}ⁿ^am^ouⁿ^t^{, du}^ratⁱ^oⁿ^an^d^sco^p^e^{. Ch}^an^g^e^{s in}^co^m^p^ar^ab^ility^o^r^statew^id^en^{ess f}^o^r
^g/w^ben^e^fⁱ^t^s^f^o^{r C}^N^an^{d MN}^g^r^ou^ps^requⁱ^r^{e a w}^aⁱ^v^er.
^s^.or
^le^ak^{Full Benef}ⁱ^t^{Eligible Indiv}ⁱ^duals.^S^e^e^a^b^o^v^e^.^Eⁿ^r^o^l^l^m^eⁿ^tⁱⁿ^b^eⁿ^c^hm^a^r^k^aⁿ^d^b^e^nc^hm^a^r^k-e^q^ui^va^l^e^nt
^co^v^e^r^a^g^e^can^b^e^r^e^q^u^ir^ed^f^o^r^“^f^u^l^l^b^eⁿ^e^f^{it elig}^ib^le
^://wikiⁱⁿ^dⁱ^vⁱ^d^u^{als,” in}^clu^dⁱⁿ^g^p^e^r^s^oⁿ^{s elig}^ib^{le f}^o^r^{all ser}^v^ices
^h^ttp^co^v^e^r^e^d^f^o^r^th^{e CN, o}^r^an^y^o^t^h^e^r^categ^o^r^y^o^f^elig^ib^ility
^f^o^{r all cov}^e^red^s^e^rv^ices^uⁿ^d^{er th}^{e s}^t^{ate Medicaid plan}^as
^determⁱⁿ^{ed by}^th^{e Secretary}^.^C^e^rtainⁱⁿ^divⁱ^du^als^w^o^u^l^d
^b^e^ex^clu^d^ed^f^r^o^m^th^e^d^e^fⁱⁿ^itioⁿ^o^f^{a f}^u^ll-^b^eⁿ^e^f^{it elig}^ib^le,
ⁱⁿ^clu^dⁱⁿ^g⁽¹⁾^th^{e MN; (}²⁾^CNⁱⁿ^dⁱ^vⁱ^d^u^{als in}^cer^tain^states
^w^h^o^are^requ^{ired to pay}^f^o^{r m}^e^{dical ex}^pen^s^es^f^r^om^th^eir
ⁱⁿ^co^m^e^uⁿ^{til th}^eir^r^e^m^aⁱⁿⁱⁿ^gⁿ^e^{t in}^co^m^e^m^e^e^t^s^S^S^I
^fⁱⁿ^aⁿ^cⁱ^a^l^s^t^an^da^r^d^sⁱⁿ^ef^f^ectⁱⁿ^1972;^an^{d (3) ot}^h^e^r
ⁱⁿ^di^vⁱ^du^al^s^w^h^{o qu}^alⁱ^f^y^f^o^{r Medi}^cai^{d w}^h^eⁿ^c^o^s^t^s
ⁱⁿ^cu^rred^f^o^{r m}^e^{dical ex}^pen^s^es^{or oth}^e^{r rem}^e^{dial care are}
^su^b^t^r^acted^f^r^o^mⁱⁿ^co^m^e^to^m^{eet f}ⁱⁿ^aⁿ^c^{ial elig}^ib^ility
^requⁱ^r^em^en^t^s^(al^s^{o k}ⁿ^o^wⁿ^as^s^p^en^d-^dowⁿ^popu^l^a^tⁱ^oⁿ^s^).

CRS-71
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
^E^x^e^m^pte^d^Gr^oups^.^N^o^p^r^o^vⁱ^sⁱ^oⁿ^.^Specifⁱ^c^g^r^ou^ps^{are ex}^em^pted^f^r^om^m^aⁿ^d^atory
^en^r^o^llm^en^{t in}^th^{e b}^eⁿ^e^f^{it p}^ack^ag^e^o^p^t^ioⁿ^,ⁱⁿ^clu^dⁱⁿ^g⁽¹⁾
^m^aⁿ^d^at^ory^pregⁿ^aⁿ^t^w^o^m^eⁿ^;^{(2) i}ⁿ^di^vⁱ^du^al^s^w^h^{o qu}^alⁱ^f^y
^f^o^{r Medicaid u}ⁿ^d^{er th}^{e s}^t^{ate plan}^on^th^{e bas}ⁱ^s^of^bein^g
^b^lin^d^o^r^dⁱ^sab^l^ed^r^e^g^a^r^d^{less o}^f^th^eir^elig^ib^ility^f^o^r^SSI^oⁿ
^su^ch^b^a^{sis, in}^clu^dⁱⁿ^g^chⁱ^l^d^r^eⁿ^th^{at m}^{eet SSI}^dⁱ^sab^ility
^stan^d^a^r^d^{s w}^h^o^r^e^q^uⁱ^r^eⁱⁿ^stitu^tioⁿ^a^{l car}^{e, b}^u^{t f}^o^r^w^h^o^m
^car^{e is d}^e^liv^er^ed^o^u^tsid^{e th}^{e in}^stitu^tioⁿ^,^an^d^th^{e co}^{st o}^f
^th^at^{care d}^o^e^{s n}^o^{t ex}^ceedⁱⁿ^stitu^tioⁿ^a^{l care (also}^kⁿ^o^wⁿ
^{as Katie}^B^eck^ett^o^r^T^E^FRA^ch^ild^r^eⁿ⁾^{; (}³⁾^d^u^{al elig}^ib^les;
ⁱ^{ki/CRS-RL33251}⁽⁴⁾^ter^mⁱⁿ^ally^{ill h}^o^sp^{ice p}^a^tien^t^{s; (}⁵⁾ⁱⁿ^dⁱ^vⁱ^d^u^{als in}^m^e^dⁱ^calⁱⁿ^stitu^tioⁿ^s^w^h^o^ar^{e r}^e^q^u^ir^ed^to^p^a^y^f^o^r^co^sts^o^f
^g/w^m^e^{dical s}^e^rv^ices^ex^{cept f}^o^{r a m}ⁱⁿⁱ^m^a^{l am}^ouⁿ^t^retain^ed
^s^.or^f^r^om^th^{eir in}^com^e^f^o^{r pers}^on^{al n}^eeds^;^{(6) in}^divⁱ^du^als
^le^ak^w^h^{o ar}^e^m^e^dically^f^r^{ail or w}^h^{o h}^a^v^e^s^p^{ecial m}^e^dical
^://wikiⁿ^eeds^,^as^iden^tif^{ied in}^accord^an^{ce w}^ith^reg^u^l^ation^s^of^th^e^Secretary^;^{(7) in}^divⁱ^du^al^s^w^h^{o qu}^alⁱ^f^y^f^o^r^M^e^di^cai^d
^h^ttp^loⁿ^g^-^ter^m^car^{e ser}^v^{ices (}ⁱ^.e.^,ⁿ^u^r^sⁱⁿ^g^f^acility^o^r
^equⁱ^v^a^len^t^lev^e^{l of}^{care, h}^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^ed
^w^a^iv^{er s}^e^rv^ices^,^h^o^m^e^h^ealth^{, h}^o^m^e^an^{d com}^m^uⁿ^ity^care
^f^o^{r f}^uⁿ^c^tⁱ^oⁿ^a^l^l^y^di^s^a^bl^{ed el}^derl^y^,^pers^on^al^{care, an}^{d ot}^h^e^r
^o^p^tioⁿ^a^l^loⁿ^g^-^ter^m^car^{e o}^f^f^e^r^e^d^b^y^th^{e state)}^;⁽⁸⁾^ch^ild^r^eⁿ
ⁱⁿ^f^o^s^t^{er care rec}^e^ivⁱⁿ^g^ch^{ild w}^e^lf^{are s}^e^rv^ices^(uⁿ^d^er
^T^{itle IV-}^B^{) an}^{d ch}^ildren^receivⁱⁿ^g^f^o^s^t^{er care or adoption}
^assistan^{ce u}ⁿ^d^er^T^{itle I}^V^-^E^r^e^g^a^r^d^l^e^{ss o}^f^ag^{e; (}⁹⁾
ⁱⁿ^di^vⁱ^du^al^s^w^h^{o qu}^alⁱ^f^y^{for Medi}^cai^{d on}^t^h^{e bas}ⁱ^s^of
^receivⁱⁿ^g^as^sⁱ^s^t^an^{ce u}ⁿ^d^{er T}^A^{NF (as}ⁱⁿ^ef^f^{ect on}^or^af^ter
^th^{e w}^e^lf^{are ref}^o^rm^ef^f^ectiv^{e date}^{applicable to th}^{e s}^t^ate);
⁽¹⁰⁾^w^o^m^eⁿⁱⁿ^th^{e b}^r^{east an}^d^cer^vⁱ^{cal can}^cer^elig^ib^ility

CRS-72
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
^g^r^ou^p;^an^{d (11) ot}^h^e^{r “}^lⁱ^mⁱ^t^e^{d s}^e^rvⁱ^ces^ben^e^fⁱ^ci^a^rⁱ^e^s^,^”
ⁱⁿ^clu^dⁱⁿ^g^certain^tu^bercu^l^os^is^-ⁱⁿ^f^{ected in}^divⁱ^du^als^,^an^d
^leg^a^{l an}^{d u}ⁿ^docu^m^en^{ted n}^oⁿ^-^citizen^s^w^h^{o m}^{eet th}^e
^fⁱⁿ^aⁿ^c^{ial an}^{d categ}^{orical requ}^irem^en^t^s^f^o^{r Medicaid}
^elig^ib^ility^w^ith^o^u^{t r}^e^g^a^r^d^to^tim^{e in}^th^{e U.S}^.^aⁿ^d^ar^e
^elig^{ible on}^ly^f^o^{r em}^erg^eⁿ^c^y^m^e^{dical s}^e^rv^ices^.
^S^t^a^nda^r^d^Be^ne^fits^.^A^s^des^c^ri^{bed abov}^{e, s}^o^m^e^ben^e^fⁱ^t^s^are^m^aⁿ^d^at^ory^f^o^{r t}^h^e^C^N^B^e^nc^hm^a^r^{k a}ⁿ^d^b^e^nc^hm^a^r^k-e^q^ui^va^l^e^nt^p^a^c^k^a^g^e^s^w^o^ul^d
⁽^e^.g^{., in}^p^a^tien^t^an^d^o^u^t^p^a^tⁱ^eⁿ^t^h^o^sp^{ital car}^{e, lab}^an^d^x^-^r^a^y^b^eⁿ^ear^ly^id^en^{tical to}^th^o^s^{e o}^f^f^e^r^e^d^uⁿ^d^er^SCHI^P^,^w^ith
^ser^v^{ices, p}^h^y^s^ician^ser^v^ices,^FQHC^ser^v^{ices, n}^u^r^sin^g^f^acility^so^m^e^ad^d^itioⁿ^s^{. B}^eⁿ^c^h^m^ar^k^co^v^e^r^a^g^e^w^o^u^l^dⁱⁿ^clu^d^e⁽¹⁾
ⁱ^{ki/CRS-RL33251}^{care f}^o^{r pers}^on^s^ag^{e 21 an}^{d ov}^er).^Oth^e^r^ben^e^f^its^{are option}^a^l^f^o^r^th^{e CN (}^e^.g^{., o}^t^h^e^r^p^r^actitioⁿ^e^r^ser^v^{ices, r}^o^u^tⁱⁿ^e^d^eⁿ^t^al^t^h^e^s^t^an^{dard Bl}^u^e^C^r^os^s^/^Bl^u^e^S^hⁱ^e^l^d^pref^{erred prov}ⁱ^d^er^plan^uⁿ^d^{er FEHB}^P^;^{(2) h}^ealth^coverag^e^f^o^{r s}^t^ate
^g/w^care,^ph^y^s^{ical th}^erapy⁾^{. B}^eⁿ^e^f^its^of^f^e^{red to C}^N^g^r^ou^ps^m^u^s^t^e^m^p^l^o^y^ees^{; (3) h}^ealth^cov^e^rag^e^of^f^e^{red by}^th^{e larg}^es^t
^s^.or^{be t}^h^{e s}^a^m^e^s^t^at^ewⁱ^d^{e, an}^{d i}ⁿ^am^ount^,^d^u^ratⁱ^oⁿ^an^{d s}^c^ope.^com^m^e^{rcial HMO; an}^d^{(4) s}^ecretary^approv^{ed cov}^e^rag^e
^le^ak^States^m^a^y^of^f^e^{r a m}^o^{re res}^t^rictiv^{e ben}^e^fⁱ^t^p^a^c^k^ag^{e to th}^e^w^hⁱ^c^{h ma}^{y i}ⁿ^c^l^ud^e^aⁿ^y^o^t^he^r^he^a^l^t^h^b^e^ne^fi^t^s^c^o^ve^r^a^ge
^{MN, bu}^{t m}^u^s^t^of^f^e^{r pren}^at^a^l^an^{d deliv}^ery^s^e^rv^ices^,^th^{at th}^{e Secr}^etar^y^d^e^ter^mⁱⁿ^{es w}^{ill p}^r^o^v^id^{e ap}^p^r^o^p^r^iate
^://wiki^am^b^u^lato^r^y^ser^v^{ices f}^o^r^p^e^r^s^oⁿ^s^uⁿ^d^er²¹^an^d^th^o^s^{e en}^titled^c^o^v^e^r^a^g^e^f^o^r^t^h^e^popu^l^a^tⁱ^oⁿ^t^a^r^g^e^t^e^d^t^o^r^eceiv^e^s^u^c^h
^h^ttp^toⁱⁿ^stitu^tioⁿ^a^{l ser}^v^{ices, an}^d^h^o^m^e^h^ealth^ser^v^{ices f}^o^r^th^o^s^e^c^o^ve^r^a^ge^.^B^e^nc^hm^a^r^k^-^e^q^ui^va^l^e^nt^c^o^ve^r^a^ge^w^o^ul^d^ha^ve
^en^titled^toⁿ^u^r^sⁱⁿ^g^f^acility^car^{e. B}^eⁿ^e^f^{its o}^f^f^e^r^e^d^to^MN^th^{e s}^a^m^e^actu^a^rial^v^a^lu^e^as^on^e^of^th^{e ben}^c^h^m^ark^plan^s^.
^g^r^ou^ps^m^u^s^t^{be th}^{e s}^a^m^e^s^t^atew^{ide, an}^{d in}^am^ouⁿ^t^{, d}^u^r^a^tⁱ^oⁿ^Su^ch^c^o^v^e^r^a^g^eⁱⁿ^clu^d^{es (}¹⁾ⁱⁿ^p^a^tien^t^an^d^o^u^tp^atien^t
^an^d^sco^p^e^{. Ch}^an^g^e^{s in}^co^m^p^ar^ab^ility^o^r^statew^id^en^{ess f}^o^r^h^o^sp^{ital ser}^v^{ices, (}²⁾^p^h^y^s^ici^aⁿ^ser^v^{ices, (}³⁾^lab^an^d
^ben^e^fⁱ^t^s^f^o^{r C}^N^an^{d MN}^g^r^ou^ps^requⁱ^r^{e a w}^aⁱ^v^er.^x^-^ray^s^e^rv^ices^{, (4}⁾^w^e^l^l^ch^{ild care, in}^clu^dⁱⁿ^g
^im^m^uⁿⁱ^zation^s^,^an^d^{(5) oth}^e^{r appropriate prev}^en^tiv^e^care
^(des^igⁿ^a^{ted by}^th^{e Secretary}⁾^.^Su^ch^cov^e^rag^e^m^u^s^t^als^o
ⁱⁿ^clu^d^{e at leas}^{t 75% of}^th^{e actu}^a^{rial v}^a^lu^{e of}^c^o^v^e^rag^e
^uⁿ^d^{er th}^{e ben}^c^h^m^ark^plan^f^o^r:^{(1) pres}^{cribed dru}^g^s^{, (2)}
^m^eⁿ^t^{al h}^ealth^s^e^rv^ices^{, (3) v}ⁱ^sⁱ^oⁿ^{care, an}^{d (4) h}^earin^g
^ser^v^{ices. Deter}^mⁱⁿ^atioⁿ^o^f^actu^a^rⁱ^al^v^a^lu^e^w^o^u^l^d^f^o^llo^w
^g^eⁿ^e^rally^{accepted actu}^a^ri^a^l^p^rⁱⁿ^cⁱ^p^l^e^s^an^d
^m^e^t^h^odol^ogⁱ^e^s^an^{d w}^o^u^l^{d be}^con^d^u^c^t^e^d^by^{a m}^e^m^b^{er of}

CRS-73
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Am^{ended by the Senate}
^th^{e A}^m^erican^A^cadem^y^of^A^c^tu^aries^.
^Wr^a^p^-A^r^{ound Be}^ne^fits^for^Childr^e^{n Only}^.^Un^{der th}^{e Early}^an^d^P^e^rⁱ^o^dⁱ^c^,^S^c^r^eenⁱⁿ^g^,^Diagⁿ^o^s^tic^an^d^{For an}^y^ch^{ild u}ⁿ^d^e^r^ag^{e 19 in}^on^{e of}^th^{e m}^a^j^o^r
^T^r^eatm^eⁿ^t^(EP^S^DT^{) ben}^e^f^{it, Medicaid ch}^ildren^uⁿ^d^er^ag^e²¹^m^aⁿ^d^ato^r^y^an^d^o^p^tioⁿ^a^{l elig}^ib^ility^g^r^o^u^p^s⁽^d^efⁱⁿ^edⁱⁿ
ⁱⁿ^C^N^g^r^ou^ps^receiv^e^com^p^reh^eⁿ^s^iv^e^s^c^reenⁱⁿ^g^s^e^rv^ices^an^d^S^ectⁱ^oⁿ^{1902(a)(10)(A}^{)) u}ⁿ^d^er^t^h^e^s^t^at^{e Medi}^cai^{d pl}^an^,
^prev^en^tiv^{e care, an}^{d are g}^u^a^ran^t^{eed acces}^s^{to all}^federally^w^r^a^p^-a^r^o^und^b^e^ne^fi^t^s^t^o^t^h^e^b^e^nc^hm^a^r^{k o}^r^b^e^nc^hm^a^r^k-
^co^v^e^r^a^b^l^e^ser^v^icesⁿ^ecessar^y^to^tr^{eat a p}^r^o^b^l^em^o^r^coⁿ^d^itioⁿ^.^e^q^ui^va^l^e^nt^c^o^ve^r^a^geⁱⁿ^c^l^ud^e^s^E^S^P^D^T^a^s^d^e^fⁱ^ne^dⁱⁿ
^EPS^D^T^m^a^y^{be of}^f^e^{red t}^o^MN^chⁱ^l^d^ren^.^cu^rren^t^{Medicaid law}^.
^T^r^{eatment of Rural H}^{ealth Clinics}⁽^RHCs)^B^o^th^th^{e s}^e^rv^ices^prov^{ided by}^R^H^C^s^an^{d FQHC}^s^are^{States can}^oⁿ^ly^en^r^o^{ll elig}^ib^le^b^eⁿ^e^fⁱ^ciar^iesⁱⁿ^b^eⁿ^c^h^m^ar^k
ⁱ^{ki/CRS-RL33251}^de^r^a^l^l^y^Qua^lifie^{d He}^a^l^{th Ce}^nte^r^s^(FQHCs^).^requⁱ^r^{ed ben}^e^fⁱ^t^s^f^o^{r C}^N^g^r^ou^ps^uⁿ^d^{er Medi}^cai^d.^A^m^on^g^ot^h^e^{r m}^aⁿ^d^at^ory^ben^e^fⁱ^t^s^f^o^{r MN}^g^r^ou^ps^{, s}^t^at^es^m^u^s^t^of^f^e^r^aⁿ^d^b^e^nc^hm^a^r^k-e^q^ui^va^l^e^nt^c^o^ve^r^a^geⁱ^f^suc^h^p^e^r^s^oⁿ^{s ha}^ve^acces^s^{to s}^e^rv^ices^prov^{ided by}^R^H^C^s^an^{d FQHC}^s^,^an^d
^g/w^am^b^u^lato^r^y^ser^v^{ices f}^o^r^p^e^r^s^oⁿ^{s u}ⁿ^d^er²¹^an^d^th^o^s^e^eⁿ^titled^t^h^{e Medi}^cai^d^pros^pectⁱ^v^e^pay^m^en^t^s^y^s^t^em^f^o^{r bot}^h^t^y^pes
^s^.or^toⁱⁿ^stitu^tioⁿ^a^{l ser}^v^ices.^S^u^ch^am^b^u^lato^r^y^ser^v^{ices m}^a^y^of^provⁱ^d^ers^rem^aⁱⁿ^sⁱⁿ^ef^f^ect^.
^le^akⁱⁿ^clu^d^{e R}^H^C^an^{d FQHC}^s^e^rv^ices^{at s}^t^{ate option}^.^In^g^eⁿ^e^ral,
^R^H^C^s^an^{d F}^Q^H^C^s^{are pai}^d^on^{a per v}ⁱ^sⁱ^t^basⁱ^s^,^u^sⁱⁿ^g^a
^://wiki^pros^pectiv^{e pay}^m^en^{t s}^y^s^t^em^th^{at tak}^e^sⁱⁿ^{to accou}ⁿ^t^cos^t^s
^h^ttpⁱⁿ^cu^{rred an}^{d ch}^an^g^e^sⁱⁿ^th^e^s^c^ope^of^s^e^rv^ices^prov^{ided. P}^e^r
^vⁱ^s^{it pay}^m^en^{t rates}^{are als}^o^adj^u^s^t^{ed an}^nua^l^l^y^by^th^e
^{Medicare Econ}^om^{ic In}^dex^{applicable to}^p^rⁱ^m^ary^care
^s^e^rv^ices^.
^Ef^f^ect^iv^{e Dat}^e^.^N^o^provⁱ^sⁱ^oⁿ^.^T^h^es^{e prov}ⁱ^sⁱ^oⁿ^s^{are ef}^f^ectⁱ^v^{e on}^March^{31, 2006.}

CRS-74
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^M^a^na^ge^{d Ca}^r^e^Or^ga^niza^{tion P}^r^ov^ide^r^T^a^x^.^Sta^t^e^s^’^ab^ility^to^u^s^{e p}^r^o^v^id^er^-^s^p^ecifⁱ^{c tax}^e^{s to}^f^uⁿ^d^S^ecti^oⁿ⁶⁰⁵¹^.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t w}^o^u^l^{d ex}^pan^d
^M^e^dⁱ^caid^ex^p^eⁿ^d^itu^r^e^{s is lim}^ited^.^I^f^{a state estab}^lish^e^s^th^e^{Medicaid MC}^{O prov}^{ider clas}^s^{to in}^clu^d^{e all MC}^Os^.
^prov^ider-^s^pecifⁱ^{c tax}^e^s^{to f}^uⁿ^d^th^{e s}^t^ate’^s^s^h^{are of}^prog^ram^T^o^qu^alif^y^f^o^r^f^e^{deral reim}^bu^rs^em^en^{t, a s}^t^ate’^s^prov^ider
^co^sts,^r^e^im^b^u^r^s^em^en^t^o^f^th^{e f}^e^d^e^r^a^{l sh}^ar^{e w}^{ill n}^o^{t b}^e^av^ailab^l^e^t^a^x^w^o^u^l^{d n}^{eed t}^o^appl^y^t^o^bot^h^Medi^cai^{d a}ⁿ^d
^uⁿ^l^{ess th}^e^t^a^x^p^r^o^g^r^a^m^m^{eets th}^{e f}^o^llo^wⁱⁿ^g^th^r^{ee r}^u^{les: th}^eⁿ^on-Medi^cai^{d MC}^O^s^{. T}^hⁱ^s^w^o^u^l^{d m}^a^k^e^t^h^{e MC}^O
^tax^e^s^{collected can}ⁿ^o^{t ex}^{ceed 25% of}^th^{e s}^t^{ate (or}^p^r^o^v^id^er^{class m}^o^r^e^coⁿ^s^isten^t^w^ith^th^{e o}^t^h^e^r^p^r^o^v^id^er
ⁿ^oⁿ^-^f^e^{deral) s}^h^{are of}^Medicaid^ex^pen^d^itu^res^;^th^{e s}^t^{ate can}ⁿ^o^t^{classes f}^o^r^p^u^r^p^o^s^{es o}^f^d^e^ter^mⁱⁿⁱⁿ^g^if^{a p}^r^o^v^id^er^tax^is
^p^r^o^v^id^{e a}^g^u^a^r^aⁿ^t^{ee to}^th^{e p}^r^o^v^id^er^{s th}^{at th}^{e tax}^e^{s w}^{ill b}^e^broad-^bas^e^d.
ⁱ^{ki/CRS-RL33251}^retu^rn^{ed to th}^em^{; an}^{d th}^{e tax}^m^u^s^t^{be “}^b^road-^b^as^{ed.” A}
^g/w^broad-^bas^e^{d t}^a^xⁱ^s^{a t}^a^x^t^h^atⁱ^s^uⁿⁱ^f^o^rm^l^y^applⁱ^e^{d t}^o^al^l^T^h^{e prov}^is^ion^becom^e^s^ef^f^ectiv^e^u^pon^en^actm^eⁿ^t^ex^cept
^s^.or^provⁱ^d^ers^{or s}^e^r^vⁱ^c^e^s^wⁱ^t^hⁱⁿ^t^h^{e prov}ⁱ^d^{er cl}^as^s^.^T^h^{e f}^e^deralⁱⁿ^s^t^ates^w^ith^tax^e^s^bas^e^{d on}^t^h^{e cu}^rren^t^law^Medicaid
^le^ak^s^t^atu^t^{e iden}^tⁱ^fⁱ^e^s^each^of^th^{e clas}^s^e^s^of^prov^iders^{or s}^e^rv^ices^MC^{O prov}^{ider clas}^sⁱⁿ^place^as^of^Decem^{ber 8, 2005. In}
^f^o^{r t}^h^{e pu}^rpos^{e of}^det^e^rmⁱⁿⁱⁿ^g^w^h^et^h^e^r^a^t^a^xⁱ^s^broad-^bas^e^d.^th^os^{e s}^t^ates^{, th}^e^prov^is^ion^becom^e^s^ef^f^ectiv^{e on}^October
^://wiki^{1, 2009.}
^h^ttp^{Medicaid m}^aⁿ^a^g^e^{d care org}^aⁿⁱ^zation^s^(MC^O^s⁾^{are iden}^tif^ied
^as^{a s}^e^parat^e^cl^as^s^of^provⁱ^d^ers^f^o^{r t}^h^{e pu}^rpos^es^of
^d^e^ter^mⁱⁿⁱⁿ^g^if^{a tax}^{is b}^r^o^a^d^-^b^a^sed^.^T^h^{is class is u}ⁿ^lik^{e all}^o^f
^th^{e oth}^e^{r clas}^s^e^s^of^prov^iders^{or s}^e^rv^ices^becau^s^e^{it is}^lim^ited
^t^o^on^l^y^Medi^cai^{d prov}ⁱ^d^ers.^O^t^h^e^{r cl}^as^s^e^s^of^provⁱ^d^ers^or
^ser^vⁱ^c^e^s^id^en^tif^iedⁱⁿ^statu^t^{e, su}^ch^{as in}^p^a^tien^t^h^o^sp^ital
^ser^v^{ices, o}^u^tp^atien^t^h^o^sp^{ital ser}^v^{ices, p}^h^y^s^ician^s^{— ar}^{e n}^o^t
^res^t^ri^ct^{ed t}^o^Medi^cai^{d prov}^iders^{or Medicaid s}^e^rv^ices^.
^Ref^o^{rms o}^f^{Case M}^aⁿ^a^g^e^men^t^an^d^C^a^s^e^m^a^na^g^e^m^eⁿ^tⁱ^s^an^optⁱ^oⁿ^a^l^Medi^cai^{d ben}^e^fⁱ^t^desⁱ^gⁿ^e^d^S^ecti^oⁿ⁶⁰⁵²^{. T}^h^{e con}^f^eren^{ce ag}^reem^en^{t clarif}^ies^th^e
^rg^et^ed^{Case M}^aⁿ^a^g^e^men^t⁽^T^CM⁾^.^to^h^e^{lp Medicaid ben}^e^fⁱ^ciarie^s^acces^sⁿ^{eeded m}^e^dical,^s^o^cial,^activ^{ities th}^{at can}^b^e^coⁿ^s^id^er^ed^ca^{se m}^aⁿ^a^g^e^m^eⁿ^t^o^r
^edu^cation^a^{l, an}^{d oth}^e^{r s}^e^r^vⁱ^c^e^s^.^States^th^{at cov}^e^{r cas}^e^tar^g^eted^{case m}^aⁿ^a^g^e^m^eⁿ^t^{, an}^d^th^o^s^{e activ}^{ities (}^p^rⁱ^m^a^r^ily
^m^a^na^ge^m^eⁿ^t^d^o^no^t^ha^ve^t^o^o^ffe^r^t^h^e^b^e^ne^fi^t^st^a^t^e^wⁱ^d^e^aⁿ^d^f^o^ster^car^e-^r^e^lated^activ^ities)^th^{at m}^a^yⁿ^o^{t b}^e^r^e^im^b^u^r^s^ed

CRS-75
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^can^lim^{it th}^{e s}^e^rv^{ice to s}^p^ecifi^c^grou^ps^of^Medicaid^as^cas^{e m}^aⁿ^a^g^e^m^eⁿ^t^s^e^rv^ices^{or T}^C^M.
^ben^e^fⁱ^ciaries^w^h^ich^is^ref^e^{rred to as}^“^t^arg^e^{ted cas}^e
^m^a^nag^e^m^eⁿ^t^{” (T}^C^M^{). Sev}^e^{ral s}^t^ates^ex^ten^d^cas^e
^m^a^na^ge^m^e^nt^se^r^vⁱ^c^e^s^t^oⁱⁿ^dⁱ^vi^d^u^a^l^{s w}^h^o^m^a^y^a^l^so^b^e
^receivⁱⁿ^g^certain^cas^{e m}^aⁿ^a^g^e^m^eⁿ^t^s^e^rv^ices^as^{part of}^an^oth^e^r
^s^t^{ate an}^{d/or f}^e^{deral prog}^ram^(e.g^.^,^f^o^s^t^{er care, j}^u^v^eⁿ^ile
^j^u^s^tice).
^A^dditiona^{l FM}^A^P^A^d^jus^t^me^nts^.^T^h^e^f^e^{deral m}^e^{dical as}^sⁱ^s^t^an^{ce percen}^tag^e^(FMA^P⁾^is^th^e^rate^Se^c^tⁱ^oⁿ^6053.^Un^{der th}^{e con}^f^eren^{ce ag}^reem^en^t,ⁱ^f
^{at w}^h^ich^s^t^ates^{are re}ⁱ^m^bu^rs^{ed f}^o^{r m}^o^s^t^{Medicaid s}^e^rv^ice^A^l^as^k^a^’^s^F^Y^{2006 or F}^Y^{2007 F}^M^A^P^f^o^r^M^e^dⁱ^cai^{d or}
ⁱ^{ki/CRS-RL33251}^ex^pen^dⁱ^t^u^res^.^Itⁱ^s^bas^e^{d on}^{a fo}^r^m^ul^{a t}^h^at^provⁱ^d^es^hⁱ^g^h^e^r^r^e^im^b^u^r^s^em^en^{t to}^{states w}^ith^l^o^w^e^r^p^e^r^cap^{ita in}^co^m^e^s^S^C^H^I^{P i}^s^l^e^s^s^t^h^anⁱ^t^s^F^Y^{2005 F}^M^A^P^{, t}^h^e^FY²⁰⁰⁵^FMA^P^sh^{all ap}^p^l^y^.
^g/w^r^e^la^tⁱ^v^e^to^th^{e n}^a^tioⁿ^a^{l av}^er^ag^{e (}^aⁿ^d^vⁱ^{ce v}^e^r^s^a)^{; it h}^a^{s a}
^s^.or^s^t^at^u^t^ory^mⁱⁿⁱ^m^u^m^of^50%^an^{d m}^a^xⁱ^m^u^m^of^83%^{. A}ⁿ^Iⁿ^ad^d^itioⁿ^,ⁱⁿ^co^m^p^u^tin^g^Medⁱ^caid^an^d^SCHI^P^FMA^P^s
^le^ak^en^h^aⁿ^{ced FMA}^P^is^av^{ailable f}^o^{r both}^s^e^r^vⁱ^c^e^s^an^d^f^o^{r any}^y^e^{ar af}^t^e^{r 2006 f}^o^{r a s}^t^at^{e t}^h^at^t^h^{e S}^ecret^ary^of
^admⁱⁿⁱ^s^t^ration^uⁿ^d^{er th}^{e State C}^h^ildren^’^s^Health^In^s^u^ran^c^e^H^H^S^d^e^t^e^r^mⁱⁿ^e^s^ha^s^a^si^gni^fi^c^aⁿ^t^num^b^e^r^o^fⁱⁿ^dⁱ^vi^d^u^a^l^s
^://wiki^P^r^o^g^r^a^m⁽^S^CHI^P⁾^,^su^b^j^{ect to}^th^{e av}^ailab^ility^o^f^f^uⁿ^d^{s f}^r^o^m^a^w^h^{o w}^e^{re ev}^acu^{ated to an}^{d liv}^{e in}^th^e^s^t^ate^as^a^res^u^{lt of}
^h^ttp^s^t^ate’^s^SC^HIP^allotm^en^t.^H^u^rri^can^{e K}^a^t^rⁱⁿ^a^a^s^of^O^c^t^{ober 1, 2005, t}^h^{e S}^ecret^ary
^s^h^{all dis}^r^eg^{ard s}^u^ch^ev^acu^ees^an^{d th}^{eir in}^com^e^s^.

^W^h^en^s^t^{ate FMA}^P^s^{are calcu}^{lated by}^{HHS f}^o^{r an}^u^p^c^o^mⁱⁿ^g
^fⁱ^s^{cal y}^{ear, th}^{e s}^t^{ate an}^{d U.S. am}^ouⁿ^t^s^u^s^edⁱⁿ^th^{e f}^o^rm^u^l^{a are}
^equ^a^{l to th}^{e av}^erag^{e of}^th^{e th}^{ree m}^o^s^t^recen^{t calen}^d^a^{r y}^ears
^of^dat^a^on^{per capi}^t^a^pers^on^alⁱⁿ^com^e^av^ai^l^a^bl^{e f}^r^om^t^h^e
^D^e^par^t^m^eⁿ^t^of^C^o^m^m^e^rce’^s^Bu^reau^of^Econ^omⁱ^c^Aⁿ^al^y^sⁱ^s
^(B^E^A⁾^.^B^E^A^revⁱ^s^e^s^its^m^o^s^t^recen^{t es}^tim^ates^of^s^t^{ate per}
^c^a^pⁱ^t^a^p^e^r^s^oⁿ^a^lⁱⁿ^c^o^m^e^oⁿ^aⁿ^a^nnua^l^b^a^si^{s t}^oⁱⁿ^c^o^r^p^o^r^a^t^e
^revⁱ^s^e^{d C}^eⁿ^s^u^s^Bu^reau^popu^l^a^tⁱ^oⁿ^fⁱ^g^u^r^es^an^{d n}^e^w^l^y
^av^{ailable s}^o^u^r^{ce data. It als}^o^uⁿ^d^ertak^e^s^{a com}^p^reh^eⁿ^s^iv^e
^dat^a^revⁱ^sⁱ^on^—^ref^l^ectⁱⁿ^g^m^e^t^h^odol^ogⁱ^cal^an^{d ot}^h^e^{r ch}^an^g^e^s
^{— ev}^ery^f^e^w^y^ears^.

CRS-76
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^P.L^.^106-⁵⁵⁴⁽^C^oⁿ^s^o^lⁱ^d^at^{ed A}^ppropri^a^tⁱ^oⁿ^s^A^c^t^,^2001),
^provⁱ^d^{ed t}^h^at^f^o^{r F}^Y^2001-^{2005, Medi}^cai^{d an}^d^SCH^I^P
^FMA^P^s^f^o^{r A}^l^as^k^a^w^o^u^l^{d be}^calcu^{lated u}^sⁱⁿ^g^th^{e s}^t^ate’^s^per
^capi^t^aⁱⁿ^com^e^di^vⁱ^{ded by}^1.05.^Dⁱ^vⁱ^diⁿ^g^by^{1.05 l}^o^w^e^{red t}^h^e
^s^t^ate’^s^{per capita in}^com^e^{, th}^erebyⁱⁿ^creasⁱⁿ^g^its^FMA^P^.
^{DSH A}^llo^t^m^en^t^f^o^{r t}^h^{e Dist}^rict^o^f^Co^lu^mb^ia.^States^an^d^th^e^Dis^t^{rict of}^C^o^lu^m^b^{ia are requ}^ired^to^recogⁿⁱ^ze,^Se^c^tⁱ^oⁿ^6054.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t w}^o^u^l^{d rais}^e
ⁱⁿ^e^s^tab^lishⁱⁿ^g^h^o^sp^{ital p}^a^y^m^en^{t r}^a^{tes, th}^{e situ}^atioⁿ^o^f^t^h^{e al}^l^o^t^m^en^t^s^f^o^{r t}^h^{e D}ⁱ^s^t^ri^ct^of^C^o^l^u^m^bⁱ^a^f^o^{r F}^Y^2000,
^ho^s^pⁱ^t^a^l^s^t^h^at^s^e^rv^{e a di}^s^p^roportⁱ^oⁿ^a^t^eⁿ^u^m^{ber of}^Medi^caⁱ^d^{2001, an}^{d 2002 f}^r^om^$^{32 m}^illi^oⁿ^t^o^{$ 49 m}^illion^.^T^h^e
^ben^e^fⁱ^ciaries^an^{d oth}^e^{r low}^-ⁱⁿ^com^e^patien^t^s^w^ith^s^p^ecial^hⁱ^g^h^e^r^allo^tm^en^{ts w}^o^u^l^d^b^e^u^s^ed^to^c^a^lcu^l^{ate DSH}
ⁱ^{ki/CRS-RL33251}ⁿ^eeds^.^Un^{der broad f}^e^deral^g^uⁱ^delin^es^,^each^s^t^ate^determⁱⁿ^es^w^h^ich^h^o^s^p^itals^receiv^e^{DSH pay}^m^en^ts^an^{d th}^{e pay}^m^en^t^al^l^o^t^m^en^t^s^begⁱⁿⁿⁱⁿ^g^wⁱ^t^h^F^Y^{2005 am}^ount^s^.^T^h^e^prov^is^ion^w^o^u^l^{d tak}^e^ef^f^{ect as}^if^en^{acted on}^{October 1,}
^g/w^am^ouⁿ^t^s^{to be m}^a^{de to each}^qu^alif^yⁱⁿ^g^h^o^s^p^{ital. T}^h^{e f}^e^deral^{2005 an}^{d w}^o^u^l^{d appl}^y^t^o^ex^pen^dⁱ^t^u^res^m^a^{de on}^{or af}^t^e^r
^s^.or^g^o^v^e^rnm^e^nt^s^h^aresⁱⁿ^th^{e cos}^t^of^s^t^{ate DSH pay}^m^en^ts^{at th}^e^th^{at d}^a^te
^le^ak^sa^m^e^fe^d^e^r^a^l^m^a^t^c^hi^{ng p}^e^r^c^eⁿ^t^a^ge^a^s^fo^r^m^o^st^o^t^he^r^M^e^dⁱ^c^aⁱ^d
^s^e^rv^ices^{. T}^o^{tal f}^e^der^a^{l reim}^bu^rs^em^en^{t f}^o^{r each}^s^t^ate’^s^DSH
^://wiki^pay^m^en^ts^{, h}^o^w^e^v^e^{r, are cap}^{ped at a s}^t^atew^{ide ceilin}^g^,
^h^ttp^ref^e^{rred to as}^th^{e s}^t^ate’^s^{DSH allotm}^en^t.
^In^{crease I}ⁿ^M^e^dⁱ^caid^Pay^m^en^t^s^t^o^t^h^e^In^th^{e 50 s}^t^ates^an^{d th}^{e Dis}^t^{rict of}^C^o^lu^m^b^{ia, Medicaid}^is^an^S^ecti^oⁿ⁶⁰⁵⁵^.^F^o^r^each^of^F^Y^2006-^2007,^t^h^e
^su^{lar A}^r^eas.ⁱⁿ^dⁱ^vⁱ^d^u^{al en}^titlem^eⁿ^t^{. T}^h^er^{e ar}^{e n}^o^lim^{its o}ⁿ^th^{e f}^e^d^e^r^a^l^C^oⁿ^f^eren^{ce A}^g^reem^en^{t in}^creas^es^{the f}^e^{deral Medicaid}
^pay^m^ent^s^fo^{r Medicaid as}^lon^g^as^th^{e s}^t^{ate is}^{able to}^f^uⁿ^dⁱⁿ^g^cap^{s in}^th^{e in}^su^lar^ar^eas^{. For P}^u^{erto R}ⁱ^{co, th}^e
^c^o^nt^rⁱ^b^u^t^eⁱ^t^s^s^h^a^r^e^o^f^t^h^e^m^a^t^c^hi^{ng fund}^s.^Iⁿ^c^o^nt^r^a^st^,^f^e^{deral Medicaid}^cap^isⁱⁿ^creas^ed^by^{$12 m}^illionⁱⁿ^each
^{Medicaid prog}^ram^sⁱⁿ^th^{e territories}^{are s}^u^bj^e^c^t^t^o^s^p^en^din^g^of^F^Y^{2006 an}^{d F}^Y^{2007. F}^o^{r t}^h^e^Vⁱ^r^gⁱⁿ^Is^l^aⁿ^d^s^an^d
^caps^.^F^o^{r F}^Y^{1999 an}^{d s}^u^bs^equ^eⁿ^t^fⁱ^s^cal^y^ears^,^t^h^es^{e caps}^are^G^u^a^m^{, th}^{e f}^e^{deral Medicaid caps}^isⁱⁿ^creas^{ed by}^$2.5
ⁱⁿ^creas^e^d^b^y^th^{e percen}^tag^e^ch^an^g^eⁱⁿ^th^{e m}^e^{dical care}^m^illionⁱⁿ^{FY2006, an}^d^by^{$5.0 m}^illionⁱⁿ^{FY2007. For}
^co^m^p^oⁿ^en^{t of}^th^{e C}^oⁿ^s^u^m^{er P}^r^{ice In}^dex^(C^P^I^-^U^{) f}^o^{r all}^th^{e North}^e^rn^Marian^as^{, th}^{e f}^e^{deral Medicaid cap is}
^U^r^baⁿ^Co^ns^u^m^ers^(as^pu^blⁱ^s^h^e^{d by}^t^h^{e Bu}^reau^of^L^a^borⁱⁿ^creas^{ed by}^{$1.0 m}^illionⁱⁿ^{FY2006, an}^d^by^$2.0
^Statistics)^.^T^h^{e f}^e^d^e^r^a^{l Med}ⁱ^caid^m^a^tchⁱⁿ^g^r^a^{te, w}^h^ich^m^illionⁱⁿ^{FY2007. For}^Am^er^ican^Sam^o^{a, th}^{e f}^e^deral
^d^e^ter^mⁱⁿ^{es th}^{e sh}^ar^e^if^Medⁱ^caid^ex^p^eⁿ^d^itu^r^e^s^p^a^id^f^o^r^b^y^th^e^{Medicaid cap is}ⁱⁿ^creas^{ed by}^{$2.0 m}^illionⁱⁿ^FY2006,

CRS-77
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^f^e^d^e^r^a^{l g}^o^v^e^rⁿ^m^eⁿ^t^{, is statu}^t^o^r^ily^{set at 5}⁰^%^o^f^th^{e ter}^r^ito^rⁱ^es.^an^d^b^y^$⁴^.⁰^m^illioⁿⁱⁿ^FY2^{007. F}^o^r^F^Y^{2008 an}^d
^T^h^eref^{ore, th}^{e f}^e^{deral g}^o^v^e^rn^m^eⁿ^t^pay^s^{50% of}^th^{e cos}^t^o^f^s^u^bs^equ^eⁿ^t^fⁱ^s^{cal y}^ears^,^th^{e total ann}^u^a^{l cap on}^f^e^deral
^Medⁱ^caid^item^s^an^d^ser^v^{ices in}^th^{e ter}^r^ito^rⁱ^{es u}^p^t^o^th^e^f^uⁿ^dⁱⁿ^g^f^o^r^th^{e Med}ⁱ^caid^p^r^o^g^r^a^m^sⁱⁿ^th^{e in}^su^lar^ar^eas^is
^s^p^en^din^g^caps^.^calcu^lated^byⁱⁿ^creasⁱⁿ^g^th^{e FY2007 ceilin}^g^f^o^rⁱⁿ^f^l^ation^.
^T^h^e^C^oⁿ^f^eren^ce^A^g^reem^en^{t is}^ef^f^ectiv^{e u}^pon^en^actm^eⁿ^t
^o^f^th^{is act}

ⁱ^{ki/CRS-RL33251}
^g/w
^s^.or
^le^ak
^://wiki
^h^ttp

CRS-78
Chapter 6. Other Provisions
Subchapter A — Family Opportunity Act.
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^Opportunity^{for Families o}^f^Disabled^Fo^r^ch^ild^r^eⁿ^w^ith^dⁱ^sab^{ilities, th}^er^e^a^r^e^{a n}^u^m^b^e^r^o^f^S^ecti^oⁿ^6062(a)(1).^T^h^{e ag}^re^e^m^eⁿ^{t creates}^{a n}^e^w^option^a^l
^ild^ren^t^o^Pu^rch^{ase M}^e^dⁱ^c^aⁱ^d^Co^v^e^rag^e^f^o^r^p^o^t^en^tially^ap^p^licab^{le Med}ⁱ^caid^elig^ib^ility^g^r^o^u^p^s^{, so}^m^e^Medⁱ^caid^elig^ib^ility^g^r^o^u^p^f^o^r^ch^ild^r^eⁿ^w^ith^dⁱ^sab^{ilities u}ⁿ^d^er
^m^aⁿ^d^at^ory^bu^t^m^o^s^t^optⁱ^oⁿ^a^l^.^F^o^{r s}^o^m^e^of^t^h^es^{e g}^r^ou^ps^,^ag^e¹⁹^w^h^o^m^{eet th}^{e sev}^e^r^ity^o^f^dⁱ^sab^ility^r^e^q^u^ir^ed^uⁿ^d^er^SSI
^dⁱ^sab^ility^statu^s^o^r^m^e^dⁱ^{cal n}^eed^is^dⁱ^r^ectly^r^e^lated^to^w^ith^o^u^{t r}^e^g^a^r^d^to^an^yⁱⁿ^co^m^e^o^r^{asset elig}^ib^ility^r^e^q^u^ir^em^en^ts
^Medⁱ^caid^elig^ib^ility⁽^e^.^g^{., ch}^ild^ren^receivⁱⁿ^g^applicable^uⁿ^d^er^SSI^f^o^{r ch}^ildren^,^an^{d w}^h^os^{e f}^a^m^ilyⁱⁿ^com^e
^Su^p^p^l^em^en^{tal Secu}^r^ity^Iⁿ^co^m^e^o^r^SSI^w^ith^f^a^m^ily^doesⁿ^o^{t ex}^{ceed 300%}^F^P^L^.^(S^tates^can^ex^{ceed 300%}^F^P^L^,
ⁱⁿ^com^e^below^{75% FP}^L⁾^.^T^h^{ere are oth}^e^{r path}^w^a^y^s^wⁱ^t^h^o^u^t^fe^d^e^r^a^l^m^a^t^c^hi^{ng fund}^{s fo}^r^suc^h^c^o^ve^r^a^ge^.⁾^M^e^dⁱ^c^aⁱ^d
ⁱ^{ki/CRS-RL33251}^t^h^r^o^{ugh w}^hⁱ^c^{h suc}^h^c^hⁱ^l^d^r^e^{n m}^a^y^a^l^so^q^u^a^lⁱ^f^y^fo^r^co^v^e^r^a^g^e^w^{ill b}^e^p^h^as^e^dⁱⁿ^b^y^ag^{e g}^r^o^u^p^,^b^e^gⁱⁿⁿⁱⁿ^g^w^ith
^g/w^Medi^cai^{d cov}^e^rag^e^f^o^{r w}^hⁱ^c^h^di^s^a^bi^lⁱ^t^y^s^t^at^u^s^an^d/^or^c^hⁱ^l^d^r^eⁿ^t^h^r^o^{ugh a}^g^e^si^{x i}ⁿ^t^h^e^se^c^o^nd^t^h^r^o^{ugh fo}^ur^t^h^q^u^a^r^t^e^r^s
^s^.or^m^e^{dical n}^{eed are irrelev}^aⁿ^t^(e.g^{., ch}^ildren^uⁿ^d^{er ag}^{e 6}^of^F^Y^{2007, t}^h^en^cov^e^riⁿ^g^chⁱ^l^d^ren^t^h^ro^ugh^a^g^e¹²^b^e^giⁿⁿⁱ^ng
^le^ak^w^ith^f^a^m^ilyⁱⁿ^co^m^e^b^e^lo^w¹³³^%^F^P^L)^{. A}^{ll o}^f^th^eⁱⁿ^F^Y^{2008, an}^d^fi^nal^l^y^{, cov}^e^riⁿ^g^chⁱ^l^d^ren^t^h^ro^{ugh a}^g^e¹⁸
^Medⁱ^c^aⁱ^d^elig^ib^ility^p^a^th^w^a^y^s^f^o^r^ch^ild^r^eⁿ^r^e^q^u^ir^e^du^riⁿ^g^F^Y^{2009 an}^{d t}^h^ereaf^t^e^r.
^://wikiⁱⁿ^com^e^l^e^v^e^l^s^t^h^at^{are g}^eⁿ^e^ral^l^y^bel^o^w^300%^of^t^h^e
^h^ttp^f^e^d^e^r^a^{l p}^o^v^er^ty^lev^e^{l (}^F^P^L⁾^w^ith^so^m^e^sta^t^e^-^sp^ecifⁱ^c
^ex^ception^s^.
^Inte^r^a^c^t^{ion w}ⁱ^{th E}^m^ploy^e^r^-S^pons^or^e^d^S^t^ates^m^a^y^requ^{ire Medicaid}^ben^e^fⁱ^ciaries^{to apply}^f^o^r^S^ecti^oⁿ^6062(a)(2)^{. Un}^{der th}^{e ag}^reem^eⁿ^t^,^s^t^ates^m^u^s^t
^Cov^e^rage.^cov^e^rag^eⁱⁿ^cert^aⁱⁿ^em^pl^oy^er-^s^pon^s^o^{red g}^r^ou^{p he}^al^t^h^r^e^q^u^ir^{e cer}^tain^p^a^r^eⁿ^t^s^o^f^ch^ild^r^eⁿ^elig^ib^{le f}^o^r^Medⁱ^caid^uⁿ^d^er
^p^l^an^{s (}ⁱⁿ^w^h^ich^su^ch^p^e^r^s^oⁿ^s^a^r^{e elig}^ib^le)^w^h^en^{it is}^th^{e n}^e^w^o^p^tioⁿ^a^{l co}^v^e^r^a^g^e^g^r^o^u^p^t^o^en^r^o^{ll in}^{, an}^d^p^a^y
^co^s^t^-^e^f^f^ectiv^{e to}^d^o^so⁽^d^efⁱⁿ^ed^b^e^lo^w⁾^{. T}^h^is^p^r^e^mⁱ^u^m^s^fo^r^,^fa^mⁱ^l^y^c^o^ve^r^a^ge^t^h^r^o^{ugh e}^m^p^l^o^y^e^r^-sp^oⁿ^so^r^e^d
^r^e^q^uⁱ^r^em^en^{t m}^a^y^b^e^im^p^o^s^ed^{as a co}ⁿ^d^itioⁿ^o^fⁱⁿ^su^r^aⁿ^{ce if}^cer^tain^coⁿ^d^itioⁿ^s^ar^{e m}^e^t.^W^h^eⁿ^th^{e em}^p^l^o^y^er
^coⁿ^tin^uⁱⁿ^g^Medⁱ^caid^elig^ib^ility^{, ex}^cep^{t th}^{at f}^a^il^u^r^{e o}^f^a^o^f^f^e^r^s^f^a^mⁱ^l^y^co^v^e^r^a^g^e^{, th}^{e p}^a^r^eⁿ^t^{is elig}^ib^{le f}^o^r^su^ch
^p^a^r^eⁿ^t^to^en^r^o^{ll a ch}^ild^m^u^{st n}^o^{t af}^f^{ect th}^e^c^hⁱ^l^d^’^s^cov^e^rag^e^{, an}^{d the}^e^m^p^l^o^y^{er con}^t^ribu^tes^{at leas}^{t 50% of}^th^e
^coⁿ^tin^uⁱⁿ^g^elig^ib^ility^f^o^r^Medⁱ^caid^.^I^f^{all m}^e^m^b^er^{s o}^f^th^e^t^o^t^a^l^c^o^st^o^f^a^nnua^l^p^r^e^mⁱ^u^m^s^fo^r^suc^h^c^o^ve^r^a^ge^,^st^a^t^e^s^m^u^st
^f^a^m^ily^ar^{e n}^o^{t elig}^ib^{le f}^o^r^Medⁱ^caid^,^an^d^th^e^g^r^o^u^p^r^e^q^u^ir^{e p}^a^r^ticip^atioⁿⁱⁿ^su^ch^co^v^e^r^a^g^e^{as a co}ⁿ^d^itioⁿ^o^f
^h^e^a^l^t^h^p^l^an^r^e^q^u^ir^{es en}^r^o^llm^en^{t o}^f^th^{e en}^tir^{e f}^a^m^ily^,^coⁿ^tin^uⁱⁿ^g^Medⁱ^caid^elig^ib^ility^f^o^r^th^{e ch}^ild^.^States^can^p^a^y

CRS-79
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^{Medicaid w}^ill^p^a^y^as^s^o^{ciated prem}^iu^m^s^f^o^{r f}^u^{ll f}^a^m^ily^an^y^p^o^r^tioⁿ^o^f^r^e^q^u^ir^ed^p^r^em^iu^m^s^oⁿ^b^e^h^a^lf^o^f^elig^ib^le
^co^v^e^r^a^g^e^if^d^oⁱⁿ^g^so^{is co}^st-^e^f^f^ectiv^{e. Med}ⁱ^caid^w^illⁿ^o^t^ch^ildren^uⁿ^d^{er s}^u^ch^em^ploy^{er plan}^s^.^Medicaid^w^o^u^l^{d be th}^e
^pay^dedu^ctⁱ^b^l^e^s^,^coiⁿ^s^u^r^aⁿ^{ce or ot}^h^e^{r cos}^t^-^s^h^a^riⁿ^g^f^o^r^s^econ^d^ary^pay^e^r^{to th}^es^{e em}^ploy^{er plan}^s^.^B^eⁿ^e^f^its^of^f^e^red^by
^f^a^m^ily^m^e^m^b^er^{s in}^elig^ib^{le f}^o^r^Medⁱ^caid^.^T^h^ir^d^p^a^r^t^y^Medi^cai^{d bu}^tⁿ^o^t^o^f^fe^r^e^{d by}^t^h^{e em}^pl^oy^{er pl}^an^s^w^o^u^l^{d be}
^lⁱ^ab^ility^r^u^{les ap}^p^l^y^to^co^v^e^r^a^g^eⁱⁿ^{a g}^r^o^u^p^h^ealth^p^l^aⁿ^;^cov^e^red^uⁿ^d^er^{Medicaid. A}^l^s^o^{, if}^s^u^ch^em^ploy^er^cov^e^rag^e^is
^th^{at is}^{, s}^u^ch^p^l^aⁿ^s^,ⁿ^o^{t Medicaid, m}^u^s^t^pay^f^o^{r all}^obtain^e^{d, s}^t^ates^m^u^s^t^redu^{ce in}^com^e^-^r^{elated prem}^iu^m^s^f^o^r
^cov^e^{red s}^e^rv^ices^uⁿ^d^{er th}^e^p^l^an^{. C}^o^s^t^-^e^f^f^ectiv^en^es^s^Medi^cai^{d cov}^e^rag^e^(permⁱ^t^t^e^{d u}ⁿ^d^{er S}^ectⁱ^oⁿ^6062(b);^s^e^e
^m^ean^{s th}^{at th}^{e r}^e^d^u^ctioⁿⁱⁿ^Medⁱ^caid^e^x^p^eⁿ^d^itu^r^e^{s f}^o^r^below⁾^b^y^aⁿ^am^ouⁿ^t^th^{at reas}^on^ably^ref^l^ects^th^{e prem}^iu^m
^{Medicaid ben}^e^fⁱ^ciaries^en^{rolled in}^{a g}^r^ou^{p h}^ealth^plan^is^con^t^ri^bu^tⁱ^oⁿ^m^a^{de by}^t^h^{e paren}^t^f^o^{r pri}^v^at^{e cov}^e^r^a^g^e^on
^lik^ely^to^b^e^g^r^eater^th^an^th^{e ad}^d^itioⁿ^a^{l co}^{sts f}^o^r^b^e^h^a^lf^o^f^{a ch}^ild^w^ith^{a d}ⁱ^sab^ility^.
ⁱ^{ki/CRS-RL33251}^prem^iu^m^s^an^{d cos}^t^-s^h^a^rin^g^requ^{ired u}ⁿ^d^{er th}^{e g}^r^ou^p^h^ealth^plan^.
^g/w
^s^.or^St^at^{e O}^p^tⁱ^oⁿ^t^o^Imp^o^{se In}^c^o^me-^R^elat^ed^Fo^r^cer^tain^elig^ib^ility^categ^o^r^ies^,^s^t^a^t^{es m}^a^yⁿ^o^{t im}^p^o^s^e^S^ecti^oⁿ^6062(b⁾^{. States ar}^{e p}^e^r^m^itted^,^w^ithⁱⁿ^cer^tain^lim^its,
^le^ak^iu^m^s^.^en^rollm^en^{t f}^ees^{, prem}^iu^m^s^{or s}ⁱ^m^{ilar ch}^arg^e^s^.^States^are^to^r^e^q^u^ir^{e f}^a^m^{ilies w}^ith^ch^ild^r^eⁿ^th^{at q}^u^alif^y^f^o^r^Medⁱ^caid
^s^p^eci^fⁱ^cal^l^y^prohⁱ^bⁱ^t^e^{d f}^r^om^requⁱ^rⁱⁿ^g^pay^m^en^t^of^uⁿ^d^e^r^th^{e n}^e^w^o^p^tioⁿ^a^{l elig}^ib^ility^categ^o^r^y^to^p^a^y^m^oⁿ^t^h^l^y
^://wiki^d^e^d^u^c^tⁱ^o^ns,^c^o^s^t^-sha^rⁱ^{ng o}^r^si^mⁱ^l^a^r^c^h^a^r^ge^{s fo}^r^se^r^vⁱ^c^e^s^pr^emⁱ^u^m^s^on^{a s}^lⁱ^dⁱⁿ^g^s^cal^{e bas}^e^{d on}ⁱⁿ^com^e^{, bu}^t^on^l^yⁱ^f
^h^ttp^f^u^rnⁱ^s^h^e^{d t}^o^chⁱ^l^d^ren^uⁿ^d^{er 18 (u}^p^t^o^ag^{e 21, or}^s^p^e^cⁱ^{fic caps}^on^ag^g^r^eg^{ate pay}^m^en^ts^f^o^{r cos}^t^-^s^h^a^rin^g^,
^rea^s^oⁿ^a^b^{le s}^u^bcateg^ories^,^{at s}^t^{ate option}⁾^{. A}^l^s^o^{, in}ⁱⁿ^cl^u^dⁱⁿ^g^premⁱ^u^m^s^f^o^r^em^pl^oy^er-^s^pon^s^o^{red f}^a^mⁱ^l^y^cov^e^rag^e
^certain^circu^m^s^t^an^ces^{, s}^t^ates^m^a^y^im^pos^{e m}^oⁿ^t^h^l^y^if^{applicable, an}^d^oth^e^{r ch}^arg^e^s^{are m}^e^{t. T}^h^es^{e caps}^s^p^ecif^y
^prem^iu^m^s^f^o^{r Medicaid. For ex}^am^ple,^s^t^ates^m^a^y^requ^ire^th^{at co}^st-^s^h^a^rin^g^canⁿ^o^t^e^x^ceed⁵^%^o^fⁱⁿ^co^m^e^f^o^{r f}^a^m^ilies
^cer^tain^w^o^r^k^er^{s w}^ith^dⁱ^sab^{ilities to}^p^a^y^p^r^em^iu^m^s^an^d^w^ithⁱⁿ^com^e^u^p^{to 200%}^F^P^L^,^an^{d can}ⁿ^o^{t ex}^{ceed 7.5%}^of
^cos^t^-^s^h^a^rin^g^s^e^{t on}^{a s}^lidin^g^s^{cale bas}^e^{d on}ⁱⁿ^com^e^{. For}ⁱⁿ^c^o^m^e^f^o^{r f}^a^m^ilies^w^ithⁱⁿ^com^e^betw^een^{200% an}^{d 300}^%
^on^{e of}^th^es^{e g}^r^ou^ps^{, s}^t^ates^m^a^y^r^e^qu^{ire th}^os^{e w}^ith^FP^L^.^States^canⁿ^o^{t requ}^{ire prepay}^m^eⁿ^t^of^prem^iu^m^s^,ⁿ^o^r^can
ⁱⁿ^com^e^bet^w^een^250%^an^d^450%^F^P^L^t^o^pay^t^h^{e f}^u^l^l^{states ter}^mⁱⁿ^{ate elig}^ib^ility^o^f^an^en^r^o^lled^ch^ild^f^o^r^f^a^ilu^r^e^to
^prem^iu^m^.^B^u^{t th}^{e s}^u^m^of^s^u^ch^pay^m^en^ts^m^a^yⁿ^o^{t ex}^ceed^pay^premⁱ^u^m^s^unl^e^s^s^l^ack^of^pay^m^en^t^con^tⁱⁿ^u^e^s^f^o^{r a}
^7.5%^ofⁱⁿ^com^e^{. F}^o^{r ot}^h^e^{r g}^r^ou^ps^{, s}^t^at^e^s^m^a^yⁿ^o^t^mⁱⁿⁱ^m^u^m^of^{60 day}^s^be^y^oⁿ^d^t^h^{e du}^{e dat}^e^{. S}^t^at^es^can^w^aⁱ^v^e
^requ^ire^prepay^m^eⁿ^t^of^prem^iu^m^s^an^{d m}^a^yⁿ^o^{t term}ⁱⁿ^ate^pay^m^en^{t of}^prem^iu^m^s^w^h^en^s^u^c^h^pay^m^en^{t w}^o^u^l^{d cau}^s^e
^elig^ib^ility^d^u^{e to}^f^a^ilu^r^e^to^p^a^y^p^r^em^iu^m^s^{, u}ⁿ^l^{ess su}^ch^und^ue^ha^r^d^shi^p^.

^f^a^ilu^{re con}^tin^u^e^s^f^o^{r at leas}^{t 60 day}^s^{. States}^m^a^y^als^o

CRS-80
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^w^a^iv^{e prem}^iu^m^s^w^h^en^s^u^ch^pay^m^en^ts^w^o^u^l^{d cau}^s^e
^und^ue^ha^r^d^shi^p^.
^Confor^{ming A}^m^e^ndmeⁿ^ts^.^Un^les^s^oth^e^rw^is^{e s}^p^ecifⁱ^{ed f}^o^{r a g}ⁱ^v^eⁿ^cov^e^r^a^ge^grou^p,^S^ecti^o^{n 6062(c)}^{. T}^h^{e ag}^reem^en^{t perm}^its^th^{e u}^{pper in}^com^e
^M^e^dⁱ^caid^elig^ib^ility^f^o^r^ch^ild^r^eⁿ^{is lim}^ited^to^th^o^s^eⁱⁿ^l^e^v^e^l^f^o^{r t}^h^{e n}^e^w^optⁱ^oⁿ^a^l^cov^e^rag^e^g^r^ou^{p (s}^et^at^300%^F^P^L⁾
^fam^ilies^w^ithⁱⁿ^com^e^u^p^{to 133 an}^{d 1/3%}^o^f^t^h^e^{to ex}^{ceed th}^{e oth}^e^rw^is^{e app}^{licable A}^F^DC^-^r^{elated in}^com^e
^applicable^AF^D^C^p^a^y^m^en^{t s}^t^an^{dard in}^{place as}^of^J^u^ly^s^t^an^dard^fo^{r ch}^ildren^uⁿ^d^{er Medicaid. T}^h^is^s^ection^als^o
¹⁶^{, 1996. In}^addition^,^targ^{eted low}^-ⁱⁿ^com^e^ch^ildren^stip^u^l^{ates th}^{at ch}ⁱ^l^d^r^eⁿ^w^ith^dⁱ^sab^{ilities m}^a^d^e^elig^ib^{le f}^o^r
^uⁿ^d^{er SC}^HIP^s^t^atu^t^{e are def}ⁱⁿ^e^{d as}^th^os^{e w}^h^{o w}^o^u^l^dⁿ^o^t^M^e^dⁱ^c^aⁱ^d^t^h^r^o^{ugh t}^h^e^ne^w^o^p^tⁱ^o^na^l^c^o^ve^r^a^ge^gr^o^u^p^w^o^ul^d^no^t
^qu^alif^y^f^o^{r Medicaid und}^e^r^th^{e s}^t^{ate plan}ⁱⁿ^ef^f^{ect on}^{be con}^s^{idered to be}^targ^eted^lo^w^-ⁱⁿ^co^m^e^ch^ild^r^eⁿ^{as d}^e^fⁱⁿ^e^d
ⁱ^{ki/CRS-RL33251}^Mar^c^h³¹^{, 1997. Pay}^m^en^t^s^f^o^{r s}^e^rvⁱ^ces^provⁱ^d^{ed t}^o^ch^ildren^w^h^{o receiv}^e^{Medicaid ben}^e^f^its^th^ro^ugh^an^uⁿ^d^{er SC}^HIP^.^T^h^u^s^{, th}^{e reg}^u^l^ar^Medicaid^FMA^P^{, rath}^{er th}^an^th^{e h}ⁱ^g^h^e^r^SCHI^P^E-^FMA^P^{, ap}^p^{lies f}^o^r^d^e^ter^mⁱⁿⁱⁿ^g^th^e
^g/w^ex^p^aⁿ^s^ioⁿ^o^f^elig^ib^ility^uⁿ^d^er^SCHI^P^au^th^o^rⁱ^t^y^ar^e^f^e^deral^sh^{are of}^Medi^cai^{d ex}^pen^dⁱ^t^u^res^f^o^{r t}^h^{e n}^e^w^optⁱ^oⁿ^a^l
^s^.or^r^e^im^bu^rs^{ed by}^th^{e f}^e^{deral g}^o^v^e^rn^m^eⁿ^t^{at th}^{e en}^h^a^nc^e^d^co^v^e^r^a^g^e^g^r^o^u^p^.^Iⁿ^ad^d^itioⁿ^,^f^e^d^e^r^a^{l p}^a^y^m^en^{ts w}^ill^b^e^d^r^awⁿ
^le^ak^f^e^{deral m}^e^{dical as}^sⁱ^s^t^an^{ce percen}^tag^e^(E-^F^MA^P⁾^rate,^fr^om^th^{e open}^-^en^{ded Medicaid accou}ⁿ^t^an^{d n}^o^{t th}^{e ca}^p^p^e^d
^aⁿ^d^fund^{s b}^a^se^d^oⁿ^t^hⁱ^s^r^a^t^e^a^r^e^d^r^a^w^{n fr}^o^m^a^nnua^l^SC^HIP^accouⁿ^t^.
^://wiki^SCHI^P^allo^tm^en^{ts. T}^h^{e SCHI}^P^E-^FMA^P^b^u^ild^{s o}ⁿ^th^e
^h^ttp^Medi^cai^{d F}^M^A^P^{. T}^h^{e F}^M^A^P^f^o^rm^u^l^{a i}^s^desⁱ^gⁿ^e^{d t}^o
^p^r^o^v^id^{e a}^hⁱ^g^h^e^r^f^e^d^e^r^a^{l m}^a^tchⁱⁿ^g^r^a^{te f}^o^r^{states w}^ith
^low^e^{r av}^erag^{e per capita pers}^on^{al in}^com^e^{, co}^m^p^a^r^{ed to}
^th^{e n}^a^tion^a^{l av}^erag^e.
^Ef^f^ect^iv^{e Dat}^e^.^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^6062(d⁾^.^T^h^es^{e prov}^is^ion^s^{are ef}^f^ectiv^e^f^o^rⁱ^t^e^m^s
^an^{d s}^e^rvⁱ^ces^f^u^rnⁱ^s^h^e^{d on}^{or af}^t^e^{r Jan}^u^a^ry^{1, 2007.}
^De^mons^tr^a^t^{ion P}^r^oje^c^t^s^Re^ga^r^d^{ing Home}^-^{Medicaid h}^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed s}^e^rv^ic^e⁽^H^C^B^S)^S^ecti^oⁿ^6063.^T^h^e^con^f^eren^ce^ag^reem^en^{t es}^tablis^h^e^s^{a f}ⁱ^v^e^-
^d^Co^mmuⁿⁱ^t^y^-^B^ased^A^l^t^e^rn^at^iv^{es t}^o^w^aⁱ^v^ers^au^t^h^ori^{zed by}^S^ectⁱ^oⁿ^{1915(c) of}^t^h^{e S}^o^ci^al^y^ear^d^e^m^oⁿ^s^tr^atioⁿ^p^r^o^j^{ect in}^w^h^ich^u^p^to¹⁰^sta^t^e^s^c^o^u^l^d
^c^hⁱ^at^{ric Resident}^{ial T}^r^eat^ment^Facilit^{ies f}^o^r^Secu^r^ity^A^c^{t allo}^w^s^s^t^{ates to}^p^r^o^v^id^{e a b}^r^o^a^d^r^aⁿ^g^e^o^f^provⁱ^d^{e a broad ran}^g^e^of^h^o^m^e^-^an^{d com}^m^uⁿⁱ^t^y^-^b^as^ed
^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed s}^e^rv^ices^{to Medicaid}^ser^v^ices^to^ch^ild^r^eⁿ^w^h^o^w^o^u^l^d^o^t^h^e^r^w^{ise r}^e^q^u^ir^{e ser}^v^{ices in}
^ben^e^fⁱ^ciaries^w^h^{o w}^o^u^l^{d oth}^e^rw^is^{e n}^{eed th}^{e lev}^e^l^of^care^{a p}^s^y^c^hⁱ^atrⁱ^{c r}^e^sid^eⁿ^{tial tr}^eatm^eⁿ^t^f^acility^{. T}^h^{e d}^e^m^oⁿ^s^tr^atioⁿ

CRS-81
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^p^r^o^v^id^edⁱⁿ^{a h}^o^sp^{ital, n}^u^r^sin^g^f^acility^{, o}^rⁱⁿ^ter^m^ed^iate^w^o^u^l^d^test^th^{e ef}^f^ectiv^en^{ess o}^f^im^p^r^o^vⁱⁿ^g^o^r^m^aⁱⁿ^tainⁱⁿ^g^th^e
^car^e^f^acility^f^o^rⁱⁿ^dⁱ^vⁱ^d^u^{als w}^ith^m^eⁿ^t^{al r}^e^tar^d^atioⁿ⁽^I^CF-^ch^ild^’^s^f^uⁿ^c^tioⁿ^a^{l lev}^e^{l, an}^d^th^{e co}^st-^e^f^f^ectiv^eⁿ^e^{ss o}^f
^MR)^.^T^h^{e HCB}^S^w^a^iv^er^d^o^e^{s n}^o^t^allo^w^states^to^p^r^o^v^id^e^p^r^o^v^idⁱⁿ^g^th^{ese ty}^p^e^{s o}^f^ser^vⁱ^c^e^s^{as an}^alterⁿ^ativ^{e to}
^th^es^{e ty}^pes^of^prog^ram^s^as^an^altern^ativ^{e to a ps}^y^c^hⁱ^atric^ps^y^c^hⁱ^{atric res}ⁱ^den^{tial treatm}^eⁿ^t^s^e^rv^ices^.
^r^e^sid^eⁿ^{tial tr}^eatm^eⁿ^t^f^acility^f^o^r^ch^ild^r^eⁿ^w^ith^p^s^y^c^hⁱ^atrⁱ^c
^dⁱ^sab^ilities.
^St^at^{e Demo}ⁿ^s^t^r^at^ioⁿ^.^N^o^p^r^o^vⁱ^sⁱ^oⁿ^T^he^st^a^t^e^d^e^m^o^nst^r^a^tⁱ^o^{n p}^r^o^j^e^c^t^s^ma^y^p^r^o^vⁱ^d^e^a^va^rⁱ^e^t^y^o^f
^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed s}^e^rv^ices^as^an^al^t^e^rⁿ^ativ^{e to}
^p^s^y^c^hⁱ^atrⁱ^{c r}^e^sid^eⁿ^{tial tr}^eatm^eⁿ^t^f^{acilities. T}^h^{e p}^r^o^j^{ects m}^u^st
ⁱ^{ki/CRS-RL33251}^f^o^llo^w^th^{e ex}^istin^g^r^e^q^u^ir^em^en^{ts o}^f^th^e^HCB^S^w^a^iv^er^{, an}^d^b^e^bu^dg^{et n}^e^u^t^{ral. T}^h^{e s}^t^{ate m}^u^s^t^als^o^prov^{ide f}^o^{r an}ⁱⁿ^terim
^g/w^an^{d f}ⁱⁿ^a^{l ev}^alu^a^tion^s^th^{at m}^u^s^t^{be con}^d^u^c^{ted by}^an
^s^.orⁱⁿ^d^e^p^eⁿ^d^en^{t th}^ir^d^p^a^r^t^y^.
^le^ak
^Fo^llo^wⁱⁿ^g^th^{e d}^e^m^oⁿ^s^tr^atioⁿ^,^{a state m}^a^y^coⁿ^tin^u^e^to^p^r^o^v^id^e
^://wiki^h^o^m^e^an^{d c}^o^m^m^uⁿ^ity^-^b^as^{ed s}^e^rv^ices^{to th}^os^{e ch}^ildren^w^h^o
^h^ttp^a^r^{e en}^r^o^lledⁱⁿ^th^{e d}^e^m^oⁿ^s^tr^atioⁿ^p^r^o^j^{ect as o}^f^th^{e p}^r^o^j^e^c^t^’^s
^ter^mⁱⁿ^atioⁿ^d^a^te.
^Fe^de^r^a^{l E}^v^a^l^ua^{tion a}^{nd Re}^por^t.^N^o^p^r^o^vⁱ^sⁱ^oⁿ^.^T^h^{e Secretary}^is^requ^{ired to}^com^p^lete^e^v^a^l^ua^tⁱ^o^ns^o^f^t^h^e
^proj^{ect an}^{d report}^th^{e f}ⁱⁿ^dⁱⁿ^g^s^{to th}^{e P}^r^es^iden^{t an}^{d C}^oⁿ^g^r^es^s
^w^ithⁱⁿ¹²^m^oⁿ^t^h^s^o^f^co^m^p^letin^g^th^{e ev}^alu^a^tioⁿ^s^{. Of}^th^e
^am^ouⁿ^t^{appropriated f}^o^r^th^{e dem}^oⁿ^s^tration^,^th^{e Secretary}
^m^a^y^u^s^{e $1 m}^illion^each^y^{ear in}^th^{e FY2007-}^{FY2011 period}
^f^o^{r t}^hⁱ^s^pu^rpos^e.
^A^ppr^opr^ia^tion.^No^prov^is^ion^.^T^h^e^c^o^nfe^r^eⁿ^c^e^a^g^r^e^e^m^eⁿ^{t appropriates}^{$218 m}^illion^f^o^r
^F^Y^2007-^F^Y^{2011 t}^o^carry^ou^t^t^h^{e dem}^oⁿ^s^t^r^atⁱ^oⁿ^.^T^h^{e f}^uⁿ^d^s
^av^{ailable f}^o^{r th}^is^dem^oⁿ^s^tr^ation^total:^$21^m^illionⁱⁿ^FY2007;

CRS-82
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^{$37 m}^illionⁱⁿ^{FY2008; $49 m}^illionⁱⁿ^{FY2009, $53 m}^illion
ⁱⁿ^{FY2010; an}^{d $57 m}^illionⁱⁿ^FY2011.
^Fa^mi^l^y^-to-F^a^mⁱ^l^y^H^e^a^l^t^h^Iⁿ^for^m^a^tⁱ^oⁿ^Fam^ily^-^t^o^-^f^a^m^ily^h^ealth^cen^ter^s^p^r^o^v^id^{e in}^f^o^r^m^atioⁿ^an^d^S^ecti^oⁿ^6064.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t in}^creas^es^f^uⁿ^dⁱⁿ^g
^t^ers.^assistan^{ce to}^h^e^lp^f^a^m^{ilies o}^f^ch^ild^r^eⁿ^w^ith^sp^{ecial h}^ealth^uⁿ^d^er^th^{e SP}^RA^{NS p}^r^o^g^r^a^m^o^f^T^itle^V^o^f^th^e^So^{cial Secu}^r^ity
^{care n}^eedsⁿ^a^vⁱ^g^a^{te th}^{e s}^y^s^t^em^of^{care an}^{d m}^a^k^e^A^c^t^f^o^r^t^h^{e dev}^e^l^opm^en^t^an^{d s}^u^pport^ofⁿ^e^w^f^a^mⁱ^l^y^-^t^o-^f^a^mⁱ^l^y
^deci^sⁱ^on^s^abou^t^t^h^{e n}^eeds^an^{d av}^ai^l^a^bl^{e s}^u^pport^s^f^o^r^t^h^ei^r^h^e^a^lthⁱⁿ^f^o^r^m^atioⁿ^cen^ter^s^{. I}^t^ap^p^r^o^p^r^{iates an}^ad^d^itioⁿ^a^{l $}³
^c^h^ild^{. No}^p^r^o^v^isioⁿⁱⁿ^cu^r^r^eⁿ^t^law^sp^ecifⁱ^cally^m^illion^f^o^{r FY2007, $4 m}^illioⁿ^f^o^{r FY2008, an}^{d $5}^mⁱ^llioⁿ
^au^th^orizes^{a dedicated am}^ouⁿ^t^of^f^uⁿ^d^s^f^o^r^th^es^{e f}^a^m^ily^-^f^o^r^F^Y²⁰⁰⁹^f^o^{r th}^isⁿ^e^w^pu^rpos^{e. F}^o^{r each}^of^F^Y^s^{2010 an}^d
^t^o^-^f^am^ily^h^ealthⁱⁿ^f^o^r^m^atioⁿ^cen^ter^s^{. Ho}^w^e^v^e^r^,^sin^c^e^2011,^th^e^con^f^eren^ce^ag^reem^en^{t au}^th^orizes^{$5 m}^illion^f^o^{r th}^is
ⁱ^{ki/CRS-RL33251}²⁰⁰²^,^t^h^e^D^e^p^a^r^t^m^eⁿ^t^o^f^H^e^a^l^t^h^aⁿ^d^H^u^m^aⁿ^S^e^r^vⁱ^ces⁽^H^HS)^h^a^{s aw}^ar^d^e^d^ap^p^r^o^x^im^ately^$⁶^.⁹^m^illioⁿ^to^p^u^r^p^o^s^{e. Fu}ⁿ^d^{s w}^o^u^l^d^r^e^m^aⁱⁿ^av^ailab^l^{e u}ⁿ^{til ex}^p^eⁿ^d^ed^.
^g/w^dev^e^lo^p^t^h^es^{e in}^f^o^rm^ation^cen^tersⁱⁿ^{36 s}^t^ates^uⁿ^d^er^T^h^{e p}^u^r^p^o^s^{e o}^f^th^{e f}^a^m^ily^-^t^o^-^f^a^m^ily^h^ealt^hⁱⁿ^f^o^r^m^atioⁿ
^s^.or^v^a^rⁱ^o^u^{s p}^r^o^g^r^a^m^au^th^o^r^{ities in}^clu^dⁱⁿ^g⁽¹⁾^Sp^ecial^cen^ter^sⁱ^s^to^{: (}¹⁾^{assist f}^a^m^{ilies o}^f^ch^ild^r^eⁿ^w^ith^dⁱ^sab^ilities
^le^ak^P^r^oj^ects^of^R^e^gⁱ^on^al^an^{d Nation}^a^{l Sig}ⁿⁱ^fⁱ^can^{ce P}^r^og^ram^{or s}^p^{ecial h}^ealth^{care n}^eeds^{to m}^a^k^eⁱⁿ^f^o^rm^{ed ch}^oices^abou^t
^(SP^R^A^N^{S) of}^th^{e Matern}^{al an}^d^C^h^{ild Serv}^ices^B^l^ock^h^e^a^l^t^h^{care s}^o^as^t^o^prom^ot^{e g}^{ood t}^r^eat^m^eⁿ^t^deci^sⁱ^on^s^,^cos^t^-^ef^f^ectiv^en^es^s^,^an^{d im}^prov^{ed h}^ealth^ou^tcom^es^{for s}^u^ch
^://wiki^Gr^an^{t (}^T^{itle V o}^f^th^{e So}^{cial Secu}^rⁱ^t^y^A^c^t)^o^p^e^r^a^ted^b^y
^h^ttp^th^{e Health}^R^e^s^o^u^r^ces^Serv^ices^A^d^mⁱⁿⁱ^s^t^ration^(HR^S^A⁾^;^ch^ild^r^eⁿ^;⁽²⁾^p^r^o^v^id^{e in}^f^o^r^m^atioⁿ^r^e^g^a^r^dⁱⁿ^g^th^{e h}^ealth^car^eⁿ^eed^s^o^f^{, an}^d^r^e^so^u^r^{ces av}^ailab^l^{e f}^o^r^ch^ild^r^eⁿ^w^ith^dⁱ^sab^ilities
^{(2) th}^{e R}^{eal C}^h^{oice Sy}^s^t^em^s^C^h^an^{ge g}^r^an^{t prog}^ram^{or s}^p^{ecial h}^ealth^ca^r^eⁿ^eeds^;^{(3) iden}^tif^y^s^u^cces^s^f^u^l^h^ealth
^operat^e^{d by}^t^h^e^Ce^nt^ers^f^o^{r Medi}^{care an}^{d Medi}^cai^d^delⁱ^v^ery^m^odel^s^;^{(4) dev}^e^l^{op a m}^odel^f^o^{r co}^l^l^aboratⁱ^oⁿ
^S^e^rvⁱ^ces^(C^MS^);^an^{d (3) a}^on^e-^y^{ear direct con}^g^r^es^sⁱ^on^al^b^e^tw^een^f^a^m^{ilies o}^f^su^ch^ch^ild^r^eⁿ^an^d^h^ealth^p^r^o^f^essioⁿ^als;
^ap^p^r^o^p^r^iatioⁿ^to^an^o^r^g^aⁿⁱ^zatioⁿⁱⁿ^I^o^w^a^.^F^e^d^e^r^a^l⁽⁵⁾^p^r^o^vⁱ^d^e^trainⁱⁿ^g^an^{d g}^uⁱ^dan^{ce w}^ith^reg^a^{rd to th}^{e care of}
^f^uⁿ^dⁱⁿ^g^f^o^r^th^{ese p}^r^o^j^{ects is tim}^e-^lim^ited^.^Ex^cep^{t f}^o^r^th^e^su^ch^ch^ild^ren^;^an^d⁽⁶^{) co}ⁿ^d^u^c^{t o}^u^treach^activ^{ities to}^th^e
^on^e-^y^{ear direct appropriation}^,^s^t^{ate proj}^ects^h^a^v^e^f^a^m^ilie^s^o^f^s^u^c^h^c^hⁱ^l^d^r^eⁿ^,^h^e^a^l^t^h^p^r^o^f^e^s^sⁱ^oⁿ^a^l^s^,^s^c^h^o^o^l^s^,^aⁿ^d
^g^eⁿ^e^rally^been^f^uⁿ^d^{ed f}^o^{r a th}^ree-^o^r^f^o^u^r^-^y^{ear period.}^o^t^h^e^r^ap^p^r^o^p^r^{iate en}^{tities an}^dⁱⁿ^dⁱ^vⁱ^d^u^{als. T}^h^{e f}^a^m^ily^-^t^o^-
^HRSAⁱⁿ^ten^d^{s to}^f^uⁿ^d^ad^d^itioⁿ^a^{l f}^a^m^ily^-^t^o^-^f^a^m^ily^h^ealth^f^a^m^ily^h^ealthⁱⁿ^f^o^r^m^atioⁿ^cen^ter^w^o^u^l^d^b^e^staf^f^e^d^b^y^f^a^m^ilies
ⁱⁿ^f^o^r^m^atioⁿ^cen^ter^s^aw^ar^dⁱⁿ^g^u^p^to^$²^.⁴^m^illioⁿ^to^six^w^h^{o h}^a^v^e^ex^pertis^{e in}^pu^{blic an}^{d priv}^{ate h}^ealth^{care s}^y^s^t^em^s
^proj^ect^s^f^o^{r a f}^o^u^r^-^y^{ear peri}^{od s}^t^artⁱⁿ^gⁱⁿ^F^Y^2006.^an^{d by}^h^eal^t^h^prof^es^sⁱ^on^al^s^.

CRS-83
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^T^h^{e Secr}^etar^y^is^r^e^q^u^ir^ed^to^d^e^v^e^lo^p^f^a^m^ily^-^t^o^-^f^a^m^ily^h^ealth
ⁱⁿ^f^o^rm^atⁱ^oⁿ^cen^t^e^rsⁱⁿ^at^l^eas^t²⁵^s^t^at^esⁱⁿ^F^Y^{2007, 40 s}^t^at^es
ⁱⁿ^F^Y^{2008, an}^{d al}^l^s^t^at^esⁱⁿ^F^Y^2009.
^Rest^orat^{ion of}^M^e^{dicaid Eligib}^ilit^y^f^o^r^SSI^an^d^Medⁱ^caid^elig^ib^ility^{is ef}^f^ecti^v^e^oⁿ^th^{e later}^o^f^S^ecti^oⁿ^6065.^T^h^{e ag}^r^eem^en^{t ex}^ten^d^{s Med}ⁱ^caid^elig^ib^ility^to
^ain^{SSI Ben}^e^fⁱ^ciaries.⁽¹⁾^th^{e f}ⁱ^r^s^{t d}^a^y^o^f^th^{e m}^oⁿ^t^h^f^o^llo^wⁱⁿ^g^th^{e d}^a^t^e^t^h^e^pers^on^s^w^h^{o are u}ⁿ^d^{er ag}^{e 21 an}^{d w}^h^{o are}^elig^{ible f}^o^{r SSI,}
^ap^p^licatioⁿ^{is f}^iled^,^o^r⁽²⁾^th^{e f}ⁱ^r^s^{t d}^a^y^o^f^th^{e m}^oⁿ^t^h^ef^f^ectiv^{e o}ⁿ^th^{e later}^o^f^{: (}¹⁾^th^{e d}^a^te^th^e^ap^p^licatioⁿ^{is f}^iled^,
^f^o^llo^wⁱⁿ^g^th^{e d}^a^{te th}^{at th}^{e in}^dⁱ^vⁱ^d^u^{al is d}^e^ter^mⁱⁿ^ed^o^r⁽²⁾^th^{e d}^a^{te SSI}^elig^ib^ility^{is g}^r^an^ted^.^T^h^{is p}^r^o^v^isi^oⁿ^is
^elig^ib^le.^ef^f^ectiv^{e on}^{e y}^{ear af}^{ter th}^{e date of}^en^actm^eⁿ^t^.
ⁱ^{ki/CRS-RL33251}
^g/w
^s^.or
^le^ak
^://wiki
^h^ttp
Subchapter B — Money Follows the Person Rebalancing Demonstration.
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^M^one^y^Follow^s^the^P^e^r^s^{on De}^mons^tr^a^t^ion.^States^c^aⁿ^p^r^o^v^ide^a^v^a^riety^of^h^o^m^e^an^{d com}^m^uⁿ^ity^-^Se^c^tⁱ^oⁿ^6071(a).^T^h^{e con}^f^eren^{ce ag}^reem^en^{t au}^th^orizes^t^h^e
^bas^e^d^s^e^rv^ices^{to Medicaid ben}^e^fⁱ^ciaries^w^h^{o n}^{eed lon}^g^-^Secretary^t^o^c^oⁿ^d^u^c^t^a^dem^oⁿ^s^tra^tion^proj^{ect in}^s^t^ates^{to (1)}
^term^{care. Som}^e^o^f^t^h^e^s^e^s^e^rv^ices^m^a^y^{be of}^f^e^redⁱⁿ^creas^{e th}^{e u}^s^e^o^f^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed care in}^s^t^ead

CRS-84
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^s^t^atew^{ide as}^{part of}^th^{e Me}^{dicaid s}^t^{ate plan}^(e.g^{., h}^o^m^e^o^fⁱⁿ^stitu^tioⁿ^s^b^y^r^e^lo^catin^gⁱⁿ^dⁱ^vⁱ^d^u^{als f}^r^o^mⁱⁿ^stitu^tioⁿ^sⁱⁿ^to
^h^ealth^s^e^rv^ices^aⁿ^d^p^e^rs^on^{al care s}^e^rv^ices^{). Oth}^e^r^th^{e com}^m^uⁿⁱ^t^y^{, (2) ex}^pan^d^th^e^s^t^ate’^s^capacity^{to prov}^ide
^se^r^vⁱ^c^e^s^m^a^y^b^e^o^ffe^r^e^d^t^h^r^o^{ugh a}^ho^m^e^aⁿ^d^c^o^m^m^uni^t^y^-^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed lon}^g^-^term^car^e^s^e^rv^ices^f^o^r
^bas^e^d^s^e^rvⁱ^ces^(H^C^B^S⁾^w^aⁱ^v^{er u}ⁿ^d^{er S}^ectⁱ^oⁿ^1915(c)^ofⁱⁿ^dⁱ^vⁱ^d^u^{als w}^h^o^ch^o^o^s^{e to}^tr^an^sitioⁿⁱⁿ^to^th^{e co}^m^m^uⁿ^ity^{; an}^d
^th^{e Social Secu}^rity^A^c^t.^T^h^{e HC}^B^S^w^a^iv^ers^allow^s^t^ates⁽³^{) to}^en^su^{re th}^{at p}^r^o^ced^u^r^{es are in}^p^l^{ace to}^p^r^o^v^id^{e q}^u^ality
^t^o^provⁱ^d^e^{a broad ran}^g^e^of^h^o^m^e^an^d^com^m^uⁿⁱ^t^y^-^b^as^ed^assu^r^aⁿ^{ce an}^d^coⁿ^tin^u^o^u^s^q^u^ality^im^p^r^o^v^em^en^{t, th}^{at is}^at^least
^s^e^rv^ices^(e.g^{., res}^p^{ite, adu}^{lt day}^{care) to in}^divⁱ^du^als^w^h^o^com^p^{arable to oth}^e^{r Medicaid h}^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^ed
^w^o^u^l^d^o^t^h^e^r^w^{ise r}^e^q^u^ir^{e th}^{e lev}^e^{l o}^f^car^{e p}^r^o^v^id^edⁱⁿ^s^e^rv^ices^.
^cer^tain^ty^p^e^{s o}^fⁱⁿ^stitu^tioⁿ^s⁽ⁱ^{.e., a h}^o^sp^{ital, n}^u^r^sin^g
^f^acility^o^rⁱⁿ^ter^m^ed^{iate car}^{e f}^acility^f^o^rⁱⁿ^dⁱ^vⁱ^d^u^als^w^ith
ⁱ^{ki/CRS-RL33251}^m^eⁿ^t^al^ret^a^rdatⁱ^on⁽^I^C^F^-^M^R^{)). A}^s^part^of^t^h^{e HC}^BS^w^a^iv^er^{, states h}^a^v^e^th^{e ab}^ility^to^d^e^fⁱⁿ^e^th^e^c^o^v^e^r^e^d
^g/w^s^e^rvⁱ^ces^an^{d s}^p^ecⁱ^f^y^a^t^a^rg^et^popu^l^a^tⁱ^oⁿ^(e.g^{., el}^derl^y
^s^.orⁱⁿ^dⁱ^vⁱ^d^u^als)^.^{States m}^a^y^also^lim^{it th}^{e n}^u^m^b^e^r^o^f^w^a^iv^er
^le^ak^p^a^r^ticip^an^ts.
^://wiki^Medⁱ^caid^b^eⁿ^e^fⁱ^ciar^{ies w}^h^o^ar^{e r}^e^sid^eⁿ^t^{s o}^f^anⁱⁿ^stitu^tioⁿ
^h^ttp⁽^s^uc^{h a}^s^a^nur^si^{ng ho}^m^e⁾^aⁿ^d^w^h^o^w^o^ul^d^lⁱ^k^e^t^o^l^e^a^v^e
^th^{at in}^stitu^tioⁿ^w^o^u^l^d^b^e^en^titled^to^receiv^e^th^o^s^e
^Medica^{id s}^e^rv^ices^cov^e^red^by^th^{e Medicaid s}^t^{ate plan}^.
^How^e^v^e^{r, in}^di^vi^d^u^als^m^a^yⁿ^o^{t be able to acces}^s^th^e
^bro^a^{der ran}^g^e^of^s^e^rv^ices^uⁿ^d^{er an}^HC^B^S^w^a^iv^er
^b^ecau^{se m}^aⁿ^y^{states h}^a^v^e^w^a^itin^g^lists.
^St^at^{e Demo}ⁿ^s^t^r^at^ioⁿ^s^.^N^o^p^r^o^vⁱ^sⁱ^oⁿ^S^t^a^t^e^s^a^w^a^r^{ded a dem}^oⁿ^s^tration^w^o^u^l^d^receiv^e^add^itioⁿ^a^l
^f^e^{deral f}^uⁿ^dⁱⁿ^g^f^o^{r th}^e^cos^t^s^of^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^ed,
^lon^g^-^term^{care s}^e^rv^ices^(uⁿ^d^er^a^HC^B^S^w^a^iv^{er an}^{d/or th}^e
^s^t^{ate plan}^{) f}^o^{r 12 m}^oⁿ^t^h^s^f^o^llowⁱⁿ^g^{a dem}^oⁿ^s^trati^oⁿ
^p^a^r^ticip^an^t’^{s tr}^an^sitioⁿ^f^r^o^m^anⁱⁿ^s^titu^tioⁿⁱⁿ^to^th^e
^c^o^m^m^uni^t^y^.^Iⁿ^a^gi^ve^{n fi}^sc^a^l^y^e^a^r^,^fundⁱ^ng^w^o^ul^d^b^e^c^a^p^p^e^d

CRS-85
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^{at th}^{e am}^ouⁿ^t^of^{a s}^t^ate’^s^g^r^an^t^a^w^a^r^{d. A}^f^{ter th}^{e 12 m}^oⁿ^t^h^s
^of^g^r^an^t^fundiⁿ^g^,^t^h^{e s}^t^at^{e w}^o^u^l^{d be requ}ⁱ^r^{ed t}^o^con^tⁱⁿ^u^e
^p^r^o^vⁱ^dⁱ^{ng se}^r^vⁱ^c^e^s^t^h^r^o^{ugh a}^M^e^dⁱ^c^aⁱ^d^ho^m^e^aⁿ^d^c^o^m^m^uni^t^y^-
^bas^e^{d l}^oⁿ^g^-^t^e^rm^{care prog}^ram^.
^{Eligible Indiv}ⁱ^duals.^No^p^r^o^v^isioⁿ^.^Iⁿ^dⁱ^vⁱ^d^u^{als m}^a^y^p^a^r^ticip^{ate in}^th^e^d^e^m^oⁿ^s^tr^atioⁿ^if^th^ey^m^eet
^th^{e f}^o^llo^wⁱⁿ^g^cr^iterⁱ^a:⁽¹⁾^th^ey^ar^{e r}^e^sid^eⁿ^t^{s o}^f^{a h}^o^sp^ital,
ⁿ^u^r^sin^g^f^acility^{, I}^C^F-^{MR, o}^r^anⁱⁿ^stitu^tioⁿ^f^o^r^m^eⁿ^t^al^dⁱ^sease
⁽^I^MD)⁽^b^u^t^oⁿ^ly^to^th^{e ex}^ten^t^th^{at th}^{e I}^M^{D b}^eⁿ^e^f^it^is^o^f^f^e^r^e^d
^as^{part of}^th^{e ex}ⁱ^s^tⁱⁿ^g^s^t^ate^{Medicaid plan}^{); (2) th}^ey^h^a^v^e
ⁱ^{ki/CRS-RL33251}^r^e^sⁱ^d^e^dⁱⁿ^th^{e f}^acility^f^o^rⁿ^o^{less th}^an^six^m^oⁿ^t^h^s^o^r^f^o^r^a^lon^g^e^{r tim}^{e period s}^p^ecifⁱ^{ed by}^th^e^s^t^ate^(u^p^{to a m}^a^xⁱ^m^u^m^of
^g/w^tw^{o y}^ears⁾^;⁽³^{) th}^ey^{are receiv}ⁱⁿ^g^{Medicaid ben}^e^f^its^f^o^{r th}^e
^s^.or^ser^v^{ices in}^th^{is f}^acility^{; (}⁴⁾^th^ey^wⁱ^{ll co}ⁿ^tin^u^e^to^r^e^q^u^ir^{e th}^e
^le^ak^lev^e^{l o}^f^car^{e o}^f^th^e^f^a^cility^b^u^{t f}^o^r^th^{e p}^r^o^v^isioⁿ^o^f^HCB^S
^s^e^rv^ices^.
^://wiki
^h^ttp^A^f^ter^r^e^lo^catin^gⁱⁿ^to^th^{e co}^m^m^uⁿ^ity^{, th}^eⁱⁿ^dⁱ^vⁱ^d^u^{al m}^u^st
^resⁱ^{de i}ⁿ^on^{e of}^t^h^{e f}^o^l^l^o^wⁱⁿ^g^:^{a h}^o^m^e^owⁿ^e^{d or l}^e^a^s^e^d^by
^th^{e in}^dⁱ^vⁱ^d^u^{al o}^r^hⁱ^s/h^e^r^f^a^m^ily^{; an}^ap^ar^tm^en^{t w}^ith^an
ⁱⁿ^dⁱ^vⁱ^d^u^{al lease in}^w^h^ich^th^{e in}^dⁱ^vⁱ^d^u^{al (}^o^r^f^a^m^ily⁾^h^a^s
^dom^ain^an^{d con}^t^{rol ov}^{er th}^{e s}^p^{ace; or a com}^m^uⁿ^ity^-^b^a^s^ed
^r^e^sⁱ^d^e^ntⁱ^a^l^se^t^tⁱ^{ng w}^h^e^r^e^no^m^o^r^e^t^h^aⁿ^fo^ur^unr^e^l^a^t^e^d
ⁱⁿ^di^vⁱ^du^al^s^resⁱ^de.
^St^at^{e A}^p^p^licat^ioⁿ^.^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^6071(c)^{. T}^h^{e s}^t^ate’^s^application^f^o^r^a^dem^oⁿ^s^tration
^proj^{ect is}^requ^ir^e^d^t^oⁱⁿ^clu^d^{e, at a m}ⁱⁿⁱ^m^u^m^,^th^{e f}^o^llowⁱⁿ^g
ⁱⁿ^f^o^rm^ation^:⁽¹⁾^a^s^s^u^ran^{ce th}^{at th}^{e proj}^{ect w}^a^s^dev^e^loped
^aⁿ^d^w^{ill b}^e^o^p^e^r^a^te^d^thr^o^{ugh a}^p^u^b^lic^inp^u^{t p}^r^o^c^e^{ss; (}²⁾
^assu^r^aⁿ^{ce th}^{at th}^{e p}^r^o^j^ect^w^ill^o^p^e^r^a^teⁱⁿ^coⁿ^j^uⁿ^c^tioⁿ^w^ith^an

CRS-86
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^ex^is^tin^g^Medicaid^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed prog}^ram^;⁽³⁾
^th^{e d}^u^r^a^tioⁿ^o^f^th^{e p}^r^o^j^{ect, w}^h^ich^m^u^{st b}^e^f^o^r^a^t^l^e^{ast tw}^o
^con^s^e^c^u^tiv^{e f}ⁱ^s^{cal y}^earsⁱⁿ^{a f}ⁱ^v^e^-^y^{ear period s}^t^artin^gⁱⁿ
^F^Y^2007;^{(4) t}^h^{e s}^e^rvⁱ^{ce area, w}^hⁱ^c^h^m^a^y^be^s^t^at^ewⁱ^d^{e or l}^e^s^s^-
^t^h^aⁿ^-s^tatewⁱ^{de; (5) th}^{e targ}^{et g}^r^ou^ps^an^{d th}^{e proj}^ected
ⁿ^u^m^b^e^r^to^b^e^en^r^o^lled^an^d^th^{e estim}^ated^to^tal^ex^p^eⁿ^d^itu^r^e^{s f}^o^r
^each^fⁱ^s^{cal y}^{ear; (6) as}^s^u^ran^{ce tha}^t^t^h^e^proj^{ect def}^e^rs^to
ⁱⁿ^dⁱ^vⁱ^d^u^{al ch}^oⁱ^{ce an}^d^th^at^th^e^state^w^{ill co}ⁿ^tin^u^e^ser^v^{ices f}^o^r
^p^a^r^ticip^an^ts^af^ter^th^{e d}^e^m^oⁿ^s^tr^atioⁿ^en^d^s^{, as lo}ⁿ^g^{as th}^e^state
^o^f^f^e^r^s^su^ch^ser^v^{ices an}^d^th^{e in}^dⁱ^vⁱ^d^u^{al r}^e^m^aⁱⁿ^{s elig}^ib^le;⁽⁷⁾
ⁱ^{ki/CRS-RL33251}ⁱⁿ^f^o^rm^ation^on^recen^{t Medicaid ex}^pen^d^itu^res^f^o^{r lon}^g^-^term^{care an}^{d h}^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^e^d^s^e^rv^ices^th^{e y}^ear
^g/w^precedin^g^th^{e dem}^oⁿ^s^tration^,^an^{d propos}^{ed m}^e^th^o^d^s^to
^s^.orⁱⁿ^creas^{e th}^{e s}^t^ate’^sⁱⁿ^v^e^s^t^m^eⁿ^tⁱⁿ^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^ed
^le^ak^ser^v^{ices; (}⁸⁾^m^e^th^o^d^s^th^{e state w}^{ill u}^s^{e to}^elimⁱⁿ^at^e^b^a^r^rⁱ^er^s
^://wiki^to^p^a^yⁱⁿ^g^f^o^r^l^oⁿ^g^-^t^e^r^m^car^{e ser}^v^{ices f}^o^r^p^a^r^ticip^an^{ts in}^th^e^settin^g⁽^s)^o^f^th^eir^ch^oⁱ^{ce; (}⁹⁾^assu^r^aⁿ^ce^th^at^th^{e state w}^{ill m}^eet
^h^ttp^{a m}^aⁱⁿ^ten^aⁿ^{ce of}^ef^f^o^{rt f}^o^{r Medicaid HC}^B^S^ex^pen^d^itu^res^an^d
^w^{ill co}ⁿ^tⁱⁿ^u^e^to^o^p^e^r^a^{te a HCB}^S^w^a^iv^er^th^{at m}^{eets th}^e
^statu^t^o^r^y^r^e^q^u^ir^em^en^{ts f}^o^r^co^st-ⁿ^eu^tr^ality^.
^A^s^t^{ate is}^als^o^requ^{ired to ident}ⁱ^f^y^aⁿ^y^requ^es^{ted w}^a^iv^ers^of
^M^e^dⁱ^caid^law^;^d^e^scrⁱ^b^e^{a p}^l^an^f^o^r^q^u^ality^assu^r^aⁿ^ce^aⁿ^d
ⁱ^m^prov^em^en^{t of}^HC^B^S^s^e^rv^ices^uⁿ^d^{er Medicaid;}ⁱ^f
^ap^p^licab^{le, th}^e^p^r^o^{cess f}^o^r^p^a^r^ticip^an^{ts to}^self^-^d^ir^{ect h}ⁱ^{s o}^r^h^e^r
^owⁿ^s^e^rvⁱ^ces^(m^eetⁱⁿ^g^s^t^an^dards^d^e^scri^{bed bel}^o^w⁾^;^an^d
^co^m^p^lian^c^e^w^ith^r^e^p^o^r^{ts an}^d^ev^alu^a^tioⁿ^,^{as r}^e^q^u^ir^ed^b^y^th^e
^Secretary^.
^Req^uⁱ^remen^t^{s f}^o^{r Self}^-^D^irect^ed^Serv^ices.^No^p^r^o^v^isioⁿ^.^I^f^a^state^allo^w^s^d^e^m^oⁿ^s^tr^atioⁿ^p^a^r^ticip^an^{ts to}^self^-^d^ir^{ect th}^eir

CRS-87
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^ed^lon^g^-^term^care^s^e^rv^ices^{, th}^{e s}^t^ate
^m^u^s^tⁱⁿ^clu^d^{e th}^{e f}^o^llowⁱⁿ^g^:^{(1) an}^as^s^e^s^s^m^eⁿ^t^of^th^e
ⁱⁿ^dⁱ^vⁱ^d^u^al’^sⁿ^eed^s,^cap^ab^{ilities an}^d^p^r^ef^er^en^{ces; (}²⁾^{a ser}^v^ice
^p^l^an^th^{at is d}^e^v^e^lo^p^e^d^j^oⁱⁿ^t^l^y^w^ith^th^{e in}^dⁱ^vⁱ^d^u^{al (}^o^r^an
^au^th^{orized repres}^en^tativ^e).
^If^{a s}^t^{ate allow}^s^f^o^{r an}ⁱⁿ^divⁱ^du^{alized bu}^dg^e^t^w^hⁱ^c^h^is^th^e
^v^a^lu^{e of}^th^e^s^e^lf^-^d^irected^s^e^rv^ices^,^th^e^s^t^{ate m}^u^s^t^des^c^{ribe th}^e
^m^e^th^{od u}^s^{ed to s}^e^{t th}^e^bu^dg^et,^defⁱⁿ^e^a^proces^s^{to adj}^u^s^t^th^e
^bu^dg^{et to ref}^l^{ect ch}^an^g^e^sⁱⁿⁱⁿ^di^vi^d^u^als^as^s^e^s^s^m^en^{t an}^d
ⁱ^{ki/CRS-RL33251}^s^e^rv^{ice plan}^s^,^an^{d ev}^alu^a^{te ex}^pen^d^itu^res^uⁿ^d^{er th}^{e bu}^dg^et.
^g/w^Secret^ary^’^{s A}^w^ard^o^f^Co^mp^et^it^iv^{e G}^r^an^t^s^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^6071(d⁾^.^Iⁿ^ad^d^itioⁿ^to^ev^alu^a^tiⁿ^g^t^h^{e m}^e^r^{its o}^f^a
^s^.or^d^W^a^iv^ers.^state’^{s ap}^p^licatioⁿ^,ⁱⁿ^selectin^g^d^e^m^oⁿ^s^tr^atioⁿ^p^r^o^j^ec^t^s^,^th^e
^le^ak^Secretary^is^requ^{ired to con}^s^id^er^aⁿ^a^tioⁿ^a^l^b^a^lan^{ce o}^f^tar^g^et
^g^r^ou^ps^an^{d g}^e^og^raphⁱ^c^di^s^t^ri^bu^tⁱ^oⁿ^an^{d t}^o^gⁱ^v^e^{a pref}^e^r^eⁿ^ce
^://wiki^to^{states th}^at^c^o^v^e^r^m^u^ltip^{le g}^r^o^u^p^s^o^r^o^f^f^e^r^p^r^o^j^ect
^h^ttp^partⁱ^cⁱ^p^an^t^s^t^h^{e opport}^uⁿⁱ^t^y^t^o^s^e^l^f^-^dⁱ^r^ect^t^h^ei^{r s}^e^rvⁱ^ces^.
^T^h^{e Secretary}^is^als^o^au^th^orized^to^w^a^iv^{e cer}^tain^sectioⁿ^s^o^f
^Medⁱ^caid^law^to^ach^iev^e^th^{e d}^e^m^oⁿ^s^tr^atioⁿ^’^{s p}^u^r^p^o^s^e.
^Conditiona^{l A}^ppr^ov^a^l^{of Out-Ye}^a^r^Gr^aⁿ^ts^.^N^o^p^r^o^vⁱ^sⁱ^oⁿ^T^o^q^u^alif^y^f^o^r^g^r^aⁿ^t^a^w^a^r^d^s^a^f^t^e^r^y^e^a^r^oⁿ^e^,^s^t^a^t^e^s^w^ill^b^e
^requ^{ired to m}^{eet n}^u^m^{erical ben}^c^h^m^ark^s^m^eas^u^rⁱⁿ^g^th^e
ⁱⁿ^creas^{ed i}ⁿ^v^e^s^t^m^eⁿ^tⁱⁿ^s^e^rvⁱ^ces^uⁿ^d^{er t}^hⁱ^s^propos^a^l^an^{d t}^h^e
ⁿ^u^m^b^e^r^o^fⁱⁿ^dⁱ^vⁱ^d^u^{als tr}^an^sitioⁿ^e^dⁱⁿ^to^th^{e co}^m^m^uⁿ^ity^.
^States^wⁱ^l^l^als^o^{be requ}^{ired to dem}^oⁿ^s^{trate th}^{at th}^ey^are
^as^s^u^rin^g^th^{e h}^ealth^a^{nd w}^e^lf^{are of}^proj^{ect participan}^ts^{. For}
^s^t^ates^th^{at do n}^o^{t m}^{eet th}^es^{e requ}^irem^en^ts^{, th}^{e Secretary}^w^ill
^b^e^r^e^q^u^ir^ed^to^r^e^scin^d^th^{e g}^r^an^{t aw}^ar^d^f^o^r^f^u^tu^r^e^g^r^an^t^p^e^rⁱ^o^d^s

CRS-88
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^aⁿ^d^w^{ill b}^e^a^llo^w^e^d^to^r^e^-a^w^a^r^d^unuse^d^fund^ing.
^Pay^m^en^t^s^t^o^St^at^{es/ Carry}^o^v^{er o}^f^Un^u^s^e^d^{Medicaid ex}^pen^d^itu^res^f^o^r^s^e^rv^ices⁽ⁱⁿ^c^lu^din^g^th^e^S^ecti^oⁿ^{6071 (e).}^T^h^o^s^{e s}^t^ates^aw^{arded a dem}^oⁿ^s^tration
^aⁿ^{t A}^m^ounts^.^{Medicaid s}^t^{ate plan}^an^{d HC}^B^S^w^a^iv^{er) are}^ge^nerally^w^o^ul^d^receiv^e^an^en^h^aⁿ^{ced FMA}^P^{rate (ref}^e^{rred to as}^th^e
^s^h^{ared betw}^een^th^{e f}^e^{deral an}^{d s}^t^ate^g^o^v^e^rn^m^eⁿ^t^s^.^T^h^e^`M^F^P^-e^nha^nc^e^d^F^M^AP^’)^e^q^ua^l^t^o^th^{e cu}^rren^{t FMA}^P^rate^f^o^r
^s^p^ecifⁱ^{c f}^e^{deral s}^h^a^r^e^o^f^{a s}^t^{ate is}^bas^e^{d on}^th^{e s}^t^ate’^s^th^e^s^t^ateⁱⁿ^creas^ed^by^{a n}^u^m^{ber of}^percen^tag^e^poin^t^s^equ^a^l^to
^f^e^{deral m}^e^di^c^a^l^as^sⁱ^s^t^an^{ce percen}^tag^e^(FMA^P⁾^rate^50%^of^t^h^{e di}^f^f^e^ren^{ce bet}^w^een^100%^an^{d t}^h^{e n}^o^rm^al^F^M^A^P
^w^hⁱ^c^h^can^ran^g^e^f^r^om^50%^t^o^83%^.^{rate. How}^e^v^e^{r, in}ⁿ^o^cas^{e can}^th^{e FMA}^P^{rate ex}^{ceed 90% f}^o^r
^{a state. T}^h^{e state w}^{ill receiv}^e^th^{e MFP}^-^en^h^aⁿ^ced^FMA^P^f^o^r
^t^h^{e cos}^t^s^of^h^o^m^e^an^{d com}^m^uⁿⁱ^t^y^-^b^as^{ed, l}^ong-t^e^r^m^care
ⁱ^{ki/CRS-RL33251}^se^r^vⁱ^c^e^s^fo^r¹²^m^o^nt^{hs fo}^l^l^o^wⁱⁿ^{g a}^d^e^m^o^nst^r^a^tⁱ^oⁿ^p^a^r^ticip^an^t’^{s tr}^an^s^itioⁿ^f^r^o^m^anⁱⁿ^stitu^tioⁿⁱⁿ^to^th^e
^g/w^co^m^m^uⁿ^ity^.
^s^.or
^le^ak^P^a^y^m^en^ts^f^o^r^ho^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed lon}^g^-^term^care
^ser^v^{ices u}ⁿ^d^er^th^{e d}^e^m^oⁿ^s^tr^atioⁿ^p^r^o^j^{ect w}^o^u^l^d^b^eⁱⁿ^lieu^o^f
^://wiki^pay^m^en^t^f^o^{r ex}^pen^dⁱ^t^u^res^t^h^at^cou^l^d^ot^h^e^rwⁱ^s^{e be pai}^d^f^o^{r by}
^h^ttp^M^e^dⁱ^c^aⁱ^d^.^H^o^w^e^ve^r^,ⁱ^f^a^st^a^t^e^e^xha^ust^sⁱ^t^s^gr^aⁿ^t^fundⁱ^{ng i}ⁿ^a
^particu^l^{ar y}^ear^,^t^h^e^s^t^{ate is}ⁿ^o^{t prev}^en^{ted f}^r^om^u^sⁱⁿ^g
^M^e^dⁱ^{caid to pay}^f^o^{r h}^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed lon}^g^-^term
^{care s}^e^rv^ices^{. Fin}^a^lly^{, a s}^t^{ate th}^{at does}ⁿ^o^t^us^e^a^l^l^of^its
^f^uⁿ^dⁱⁿ^gⁱⁿ^{a g}ⁱ^v^eⁿ^fⁱ^{scal y}^{ear w}^{ill co}ⁿ^tin^u^e^to^h^a^v^e^{access to}
^t^h^a^t^fundⁱ^{ng fo}^r^fo^ur^sub^s^e^q^ue^nt^fi^sc^a^l^y^e^a^r^s.
^Q^u^alit^y^A^ssu^ran^{ce an}^d^Imp^r^o^v^emen^t^;^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ⁶⁰⁷¹⁽^f^{). T}^h^{e Secretary}^is^requ^{ired to prov}^ide^f^o^r
ⁿⁱ^{cal A}^ssist^an^{ce an}^d^O^v^ersig^h^t^.^techⁿⁱ^{cal as}^sⁱ^s^t^an^{ce an}^{d ov}^ersⁱ^g^h^t^of^s^t^a^t^e^s^t^o^im^prov^{e th}^e
^q^u^ality^assu^r^aⁿ^c^{e an}^d^q^u^ality^im^p^r^o^v^em^en^{t sy}^stem^{s u}ⁿ^d^er
^{Medicaid h}^o^m^e^{and com}^m^uⁿ^ity^-^b^as^{ed w}^a^iv^ers^.^T^h^e
^Secr^etar^y^m^a^y^u^s^{e u}^p^to^$²^.⁴^mⁱ^llioⁿ^o^f^th^{e am}^o^uⁿ^t^s
^appropri^a^t^e^dⁱⁿ^t^h^e^portⁱ^oⁿ^of^F^Y^{2007 t}^h^at^begⁱⁿ^s^on^Jan^u^a^ry

CRS-89
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^{1, 2007, an}^{d en}^ds^on^S^e^pt^em^{ber 30, 2007, an}^{d f}^o^{r F}^Y^2008,
^to^car^r^y^o^u^{t th}^{ese activ}^{ities d}^u^rⁱⁿ^g^th^{e p}^e^rⁱ^o^d^b^e^gⁱⁿⁿⁱⁿ^g^oⁿ
^Jan^u^a^ry^{1, 2007, an}^{d en}^diⁿ^g^on^S^e^pt^em^{ber 30, 2011.}
^Research^an^d^Ev^alu^a^tⁱ^oⁿ^.^N^o^provⁱ^sⁱ^oⁿ^.^S^e^c^tⁱ^oⁿ^{6071 (g).}^T^h^{e con}^f^eren^ce^ag^reem^en^t^r^e^q^uⁱ^r^e^s^t^h^e
^Secretary^t^o^prov^{ide f}^o^{r res}^earch^on^{, an}^{d con}^d^u^c^{t a n}^a^tion^a^l
^ev^alu^a^tion^of^,^th^{e dem}^oⁿ^s^tration^proj^{ect. T}^h^{e Secretary}^m^u^s^t
^m^a^k^e^a^fⁱⁿ^a^{l r}^e^p^o^r^{t to}^th^{e P}^r^esid^en^{t an}^d^Coⁿ^g^r^{ess n}^o^la^t^e^r
^th^an^Septem^{ber 30, 2011, an}^d^m^a^y^us^e^up^to^{$1.1 m}^illion
^each^y^{ear f}^r^om^FY2008-^FY2011,^{to carry}^ou^{t th}^es^{e activ}^ities^.
ⁱ^{ki/CRS-RL33251}^A^ppr^opr^ia^tions^.^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^6071(h⁾^{. T}^h^{e con}^f^eren^ce^a^g^r^e^e^m^eⁿ^t^a^ppropriates
^g/w^{$250 m}^illion^f^o^{r th}^{e portio}ⁿ^o^f^F^Y^{2007 w}^h^ich^begⁱⁿ^s^on
^s^.or^Jan^u^a^ry^{1, 2007, an}^{d en}^ds^on^S^e^pt^e^m^{ber 30, 2007;}^$300
^le^ak^m^illionⁱⁿ^{FY2008; $350 m}^illionⁱⁿ^{FY2OO9; $400 m}^illion
ⁱⁿ^{FY2010; an}^{d $450 m}^illionⁱⁿ^{FY2011 to}^c^a^rry^ou^{t th}^e
^://wiki^dem^oⁿ^s^t^r^atⁱ^oⁿ^proj^ect^.
^h^ttp
^Fuⁿ^d^sⁿ^o^{t aw}^{arded to s}^t^atesⁱⁿ^{a g}ⁱ^v^eⁿ^fⁱ^s^{cal y}^{ear w}^o^u^l^d
^con^tin^u^e^{to be av}^{ailable in}^s^u^bs^equ^eⁿ^t^fⁱ^s^{cal y}^ears^,^th^rou^g^h
^S^e^pt^em^{ber 30, 2011.}

CRS-90
Subchapter C — Miscellaneous.
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^M^e^dic^aⁱ^{d T}^r^aⁿ^s^f^or^ma^{tion Gr}^aⁿ^ts^.^S^e^c^tⁱ^oⁿ^1903(a⁾^o^f^t^h^e^S^o^cⁱ^a^l^S^e^c^u^rⁱ^t^y^A^c^t^d^e^s^c^rⁱ^b^e^s^t^h^e^l^e^v^e^l^o^f^S^ecti^oⁿ⁶⁰⁸¹^.^Uⁿ^d^e^r^t^h^e^H^o^u^s^e^b^ill,ⁱⁿ^a^d^d^itioⁿ^to^th^e
^f^e^{deral reim}^b^u^rs^em^en^{t av}^{ailable to s}^t^ates^f^o^{r v}^a^riou^s^Medicaidⁿ^o^rm^al^f^e^{deral Medicaid reim}^bu^rs^em^en^{t receiv}^e^{d by}
^prog^ram^f^uⁿ^c^tion^s^{. T}^h^{e f}^e^{deral m}^e^{dical as}^sⁱ^s^t^anc^e^percen^tag^e^s^t^at^es^uⁿ^d^{er S}^ectⁱ^oⁿ^1903(a),^t^h^e^S^ecret^ary^of^H^H^S^s^h^al^l
^(FMA^P⁾^is^th^{e rate at w}^h^ich^s^t^ates^{are reim}^bu^rs^{ed for m}^o^s^t^prov^{ide f}^o^{r pay}^m^en^t^s^t^o^s^t^ates^f^o^{r th}^{e adoption}^of
^Medi^cai^{d s}^e^rvⁱ^{ce ex}^pen^dⁱ^t^u^res^.^Itⁱ^s^bas^e^{d on}^{a f}^o^rm^ul^a^t^h^atⁱⁿⁿ^o^v^a^tiv^{e m}^e^th^o^d^s^to^im^p^r^o^v^{e th}^{e ef}^f^ectiv^en^{ess an}^d
^p^r^o^v^id^{es h}ⁱ^g^h^e^r^r^e^im^b^u^r^s^em^eⁿ^t^t^o^{states w}^ith^lo^w^e^r^p^e^r^cap^ita^ef^fⁱ^cien^cyⁱⁿ^Medicaid.
ⁱⁿ^co^m^e^{s r}^e^lativ^{e to}^th^{e n}^a^tioⁿ^a^{l av}^er^ag^{e (}^aⁿ^d^vⁱ^ce^v^e^r^s^a)^{; it h}^a^{s a}
ⁱ^{ki/CRS-RL33251}^s^t^at^u^t^ory^mⁱⁿⁱ^m^u^m^of^50%^an^{d m}^a^xⁱ^m^u^m^of^83%^.^T^h^e^f^e^deral^E^x^a^m^p^l^e^s^o^fⁱ^nno^va^tⁱ^v^e^m^e^t^h^o^d^s^fo^r^w^hⁱ^c^{h fund}^{s m}^a^y^b^e
^g/w^r^e^im^b^u^r^s^em^en^{t r}^a^{te f}^o^r^Medⁱ^caid^a^d^mⁱⁿⁱ^str^a^tiv^{e ex}^p^eⁿ^d^itu^r^e^{s d}^o^e^s^u^s^{ed i}ⁿ^cl^u^d^{e (1)}^m^e^t^h^ods^f^o^{r redu}^ciⁿ^g^patⁱ^eⁿ^t^{error rat}^e^s
^s^.orⁿ^o^{t v}^a^r^y^b^y^state^an^d^{is g}^eⁿ^e^r^a^lly⁵⁰^%^{, b}^u^{t cer}^tain^ad^mⁱⁿⁱ^str^a^tiv^e^t^h^r^o^{ugh t}^h^eⁱ^m^p^l^e^m^eⁿ^t^a^tⁱ^oⁿ^aⁿ^d^use^o^f^e^l^e^c^t^r^oⁿⁱ^c
^le^ak^f^uⁿ^c^tion^s^receiv^e^en^h^aⁿ^{ced (u}^s^u^ally^{75%) reim}^bu^rs^em^en^t.^s^y^s^t^em^s^,^{(2) m}^e^t^h^ods^f^o^{r i}^m^provⁱⁿ^g^rat^e^s^of^Medi^cai^d
^co^llectioⁿ^f^r^o^m^{estates, (}³⁾^m^e^th^o^d^s^f^o^r^r^e^d^u^cin^g^w^a^ste,
^://wiki^f^r^au^{d, an}^{d abu}^s^{e, (4) im}^plem^en^tation^of^a^m^e^dication
^h^ttp^ri^s^k^m^aⁿ^a^g^e^m^e^nt^p^r^og^ram^,^{(5) m}^e^t^h^ods^f^o^{r redu}^ciⁿ^g^o^u^tp^atien^t^d^r^u^g^ex^p^eⁿ^d^itu^r^e^{s b}^yⁱⁿ^cr^easin^g^th^e^u^tilizatioⁿ
^of^g^eⁿ^e^rics^,^aⁿ^d^{(6) m}^e^th^ods^f^o^{r im}^provⁱⁿ^g^acces^s^to
^prim^ary^an^{d s}^p^ecialty^ph^y^s^ician^{care f}^o^{r th}^{e u}ⁿⁱⁿ^s^u^r^ed
^u^sⁱⁿ^gⁱⁿ^teg^r^ated^uⁿⁱ^v^e^r^s^ity^-^b^ased^h^o^sp^{ital an}^d^clin^ic
^sy^ste^m^s.
^T^o^{tal pay}^m^en^ts^w^ill^equ^a^l^an^dⁿ^o^{t ex}^{ceed $75 m}^illionⁱⁿ
^each^of^F^Y^{2007 an}^{d F}^Y^{2008. T}^h^{e S}^ecr^e^t^a^r^y^s^h^all
^s^p^e^cⁱ^fy^{a m}^e^th^{od f}^o^{r allocatin}^g^f^uⁿ^d^s^am^on^g^s^t^ates^,
^prov^idin^g^pref^eren^{ce f}^o^{r s}^t^ates^targ^etin^g^h^ealth^prov^iders
^th^{at treat s}ⁱ^gⁿⁱ^fⁱ^can^{t n}^u^m^bers^of^{Medicaid ben}^e^fⁱ^ciaries
^an^{d allocatin}^g^at^l^e^a^s^t^{25% of}^th^{e f}^uⁿ^d^s^am^on^g^s^t^ates

CRS-91
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^w^h^os^{e pop}^ul^a^tⁱ^oⁿ^s^as^of^Ju^l^y^{1, 2004 w}^e^{re m}^o^{re t}^h^an
^105%^of^t^h^ei^{r popu}^l^a^tⁱ^oⁿ^s^as^of^A^p^ri^l^{1, 2000.}
^He^a^l^{th Oppor}^tunity^A^c^c^ounts^.^Medⁱ^caid^{is a j}^oⁱⁿ^{t f}^e^d^e^r^a^l-^{state en}^titlem^eⁿ^t^p^r^o^g^r^a^m^th^at^fⁱⁿ^aⁿ^ces^S^e^c^tⁱ^oⁿ⁶⁰⁸²^{. T}^h^{e con}^f^eren^{ce ag}^reem^en^{t requ}^ires^th^e
^h^ealth^car^{e co}^v^e^r^a^g^e^f^o^r^cer^taⁱⁿ^lo^w^-ⁱⁿ^co^m^e^f^a^m^{ilies, ch}^ild^r^eⁿ^,^Secretary^of^{HHS to e}^s^t^a^blis^hⁿ^o^m^o^{re th}^en¹⁰
^pregⁿ^aⁿ^t^w^o^m^eⁿ^,^an^dⁱⁿ^divⁱ^du^als^w^h^o^are^ag^{ed or dis}^a^{bled. Each}^d^e^m^oⁿ^s^tr^atioⁿ^p^r^o^g^r^a^m^s^w^ithⁱⁿ^Medⁱ^caid^f^o^r^h^ealth
^s^t^at^e^desⁱ^gⁿ^s^an^{d adm}ⁱⁿⁱ^s^t^ersⁱ^t^s^owⁿ^prog^ram^uⁿ^d^{er broad}^f^e^deral^opportuⁿ^ity^accouⁿ^t^s^(HOA^),^ef^f^ectiv^{e Jan}^u^a^ry^{1, 2007.}
^g^uⁱ^d^e^lin^{es. Var}ⁱ^atioⁿ^ex^{ists am}^oⁿ^g^{states in}^elig^ib^ility^{, co}^v^e^r^e^d^I^f^su^ccessf^u^l⁽^b^ased^oⁿ^co^st-^e^f^f^ectiv^en^{ess, q}^u^ality^o^f^car^e
^s^e^rv^ices^{, an}^{d th}^{e deliv}^ery^of^{, an}^{d reim}^bu^rs^em^en^{t f}^o^{r s}^e^rv^ices^.^an^d^o^t^h^e^r^Secr^etar^y^-^sp^ecifⁱ^ed^cr^iterⁱ^a)^d^u^rⁱⁿ^g^th^{e in}^itial
^States^th^{at w}ⁱ^s^h^{to ex}^perim^eⁿ^t^w^ithⁿ^e^w^approach^es^f^o^{r prov}^idin^g^fⁱ^v^e^-^y^{ear t}^e^s^t^peri^{od, s}^u^ch^dem^oⁿ^s^t^r^atⁱ^oⁿ^s^m^a^y^be
ⁱ^{ki/CRS-RL33251}^h^ealth^care^cov^e^rag^e^th^{at prom}^{ote th}^{e obj}^ectiv^es^of^th^e^Medicaid^prog^r^a^m^m^a^y^s^eek^approv^al^f^o^{r S}^ectⁱ^oⁿ^{1115 dem}^oⁿ^s^t^r^atⁱ^oⁿ^ex^t^eⁿ^d^{ed or m}^a^{de perm}^an^en^t^,^an^{d ot}^h^e^{r dem}^oⁿ^s^t^r^atⁱ^oⁿ^s^m^a^y^{be approv}^ed.
^g/w^w^a^iv^er^{s. W}^h^{ile th}^{e d}^e^m^oⁿ^s^tr^ati^oⁿ^p^r^o^g^r^a^m^s^d^e^scrⁱ^b^e^dⁱⁿ^th^e
^s^.or^con^f^ereⁿ^c^e^a^g^reem^en^{t h}^a^v^e^s^o^m^e^of^th^{e elem}^en^ts^of^{a Section}^HOA^{s w}^{ill b}^e^u^s^ed^to^p^a^y⁽^v^{ia electr}^oⁿⁱ^{c f}^uⁿ^d^{s tr}^an^sf^er^s)
^le^ak^{1115 dem}^oⁿ^s^t^r^atⁱ^oⁿ^w^aⁱ^v^{er, “}^H^eal^t^h^O^pport^uⁿⁱ^t^y^A^ccouⁿ^t^s^”^{, as}^h^ealth^{care ex}^pen^s^es^s^p^ecifⁱ^e^d^b^y^th^{e s}^t^{ate; pay}^m^en^ts
^d^e^fⁱⁿ^e^d^b^y^th^{e p}^r^o^v^isioⁿ^ar^{e n}^o^{t ex}^p^licitly^au^th^o^r^ized^uⁿ^d^er^cou^l^{d be res}^t^ricted^{to licen}^s^e^{d or oth}^e^rw^is^{e au}^th^orized
^://wiki^cu^rren^t^l^a^w^.^prov^iders^as^w^e^{ll as}^{to ite}^m^s^an^{d s}^e^rv^ices^th^{at are}
^h^ttp^m^e^di^cal^l^y^appropri^a^t^e^{or n}^eces^s^a^ry^{. A}^m^on^g^ot^h^e^r^t^hⁱⁿ^g^s^,
^s^t^{ate dem}^oⁿ^s^tration^prog^ram^s^{are requ}^{ired to m}^a^k^e
^patien^t^s^aw^{are of}^th^{e h}ⁱ^g^h^cos^t^of^m^e^dical^{care, prov}^ide
ⁱⁿ^c^eⁿ^tiv^es^f^o^{r th}^em^{to s}^eek^prev^en^tiv^{e care, an}^{d reduc}^e
ⁱⁿ^{appropriate u}^s^es^of^h^ealth^care.
^Eligibilit^y^{Rules f}^o^{r Demonst}^r^a^t^ion^T^o^qu^alⁱ^f^y^f^o^{r Medi}^cai^{d, an}ⁱⁿ^di^vⁱ^du^{al m}^u^s^t^m^{eet both}^categ^orical^S^ecti^oⁿ^{6082 (b}^).^Elig^ib^ility^f^o^r^HOA^s^is^d^e^ter^mⁱⁿ^ed^b^y
^icipant^s^.^an^d^fⁱⁿ^aⁿ^c^{ial elig}^ib^ility^r^e^q^u^ir^em^en^{ts. T}^h^{e sp}^ecifⁱ^{c in}^co^m^e^an^d^t^h^e^st^a^t^e^,^t^h^o^{ugh i}ⁿ^dⁱ^vi^d^u^a^l^{s a}^g^e⁶⁵^o^r^o^l^d^e^r^,^o^r^w^h^o^a^r^e
^reso^u^r^{ce lim}^itatioⁿ^s^th^{at ap}^p^l^y^to^each^elig^ib^ility^g^r^o^u^p^{are set}^blⁱⁿ^{d or di}^s^a^bl^{ed reg}^a^rdl^e^s^s^of^w^h^et^h^e^{r t}^h^{e i}ⁿ^di^vⁱ^du^alⁱ^s
^thr^o^{ugh a}^c^o^m^b^ina^tio^{n o}^f^fe^d^e^r^a^l^p^a^r^a^m^e^te^r^s^aⁿ^d^sta^t^e^d^e^finitio^ns.^elig^ib^{le f}^o^r^SSI^oⁿ^su^ch^b^a^{sis, w}^h^o^a^r^e^p^r^egⁿ^aⁿ^t^{, w}^h^o
^h^a^v^e^been^elig^{ible f}^o^{r m}^e^{dical as}^sⁱ^s^t^an^{ce f}^o^{r a}^con^tin^u^o^s
^{period of}^les^s^t^h^aⁿ^t^h^{ree m}^oⁿ^t^h^s^{, or w}^h^{o are receiv}ⁱⁿ^g
^termⁱⁿ^{al care or lon}^g^-^term^{care, are am}^on^g^th^os^e^w^h^o^are

CRS-92
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^preclu^d^{ed f}^r^om^participatin^g^.^Oth^e^{r ex}^clu^d^{ed g}^r^ou^p^s
ⁱⁿ^clu^d^{e (}¹⁾^d^u^{al elig}^ib^{les, (}²⁾^t^e^r^mⁱⁿ^ally^{ill h}^o^sp^ice
^p^a^tien^t^{s, (}³⁾^ch^il^d^r^eⁿ^w^ith^dⁱ^sab^{ilities th}^{at m}^{eet SSI}
^dⁱ^sab^ility^stan^d^a^r^d^{s w}^h^o^r^e^q^u^ir^{e in}^stitu^tioⁿ^a^{l car}^{e, b}^u^t^f^o^r
^w^h^o^m^car^{e is d}^e^liv^er^ed^o^u^tsid^{e th}^{e in}^stitu^tioⁿ^,^an^d^th^e
^cos^t^of^th^at^{care does}ⁿ^o^{t ex}^{ceed th}^{e oth}^e^rw^is^{e applicable}
ⁱⁿ^stitu^tioⁿ^a^{l car}^{e (}^a^lso^kⁿ^o^wⁿ^{as Katie}^B^eck^{ett o}^r
^T^E^FR^A^ch^ildren⁾^;^{(4) m}^e^dically^f^r^{ail an}^{d s}^p^{ecial m}^e^dical
^ne^e^d^sⁱⁿ^divⁱ^du^als^(as^determⁱⁿ^{ed in}^accordan^{ce w}^ith
^reg^u^l^a^tⁱ^on^s^of^th^{e Secretary}⁾^{; (5)ch}^ildrenⁱⁿ^f^o^s^t^{er care}
ⁱ^{ki/CRS-RL33251}^r^e^c^eⁱ^vⁱⁿ^g^ch^ild^w^e^lf^ar^{e ser}^v^{ices (}^uⁿ^d^er^P^a^r^t^B^o^f^T^itle^IV^{) an}^{d w}^h^{o are ch}^ildren^receivⁱⁿ^g^f^o^s^t^{er care or}
^g/w^ad^o^p^tioⁿ^assistan^{ce u}ⁿ^d^er^P^a^r^t^{E o}^f^T^itle^I^V^w^ith^o^u^t
^s^.or^reg^a^{rd t}^o^ag^e;^{(6) i}ⁿ^di^vⁱ^du^al^s^w^h^{o qu}^alⁱ^f^y^f^o^{r Medi}^cai^d
^le^ak^uⁿ^d^{er t}^h^{e f}^a^mⁱ^l^y^cov^e^rag^e^provⁱ^sⁱ^oⁿ^(S^ectⁱ^{on 1931) or}
^://wiki^on^th^{e bas}ⁱ^s^of^receivⁱⁿ^g^as^sⁱ^s^t^an^{ce u}ⁿ^d^{er T}^A^{NF (as}ⁱⁿ^ef^f^{ect on}^{or af}^{ter th}^{e w}^e^lf^{are ref}^o^rm^ef^f^ectiv^{e date); (7)}
^h^ttp^w^o^m^eⁿⁱⁿ^th^{e b}^r^{east an}^d^cer^vⁱ^{cal c}^aⁿ^cer^elig^ib^ility
^g^r^ou^p;^an^{d (8) ot}^h^e^{r “}^lⁱ^mⁱ^t^e^{d s}^e^rvⁱ^ces^ben^e^fⁱ^ci^ari^e^s^,^”
ⁱⁿ^clu^dⁱⁿ^g^certain^tu^bercu^l^os^is^-ⁱⁿ^f^{ected in}^divⁱ^du^als^,^an^d
^leg^a^{l an}^{d u}ⁿ^docu^m^en^{ted n}^oⁿ^-^citizen^s^w^h^{o m}^{eet th}^e
^fⁱⁿ^a^{ncial an}^{d categ}^{orical requ}^irem^en^ts^f^o^{r Medicaid}
^elig^ib^ility^w^ith^o^u^t^r^e^g^a^r^d^to^tim^{e in}^th^{e U.S. an}^d^ar^e
^elig^{ible on}^ly^f^o^{r em}^erg^eⁿ^c^y^m^e^{dical s}^e^rv^ices^.
^T^h^{e con}^f^er^eⁿ^c^e^ag^reem^en^{t adds}^{a on}^e-^y^{ear m}^o^ratoriu^m
^f^o^r^r^een^r^o^llm^eⁿ^t^,^w^h^e^r^e^b^y^e^lⁱ^g^ib^leⁱⁿ^dⁱ^vⁱ^d^u^als
^di^s^eⁿ^r^ol^l^e^{d f}^r^om^t^h^{e s}^t^at^{e dem}^oⁿ^s^t^r^atⁱ^oⁿ^prog^ram^s^are
ⁿ^o^{t p}^e^r^m^itted^to^r^een^r^o^{ll f}^o^r^{a f}^u^{ll y}^e^a^r^f^r^o^m^su^ch
ⁱⁿ^di^vⁱ^du^al^’^s^di^s^eⁿ^r^ol^l^m^en^t^dat^e^.

CRS-93
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^B^eⁿ^e^fi^ts^for^De^mons^tr^a^tⁱ^oⁿ^Medⁱ^caid^’^s^b^a^{sic b}^eⁿ^e^f^{its r}^u^{les r}^e^q^u^ir^{e all states to}^p^r^o^v^id^e^cer^tain^T^h^{e con}^f^eren^{ce ag}^reem^en^{t requ}^ires^dem^oⁿ^s^tr^a^tion
^icipant^s^.^“^m^an^dat^o^r^y^”^s^e^rv^ices^as^lis^{ted in}^{Medicaid s}^t^atu^t^{e. Federal}^participan^ts^h^a^v^e^both^an^HOA^an^{d cov}^e^rag^e^f^o^{r m}^e^dical
^m^a^tchⁱⁿ^g^pay^m^en^ts^are^als^o^av^{ailable f}^o^{r option}^a^{l s}^e^rv^ices^if^s^t^atesⁱ^t^e^m^s^aⁿ^d^se^r^vⁱ^c^e^s^t^h^a^t^,^a^f^t^e^r^aⁿ^a^nnua^l^d^e^d^u^c^tⁱ^b^l^eⁱ^s^m^e^t^,
^ch^oos^{e to}ⁱⁿ^clu^d^e^th^emⁱⁿ^th^{eir Medicaid plan}^s^.^States^defⁱⁿ^e^th^e^{are av}^{ailable u}ⁿ^d^{er th}^{e ex}^is^tin^g^{Medicaid s}^t^{ate plan}
^s^p^ecifⁱ^{c f}^eatu^r^es^of^each^s^e^rv^{ice to be prov}^ide^d^und^e^r^th^{at plan}^an^{d/or Section}^{1115 w}^a^iv^{er au}^th^orities^.^H^O^A
^w^ithⁱⁿ^b^r^o^a^d^f^e^d^e^r^a^{l g}^uⁱ^d^e^lin^{es in}^clu^dⁱⁿ^g⁽¹⁾^A^m^o^uⁿ^t^{, d}^u^r^a^tioⁿ^,^cont^rⁱ^b^u^tⁱ^oⁿ^s^cou^l^{d be m}^a^{de by}^t^h^{e s}^t^at^{e or by}^ot^h^e^r
^an^{d s}^c^{ope. Each}^cov^e^{red s}^e^rv^{ice m}^u^s^t^{be s}^u^f^fⁱ^ci^eⁿ^{t in}^am^ouⁿ^t^,^p^e^r^s^oⁿ^{s o}^r^en^{tities, in}^clu^dⁱⁿ^g^ch^ar^itab^l^e^o^r^g^aⁿⁱ^zatioⁿ^s^as
^d^u^r^a^tioⁿ^,^an^d^sco^p^e^to^r^easoⁿ^ab^ly^ach^iev^e^{its p}^u^r^p^o^s^{e, (}²⁾^p^e^r^m^itted^uⁿ^d^er^cu^r^r^eⁿ^t^law^.^Iⁿ^clu^dⁱⁿ^g^f^e^d^e^r^a^{l s}^h^a^r^es,
^Co^m^p^ar^ab^ility^.^W^ith^cer^tain^ex^cep^tioⁿ^s^{, ser}^v^{ices av}^ailab^l^{e to}^an^y^s^t^{ate con}^t^ribu^tion^s^g^eⁿ^e^rally^m^a^yⁿ^o^{t ex}^ceed^{$2,500 f}^o^r
^categ^oricallyⁿ^eedy^ben^e^fⁱ^ciaryⁱⁿ^{a s}^t^{ate m}^u^s^t^{be equ}^a^{l in}^am^ouⁿ^t^,^each^adu^{lt an}^{d $1,000 f}^o^{r each}^ch^ild.
ⁱ^{ki/CRS-RL33251}^du^ration^,^an^{d s}^c^{ope to th}^os^{e av}^ai^l^a^b^l^{e to an}^y^oth^e^{r categ}^oricallyⁿ^eedy^ben^e^fⁱ^ciaryⁱⁿ^th^e^s^t^ate.^Sim^ilarly^,^s^e^rv^ices^av^{ailable to an}^y^On^{ce accou}ⁿ^t^h^o^lders^areⁿ^o^loⁿ^g^e^{r elig}^{ible f}^o^{r Medicaid}
^g/w^m^e^dicallyⁿ^eedy^ben^e^fⁱ^ciaryⁱⁿ^{a s}^t^{ate m}^u^s^t^b^e^equ^a^{l in}^am^ouⁿ^t^,^t^h^e^y^m^a^y^c^o^ntⁱ^nue^t^o^m^a^ke^H^O^A^wⁱ^t^h^d^r^a^w^a^l^{s und}^e^r
^s^.or^du^ratⁱ^oⁿ^,^an^{d s}^c^{ope t}^o^t^h^os^{e av}^ai^l^a^bl^{e t}^o^aⁿ^y^o^t^he^{r m}^e^di^cal^l^y^state-^sp^eci^fⁱ^ed^coⁿ^d^itioⁿ^s^f^o^r^{a p}^e^rⁱ^o^d^o^f^th^r^{ee y}^ear^s,
^le^ak^ne^e^d^y^ben^e^fⁱ^ciaryⁱⁿ^th^{e s}^t^{ate, (3) Statew}^iden^es^s^.^{State pl}^aⁿ^tho^{ugh no}^ad^d^itio^{nal acco}^{unt co}^ntrⁱ^b^u^tio^{ns w}^ill^b^e^m^a^d^e
^://wiki^se^r^vⁱ^c^e^s^m^u^st^b^e^c^o^ve^r^e^d^t^h^r^o^ugho^ut^aⁿ^eⁿ^tⁱ^r^e^st^a^t^e^,^aⁿ^d⁽⁴⁾^Freedom^of^ch^{oice. W}^ith^certain^ex^ception^s^,^{a s}^t^ate’^s^Medicaid^an^d^th^{e acco}^uⁿ^t^b^a^lan^{ces w}^{ill b}^e^r^e^d^u^ced^b^y²⁵^%^{. Fo}^rⁱⁿ^elig^ib^{le in}^dⁱ^vⁱ^d^u^al^s^w^h^o^p^a^r^ticip^atedⁱⁿ^th^e
^h^ttp^plan^m^u^s^t^allow^recipien^ts^f^r^eedo^m^o^f^c^{hoice am}^on^g^h^ealth^care^dem^oⁿ^s^tra^tⁱ^oⁿ^prog^ram^f^o^{r at leas}^{t on}^{e y}^{ear, accou}ⁿ^t^s
^p^r^o^v^id^er^{s o}^r^m^aⁿ^a^g^e^d^car^{e en}^{tities p}^a^r^ticip^atin^gⁱⁿ^Medⁱ^caid^.^cou^l^d^th^en^als^o^{be u}^s^{ed to pay}^f^o^{r h}^ealthⁱⁿ^s^u^ran^{ce or,}^at
^{state o}^p^tioⁿ^,^f^o^r^ad^d^itioⁿ^a^{l ex}^p^eⁿ^d^itu^r^e^{s su}^ch^{as j}^o^b
^t^r^aⁱⁿⁱ^{ng o}^r^e^d^uc^a^tⁱ^o^n.
^Cos^t^S^h^a^r^{ing for}^De^mons^tr^a^tⁱ^oⁿ^St^a^t^e^s^m^a^y^ge^ne^r^a^l^l^yⁱ^m^p^o^s^eⁿ^o^mi^na^l^c^o^st^-sha^rⁱ^{ng o}ⁿ^T^h^{e con}^f^eren^{ce ag}^reem^en^{t requ}^ires^dem^o^ns^tration
^icipant^s^.^ben^e^fⁱ^ciaries^,^w^ith^certain^ex^cepti^oⁿ^s^.^T^h^ey^{are preclu}^d^{ed f}^r^om^p^a^r^tⁱ^cⁱ^p^aⁿ^t^s^t^o^m^e^e^t^aⁿ^a^nnua^l^d^e^d^u^c^tⁱ^b^l^e^b^e^fo^r^e^t^h^e^y^a^r^e
^im^posⁱⁿ^g^cos^t^s^h^arin^g^on^s^e^rv^ices^f^o^{r ch}^ildren^uⁿ^d^{er 18, s}^e^rv^ices^p^e^rm^itted^to^{access co}^v^e^ra^g^e^f^o^{r m}^e^dⁱ^{cal item}^s^an^d
^r^e^l^a^t^e^d^t^o^p^r^e^gna^nc^y^,^fa^mⁱ^l^y^p^l^aⁿⁿⁱ^{ng o}^r^e^m^e^r^ge^nc^y^se^r^vⁱ^c^e^s^,^s^e^rv^ices^av^{ailable u}ⁿ^d^{er th}^{e ex}^is^tin^g^Medicaid^s^t^ate^plan
^ser^v^{ices p}^r^o^v^id^ed^toⁿ^u^r^sin^g^f^acility^r^e^sid^eⁿ^t^{s w}^h^o^ar^{e r}^e^q^u^ir^ed^to^an^{d/or Section}^{1115 w}^a^iv^{er au}^th^orities^.^T^h^{e dedu}^ctible
^s^p^en^{d all of}^th^{eir in}^com^e^f^o^r^m^e^{dical care ex}^{cept f}^o^{r a pers}^on^al^m^u^s^t^{be at}^l^eas^t^100%^{, bu}^tⁿ^o^m^o^{re t}^h^an^110%^{, of}^t^h^e
ⁿ^eeds^allow^aⁿ^{ce, an}^{d s}^e^rv^ices^f^u^rn^is^h^e^{d to in}^divⁱ^du^als^recei^vi^ng^a^nnua^l^st^a^t^e^c^o^nt^rⁱ^b^u^tⁱ^o^{ns t}^o^t^h^e^H^O^A^wⁱ^t^h^o^u^t^r^e^ga^r^d^t^o
^h^o^s^p^{ice care. States}^m^a^y^requ^{ire n}^o^mⁱⁿ^a^{l co}^pay^m^en^ts^,^s^t^ate-^s^p^ecifⁱ^{ed lim}ⁱ^t^s^on^th^{e HOA}^balan^{ce. B}^o^th^th^e

CRS-94
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^coⁱⁿ^su^r^aⁿ^{ce, o}^r^d^e^d^u^ctib^{les w}^ithⁱⁿ^f^e^d^e^r^a^{l lim}^{its f}^r^o^m^o^t^h^e^r^dedu^ctⁱ^b^l^e^an^{d t}^h^{e m}^a^xⁱ^m^u^m^f^o^{r ou}^t^-^of^-^pock^e^t^cos^t^-
^ben^e^fⁱ^ciaries^{or f}^o^{r oth}^e^{r s}^e^rv^ices^{. B}^eⁿ^e^fⁱ^ciaries^m^a^y^{be ch}^arg^e^d^sh^arⁱⁿ^g^co^u^l^d^v^a^r^y^am^oⁿ^g^f^a^m^{ilies. T}^h^{e d}^e^d^u^ctib^{le n}^eed
^oⁿ^ly^on^{e ty}^{pe of}^cos^t^s^h^arin^g^{per s}^e^rv^{ice. P}^r^ov^iders^m^a^y^c^o^l^l^e^c^tⁿ^o^{t apply}^{to prev}^en^tiv^{e care.}
^cos^t^s^h^arin^g^am^o^unts^f^r^om^ben^e^fⁱ^ciaries^an^{d g}^eⁿ^e^rally^{are n}^o^{t to}
^{be reim}^bu^rs^{ed by}^th^{e s}^t^{ate if}^th^ey^{are u}ⁿ^s^u^cces^s^f^u^lⁱⁿ^c^o^l^l^ectin^g
^c^o^st^sha^rⁱ^{ng fr}^o^m^b^e^ne^fi^cⁱ^a^rⁱ^e^s.^P^r^o^vⁱ^d^e^r^{s ge}^ne^r^a^l^l^y^m^a^y^no^t^d^e^ny
^s^e^rv^ices^if^ben^e^fⁱ^ciaries^{are u}ⁿ^a^{ble to pay}^cos^t^s^h^arin^g^am^ouⁿ^t^s^.
^Fo^r^th^{e m}^o^{st p}^a^r^t^{, states estab}^lish^th^eir^o^wⁿ^r^a^{tes to}^p^a^y^Medⁱ^caid^T^h^{e con}^f^eren^{ce ag}^reem^en^{t requ}^ir^e^s^dem^oⁿ^s^tration
^Pro^v^id^{er Pay}^m^en^t^s^.^prov^iders^f^o^{r s}^e^rv^ices^{. B}^y^reg^u^l^ation^th^es^e^rates^m^u^s^t^{be s}^u^f^fⁱ^cien^t^p^a^r^ticip^an^ts^to^b^e^ab^{le to}^o^b^t^ain^ser^v^ices^f^r^o^m^Medⁱ^caid
ⁱ^{ki/CRS-RL33251}^to^eⁿ^{list e}ⁿ^o^{ugh p}^r^o^vⁱ^d^e^r^s^so^tha^t^c^o^ve^r^e^d^se^r^v^ic^e^s^w^{ill b}^e^av^{ailable to Medicaid ben}^e^fⁱ^ciaries^{at le}^a^s^{t to th}^{e ex}^ten^t^th^ey^are^prov^iders^,^{or Medicaid}^m^aⁿ^a^g^e^{d care org}^aⁿⁱ^zation^s^at^th^{e sam}^e^p^a^y^m^en^{t r}^a^{tes th}^{at ar}^{e ap}^p^lⁱ^c^a^b^{le if}^th^e
^g/w^av^ai^l^a^bl^{e t}^o^t^h^{e g}^eⁿ^e^ral^popu^l^a^tⁱ^oⁿⁱⁿ^{a ge}^o^g^r^a^p^hⁱ^c^{area. A}^l^l^cov^e^rag^e^dedu^ctⁱ^b^l^e^di^{d n}^o^t^appl^y^,^{or f}^r^om^an^y^ot^h^e^r
^s^.or^prov^iders^ar^e^r^e^q^u^{ired to accept}^pay^m^en^ts^uⁿ^d^{er th}^{e prog}^ram^as^prov^ider^or^m^aⁿ^a^g^e^{d care org}^aⁿⁱ^zation^{at pay}^m^en^{t rates}
^le^ak^pay^m^en^{t in}^f^u^{ll fo}^r^c^o^{vered s}^e^rv^ices^ex^{cept w}^h^{ere s}^t^ates^requ^ireⁿ^o^{t ex}^ceedin^g^125%^of^s^u^ch^{Medicaid prov}^{ider pay}^m^en^t
^no^mⁱ^na^l^c^o^st^-sha^rⁱ^{ng b}^y^b^e^ne^fi^cⁱ^a^rⁱ^e^s.^rates^.^T^h^{e con}^f^eren^{ce agr}^e^e^m^en^{t requ}^ires^th^{at th}^e
^://wiki^pay^m^en^t^rat^e^s^f^o^{r Medi}^cai^{d prov}ⁱ^d^ers^or^m^aⁿ^a^g^e^{d care}
^h^ttp^o^r^gaⁿⁱ^z^a^tⁱ^o^{ns b}^e^c^o^m^p^ut^e^d^wⁱ^t^h^o^u^t^r^e^ga^r^d^t^o^aⁿ^y^c^o^st
^s^h^arin^g^th^{at are oth}^e^rw^is^{e applicable u}ⁿ^d^{er cu}^rren^t^law
^(as^m^odifⁱ^{ed by}^th^{e con}^f^eren^{ce ag}^reem^en^t).
^De^mons^tr^a^t^{ion e}^v^a^l^ua^tion.^No^p^r^o^v^isioⁿ^.^No^t^later^th^an^th^r^{ee m}^oⁿ^t^h^s^p^r^io^r^to^th^{e en}^d^o^f^th^{e in}^itial
^fⁱ^v^e^-^y^{ear tes}^t^{period, th}^{e con}^f^eren^{ce ag}^reem^en^{t requ}^ires
^th^e^Co^m^p^tr^o^ller^Gen^e^r^a^{l o}^f^th^{e Un}^{ites States to}^su^b^m^{it to}
^Co^ngr^e^{ss a}ⁿ^e^v^a^l^ua^tⁱ^o^{n o}^f^t^h^e^d^e^m^o^nst^r^a^tⁱ^o^{n p}^r^o^g^r^a^m^s
^an^d^,^o^u^{t o}^f^f^uⁿ^d^{s in}^th^{e T}^r^easu^r^yⁿ^o^{t o}^t^h^e^r^w^ise
^{appropriated, th}^{e con}^f^eren^{ce ag}^reem^en^{t appropriates}
^{$550,000 f}^o^{r t}^h^{e peri}^{od F}^Y²^007-^F^Y^{2010 t}^o^t^h^e
^Coⁿ^t^r^o^ller^Gen^e^r^a^{l o}^f^th^{e Un}^ited^States^to^car^r^y^o^u^{t su}^ch
^an^ev^alu^a^tion^.

CRS-95
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^Ef^f^ect^iv^{e Dat}^e^.^{No prov}^is^ion^.^T^h^{e ag}^reem^en^{t is}^ef^f^ectiv^{e u}^pon^en^actm^eⁿ^t^of^th^is^act.
^S^t^a^t^e^{Option to E}^s^ta^blis^{h N}^o^n-^{Federal reg}^u^l^ation^s^r^e^q^uⁱ^r^{e s}^t^ates^{to en}^s^u^{re n}^eces^s^a^ry^S^ecti^oⁿ⁶⁰⁸³^.^T^h^e^ag^reem^en^{t allow}^s^s^t^ates^{to es}^tablis^h
^e^r^ge^nc^y^M^e^di^c^a^l^Tr^aⁿ^s^por^ta^tion^t^r^an^s^port^a^tⁱ^oⁿ^f^o^{r ben}^e^fⁱ^ci^ari^e^s^t^o^an^{d f}^r^om^provⁱ^d^ers^.^Wh^en^{a n}^oⁿ^-^em^erg^eⁿ^c^y^m^e^{dical tran}^s^portation^brok^erag^e
^ogr^a^m^.^{states o}^f^f^e^r^tr^an^sp^o^r^tatioⁿ^{as an}^o^p^tioⁿ^a^{l b}^eⁿ^e^f^{it, f}^e^d^e^r^a^l^prog^ram^f^o^{r ben}^e^fⁱ^ciaries^w^h^{o n}^{eed acces}^s^{to m}^e^dic^a^l
^reim^bu^rs^em^en^{t u}^s^es^FMA^P^w^h^ich^v^a^ries^by^s^t^ate^an^d^ran^g^e^s^f^r^om^{care bu}^{t hav}^eⁿ^o^oth^e^{r m}^ean^s^of^tran^s^portation^.^States
⁵⁰^%^to⁸³^%^{. FMA}^P^r^e^im^b^u^r^s^em^en^{t is o}ⁿ^ly^av^ailab^l^{e if}^areⁿ^o^t^requ^{ired to prov}^{ide s}^u^ch^s^e^rv^ices^on^a^s^t^atew^ide
^tr^an^sp^o^r^tatioⁿ^{is f}^u^rⁿ^ish^e^d^b^y^{a p}^r^o^v^id^er^to^w^h^o^m^{a d}ⁱ^r^ect^basⁱ^s^,^com^p^{arable s}^e^rv^ices^f^o^{r a}^l^l^{Medicaid en}^rollees^{, n}^o^r
^pay^m^en^{t can}^{be m}^a^de.^B^eⁿ^e^fⁱ^ciaries^m^u^s^t^h^a^v^e^f^r^eedom^of^ch^oice^f^r^eedom^of^ch^oi^{ce am}^on^g^provⁱ^d^e^r^s^.^T^h^{e prog}^ram
^am^on^g^tran^s^portation^prov^iders^an^{d s}^u^ch^s^e^rv^ices^m^u^s^t^{be equ}^a^lⁱⁿ^clu^d^es^w^h^eelch^{air v}^aⁿ^,^taxⁱ^{, s}^t^retch^e^{r car, bu}^s^p^a^s^s^e^s
ⁱ^{ki/CRS-RL33251}ⁱⁿ^am^ouⁿ^t^{, du}^ratio^{n an}^{d s}^c^{ope f}^o^{r all ben}^e^fⁱ^ciaries^clas^sⁱ^fⁱ^{ed as}^{CN. T}^h^{is co}^m^p^ar^ab^ility^r^e^q^u^ir^em^en^{t a}^l^s^o^a^p^p^{lies am}^oⁿ^g^MN^an^d^tick^e^{ts, an}^d^o^t^h^e^r^tr^an^sp^o^r^tatioⁿ^m^e^th^o^d^s^d^e^em^ed^{appropriate by}^th^{e Secretary}^,^an^d^can^{be con}^d^u^c^{ted u}ⁿ^d^er
^g/w^g^r^ou^ps^{. Serv}^ices^m^u^s^t^als^o^{be av}^{ailable s}^t^atew^ide.^O^t^her^c^oⁿ^t^r^a^c^t^wⁱ^t^h^a^b^r^o^k^e^r^w^h^o^:⁽¹⁾ⁱ^s^se^l^e^c^t^e^d^t^h^r^o^ugh^a
^s^.or^arran^g^e^m^eⁿ^t^s^,^s^u^ch^as^pay^m^en^ts^{to a brok}^{er w}^h^{o m}^aⁿ^a^g^e^s^an^d^co^m^p^etitiv^{e b}ⁱ^d^dⁱⁿ^g^p^r^o^{cess th}^{at assesses th}^{e b}^r^o^k^er^’^s
^le^ak^pay^s^t^r^an^s^port^a^tⁱ^oⁿ^v^eⁿ^dors^,^m^u^s^t^{be cl}^ai^m^e^{d as}^an^admⁱⁿⁱ^s^t^ratⁱ^v^e^ex^perien^{ce, ref}^e^ren^ces^{, qu}^ali^f^ication^s^{, res}^o^u^r^ces^an^d
^ex^pen^s^{e rath}^{er th}^an^as^{a ben}^e^f^it.^Su^ch^cos^t^s^{are reim}^bu^rs^{ed by}^th^e^cos^t^s^;^{(2) h}^a^s^ov^ersⁱ^g^h^t^procedu^r^es^{to m}^oⁿ^itor
^://wiki^f^e^{deral g}^o^v^e^rn^m^eⁿ^t^{at 50% f}^o^{r all s}^t^ates^{, an}^{d f}^e^w^e^{r f}^e^d^e^ral^ben^e^fⁱ^ciary^acces^s^an^{d com}^p^lain^ts^an^{d to}^eⁿ^s^u^{re th}^at
^h^ttp^r^e^q^u^ir^em^en^{ts m}^u^{st b}^e^m^e^t.^tran^s^{port pers}^onⁿ^e^{l are licen}^s^e^{d, qu}^alif^{ied, com}^p^eten^t
^an^{d c}^o^ur^t^e^o^u^s^;^{(3) is}^s^u^bj^{ect to reg}^u^l^{ar au}^ditin^g^by^th^e
^stat^e^t^o^en^su^r^e^q^u^ality^o^f^ser^v^{ices an}^d^ad^eq^u^acy^o^f
^ben^e^fⁱ^ciary^acces^s^{to m}^e^{dical care; an}^{d (4)}^com^p^lies^w^ith
^r^e^q^u^ir^em^en^{ts r}^e^lated^to^p^r^o^h^ib^itioⁿ^s^oⁿ^r^e^f^e^r^r^{als an}^d
^coⁿ^f^{lict o}^fⁱⁿ^ter^e^{st estab}^lish^e^d^b^y^th^{e Secr}^etar^y^.
^T^h^is^p^r^o^vⁱ^s^ion^tak^e^s^ef^f^{ect on}^th^{e date of}^en^actm^eⁿ^t^of
^th^{is act.}
^E^x^te^ns^{ion of T}^r^aⁿ^sⁱ^tiona^{l M}^e^dic^a^l^States^{are requ}^{ired to}^con^tin^u^e^{Medicaid ben}^e^f^its^f^o^{r certain}^S^ecti^oⁿ^6084.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t ex}^ten^d^s^T^M^A
^an^c^e⁽^T^M^A⁾^aⁿ^d^A^b^s^tⁱⁿ^eⁿ^{ce Ed}^u^cat^ioⁿ^lo^w^-ⁱⁿ^co^m^e^f^a^m^{ilies w}^h^o^w^o^u^l^d^o^t^h^e^rw^{ise lo}^{se co}^v^e^rag^e^b^ecau^se^uⁿ^d^{er S}^ectⁱ^oⁿ^{1925 of}^t^h^e^So^cⁱ^al^S^ecu^ri^t^y^A^c^t^t^h^rou^g^h
^ogr^a^m^.^o^f^ch^an^g^e^{s in}^th^eirⁱⁿ^co^m^e^.^T^hⁱ^s^coⁿ^tin^u^a^tioⁿ^o^f^b^eⁿ^e^f^{its is}^Decem^{ber 31, 2006.}

^kⁿ^o^wⁿ^{as tr}^an^sitioⁿ^a^{l m}^e^dⁱ^cal^assistan^{ce (}^T^MA⁾^.^{States ar}^e

CRS-96
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^cu^r^r^eⁿ^tly^r^e^q^u^ir^ed^to^p^r^o^v^id^{e T}^M^A^to^f^a^m^{ilies lo}^sin^g^elig^ib^ility
^f^o^r^Medi^cai^{d u}ⁿ^d^{er t}^w^{o s}^cen^ari^o^s^.^Fⁱ^rs^t^,^uⁿ^d^er^S^ectⁱ^oⁿ^1931(c)^of
^th^e^{Social Secu}^rity^A^c^{t, s}^t^ates^m^u^s^t^prov^{ide f}^o^u^r^m^oⁿ^t^h^s^of^T^M^A
^co^v^e^r^a^g^e^to^f^a^m^ilies^l^o^sⁱⁿ^g^Medⁱ^caid^elig^ib^ility^d^u^{e to}ⁱⁿ^cr^eased
^chⁱ^l^d^{or s}^pou^s^a^l^s^u^pport^.^T^hⁱ^sⁱ^s^{a perm}^an^ent^p^r^o^vⁱ^sⁱ^oⁿ^of^l^a^w
^wⁱ^t^h^no^sunse^t^d^a^t^e^.
^Secoⁿ^d^{, states ar}^{e r}^e^q^u^ir^e^d^to^p^r^o^v^id^{e T}^M^A^to^f^a^m^{ilies lo}^sin^g
^M^e^dⁱ^caid^elig^ib^ility^f^o^r^w^o^r^k^-^r^elated^r^easoⁿ^{s. W}^h^{ile Secti}^oⁿ
^{1902(e)(1) of}^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t^perm^an^en^t^l^y^requⁱ^r^es^s^t^at^es
ⁱ^{ki/CRS-RL33251}^to^p^r^o^v^id^{e f}^o^u^r^m^oⁿ^t^h^s^o^f^T^M^A^to^f^a^m^{ilies lo}^sin^g^Medⁱ^caid^elig^ib^ility^d^u^{e to}^anⁱⁿ^c^r^e^a^s^{e in}^h^o^u^r^{s o}^f^w^o^r^k^o^rⁱⁿ^co^m^e^f^r^o^m
^g/w^em^pl^oy^m^eⁿ^t^{, t}^h^{e F}^a^mⁱ^l^y^S^u^pport^A^c^t⁽^FSA^{) of}^{1988 ex}^pan^d^ed
^s^.or^s^t^at^{e T}^M^A^requⁱ^r^em^en^t^s^uⁿ^d^er^S^ectⁱ^oⁿ¹⁹²⁵^of^t^h^{e S}^o^ci^al^S^ecu^ri^t^y
^le^ak^Ac^t^.^A^s^{a res}^u^{lt, s}^t^ates^{are cu}^rren^tly^requ^{ired to prov}^{ide at leas}^t
^://wiki^six^,^an^d^u^p^to¹²^,^m^oⁿ^t^h^s^o^f^T^M^A^co^v^e^r^a^g^e^to^f^a^m^{ilies lo}^sin^g^Medⁱ^caid^elig^ib^ility^d^u^{e to}ⁱⁿ^cr^eased^h^o^u^r^{s o}^f^w^o^r^k^o^rⁱⁿ^co^m^e
^h^ttp^f^r^o^m^em^p^l^o^y^m^eⁿ^t^{, as w}^e^{ll as to}^f^a^m^{ilies w}^h^o^lo^{se elig}^ib^ilit^y^d^u^e
^{to th}^{e los}^s^of^{a tim}^e-^lⁱ^m^{ited earn}^e^{d in}^com^e^dis^r^eg^{ard (s}^u^c^h
^dis^r^eg^ards^h^a^v^e^th^{e ef}^f^{ect of}ⁱⁿ^creasⁱⁿ^g^th^{e in}^com^e^lev^e^{l at w}^h^ich
^{a f}^a^m^ily^m^a^y^q^u^alif^y^f^o^r^Medⁱ^caid⁾^{. FSA}^o^r^igⁱⁿ^ally^au^th^o^r^ized
^S^ection^{1925 to replace th}^e^fo^ur^-m^on^th^T^M^A^requ^irem^en^{t in}
^S^ectⁱ^oⁿ^{1902(e)(1) t}^h^ro^{ugh FY}^{1998. H}^o^w^e^v^e^{r, t}^h^{e s}^uⁿ^s^et^dat^e^f^o^r
^S^ection^{1925 h}^a^s^been^ex^ten^d^ed^{a n}^u^m^{ber of}^tim^es^{, m}^o^s^t^recen^tly
^thr^o^{ugh Decem}^b^e^r³¹^,^2005.
^E^m^erg^eⁿ^c^y^Serv^{ices F}^u^rⁿⁱ^sh^ed^b^y^Medi^cai^{d l}^a^w^provⁱ^d^es^cert^aⁱⁿ^prot^ectⁱ^oⁿ^s^f^o^{r ben}^e^fⁱ^ci^arⁱ^e^s^S^ecti^oⁿ^6085(a).^A^Medi^cai^{d prov}ⁱ^d^{er t}^h^at^doesⁿ^o^t
ⁿ^-^C^oⁿ^t^r^act^Pro^v^id^{ers f}^o^{r M}^e^dⁱ^caid^eⁿ^r^o^l^l^e^dⁱⁿ^m^a^na^ge^d^c^a^r^e^,ⁱⁿ^c^l^udⁱ^{ng a}^ssurⁱ^{ng c}^o^ve^r^a^ge^o^f^h^a^v^e^{a con}^t^{ract w}^ith^{a Medicaid m}^aⁿ^a^g^e^{d care e}ⁿ^tⁱ^ty
^aⁿ^a^g^e^d^{Care En}^ro^llees.^em^erg^eⁿ^c^y^s^e^rv^ices^uⁿ^d^er^each^m^aⁿ^a^g^e^{d care con}^t^{ract aw}^{arded by}^(MC^E^{) th}^{at f}^u^rn^is^h^e^s^em^erg^eⁿ^c^y^c^a^r^{e to a ben}^e^fⁱ^ciary
^th^{e s}^t^ate.^en^{rolled w}^ith^t^h^{at MC}^{O m}^u^s^t^{accept as}^pay^m^en^{t in}^f^u^ll

CRS-97
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
ⁿ^o^m^o^r^e^th^an^th^{e am}^o^uⁿ^t^o^t^h^e^r^w^{ise ap}^p^licab^le^o^u^tsid^e^o^f
^m^aⁿ^a^g^e^{d care}^(e.g^.,ⁱⁿ^th^{e f}^ee-^f^o^r-^s^e^rv^{ice s}^e^ttin^g⁾^mⁱⁿ^u^s
^an^y^pay^m^en^ts^f^o^{r in}^direct^cos^t^s^of^m^e^{dical edu}^cation^an^d
^di^r^e^c^t^cos^t^s^of^g^r^adu^a^{te m}^e^{dical edu}^cation^.^A^l^s^o^{, in}^a
^s^t^{ate w}^h^{ere rates}^{paid to h}^o^s^pⁱ^t^als^uⁿ^d^{er th}^{e s}^t^ate
^Medicai^d^p^l^an^{are n}^e^g^o^{tiated by}^con^t^{ract an}^{d n}^o^t
^pu^blicly^releas^{ed, th}^{e pay}^m^en^t^am^ouⁿ^t^{applicable u}ⁿ^d^er
^th^is^prov^is^ion^m^u^s^t^b^e^t^h^{e av}^erag^{e con}^t^{ract rate th}^at
^w^o^u^l^{d apply}^uⁿ^d^{er th}^{e s}^t^{ate plan}^fo^r^g^eⁿ^e^{ral acu}^{te care}
^h^o^s^p^itals^{or th}^{e a}^v^e^r^ag^{e con}^t^{ract rate th}^{at w}^o^u^l^{d apply}
ⁱ^{ki/CRS-RL33251}^uⁿ^d^er^th^{e p}^l^an^f^o^r^ter^tiar^y^h^o^sp^itals.^T^hⁱ^s^provⁱ^sⁱ^oⁿⁱ^s^ef^f^ectⁱ^v^{e on}^Jan^u^a^ry^{1, 2007.}
^g/w
^s^.or^E^x^pa^ns^{ion of home}^a^{nd c}^o^mmunity^-^{Medicaid h}^o^m^e^an^{d com}^m^uⁿⁱ^t^y^-b^as^{ed s}^e^rv^{ice (HC}^B^{S) w}^a^iv^ers^S^ecti^oⁿ^6086.^T^h^{e con}^f^eren^{ce ag}^reem^en^{t es}^tablis^hes
^le^ak^servⁱ^ces.^au^t^h^ori^{zed by}^S^ectⁱ^oⁿ^{1915(c) of}^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t^al^l^o^w^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed s}^e^rv^ices^as^an^option^a^l
^s^t^ates^{to prov}^{ide h}^o^m^e^an^d^com^m^uⁿ^ity^-^b^as^ed^s^e^rv^ices^{to Medicaid}^M^e^dⁱ^caid^b^eⁿ^e^f^{it th}^{at w}^o^u^l^dⁿ^o^{t r}^e^q^u^ir^{e a w}^a^iv^er^aⁿ^d
^://wiki^ben^e^fⁱ^ciaries^w^h^{o w}^o^u^l^d^oth^e^rw^is^{e n}^{eed th}^{e lev}^e^{l of}^{care prov}^ided^th^{at m}^eets^certain^oth^e^{r requ}^irem^en^ts^f^o^{r in}^divⁱ^du^als
^h^ttpⁱⁿ^aⁿ^u^r^sⁱⁿ^g^f^a^cility^,ⁱⁿ^t^e^r^m^e^dⁱ^a^t^e^c^a^r^e^f^a^c^ility^f^o^r^p^e^r^s^oⁿ^{s w}^ith^w^h^os^eⁱⁿ^c^o^m^e^doe^sⁿ^o^t^ex^ceed^150%^of^t^h^e^f^e^de^r^a^l
^m^eⁿ^t^{al r}^e^tar^d^atioⁿ⁽^I^C^F-^MR)^o^r^h^o^sp^{ital. HCB}^S^w^a^iv^er^ser^v^ices^p^o^v^er^ty^lev^e^{l. T}^h^{e sco}^p^e^o^f^ser^v^ice^s^m^a^yⁱⁿ^clu^d^{e an}^y
^canⁱⁿ^clu^d^{e cas}^{e m}^aⁿ^a^g^e^m^eⁿ^t^{, h}^o^m^e^m^a^k^e^r/h^o^m^e^h^ealth^aide^s^e^rv^ices^perm^{itted u}ⁿ^d^{er Section}^1915(c)(4)(B^{) of}^th^e
^ser^v^{ices, p}^e^r^s^oⁿ^{al car}^{e, p}^s^y^c^h^o^so^cial^r^e^h^a^b^ilitatioⁿ^,^h^o^m^e^h^ealth^,^So^cial^Secu^r^ity^A^c^{t w}^h^ich^th^{e Secretary}^h^a^s^th^{e au}^th^ority
^p^r^iv^{ate d}^u^tyⁿ^u^r^sin^g^,^ad^u^{lt d}^a^y^car^{e, h}^a^b^ilitatioⁿ^,^r^e^sp^ite^car^{e, d}^a^y^t^o^approv^e,^an^{d w}^o^u^l^{d n}^o^tⁱⁿ^cl^u^d^{e an}ⁱⁿ^di^vⁱ^du^al^’^s^room
^treatm^eⁿ^t^{, an}^{d an}^y^oth^e^{r s}^e^rv^ice^r^e^qu^es^{ted by}^th^{e s}^t^{ate an}^d^an^{d board. T}^h^e^st^at^{e m}^a^y^provⁱ^d^{e t}^hⁱ^s^optⁱ^oⁿ^t^o
^a^p^p^r^o^v^e^d^by^th^{e Secretary}^.^A^s^{part of}^th^{e w}^a^iv^{er, s}^t^ates^m^a^yⁱⁿ^dⁱ^vⁱ^d^u^{als w}ⁱ^th^o^u^{t d}^e^ter^mⁱⁿⁱⁿ^g^th^{at b}^u^{t f}^o^r^th^e
^defⁱⁿ^e^th^e^s^e^rv^ices^th^at^w^ill^{be of}^f^e^{red, targ}^{et a s}^p^ecifⁱ^{c popu}^lation^provⁱ^sⁱ^oⁿ^of^s^u^ch^s^e^rvⁱ^ces^{, t}^h^{e pers}^on^w^o^u^l^{d requ}ⁱ^r^{e t}^h^e
⁽^e^.g^.^,ⁱⁿ^dⁱ^vⁱ^d^u^{als w}^ith^d^e^v^e^lo^p^m^en^{tal d}ⁱ^sab^ilities)^o^r^{a sp}^ecifⁱ^c^l^e^ve^l^o^f^c^a^r^e^p^r^o^vⁱ^d^e^dⁱⁿ^a^ho^spⁱ^t^a^l^,^nur^si^{ng ho}^m^e^,^o^r
^g^e^o^g^r^a^p^h^{ic r}^e^gⁱ^oⁿ^{, an}^d^lim^{it th}^{e n}^u^m^b^e^r^o^f^w^a^iv^er^p^a^r^ticip^an^ts^IC^F^-^MR^.

⁽^r^esu^ltin^gⁱⁿ^{a w}^a^itin^g^{list f}^o^r^ser^v^{ices in}^m^aⁿ^y^states)^.
^A^pprov^{al f}^o^{r a HC}^B^S^w^a^iv^er^is^con^tin^g^eⁿ^t^on^{a s}^t^{ate docu}^m^en^tin^g

CRS-98
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^th^{e co}^st-ⁿ^eu^tr^ality^o^f^th^{e w}^a^iv^er^{. Co}^st-ⁿ^eu^tr^ality^is^m^e^t^if^{, o}ⁿ
^av^erag^{e, th}^{e per pers}^on^cos^t^uⁿ^d^er^th^e^HC^B^S^w^a^iv^{er is}ⁿ^o^hⁱ^g^h^e^r
^th^an^th^{e co}^{st if}^th^e^p^e^r^s^oⁿ^w^e^r^e^r^e^sidⁱⁿ^gⁱⁿ^oⁿ^e^o^f^th^{e th}^r^{ee ty}^p^e^s
^o^fⁱⁿ^stitu^ti^oⁿ^s^id^en^tif^iedⁱⁿ^Medⁱ^caid^law^,⁽^h^o^s^p^{ital, n}^u^r^sin^g
^f^acility^o^r^I^C^F-^MR)^.^T^h^{e state}^d^e^t^e^r^mⁱⁿ^{es w}^h^ich^ty^p^e^o^f
ⁱⁿ^stitu^tioⁿ⁽^s)^{it w}^{ill u}^s^{e to}^m^a^k^e^th^{e co}^st-ⁿ^eu^tr^ality^calcu^latioⁿ^.^A
^HC^B^S^w^a^iv^er^is^g^eⁿ^e^rally^approv^{ed f}^o^{r a th}^ree-^{or f}ⁱ^v^e^-^y^ear^tim^e
^p^e^rⁱ^o^d^an^d^{is su}^b^j^ect^to^ad^d^itioⁿ^a^{l o}^v^er^sig^h^t^f^r^o^m^th^{e Cen}^t^er^{s f}^o^r
^{Medicare an}^{d Medicai}^{d S}^e^rvⁱ^ces^(C^MS^).
ⁱ^{ki/CRS-RL33251}^E^s^t^a^b^lish^m^en^t^o^f^Need^s-^Based^Crit^e^rⁱ^a^.^No^p^r^o^v^isioⁿ^S^tates^th^at^o^f^f^e^r^t^hⁱ^sⁿ^e^w^b^eⁿ^e^fⁱ^t^m^u^s^t^estab^lishⁿ^eed^s-^b^a^sed^cr^iterⁱ^a^to^d^e^ter^mⁱⁿ^{e an}ⁱⁿ^dⁱ^vⁱ^d^u^al’^s^elig^ib^ility^f^o^r
^g/w^HC^B^S^s^e^rv^ices^{, an}^{d th}^{e s}^p^ecifⁱ^{c HC}^B^S^th^{e in}^divⁱ^du^al
^s^.or^w^{ill receiv}^e^{. T}^h^{e state m}^u^{st also}^e^s^t^a^b^lⁱ^s^hⁿ^eed^s-^b^a^sed
^le^ak^{criteria f}^o^{r determ}ⁱⁿⁱⁿ^g^w^h^eth^e^{r an}ⁱ^ndivⁱ^du^{al requ}^ires
^th^{e lev}^e^{l o}^f^car^{e p}^r^o^vⁱ^d^edⁱⁿ^{a h}^o^sp^{ital, n}^u^r^sin^g^h^o^m^e^,
^://wiki^IC^F-^MR^{, or u}ⁿ^d^er^a^w^a^iv^{er of}^th^{e s}^t^{ate plan}^{, th}^{at is}^m^o^re
^h^ttp^s^t^rin^g^eⁿ^t^th^an^th^{e n}^eeds^-^bas^e^d^{criteria f}^o^{r th}^{e HC}^B^S
^o^p^tioⁿ^estab^lish^e^d^b^y^th^{is p}^r^o^v^isioⁿ^.
^T^h^e^ne^e^d^s-b^a^se^d^c^r^ite^rⁱ^a^m^u^{st b}^e^b^a^se^d^oⁿ^aⁿ^a^sse^ssm^eⁿ^t
^of^anⁱⁿ^divⁱ^du^al^’s^s^u^ppor^{t n}^eeds^an^{d capabilities}^,^an^d
^m^a^y^tak^eⁱⁿ^to^acco^uⁿ^t^th^{e in}^ab^ility^o^f^th^{e in}^dⁱ^vⁱ^d^u^{al to}
^p^e^r^f^o^r^m^tw^o^o^r^m^o^r^e^activ^{ities o}^f^d^a^ily^livⁱⁿ^g⁽^A^DL^s)^as
^defⁱⁿ^e^{d i}ⁿ^t^h^e^In^t^e^rn^al^R^e^v^eⁿ^u^e^S^e^rvⁱ^{ce (IR}^S⁾^{code (i}^.e.,
^b^a^thⁱⁿ^g^,^d^r^essin^g^,^tr^an^sf^er^rⁱⁿ^g^,^to^iletin^g^,^eatin^g^,^an^d
^con^tin^en^{ce), or th}^{e n}^{eed f}^o^{r s}ⁱ^gⁿⁱ^fⁱ^can^{t as}^sⁱ^s^t^an^{ce to}
^p^e^r^f^o^r^m^th^{ese activ}^{ities, an}^d^o^t^h^e^r^rⁱ^sk^f^acto^r^s
^det^e^rmⁱⁿ^{ed t}^o^{be appropri}^a^t^e^by^t^h^{e s}^t^at^e

CRS-99
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^Pro^j^ect^ed^Nu^mb^{er o}^f^En^ro^{llees in}^t^h^e^N^o^provⁱ^sⁱ^oⁿ^.^A^st^a^t^e^m^a^y^lⁱ^mⁱ^t^t^h^{e n}^u^m^{ber of}ⁱⁿ^di^vⁱ^du^al^s^w^h^o^can
^e^fⁱ^t^an^d^M^o^dⁱ^fⁱ^cat^ioⁿ^o^f^Need^s^-^Based^p^a^r^ticip^{ate in}^th^is^b^eⁿ^e^f^{it an}^d^estab^lish^w^a^itin^g^{lists. T}^h^e
^eria.^s^t^{ate m}^u^s^t^s^u^bm^{it to}^th^e^Secretary^th^{e proj}^{ected n}^u^m^ber
^o^fⁱⁿ^dⁱ^vⁱ^d^u^{als w}^h^o^w^{ill receiv}^e^HCB^S^serv^{ices u}ⁿ^d^{er th}^is
^o^p^tioⁿ^.
^If^th^e^en^rollm^en^{t in}^th^{e HC}^B^S^option^ex^ceeds^th^e
^proj^ect^e^d^en^rollm^en^{t, a s}^t^{ate m}^a^y^m^odif^y^th^{e n}^eeds^-
^bas^e^{d criteria. T}^h^{e s}^t^ateⁱ^s^no^t^requ^{ired to s}^eek^prior
^approv^{al of}^th^{e Se}^c^r^e^t^ary^if^th^{e s}^t^{ate w}ⁱ^s^h^es^{to m}^odif^y
ⁱ^{ki/CRS-RL33251}^th^{e n}^eeds^-^bas^e^{d criteria, bu}^{t m}^u^s^t^gⁱ^v^e^th^e^Secretary^an^d^t^h^{e pu}^blⁱ^c^at^l^eas^t^{60 day}^sⁿ^o^tⁱ^{ce of}^t^h^{e propos}^ed
^g/w^m^odi^fⁱ^catⁱ^oⁿ^.
^s^.or
^le^ak^If^{a s}^t^{ate m}^odifⁱ^e^s^t^h^{e n}^eeds^-^bas^e^{d criteria, ex}^is^tin^g
^://wiki^recipien^ts^of^the^HC^B^S^option^a^{l s}^t^{ate plan}^s^e^rv^ices^w^ill^c^o^ntⁱⁿ^u^e^{to be elig}^{ible to receiv}^e^th^os^{e s}^e^rv^ices^f^o^{r a}^t
^h^ttp^l^e^a^s^t¹²^m^o^nt^{hs b}^e^giⁿⁿⁱ^ng^oⁿ^t^h^e^d^a^t^e^t^h^eⁱⁿ^dⁱ^vi^d^u^a^l^fi^r^s^t
^r^eceiv^e^{d m}^e^{dical as}^sⁱ^s^t^an^{ce f}^o^{r HC}^B^S^s^e^rv^ices^{. A}^f^t^e^r
^s^u^ch^a^m^odifⁱ^cation^,^th^{e s}^t^{ate, at a m}ⁱⁿⁱ^m^u^m^,^m^u^s^t^apply
^th^{e lev}^e^{l o}^f^car^{e d}^e^ter^mⁱⁿ^atioⁿ^f^o^r^h^o^sp^itals^{, n}^u^r^sin^g
^f^{acilities, an}^d^I^C^F-^MRs^t^h^a^t^w^e^r^eⁱⁿ^ef^f^{ect p}^r^io^r^to^th^e
^ap^p^licatioⁿ^o^f^m^o^r^e^strⁱⁿ^g^eⁿ^t^cr^iterⁱ^a.
^Independent^Ev^aluatⁱ^{on of}^Eligibilit^y^.^No^p^r^o^v^isioⁿ^.^A^s^t^a^t^{e is r}^e^q^u^ir^ed^to^u^s^e^anⁱⁿ^d^e^p^eⁿ^d^en^t^ev^alu^a^ti^oⁿ^f^o^r
^d^e^ter^mⁱⁿⁱⁿ^g^anⁱⁿ^dⁱ^vⁱ^d^u^al’^s^elig^ib^ility^f^o^r^th^{e HCB}^S
^optⁱ^oⁿ^.^T^h^{e in}^depen^d^en^{t ev}^alu^a^tion^m^u^s^tⁱⁿ^clu^d^{e an}
^as^s^e^s^s^m^{ent of}^th^{e n}^eeds^of^th^{e in}^divⁱ^du^{al to: (1)}
^det^e^rmⁱⁿ^{e a n}^eces^s^a^ry^l^e^v^e^l^of^servⁱ^ces^an^{d s}^u^pport^s
^con^s^is^ten^t^w^ith^th^eⁱⁿ^divⁱ^du^al’^s^ph^y^s^{ical an}^{d m}^eⁿ^t^al

CRS-100
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^capacity^{; (2) prev}^en^{t u}ⁿⁿ^eces^s^a^ry^{or in}^{appropriate care,}
^an^d⁽³⁾^estab^lish^anⁱⁿ^dⁱ^vⁱ^d^u^alize^d^c^a^r^{e p}^l^an^f^o^r^th^e
ⁱⁿ^di^vⁱ^du^al^.
^In^d^e^p^eⁿ^d^eⁿ^t^A^ssessmen^t^Pro^cess.^No^p^r^o^v^isioⁿ^.^A^{state is r}^e^q^u^ir^ed^uⁿ^d^er^th^{e HCB}^S^o^p^tioⁿ^to^coⁿ^d^u^c^t^an
ⁱⁿ^d^e^p^eⁿ^d^en^{t assessm}^en^{t o}^f^th^eⁱⁿ^dⁱ^vⁱ^d^u^{al. T}^h^is
ⁱⁿ^depen^d^en^{t as}^s^e^s^s^m^en^{t m}^u^s^tⁱⁿ^c^l^u^d^{e (1) an}^obj^ectiv^e
^ev^alu^a^tioⁿ^o^f^anⁱⁿ^dⁱ^vⁱ^d^u^al’^sⁱⁿ^ab^ility^o^rⁿ^eed^f^o^r
^sigⁿⁱ^fⁱ^can^t^a^ssistan^{ce to}^p^e^r^f^o^r^m^tw^o^o^r^m^o^r^e^activ^ities
^o^f^d^a^ily^livⁱⁿ^g^{as d}^e^fⁱⁿ^e^dⁱⁿ^th^{e I}ⁿ^terⁿ^{al Rev}^eⁿ^u^e^Ser^v^ice
ⁱ^{ki/CRS-RL33251}^{code; (2) a f}^ace-^to-^f^{ace ev}^alu^a^ti^oⁿ^o^f^th^{e in}^divⁱ^du^{al by}^anⁱⁿ^divⁱ^du^al^train^e^{d in}^th^{e as}^s^e^s^s^m^en^{t an}^d^ev^alu^a^tion^of
^g/wⁱⁿ^dⁱ^vⁱ^d^u^als^w^h^o^s^{e p}^h^y^s^{ical o}^r^m^eⁿ^t^{al co}ⁿ^d^itioⁿ^s^tr^ig^g^e^r
^s^.or^{a poten}^{tial n}^{eed f}^o^{r HC}^B^S^{; (3}⁾^w^h^{ere appropriate,}
^le^ak^coⁿ^s^u^ltatioⁿ^w^ith^th^{e in}^dⁱ^vⁱ^d^u^a^l^’^s^f^a^m^ily^{, sp}^o^u^se,
^g^u^a^rdi^aⁿ^,^{or ot}^h^e^{r res}^pon^sⁱ^bl^{e i}ⁿ^di^vⁱ^du^al^;⁽⁴⁾
^://wiki^coⁿ^s^u^ltatioⁿ^w^ith^{all tr}^eatin^g^an^d^coⁿ^s^u^l^tⁱⁿ^g^h^ealth^an^d
^h^ttp^s^u^pport^prof^es^sⁱ^on^al^s^cariⁿ^g^f^o^{r t}^h^{e i}ⁿ^di^vⁱ^d^u^a^l^;^{(5) an}
^ex^amⁱⁿ^atioⁿ^o^f^th^{e in}^dⁱ^vⁱ^d^u^al’^s^r^e^lev^aⁿ^t^hⁱ^sto^r^y^an^d
^m^e^di^cal^records^,^an^{d car}^e^an^{d s}^u^pportⁿ^eeds^g^uⁱ^{ded by}
^bes^t^practices^an^{d res}^earc^h^oⁿ^ef^f^ectiv^{e s}^t^rategⁱ^es^th^at
^r^e^su^{lt in}^im^p^r^o^v^ed^h^ealth^an^d^q^u^ality^o^f^lif^{e o}^u^tco^m^es.
^T^h^{e assessm}^en^{t m}^u^{st also}^ev^alu^a^{te t}^h^e^a^bⁱ^lity^o^f^th^e
ⁱⁿ^dⁱ^vⁱ^d^u^{al o}^rⁱⁿ^dⁱ^vⁱ^d^u^al’^s^r^e^p^r^esen^tativ^e^to^self^-^d^ir^ect^th^e
^p^u^r^c^h^a^{se an}^d^coⁿ^t^r^o^{l o}^f^HCB^S^if^h^e^/sh^e^{elects th}^is
^option^,^an^{d if}^s^u^ch^an^option^is^cov^e^{red by}^th^{e s}^t^ate.
^Indivⁱ^dua^lize^d^Ca^r^e^P^l^aⁿ^.^N^o^p^r^o^vⁱ^sⁱ^oⁿ^.^T^h^{e state m}^u^st^e^s^t^a^b^lⁱ^s^h^a^w^r^ittenⁱⁿ^dⁱ^vⁱ^d^u^alized^car^e
^p^l^an^f^o^r^{all in}^dⁱ^vⁱ^d^u^al^p^a^r^ticip^atin^gⁱⁿ^th^{e HCB}^S^o^p^tioⁿ^.
^T^h^e^car^e^p^l^an^m^u^{st b}^e^d^e^v^e^lo^p^e^dⁱⁿ^coⁿ^s^u^ltatioⁿ^w^ith^th^e

CRS-101
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
ⁱⁿ^di^vⁱ^du^al^{, t}^h^{e i}ⁿ^di^vⁱ^du^al^’^s^ph^y^sⁱ^cⁱ^aⁿ^an^{d ot}^h^e^r^h^eal^t^h
^{care an}^{d s}^u^pport^prof^es^sⁱ^on^al^s^,^an^{d w}^h^{ere appropri}^a^t^e
^th^{e in}^dⁱ^vⁱ^d^u^al’^s^f^a^m^ily^o^r^r^e^p^r^esen^tativ^{e. T}^h^{e ser}^v^ice
^p^l^an^m^u^{st tak}^eⁱⁿ^to^ac^c^o^uⁿ^{t ex}^istin^g^f^a^m^ily^o^r^o^t^h^e^r
^s^u^pports^{, iden}^tif^yⁿ^eces^s^a^ry^h^o^m^e^an^d^com^m^uⁿ^ity^-^b^as^ed
^s^e^rv^ices^{to be prov}^ided^,^aⁿ^d^{be rev}ⁱ^ew^{ed at leas}^t
^a^nnua^l^l^y^.
^S^t^a^t^e^Opti^{on to Offe}^r^S^e^l^f-Di^r^e^c^t^e^d^No^p^r^o^v^isioⁿ^.^Fo^r^t^h^{is n}^e^w^b^eⁿ^e^f^{it, a state m}^a^y^allo^w^anⁱⁿ^dⁱ^vⁱ^d^u^al^o^r
^ices.^th^{e in}^divⁱ^du^al’^s^repres^en^tativ^{e to receiv}^e^s^e^lf^-^dⁱ^r^e^c^ted
ⁱ^{ki/CRS-RL33251}^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed s}^e^rv^ices^.^If^th^{e s}^t^ate^p^e^r^m^{its self}^-^d^ir^ectioⁿ^,^th^er^{e m}^u^{st b}^e^an^assessm^en^{t o}^f^th^e
^g/wⁿ^eed^{s, cap}^ab^{ilities an}^d^p^r^ef^er^eⁿ^{ces o}^f^th^{e in}^dⁱ^vⁱ^d^u^al.
^s^.or^T^h^{ere m}^u^s^t^als^o^{be a}^s^e^rv^ice^plan^dev^e^{loped j}^oⁱⁿ^tly^w^ith
^le^ak^th^{e in}^divⁱ^du^{al th}^{at is}^approv^{ed by}^th^{e s}^t^ate.^T^h^e^s^e^rv^ice
^plan^m^u^s^t^s^p^ecif^y^th^{e s}^e^rv^ices^to^b^e^s^e^lf^-^d^irected,
^://wiki^id^en^tif^y^th^{e m}^e^th^o^d^o^f^self^-^d^ir^ectioⁿ^,^sp^ecif^y^th^{e r}^o^les^o^f
^h^ttp^v^a^ri^ou^s^partⁱ^e^s,^an^{d, i}^f^of^f^e^{red by}^t^h^{e s}^t^at^{e, an}
ⁱⁿ^divⁱ^du^{alized bu}^dg^{et f}^o^{r th}^e^va^l^u^e^of^th^{e s}^e^rv^ices^an^d
^s^u^pport^s^t^o^{be s}^e^l^f^-^dⁱ^r^ect^ed.
^Qua^lity^A^s^s^u^r^a^nc^e^a^{nd Conflic}^t^of^No^p^r^o^v^isioⁿ^.^T^h^{e state m}^u^st^eⁿ^s^u^r^e^t^h^a^t^th^{e p}^r^o^v^isioⁿ^o^f^h^o^m^e^an^d
^t^e^rest^St^an^d^a^rd^s.^c^o^m^m^uⁿ^ity^-^b^as^{ed s}^e^rv^ices^m^eets^s^t^{ate an}^{d f}^e^deral
^g^uⁱ^d^e^lin^{es f}^o^r^q^u^ality^assu^r^aⁿ^{ce. T}^h^{e state m}^u^{st also}
^estab^lish^stan^d^a^r^d^s^f^o^r^th^{e co}ⁿ^d^u^c^{t o}^f^th^{e in}^d^e^p^eⁿ^d^en^t
^ev^alu^a^tion^an^d^as^s^e^s^s^m^en^{t to s}^a^f^e^g^u^a^{rd ag}^ain^s^{t con}^f^lict
^o^fⁱⁿ^ter^e^st.
^Re^de^te^r^m^ina^t^ions^a^{nd A}^ppe^a^l^s^.^N^o^p^r^o^vⁱ^sⁱ^o^n.^A^t^l^e^a^s^t^a^nnua^l^l^y^,^t^h^e^st^a^t^e^m^u^st^r^e^d^e^t^e^r^mⁱⁿ^e^e^lⁱ^gⁱ^b^ility
^f^o^{r th}^is^ben^e^f^{it accordin}^g^{to th}^{e f}^r^equ^eⁿ^c^y^an^d^m^e^t^h^od

CRS-102
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^u^s^{ed f}^o^{r redeterm}ⁱⁿ^ation^s^an^{d appeals}^uⁿ^d^{er th}^e
^{Medicaid s}^t^{ate plan}^.
^T^h^{e state m}^a^y^p^r^o^v^id^{e p}^r^esu^m^p^tiv^{e elig}^ib^ili^ty^{, f}^o^r^u^p^to
^Presumptⁱ^v^e^Eligibilit^y^.^{60 day}^s^{, f}^o^{r i}ⁿ^di^vⁱ^du^al^s^w^h^{o t}^h^{e s}^t^at^{e bel}ⁱ^e^v^e^s^m^a^y^be
^elig^ibl^e^fo^r^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed s}^e^rv^ices^{. A}ⁿ
ⁱⁿ^divⁱ^du^{al m}^a^y^on^ly^receiv^e^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^ed
^s^e^rv^ices^w^h^{ile th}^{e ev}^alu^a^tion^an^{d as}^s^e^s^s^m^en^{t f}^o^r
^d^e^ter^mⁱⁿⁱⁿ^g^elig^ibⁱ^l^ity^f^o^r^th^{e HCB}^S^b^eⁿ^e^f^{it is car}^rⁱ^ed
^ou^t^.
ⁱ^{ki/CRS-RL33251}^{No E}^f^fe^c^t^{on Othe}^r^Wa^iv^e^r^A^u^thor^ity^.^T^h^is^p^r^o^v^isioⁿ^d^o^e^sⁿ^o^t^a^f^f^e^c^t^a^s^t^a^t^e’^{s o}^p^tioⁿ^to^o^f^f^e^r
^g/w^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed s}^e^r^v^ices^uⁿ^d^{er w}^a^iv^ers^of
^s^.or^Se^ctⁱ^oⁿ^s^{1915(c) or (d), or S}^ectⁱ^oⁿ^{1115 of}^t^h^{e S}^o^ci^al
^le^ak^Secu^rity^A^c^t
^://wiki^Continue^d^F^e^de^r^a^{l M}^e^dic^aⁱ^{d Funding}^F^e^d^e^r^a^l^M^e^dⁱ^c^aⁱ^d^fundⁱ^{ng c}^o^ntⁱ^nue^{s t}^o^b^e^a^v^aⁱ^l^a^b^l^e^fo^r
^h^ttp^Ce^r^t^aⁱ^{n Indiv}ⁱ^dua^ls^.^Medⁱ^caid^b^eⁿ^e^fⁱ^ciar^{ies w}^h^o^ar^{e r}^e^sidⁱⁿ^gⁱⁿ^anⁱⁿ^stitu^tioⁿ^,
^or^receivⁱⁿ^g^h^o^m^e^an^{d com}^m^uⁿ^ity^-^b^as^{ed s}^e^rv^ices^uⁿ^d^er
^a^w^aⁱ^v^er^of^S^ectⁱ^oⁿ^{1915(c), (d) or S}^ectⁱ^oⁿ¹¹¹⁵^of^t^hⁱ^s
^{act as}^of^th^{e ef}^f^ectiv^{e date of}^{a s}^t^{ate plan}^am^en^dm^en^t^th^at
^ad^d^s^th^{is HCB}^S^b^eⁿ^e^f^it,^wⁱ^t^h^o^u^{t r}^e^g^a^r^d^to^w^h^eth^e^r^th^e
ⁱⁿ^dⁱ^vⁱ^d^u^{al satisf}ⁱ^es^th^{e m}^o^r^e^strⁱⁿ^g^eⁿ^t^elig^ib^ility^cr^iterⁱ^a
^estab^lish^e^d^b^y^th^{is o}^p^tioⁿ^.^T^h^e^f^e^d^e^r^a^{l Med}ⁱ^caid^f^uⁿ^dⁱⁿ^g
^w^{ill b}^e^a^v^aⁱ^l^a^b^l^{e u}ⁿ^{til th}^{e in}^dⁱ^vⁱ^d^u^{al is d}ⁱ^sch^a^r^g^ed^f^r^o^m
^th^{e in}^stitu^tioⁿ^o^r^w^a^iv^er^p^r^o^g^r^a^m^,^o^rⁿ^o^loⁿ^g^e^r^r^e^q^u^ir^es
^s^u^ch^lev^e^{l of}^care
^Q^u^alit^y^o^f^{care measu}^res.^T^h^e^p^r^o^vⁱ^sⁱ^oⁿ^r^e^q^uⁱ^r^e^s^t^h^e^Se^c^r^e^t^a^r^y^a^c^tⁱ^ng^t^h^r^o^ugh^t^h^e
^{Director of}^th^{e A}^g^en^cy^f^o^{r Health}^{care R}^e^s^earch^an^d

CRS-103
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^Qu^ality^{, to}^coⁿ^s^u^{lt w}^ith^coⁿ^s^u^m^er^{s an}^d^h^ealth^an^d^so^cial
^s^e^rv^{ice prov}^iders^an^{d oth}^e^{r prof}^es^sⁱ^on^als^kⁿ^o^w^l^edg^eable
^abou^t^l^oⁿ^g^-^t^e^rm^{care s}^e^rvⁱ^ces^an^{d s}^u^pport^s^t^o^dev^e^l^o^p
^p^r^og^ram^perf^orm^aⁿ^{ce i}ⁿ^di^cat^ors^,^clⁱ^eⁿ^t^f^uⁿ^c^tⁱ^oⁿ
ⁱⁿ^dicators^,^an^{d m}^eas^u^r^es^of^clien^t^s^a^tis^f^action^reg^a^rdin^g
^H^C^BS^of^f^e^{red u}ⁿ^d^{er Medi}^cai^d.
^T^h^{e Sec}^r^e^t^a^r^y^is^requ^{ired to u}^s^{e th}^{e in}^dicators^an^d
^m^eas^u^r^es^{to as}^s^e^s^s^HC^B^S^an^{d o}^u^t^c^om^es^{, particu}^l^arly
^w^ith^r^e^s^p^e^c^t^{to a recipien}^t’^s^h^ealth^an^{d w}^e^lf^{are, an}^{d th}^e
ⁱ^{ki/CRS-RL33251}^ov^{erall s}^y^s^t^em^f^o^{r R}^C^B^S^uⁿ^d^er^Medicaid.^T^h^{e Secretary}^is^als^o^requ^{ired to m}^a^k^e^bes^t^practices^and^c^o^m^p^arativ^e
^g/w^an^aly^s^es^of^s^y^s^t^em^f^eatu^r^es^av^{ailable to th}^{e pu}^blic.
^s^.or
^le^ak^T^h^{e co}ⁿ^f^er^en^{ce ag}^r^eem^en^{t ap}^p^r^o^p^r^{iates $}¹^m^illioⁿ^f^o^r
^://wiki^t^h^{e peri}^{od of}^F^Y^2006-^F^Y^{2010 f}^o^{r t}^h^{e S}^ecret^ary^t^o^carry^o^u^{t th}^{ese activ}^ities.
^h^ttp^T^h^is^s^ection^w^o^u^l^{d be ef}^f^ectiv^{e f}^o^{r ho}^m^e^an^d
^com^m^uⁿ^ity^-^b^as^{ed s}^e^rv^ices^f^u^rn^is^h^e^{d on}^{or af}^ter^J^aⁿ^u^a^ry
^{1, 2007.}
^Optiona^{l Choic}^e^{of S}^e^lf-Dir^e^c^t^e^d^T^r^ad^itioⁿ^a^lly^{, Me}^dⁱ^caid^p^e^r^s^oⁿ^{al car}^{e ser}^v^{ices h}^a^v^e^b^een^p^r^o^v^id^ed^S^ecti^oⁿ^6087.^T^hⁱ^s^propos^al^w^o^u^l^{d al}^l^o^w^a^st^a^t^{e t}^o
^rsoⁿ^a^{l A}^ssist^an^{ce Serv}^{ices (}^C^ash^aⁿ^d^t^oⁱⁿ^dⁱ^vi^d^u^a^l^{s t}^h^r^o^ugh^l^o^c^a^l^p^u^b^lⁱ^c^o^r^p^rⁱ^v^a^t^e^a^g^eⁿ^cⁱ^e^s^.^H^o^w^e^ve^r^,^cov^e^r,^uⁿ^d^{er t}^h^{e Medi}^cai^{d prog}^ram^,^pay^m^en^t^f^o^r^part^or
^e^ling).ⁱⁿ^t^h^{e last d}^ecad^{e, Med}ⁱ^caid^b^eⁿ^e^fⁱ^{ciaries w}^ith^dⁱ^sab^ilities^o^r^{all of}^th^{e cos}^t^of^s^e^lf^-^dⁱ^r^{ected pers}^on^{al as}^sⁱ^s^t^an^ce
^ch^r^oⁿⁱ^c^coⁿ^d^itioⁿ^s^an^d^f^e^d^e^r^a^{l an}^d^{state p}^o^licy^m^ak^er^{s h}^a^v^e^b^een^ser^v^{ices (}^o^th^er^th^an^r^o^o^m^an^d^b^o^a^r^d⁾^b^a^sed^oⁿ^{a w}^r^itten
ⁱⁿ^creasⁱⁿ^g^th^{e dis}^c^retion^th^{at ben}^e^fⁱ^ciaries^h^a^v^e^ov^{er k}^e^y^elem^en^ts^pl^an^of^c^a^r^e^t^oⁱⁿ^di^vⁱ^du^al^s^f^o^{r w}^h^om^t^h^{ere h}^a^s^been^a
^of^th^{e s}^e^rv^ice^(e.g^.,^w^h^{at tim}^{e a pers}^on^{al care w}^o^rk^{er com}^e^s^{to th}^e^d^e^ter^mⁱⁿ^atioⁿ^th^{at, b}^u^{t f}^o^r^th^{e p}^r^o^v^isioⁿ^o^f^su^ch^ser^v^ices,
^h^o^m^e^{to help th}^{e ben}^e^fⁱ^ciary^,^w^h^{o prov}^ides^th^{e s}^e^rv^{ice, etc.)}^t^h^eⁱⁿ^divⁱ^du^als^w^o^u^l^{d requ}^{ire an}^{d receiv}^e^pers^on^{al car}^e
^T^h^es^{e ty}^pes^of^prog^ram^s^{are br}^oadly^kⁿ^o^wⁿ^as^`^s^elf^-^d^irected’^or^s^e^rv^ices^uⁿ^d^{er Medicaid s}^t^{ate plan}^o^r^ho^m^e^an^d
^`^c^on^s^u^m^e^r-^directed’^prog^ram^s^{. T}^h^{e s}^p^ecifⁱ^c^e^l^em^en^ts^th^{at a}^com^m^uⁿ^ity^-^b^as^ed^s^e^rv^ices^uⁿ^d^{er a HC}^B^S^w^a^iv^{er. Self}^-

CRS-104
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^Medi^cai^{d ben}^e^fⁱ^ci^ary^can^con^t^rol^v^a^ry^wⁱ^del^y^depen^dⁱⁿ^g^u^pon^t^h^e^{directed pers}^ona^l^as^sⁱ^s^t^an^{ce s}^e^rv^ices^m^a^yⁿ^o^{t be}
^s^t^{ate an}^{d th}^e^t^y^p^e^of^s^e^rv^{ice cov}^e^{red. C}^u^rren^tly^{, Medicaid law}^provⁱ^d^{ed t}^oⁱⁿ^di^vⁱ^du^al^s^w^h^{o res}ⁱ^{de i}ⁿ^{a h}^o^m^e^{or propert}^y
^allo^w^s^cer^tain^ty^p^e^{s o}^f^self^dⁱ^r^ected^p^r^o^g^r^a^m^s^to^b^e^im^p^l^em^en^ted^t^h^atⁱ^s^owⁿ^e^{d, op}^e^r^a^t^e^d^,^{or con}^t^rol^l^e^{d by}^{a prov}ⁱ^d^{er of}
^t^h^r^o^{ugh t}^h^e^no^r^m^a^l^M^e^dⁱ^c^aⁱ^d^st^a^t^e^p^l^aⁿ^aⁿ^d^H^C^B^S^w^aⁱ^v^e^r^s^e^rvⁱ^ces^{, n}^o^t^rel^a^t^e^{d by}^bl^{ood or m}^a^rri^a^g^e^.
^proces^s^.^Oth^e^{r ty}^pes^of^s^e^lf^-^d^{irected prog}^ram^s^requ^{ire a}^res^earch
^a^{nd dem}^oⁿ^s^t^r^atⁱ^oⁿ^w^aⁱ^v^{er u}ⁿ^d^{er S}^ectⁱ^oⁿ^{1115 of}^t^h^{e S}^o^ci^a^l
^Secu^r^ity^A^c^t.
^Gen^e^rally^{, C}^M^{S policy}^h^a^s^been^th^{at pay}^m^en^ts^f^o^r^pers^on^{al care}
⁽^o^r^sim^ilar⁾^ser^v^{ices d}^e^liv^er^ed^b^y^leg^a^lly^r^e^sp^oⁿ^sib^l^{e in}^dⁱ^vⁱ^d^u^als
ⁱ^{ki/CRS-RL33251}⁽^e^.g^{., th}^{e p}^a^r^eⁿ^t^o^f^{a m}ⁱⁿ^o^r^c^h^ild^o^r^{a sp}^o^u^se)^ar^{e n}^o^{t elig}^ib^{le f}^o^r^f^e^{deral Me}^dⁱ^{caid m}^a^tchⁱⁿ^g^f^uⁿ^d^s^.^How^e^v^e^{r, C}^M^{S h}^a^s^recen^tly
^g/w^a^m^eⁿ^d^e^dⁱ^t^s^p^o^lⁱ^c^y^so^t^h^a^t^und^e^r^a^H^C^B^S^w^aⁱ^v^e^r⁽^t^ho^{ugh no}^t^t^h^e
^s^.or^{Medicaid pers}^on^{al care ben}^e^f^it),^s^t^ates^h^a^v^e^th^{e option}^of^payⁱⁿ^g
^le^ak^leg^a^lly^res^pon^sⁱ^{ble relativ}^esⁱⁿ^ex^traordin^ary^circu^m^s^t^an^ces^w^h^en
^://wiki^th^{e p}^r^o^v^isioⁿ^o^f^p^e^r^s^oⁿ^{al car}^{e ser}^v^{ices is d}^e^ter^mⁱⁿ^ed^to^b^eⁿ^eces^s^a^ry^{to en}^s^u^{re th}^{e h}^ealth^an^{d w}^e^lf^{are of}^t^h^e^w^a^iv^er
^h^ttp^participan^t^an^d^s^o^lon^g^as^th^{e paren}^t^{or s}^pou^s^e^m^eets^th^e^Medicaid
^prov^{ider requ}^irem^en^ts^es^tablis^h^e^{d by}^th^{e s}^t^ate.
^St^at^{e Req}^uⁱ^remen^t^s.^T^h^{e s}^t^{ate m}^u^s^t^en^s^u^{re th}^{at th}^{e n}^eces^s^a^ry^s^a^f^e^g^u^a^rds^h^a^v^e
^been^tak^eⁿ^{to protect th}^{e h}^ealth^an^d^w^e^l^f^a^r^{e of}
ⁱⁿ^divⁱ^du^als^receivⁱⁿ^g^th^es^{e s}^e^rv^ices^a^{nd to as}^s^u^re
^fⁱⁿ^aⁿ^c^{ial acco}^uⁿ^t^ab^ility^f^o^{r f}^uⁿ^d^s^ex^p^eⁿ^d^ed^f^o^{r th}^ese
^s^e^rv^ices^.
^T^h^{e s}^t^{ate m}^u^s^t^a^l^s^o^e^v^alu^a^{te th}^{e n}^{eed f}^o^{r pers}^on^{al care}
^uⁿ^d^{er th}^{e Medicaid s}^t^{ate plan}^or^pers^on^{al s}^e^rv^ices^uⁿ^d^er
^{a HCB}^S^w^a^iv^er^f^o^rⁱⁿ^dⁱ^vⁱ^d^u^{als w}^h^o⁽¹⁾^ar^{e en}^titled^to
^{Medicaid pers}^on^a^l^{care u}ⁿ^d^{er th}^{e s}^t^{ate plan}^{or receiv}^e

CRS-105
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^HCB^S^w^a^iv^e^r^ser^v^{ices; (}²⁾^m^a^y^r^e^q^u^ir^{e self}^-^d^ir^ected
^pers^on^{al as}^sⁱ^s^t^an^{ce s}^e^rv^ices^{; an}^{d (3)}^m^a^y^be^elig^ible^f^o^r
^s^e^lf^-^d^{irected pers}^on^{al as}^sⁱ^s^t^an^{ce s}^e^rv^ices^{. If}^cov^e^{red by}
^the^s^t^a^t^{e an}^{d at th}^{e ch}^{oice of}^th^{e in}^divⁱ^du^{al, th}^os^{e w}^h^o
^{are lik}^ely^{to requ}^{ire pers}^on^{al care or HC}^B^S^w^a^iv^er
^ser^v^{ices m}^u^{st b}^eⁱⁿ^f^o^r^m^ed^o^f^th^{e f}^easib^{le alter}ⁿ^ativ^{es in}
^th^{e prov}^is^ion^o^f^M^e^dⁱ^{caid pers}^on^{al care s}^e^rv^ices^or
^pers^on^{al as}^sⁱ^s^t^an^{ce s}^e^rv^ices^uⁿ^d^{er a HC}^B^S^w^a^iv^er.
^T^h^{e s}^t^at^{e m}^u^s^t^pr^o^vⁱ^d^{e a s}^u^pport^s^y^s^t^em^t^h^at^en^s^u^res
ⁱ^{ki/CRS-RL33251}^p^a^r^ticip^an^{ts in}^th^e^p^r^o^g^r^a^m^ar^{e ap}^p^r^o^p^r^iately^assessed^an^{d cou}ⁿ^s^{eled prior to}^en^rollm^en^{t an}^{d are able to}^m^aⁿ^a^g^e
^g/w^t^h^eⁱ^r^b^u^d^g^e^t^s.^A^d^dⁱ^tⁱ^oⁿ^a^l^c^o^unse^lⁱ^{ng a}ⁿ^d^m^a^na^ge^m^e^nt
^s^.or^s^u^pport^m^a^y^be^provⁱ^d^{ed at}^t^h^{e requ}^es^t^of^t^h^{e part}ⁱ^cⁱ^p^an^t^.
^le^ak
^Re^por^ts^a^{nd E}^v^a^l^ua^tion.^St^a^t^e^s^t^h^a^t^e^l^e^c^t^t^hⁱ^s^o^p^tⁱ^o^{n m}^u^st^sub^mⁱ^t^aⁿ^a^nnua^l^r^e^p^o^r^t
^://wiki^{to th}^{e Secretary}^w^h^ichⁱⁿ^clu^d^e^s^t^h^{e n}^u^m^{ber of}
^h^ttpⁱⁿ^dⁱ^vⁱ^d^u^als^ser^v^ed^an^d^to^{tal ex}^p^eⁿ^d^itu^r^e^{s o}ⁿ^th^eir^b^e^h^a^lf^,
ⁱⁿ^th^{e ag}^g^r^eg^{ate. T}^h^e^s^t^{ate m}^u^s^t^als^o^prov^{ide an}
^ev^alu^a^tion^of^ov^{erall im}^{pact on}^th^{e h}^ealth^an^d^w^e^lf^are^of
^p^a^r^ticip^an^ts^co^m^p^ar^ed^toⁿ^oⁿ^-^p^a^r^ticip^an^{ts ev}^er^y^th^r^e^e
^y^ears^.
^Limit^s^t^o^t^h^{e A}^v^ailabilit^y^of^S^e^lf^-^A^s^t^{ate m}^a^y^prov^{ide s}^e^lf^-^d^{irected pers}^on^{al as}^sⁱ^s^t^an^ce
^ed^Serv^ices.^s^e^rv^ices^uⁿ^d^{er th}^{e s}^t^{ate plan}^w^ith^ou^{t reg}^a^{rd to th}^e
^{Medicaid requ}^irem^en^ts^f^o^{r s}^t^atew^iden^es^s^(uⁿ^d^{er Section}
^{1902(a)(1) of}^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t⁾^{, an}^{d m}^a^y^lⁱ^mⁱ^t^t^h^e
^popu^lation^elig^{ible to}^r^eceiv^e^th^es^{e s}^e^rv^ices^an^{d th}^e
ⁿ^u^m^{ber of}^pers^on^s^s^e^rv^ed^wⁱ^t^h^ou^t^reg^a^{rd t}^o^Medi^cai^d
^r^e^q^u^ir^e^m^eⁿ^t^s^r^e^g^a^r^dⁱⁿ^g^c^o^m^p^ar^ab^ility⁽^S^ectioⁿ

CRS-106
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^{1902(a)(10)(B) of}^t^h^{e S}^o^ci^al^S^ecu^ri^t^y^A^c^t⁾^.
^S^c^ope^{of S}^e^lf-Dir^e^c^t^e^d^P^e^r^s^ona^l^T^h^{e term}^`^s^elf^-^d^{irected pers}^on^{al as}^sⁱ^s^t^an^{ce s}^e^rv^ices^’
^an^{ce Serv}^ices.^m^ean^s^pers^on^al^c^a^r^{e an}^{d related s}^e^rv^ices^{, or HC}^B^S
^w^a^iv^{er s}^e^rv^ices^th^{at are}^p^r^o^v^id^ed^to^an^elⁱ^g^ib^le
^p^a^r^ticip^an^t^.^Iⁿ^dⁱ^vⁱ^d^u^{als p}^a^r^ticip^atin^gⁱⁿ^su^ch^ser^v^ices
^w^o^u^l^d^b^e^p^e^r^m^itted^,^w^ithⁱⁿ^an^a^p^p^r^o^v^ed^self^-^d^ir^ected
^s^e^rv^ices^plan^an^{d bu}^dg^{et, to}^pu^rch^a^s^e^pers^on^{al as}^sⁱ^s^t^an^ce
^an^{d related}^s^e^r^v^ices^{, an}^{d h}ⁱ^{re, f}ⁱ^{re, s}^u^perv^is^{e, an}^d
^m^a^na^ge^t^h^eⁱⁿ^dⁱ^vi^d^u^a^l^{s p}^r^o^vⁱ^dⁱ^{ng suc}^h^se^r^vⁱ^c^e^s^.
ⁱ^{ki/CRS-RL33251}^A^t^th^{e electio}ⁿ^o^f^th^e^state,^{a p}^a^r^ticip^an^{t is b}^e^allo^w^e^d^to
^g/w⁽¹⁾^c^h^oos^{e as}^{a paid s}^e^rv^{ice prov}^{ider, an}^yⁱⁿ^divⁱ^du^a^l
^s^.or^cap^ab^le^o^f^p^r^o^v^idⁱⁿ^g^th^{e assig}ⁿ^e^d^task^{s in}^clu^dⁱⁿ^g^leg^a^lly
^le^ak^{liable relativ}^es^{, an}^{d (2) u}^s^{e th}^{e in}^divⁱ^du^{alized bu}^dg^{et to}
^acq^uⁱ^r^e^item^s^th^{at in}^cr^{ease in}^d^e^p^eⁿ^d^en^{ce o}^r^su^b^s^titu^te
^://wiki^(su^c^h^{as a}^mⁱ^cro^w^av^e^o^v^en^o^r^an^accessib^ility^ram^p^{) f}^o^r
^h^ttp^h^u^m^an^as^sⁱ^s^t^an^{ce, to th}^{e ex}^ten^t^th^{at ex}^pen^d^itu^res^w^o^u^l^d
^oth^e^rw^is^{e be m}^a^{de f}^o^{r th}^{e h}^u^m^an^as^sⁱ^s^t^an^ce.
^Self^-^D^irect^ed^Serv^{ices Plan}^.^T^h^{e approv}^{ed s}^e^lf^-^d^{irected s}^e^rv^ic^e^s^p^l^an^dev^e^loped
^uⁿ^d^e^r^o^p^tioⁿ^m^u^{st m}^{eet th}^{e f}^o^llo^wⁱⁿ^g^r^e^q^u^ir^em^en^{ts: (}¹⁾
^T^h^{e p}^a^r^ticip^an^{t (}^o^r^hⁱ^s/h^e^r^g^u^a^r^d^ian^o^r^au^th^o^r^ized
^repres^en^ta^tⁱ^v^{e if}^{appropriate) ex}^ercis^e^s^ch^{oice an}^d
^con^t^rol^ov^{er t}^h^{e bu}^dg^et^{, pl}^anⁿⁱⁿ^g^,^an^{d pu}^rch^a^s^e^of^s^e^l^f^-
^{directed pers}^on^{al as}^sⁱ^s^t^an^{ce s}^e^rv^ices^{, in}^cl^udin^g^th^e
^am^ouⁿ^t^{, du}^ratⁱ^oⁿ^,^s^c^{ope, prov}ⁱ^d^{er an}^{d l}^o^catⁱ^oⁿ^of^s^e^rvⁱ^c^e
^prov^is^ion^;^{(2) T}^h^{ere is}^an^as^s^e^s^s^m^eⁿ^{t of}^th^{e n}^eeds^,
^s^t^ren^g^t^h^s^{, an}^{d pref}^eren^c^e^s^o^f^th^{e participan}^ts^f^o^{r s}^u^ch
^s^e^rvⁱ^ce;^{(3) A}ⁿⁱⁿ^di^vⁱ^du^al^{’s p}^l^aⁿ^fo^r^se^l^f-dⁱ^r^e^c^t^e^d

CRS-107
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^s^e^rvⁱ^ces^aⁿ^d^su^pport^s^{, w}^hⁱ^c^h^h^a^s^been^dev^e^l^{oped an}^d
^approv^{ed by}^t^h^{e s}^t^at^{e, i}^s^bas^e^{d on}^{a perso}ⁿ^-c^eⁿ^t^e^red
^assessm^en^{t p}^r^o^{cess th}^at^b^u^ild^{s u}^p^oⁿ^th^{e p}^a^r^ticip^an^t’^s
^cap^acity^to^en^g^a^g^eⁱⁿ^activ^{ities th}^{at p}^r^o^m^o^t^{e co}^m^m^uⁿ^ity
^lif^{e; res}^p^ects^th^{e participan}^t’^s^pref^eren^ces^,^c^hoices^an^d
^ab^{ilities; an}^dⁱⁿ^v^o^lv^{es f}^a^m^ilie^{s, an}^d^p^r^o^f^essioⁿ^{als in}^th^e
^pl^anⁿⁱⁿ^g^{or del}ⁱ^v^ery^of^s^e^rvⁱ^ces^{or s}^u^pport^s^as^desⁱ^red^or
^r^e^q^u^ir^ed^b^y^th^{e p}^a^r^ticip^an^t.
^S^e^{lf-Directed S}^e^rv^{ices Budget.}^T^h^{e bu}^dg^et^f^o^{r s}^e^l^f^-^dⁱ^r^e^c^t^e^{d s}^e^rvⁱ^ces^an^d^s^u^pport^s^m^u^s^t
ⁱ^{ki/CRS-RL33251}^{be dev}^e^l^{oped an}^{d approv}^{ed by}^t^h^{e s}^t^at^{e bas}^e^{d on}^t^h^e^as^s^e^s^s^m^en^t^and^pl^an^{, an}^{d on}^{a m}^e^t^h^odol^og^y^t^h^at^u^s^es
^g/w^v^a^lid^,^r^e^liab^l^e^co^{st d}^a^{ta, is o}^p^eⁿ^to^p^u^b^{lic in}^sp^ectioⁿ^,^an^d
^s^.orⁱⁿ^clu^d^es^{a calcu}^lation^of^th^{e ex}^{pected cos}^t^of^s^u^ch
^le^ak^s^e^rv^ices^if^th^os^{e s}^e^rv^ices^w^e^{re n}^o^{t s}^e^lf^-^d^{irected. T}^h^e
^bu^dg^{et m}^a^yⁿ^o^{t res}^t^ric^t^acces^s^{to oth}^e^{r m}^e^dically
^://wikiⁿ^eces^s^a^ry^{care an}^{d s}^e^rv^ices^f^u^rn^is^h^e^{d u}ⁿ^d^er^th^e^plan^an^d
^h^ttp^approv^{ed by}^th^{e s}^t^{ate bu}^{t n}^o^{t in}^clu^d^{ed in}^th^{e bu}^dg^et.
^A^pplic^a^t^{ion of Qua}^lity^A^s^s^u^r^a^nc^e^In^es^tablis^hⁱⁿ^g^an^{d im}^plem^en^tin^g^th^{e s}^e^l^f^-^d^irected
^k^M^a^na^ge^me^nt.^ser^v^{ices p}^l^an^an^d^b^u^d^g^{et, ap}^p^r^o^p^r^iate^q^u^ality^assu^r^aⁿ^c^e
^aⁿ^d^rⁱ^{sk m}^a^na^ge^m^e^nt^t^e^c^hni^q^u^e^s^m^u^st^b^e^use^d^w^hⁱ^c^h
^recogⁿⁱ^{ze th}^{e roles}^an^{d s}^h^arin^g^of^res^pon^sⁱ^bⁱ^lⁱ^tiesⁱⁿ
^obtainⁱⁿ^g^s^e^rv^icesⁱⁿ^{a s}^e^lf-dⁱ^r^{ected m}^aⁿⁿ^e^{r an}^{d w}^h^ich
^as^s^u^{re th}^{e appr}^o^p^rⁱ^a^ten^e^s^s^of^th^{e plan}^an^{d th}^{e bu}^dg^et,
^b^a^sed^oⁿ^th^{e in}^dⁱ^vⁱ^d^u^al’^s^r^e^so^u^r^{ces an}^d^cap^ab^ilities.

CRS-108
^Provisⁱ^on^{Current L}^a^w^C^onf^{erence Agreem}^{ent, as}^Pas^s^{ed by the Senate}
^Fina^nc^ia^{l M}^a^na^ge^me^{nt E}ⁿ^tity^.^A^{state m}^a^y^em^p^l^o^y^a^fⁱⁿ^aⁿ^cⁱ^a^l^m^aⁿ^a^g^e^m^eⁿ^t^en^tity^to
^m^a^k^e^pay^m^en^ts^{to prov}^iders^,^track^cos^t^s^,^an^{d m}^a^k^e
^r^e^p^o^r^{ts u}ⁿ^d^er^th^is^p^r^o^g^r^a^m^.^P^a^y^m^en^{t f}^o^r^th^{e activ}^{ities o}^f
^th^{e f}ⁱⁿ^aⁿ^c^{ial m}^aⁿ^a^g^e^m^eⁿ^t^eⁿ^tity^{is r}^e^im^b^u^r^s^ed^{at th}^e
^sam^e^r^a^{te as o}^t^h^e^r^Medⁱ^caid^ad^mⁱⁿⁱ^str^a^tiv^{e activ}^ities
^(g^en^erally^f^e^{deral Medicaid adm}ⁱⁿⁱ^s^t^rativ^e
^r^e^im^b^u^r^s^e^m^eⁿ^{t is 5}⁰^%,^tho^ugh^c^e^r^ta^{in a}^c^tivitie^{s m}^a^y^b^e
^elig^ib^{le f}^o^r⁷⁵^{% r}^e^im^b^u^r^s^em^en^t)^.
^Ef^f^ect^iv^{e d}^a^t^e^.^T^hⁱ^s^provⁱ^sⁱ^oⁿ^becom^e^s^ef^f^ectⁱ^v^{e on}^Jan^u^a^ry^{1, 2007.}

ⁱ^{ki/CRS-RL33251}
^g/w
^s^.or
^le^ak
^://wiki
^h^ttp

CRS-109
btitle B — State Children’s Health Insurance Program
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^A^d^dⁱ^tⁱ^oⁿ^a^{l allo}^t^m^en^t^s^t^o^elimin^at^{e F}^Y²⁰⁰⁶^S^ecti^oⁿ⁶¹⁰¹^{. Ou}^{t of}^m^oⁿ^e^yⁿ^o^{t oth}^e^rw^is^{e av}^ail^a^{ble in}
^hor^tfa^lls^.^th^{e T}^r^eas^u^r^y^,^th^{e C}^oⁿ^f^eren^{ce A}^g^reem^en^{t au}^t^h^o^rⁱ^zes^an^d
^appropri^a^t^e^s^$283,00⁰^,^{000 f}^o^{r t}^h^{e pu}^rpos^{e of}^provⁱ^dⁱⁿ^g
^ad^d^itioⁿ^a^{l SCHI}^P^allo^tm^en^{ts to}^sh^o^r^tf^{all states an}^d
^t^e^rri^t^o^ri^esⁱⁿ^F^Y^2006.^T^h^{e C}^oⁿ^f^eren^{ce A}^g^reem^en^t^defⁱⁿ^e^s
^s^h^ortf^{all s}^t^ates^as^th^os^{e w}^ith^an^approv^ed^SC^HIP^plan^f^o^r
^w^h^ich^(bas^{ed on}^th^{e m}^o^s^t^recen^{t SC}^HIP^d^a^t^a^a^s^of
ⁱ^{ki/CRS-RL33251}^Decem^{ber 31, 2005) th}^{e S}^ecretary^es^tim^ates^th^{at suc}^h
^g/w^s^t^ate’^s^F^Y^{2006 proj}^ected^ex^pen^d^itu^res^ex^{ceed th}^{e s}^u^m^of
^s^.or^al^l^f^uⁿ^d^s^av^ai^l^a^bl^{e f}^o^{r ex}^pen^dⁱ^t^u^{re by}^t^h^at^s^t^at^eⁱⁿ^F^Y²⁰⁰⁶
^le^akⁱⁿ^cl^u^dⁱⁿ^g^{(1) t}^h^{e am}^ount^,ⁱ^f^an^y^,^t^h^atⁱ^s^redi^s^t^ri^bu^t^e^{d t}^o
^s^u^ch^s^t^at^{e f}^r^om^uⁿ^s^pen^t^F^Y^{2003 ori}^gⁱⁿ^a^l^al^l^o^t^m^en^t^s
^://wiki^d^u^rⁱⁿ^g^F^Y^2006;^{(2) t}^h^{e am}^ouⁿ^t^of^s^u^ch^s^t^at^e’^s^F^Y²⁰⁰⁴
^h^ttp^an^{d FY2005 orig}ⁱⁿ^{al allotm}^en^ts^th^{at w}^{ill n}^o^t^be^ex^pen^d^ed
ⁱⁿ^F^Y^{2005 an}^{d t}^h^at^r^e^m^aⁱⁿ^av^ai^l^a^bl^{e f}^o^{r ex}^pen^dⁱ^t^u^{re i}ⁿ
^F^Y^2006;^an^{d (3) t}^h^{e am}^ou^nt^o^f^su^ch^s^t^at^e’^sⁿ^e^w^l^y
^av^ai^l^a^bl^{e F}^Y^{2006 ori}^gⁱⁿ^al^al^l^o^t^m^en^t^.
^From^th^{e addition}^a^{l FY2006}^SC^HIP^{appropriation}^,^af^{ter a}
^{1.05% s}^e^{t as}^{ide f}^o^r^dis^t^ribu^tion^am^on^g^th^{e territories}^{, each}
^F^Y^{2006 s}^h^ortf^{all s}^t^{ate w}^o^u^l^{d receiv}^e^an^allotm^en^{t to cov}^e^r
^its^p^r^o^j^ected^sh^o^r^tf^{all. Su}^ch^ad^d^itioⁿ^a^{l SCHI}^P^allo^tm^en^ts
^{are av}^ai^l^a^bl^{e f}^o^{r on}^{e y}^{ear on}^l^y^{. O}ⁿ^O^c^t^{ober 1, 2006, an}^y
^r^e^m^aⁱⁿⁱⁿ^g^uⁿ^s^p^eⁿ^t^ad^d^itioⁿ^a^{l allo}^tm^en^{ts w}ⁱ^l^lⁿ^o^{t b}^e
^su^b^j^{ect to}^r^e^dⁱ^strⁱ^b^u^tioⁿ^,^b^u^t^w^{ill in}^stead^r^e^v^e^r^t^to^th^e
^T^r^eas^u^r^y^.^T^h^{e C}^oⁿ^f^eren^{ce A}^g^reem^en^{t is}^s^ilen^t^on^h^o^w^th^e

CRS-110
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^Secr^etar^y^w^ill^dⁱ^strⁱ^b^u^{te th}^{e ad}^d^itioⁿ^a^{l ap}^p^r^o^p^r^iated^f^uⁿ^d^s
ⁱ^f^s^u^ch^f^u^nd^s^a^r^{e i}ⁿ^adequ^a^t^e^t^o^cov^e^{r t}^h^{e F}^Y²⁰⁰⁶
^proj^ect^{ed s}^h^ort^f^al^l^s^.
^{Use o}^f^A^d^dⁱ^tⁱ^oⁿ^a^{l F}^Y^{2006 A}^p^p^r^o^p^r^iatⁱ^oⁿ^Lⁱ^k^e^Medⁱ^caid^,^SCHI^Pⁱ^s^{a f}^e^d^e^r^a^{l -}^s^{tate m}^a^tchⁱⁿ^g^T^h^{e C}^oⁿ^f^eren^{ce A}^g^reem^en^{t lim}^its^th^{e ty}^pes^of^pay^m^en^ts
^{r Ch}^ild^Healt^h^A^ssist^aⁿ^c^e^f^o^{r T}^a^rg^et^ed^L^o^w^-^prog^ram^.^{For each}^{dollar of}^s^t^{ate s}^p^en^din^g^,^th^{e f}^e^deral^t^h^a^t^m^a^y^b^e^m^a^t^c^he^d^a^t^t^h^e^SCH^I^P^e^nha^nc^e^d^m^a^t^c^hi^{ng r}^a^t^e
^g^o^v^e^rⁿ^m^e^nt^m^a^ke^{s a}^m^a^t^c^hi^{ng p}^a^y^m^eⁿ^t^d^r^a^w^{n fr}^o^m^f^o^r^S^C^HI^P^ex^p^eⁿ^d^itu^r^e^{s d}^r^awⁿ^ag^ain^s^{t th}^{e ad}^d^itioⁿ^a^l
^SC^HIP^accouⁿ^t^s^.^T^h^{e f}^e^{deral g}^o^v^e^rn^m^eⁿ^t^con^t^ribu^tes^F^Y²⁰⁰⁶^a^p^propri^a^tⁱ^oⁿ^av^ai^l^a^bl^{e t}^o^s^h^ort^f^al^l^s^t^at^es^t^o
^m^o^r^e^to^w^a^r^d^th^e^co^v^e^r^a^g^e^o^fⁱⁿ^dⁱ^vⁱ^d^u^{als in}^SCHI^P^th^an^itⁱⁿ^clu^d^{e ch}^{ild h}^ealth^as^sⁱ^s^t^aⁿ^{ce pay}^m^en^ts^m^a^{de on}^beh^a^lf
^do^es^f^o^{r th}^os^{e cov}^e^{red u}ⁿ^d^{er Medicaid. A}^{ll SC}^HIP^o^f^tar^g^eted^lo^w^-ⁱⁿ^co^m^e^ch^ild^r^eⁿ^.
ⁱ^{ki/CRS-RL33251}^as^sⁱ^s^t^an^{ce f}^o^{r targ}^{eted low}^-ⁱⁿ^com^e^ch^ildren^,ⁱⁿ^clu^dⁱⁿ^g^claim^s^su^b^m^itted^an^d^ap^p^r^o^v^ed^b^y^{CMS f}^o^r^ex^p^eⁿ^d^itu^r^e^s^T^h^{e am}^en^dm^en^t^s^m^a^{de by}^th^is^s^ection^of^th^{e C}^oⁿ^f^eren^ce
^g/w^uⁿ^d^{er t}^h^{e S}^ectⁱ^oⁿ^{1115 w}^aⁱ^v^{er au}^t^h^ori^t^y^{, are m}^a^t^c^h^e^{d at}^A^g^r^e^e^m^eⁿ^t^appl^y^t^oⁱ^t^e^m^s^an^{d s}^e^rvⁱ^ces^f^u^rnⁱ^s^h^e^{d on}^or
^s^.or^th^{e en}^h^aⁿ^{ced f}^e^{deral m}^e^{dical as}^sⁱ^s^t^aⁿ^{ce percen}^tag^e^af^t^e^{r O}^c^t^{ober 1, 200}^{5, w}ⁱ^t^h^ou^t^reg^a^{rd t}^o^w^e^t^h^{er or n}^o^t
^le^ak⁽^e^nha^nc^e^d^{- FM}^A^P⁾^.^reg^u^l^ation^s^im^plem^en^tin^g^s^u^ch^am^en^dm^en^ts^h^a^v^e^been
^issue^d^.
^://wiki^T^{itle XXI}^o^f^th^{e So}^cial^Secu^r^ity^A^c^t^sp^ecifⁱ^{es th}^{at f}^e^d^e^r^a^l
^h^ttp^SC^HIP^f^uⁿ^d^s^can^{be u}^s^ed^f^o^r^ch^ild^h^ealth^as^sⁱ^s^t^an^{ce, th}^at
^m^eets^certain^requ^irem^en^ts^{. A}^p^{art f}^r^om^th^es^{e ben}^e^fⁱ^t
^pay^m^eⁿ^t^s^{, SC}^HIP^pay^m^en^ts^{at th}^{e en}^h^aⁿ^{ced FMA}^P^rate
^f^o^{r f}^o^u^r^oth^e^{r s}^p^ecifⁱ^{c h}^ealth^{care activ}^itⁱ^e^s^can^{be m}^a^de,
ⁱⁿ^clu^dⁱⁿ^g^{(1) oth}^e^{r ch}^{ild h}^eal^t^h^as^sⁱ^s^t^an^{ce f}^o^{r targ}^eted
^lo^w^-ⁱⁿ^c^o^m^e^ch^ild^r^eⁿ^;⁽²⁾^h^ealth^ser^v^{ices in}^itiativ^{es to}
^im^prov^{e th}^{e h}^ealth^of^targ^{eted low}^-ⁱⁿ^com^e^chⁱ^l^d^ren^an^d
^o^t^h^e^{r lo}^w^-ⁱⁿ^co^m^e^ch^ild^ren^;⁽³^{) o}^u^treach^activ^ities;^an^d⁽⁴⁾
^oth^e^{r reas}^on^{able adm}ⁱⁿⁱ^s^t^rativ^{e cos}^t^s^.
^P^r^o^hⁱ^bⁱ^tⁱ^oⁿ^a^g^aⁱ^ns^{t c}^o^v^e^rⁱ^{ng nonpr}^e^gna^nt^S^ectⁱ^oⁿ^{1115 of}^t^h^{e S}^o^cⁱ^a^l^S^ecu^ri^t^y^A^c^t^gⁱ^v^e^s^t^h^e^S^ecti^oⁿ⁶¹⁰²^{. T}^h^{e C}^oⁿ^f^eren^{ce A}^g^reem^en^{t lim}ⁱ^t^s^t^h^e
^wⁱ^{th S}^CHIP^funds^.^S^ecre^t^a^r^y^o^f^H^H^S^{broad au}^t^h^ori^t^y^t^o^m^odi^f^y^vⁱ^rt^u^a^l^l^y^al^l^S^ecret^ary^of^H^eal^t^h^an^{d H}^u^m^aⁿ^S^e^rvⁱ^ces^’^S^ectⁱ^oⁿ¹¹¹⁵
^as^pect^s^of^t^h^e^M^e^dⁱ^cai^{d an}^{d S}^C^H^I^{P prog}^ram^s^{. U}ⁿ^der^w^aⁱ^v^{er au}^t^h^ori^t^y^by^prohⁱ^bⁱ^tⁱⁿ^g^t^h^{e approv}^al^ofⁿ^e^w

CRS-111
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^S^e^c^tⁱ^oⁿ¹^115,^t^h^e^S^e^c^r^e^t^a^r^y^m^a^y^w^aⁱ^v^e^r^e^q^uⁱ^r^e^m^eⁿ^t^sⁱⁿ^w^a^iv^er^{, ex}^p^e^rⁱ^m^eⁿ^t^{al, p}^ilo^{t, o}^r^d^e^m^oⁿ^s^tr^atioⁿ^p^r^o^j^e^c^t^s
^Sectⁱ^oⁿ^{1902 (u}^s^u^al^l^y^{, f}^r^eedom^of^ch^oi^{ce of}^provⁱ^d^e^r^,^(approv^{ed on}^{or af}^t^e^{r O}^c^t^{ober 1, 2005) t}^h^at^al^l^o^w^f^e^deral
^co^m^p^ar^ab^ility^{, an}^d^s^t^atew^id^en^ess)^{. Fo}^r^SCHI^P^,ⁿ^o^sp^ecifⁱ^c^SCH^I^P^fund^{s t}^o^b^e^use^d^t^o^p^r^ov^{ide ch}^{ild h}^ealth^as^sⁱ^s^t^an^ce
^s^ection^s^{or requ}^irem^en^ts^{are cited as}^“^w^aiv^e^-^a^ble.”^SC^HIP^o^r^o^t^he^r^he^a^l^t^h^b^e^ne^fi^t^s^c^o^ve^r^a^ge^t^o^no^np^r^e^gna^nt^c^hⁱ^l^d^l^e^ss
^s^t^at^u^t^{e s}ⁱ^m^p^l^y^s^t^at^es^t^h^at^S^ectⁱ^oⁿ^{1115, pert}^aiⁿⁱ^ng^t^o^a^d^u^lts^{. T}^h^{e C}^oⁿ^f^eren^{ce A}^g^reem^en^{t allow}^s^th^{e Secr}^e^t^a^r^y
^res^earch^an^{d dem}^oⁿ^s^tration^proj^ects^,^applies^{to SC}^HIP^.^{to con}^tin^u^e^{to approv}^{e proj}^ects^th^{at ex}^pan^d^t^h^{e SC}^HIP
^p^r^og^ram^{to caretak}^{er relativ}^es^of^{Medicaid or SC}^H^I^P^-
^W^ith^r^e^sp^ect^to^SCHI^P^,^th^{e Clin}^toⁿ^A^d^mⁱⁿⁱ^str^a^tioⁿ^issu^ed^elⁱ^gⁱ^b^l^e^chⁱ^l^d^ren^(as^defⁱⁿ^e^{d u}ⁿ^d^e^r^Sectⁱ^oⁿ^1931of
^{a Ju}^l^y^{31, 2000, l}^e^t^t^e^{r reg}^a^rdiⁿ^g^t^r^eat^m^eⁿ^t^of^a^d^ul^t^s^.^M^e^dⁱ^c^aⁱ^d^st^a^t^ue⁾^,^aⁿ^d^t^o^p^r^e^gna^nt^a^d^ul^t^s^.^Fⁱ^na^l^l^y^,^t^h^e
^Whⁱ^l^e^t^hⁱ^s^A^d^mⁱⁿⁱ^s^t^ratⁱ^oⁿ^w^a^s^s^u^pportⁱ^v^{e of}^u^sⁱⁿ^g^t^h^e^C^oⁿ^f^eren^{ce A}^g^reem^en^{t allow}^s^th^{e co}ⁿ^tin^u^a^tioⁿ^o^f^ex^istin^g
ⁱ^{ki/CRS-RL33251}^{1115 au}^t^h^ori^t^y^t^o^ex^pan^d^S^C^H^I^{P t}^o^paren^t^s^of^Medi^cai^{d or}^SCHI^P^-^elig^ib^{le ch}^ild^r^eⁿ^,^as^w^e^{ll as to}^cer^tain^p^r^egⁿ^aⁿ^t^Medi^cai^{d or S}^C^H^I^{P w}^aⁱ^v^{er proj}^ect^s^(an^d^/^o^r^e^x^t^eⁿ^sⁱ^oⁿ^s^,^am^en^dm^en^ts^{, or ren}^e^w^a^ls^{to s}^u^c^h^proj^ects⁾^af^f^ectin^g
^g/w^w^o^m^eⁿ^,ⁱ^t^oppos^ed^cov^e^rag^e^of^chⁱ^l^d^l^e^s^s^adu^l^t^s^{. U}ⁿ^{der t}^h^e^f^e^deral^SC^HIP^f^uⁿ^d^s^th^{at w}^e^{re approv}^{ed u}ⁿ^d^er^th^e^Section
^s^.or^B^u^sh^A^d^mⁱⁿⁱ^str^a^tioⁿ^,^th^e^Health^Iⁿ^su^r^aⁿ^{ce Flex}^ib^ility^an^d^{1115 w}^aⁱ^v^{er au}^t^h^ori^t^y^bef^o^{re t}^h^{e dat}^e^of^en^act^m^eⁿ^t^of^t^hⁱ^s
^le^ak^A^cco^uⁿ^t^ab^ility⁽^H^I^F^A⁾^Iⁿ^itiativ^{e w}^a^{s im}^p^l^em^en^ted^u^sⁱⁿ^g^act.
^://wiki^th^{e 1115 w}^a^iv^{er au}^th^ority^.^T^h^{e in}^itiativ^{e w}^a^s^{created to}^en^cou^r^ag^{e s}^t^ates^{to in}^creas^{e th}^{e n}^u^m^{ber of}ⁱⁿ^di^vi^du^als^T^h^{e C}^oⁿ^f^eren^{ce A}^g^reem^en^{t is}^ef^f^ectiv^{e as}^if^en^act^e^d^oⁿ
^h^ttp^w^ith^h^ealthⁱⁿ^su^r^aⁿ^{ce co}^v^e^r^a^g^e⁽ⁱⁿ^c^lu^dⁱⁿ^g^ch^ild^{less ad}^u^lts)^O^c^t^{ober 1, 2005, an}^{d s}^h^al^l^appl^y^t^o^an^y^w^aⁱ^v^er,
^w^ithⁱⁿ^cu^r^r^en^{t p}^r^o^g^r^a^m^r^e^so^u^r^ces^e^x^p^e^rⁱ^m^eⁿ^t^{al, p}^ilo^{t, o}^r^d^e^m^oⁿ^s^tr^atioⁿ^p^r^o^j^{ect th}^{at is}
^approv^{ed on}^{or af}^t^e^{r t}^h^at^dat^e^.
^Continue^d^a^u^thor^ity^for^qua^lifyⁱ^ng^s^t^a^t^e^s^C^u^rren^{t law}^perm^its^qu^alif^yⁱⁿ^g^s^t^ates^(i.^e^{., s}^t^ates^th^{at on}^S^ectⁱ^oⁿ^6103.^T^h^{e C}^oⁿ^f^eren^{ce A}^g^reem^en^{t con}^tin^u^e^s^th^e
^e^c^e^r^ta^{in funds}^for^M^e^dic^aⁱ^{d e}^x^p^e^nditur^e^s^.^{or af}^ter^A^p^ril^15,^{1997, h}^a^{d an}ⁱⁿ^com^e^elig^ibility^s^t^an^dard^au^t^h^ori^t^y^f^o^{r qu}^alⁱ^f^yⁱⁿ^g^s^t^at^es^t^o^appl^y^f^e^deral^S^C^H^I^P
^f^o^r^c^hⁱ^l^d^ren^,^ot^h^e^{r t}^h^anⁱⁿ^f^aⁿ^t^s^,^of^at^l^eas^t^184%^of^t^h^e^m^a^t^c^hi^{ng fund}^{s t}^o^w^a^r^d^t^h^e^c^o^ve^r^a^ge^o^f^c^e^r^t^aⁱⁿ^c^hⁱ^l^d^r^eⁿ
^FP^L^.^{— Oth}^e^{r qu}^alif^ication^s^als^o^appl^y^t^o^s^t^ates^w^ith^en^{rolled in}^reg^u^l^ar^M^e^dⁱ^{caid (n}^{ot an}^SC^HIP^Medicaid
^s^t^at^ewⁱ^d^{e w}^aⁱ^v^ers^uⁿ^d^e^r^S^ectⁱ^oⁿ^{1115 of}^t^h^{e S}^o^ci^al^ex^pan^s^ion⁾^{. Specif}ⁱ^cally^{, th}^{e C}^oⁿ^f^eren^{ce A}^g^reem^en^t
^Secu^rity^A^c^{t) to receiv}^e^th^{e SC}^HIP^en^h^aⁿ^ced^fe^d^e^ral^a^l^l^o^w^s^qu^alⁱ^f^yⁱⁿ^g^s^t^at^es^t^o^u^s^{e an}^y^av^ai^l^a^bl^{e F}^Y^2001,
^m^a^tchⁱⁿ^g^r^a^te^f^o^r^th^e^co^v^e^r^a^g^e^o^f^cer^tain^ch^ild^r^eⁿ^en^r^o^lled^F^Y^{2004 an}^{d F}^Y^{2005 S}^C^H^I^{P f}^uⁿ^d^s⁽ⁱ^.e.,^F^Y^2001,
ⁱⁿ^reg^u^l^{ar Medicaid. Specif}ⁱ^cally^{, f}^o^{r s}^e^rv^ices^deliv^ered^F^Y^{2004, an}^d^F^Y²⁰⁰⁵^ori^gⁱⁿ^al^al^l^o^t^m^en^t^s^{, an}^d/^{or F}^Y^2001,
^{to Medicaid ben}^e^fⁱ^ciaries^uⁿ^d^{er th}^{e ag}^{e of}¹⁹^w^h^{o are n}^o^t^F^Y²⁰⁰⁴^an^{d F}^Y^{2005 ret}^aⁱⁿ^{ed al}^l^o^t^m^en^t^s^or^redi^s^t^ri^bu^t^e^d

CRS-112
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^o^t^h^e^r^w^{ise elig}^ib^{le f}^o^r^SCHI^P^an^d^h^a^v^e^f^a^m^ilyⁱⁿ^co^m^e^th^at^f^uⁿ^d^s^,^as^th^{e cas}^{e m}^a^y^{be) f}^o^{r s}^u^ch^{Medicaid s}^e^rv^ices
^ex^ceeds^150%^of^th^{e F}^P^L^,^f^e^{deral S}^C^HIP^f^u^nd^{s can}^be^m^a^{de on}^{or af}^t^e^{r O}^c^t^ober¹^,²^{005 u}ⁿ^d^{er t}^h^{e 20%}
^u^s^{ed to pay}^th^{e dif}^f^e^ren^{ce betw}^een^th^{e S}^C^HIP^en^h^aⁿ^ced^allow^aⁿ^ce.
^f^e^dera^l^m^a^t^c^hⁱⁿ^g^rat^e^an^{d t}^h^{e reg}^u^l^{ar Medi}^cai^{d f}^e^deral
^ma^t^c^hⁱ^{ng r}^a^t^e^.^T^h^e^m^a^xi^m^u^m^a^m^o^unt^t^h^a^t^q^u^a^lⁱ^f^yⁱ^ng^T^h^{e C}^oⁿ^f^eren^{ce A}^g^reem^en^{t i}^s^ef^f^ectiv^{e on}^{or af}^ter
^{states m}^a^y^c^l^aⁱ^m^uⁿ^d^er^th^{is allo}^w^aⁿ^{ce is th}^{e lesser}^o^f^th^e^O^c^t^{ober 1, 2005.}

^f^o^llowⁱⁿ^g^tw^{o am}^ouⁿ^t^s^:⁽¹⁾²⁰^%^o^f^th^{e s}^t^ate’^s^av^ailable
^F^Y^{1998 t}^h^ro^{ugh FY}^{2001 ori}^gⁱⁿ^al^S^C^H^I^{P al}^l^o^t^m^en^t^s^;^an^d
^{(2) th}^{e s}^t^ate’^s^balan^{ce (calcu}^{lated qu}^arterly⁾^of^an^y
^av^ai^l^a^bl^{e F}^Y^{1998 t}^o^F^Y²^{001 f}^e^deral^S^C^H^I^{P f}^uⁿ^d^s
ⁱ^{ki/CRS-RL33251}⁽^o^rⁱ^gⁱⁿ^a^{l allo}^tm^en^{ts o}^r^r^eallo^cated^f^uⁿ^d^s)^{. I}^f^th^er^{e is n}^o^balan^{ce, s}^t^ates^m^a^y^no^{t claim}^{20% s}^p^en^din^g^.^{No 20%}
^g/w^s^p^en^din^g^wⁱ^l^l^b^e^perm^{itted in}^{FY2006 or an}^y^fⁱ^s^{cal y}^ear
^s^.or^th^ereaf^ter.
^le^ak
^://wiki
^h^ttp

CRS-113
btitle C — Katrina Relief
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^A^dditiona^{l Fe}^de^r^a^{l P}^a^y^m^eⁿ^ts^Unde^r^T^h^{e f}^e^deral^m^e^{dical as}^sⁱ^s^t^an^{ce percen}^tag^e^(FMA^P⁾^is^th^{e rate at}^S^ecti^oⁿ^6201.^T^h^e^con^f^eren^{ce ag}^reem^en^{t appropriates}^$2
^rrican^e-^Relat^e^d^M^u^lt^i-^St^at^{e Sect}^ioⁿ¹¹¹⁵^w^h^ich^s^t^ates^{are reim}^bu^rs^{ed f}^o^{r m}^o^s^t^{Medicaid s}^e^rv^ice^b^illioⁿ⁽ⁱⁿ^ad^d^itioⁿ^to^an^y^f^uⁿ^d^{s m}^a^d^e^av^ailab^l^e^f^o^r^th^e
^mons^tr^a^t^ions^.^ex^pen^dⁱ^t^u^res^.^Itⁱ^s^bas^e^{d on}^a^fo^r^m^u^l^{a t}^h^at^provⁱ^d^es^hⁱ^g^h^e^r^Nation^a^{l Dis}^a^s^t^{er Medical Sy}^s^t^em^uⁿ^d^{er th}^e^D^e^partm^eⁿ^t
^r^e^im^b^u^r^s^em^en^{t to}^{states w}^ith^lo^w^e^r^p^e^r^cap^{ita in}^co^m^e^s^r^e^lativ^e^of^Hom^e^lan^d^Secu^rity^f^o^{r h}^ealt^h^{care cos}^t^s^{related to}
^{to th}^{e n}^a^tion^a^{l av}^erag^{e (an}^d^vⁱ^{ce v}^e^rs^a⁾^;ⁱ^t^h^a^s^{a s}^t^atu^t^ory^Hu^rrican^{e Katrin}^{a) f}^o^{r u}^s^{e by}^th^{e Secretary}^of^HHS^{to pay}
^miⁿⁱ^mu^{m o}^f⁵⁰^%^aⁿ^d^ma^xⁱ^mu^{m o}^f⁸³^%^.^Aⁿ^eⁿ^h^aⁿ^c^e^d^F^M^A^P^elig^{ible s}^t^ates^(th^o^s^e^w^h^{o h}^a^v^e^p^r^o^vⁱ^d^{ed care to af}^f^ected
^{is av}^ailab^l^{e f}^o^r^b^o^t^h^ser^v^ic^e^s^aⁿ^d^ad^mⁱⁿⁱ^str^a^tioⁿ^uⁿ^d^er^SCHI^P^,ⁱⁿ^di^vⁱ^du^al^s^{or ev}^acu^ees^uⁿ^d^{er a}^S^ectⁱ^oⁿ¹¹¹⁵^proj^ect^{) f}^o^r:
^su^b^j^{ect to}^th^{e a}^v^aⁱ^l^a^b^ility^o^f^f^uⁿ^d^{s f}^r^o^m^{a state’}^{s SCHI}^P⁽¹^{) th}^{e n}^oⁿ^-^f^e^{deral (i.e., s}^t^{ate) s}^h^{are of}^ex^pen^d^itu^re^s^fo^r
ⁱ^{ki/CRS-RL33251}^allo^tm^en^t.^h^ealth^{care prov}^{ided to af}^f^{ected in}^divⁱ^du^als^(t^h^o^s^e^w^h^o
^g/w^resⁱ^{ded i}ⁿ^{a cou}ⁿ^t^y^{or pari}^s^h^d^e^sⁱ^gⁿ^a^t^e^{d f}^o^{r i}ⁿ^di^vⁱ^du^al
^s^.or^as^sⁱ^s^t^an^{ce pu}^rs^u^aⁿ^t^{to th}^{e Staf}^f^o^r^d^Ac^t^a^s^{a res}^u^{lt of}
^le^ak^Hu^rrican^e^Katrin^{a an}^{d con}^tin^u^e^{to res}ⁱ^{de in}^th^{e s}^a^m^e^s^t^ate)
^an^{d ev}^acu^ees^(af^f^{ected in}^divⁱ^du^als^dis^p^l^a^c^e^{d to an}^oth^e^r
^://wiki^s^t^a^t^e⁾^und^e^r^a^p^p^r^o^v^e^d^m^u^lti-sta^t^e^Se^c^tⁱ^oⁿ¹¹¹⁵
^h^ttp^dem^oⁿ^s^tr^a^tⁱ^oⁿ^p^r^o^j^e^c^t^s^;^{(2) reas}^on^{able adm}ⁱⁿⁱ^s^t^rativ^{e cos}^t^s
^r^e^lated^to^su^ch^p^r^o^j^{ects; (}³⁾^oⁿ^ly^w^ith^r^e^s^p^e^c^t^to^af^f^ected
^couⁿ^ties^an^{d paris}^h^es^{, th}^{e n}^oⁿ^-^f^e^{deral s}^h^a^r^{e of}
^ex^pen^d^itu^res^f^o^{r m}^e^{dical as}^sⁱ^s^t^an^{ce provi}^d^e^{d to}
ⁱⁿ^divⁱ^du^als^uⁿ^d^{er ex}^is^tin^g^{Medicaid an}^{d SC}^HIP^s^t^ate
^pl^an^s;^aⁿ^{d (4) ot}^h^e^{r pu}^rpos^es^{, i}^f^approv^{ed by}^t^h^e
^Secretary^,^{to res}^t^{ore acces}^s^{to h}^ealth^{care in}^im^pacted
^co^m^m^uⁿ^ities.
^Usin^g^an^ap^p^licatioⁿ^tem^p^{late d}^e^v^e^lo^p^e^d^b^y^t^h^e^C^eⁿ^t^er^{s f}^o^r^T^h^{e n}^oⁿ^-^f^e^d^e^r^a^{l sh}^ar^{e p}^a^id^to^elig^ib^le^s^t^a^t^{es sh}^{all n}^o^{t b}^e
^{Medicare an}^{d Medicaid Serv}^ices⁽^C^MS)^w^ithⁱⁿ^{HHS, a n}^u^m^b^e^r^reg^a^r^d^e^d^as^f^e^deral^f^uⁿ^d^s^f^o^{r pu}^rpos^es^of^Medi^cai^d
^of^s^t^ates^{(17 as}^of^Decem^{ber 15, 2005) h}^a^v^e^b^e^en^g^r^an^ted^m^a^tchⁱⁿ^g^r^e^q^u^ir^em^en^{ts. No}^p^a^y^m^en^{t o}^b^lig^atioⁿ^s^m^a^y^b^e
^w^aⁱ^v^ers^uⁿ^d^{er S}^ectⁱ^oⁿ¹¹¹⁵^of^t^h^e^S^o^ci^al^S^ecu^ri^t^y^A^c^t^t^o^provⁱ^d^eⁱⁿ^cu^rred^uⁿ^d^{er approv}^{ed m}^u^lti-^s^t^{ate Section}^{1115 proj}^ects

CRS-114
^Provisⁱ^on^{Current L}^a^w^C^on^{ference Agreem}^{ent, as}^Pas^s^e^{d by the Senate}
^{Medicaid an}^{d SC}^HIP^s^e^rv^ices^{to certain}ⁱⁿ^divⁱ^du^als^af^f^{ected by}^f^o^{r: (1) cos}^t^s^of^h^ealth^{care prov}^{ided as}^Medicai^d^o^r
^Hu^rrican^{e Katrin}^{a (th}^e^s^e^w^a^iv^ers^are^ref^e^rred^{to as}^bein^g^{part of}^S^C^H^I^{P m}^e^di^cal^as^sⁱ^s^t^an^{ce i}ⁿ^cu^{rred af}^t^e^{r Ju}ⁿ^e^{30, 2006,}
^{a m}^u^lti-^{state d}^e^m^oⁿ^s^tr^atioⁿ^p^r^o^j^ect)^.^{(2) u}ⁿ^c^om^pen^s^{ated care}^cos^t^sⁱⁿ^cu^{rred af}^{ter J}^aⁿ^u^a^ry^31,
^2006,⁽³⁾^uⁿ^c^om^pen^s^at^{ed care cos}^t^s^f^o^{r an}ⁱ^t^e^m^or^s^e^rvⁱ^c^e
^A^{ll o}^f^th^{e w}^a^iv^er^{s g}^r^an^ted^th^u^s^f^a^r^cr^eate^a^tem^p^o^r^ar^y^elig^ib^ility^receiv^e^{d by}^an^ev^acu^{ee or an}^af^f^{ected in}^divⁱ^du^a^l^from^an
^{period, n}^o^{t to ex}^{ceed f}ⁱ^v^e^m^ont^hs^,^du^rin^g^w^h^ich^certainⁱⁿ^di^vⁱ^du^al^{or org}^aⁿⁱ^zatⁱ^oⁿ^as^pa^r^t^of^{a pu}^blⁱ^c^{or pri}^v^at^e
^Hu^rrican^e^Katrin^a^ev^acu^ees^w^{ill b}^e^g^r^an^ted^{access to}^Medⁱ^caid^h^u^rrican^{e relief}^ef^f^o^rt.

^an^{d SC}^HIP^s^e^rv^icesⁱⁿ^th^{e h}^o^s^t^s^t^{ate (i.e., th}^{e s}^t^ate^th^{at h}^a^s^been
^g^r^an^{ted a Section}^{1115 w}^a^iv^{er) bas}^e^{d on}^sⁱ^m^p^lif^{ied elig}^ibility
^cr^iterⁱ^{a. I}ⁿ^ad^d^itioⁿ^,^w^aⁱ^v^er^{s f}^o^r^so^m^e^{states also}^cr^{eate an}
ⁱ^{ki/CRS-RL33251}^uⁿ^c^om^pen^s^at^{ed care pool}^t^h^at^m^a^y^be^u^s^ed^t^h^ro^{ugh J}^a^nua^r^y³¹^,^{2006, t}^o^au^g^m^en^t^Medi^cai^{d an}^{d S}^C^H^I^{P s}^e^rvⁱ^ces^f^o^{r ev}^a^c^u^e^e^s
^g/w^an^d^to^reim^bu^rs^{e prov}^iders^th^{at in}^cu^{r u}ⁿ^c^om^pen^s^{ated care}^cos^t^s
^s^.or^f^o^{r u}ⁿⁱⁿ^s^u^r^ed^e^v^a^c^u^e^e^s^w^h^{o do n}^o^t^qu^alⁱ^f^y^f^o^{r Medi}^cai^{d or}
^le^ak^SCHI^P^.
^://wiki
^h^ttp