§ 1396p. Liens, adjustments and recoveries, and transfers of assets

Legislative history

Reconstructed from this section’s Code source credit and amendment notes, resolved against the local Statutes at Large. Editorial notes are evidence, not the law that made the change.

1. 1935

   Pub. L. 97–248 title I § 132(b) · 96 Stat. 324

   Enacted · 42 U.S.C. § 1396p

   Aug. 14, 1935, ch. 531, title XIX, § 1917, as added Pub. L. 97–248, title I, § 132(b), Sept. 3, 1982, 96 Stat. 370

   Source evidence

   Code source credit
   Aug. 14, 1935, ch. 531, title XIX, § 1917, as added Pub. L. 97–248, title I, § 132(b), Sept. 3, 1982, 96 Stat. 370

   Enacted provision · exact public law section
   (b) Title XIX of such Act is amended by adding after section 1916 (added by section 131 of this Act) the following new section: “liens, adjustments and recoveries, and transfers of assets “Sec. 1917. (a) (1) No lien may be imposed against the property of 42 USC 1396p. any individual prior to his death on account of medical assistance paid or to be paid on his behalf under the State plan, except— “(A) pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of such individual, or “(B) in the case of the real property of an individual— “(i) who is an inpatient in a skilled nursing facility, intermediate care facility, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, and “(ii) with respect to whom the State determines, after notice and opportunity for a hearing (in accordance with procedures established by the State), that he cannot reasonably be expected to be discharged from the medical institution and to return home, except as provided in paragraph (2). “(2) No lien may be imposed under paragraph (1)(B) on such individual’s home if— “(A) the spouse of such individual, “(B) such individual’s child who is under age 21, or (with respect to States eligible to participate in the State program established under title XVI) is blind or permanently and totally 42 USC 1381. disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1614, or 42 USC 1382c. “(C) a sibling of such individual (who has an equity interest in such home and who was residing in such individual’s home for a period of at least one year immediately before the date of the individual’s admission to the medical institution), is lawfully residing in such home. “(3) Any lien imposed with respect to an individual pursuant to paragraph (1)(B) shall dissolve upon that individual’s discharge from the medical institution and return home. “(b) (1) No adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be made, except— “(A) in the case of an individual described in subsection (a)(1)(B), from his estate or upon sale of the property subject to a lien imposed on account of medical assistance paid on behalf of such individual, and “(B) in the case of any other individual who was 65 years of age or older when he received such assistance, from his estate. “(2) Any adjustment or recovery under paragraph (1) may be made only after the death of the individual’s surviving spouse, if any, and only at a time— “(A) when he has no surviving child who is under age 21, or (with respect to States eligible to participate in the State program established under title XVI) is blind or permanently and 42 USC c. totally disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1614; and “(B) in the case of a lien on an individual’s home under subsection (a)(1)(B), when— “(i) no sibling of the individual (who was residing in the individual’s home for a period of at least one year immediately before the date of the individual’s admission to the medical institution), and “(ii) no son or daughter of the individual (who was residing in the individual’s home for a period of at least two years immediately before the date of the individual’s admission to the medical institution, and who establishes to the satisfaction of the State that he or she provided care to such individual which permitted such individual to reside at home rather than in an institution), is lawfully residing in such home and has lawfully resided in such home on a continuous basis since the date of the individual’s admission to the medical institution. “(c) (1) Notwithstanding any other provision of this title, an individual who would otherwise be eligible for medical assistance under the State plan approved under this title may be denied such assistance if such individual would not be eligible for such medical assistance but for the fact that he disposed of resources for less than fair market value. If the State plan provides for the denial of such assistance by reason of such disposal of resources, the State plan shall specify a procedure for implementing such denial which, except as provided in paragraph (2), is not more restrictive than the procedure specified in section 1613(c) of this Act, and which may 42 USC 1382b. provide for a waiver of denial of such assistance in any instance where the State determines that such denial would work an undue hardship. “(2) (A) In any case where the uncompensated value of disposed of resources exceeds $12,000, the State plan may provide for a period of ineligibility which exceeds 24 months. If a State plan provides for a period of ineligibility exceeding 24 months, such plan shall provide for the period of ineligibility to bear a reasonable relationship to such uncompensated value. “(B) (i) In the case of any individual who is an inpatient in a skilled nursing facility, intermediate care facility, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, and, who, at any time during or after the 24-month period immediately prior to application for medical assistance under the State plan, disposed of a home for less than fair market value, the State plan (subject to clause (iii)) may provide for a period of ineligibility for medical assistance in accordance with clause (ii). “(ii) If the State plan provides for a period of ineligibility under clause (i), such plan— “(I) shall provide that such individual shall be ineligible for all medical assistance for a period of 24 months after the date on which he disposed of such home, except that, in the case where the uncompensated value of the home is less than the average amount payable under the State plan as medical assistance for 24 months of care in a skilled nursing facility, the period of ineligibility shall be such shorter time as bears a reasonable relationship (based upon the average amount payable under the State plan as medical assistance for care in a skilled nursing facility) to the uncompensated value of the home, and “(II) may provide (at the option of the State) that, in the case where the uncompensated value of the home is more than the average amount payable under the State plan as medical assistance for 24 months of care in a skilled nursing facility, such individual shall be ineligible for all medical assistance for a period in excess of 24 months after the date on which he disposed of such home which bears a reasonable relationship (based upon the average amount payable under the State plan as medical assistance for care in a skilled nursing facility) to the uncompensated value of the home, “(iii) An individual shall not be ineligible for medical assistance by reason of clause (ii) if— “(I) a satisfactory showing is made to the State (in accordance with any regulations promulgated by the Secretary) that the individual cannot reasonably be expected to be discharged from the medical institution and to return to that home, “(II) title to such home was transferred to the individual’s spouse or child who is under age 21, or (with respect to States eligible to participate in the State program established under title XVI) is blind or permanently and totally disabled, or (with 42 USC 1381. respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1614, 42 USC 1382c. “(III) a satisfactory showing is made to the State (in accordance with any regulations promulgated by the Secretary) that the individual intended to dispose of the home either at fair market value, or for other valuable consideration, or “(IV) if the State determines that denial of eligibility would work an undue hardship. “(3) In any case where an individual is ineligible for medical assistance under the State plan solely because of the applicability to such individual of the provisions of section 1613(c), the State plan 42 USC 1382b. may provide for the eligibility of such individual for medical assistance under the plan if such individual would be so eligible if the State plan requirements with respect to disposal of resources applicable under paragraphs (1) and (2) of this subsection were applied in lieu of the provisions of section 1613(c).”.

2. 1983

   Pub. L. 97–448 § 309(b)(21) · 96 Stat. 2365

   Substituted · 42 U.S.C. § 1396p(b)(2)(B)

   Pub. L. 97–448, § 309(b)(21), substituted “who” for “and” before “has lawfully resided”

   Source evidence

   Code amendment note
   Subsec. (b)(2)(B). Pub. L. 97–448, § 309(b)(21), substituted “who” for “and” before “has lawfully resided”.

   Enacted provision · exact public law section
   (21) Ante, p. 370.42 USC 1396p. Section 1917(b)(2)(B) of such Act is amended by striking out “and has lawfully resided” and inserting in lieu thereof “who has lawfully resided”.

3. 1983

   Pub. L. 97–448 § 309(b)(22) · 96 Stat. 2365

   1. Substituted · 42 U.S.C. § 1396p(c)(2)(B)(iii)

      Pub. L. 97–448, § 309(b)(22), substituted in subcl. (I) “can” for “cannot”

   2. Struck · 42 U.S.C. § 1396p(c)(2)(B)(iii)

      Pub. L. 97–448, § 309(b)(22), struck out from subcl. (IV) the introductory word “if”

   Source evidence

   Code amendment note
   Subsec. (c)(2)(B)(iii). Pub. L. 97–448, § 309(b)(22), substituted in subcl. (I) “can” for “cannot” and struck out from subcl. (IV) the introductory word “if”.

   Enacted provision · exact public law section
   (22) Section 1917(c)(2)(B)(iii) of such Act is amended— (A) in subclause (I), by striking out “cannot” and inserting in lieu thereof “can”; and (B) in subclause (IV), by striking out “if”.

4. 1987

   Pub. L. 100–203 § 4211(h)(12)(A) · 101 Stat. 1330

   Substituted · 42 U.S.C. § 1396p(a)(1)(B)(i); 42 U.S.C. § 1396p(c)(2)(B)(i)

   Pub. L. 100–203, § 4211(h)(12)(A), substituted “nursing facility, intermediate care facility for the mentally retarded” for “skilled nursing facility, intermediate care facility”

   Source evidence

   Code amendment note
   Subsecs. (a)(1)(B)(i), (c)(2)(B)(i). Pub. L. 100–203, § 4211(h)(12)(A), substituted “nursing facility, intermediate care facility for the mentally retarded” for “skilled nursing facility, intermediate care facility”.

   Enacted provision · exact public law section
   (A) in subsections (a)(1)(B)(i) and (c)(2)(B)(i), by striking “skilled nursing facility, intermediate care facility” and inserting “nursing facility, intermediate care facility for the mentally retarded”, and

5. 1987

   Pub. L. 100–203 § 4211(h)(12)(B) · 101 Stat. 1330

   1. Amended · 42 U.S.C. § 1396p(c)(2)(B)(ii)

      Pub. L. 100–203, § 4211(h)(12)(B), as amended by Pub. L. 100–360, § 411(l)(3)(I)

   2. Substituted · 42 U.S.C. § 1396p(c)(2)(B)(ii)

      Pub. L. 100–203, § 4211(h)(12)(B), as substituted “a nursing facility” for “a skilled nursing facility” in two places each in subcls. (I) and (II)

   Source evidence

   Code amendment note
   Subsec. (c)(2)(B)(ii). Pub. L. 100–203, § 4211(h)(12)(B), as amended by Pub. L. 100–360, § 411(l)(3)(I), substituted “a nursing facility” for “a skilled nursing facility” in two places each in subcls. (I) and (II).

   Enacted provision · exact public law section
   (B) in subsection (c)(3)(A), by striking “skilled”.

6. 1988

   Medicare Catastrophic Coverage Act of 1988

   Pub. L. 100–360 § 303(b) · 102 Stat. 683

   1. Amended · 42 U.S.C. § 1396p(c)

      Pub. L. 100–360, § 303(b), amended subsec. (c) generally

   2. Substituted · 42 U.S.C. § 1396p(c)

      Pub. L. 100–360, § 303(b), substituting pars. (1) to (4) relating to taking into account certain transfers of assets, for former pars. (1) to (3) relating to denial of medical assistance, period of eligibility, and exceptions

   Source evidence

   Code amendment note
   Subsec. (c). Pub. L. 100–360, § 303(b), amended subsec. (c) generally, substituting pars. (1) to (4) relating to taking into account certain transfers of assets, for former pars. (1) to (3) relating to denial of medical assistance, period of eligibility, and exceptions.

   Enacted provision · exact public law section
   (b) Taking Into Account Certain Transfers of Assets.— Subsection (c) of section 1917 (42 U.S.C. 1396p) is amended to read as follows: “(c) (1) In order to meet the requirements of this subsection (for purposes of section 1902(a)(51)(B)), the State plan must provide for a period of ineligibility in the case of an institutionalized individual (as defined in paragraph (3)) who, at any time during the 30-month period immediately before the individual’s application for medical assistance under the State plan, disposed of resources for less than fair market value. The period of ineligibility shall begin with the month in which such resources were transferred and the number of months in such period shall be equal to the lesser of— “(A) 30 months, or “(B) (i) the total uncompensated value of the resources so transferred, divided by (ii) the average cost, to a private patient at the time of the application, of nursing facility services in the State or, at State option, in the community in which the individual is institutionalized. “(2) An individual shall not be ineligible for medical assistance by reason of paragraph (1) to the extent that— “(A) the resources transferred were a home and title to the Real property. home was transferred to— “(i) the spouse of such individual; “(ii) a child of such individual who is under age 21, or Children and youth. Blind persons. Handicapped persons. (with respect to States eligible to participate in the State program established under title )(VI) is blind or permanently and totally disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1614; “(iii) a sibling of such individual who has an equity interest in such home and who was residing in such individual’s home for a period of at least one year immediately before the date of the individual’s admission to the medical institution or nursing facility, or “(iv) a son or daughter of such individual (other than a child described in clause (ii)) who was residing in such individual’s home for a period of at least two years immediately before the date of such individual’s admission to the medical institution or nursing facility, and who (as determined by the State) provided care to such individual which permitted such individual to reside at home rather than in such an institution or facility; “(B) the resources were transferred to (or to another for the Children and youth. Blind persons. Handicapped persons sole benefit of) the community spouse, as defined in section 1924(h)(2), or the individual’s child who is blind or permanently and totally disabled; “(C) a satisfactory showing is made to the State (in accordance with any regulations promulgated by the Secretary) that (i) the individual intended to dispose of the resources either at fair market value, or for other valuable consideration, or (ii) the resources were transferred exclusively for a purpose other than to qualify for medical assistance; or “(D) the State determines that denial of eligibility would work an undue hardship. “(3) In this subsection, the term ‘institutionalized individual’ means an individual who is an inpatient in a medical institution or nursing facility. “(4) A State (including a State which has elected treatment under section 1902(f)) may not provide for any period of ineligibility for an individual due to transfer of resources for less than fair market value except in accordance with this subsection.”.

7. 1988

   Medicare Catastrophic Coverage Act of 1988

   Pub. L. 100–360 § 411 · 102 Stat. 683

   Amended · 42 U.S.C. § 1396p(c)(2)(B)(ii)

   Pub. L. 100–360, § 411(l)(3)(I), amended Pub. L. 100–203, § 4211(h)(12)(B), see 1987 Amendment note below

   Source evidence

   Code amendment note
   Subsec. (c)(2)(B)(ii). Pub. L. 100–360, § 411(l)(3)(I), amended Pub. L. 100–203, § 4211(h)(12)(B), see 1987 Amendment note below.

   Enacted provision · exact public law section
   SEC. 411. TECHNICAL CORRECTIONS TO CERTAIN HEALTH CARE PROVISIONS IN THE OMNIBUS BUDGET RECONCILIATION ACT OF 1987. (a) Reference to OBRA and Effective Dates.— (1) Reference.— In this section, the term “OBRA” refers to the Omnibus Budget Reconciliation Act of 1987 (Public Law 100–203). (2) Effective date.— Except as specifically provided in this section, the amendments made by this section, as they relate to a provision in OBRA, shall be effective as if they were included in the enactment of that provision in OBRA. (3) Ratification of enrollment corrections and printed enrollment.— (A) In general.— Except as provided in subparagraph (B), the enrollment corrections noted in footnotes numbered 9 through 72 of OBRA are hereby ratified and shall be considered to have been enacted as part of OBRA. The printed enrollment of title IV of OBRA, as prepared and printed under section 8004 of OBRA (including the footnote corrections described in subparagraph (B) and as incorporating the clarifications described in subparagraph (C)), shall be deemed to constitute title IV of OBRA as enacted. (B) Footnote corrections.— (i) With respect to the reference to which footnote 28 relates (101 Stat. 1330–81), the reference shall be deemed to have read “1320a–7b)”. (ii) With respect to the word to which footnote 30 relates (101 Stat. 1330–91), the word shall be deemed to have read “the”. (iii) With respect to the designation to which footnote 52 relates (101 Stat. 1330–151), the designation shall be deemed to have read “(F)”. (C) Clarifications of illegible matter.— (i) Section 1842(n)(1)(A) of the Social Security Act, as added by section 42 USC 1395u. 4051(a) of OBRA (101 Stat. 1330–93), is deemed to nave the phrase “the supplier’s reasonable charge to individuals enrolled under this part for the test” immediately after “or, if lower, the”. (ii) Section 1834(a)(7)(B)(i) of the Social Security Act, as 42 USC 1395m. inserted by section 4062(b) of OBRA (101 Stat. 1330–103), is deemed to have a reference to “1987” immediately after “December”. (b) Corrections Relating to Part 1 of Subtitle A of Title IV (Part A of the Medicare Program).— (1) Section 4002.— (A) Subclauses (III) and (IV) of section 1886(b)(3)(B)(i) of the Social Security Act, as amended by section 42 USC 1395ww. 4002(a) of OBRA, are amended by striking “other hospitals” and inserting “for hospitals located in other urban areas”. (B) Section 1886(b)(3)(B)(i)(IV) of the Social Security Act, as amended by section 4002(a) of OBRA, is amended by striking “percent” each place it appears and inserting “percentage points”. (C) Section 18860(b)(3)(B)(i)(V) of the Social Security Act, as amended by section 4002(a) of OBRA, is amended by inserting 42 USC 1395ww. “increase” after “market basket percentage”. (D) The second sentence of section 1886(d)(2)(D) of the Social Security Act, as amended by section 4002(b) of OBRA, is amended by striking “the publication described in subsection (e)(5)(B)” and inserting “the publications described in subsection (e)(5)”. (E) Section 4002(c)(1)(B)(iii) of OBRA is amended, in the 42 USC 1395ww. matter stricken, by striking the comma after “available”. (F) Section 1886(d)(3)(A)(ii) of the Social Security Act, as Urban areas. amended by section 4002(c)(1)(C) of OBRA, is amended by striking “in urban areas” and inserting “in other urban areas”. (G) Section 1886(d)(1)(A)(iii) of the Social Security Act, as Urban areas. Rural areas. amended by section 4002(d) of OBRA, is amended by striking “if greater” and inserting “if the average standardized amount (described in clause (i)(I) or clause (ii)(I) of paragraph (3)(D)) for hospitals within the region of, and in the same rural, large urban, or other urban area as, the hospital is greater than the average standardized amount (described in the respective clause) for hospitals within the United States in that type of area”. (H) (i) Section 1886(d)(2)(D) of the Social Security Act is amended by striking the last sentence (added by section 4002(f)(1)(A) of OBRA). (ii) Section 4002(f) of OBRA is amended by adding at the end the following new paragraph: “(3) The second sentence of section 1813(b)(1) of the Social Security Act (42 U.S.C. 1395e(b)(1)) is amended by striking ‘applicable percentage increase’ and all that follows through ‘is applied’ and inserting ‘Secretary’s best estimate of the payment-weighted average of the applicable percentage increases (as defined in section 1886(b)(3)(B)) which are applied.”. (iii) The amendment made by clause (ii) shall apply to the Effective date. 42 USC 1395e note. inpatient hospital deductible for years beginning with 1989. (I) Section 4002(g) of OBRA is amended— (i) in paragraph (1)(A), by striking “1886(a)(1)(A)(iii)” and 42 USC 1395ww note. inserting “1886(d)(1)(A)(iii)”. (ii) in paragraphs (1)(B) and (2)(B), by striking “1886(d)(3)(B)” and inserting “1886(b)(3)(B)”, and (iii) in paragraph (6), by striking “1886(d)(10)(B)” and inserting “1886(d)(1)(B)”. (2) Section 4003.— Section 4003(d) of OBRA is amended— 101 Stat. 1330–46. (A) in paragraph (2)— (i) by inserting “(other than under section 1886(d)(5)(F) of such Act)” after “receives payments”, and (ii) by inserting “of such services” after “reasonable costs”; and (B) in the matter following paragraph (2), by inserting “the” after “facilities of”. (3) Section 4004.— Section 4004(a) of OBRA is amended by 42 USC 1395ww. inserting “(1)” after “Survey.—” and by adding at the end the following new paragraph: “(2) Section 1886(d)(9)(C)(iv) of such Act is amended by adding at Puerto Rico. the end the following new sentence: “The second and third sentences of paragraph (3)(E) shall apply to subsection (d) Puerto Rico hospitals under this clause in the same manner as they apply to subsection (d) hospitals under such paragraph and, for purposes of this clause, any reference in such paragraph to a subsection (d) hospital is deemed a reference to a subsection (d) Puerto Rico hospital.”. (4) Section 4005.— (A) Section 1886(d)(8)(B) of the Social 42 USC 1395ww. Security Act, as added by section 4005(a)(1)(D) of OBRA, is amended— (i) by striking “The Secretary” and inserting “For purposes of this subsection, the Secretary”, and (ii) by striking all that follows “if’ and inserting the Rural areas. following: “the rural county would otherwise be considered part of an urban area, under the standards for designating Metropolitan Statistical Areas (and for designating New England County Metropolitan Areas) published in the Federal Register on January 3, 1980, if the commuting rates used in determining outlying counties (or, for New England, similar recognized areas) were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous Metropolitan Statistical Areas (or New England County Metropolitan Areas).”. (B) Section 1886(d)(8)(C) of the Social Security Act, as added by section 4005(a)(1)(D) of OBRA, is amended by striking “standardized amount” and inserting “standardized amounts”. (C) Section 4005(a) of OBRA is amended— (i) in paragraph (1)(D), by striking “subparagraph” and inserting “subparagraphs”, and (ii) in paragraph (3), by striking “This section, and the amendments made by paragraph (1),” and inserting “This subsection”. (D) Section 1883(d)(3) of the Social Security Act, as added by 42 USC 1395tt. section 4005(b)(2)(B) of OBRA, is amended by inserting before the period at the end the following: “, except that such payment shall continue to be made in the period for those patients who are receiving extended care services at the time the hospital reaches the limit specified in this paragraph”. (5) Section 4006.— (A) Section 1886(g)(3)(A)(iv) of the Social Security Act, as amended by section 4006(a) of OBRA, is amended by inserting “for payments attributable” after “15 percent”. (B) Section 4006(a) of OBRA is amended— (i) by adding “and” at the end of subparagraph (A), and (ii) by redesignating subparagraphs (A) and (B) as paragraphs (1) and (2), respectively. (6) Section 4007.— Section 4007 of OBRA is amended— (A) in the second sentence of subsection (a), by striking “updata” and inserting “updated”; (B) by amending subsection (b) to read as follows: “(b) Requiring Reporting of Standardized Cost Report Electronically.— “(1) In general.— Section 1886(f)(1) of the Social Security Act (42 U.S.C. 1395ww(f)(1)) is amended— “(A) by striking for a period ending not earlier than September 30, 1988,”, “(B) by inserting ‘(A)’ after ‘(f)(1)’, and “(C) by adding at the end the following new subparagraph: “(B) (i) Subject to clause (ii), the Secretary shall place into effect a standardized electronic cost reporting format for hospitals under this title. “(ii) The Secretary may delay or waive the implementation of such format in particular instances where such implementation would result in financial hardship (in particular with respect to hospitals with a small percentage of inpatients entitled to benefits under this title).”. “(2) Effective date.— The amendment made by paragraph 42 USC 1395ww note. (1)(0 shall apply to hospital cost reporting periods beginning on or after October 1, 1989”; and (C) in subsection (c)— 42 USC 1395ww note. (i) in paragraph (1)— (I) by striking “3-year”, and (II) by striking “contracting” and inserting “conducting”; (ii) in paragraph (2), by striking “by category of service and” in subparagraphs (A) and (B); (iii) in paragraph (2)(0, by striking “(by category of service)”; (iv) in paragraph (2), by striking subparagraph (D) and redesignating subparagraphs (E) through (L) as subparagraphs (D) through (K), respectively; (v) by amending subparagraph (1), as so redesignated, to read as follows: “(I) Bad debt and charity care.”; (vi) in paragraph (2), by adding at the end the following: “The Secretary shall develop a definition of ‘outpatient visit’ for purposes of reporting hospital information.”; (vii) in paragraph (5), by striking “paragraph (3)” and inserting “paragraph (2)”; (viii) in paragraph (5)(A), by striking “The terms” and all that follows through “as” and inserting “The term ‘bad debt and charity care’ has such meaning as”; (ix) in paragraph (5)(B)— (I) by inserting “at least” after “to payors”, (II) by striking “title VIII” and inserting “title XVIII”, and (III) by striking “self-paying individuals” and inserting “and other persons (including self-paying individuals)”; and (x) in paragraph (6)— (I) by striking “$1,000,000 for each of” and inserting “a total of $3,000,000 for”, (II) by inserting “or from operation funds” after “research funds”, (III) by striking “, and at least” and all that follows through “operations funds” and inserting “and”, and (IV) by striking “over 3 years”. (7) Section 4008.— Section 4008(d)(1)(B) of OBRA is amended 42 USC 1395ww note. by striking “1886” and inserting “1886(d)”. (8) Section 4009.— (A) Section 4009(a) of OBRA is amended— 42 USC 1395dd. (i) by striking paragraphs (1) and (2) and inserting the following: “(1) Increase in civil monetary penalty and exclusion of responsible physician violators.— Section 1867(d)(2) of the Social Security Act (42 U.S.C. 1395dd(d)(2)) is amended— “(A) in the second sentence— “(i) by redesignating such sentence as subparagraph (C), “(ii) by striking ‘previous sentence’ and inserting ‘this paragraph’, and “(iii) by redesignating subparagraphs (A) and (B) as clauses (i) and (ii), respectively, and “(B) by striking the first sentence and inserting the following: ‘(A) A participating hospital that knowingly violates a requirement of this section is subject to a civil money penalty of not more than $50,000 for each such violation. The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply with respect to a penalty or proceeding under section 1128A(a). “‘(B) The responsible physician in a participating hospital with respect to the hospital’s violation of a requirement of this subsection is subject to the sanctions described in section 1842(j)(2), except that, for purposes of this subparagraph, the civil money penalty with respect to each violation may not exceed $50,000, rather than $2,000.’”and (ii) by redesignating paragraph (3) as paragraph (2). (B) Section 4009(d)(1)(A) of OBRA is amended, in the matter inserted by such section, by striking the comma after “representatives”. (C) Section 4009(i) of OBRA is amended by striking “New England county metropolitan areas” and “4001(b)” and inserting “urban areas in New England” and “4002(b)”, respectively. (D) Section 4009j) of OBRA is amended by adding at the end the following new paragraphs: “(9) Section 1818(c) of the Social Security Act (42 U.S.C. 1395i–2(c)) is amended by striking paragraph (4) and redesignating paragraphs (5) through (7) as paragraphs (4) through (6), respectively. “(10) Section 9305(d) of the Omnibus Budget Reconciliation 100 Stat. 1988 . Act of 1986 is amended by striking ‘2 years after the date of the enactment of this Act’ and inserting ‘January 1, 1990’.”. (c) Corrections Relating to Subpart A of Part 2 of Subtitle A of Title IV (Health Maintenance Organization Reforms).— (1) Section 4011.— Subparagraph (F) of section 1876(c)(3) of the Social Security Act, as added by the amendment made by 42 USC 1395mm. section 4011(a)(1) of OBRA, is amended by moving its indentation 4 ems to the left so its left margin is aligned with the left margin of subparagraph (G) of that section, as added by section 4011(b)(1) of OBRA. (2) Section 4012.— (A) (i) Section 1866(a)(1)(O) of the Social Security Act, as inserted by section 4012(a) of OBRA, is amended by striking “with a risk-sharing contract under section 1876” and inserting “(i) with a risk-sharing contract under section 1876, under section 1876(i)(2)(A) (as in effect before February 1, 1985), under section 402(a) of the Social Security Amendments of 1967, or under section 222(a) of the Social Security Amendments of 1972, and (ii) which does not have a contract establishing payment amounts for services furnished to members of the organization”. (ii) The amendment made by clause (i) shall apply to admissions Effective date. 42 USC 1395cc note. occurring on or after the first day of the fourth month beginning after the date of the enactment of this Act. (B) Section 4012(c) of OBRA is amended by striking “paragraph (2)” 42 USC 1395mm note. and inserting “subsection (a)”. (3) Section 4013.— Section 4013 of OBRA is amended by striking 42 USC 1395mm. “(a) In General” and all that follows through the end and inserting the following: “Section 2350(b)(3) of the Deficit Reduction Act of 1984 is amended 42 USC 1395mm note. by striking ‘four years after the date of the enactment of this Act’ and inserting ‘September 30, 1990’.”. (4) Section 4014.— Section 1876(i)(6) of the Social Security Act, as amended by section 4014 of OBRA, is amended— 42 USC 1395mm. (A) in subparagraph (A), by inserting “, in addition to any other remedies authorized by law,” after “the Secretary may provide”, and (B) in the last sentence of subparagraph (B), by striking “under that section” and inserting “or proceeding under section 1128A(a)”. (5) Section 4018.— Section 1876(f)(3)(A) of the Social Security Act, as inserted by section 4018(a) of OBRA, is amended— (A) by inserting “enrollment and residency requirements under this section and for” after “for purposes of”, and (B) by striking “of the subdivision” and inserting “described in subparagraph (B)(iii) who receive services through the subdivision”. (d) Corrections Relating to Subpart B of Part 2 of Subtitle A of Title IV (Home Health Quality).— (1) Section 4021.— (A) Section 1891(a) of the Social Security Act, as added by section 4021(b) of OBRA, is amended— 42 USC 1395bbb. (i) in paragraph (3)(A), by striking “who is not a licensed health care professional (as defined in subparagraph (F))”, (ii) in paragraph (3)(F), by inserting “physical or occupational Health care professionals. therapy assistant,” after “occupational therapist,”, and (iii) by striking paragraph (4) and by redesignating paragraphs (5) and (6) as paragraphs (4) and (5), respectively. (B) (i) Section 1861(n) of the Social Security Act (42 U.S.C. 1395x(n)) is amended by inserting before the period at the end the following: “; except that such term does not include such equipment furnished by a supplier who has used, for the demonstration and use of specific equipment, an individual who has not met such minimum training standards as the Secretary may establish with respect to the demonstration and use of such specific equipment”. (ii) The amendment made by clause (i) shall apply to equipment Effective date. furnished on or after the effective date provided in section 4021(c) of OBRA. (2) Section 4022.— (A) The third sentence of section 1891(c)(1) of the Social Security Act, as added by section 4022(a) of OBRA, is amended by inserting “(other than subsections (a) and (b))” after “1128A”. (B) Section 1891(d)(2)(A) of the Social Security Act, as added 42 USC 1395bbb. by section 4022(a) of OBRA, is amended by striking “1991” and inserting “1992”. (3) Section 4023.— (A) Section 4023 of OBRA is amended by inserting “(a) In General.—” before “Section 1891”. (B) Section 1891(f)(2)(A) of the Social Security Act, as added by section 4023 of OBRA, is amended— (i) by moving the indentation of clauses (i) through (iii) (and the sentence following clause (iii)) 2 ems to the left, (ii) in clause (i), by striking “for each day of noncompliance” and inserting “in an amount not to exceed $10,000 for each day of noncompliance”, and (iii) by inserting after and below clause (iii), the following: “The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (i) in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).”. (C) Section 4023(b) of OBRA is amended by inserting before the period at the end the following: “, and no intermediate sanction described in section 1891(f)(2)(A) of such Act shall be imposed for violations occurring before such effective date”. (4) Section 4025.— (A) Section 1864(a) of the Social Security 42 USC 1395aa. Act is amended— (i) in the first sentence added by section 4025(a) of OBRA, by striking “most recent accreditation survey conducted with respect to the agency,” and inserting “most recent accreditation survey conducted by a State agency or private accreditation agency under section 1865 with respect to the home health agency,”, and (ii) in the second sentence so added— (I) by inserting “such State or local” before “agency” the first place it appears, and (II) by striking “section 1864” and inserting “section 1865”. (B) Section 4025 of OBRA is amended— (i) in subsection (b), by striking “subsection (a)” and inserting “this section” and by redesignating such subsection as subsection (c), and (ii) by inserting after subsection (a) the following new subsection: “(b) Conforming Amendment.— The last sentence of section 1865(a) of such Act (42 U.S.C. 1395bb(a)) is amended by inserting ‘(other than a survey with respect to a home health agency’ after ‘any accreditation survey’.”. (5) Section 4026.— (A) Section 1861(v)(1)(L)(iii) of the Social 42 USC 1395x. Security Act, as added by section 4026(a)(1)of OBRA, is amended— (i) by striking “audited” each place it appears and inserting “verified”, and (ii) by adding at the end the following: “ Wages. In the case of a home health agency that refuses to provide data, or deliberately provides false data, respecting wages for purposes of this clause upon the request of the Secretary, the Secretary may withhold up to 5 percent of the amount of the payments otherwise payable to the agency under this title until such date as the Secretary determines that such data has been satisfactorily provided.”. (B) Section 4026(a)(2) of OBRA is amended by striking “July 1, 42 USC 1395x note. 1988” and inserting “July 1, 1989”. (C) Section 4026(b) of OBRA is amended by striking “June 1, 1988” and inserting “June 1, 1989”. (6) Section 4027.— Section 4027(a) of OBRA is amended by 42 USC 1395n note. striking “July 1, 1988” and inserting “April 1, 1989”. (e) Corrections Relating to Subpart C of Part 2 of Subtitle A of Title IV (Other Medicare Part A and B Provisions).— (1) Section 4032.— (A) Section 4032 of OBRA is amended by 42 USC 1395b. striking “and Physician Review” in the heading of subsection (a) and by striking “and Carriers” in the heading of subsection (b). (B) Section 18166)(2) of the Social Security Act, as added by section 4032(a) of OBRA, is amended— 42 USC 1395h. (i) by inserting “in the case of a request for reconsideration of a denial,” after “(2)”, and (ii) by inserting “the” before “disposition”. (C) Section 4032(c)(1)(B) of OBRA is amended by striking 42 USC 1395b note. “claims filed” and inserting “reconsiderations requested”. (2) Section 4033.— Section 4033 of OBRA is amended— (A) by striking “(a) In General.—” 42 USC 426. (B) by redesignating paragraphs (1) and (2) (and subparagraphs 42 USC 426 note. (A) and (B) of paragraph (2)) as subsections (a) and (b) (and paragraphs (1) and (2) of subsection (b)), respectively, and (C) by aligning the left margins of the matter in such section flush left. (3) Section 4039.— Section 4039 of OBRA is amended by adding at the end the following new subsection: “(h) Technical Corrections.— “(1) Section 1128A(b) of the Social Security Act (42 U.S.C. 1320a–7a(b)) is amended— “(A) in paragraph (1)(A), by striking ‘)(VII’ and inserting ‘XVII’, and “(B) in paragraph (2) by inserting ‘each’ after ‘$2,000 for’. “(2) Section 1138(a)(1)(B) of such Act (42 U.S.C. 1320b–8(a)(1)(B)) is amended by striking ‘In’ and inserting ‘in’. “(3) Section 1154(a)(4) of such Act (42 U.S.C. 1320c–3(a)(4)) is amended— “(A) by indenting subparagraphs (B) and (C) (and clauses (i) through (iii) of subparagraph (C) two additional ems; “(B) in subparagraph (B), by inserting ‘risk-sharing’ before ‘contract under section 1876’; and “(C) in subparagraph (C)(i), by adding before the comma at the end the following: ‘(other than the ability to perform review functions under this section that are not described in subparagraph (B))’. “(4) Section 1154(d) of such Act (42 U.S.C. 1320c–3(d)) is amended by striking “1164(b)(4)” and inserting ‘1164’. “(5) Section 1156(b) of such Act (42 U.S.C. 1320c–5(b)) is amended— “(A) in the second sentence of paragraph (1), by striking ‘such services on a reimbursable basis.’ and inserting ‘services under this Act on a reimbursable basis.’, and “(B) in paragraph (2), by striking ‘at such time’ and all that follows through ‘and shall remain’ and inserting ‘on the same date and in the same manner as an exclusion from participation under the programs under this Act becomes effective under section 1128(c), and shall remain’. “(6) Section 1160 of such Act (42 U.S.C. 1320c–9) is amended by adding at the end the following new subsection: “‘(e) For purposes of this section and section 1157, the term “organization with a contract with the Secretary under this part” includes an entity with a contract with the Secretary under section 1154(a)(4)(C).’. “(7) The heading of section 1870 of such Act (42 U.S.C. 1395gg) is amended to read as follows: “(8) Section 1876(i)(7) of such Act (42 U.S.C. 1395mm(i)(7)) is amended— “(A) in subparagraph (A), by striking ‘Except as provided under section 1154(a)(4)(C), each’ and inserting ‘Each’; “(B) in subparagraph (A), by inserting ‘or with an entity selected by the Secretary under section 1154(a)(4)(C)’ after ‘located)’; and “(C) by striking ‘peer’ in subparagraph (B) and the second place it appears in subparagraph (A). “(9) Section 9353 of the Omnibus Budget Reconciliation Act of 42 USC 1320c–3 note. Contracts. 1986 is amended— “(A) in subsection (a)(6)(A)(i), by striking ‘paragraphs (1) and (2)(D) shall apply to contracts as of and inserting ‘paragraph (1) shall apply to contracts entered into or renewed on or after’; “(B) in subsection (a)(6)(B), by striking ‘amendment made by paragraph (2)(B)’ and inserting ‘amendments made by paragraphs (2)(B) and (2)(D)’; and “(C) in subsection (e)(3)(B), by adding at the end the following: “The provisions of section 1876(1)(7) of the Social Security Act (added by such amendment) shall apply to health maintenance organizations with contracts in effect under section 1876 of such Act (as in effect before the date of the enactment of Public Law 97–248) in the same manner as it applies to eligible organizations with risk-sharing contracts in effect under section 1876 of such Act (as in effect on the date of the enactment of this Act).’.”. (f) Corrections Relating to Subpart A of Part 3 of Subtitle A of Title IV (Payments for Physicians’ Services).— (1) Section 4041.— (A) Section 4041(a)(1)(B) of OBRA is amended— (i) by inserting “as amended retroactively by section 4085(i)(7)(C),” after “(j)(1)(C),”, and (ii) by redesignating the clause added by such section as clause (viii). (B) The last sentence of section 1842(b)(2) of the Social 42 USC 1395u. Security Act, as added by section 4041(a)(3)(A) of OBRA, is amended by striking “and subsection (h)” and inserting “, subsection (h), and section 1845(f)(2)”. (C) Subclause (II) of section 4041(a)(3)(B)(iii) of OBRA is amended to read as follows: “(II) by striking ‘April 1’ and inserting ‘September 30’, and”. (2) Section 4042.— (A) Section 1842(b)(4)(F)(iii) of the Social Security Act, as added by section 4042(a) of OBRA, is amended— 42 USC 1395u. (i) in subclause (I), by striking the semicolon and inserting a comma, and (ii) in subclause (ID, by striking “physician’s” and inserting “physicians’ ”. (B) Section 1842(b)(4)(F)(ii)(1) of the Social Security Act, as added by section 4042(a) of OBRA, is amended by striking “subparagraph (E)(iii) ” and inserting “subsection (i)(4)”. (C) Section 4042(b) of OBRA is amended by striking “Section” and all that follows up to “The term” and inserting the following: “(1) Section 1842 of such Act (42 U.S.C. 1395u) is amended— “(A) in subsection (h)(7), by striking described in paragraph (8)’; “(B) in paragraph (8) of subsection (h)— “(i) by striking ‘(8) For purposes of this title, a’ and inserting ‘(1) A’, “(ii) by indenting such paragraph 2 ems, and “(iii) by inserting before such paragraph the following: “‘(i) For purposes of this title:’; (C) in subsection (b)(4)(E)— “(i) by striking ‘(E) In this section:’, “(ii) by redesignating clauses (i) and (ii), as paragraphs (2) and (3), respectively, and “(iii) by transferring and inserting such paragraphs, as redesignated, before subsection (j); “(D) in subsection (b)(4), by redesignating subparagraphs (F) and (G) of subsection (b)(4), as subparagraphs (E) and (F), respectively; and “(E) by inserting, after the paragraphs transferred and inserted by subparagraph (C)(iii), the following new paragraph: “‘4’” . (D) Section 4042(b) of OBRA is further amended by adding at 42 USC 1395u. the end the following: “(2) (A) Section 1842(b)(4)(A)(vii) of such Act, as redesignated by sections 4041(a)(1)(A)(i) and 4044(a), is amended by striking ‘subparagraph (E)(ii)’ and inserting ‘subsection (i)(3)’. “(B) Section 1833(1)(2) of such Act (42 U.S.C. 139510)(2)) is amended by striking ‘1842(b)(4)(E)(ii)’ and inserting ‘18420)(3)’.”. (E) The last sentence of section 1842(b)(4)(A)(iv)(II) of the Social Security Act, as added by section 4042(c)(2) of OBRA, is amended by striking “January 1, 1988” and inserting “January 1, 1989”. (F) Section 4042(c) of OBRA is amended— (i) by striking “Section” and all that follows up to “In the previous sentence” and inserting the following: “(1) The first sentence of clause (iv) of section 1842(b)(4)(A) of such Act (42 U.S.C. 139u(b)(4)(A)) is amended to read as follows: ‘The reasonable charge for physicians’ services furnished on or Health care professionals. after January 1, 1987, by a nonparticipating physician shall be no greater than the applicable percent of the prevailing charge levels established under the third and fourth sentences of paragraph (3) (or under any other applicable provision of law affecting the prevailing charge level)?.”, and (ii) by adding at the end the following: “(2) Subclauses (I) and (II) of section 1842(j)(1)(C)(i) of such Act are amended by striking ‘prevailing charge for the year involved for such service furnished by nonparticipating physicians’ and inserting ‘applicable percent (as defined in subsection (b)(4)(A)(iv)) of the prevailing charge for the year and service involved’.”. (3) Section 4044.— (A) Section 4044(a) of OBRA is amended by striking “Increase in Prevailing Charges” and inserting “Prevailing Charge Floor”. (B) Section 1842(b)(4)(A)(vi) of the Social Security Act, as 42 USC 1395u. inserted by section 4044(a) of OBRA, is amended— (i) by striking “subparagraph (E)(iii)” and inserting “subsection (i)(4)”. (ii) by striking “the average of the prevailing charge levels” and inserting “the estimated average prevailing charge levels based on the best available data”, and (iii) by striking “for participating physicians”. (4) Section 4045.— (A) Section 1842(b)(10) of the Social Security Act, as amended by section 4045(a) of OBRA, is amended— (i) in subparagraph (A)(i)— (I) by striking “under paragraph (3)”, (II) by striking “subparagraph (C)” and inserting “subparagraph (B)”, and (III) by striking “for participating and nonparticipating physicians”; (ii) in subparagraph (A)(iii), by striking “clause (i)(ID” and inserting “clause (i)(I)”; (iii) in subparagraph (B) by inserting “(including subsequent insertion of an intraocular lens)” after “cataract surgery”; and (iv) in subparagraph (D), by inserting “under” after “review”. (B) Section 4045(c)(2) of OBRA is amended— (i) in subparagraph (B), by inserting before the period at the end the following: “and by striking the second sentence”, and (ii) by adding at the end the following new subparagraph: “(D) The fourth sentence of section 1842(b)(3) of the Social Security Act (42 U.S.C. 1395u(b)(3)) is amended by inserting ‘(or under any other provision of law affecting the prevailing charge level)’ after ‘the level determined under this sentence’.”. (C) Section 1842(j)(1)(D)(iv) of the Social Security Act, as added by section 4045(c)(1)(B) of OBRA, is amended by striking “imposes a charge” and inserting “bills”. (D) (i) Section 1862(a)(15) of the Social Security Act (42 U.S.C. 1395y(a)(15)) is amended by inserting “(including subsequent insertion of an intraocular lens)” after “operation”. (ii) The amendment made by clause (i) shall apply to operations performed on or after 60 days after the date of the enactment of this Act. (5) Section 4048.— (A) Section 1842(b)(H)(C)(i) of the Social Security Act, as inserted by section 4046(a)(1)(C) of OBRA and as designated by section 4063(a)(1)(A), is amended by striking “implantation” and inserting “insertion”. (B) Section 1842(j)(1)(D)(ii)(IV) of the Social Security Act, as inserted by section 4046(a)(2)(A) of OBRA, is amended by striking 42 USC 1395u. “is”. (6) Section 4047.— (A) The heading of section 4047 of OBRA is amended by striking “PRIMARY CARE” and inserting “CERTAIN”. (B) Section 1842(b)(4)(G) of the Social Security Act, as added by section 4047(a) of OBRA, is amended— (i) by inserting “than” after “(other”, and (ii) by striking “(as determined under the third and fourth sentences of paragraph (3) and under paragraph (4))”. (C) Section 4047(b) of OBRA is amended by inserting “on or” 42 USC 1395u note. after “medicare beneficiaries”. (D) The item in the table of contents of title IV of OBRA relating to section 4047 is amended to read as follows: “Sec. 4047. Customary charges for certain services of new physicians.”. (7) Section 4048.— (A) Paragraph (14) of section 1842(b) of the Social Security Act, as added by section 4048(a) of OBRA, is redesignated as paragraph (13). (B) Section 4048 of OBRA is amended by adding at the end the 101 Stat. 1330–89. following new subsection: “(e) Conforming Amendment to Maxmimum Allowable Actual Charge.— Section 1842(1)(1)(C) of the Social Security Act (42 U.S.C. 1395u(j)(1)(C)), as amended by sections 4085(i)(7)(C) and 4041(a)(1)(B) of this title, is amended by adding at the end the following new clause: “(ix) If there is a reduction under subsection (b)(IS) in the Health care professionals. reasonable charge for medical direction furnished by a nonparticipating physician, the maximum allowable actual charge otherwise permitted under this subsection for such services shall be reduced in the same manner and in the same percentage as the reduction in such reasonable charge.’.”. (8) Section 4049.— (A) Section 1834(b)(6) of the Social Security Act, as added by section 4049(a)(2) of OBRA, is amended by 42 USC 1395m. striking “radiologic” each place it appears and inserting “radiology”. (B) Section 4049(a) of OBRA is amended— (i) in paragraph (1), by striking “4062(c)(3)” and inserting 42 USC 1395l. “4062(d)(3)”, and (ii) in paragraph (2), by striking “4062(a)” and inserting 42 USC 1395n. “4062(b)’. (C) Section 1833(a)(1) of the Social Security Act, as amended by section 4049(a)(1)of OBRA, is amended in the clause added 42 USC 1395l. by that section by striking “1834(b)(5)” and inserting “1834(b)(6)”. (D) Section 1834(b) of the Social Security Act, as added by section 4049(a)(2) of OBRA, is amended— (i) “physicians”; (ii) in paragraph (5)(0, by striking “imposes a charge” and inserting “bills”; (iii) in paragraph (5)(0, by inserting “in the same manner as such sanctions may apply to a physician” after “18420)(2)”; (iv) in paragraph (6), by striking “, section 1833(a)(1)(I), and section 1842(h)(1)(B)” and inserting “and section 1833(a)(1)(J)”; and (v) in paragraph (6)(B), by striking “billings” and inserting “the total amount of charges”. (E) Section 4049(b) of OBRA is amended by striking “establish” and inserting “propose”. (9) Section 4051.— Section 1842(n) of the Social Security Act, 42 USC 1395u. as added by section 4051(a) of OBRA, is amended— (A) in paragraph (1) in the matter before subparagraph (A)— (i) by striking “to a patient”, (ii) by inserting “the bill or request for” after “for which”, (iii) by striking “his” and inserting “a”, and (iv) by striking “supervised the test” and inserting “supervised the performance of the test”; (B) in paragraph (1)(A), by striking “to individuals enrolled under this part”; (C) in paragraph (2)(A), by inserting “the payment amount specified in paragraph (1)(A) and” after “other than”; and (D) in paragraph (3), by striking “or supplier”. (10) First section 4052.— (A) Section 1892(a) of the Social 42 USC 1395ccc. Security Act, as added by the first section 4052(a) of OBRA, is amended— (i) in paragraphs (2)(C)(ii) and (3)(B), by striking “paragraph (3)” and inserting “paragraph (4)”, (ii) in paragraph (4), by striking “bar” and inserting “exclude”, and (iii) in paragraph (4), by inserting before the period at the end the following: “if a State requests that the physician not be excluded”. (B) The first section 4052(b) of OBRA (relating to conforming reference) is amended by striking “338E(b)(1)” and “254o(b)(1)K and inserting “338E)(b)(1)(B)(i)” and “254o(b)(1)(B)(i)”, respectively. (C) (i) Section 1892 of the Social Security Act, as added by the first section 4052(a) of OBRA, is amended— (I) in the heading, by striking “physicians” and “schoolarship” and inserting “individuals” and “scholarship” and inserting “individuals” and “scholarship and loan”, respectively; (II) by striking “physician” each place it appears (other than the third place it appears in subsection (a)(4)) and inserting “individual”; (III) by striking “physician” the third place it appears in subsection (a)(4) and inserting “practitioner”; (IV) in paragraph (1)(A), by inserting “, the Physician Shortage Area Scholarship Program, or the Health Education Assistance Loan Program,” after “Scholarship Program”; (V) in subsection (b), by striking “, and (2)” and all that follows through “Act” and inserting “or under subpart III of part F of title VII of such Act (as in effect before October 1, 1976) and which has not been paid by the deadline established by the Secretary pursuant to such respective section”; and (VI) in subsection (b), by striking the period at the end and inserting or” and by adding at the end the following: “(2) owed by an individual to the United States by reason of a Loans. loan covered by Federal loan insurance under subpart I of part C of title VII of the Public Health Service Act and payment for which has not been cancelled, waived, or suspended by the Secretary under such subpart.”. (ii) Section 733(0 of the Public Health Service Act (42 U.S.C. 294(f)) is amended by adding at the end the following: “Procedures for reduction of payments under the medicare program are provided under section 1892 of the Social Security Act.”. (iii) The amendments made by this subparagraph shall be Effective date. 42 USC 294f note. effective 30 days after the date of the enactment of this Act. (11) Second section 4052.— (A) The second section 4052(a) of OBRA is amended by striking “is amended” and all that follows 42 USC 1395u. through the end and inserting the following: “is amended by inserting before the period at the end of the next-to-last sentence the following: ‘, and shall remain at such prevailing charge level until the prevailing charge for a year (as adjusted by economic index data) equals or exceeds such prevailing charge level’.”. (B) The second section 4052(b) of OBRA is amended by striking 42 USC 1395u note. “January” and inserting “April”. (12) Section 4054.— (A) Section 4054 of OBRA is amended to 42 USC 1395l note. read as follows: “SEC. 4054. APPLYING COPAYMENT AND DEDUCTIBLE TO CERTAIN OUT-PATIENT PHYSICIANS’ SERVICES. “(a) In General.— Section 1833 of the Social Security Act (42 U.S.C. 13951) is amended— “(1) in subsection (a)(1), by striking clause (F), “(2) in subsection (b), by striking paragraph (3) and by re-designating paragraphs (4) and (5) as paragraphs (3) and (4), respectively, and “(3) in subsection (i), by striking paragraph (4). “(b) Effective Date.— The amendments made by subsection (a) shall apply to services furnished on or after April 1, 1988.”. (B) The item relating to section 4054 in the table of contents of title IV of OBRA is amended to read as follows: “Sec. 4054. Applying copayment and deductible to certain outpatient physicians’ services.”. (13) Section 4055.— Section 4055 of OBRA is amended— (A) in subsection (a)(2), by striking “such list” and inserting 42 USC 1395u note. “such definitions”, and (B) in subsection (b)(1), by striking “dermatology,”. 42 USC 1395w–1 note. (14) Redesignation.— The second section 4052 of OBRA and sections 4053, 4054, and 4055 of OBRA are redesignated as 42 USC 1395u, 1395u notes, 1395l, 1395l notes, 1395w–1 note. sections 4053 through 4056, respectively. (g) Corrections Relating to Subpart B of Part 3 of Subtitle A of Title IV (Payments for Other Part B Services).— (1) Section 4062.— (A) The heading of section 1834 of the Social Security Act, as inserted by section 4062(b) of OBRA, is 42 USC 1395m. amended by inserting “items and” after “particular”. (B) Subsection (a) of section 1834 of the Social Security Act, as so inserted, is amended— (i) in paragraph (1)(C), by inserting “or under part A to a home health agency” after “under this part”; (ii) in the second sentence of paragraph (2)(A), by striking “rental” before “payments”; (iii) in paragraph (2)(B)(i), by striking “allowed” and inserting ’‘reasonable”, and in paragraphs (3)(B)(i) and (8)(A)(i)(I), by striking “allowable” and inserting “reasonable”; (iv) in paragraph (3)(A), by striking the extra space after “ventilators”; (v) in paragraph (4), by inserting after “individual patient” the following: and for that reason cannot be grouped with similar items for purposes of payment under this title,”; (vi) in paragraph (4), by inserting “(A)” after “in a lump-sum amount” and by inserting “(B)” after “for that item, and”; (vii) in paragraph (4), by striking “maintenance and service” each place it appears and inserting “maintenance and servicing”, in paragraph (7)(A)(iii), by striking “service and maintenance” and inserting “maintenance and servicing”, and in paragraphs (7)(A)(ii) and (11)(A), by striking “servicing” and inserting “maintenance and servicing”; (viii) in paragraph (7)(A)(iii)(I), by striking “fee established by the carrier” and inserting “fee or fees established by the Secretary ”; (ix) in paragraph (9)(A)(ii)(I), by striking “12-month period” and inserting “6-month period”; (x) in paragraph (9)(A)(ii)(H), by striking “and to 1991” and inserting “, 1991, and 1992”; (xi) in paragraphs (9)(B)(i) and (10)(B)(i), by striking the comma after “1991”; (xii) in paragraph (9)(C)(i), by striking “subparagraph (A)(ii)(D” and inserting “subparagraph (A)(ii)”; (xiii) in paragraph (10)(B), by inserting before the period the following: ,rand payments under this subsection as such provisions apply to physicians’ services and physicians and a reasonable charge under section 1842(b)”; (xiv) in the last sentence of paragraph (11)(A), by striking “under subsection (j)(2)” and inserting “under section 1842q)(2)”; (xv) in paragraph (12), by striking “(as defined in section 1886(d)(2)(D))”; and (xvi) by striking paragraph (14). (C) Section 4062(c)(4) of OBRA is amended— (i) by inserting “and payment of a reasonable copying fee which the Secretary may establish” after “upon written request”, and (ii) by inserting before the period at the end the following: “, but only in a form which does not permit identification of individual suppliers”. (D) The last sentence of section 1866(a)(2)(A) of the Social Security Act, as added by section 4062(d)(4) of OBRA, is amended by striking “section 1834(a)(2)” and inserting “section 1834(a)(1)(B)”. (E) The matter added by section 4062(d)(3)(A)(ii) of OBRA is amended by striking “and” before “(I)”. (2) Section 4063.— (A) Section 1842(b)(H)(C)(ii) of the Social Security Act, as amended by section 4063(a)(1)(A) of OBRA, is 42 USC 1395u. amended— (i) by striking “implanted” and inserting “inserted”, and (ii) by inserting “or subsequent to” after “during”. (B) Subclause (IV) of section 1842(j)(1)(D)(ii) of the Social Security Act, as inserted by section 4063(a)(2)(A) of OBRA, is redesignated as subclause (V) and is amended by striking “is”. (C) Section 4063(a)(2)(B) of OBRA is amended by striking 42 USC 1395l. clause (ii) and by redesignating clauses (iii) and (iv) as clauses (ii) and (iii), respectively. (D) Section 1833(i)(2)(A)(iii) of the Social Security Act, as inserted by section 4063(b)(3) of OBRA is amended— 42 USC 1395l. (i) by striking “implantation” and inserting “insertion”, and (ii) by inserting “or subsequent to” after “during”. (E) Section 4063 of OBRA is amended by adding at the end the following new subsection: “(e) Prevention of Additional Billings for IOLs.— “(1) Section 1833(i) of the Social Security Act (42 U.S.C. 13951(i)) is amended by adding at the end the following new paragraph: “(6) Any person, other than a facility having an agreement under Contracts. Claims. Law enforcement and crime. section 1832(a)(2)(F)(i), who knowingly and willfully presents, or causes to be presented, a bill or request for payment, for an intraocular lens inserted during or subsequent to cataract surgery for which payment may be made under paragraph (2)(A)(iii), is subject to a civil money penalty of not to exceed $2,000. The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).’. “(2) Section 1832(a)(2)(F)(i) of such Act (42 U.S.C. 1395k(a)(2)(F)(D) is amended by inserting ‘(including intraocular lens in cases described in section 1833(i)(2)(A)(iiD)Y after ‘services’ each place it appears.”. (3) Section 4064.— (A) Section 4064(a) of OBRA is amended by 42 USC 1395l note. striking all that follows the first dash and inserting the following: “Paragraph (2) of section 1833(h) of the Social Security Act (42 U.S.C. 13951(h)) is amended— “(1) by inserting ‘(A)(i)’ after ‘(2)’; “(2) in the second sentence— “(A) by redesignating clauses (A) and (B) as clauses (i) and (ii), respectively, and “(B) by designating such sentence as subparagraph (B); and “(3) by adding at the end of subparagraph (A)(i), as designated under paragraph (1), the following new clause: “‘(ii) Notwithstanding any other provision of this subsection— “‘(I) any change in the fee schedules which would have become effective under this subsection for tests furnished on or after January 1, 1988, shall not be effective for tests furnished during the 3-month period beginning on January 1, 1988, and ‘“(II) the Secretary shall not adjust the fee schedules under clause (i) to take into account any increase in the consumer price index for 1988.’.”. (B) Section 4064(b)(1)of OBRA is amended— (i) by striking “1833(h)(2) of the Social Security Act (42 U.S.C. 13951(h)(2))” and inserting “1833(h)(2)(A) of the Social Security Act (42 U.S.C. 13951(h)(2)(A)), as amended by subsection (a),”; (ii) by striking “the following: ‘In establishing fee schedules under the first sentence of this paragraph with respect to” and inserting “the following new clause: “‘(iii) In establishing fee schedules under clause (i) with respect to”; and (iii) by moving the indentation of all the matter added following “with respect to” 2 ems to the left. (C) The clause added by section 4064(b)(1) of OBRA, as amended by subparagraph (A), is amended by inserting before the period at the end the following: and such reduced fee schedules shall serve as the base tor 1989 and subsequent years”. (D) Section 1833(h)(4)(B)(ii) of the Social Security Act, as amended by section 4064(b)(2)(B) of OBRA, is 42 USC 1395l. amended by inserting “after” before “March”. (E) Section 4064(c) of OBRA is amended by striking all that follows the dash and inserting the following: “Section 1833(h)(1)(D) of such Act is amended by inserting “, in a sole community hospital (as defined in the last sentence of section 1886(d)(5)(C)(ii))? after ‘a hospital laboratory’.”. (F) Section 4064(c) of OBRA is amended by inserting “(1)” after the dash and by adding at the end the following new paragraph: “(2) The amendment made by paragraph (1) shall apply with respect to diagnostic laboratory tests furnished on or after April 1, 1988.”. (G) Section 1846 of the Social Security Act, as added by 42 USC 1395w–2. section 4064(d)(1)of OBRA, is amended— (i) in subsection (a)— (I) by striking “certified” and “certification” and inserting “approved” and “approval”, respectively, (II) by inserting “or for coverage” after “conditions of participation”, and (III) by striking “cancelling immediately the certification of the provider or clinical laboratory” and inserting “terminating immediately the provider agreement or cancelling immediately approval of the clinical laboratory”; (ii) in subsections (b)(1)(A) and (b)(2)(A)(iv), by striking “certified”; (iii) in subsection (b)(2)(A)(ii), by striking “civil fines and penalties” and inserting “civil money penalties in an amount not to exceed $10,000 for each day of substantial noncompliance”; (iv) in subsection (b)(2)(A), by adding at the end the following new sentence: Law enforcement and crime. “The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (ii) in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a). (v) in subsection (b)(2)(A)(iii), by striking “certification”; (vi) in subsection (b)(2)(A)(iv), by striking “provided on or after the date in” and inserting “furnished on or after the date on”; and (vi) in subsection (b)(3), by striking “fines” and inserting “penalties” each place it appears. (H) The matter inserted in section 1861(s) of the Social Security Act by section 4064(e)(1) of OBRA is amended by inserting a 42 USC 1395x. comma after “year”. (4) Section 4066.— (A) The heading of section 4066 of OBRA is amended by inserting “AND OTHER DIAGNOSTIC TESTS” after “RADIOLOGY” (B) The item relating to section 4066 in the table of contents of title IV of OBRA is amended to read as follows: “Sec. 4066. Payments to hospital outpatient departments for radiology and other diagnostic tests.”. (C) Section 1833(n) of the Social Security Act, as added by section 4066(a)(2) of OBRA, is amended— 42 USC 1395l. (i) in paragraph (1)(A), by striking “beginning on or after October 1, 1988, under this part for services described in subsection (a)(2)(E)” and inserting “for services described in subsection (a)(2)(E)(i) furnished under this part on or after October 1, 1988, and for services described in subsection (a)(2)(E)(ii) furnished under this part on or after October 1, 1989,”; (ii) in paragraph (1)(B)(i)(II), by inserting “or (for services described in subsection (a)(2)(E)(i) furnished on or after January 1, 1989) the fee schedule amount established” after “the prevailing charge”; and (iii) by amending subclauses (I) and (II) of paragraph (1)(B)(ii) to read as follows: “(I) The term ‘cost proportion’ means 50 percent, except that such term means 65 percent in the case of outpatient radiology services for portions of cost reporting periods which occur in fiscal year 1989 and in the case of diagnostic procedures described in subsection (a)(2)(E)(ii) for portions of cost reporting periods which occur in fiscal year 1990. “(II) The term ‘charge proportion’ means 100 percent minus the cost proportion.”. (5) Section 4067.— Section 1833(f) of the Social Security Act, as inserted by section 4067(a) of OBRA, is amended by striking “medicare economic index (referred to in the fourth sentence of section 1842(b)(3)) applicable to physicians’ services” and inserting “MEI (as defined in section 1842(i)(3)) applicable to primary care services (as defined in section 1842(i)(4))”. (6) Section 4068.— The last sentence of section 1135(d)(3) of the Social Security Act, as added by section 4068(b)(1)of OBRA, 42 USC 1320b–5. is amended by striking “speciality” and inserting “specialty”. (h) Corrections Relating to Subpart B of Part 3 of Subtitle A of Title IV (Part B Eligibility and Benefits Changes).— (1) Section 4070.— (A) The last sentence of section 1833(c) of Prescription drugs. the Social Security Act, as added by section 407()(a)(2) of OBRA, is amended by striking “prescribing or monitoring prescription drugs” and inserting “monitoring or changing drug prescriptions”. (B) Section 1861(ff) of the Social Security Act, as added by section 4070(b)(2) of OBRA, is amended— (i) by inserting before such subsection the following heading: (ii) in paragraph (3), by striking “hospital-based or hospital-affiliated (as defined by the Secretary)” and inserting “furnished by a hospital to its outpatients”. (2) Section 4071.— Section 1861(s)(10)(A) of the Social Security 42 USC 1395x. Act, as amended by section 4071(a) of OBRA, is amended by inserting “, subject to section 4071(b) of the Omnibus Budget Reconciliation Act of 1987,” before “influenza vaccine”. (3) Section 4072.— (A) Section 1861(s)(12) of the Social Security Act, as amended by section 4072(a) of OBRA, is amended by inserting “subject to section 4072(e) of the Omnibus Budget Reconciliation Act of 1987,” after “(12)”. (B) Section 4072(b) of OBRA is amended— (i) by striking “by inserting after subsection (e)” and inserting “by adding at the end, as previously amended,”, and (ii) by redesignating the subsection added by such section as subsection (o). (4) Section 4073.— Section 4073 of OBRA is amended— (A) by striking paragraph (1) of subsection (b); (B) in paragraph (2) of subsection (b)— (i) by redesignating such paragraph as paragraph (1); (ii) by inserting “and” at the end of subparagraph (A); (iii) by striking subparagraph (B); (iv) in the matter added by subparagraph (C)— (I) by striking “and (I)” and inserting “(K)”, (II) by inserting “80 percent of the lesser of the actual charge for the services or” after “amounts paid shall be”, (III) by striking “but in no event more than” and inserting “but in no event shall such fee schedule exceed”, and (IV) by striking the semicolon and inserting a comma; and (v) by redesignating subparagraph (C) as subparagraph (B); (C) in paragraph (3) of subsection (b)— (i) by inserting “, as previously amended,” after “at the end”, (ii) by redesignating such paragraph as paragraph (2), (iii) by redesignating the subsection added by such paragraph as subsection (p), and (iv) by adding at the end of the subsection added by such paragraph the following: “Except for deductible and coinsurance amounts applicable under section 1833, whoever knowingly and willfully presents, or causes to be presented, to an individual enrolled under this part a bill or request for payment for services described in the previous sentence, is subject to a civil money penalty of not to exceed $2,000 for each such bill or request. The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).; (D) in the subsection added by subsection (c)— 42 USC 1395x. (i) by redesignating such subsection as subsection (gg), and (ii) in paragraph (1), by striking “his” and inserting “the nurse-midwife’s” and by striking “physician’s” and inserting “physicians” and (E) in the matter inserted by subsection (d)(1), by striking 42 USC 1396d. “section 1861(ff)” and inserting “section 1861(gg)”. (5) Section 4074.— Section 4074 of OBRA is amended— 42 USC 1395x. (A) in the matter inserted by subsection (a)(1), by striking “(ff)” and inserting “(hh)”, and (B) by redesignating the subsection added by subsection (b) as subsection (hh). (6) Section 4076.— Subsection (a) of section 4076 of OBRA is 42 USC 1395x. amended to read as follows: “(a) Services Covered.— Section 1861(s)(2)(K) of the Social Security Rural areas. Act (42 U.S.C. 1395x(s)(2)(K)) is amended by inserting “(D’ before ‘in a hospital’ and by striking ‘or as an assistant at surgery’ and inserting (II) as an assistant at surgery. or (III) in a rural area (as defined in section 1886(d)(2)(D)) that is designated, under section 332(a)(1)(A) of the Public Health Service Act, as a health manpower shortage area,’.”. (7) Section 4077.— Section 4077(b) of OBRA is amended— (A) in paragraph (1), by inserting “by section 4073(a) of 42 USC 1395x. this title” after “as amended”; (B) by striking paragraph (2); 42 USC 1395k. (C) in paragraph (3)— 42 USC 1395l. (i) by striking “1395k(a)(1))” and inserting “13951(a)(1)),” (ii) by striking subparagraphs (A) and (B), (iii) in subparagraph (C), by striking “(I)” and inserting “(K)” and by redesignating such subparagraph as subparagraph (A), (iv) in subparagraph (D), by striking “subparagraph:” and inserting “clause.” and by redesignating such subparagraph as subparagraph (B), and (v) in the matter added by subparagraph (B), as so redesignated— (I) by striking “(J)” and inserting “(L)”, and (II) by inserting “80 percent of the lesser of the actual charge for the services or” after “amounts paid shall be”; (D) in paragraph (4), by striking “section 4073(b)(3)” and 42 USC 1395l. inserting “4073(b)(2)”; (E) in paragraph (5), by redesignating the subsection (gg) 42 USC 1395x. added by such paragraph as subsection (ii); and (F) by redesignating paragraphs (3) through (6) as paragraphs 42 USC 1395l, 1395x, 1395k note. (2) through (5), respectively. (8) Section 4079.— Section 4079(c)(1) of OBRA is amended by 42 USC 1395mm note. striking “subsection (d)” and inserting “subsection (e)”. (i) Provisions Relating to Subpart D of Part 3 of Subtitle A of Title IV (Other Part B Provisions).— (1) Section 4081.— (A) Section 1842(h)(3)(B) of the Social Security Act, as added by section 4081(a) of OBRA, is amended— 42 USC 1395u. (i) in the second sentence— (I) by striking “claims” and inserting “payment”, and (II) by striking “including such information as the Secretary determines is generally provided” and inserting “shall include an explanation of benefits and any additional information that the Secretary may determine to be appropriate in order”; (ii) in the third sentence, by striking “arrangements” and inserting “agreements”; and (iii) in the fourth sentence— (I) by inserting “by a carrier” after “under this subparagraph”, and (II) by inserting before the period at the end the following: “, and such user fees shall be collected and retained by the carrier” (B) Section 4081(b)(2) of OBRA is amended by redesignating subparagraphs (A) through (C) as subparagraphs (B) through (D), respectively, and by inserting before subparagraph (B), as so redesignated, the following: “(A) in the matter before paragraph (1), by inserting ‘(or, with respect to paragraph (3), the issuer of the policy)’ after ‘he finds that such policy’,”. (C) Section 1882(c)(3) of the Social Security Act, as inserted by section 4081(b)(2)(C) of OBRA, is amended— (i) in subparagraph (A), by striking “claims form” each place it appears and inserting “claim form” in the first 2 places and “notice” in the third place, (ii) in subparagraph (B)(i), by inserting “under the policy” after “payment determination”, and (iii) in subparagraph (B)(ii), by striking “appropriate payment” and inserting “payment covered by such policy’. (D) Section 4081(c)(2)(B)(i) of OBRA is amended by striking “medical” and inserting “medicare”. (E) Section 4081(c)(2)(B)(ii) of OBRA is amended by inserting “or which has not enacted such legislation before July 1, 1988,” after “in which such legislation may be considered”. (2) Section 4082.— Section 4082(c) of OBRA is amended— (A) by striking “1842(b)(5) of such Act (42 U.S.C. 1395u(b)(5)” and inserting “1842(b)(2) of such Act (42 U.S.C. 1395u(b)(2))”, and (B) in paragraph (1), by striking “(5)” and inserting “(2)”. (3) Section 4084.— Section 4084 of OBRA is amended by adding at the end the following new subsection: “(c) Additional Technical Corrections.— “(1) Section 1861(bb)(2) of the Social Security Act (42 U.S.C. 1395x(bb)(2)) is amended by adding at the end the following: ‘Such term also includes, as prescribed by the Secretary, an anesthesiologist assistant.’. “(2) Section 1833(a)(1)(H) of such Act (42 U.S.C. 13951(a)(1)(H)) is amended by striking ‘lesser of the actual charge’ and inserting ‘least of the actual charge, the prevailing charge that would be recognized if the services had been performed by an anesthesiologist,’. “(3) The amendments made by this subsection shall apply to services furnished after December 31, 1988.”. (4) Section 4085.— (A) Section 1845(f) of the Social Security Act, as added by section 4085(a) of OBRA, is amended— (i) in paragraph (1), by striking “October 1st” and inserting “December 31st”, and (ii) in paragraph (2), by striking “July 1st of the following year” and inserting “the later of (A) July 1st of the following year, or (B) 45 days after the date of a reasonable charge update”. (B) Subparagraph (D) of section 1833(h)(5) of the Social Security Act, as added by section 4085(b)(1) of OBRA, is amended— 42 USC 1395l. (i) by striking “If a person” and all that follows through “under subparagraph (C)” and inserting the following: “A person may not bill for a clinical diagnostic laboratory test performed by a laboratory, other than a rural health clinic, other than on an assignment-related basis. If a person knowingly and willfully and on a repeated basis bills for a clinical diagnostic laboratory test in violation of the previous sentence”, and (ii) by striking “section 1842(j)(2)” and inserting “paragraphs (2) and (3) of section 1842Q) in the same manner such paragraphs apply with respect to a physician”. (C) Section 4085(i) of OBRA is amended— (i) in the matter inserted by paragraph (1)(A), by inserting 42 USC 1395l. a comma after “assignment-related basis”; (ii) in paragraph (1), by striking subparagraph (B); (iii) in paragraph (11), by striking “9367(a)” and inserting 42 USC 1395x. “4072(a)’, (iv) in paragraph (21)(D)(1), by inserting “by” after “(i)”; 42 USC 1395l. (v) in paragraph (21)(D)(ii), by striking “and by” and all 42 USC 1395l. that follows up to the semicolon; and (vi) by adding at the end the following: “(22) (A) Section 1832(a)(2)(F)(ii) of the Social Security Act (42 U.S.C. 1395k(a)(2)(F)(ii)) is amended by striking ‘an assignment described in section 1842(b)(3)(B)(ii)’ and inserting ‘payment on an assignment-related basis’. “(B) Section 1833(h)(5) of such Act (42 U.S.C. 1395101)(5)) is amended, in each of subparagraphs (A) and (C), by striking ‘on the basis of an assignment’ and all that follows through ‘1870(f)(1),’ and inserting ‘on an assignment-related basis’. “(C) Section 1842(b)(7)(B)(iii) of such Act (42 U.S.C. 1395u(b)(7)(B)(ii)) is amended by striking ‘the basis of’ and all that follows through ‘1870(f)(1)’ and inserting ‘an assignment-related basis’. “(23) Section 1833(1)(5)(B)(ii) of such Act (42 U.S.C. 1395k(l)(5)(B)(ii)) is amended— “(A) in the first sentence by striking ‘monetary’ and inserting ‘money’, and “(B) by amending the second sentence to read as follows: ‘The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).’. “(24) The fourth sentence of section 1842(b)(3) of such Act (42 U.S.C. 1395u(b)(3)) is amended by striking ‘physician services’ and ‘physicians services’ and inserting ‘physicians’ services’ in both places. “(25) Section 1842(b)(12)(C) of such Act (42 U.S.C. 1395u(b)(12)(C)) is amended— “(A) in the first sentence by striking ‘monetary’ and inserting ‘money’, and “(B) by amending the second sentence to read as follows: ‘The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).’. “(26) Section 1842(j)(2) of such Act (42 U.S.C. 1395u(j)(2)(B)) is amended— “(A) by striking ‘title’ each place it appears and inserting ‘Act’, and “(B) in subparagraph (B)— “(i) by striking ‘the imposition of, “(ii) by inserting ‘and assessments’ after ‘such penalties’, and “(iii) by amending the second sentence to read as follows: ‘The provisions of section 1128A (other than the first 2 sentences of subsection (a) and other than subsection (b)) shall apply to a civil money penalty and assessment under subparagraph (B) in the same manner as such provisions apply to a penalty, assessment, or proceeding under section 1128A(a), except to the extent such provisions are inconsistent with subparagraph (A) or paragraph (3).’. “(27) Section 1842(l)(1)(C)(i) of such Act (42 U.S.C. 1395u(l)(1)(C)(i)) is amended by inserting ‘the physician establishes that’ after ‘(i)’. “(28) Section 1866(g) of such Act (42 U.S.C. 1395cc(g)) is amended— “(A) in the first sentence by striking ‘monetary’ and inserting ‘money’, and “(B) by amending the second sentence to read as follows: ‘The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).’.”. (D) (i) Section 1862(e) of the Social Security Act (42 U.S.C. 1395y(e)) is amended— (I) by striking “or section 1128A” and inserting “, 1128A, 1156, 1842(j)(2), or 1867(d)”, (II) by redesignating paragraphs (1) and (2) as subparagraphs (A) and (B), and (III) by inserting “(1)” after “(e)”. (ii) Section 1890 of the Social Security Act, as added by section 42 USC 1395aaa. 10 of Public Law 100–93, is amended— (I) by striking its heading, (II) by striking “Sec. 1890” and inserting “(2)”; (III) by inserting “1842(j)(2),” before “1862(d),”; (IV) by striking “or 1866” and inserting “1866, or 1867(d)”; and (V) by transferring and adding such provision at the end 42 USC 1395y. of section 1862(e) of such Act. (j) Corrections to Part 4 of Subtitle A of Title IV (Relating to Peer Review Organizations).— (1) Section 4091.— Section 4091(a)(1)(B) of OBRA is amended by striking “renewals occurring” and inserting “contracts expiring”. (2) Section 4093.— Section 1154(a)(3) of the Social Security Act, as amended by section 4093(a) of OBRA, is amended by 42 USC 1320c–3. amending the last sentence to read as follows: “(C) The discussion and review conducted under subparagraph Health care professionals. (B)(H) shall not affect the rights of a practitioner or provider to a formal reconsideration of a determination under this part (as provided under section 1155).”. (3) Section 4094.— (A) Section 4094(a) of OBRA is amended by 42 USC 1320c–3. striking “subparagraph (B)” and inserting “subparagraph (A)”. (B) Section 1154(a)(15) of the Social Security Act, as added by section 4094(b) of OBRA, is amended by striking “at at” and inserting “in at”. (4) Section 4096.— (A) Section 4096(a)(1)(A) of OBRA is 42 USC 1395u. amended by striking “(b)(3)(ii)” and inserting “(b)(3)(B)(ii)”. (B) Section 1870(f) of the Social Security Act, as amended by section 4096(a)(2) of OBRA, is amended by striking “specified in 42 USC 1395gg. subclauses (I) and (II) of ” and inserting “of assignment specified in”. (C) Sections 1154(e)(3)(A)(i) and 1154(e)(3)(B) (42 U.S.C. 1320c–3(e)(3)(A)(i), 1320c–3(e)(2)(B)), as amended by section 4096(c) of OBRA, are each amended by striking “or (2)” before “paragraph (2)”. (5) Section 4097.— Section 4097(b) of OBRA is amended by 42 USC 1395cc. striking “1866(a)(4)(C)(ii) of such Act (42 U.S.C. 1395cc(a)(4)(C)(ii)) ” and inserting “1866(a)(3)(C)(ii) of such Act (42 U.S.C. 1395cc(a)(3)(C)(ii))”. (k) Corrections to Subtitle B of Title IV (Relating to Medic-aid).— (1) Table of contents.— The table of contents of title IV of OBRA is amended by striking the item relating to section 4105 and by redesignating the items relating to sections 4106 and 4107 as relating to sections 4105 and 4106, respectively. (2) Section 4101.— Section 1916(c)(1)of the Social Security Act, as inserted by section 4101(d)(1)(C) of OBRA, is amended by 42 USC 1396o. striking “nonfarm”. (3) Section 4102.— (A) Section 1915(d)(5)(B) of the Social Security Act, as amended by section 4102(a)(1)(B) of OBRA, is 42 USC 1396n. amended— (i) in clause (iii)(TII), by striking “75” and inserting “65”, and (ii) by inserting before “Effective on” the following: “The Secretary shall develop (by not later than October 1, 1989) a method for projecting, on a State-specific basis, the percentage increase in the number of residents in each State who are over 75 years of age for any period.”. (B) Section 1915(d)(5)(C)(i) of the Social Security Act, as amended by section 4102(a)(1)(B) of OBRA, is amended— (i) by striking “(4)(B),” and inserting “(4), and”, and (ii) by striking “, and services furnished” and all that follows through “subsection (c)”. (4) Section 4103.— Section 1905(a)(5)(B) of the Social Security Act, as inserted by section 4103(a) of OBRA, is amended by 42 USC 1396d. striking “subparagraph” and inserting “clause”. (5) Section 4104.— (A) Paragraph (1) of section 4104(1) of OBRA is amended to read as follows: 42 USC 1396a. “(1) by striking ‘, or’ at the end of subclause (I)() and inserting a semicolon and by inserting ‘or’ at the end of subclause ()(); and”. (B) Section 1902(a)(10)(A)(ii)()(I) of the Social Security Act, as added by section 4104(2) of OBRA, is amended— (i) by striking “are more restrictive” and inserting “may be more restrictive”, and (ii) by striking the period at the end and inserting a semicolon. (6) Section 4112.— (A) Section 4112 of OBRA is amended— (i) in subsection (a)(2)(A)— (I) by striking “such date” and inserting “April 1, 1989”, and (II) by inserting “, effective for inpatient hospital services provided on or after July 1, 1989” before the period; (ii) in subsection (a)(2)(B)— (I) by striking “such date” and inserting “April 1, 1990”, and (II) by inserting “, effective for inpatient hospital services provided on or after July 1, 1990” before the period; (iii) the undesignated paragraph at the end of subsection (a) is amended— (I) by striking “June 30 of each year in which the State is required to submit” and inserting “90 days after the date a State submits”, (II) by indenting all of such paragraph 2 ems, and (III) by designating the first two sentences thereof as paragraph (3) and the last sentence thereof as paragraph (4); (iv) in subsection (b)(2), by striking “the State plan” and inserting “a State plan”; (v) in subsection (b)(3)(B)(i), by inserting “, less the portion of any cash subsidies described in clause (i)(II) in the period reasonably attributable to inpatient hospital services” after “charity care in a period”; (vi) in subsection (c)— (I) by striking “paragraphs (2)(A) and (2)(B)” and inserting “paragraphs (1)(B) and (2)(A) of subsection (a)”, (II) by striking “paragraph (2)(A)” and “paragraph (2)(B)” and inserting “such paragraph (1)(B)” and “such paragraph (2)(A)”, respectively, (III) in paragraph (1), by inserting “at least” after “equal to”, (IV) in paragraph (2), by inserting “(without regard to the election made by a State under subsection (b)(1))” after “payment) and”, (V) in the matter after paragraph (2), by inserting “at least” before “one-third” and before “two-thirds”, and (VI) by adding at the end the following new Children and youth. sentences: “In the case of a hospital described in subsection (d)(2)(A)(i) (relating to children’s hospitals), in computing the hospital’s disproportionate share adjustment percentage for purposes of paragraph (1)(B) of this subsection, the disproportionate patient percent-age (defined in section 1886(d)(5)(F)(vi)) shall be computed by substituting for the fraction described in subclause (I) of such section the fraction described in subclause (ID of that section. If a State elects in a State plan amendment under subsection (a) to provide the State and local governments. payment adjustment described in paragraph (2), the State must include in the amendment a detailed description of the specific methodology to be used in determining the specified additional payment amount (or increased percentage payment) to be made to each hospital qualifying for such a payment adjustment and must publish at least annually the name of each hospital qualifying for such a payment adjustment and the amount of such payment adjustment made for each such hospital.”; and (vii) in subsection (e)— (I) by inserting “(1)” after “Special Rule.—”, (II) by inserting “based on a pooling arrangement involving a majority of the hospitals participating under the plan” after “payment adjustments”, and (III) by adding at the end the following new paragraph: “(2) In the case of a State that used a health insuring organization before January 1, 1986, to administer a portion of its plan on a State-wide basis, during the 3-year period beginning on July 1, 1988— “(A) the requirements of subsections (b) and (c) shall not apply if the aggregate amount of the payment adjustments under the plan for disproportionate share hospitals (as defined under the State plan) is not less than the aggregate amount of payment adjustments otherwise required to be made if such subsections applied, and “(B) subsection (d)(2)(B) shall apply to hospitals located in Urban areas. Rural areas. 42 USC 1396a note. urban areas, as well as in rural areas.”;. (B) Section 4112 of OBRA is further amended— (i) by striking “(a) Implementation of Requirement.—” and inserting the following: “(a) In General.— Title )(I)( of the Social Security Act is amended— “(1) by redesignating section 1923 as section 1924, and 42 USC 1396s. “(2) by inserting after section 1922 the following new section: “Sec. 1923. “ ‘adjustment in payment for inpatient hospital services furnished by disproportionate share hospitals (a) Implementation of Requirement.— (ii) in subsection (a)(1), by striking “A State’s plan under title )(I)( of the Social Security Act” and inserting “A State plan under this title”; (iii) in subsection (a)(1), by striking “of such Act”; (iv) in subsection (a), by striking “of Health and Human Services” each place it appears; (v) in the matter following paragraph (2)(B) of subsection (a), by striking “of the Social Security Act”; (vi) in subsections (b) and (c), by striking “under title )(I)( of the Social Security Act” each place it appears and inserting “under this title”, (vii) in subsection (d)(2)(B), by striking “of the Social Security Act”; (viii) in subsections (b)(2), (b)(3), and (d)(2)(B), by striking double quotation marks enclosing terms and inserting single quotation marks; (ix) by placing opening double quotation marks at the beginning of any matter with an initial paragraph indentation (beginning with subsection (a)(1)) and closing double quotation marks at the end of subsection (e); and (x) by adding at the end the following: “(b) Conforming Amendment.— Section 1903(i)(3) of such Act (42 U.S.C. 1396b(i)(3)) is amended by inserting ‘(other than amounts attributable to the special situation of a hospital which serves a disproportionate number of low income patients with special needs)’ before ‘to the extent’.”. (7) Section 4113.— Section 4113 of OBRA is amended— (A) in the matter inserted by subsection (a)(1)(B)— (i) by moving the left margin of the matter 2 ems to the left, and (ii) by striking “subparagraph (G)” and inserting “subparagraph (E) or (G)”; (B) in the matter inserted by subsection (a)(2), by striking “paragraph (2)(G) or (6)” and inserting “paragraph (2)(B)(iii), (2)(E), (2)(G), or (6)”; (C) in subsection (b)(2)(ii), by striking “such”; and (D) by striking subsection (d) and redesignating subsection (e) as subsection (d). (8) Section 4114.— (A) Section 4114 of OBRA is amended in paragraph (1), by striking “ ‘(1)’ ” and inserting “ ‘(o)(1)’ ”. (B) Section 1905(o)(1)(B) of the Social Security Act, as added by section 4114(3) of OBRA, is amended— (i) by striking “only”, and (ii) by striking “immunodeficiency syndrome” and inserting “immune deficiency syndrome (AIDS)”. (9) Section 4115.— (A) Section 4115 of OBRA is amended— (A) in subsection (b)(4)(B), by striking “program” and inserting “Program”, (B) in subsection (c)— (i) by inserting “under section 9121 of this Act” after “Upon approval”, and (ii) by striking “1916, and 1924” and inserting “1902(e)(1), and 1916”, and (C) by adding at the end the following: “(d) Extension of Texas State Waiver.— Section 9523(a) of the 100 Stat. 217 . Consolidated Omnibus Budget Reconciliation Act of 1985 is amended by striking ‘January 1, 1989’ and inserting ‘January 1, 1990’.”. (10) Section 4118.— (A) Section 1915(c)(10) of the Social 42 USC 1396n. Security Act, as added by section 4118(b) of OBRA, is amended— (i) by striking “No waiver under this subsection shall limit by an amount less than 200” and inserting “The Secretary shall not limit to fewer than 200”, and (ii) by striking “under such waiver” and inserting “under a waiver under this subsection”. (B) Section 4118(e) of OBRA is amended— (i) in paragraph (3), by striking “amendment” and inserting “amendments”, and (ii) in paragraph (1)— (I) by inserting “(A)” after “(1)”, (II) by striking “1128A(a)(D” and “1320a–7(a)(1)” and 42 USC 1320a–7a, 1320a–7. 42 USC 1320a–7a. inserting “1128(a)” and “1320a–7(a))”, respectively, and (III) by adding at the end the following: “(B) Section 1128A of such Act is amended by adding at the 42 USC 1320a–7. end the following new subsection: “(l) ‘A principal is liable under this section for the actions of the principal’s agent acting within the scope of the agency.’” (C) Section 1128(d)(3)(B)(u) of the Social Security Act, as added by section 4118(e)(2)(B) of OBRA, is amended by striking “under a program”. (D) Section 4118(e) of OBRA is amended by redesignating 42 USC 1320a–7a note. paragraph (3) as paragraph (14) and by inserting after paragraph (2) the following new paragraphs: “(3) Section 1128(b)(8)(A)(i) of such Act is amended by inserting after ‘(A)(i)’ the following: ‘who has a direct or indirect ownership or control interest of 5 percent or more in the entity or’. “(4) Section 1128(d) of such Act is amended— “(A) in paragraph (1), by striking ‘subsection (b)’ and inserting ‘this section and section 1128A’, and “(B) in paragraph (3)(A), by striking ‘under a program’. “(5) Section 1128(i) of such Act is amended— “(A) in the matter before paragraph (1), by striking ‘a physician or other individual and inserting “an individual or entity”, “(B) in paragraphs (1) through (4), by striking ‘physician or other individual’ each place it appears and inserting ‘individual or entity’, and “(C) in paragraph (4), by striking ‘first offender or other program’ and inserting ‘first offender, deferred adjudication, or other arrangement or program’. “(6) Section U28A(a)(D(D) of such Act is amended— “(A) by striking ‘excluded under’ and inserting ‘excluded from’, and “(B) by inserting ‘or as a result of the application of the provisions of section 1842(j)(2) or section 1867(d)(2)’ after ‘or 1866(b)’. “(7) The second sentence of section 1128A(c)(1) of such Act is amended— “(A) by inserting “, request for payment, or other occurrence described in this section’ after ‘any claim’, and “(B) by inserting “, the request for payment was made, or the occurrence took place’ after ‘claim was presented’. “(8) Section 1128A(i) of such Act is amended, in the matter before paragraph (1), by striking ‘subsection’ and inserting ‘section’. “(9) Section 1128A(i)(1) of such Act is amended by inserting ‘or title )()(’ after ‘title V’. “(10) Section 1128A of such Act is further amended— “(A) in the matter in subsection (a) before paragraph (1), by inserting but excluding a beneficiary, as defined in subsection (1)(5)’ after ‘other entity’, “(B) in subsection (i)(2), by striking ‘submitted by’ and all that follows through the end and inserting ‘for payments for items and services under title V, )(VIII, )(I)(, or )()( of this Act.’, and “(C) by adding at the end the following new paragraph: “’(5) The term “beneficiary” means an individual who is eligible to receive items or services for which payment may be made under title V, XVIII, XIX, or XX but does not include a provider, supplier, or practitioner.’. “(11) Section 1903(i)(2) of such Act (42 U.S.C. 1396b(i)(2)) is amended— “(A) in subparagraph (A), by striking ‘in the State plan under this title pursuant to section 1128 or section 1128A’ and inserting ‘under title V, XVIII, or XX or under this title pursuant to section 1128, 1128A, 1156, 1842(j)(2), or 1867(d)(2)’, and “(B) in subparagraph (B), by striking ‘pursuant to section 1128 or section U28A from participation in the program under this title’ and inserting ‘from participation under title V, XVIII, or XX or under this title pursuant to section 1128, 1128A, 1156, 1842(j)(2), or 1867(d)(2)’. “(12) Section 504(b)(6) of such Act (42 U.S.C. 704(b)(6)) is amended by striking ‘pursuant to section 1128 or section 1128A from participation in the program under this title’ each place it appears and inserting ‘under this title or title XVIII, XIX, or XX pursuant to section 1128, U28A, 1156, 1842(j)(2), or 1867(d)(2)’. “(13) Section 2005(a)(9) of such Act (42 U.S.C. 1397d(a)(9)) is amended by striking ‘pursuant to section 1128 or section 1128A from participation in the program under this title’ each place it appears and inserting ‘under this title or title V, XVIII, or XIX pursuant to section 1128, 1128A, 1156, 1842(j)(2), or 1867(d)(2)’.”. (E) Section 4118(f)(1) of OBRA is amended by striking “4111(g)(8)” and inserting “4211(h)(8)”. (F) Section 4118(g)(D(B) of OBRA is amended by striking “insert” and inserting “inserting”. (G) Section 4118(h) of OBRA is amended— (i) by inserting a dash after “Expenses.”; (ii) in paragraph (1), by striking “Section 1902(a)(17) of the Social Security Act (42 U.S.C. 1396a(a)(17)) is amended” and inserting “Sections 1902(a)(17) and 1903(f)(2) of the Social Security Act (42 U.S.C. 1396a(a)(17), 1396b(f)(2)) are each amended”; (iii) in paragraph (2), by striking “(2) The amendment made by paragraph (1)” and inserting “(3) The amendments made by this subsection”, and (iv) by inserting after paragraph (1) the following new paragraph: “(2) The first sentence of section 1902(f) of such Act (42 U.S.C. 1396a(f)) is amended by inserting after ‘as recognized under State law’ the following: ‘regardless of whether such expenses are reimbursed under another public program of the State or political subdivision thereof’.”. (H) Section 1915(c)(7)(B) of the Social Security Act, as added by section 4118(k) of OBRA, is amended by inserting before the period at the end the following: “, without regard to the availability of beds for such inpatients”. (I) Section 4118(1)(1) of OBRA is amended by inserting “, as redesignated by section 4102(a),” after “1396n(h))”. (J) Section 9414(b)(3) of the Omnibus Budget Reconciliation Act of 1986, as amended by section 4U8(o)(1)(C) of OBRA, is 100 Stat. 2064. amended by striking “nonfarm”. (K) Section 4118(o)(2)(A) of OBRA is amended by inserting 101 Stat. 1330–158. “each place it appears” before “and inserting”. (L) Section 4118(p)(9) of OBRA is amended by striking 42 USC 1396s. “1925(a)” and “(4111(a))” and inserting “1923(a)” and “4211(a)”, respectively. (M) Section 4118(p) of OBRA is amended by adding at the end the following new paragraph: “(11) Paragraph (5) of section 9432(c) of the Omnibus Budget Reconciliation Act of 1986 is amended to read as follows: 42 USC 1396a note. Reports. “‘(5) The Secretary shall submit an interim report on the results of the study, including an analysis of the geographic variations under paragraph (2), to the Congress not later than January 1, 1990, and shall report the final results of the study to the Congress not later than January 1, 1992.’.”. (11) Omitted section.— (A) Part 2 of subtitle B of title IV of OBRA is amended by adding at the end the following new section: “SEC. 4119. STUDY OF MEANS OF RECOVERING COSTS OF NURSING FACILITY SERVICES FROM ESTATES OF BENEFICIARIES. “The Secretary of Health and Human Services shall study the means of recovering amounts from estates of deceased medicare beneficiaries (or the estates of the spouses of such deceased beneficiaries) to pay for the medical assistance for skilled nursing facility or intermediate care facility services furnished, under title XIX of the Social Security Act, to such medicare beneficiaries. The Secretary Reports. shall report to Congress, not later than December 31, 1988, on such means, and include appropriate recommendations for changes in legislation.”. (B) The table of contents of title IV of OBRA is amended by inserting after the item relating to section 4118 the following new item: “Sec. 4119. Study of means of recovering costs of nursing facility services from estates of beneficiaries.”. (12) Medicare conforming amendment to section 4014 of obra.— (A) Paragraph (5) of section 1903(m) of the Social Security Act (42 U.S.C. 1396b(m)) is amended to read as follows: (5) (A) If the Secretary determines that an entity with a contract under Contracts. this subsection— (i) fails substantially to provide medically necessary items and services that are required (under law or under the contract) to be provided to an individual covered under the contract, if the failure has adversely affected (or has substantial likelihood of adversely affecting) the individual; (ii) imposes premiums on individuals enrolled under this subsection in excess of the premiums permitted under this title; “(iii) acts to discriminate among individuals in violation of the provision of paragraph (2)(A)(v), including expulsion or refusal to re-enroll an individual or engaging in any practice that would reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by this subsection) by eligible individuals with the organization whose medical condi- tion or history indicates a need for substantial future medical services; or “(iv) misrepresents or falsifies information that is furnished— “(I) to the Secretary or the State under this subsection, or “(II) to an individual or to any other entity under this subsection, the Secretary may provide, in addition to any other remedies available under law, for any of the remedies described in subparagraph (B). “(B) The remedies described in this subparagraph are— “(i) civil money penalties of not more than $25,000 for each determination under subparagraph (A), or, with respect to a determination under clause (iii) or (iv)(I) of such subparagraph, of not more than $100,000 for each such determination, plus, with respect to a determination under subparagraph (A)(ii), double the excess amount charged in violation of such subparagraph (and the excess amount charged shall be deducted from the penalty and returned to the individual concerned), and plus, with respect to a determination under subparagraph (A)(iii), $15,000 for each individual not enrolled as a result of a practice described in such subparagraph, or “(ii) denial of payment to the State for medical assistance furnished under the contract under this subsection for individuals enrolled after the date the Secretary notifies the organization of a determination under subparagraph (A) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur. The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (i) in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).’. (B) The amendment made by subparagraph (A) shall apply to actions occurring on or after the date of the enactment of this Act. (13) Treatment of educationally-related services.— (A) Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended by inserting after subsection (b) the following new subsection: “(c) Nothing in this title shall be construed as prohibiting or restricting, or authorizing the Secretary to prohibit or restrict, payment under subsection (a) for medical assistance for covered services furnished to a handicapped child because such services are included in the child’s individualized education program established pursuant to part B of the Education of the Handicapped Act or furnished to a handicapped infant or toddler because such services are included in the child’s individualized family service plan adopted pursuant to part H of such Act.”. (B) The amendment made by subparagraph (A) shall take effect on the date of the enactment of this Act. (14) Clarification of term “institution for mental diseases”.— (A) Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended by inserting after subsection (h) the following new subsection: “(i) The term ‘institution for mental diseases’ means a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.”. (B) The amendment made by subparagraph (A) shall take Effective date. 42 USC 1396d note. effect on the date of the enactment of this Act. (15) Eligibility verification technical correction.— (A) Section 1137 of the Social Security Act (42 U.S.C. 1320b–7) is amended by adding at the end the following new subsection: “(f) Subsections (a)(1) and (d) shall not apply with respect to aliens Aliens. seeking medical assistance for the treatment of an emergency medical condition under section 1903(v)(2).”. (B) The amendment made by subparagraph (A) shall apply as Effective date. 42 USC 1320b–7 note. if it were included in the enactment of section 9406 of the Omnibus Budget Reconciliation Act of 1986. (16) Technical corrections relating to presumptive eligibility.— (A) Section 1920(d)(1)(B) of the Social Security Act (42 U.S.C. 1396r–1(d)(D(B)) is amended by striking “by a qualified provider” and inserting “by a provider that is eligible for payments under the State plan”. (B) Section 192()(b)(2)(D) of such Act (42 U.S.C. 1396r–1(b)(2)(D)) is amended— (i) in clause (i)— (I) in subclause (I), by striking “or section 330” and inserting 330, or 340” and by striking “or” at the end, (II) in subclause (II), by striking the semicolon at the end and inserting “, or”, and (III) by adding after subclause (II) the following new subclause: “(III) title V of the Indian Health Care Improvement Act;”; (ii) in clause (ii), by striking “or” at the end; and (iii) by adding at the end the following new clause: “(iv) is the Indian Health Service or is a health program Indians. or facility operated by a tribe or tribal organization under the Indian Self-Determination Act (Public Law 93–638).”. (C) The amendments made by this paragraph shall be effective Effective date. 42 USC 1396r–1 note. as if they were included in section 9407(b) of the Omnibus Budget Reconciliation Act of 1986. (17) Waiver for children infected with aids or drug dependent at birth.— (A) Section 1915 of the Social Security Act (42 U.S.C. 1396n) is amended— (i) by redesignating subsection (f) as paragraph (2); (ii) in subsection (e), by striking paragraph (2) and by redesignating such subsection as subsection (f); (iii) by inserting after subsection (d) the following new subsection: “(e) (1) (A) Subject to paragraph (2), the Secretary shall grant a State and local governments. Prescription drugs. Children and youth. Transportation. waiver to provide that a State plan approved under this title shall include as ‘medical assistance’ under such plan payment for part or all of the cost of nursing care, respite care, physicians’ services, prescribed drugs, medical devices and supplies, transportation services, and such other services requested by the State as the Secretary may approve which are provided pursuant to a written plan of care to a child described in subparagraph (B) with respect to whom there has been a determination that but for the provision of such services the infants would be likely to require the level of care provided in a hospital or nursing facility the cost of which could be reimbursed under the State plan. “(B) Children described in this subparagraph are individuals under 5 years of age who— “(i) at the time of birth were infected with (or tested positively for) the etiologic agent for acquired immune deficiency syndrome (AIDS), “(ii) have such syndrome, or “(iii) at the time of birth were dependent on heroin, cocaine, or phencyclidine, and with respect to whom adoption or foster care assistance is (or will be) made available under part E of title IV. “(2) A waiver shall not be granted under this subsection unless the State provides assurances satisfactory to the Secretary that— “(A) necessary safeguards (including adequate standards for provider participation) have been taken to protect the health and welfare of individuals provided services under the waiver and to assure financial accountability for funds expended with respect to such services; ”(B) under such waiver the average per capita expenditure estimated by the State in any fiscal year for medical assistance provided with respect to such individuals does not exceed 100 percent of the average per capita expenditure that the State reasonably estimates would have been made in that fiscal year for expenditures under the State plan for such individuals if the waiver had not been granted; and “(C) the State will provide to the Secretary annually, consistent with a data collection plan designed by the Secretary, information on the impact of the waiver granted under this subsection on the type and amount of medical assistance provided under the State plan and on the health and welfare of recipients. “(3) A waiver granted under this subsection may include a waiver of the requirements of section 1902(a)(1)(relating to statewideness) and section 1902(a)(10)(B) (relating to comparability). A waiver under this subsection shall be for an initial term of 3 years and, upon the request of a State, shall be extended for additional five-year periods unless the Secretary determines that for the previous waiver period the assurances provided under paragraph (2) nave not been met. “(4) The provisions of paragraph (6) of subsection (d) shall apply to this subsection in the same manner as it applies to subsection (a).”; and (iv) in subsection (h), by striking “or (d)” and inserting“(d), or (e)”. (B) Section 1902(a)(10)(A)(ii)(VI) of such Act (42 U.S.C. 1396a(a)(10)(A)(ii)(VI)) is amended by striking “(c) or (d)” each place it appears and inserting “(c), (d), or(e)”. (l) Corrections Relating to Subtitle C of Title IV (Nursing Home Reform).— (1) Section 4201.— (A) Section 1819 of the Social Security Act, 42 USC 1395i–3. as added by section 4201(a)(3) of OBRA, is amended— (i) in subsection (b)(3)(C)(i)(1), by striking “October 1, 1990” the second place it appears and inserting “January 1, 1991”; (ii) in subsection (b)(4)(C)(i)— (I) by inserting “licensed” after “24-hour”, (II) by striking “employ” and inserting “use”, and (III) by striking “during the day tour of duty (of at least 8 hours a day)” and inserting “at least 8 consecutive hours a day,”; (III) in subsection (b)(5)(A), by striking “October 1, 1989” and all that follows through “July 1, 1989” and inserting “January 1, 1990”; (iv) in subsection (e)(1)(A), by striking “March 1, 1989” and inserting “January 1, 1989”, (v) in subsection (e)(1)(B), by striking “March 1, 1990” and inserting “January 1, 1990”; (vi) in subsection (e)(2)(A), by striking “March 1, 1989” and inserting “January 1, 1989’”; (vii) in subsection (e)(3), by striking “October 1, 1990” and inserting “October 1, 1989”; (viii) in subsection (e)(5), by striking “July 1, 1989” and inserting “July 1, 1990”; (ix) in subsection (f)(3), by striking “October 1, 1989” and inserting “October 1, 1988”; (x) in subsection (f)(6)(A), by striking “July 1, 1989” and inserting “January 1, 1989”; and (xi) in subsection (f)(6)(B), by striking “October 1, 1990” and inserting “April 1, 1990”. (B) Section 4201(d) of OBRA is amended— 42 USC 1395x. (i) by striking “Amendment.—” (ii) by striking “1919(a)(2)” and inserting “1819(a)(1)”, and (iii) by adding at the end the following new paragraph: “(2) Section 1861(n) of such Act (42 U.S.C. 1395x(n)) is amended by striking ‘or (j)(1) of this section’ and inserting ‘or of section 1819(a)(D’.”. (2) Sections 4201 and 4211.— (A) Sections 1819(b)(3)(A)(iv) and 1919(b)(3)(A)(iv) of the Social Security Act, as added by section 4201(a)(3) and as inserted by section 4211(a)(3) of OBRA, respectively, 42 USC 1395i–3, 1396r. are amended by striking “in the case of a resident eligible for benefits under part A of this title” and by striking “in the case of a resident eligible for benefits under part A of title XVIII respectively”. (B) Sections 1819(b)(3)(A)(iii) and 1919(b)(3)(A)(iii) of the Social Security Act, as added by section 4201(a)(3) and as inserted by section 4211(a)(3) of OBRA, respectively, are amended by striking “in the case of a resident eligible for benefits under title )(I)(,” and “in the case of a resident eligible for benefits under this title,”, respectively. (C) Subclause (III) of each of sections 1819(b)(3)(B)(ii) and 1919Cb)(3)(B)(ii) of the Social Security Act, as added by section 4201(a)(3) and as inserted by section 4211(a)(3) of OBRA, respectively, is amended to read as follows: “(III) The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under this clause in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).”. (D) Sections 1819(b)(5) and 1919(b)(5) of the Social Security Act, as added by section 4201(a)(3) of OBRA and as inserted by section 4211(a)(3) of OBRA, respectively, are each amended— (i) in subparagraph (A), by striking “, who is not a licensed health care professional (as defined in subparagraph (E)),”, (ii) in subparagraph (A)(ii), by striking “such services” and inserting “nursing or nursing-related services”, and (iii) in subparagraph (G), by inserting “physical or occupational therapy assistant,” after “occupational therapist,”. (E) Effective as of the date of the enactment of this Act and until the effective date of section 1819(c) of such Act, section 1861(j) of the Social Security Act is deemed to include the requirement described in section 1819(c)(3)(A) of such Act (as added by section 4201(a)(3) of OBRA). (F) Sections 1819(c)(2)(A)(v) and 1919(c)(2)(A)(v) of the Social Security Act, as added by section 4201(a)(3) and as inserted by 42 USC 13951–3, 1396r. section 4211(a)(3) of OBRA, respectively, are each amended by striking “an allowable charge” and all that follows through the semicolon and inserting “for a stay at the facility;”. (G) Sections 1819(c)(6) and 1919(c)(6) of the Social Security Act, as added by section 4201(a)(3) and as inserted by section 4211(a)(3) of OBRA, respectively, are each amended— (i) in subparagraph (A)(ii), by striking “once the facility accepts” and inserting “upon”, and (ii) in subparagraph (B), by striking “a facility’s acceptance of”. (H) Sections 1819(e)(2)(B) and 1919(e)(2)(B) of the Social Security Act, as added by section 4201(a)(3) and as inserted by section 4211(a)(3) of OBRA, respectively are each amended by inserting State and local governments. Public information. Records. after the first sentence the following sentence: “The State shall make available to the public information in the registry.”. (I) Sections 1819(e)(3), 1819(f)(3), 1919(e)(3), and 1919(f)(3) of the Social Security Act, as added by section 4201(a)(3) and as inserted by section 42U(a)(3) of OBRA, are each amended— (i) by inserting “and discharges” after “transfers” (ii) by inserting “and discharges” after “transfers”. (J) Sections 1819(f)(2)(A)(i)(I) and 1919tf)(2)(A)(i)(I) of the Social Security Act, as added by section 4201(a)(3) and as inserted by section 4211(a)(3) of OBRA, respectively, are each amended by striking “cognitive, behavioral and social care” and inserting “recognition of mental health and social service needs”. (K) Sections 1819(f)(7) and 1919(f)(7) of the Social Security Act, as added by section 4201(a)(3) and as inserted by section 4211(a)(3) of OBRA, respectively, are each amended by striking “patients” and inserting “residents”. (L) (i) Section 1819(1)(7)(8) of the Social Security Act, as added by section 4201(a)(3), is amended by striking “shall not” and inserting “shall”. (ii) Section 1919(f)(7)(B) of the Social Security Act, as inserted by section 4211(a)(3) of OBRA, is amended by striking “do not”. (3) Section 4211.— (A) Section 1919(b)(4)(C) of the Social Security Act, as inserted by section 4211(a) of OBRA, is amended— (i) by striking “registered nurse” each place it appears and inserting “registered professional nurse”; (ii) by striking “employ” and inserting “use”; (iii) by striking “(u) Facility waivers.—” and all that follows through “(i) Waiver” and inserting “(ii) Waiver”; (iv) by striking “and subject to clause (ii)” and inserting “and subject to clause (iii)”; (v) by striking “(ii) Assumption” and inserting “(iii) Assumption”; and (vi) in clause (iii), as so redesignated, by striking “excercise” and inserting “exercise”. (B) Section 1919(b)(5)(A) of the Social Security Act, as added 42 USC 1396r. by section 4211(a)(3) of OBRA, is amended by striking “subparagraph (E)” and inserting “subparagraph (F)”. (C) Effective as of the date of the enactment of this Act and Effective date. until the effective date of section 1919(c) of such Act, section 1905(c) of the Social Security Act is deemed to include the 42 USC 1396d. requirement described in section 1919(c)(3)(A) of such Act (as inserted by section 4211(a)(3) of OBRA). (D) Section 1919 of the Social Security Act, as inserted by section 4211(a)(3) of OBRA, is amended— (i) in subsection (e)(1)(A), by striking “September 1, 1988” and inserting “January 1, 1989”; (ii) in subsection (e)(1)(B), by striking “September 1, 1990” and inserting “January 1, 1990”; (iii) in subsection (e)(7)(E), by striking “October 1, 1988” and inserting “April 1, 1989”; and (iv) in subsection (f)(2), by striking “July 1, 1988” and inserting “September 1, 1988”. (E) Section 1902(a)(28)(D)(i) of the Social Security Act, as amended by section 4211(b)(1)(B) of OBRA, is amended by striking 42 USC 1396a. “1919(f)” and all that follows through “instrument)” and inserting “1919(e)”. (F) Section 4211(d)(2) of OBRA is amended by striking “For 42 USC 1396b note. calendar quarters during fiscal years 1988 and 1989” and inserting “For the 8 calendar quarters (beginning with the calendar quarter that begins on July 1, 1988)”. (G) Section 4211(h)(10)(G) of OBRA is amended by adding 42 USC 1396n. before the period at the end the following: “, and by striking ‘skilled nursing facility or intermediate care facility’ in subparagraph (B) and inserting ‘nursing facility’”. (H) Section 4211(h)(2) of OBRA is amended— 42 USC 1396a. (i) in subparagraph (C), by striking “inserting ‘nursing facilities’” each place it appears and inserting “inserting ‘nursing facilities and for intermediate care facilities for the mentally retarded’ ”, (ii) in subparagraph (D)(i), by striking “inserting ‘nursing facility’ ” and inserting “inserting ‘nursing facility or intermediate care facility for the mentally retarded’ ”, and (iii) in subparagraph (D)(ii), by striking “inserting ‘nursing facility’ ” and inserting “inserting ‘nursing facility services or services in an intermediate care facility for the mentally retarded”. (I) Subparagraph (B) of section 4211(h)(12) of OBRA is 42 USC 1396p. amended to read as follows: “(B) in subsection (c)(2)(B)(ii), by striking ‘skilled’ each place it appears.”. (4) Section 4202.— Section 1819(g)(2)(C)(i) of the Social Security Act, as added by section 4202(a) of OBRA, is amended by 42 USC 1395i—3. striking “October 1, 1990” and inserting “January 1, 1990”. (5) Sections 4202 and 4212.— Sections 1819(g) and 1919(g) of the Social Security Act, as added by sections 4202(a)(2) and 42 USC 1395i–3, 1396r. 4212(a) of OBRA, respectively, are amended— (A) in paragraph (1)(C), by striking “, review,” and inserting “and timely review”; (B) in the first sentence of paragraph (1)(C), by inserting “or by another individual used by the facility in providing services to such a resident” after “a nursing facility”; (C) by striking the second sentence of paragraph (1)(C) State and local governments. Health care professionals. and inserting the following: “The State shall, after notice to the individual involved and a reasonable opportunity for a hearing for the individual to rebut allegations, make a finding as to the accuracy of the allegations. If the State finds that a nurse aide has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the nurse aide and the registry of such finding. If the State finds that any other individual used by the facility has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the appropriate licensure authority.”; (D) in paragraph (1)(D), by striking “to establish standards under subsection (f)” and inserting “to issue regulations to carry out this subsection”; (E) in paragraph (2)(A)(i), by amending the third sentence to read as follows: “The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).”; (F) in paragraph (3)(D) (relating to special surveys of compliance, as redesignated by paragraph (6)(A) in the case of section 1919(g)), by striking “on that basis” and inserting “on the basis of that survey”; and (G) in paragraph (4), by striking “chronically”. (6) Section 4212.— (A) Section 1919(g)(3) of the Social Security Act, as added by section 4212(a) of OBRA, is amended by redesignating the second subparagraph (C) (relating to special surveys of compliance) as subparagraph (D). (B) Section 4212(b) of OBRA is amended to read as follows: “(b) Posting Survey Results.— Section 1919(c) of such Act is amended by adding at the end the following new paragraph: “(7) Posting or survey results.— A nursing facility must post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility conducted under subsection (g).’”. (C) Section 1902(a)(33)(B) of the Social Security Act, as amended by section 4212(d)(3) of OBRA, is amended by striking “1919(d)” and inserting “1919(g)”. (D) Section 4212(e)(1)(B) of OBRA is amended by inserting “provided” after “services” each place it appears. (E) Section 4212(e) of OBRA is amended by adding at the end the following new paragraph: “(5) Section 1922(e) of such Act, as redesignated and transferred by section 4211(a)(2) of this Act, is amended by striking ‘1910(c)’ in paragraphs (1) and (2)(A) and inserting ‘1910(b)’.”. (7) Sections 4203 and 4213.— (A) Sections 1819(h)(2)(B)(ii) and 1919(h)(3)(C)(ii) of the Social Security Act, as added by sections 4203(a)(2) and 4213(a) of OBRA, respectively, are each amended 42 USC 1395i–3, 1396r. by striking “and the Secretary” and all that follows through “1128A.” and inserting the following: “. The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).”. (B) Sections 1819(h)(6) and 1919(h)(9) of the Social Security Act, as added by sections 4203(a)(2) and 4213(a) of OBRA, respectively, are each amended by inserting “by such facilities” after “shall be made available”. (8) Section 4213.— (A) Section 4213(a) of OBRA is amended by 42 USC 1396r. striking “as inserted by section 4201 and amended by section 4202” and inserting “as inserted by section 4211 and amended by section 4212”. (B) Section 1919(h) of the Social Security Act, as added by section 4213(a) of OBRA, is amended— (i) in the last sentence of paragraph (1), by striking “(2)(A)(i)” and inserting “(2)(A)(ii)”, (ii) in the second sentence of paragraph (2)(B)(i), by striking “or otherwise”, and (iii) in paragraph (5), by striking “State and the Secretary” and inserting “State or the Secretary, respectively”. (C) Paragraph (1) of section 4213(b) of OBRA is amended by 42 USC 1396a. striking “1902” and all that follows through the end and inserting the following: “1902(i) of such Act (42 U.S.C. 1396a(i)) is amended— “(A) in paragraph (1), by striking ‘skilled nursing facility or intermediate care facility’ and inserting ‘intermediate care facility for the mentally retarded’; “(B) in paragraph (1), by striking ‘the provisions of section 18610) or section 1905(c), respectively,’ and inserting ‘the requirements for such a facility under this title’; and “(C) in paragraphs (2) and (3), by striking ‘the provisions of section 18610) or section 1905(c) (as the case may be)’ and inserting ‘the requirements for such a facility under this title’.”. (9) Section 4204.— (A) Section 4204(a) of OBRA is amended by 42 USC 1395i—3 note. striking “extended care”. (B) Section 4204 of OBRA is amended— (i) in subsection (a), by striking “made by this part” and inserting “made by sections 4201 and 4202 (relating to skilled nursing facility requirements and survey and certification requirements)”, (ii) by redesignating subsection (c) as subsection (d), and (iii) by inserting after subsection (a) the following new subsection: “(b) Enforcement.— (1) Except as otherwise specifically provided Effective date. n section 1819 of the Social Security Act, the amendments made by section 4203 of this Act apply January 1, 1988, without regard to whether regulations to implement such amendments are promulgated by such date. “(2) In applying the amendments made by section 4203 of this Act or services furnished by a skilled nursing facility before October 1, 1990, any reference to a requirement of subsection (b), (c), or (d), of section 1819 of the Social Security Act is deemed a reference to the provisions of section 1861(j) of such Act.”. (10) Section 4214.— Section 4214 of OBRA is amended— (A) by striking “(c) Transitional Rule.—”and inserting “(2)”, (B) by inserting “of section 1919 of the Social Security Act” after “(b), (c), or (d)”, and (C) by redesignating subsection (d) as subsection (c). (m) Corrections to Subtitle E of Title IV (Relating to Rural Health).— (1) Section 4401.— Section 711(b)(1) of the Social Security Act, 42 USC 912. as added by section 4401 of OBRA, is amended by striking “section 4083 of the Omnibus Budget Reconciliation Act of 1987” and inserting “section 4403 of the Omnibus Budget Reconciliation Act of 1987 (as such section pertains to rural health issues)”. (2) Section 4403.— (A) Section 4403 of OBRA is amended— (i) in the heading, by striking “EXPERIMENTS AND DEMONSTRATION PROJECTS RELATING TO RURAL HEALTH CARE ISSUES” and inserting “RESEARCH AND DEMONSTRATION PROJECTS ON RURAL AND INNER-CITY HEALTH ISSUES”; (ii) in subsection (a)— (I) by striking “Set Aside.—” and inserting “Set Asides for Issues of Health Care in Rural Areas and In Inner-City Areas.—(1)”, (II) by striking “expended in each fiscal year” and all that follows through “1972” and inserting “annually appropriated to, and expended by, the Health Care Financing Administration for the conduct of research and demonstration projects in fiscal years 1988, 1989, and 1990”, (III) by striking “experiments” and inserting “research”; (iii) by adding at the end the following new paragraph: “(2) Not less than ten percent of the total amounts annually appropriated to, and expended by, the Health Care Financing Administration for the conduct of research and demonstration projects in fiscal years 1988, 1989, and 1990 shall be expended for research and demonstration projects relating exclusively or substantially to issues of providing health care in inner-city areas, including (but not limited to) the impact of the payment methodology under section 1886(d) of the Social Security Act on the financial viability of inner-city hospitals and the impact of medicare policies on access to (and the quality of) health care in inner-city areas.”; and (iv) in subsection (b)— (I) by striking “of experiments” and inserting “of research”, (II) by inserting “or to inner-city health issues” after “rural health issues”, and (III) by striking “experiments and”. (B) The item in the table of contents of OBRA relating to section 4403 is amended to read as follows: “Sec. 4403. Set aside for research and demonstration projects on rural and inner-city health issues.”. (n) Corrections to Certain Health-Related Provisions in Title I)(.— (1) Section 9010.— The last sentence of section 226(b) of the Social Security Act, as added by section 9010(e)(3) of OBRA, is 42 USC 426. amended to read as follows: “In determining when an individual’s entitlement or status terminates for purposes of the preceding sentence, the term ‘36 months’ in the second sentence of section 223(a)(1), in section 202(d)(1)(G)(i), in the last sentence of section 202(e)(1), and in the last sentence of section 202(f)(1) shall be applied as though it read ‘15 months’.”. (2) Section 9115.— Section 9115(b) of OBRA is amended by 42 USC 1396a. striking “1902(1)” and inserting “1902(o)”. (3) Section 9119.— Section 9119 of OBRA is amended by 42 USC 1396a note. adding at the end the following new subsection: “(d) Conforming Amendments to Medicare Program for the Medically Needy.— (1) Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended— “(A) in subsection (a)— “(i) by striking ‘and’ at the end of paragraph (48), “(ii) by striking the period at the end of paragraph (49) and inserting “; and’, and “(iii) by inserting after paragraph (49) the following new paragraph: “‘(50) provide, in accordance with subsection (q), for a monthly personal needs allowance for certain institutionalized individuals and couples.’; and “(B) by adding at the end the following new subsection: “‘(q) (1) (A) In order to meet the requirement of subsection (a)(50), State and local governments. the State plan must provide that, in the case of an institutionalized individual or couple described in subparagraph (B), in determining the amount of the individual’s or couple’s income to be applied monthly to payment for the cost of care in an institution, there shall be deducted from the monthly income (in addition to other allowances otherwise provided under the State plan) a monthly personal needs allowance— “‘(i) which is reasonable in amount for clothing and other personal needs of the individual (or couple) while in an institution, and “‘(ii) which is not less (and may be greater) than the minimum monthly personal needs allowance described in paragraph (2). “(B) In this subsection, the term “institutionalized individual or couple” means an individual or married couple— “‘(i) who is an inpatient (or who are inpatients) in a medical institution or nursing facility for which payments are made under this title throughout a month, and “‘(ii) who is or are determined to be eligible for medical assistance under the State plan. “‘(2) The minimum monthly personal needs allowance described Blind persons. Handicapped persons. in this paragraph is $30 for an institutionalized individual and $60 for an institutionalized couple (if both are aged, blind, or disabled, and their incomes are considered available to each other in determining eligibility).’. “(2) The amendments made by paragraph (1) apply to payments 42 USC 1396a note. under title XIX of the Social Security Act for calendar quarters beginning on or after July 1, 1988, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date.”. (o) Subtitle D of Title IV.— (1) Section 4303.— Section 2115 of the Public Health Service 42 USC 300aa–15. Act is amended— (A) in subsection (i)(1), as added by section 4303(a) of OBRA, by striking “from appropriations under subsection (i)” and inserting “by the Secretary from appropriations under subsection (j)”, and (B) in subsection (j), as added by section 4303(b) of OBRA, by inserting “to the Department of Health and Human Services” after “to be appropriated”. (2) Section 4307.— Section 4307(3)(0 of OBRA is amended by striking “subsection (g)” and inserting “subsection (e), as redesignated by section 4303(d)(2)(A),”. (3) Section 4308.— (A) Subtitle D of title IV of OBRA is amended by adding at the end the following new section: “SEC. 4308. TECHNICAL AMENDMENTS RELATING TO COURT OF CLAIMS PROCEDURES. “(a) Duties of Special Masters.— Section 2112(c)(2) of the Public Health Service Act (42 U.S.C. 300aa–12(a)) is amended— “(1) by inserting shall prepare and submit to the court proposed findings of fact and conclusions of law,’ after ‘adjunct to the court’, “(2) by inserting ‘and’ at the end of subparagraph (C), “(3) by striking ‘, and’ at the end of subparagraph (D) and inserting a period, and “(4) by striking subparagraph (E). “(b) Requiring Filing of Appeals Within 60 Days.— Section 2112(e) of such Act (42 U.S.C. 300aa–12(e)), as redesignated by section 4303(d)(2)(A), is amended by inserting ‘within 60 days of the date of the judgment’ after ‘petition filed’. “(c) Clarification on Timing of Bringing Additional Actions.— The second sentence of section 2121(a) of such Act (42 U.S.C. 300aa–21(a)) is amended by striking ‘the entry of the court’s judgment’ and inserting ‘the court’s final judgment’.”. (B) The table of contents relating to title IV of OBRA is amended by inserting after the item relating to section 4307 the following new item: “Sec. 4308. Technical amendments relating to Court of Claims procedures.”.

8. 1988

   Family Support Act of 1988

   Pub. L. 100–485 § 608(d)(16)(B)(i) · 102 Stat. 2343

   Substituted · 42 U.S.C. § 1396p(c)(1)

   Pub. L. 100–485, § 608(d)(16)(B)(i), substituted “period of ineligibility for nursing facility services and for a level of care in a medical institution equivalent to that of nursing facility services and for services under section 1396n(c) of this title in the case of an institutionalized individual (as defined in paragraph (3)) who, at any time during or after the 30-month period immediately before the date the individual becomes an institutionalized individual (if the individual is entitled to medical assistance under the State plan on such date) or, if the individual is not so entitled, the date the individual applies for such assistance while an institutionalized individual” for “period of ineligibility in the case of an institutionalized individual (as defined in paragraph (3)) who, at any time during the 30-month period immediately before the individual’s application for medical assistance under the State plan”

   Source evidence

   Code amendment note
   Subsec. (c)(1). Pub. L. 100–485, § 608(d)(16)(B)(i), substituted “period of ineligibility for nursing facility services and for a level of care in a medical institution equivalent to that of nursing facility services and for services under section 1396n(c) of this title in the case of an institutionalized individual (as defined in paragraph (3)) who, at any time during or after the 30-month period immediately before the date the individual becomes an institutionalized individual (if the individual is entitled to medical assistance under the State plan on such date) or, if the individual is not so entitled, the date the individual applies for such assistance while an institutionalized individual” for “period of ineligibility in the case of an institutionalized individual (as defined in paragraph (3)) who, at any time during the 30-month period immediately before the individual’s application for medical assistance under the State plan”.

   Enacted provision · exact public law section
   (i) in paragraph (1)— (I) by inserting “for nursing facility services and for a level of care in a medical institution equivalent to that of nursing facility services and for services under section 1915(c)” after “period of ineligibility” the first place it appears, (II) by inserting “or after” after “during”, and (III) by striking “the individual’s application for medical assistance under the State plan” and inserting “the date the individual becomes an institutionalized individual (if the individual is entitled to medical assistance under the State plan on such date) or, if the individual is not so entitled, the date the individual applies for such assistance while an institutionalized individual”;

9. 1988

   Family Support Act of 1988

   Pub. L. 100–485 § 608(d)(16)(B)(ii) · 102 Stat. 2343

   Inserted · 42 U.S.C. § 1396p(c)(2)(A)(ii)

   Pub. L. 100–485, § 608(d)(16)(B)(ii), inserted subcl. (I) and (II) designations

   Source evidence

   Code amendment note
   Subsec. (c)(2)(A)(ii). Pub. L. 100–485, § 608(d)(16)(B)(ii), inserted subcl. (I) and (II) designations.

   Enacted provision · exact public law section
   (ii) in paragraph (2)(A)(ii), by inserting “®” after “who” and by inserting “(II)” after “or” the first place it appears;

10. 1988

    Family Support Act of 1988

    Pub. L. 100–485 § 608(d)(16)(B)(iii) · 102 Stat. 2343

    Substituted · 42 U.S.C. § 1396p(c)(2)(A)(iii)

    Pub. L. 100–485, § 608(d)(16)(B)(iii), substituted “the individual becomes an institutionalized individual” for “of the individual’s admission to the medical institution or nursing facility”

    Source evidence

    Code amendment note
    Subsec. (c)(2)(A)(iii). Pub. L. 100–485, § 608(d)(16)(B)(iii), substituted “the individual becomes an institutionalized individual” for “of the individual’s admission to the medical institution or nursing facility”.

    Enacted provision · exact public law section
    (iii) in paragraph (2)(A)(iii), by striking “of the individual’s admission to the medical institution or nursing facility” and inserting “the individual becomes an institutionalized individual”;

11. 1988

    Family Support Act of 1988

    Pub. L. 100–485 § 608(d)(16)(B)(iv) · 102 Stat. 2343

    Substituted · 42 U.S.C. § 1396p(c)(2)(A)(iv)

    Pub. L. 100–485, § 608(d)(16)(B)(iv), substituted “the individual becomes an institutionalized individual” for “of such individual’s admission to the medical institution or nursing facility”

    Source evidence

    Code amendment note
    Subsec. (c)(2)(A)(iv). Pub. L. 100–485, § 608(d)(16)(B)(iv), substituted “the individual becomes an institutionalized individual” for “of such individual’s admission to the medical institution or nursing facility”.

    Enacted provision · exact public law section
    (iv) in paragraph (2)(A)(iv), by striking “of such individual’s admission to the medical institution or nursing facility” and inserting “the individual becomes an institutionalized individual”;

12. 1988

    Family Support Act of 1988

    Pub. L. 100–485 § 608(d)(16)(B)(v) · 102 Stat. 2343

    1. Inserted · 42 U.S.C. § 1396p(c)(2)(B)

       Pub. L. 100–485, § 608(d)(16)(B)(v), inserted cl. (i) designation

    2. Substituted · 42 U.S.C. § 1396p(c)(2)(B)

       Pub. L. 100–485, § 608(d)(16)(B)(v), substituted “section 1396r–5(h)(2) of this title,,” for “section 1396r–5(h)(2) of this title, or the individual’s child who is blind or permanently and totally disabled”

    3. Added · 42 U.S.C. § 1396p(c)(2)(B)

       Pub. L. 100–485, § 608(d)(16)(B)(v), added cl. (ii)

    Source evidence

    Code amendment note
    Subsec. (c)(2)(B). Pub. L. 100–485, § 608(d)(16)(B)(v), inserted cl. (i) designation, substituted “section 1396r–5(h)(2) of this title,,” for “section 1396r–5(h)(2) of this title, or the individual’s child who is blind or permanently and totally disabled”, and added cl. (ii).

    Enacted provision · exact public law section
    (v) in paragraph (2)(B)— (I) by inserting “(i)” after “transferred”, and (II) by striking “or the individual’s child who is blind or permanently and totally disabled” and inserting “, (ii) to the individual’s child described in subparagraph (A)(ii)(II), or (iii) to (or to another for the sole benefit of) the individual’s spouse if such spouse does not transfer such resources to another person other than the spouse for less than fair market value”;

13. 1988

    Family Support Act of 1988

    Pub. L. 100–485 § 608(d)(16)(B)(vi) · 102 Stat. 2343

    Substituted · 42 U.S.C. § 1396p(c)(3)

    Pub. L. 100–485, § 608(d)(16)(B)(vi), substituted “in a nursing facility, who is an inpatient in a medical institution and with respect to whom payment is made based on a level of care provided in a nursing facility, or who is described in section 1396a(a)(10)(A)(ii)(VI) of this title” for “in a medical institution or nursing facility”

    Source evidence

    Code amendment note
    Subsec. (c)(3). Pub. L. 100–485, § 608(d)(16)(B)(vi), substituted “in a nursing facility, who is an inpatient in a medical institution and with respect to whom payment is made based on a level of care provided in a nursing facility, or who is described in section 1396a(a)(10)(A)(ii)(VI) of this title” for “in a medical institution or nursing facility”.

    Enacted provision · exact public law section
    (vi) in paragraph (3), by striking “in a medical institution or nursing facility” and inserting “in a nursing facility, who is an inpatient in a medical institution and with respect to whom payment is made based on a level of care provided in a nursing facility, or who is described in section 1902(a)(10)(A)(ii)(VI)”; and

14. 1988

    Family Support Act of 1988

    Pub. L. 100–485 § 608(d)(16)(B)(vii) · 102 Stat. 2343

    Added · 42 U.S.C. § 1396p(c)(5)

    Pub. L. 100–485, § 608(d)(16)(B)(vii), added par. (5)

    Source evidence

    Code amendment note
    Subsec. (c)(5). Pub. L. 100–485, § 608(d)(16)(B)(vii), added par. (5).

    Enacted provision · exact public law section
    (vii) by adding at the end the following new paragraph: “(5) In this subsection, the term ‘resources’ has the meaning given such term in section 1613, without regard to the exclusion described in subsection (a)(1) thereof.”.

15. 1989

    Omnibus Budget Reconciliation Act of 1989

    Pub. L. 101–239 § 6411(e)(1)(A) · 103 Stat. 2106

    Inserted · 42 U.S.C. § 1396p(c)(1)

    Pub. L. 101–239, § 6411(e)(1)(A), inserted “or whose spouse,” after “an institutionalized individual (as defined in paragraph (3)) who,”

    Source evidence

    Code amendment note
    Subsec. (c)(1). Pub. L. 101–239, § 6411(e)(1)(A), inserted “or whose spouse,” after “an institutionalized individual (as defined in paragraph (3)) who,”.

    Enacted provision · exact public law section
    (A) in paragraph (1), by inserting “or whose spouse,” after “an institutionalized individual (as defined in paragraph (3)) who,”, and

16. 1989

    Omnibus Budget Reconciliation Act of 1989

    Pub. L. 101–239 § 6411(e)(1)(B)(i) · 103 Stat. 2106

    Amended · 42 U.S.C. § 1396p(c)(2)(B)(i)

    Pub. L. 101–239, § 6411(e)(1)(B)(i), amended cl. (i) generally. Prior to amendment, cl. (i) read as follows: “to (or to another for the sole benefit of) the community spouse, as defined in section 1396r–5(h)(2) of this title,,”

    Source evidence

    Code amendment note
    Subsec. (c)(2)(B)(i). Pub. L. 101–239, § 6411(e)(1)(B)(i), amended cl. (i) generally. Prior to amendment, cl. (i) read as follows: “to (or to another for the sole benefit of) the community spouse, as defined in section 1396r–5(h)(2) of this title,,”.

    Enacted provision · exact public law section
    (i) by amending clause (i) to read as follows: “(i) to or from (or to another for the sole benefit of) the individual’s spouse, or”, and

17. 1989

    Omnibus Budget Reconciliation Act of 1989

    Pub. L. 101–239 § 6411(e)(1)(B)(ii) · 103 Stat. 2106

    1. Struck · 42 U.S.C. § 1396p(c)(2)(B)(ii); 42 U.S.C. § 1396p(c)(2)(B)(iii)

       Pub. L. 101–239, § 6411(e)(1)(B)(ii), struck out “, or” after “subparagraph (A)(ii)(II)” in cl. (ii)

    2. Struck · 42 U.S.C. § 1396p(c)(2)(B)(ii); 42 U.S.C. § 1396p(c)(2)(B)(iii)

       Pub. L. 101–239, § 6411(e)(1)(B)(ii), struck out cl. (iii) which read as follows: “to (or to another for the sole benefit of) the individual’s spouse if such spouse does not transfer such resources to another person other than the spouse for less than fair market value”

    Source evidence

    Code amendment note
    Subsec. (c)(2)(B)(ii), (iii). Pub. L. 101–239, § 6411(e)(1)(B)(ii), struck out “, or” after “subparagraph (A)(ii)(II)” in cl. (ii) and struck out cl. (iii) which read as follows: “to (or to another for the sole benefit of) the individual’s spouse if such spouse does not transfer such resources to another person other than the spouse for less than fair market value”.

    Enacted provision · exact public law section
    (ii) by striking “, or (iii)” and all that follows through “fair market value”.

18. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13612(a) · 107 Stat. 312

    Substituted · 42 U.S.C. § 1396p(b)(1)

    Pub. L. 103–66, § 13612(a), substituted “except that the State shall seek adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan in the case of the following individuals:” and subpars. (A) to (C) for “except—” and former subpars. (A) and (B) which read as follows:

    Source evidence

    Code amendment note
    Subsec. (b)(1). Pub. L. 103–66, § 13612(a), substituted “except that the State shall seek adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan in the case of the following individuals:” and subpars. (A) to (C) for “except—” and former subpars. (A) and (B) which read as follows:

    “(A) in the case of an individual described in subsection (a)(1)(B) of this section, from his estate or upon sale of the property subject to a lien imposed on account of medical assistance paid on behalf of such individual, and “(B) in the case of any other individual who was 65 years of age or older when he received such assistance, from his estate.”

19. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13612(b) · 107 Stat. 312

    Added · 42 U.S.C. § 1396p(b)(3)

    Pub. L. 103–66, § 13612(b), added par. (3)

    Source evidence

    Code amendment note
    Subsec. (b)(3). Pub. L. 103–66, § 13612(b), added par. (3).

20. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13612(c) · 107 Stat. 312

    Added · 42 U.S.C. § 1396p(b)(4)

    Pub. L. 103–66, § 13612(c), added par. (4)

    Source evidence

    Code amendment note
    Subsec. (b)(4). Pub. L. 103–66, § 13612(c), added par. (4).

21. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13611(a)(1) · 107 Stat. 312

    Amended · 42 U.S.C. § 1396p(c)(1)

    Pub. L. 103–66, § 13611(a)(1), amended par. (1) generally. Prior to amendment, par. (1) read as follows: “In order to meet the requirements of this subsection (for purposes of section 1396a(a)(51)(B) of this title), the State plan must provide for a period of ineligibility for nursing facility services and for a level of care in a medical institution equivalent to that of nursing facility services and for services under section 1396n(c) of this title in the case of an institutionalized individual (as defined in paragraph (3)) who, or whose spouse, at any time during or after the 30-month period immediately before the date the individual becomes an institutionalized individual (if the individual is entitled to medical assistance under the State plan on such date) or, if the individual is not so entitled, the date the individual applies for such assistance while an institutionalized individual, disposed of resources for less than fair market value. The period of ineligibility shall begin with the month in which such resources were transferred and the number of months in such period shall be equal to the lesser of—

    Source evidence

    Code amendment note
    Subsec. (c)(1). Pub. L. 103–66, § 13611(a)(1), amended par. (1) generally. Prior to amendment, par. (1) read as follows: “In order to meet the requirements of this subsection (for purposes of section 1396a(a)(51)(B) of this title), the State plan must provide for a period of ineligibility for nursing facility services and for a level of care in a medical institution equivalent to that of nursing facility services and for services under section 1396n(c) of this title in the case of an institutionalized individual (as defined in paragraph (3)) who, or whose spouse, at any time during or after the 30-month period immediately before the date the individual becomes an institutionalized individual (if the individual is entitled to medical assistance under the State plan on such date) or, if the individual is not so entitled, the date the individual applies for such assistance while an institutionalized individual, disposed of resources for less than fair market value. The period of ineligibility shall begin with the month in which such resources were transferred and the number of months in such period shall be equal to the lesser of—

    “(A) 30 months, or “(B)(i) the total uncompensated value of the resources so transferred, divided by (ii) the average cost, to a private patient at the time of the application, of nursing facility services in the State or, at State option, in the community in which the individual is institutionalized.”

    Enacted provision · exact public law section
    (1) In general.— Section 1917(c)(1) (42 U.S.C. 1396p(c)(1)) is amended to read as follows: “(1) (A) In order to meet the requirements of this subsection for purposes of section 1902(a)(18), the State plan must provide that if an institutionalized individual or the spouse of such an individual (or, at the option of a State, a noninstitutionalized individual or the spouse of such an individual) disposes of assets for less than fair market value on or after the look-back date specified in subparagraph (B)(i), the individual is ineligible for medical assistance for services described in subparagraph (C)(i) (or, in the case of a noninstitutionalized individual, for the services described in subparagraph (C)(ii)) during the period beginning on the date specified in subparagraph (D) and equal to the number of months specified in subparagraph (E). “(B) (i) The look-back date specified in this subparagraph is a date that is 36 months (or, in the case of payments from a trust or portions of a trust that are treated as assets disposed of by the individual pursuant to paragraph (3)(A)(iii) or (3)(B)(ii) of subsection (d), 60 months) before the date specified in clause (ii). “(ii) The date specified in this clause, with respect to— “(I) an institutionalized individual is the first date as of which the individual both is an institutionalized individual and has applied for medical assistance under the State plan, or “(II) a noninstitutionalized individual is the date on which the individual applies for medical assistance under the State plan or, if later, the date on which the individual disposes of assets for less than fair market value. “(C) (i) The services described in this subparagraph with respect to an institutionalized individual are the following: “(I) Nursing facility services. “(II) A level of care in any institution equivalent to that of nursing facility services. “(III) Home or community-based services furnished under a waiver granted under subsection (c) or (d) of section 1915. “(ii) The services described in this subparagraph with respect to a noninstitutionalized individual are services (not including any services described in clause (i)) that are described in paragraph (7), (22), or (24) of section 1905(a), and, at the option of a State, other long-term care services for which medical assistance is otherwise available under the State plan to individuals requiring long-term care. “(D) The date specified in this subparagraph is the first day of the first month during or after which assets have been transferred for less than fair market value and which does not occur in any other periods of ineligibility under this subsection. “(E) (i) With respect to an institutionalized individual, the number of months of ineligibility under this subparagraph for an individual shall be equal to— “(I) the total, cumulative uncompensated value of all assets transferred by the individual (or individual’s spouse) on or after the look-back date specified in subparagraph (B)(i), divided by “(II) the average monthly cost to a private patient of nursing facility services in the State (or, at the option of the State, in the community in which the individual is institutionalized) at the time of application. “(ii) With respect to a noninstitutionalized individual, the number of months of ineligibility under this subparagraph for an individual shall not be greater than a number equal to— “(I) the total, cumulative uncompensated value of all assets transferred by the individual (or individual’s spouse) on or after the look-back date specified in subparagraph (B)(i), divided by “(II) the average monthly cost to a private patient of nursing facility services in the State (or, at the option of the State, in the community in which the individual is institutionalized) at the time of application. “(iii) The number of months of ineligibility otherwise determined under clause (i) or (ii) with respect to the disposal of an asset shall be reduced— “(I) in the case of periods of ineligibility determined under clause (i), by the number of months of ineligibility applicable to the individual under clause (ii) as a result of such disposal, and “(II) in the case of periods of ineligibility determined under clause (ii), by the number of months of ineligibility applicable to the individual under clause (i) as a result of such disposal.

22. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13611(a)(2)(A) · 107 Stat. 312

    Substituted · 42 U.S.C. § 1396p(c)(2)(A)

    Pub. L. 103–66, § 13611(a)(2)(A), substituted “assets” for “resources” in introductory provisions

    Source evidence

    Code amendment note
    Subsec. (c)(2)(A). Pub. L. 103–66, § 13611(a)(2)(A), substituted “assets” for “resources” in introductory provisions.

    Enacted provision · exact public law section
    (A) in paragraph (2)(A), by striking “resources” and inserting “assets”;

23. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13611(a)(2)(B) · 107 Stat. 312

    Amended · 42 U.S.C. § 1396p(c)(2)(B)

    Pub. L. 103–66, § 13611(a)(2)(B), amended subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: “the resources were transferred (i) to or from (or to another for the sole benefit of) the individual’s spouse, or (ii) to the individual’s child described in subparagraph (A)(ii)(II);”

    Source evidence

    Code amendment note
    Subsec. (c)(2)(B). Pub. L. 103–66, § 13611(a)(2)(B), amended subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: “the resources were transferred (i) to or from (or to another for the sole benefit of) the individual’s spouse, or (ii) to the individual’s child described in subparagraph (A)(ii)(II);”.

    Enacted provision · exact public law section
    (B) by amending paragraph (2)(B) to read as follows: “(B) the assets— “(i) were transferred to the individual’s spouse or to another for the sole benefit of the individual’s spouse, “(ii) were transferred from the individual’s spouse to another for the sole benefit of the individual’s spouse, “(iii) were transferred to, or to a trust (including a trust described in subsection (d)(4)) established solely for the benefit of, the individual’s child described in subparagraph (A)(ii)(II), or “(iv) were transferred to a trust (including a trust described in subsection (d)(4)) established solely for the benefit of an individual under 65 years of age who is disabled (as defined in section 1614(a)(3));”;

24. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13611(a)(2)(C) · 107 Stat. 312

    1. Substituted · 42 U.S.C. § 1396p(c)(2)(C)

       Pub. L. 103–66, § 13611(a)(2)(C), in introductory provisions, substituted “with regulations” for “with any regulations”, in cl. (i)

    2. Substituted · 42 U.S.C. § 1396p(c)(2)(C)

       Pub. L. 103–66, § 13611(a)(2)(C), in introductory provisions, substituted “assets” for “resources”

    3. Struck · 42 U.S.C. § 1396p(c)(2)(C)

       Pub. L. 103–66, § 13611(a)(2)(C), in introductory provisions, struck out “or” at end, in cl. (ii)

    4. Substituted · 42 U.S.C. § 1396p(c)(2)(C)

       Pub. L. 103–66, § 13611(a)(2)(C), in introductory provisions, substituted “assets” for “resources”

    5. Substituted · 42 U.S.C. § 1396p(c)(2)(C)

       Pub. L. 103–66, § 13611(a)(2)(C), in introductory provisions, substituted “, or” for “; or”

    6. Added · 42 U.S.C. § 1396p(c)(2)(C)

       Pub. L. 103–66, § 13611(a)(2)(C), in introductory provisions, added cl. (iii)

    Source evidence

    Code amendment note
    Subsec. (c)(2)(C). Pub. L. 103–66, § 13611(a)(2)(C), in introductory provisions, substituted “with regulations” for “with any regulations”, in cl. (i), substituted “assets” for “resources” and struck out “or” at end, in cl. (ii), substituted “assets” for “resources” and “, or” for “; or”, and added cl. (iii).

    Enacted provision · exact public law section
    (C) in paragraph (2)(C)— (i) by striking “resources” each place it appears and inserting “assets”, (ii) by striking “any”, (iii) by striking “or (ii)” and inserting “(ii)”, and (iv) by striking “; or” and inserting “, or (iii) all assets transferred for less than fair market value have been returned to the individual; or”;

25. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13611(a)(2)(D) · 107 Stat. 312

    Amended · 42 U.S.C. § 1396p(c)(2)(D)

    Pub. L. 103–66, § 13611(a)(2)(D), amended subpar. (D) generally. Prior to amendment, subpar. (D) read as follows: “the State determines that denial of eligibility would work an undue hardship.”

    Source evidence

    Code amendment note
    Subsec. (c)(2)(D). Pub. L. 103–66, § 13611(a)(2)(D), amended subpar. (D) generally. Prior to amendment, subpar. (D) read as follows: “the State determines that denial of eligibility would work an undue hardship.”

    Enacted provision · exact public law section
    (D) by amending paragraph (2)(D) to read as follows: “(D) the State determines, under procedures established by the State (in accordance with standards specified by the Secretary), that the denial of eligibility would work an undue hardship as determined on the basis of criteria established by the Secretary;”;

26. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13611(a)(2)(E) · 107 Stat. 312

    1. Added · 42 U.S.C. § 1396p(c)(3)

       Pub. L. 103–66, § 13611(a)(2)(E), added par. (3)

    2. Struck · 42 U.S.C. § 1396p(c)(3)

       Pub. L. 103–66, § 13611(a)(2)(E), struck out former par. (3) which read as follows: “In this subsection, the term ‘institutionalized individual’ means an individual who is an inpatient in a nursing facility, who is an inpatient in a medical institution and with respect to whom payment is made based on a level of care provided in a nursing facility, or who is described in section 1396a(a)(10)(A)(ii)(VI) of this title.”

    Source evidence

    Code amendment note
    Subsec. (c)(3). Pub. L. 103–66, § 13611(a)(2)(E), added par. (3) and struck out former par. (3) which read as follows: “In this subsection, the term ‘institutionalized individual’ means an individual who is an inpatient in a nursing facility, who is an inpatient in a medical institution and with respect to whom payment is made based on a level of care provided in a nursing facility, or who is described in section 1396a(a)(10)(A)(ii)(VI) of this title.”

    Enacted provision · exact public law section
    (E) by striking paragraph (3) and inserting the following: “(3) For purposes of this subsection, in the case of an asset held by an individual in common with another person or persons in a joint tenancy, tenancy in common, or similar arrangement, the asset (or the affected portion of such asset) shall be considered to be transferred by such individual when any action is taken, either by such individual or by any other person, that reduces or eliminates such individual’s ownership or control of such asset.”; and

27. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13611(a)(2)(F) · 107 Stat. 312

    Inserted · 42 U.S.C. § 1396p(c)(4)

    Pub. L. 103–66, § 13611(a)(2)(F), inserted at end “In the case of a transfer by the spouse of an individual which results in a period of ineligibility for medical assistance under a State plan for such individual, a State shall, using a reasonable methodology (as specified by the Secretary), apportion such period of ineligibility (or any portion of such period) among the individual and the individual’s spouse if the spouse otherwise becomes eligible for medical assistance under the State plan.”

    Source evidence

    Code amendment note
    Subsec. (c)(4). Pub. L. 103–66, § 13611(a)(2)(F), inserted at end “In the case of a transfer by the spouse of an individual which results in a period of ineligibility for medical assistance under a State plan for such individual, a State shall, using a reasonable methodology (as specified by the Secretary), apportion such period of ineligibility (or any portion of such period) among the individual and the individual’s spouse if the spouse otherwise becomes eligible for medical assistance under the State plan.”

    Enacted provision · exact public law section
    (F) by adding at the end of paragraph (4) the following: Intergovernmental relations. “In the case of a transfer by the spouse of an individual which results in a period of ineligibility for medical assistance under a State plan for such individual, a State shall, using a reasonable methodology (as specified by the Secretary), apportion such period of ineligibility (or any portion of such period) among the individual and the individual’s spouse if the spouse otherwise becomes eligible for medical assistance under the State plan.”.

28. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13611(b) · 107 Stat. 312

    Added · 42 U.S.C. § 1396p(d)

    Pub. L. 103–66, § 13611(b), added subsec. (d)

    Source evidence

    Code amendment note
    Subsec. (d). Pub. L. 103–66, § 13611(b), added subsec. (d).

    Enacted provision · exact public law section
    (b) Treatment of Trust Amounts.— Section 1917 (42 U.S.C. 1396p) is amended by adding at the end the following: “(d) (1) For purposes of determining an individual’s eligibility for, or amount of, benefits under a State plan under this title, subject to paragraph (4), the rules specified in paragraph (3) shall apply to a trust established by such individual. “(2) (A) For purposes of this subsection, an individual shall be considered to have established a trust if assets of the individual were used to form all or part of the corpus of the trust and if any of the following individuals established such trust other than by will: “(i) The individual. “(ii) The individual’s spouse. “(iii) A person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual’s spouse. “(iv) A person, including any court or administrative body, acting at the direction or upon the request of the individual or the individual’s spouse. “(B) In the case of a trust the corpus of which includes assets of an individual (as determined under subparagraph (A)) and assets of any other person or persons, the provisions of this subsection shall apply to the portion of the trust attributable to the assets of the individual. “(C) Subject to paragraph (4), this subsection shall apply without regard to— “(i) the purposes for which a trust is established, “(ii) whether the trustees have or exercise any discretion under the trust, “(iii) any restrictions on when or whether distributions may be made from the trust, or “(iv) any restrictions on the use of distributions from the trust. “(3) (A) In the case of a revocable trust— “(i) the corpus of the trust shall be considered resources available to the individual, “(ii) payments from the trust to or for the benefit of the individual shall be considered income of the individual, and “(iii) any other payments from the trust shall be considered assets disposed of by the individual for purposes of subsection (c). “(B) In the case of an irrevocable trust— “(i) if there are any circumstances under which payment from the trust could be made to or for the benefit of the individual, the portion of the corpus from which, or the income on the corpus from which, payment to the individual could be made shall be considered resources available to the individual, and payments from that portion of the corpus or income— “(I) to or for the benefit of the individual, shall be considered income of the individual, and “(II) for any other purpose, shall be considered a transfer of assets by the individual subject to subsection (c); and “(ii) any portion of the trust from which, or any income on the corpus from which, no payment could under any circumstances be made to the individual shall be considered, as of the date of establishment of the trust (or, if later, the date on which payment to the individual was foreclosed) to be assets disposed by the individual for purposes of subsection (c), and the value of the trust shall be determined for purposes of such subsection by including the amount of any payments made from such portion of the trust after such date. “(4) This subsection shall not apply to any of the following trusts: “(A) A trust containing the assets of an individual under age 65 who is disabled (as defined in section 1614(a)(3)) and which is established for the benefit of such individual by a parent, grandparent, legal guardian of the individual, or a court if the State will receive all amounts remaining in the trust upon the death of such individual up to an amount equal to the total medical assistance paid on behalf of the individual under a State plan under this title. “(B) A trust established in a State for the benefit of an individual if— “(i) the trust is composed only of pension, Social Security, and other income to the individual (and accumulated income in the trust), “(ii) the State will receive all amounts remaining in the trust upon the death of such individual up to an amount equal to the total medical assistance paid on behalf of the individual under a State plan under this title, and “(iii) the State makes medical assistance available to individuals described in section 1902(a)(10)(A)(ii)(V), but does not make such assistance available to individuals for nursing facility services under section 1902(a)(10)(C). “(C) A trust containing the assets of an individual who is disabled (as defined in section 1614(a)(3)) that meets the following conditions: “(i) The trust is established and managed by a non-profit association. “(ii) A separate account is maintained for each beneficiary of the trust, but, for purposes of investment and management of funds, the trust pools these accounts. “(iii) Accounts in the trust are established solely for the benefit of individuals who are disabled (as defined in section 1614(a)(3)) by the parent, grandparent, or legal guardian of such individuals, by such individuals, or by a court. “(iv) To the extent that amounts remaining in the beneficiary’s account upon the death of the beneficiary are not retained by the trust, the trust pays to the State from such remaining amounts in the account an amount equal to the total amount of medical assistance paid on behalf of the beneficiary under the State plan under this title. “(5) Intergovernmental relations. The State agency shall establish procedures (in accordance with standards specified by the Secretary) under which the agency waives the application of this subsection with respect to an individual if the individual establishes that such application would work an undue hardship on the individual as determined on the basis of criteria established by the Secretary.”. “(6) The term ‘trust’ includes any legal instrument or device that is similar to a trust but includes an annuity only to such extent and in such manner as the Secretary specifies. .

29. 1993

    Omnibus Budget Reconciliation Act of 1993

    Pub. L. 103–66 § 13611(c) · 107 Stat. 312

    Added · 42 U.S.C. § 1396p(e)

    Pub. L. 103–66, § 13611(c), added subsec. (e)

    Source evidence

    Code amendment note
    Subsec. (e). Pub. L. 103–66, § 13611(c), added subsec. (e).

    Enacted provision · exact public law section
    (c) Definitions.— Section 1917 (42 U.S.C. 1396p), as amended by subsection (b), is further amended by adding at the end the following new subsection: “(e) In this section, the following definitions shall apply: “(1) The term ‘assets’, with respect to an individual, includes all income and resources of the individual and of the individual’s spouse, including any income or resources which the individual or such individual’s spouse is entitled to but does not receive because of action— “(A) by the individual or such individual’s spouse, “(B) by a person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or such individual’s spouse, or “(C) by any person, including any court or administrative body, acting at the direction or upon the request of the individual or such individual’s spouse. “(2) The term ‘income’ has the meaning given such term in section 1612. “(3) The term ‘institutionalized individual’ means an individual who is an inpatient in a nursing facility, who is an inpatient in a medical institution and with respect to whom payment is made based on a level of care provided in a nursing facility, or who is described in section 1902(a)(10)(A)(ii)(VI). “(4) The term ‘noninstitutionalized individual’ means an individual receiving any of the services specified in subsection (c)(1)(C)(ii). “(5) The term ‘resources’ has the meaning given such term in section 1613, without regard (in the case of an institutionalized individual) to the exclusion described in subsection (a)(1) of such section.”.

30. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6021(a)(1)(A)(i) · 120 Stat. 4

    Inserted · 42 U.S.C. § 1396p(b)(1)(C)(ii)

    Pub. L. 109–171, § 6021(a)(1)(A)(i), inserted “and which satisfies clause (iv), or which has a State plan amendment that provides for a qualified State long-term care insurance partnership (as defined in clause (iii))” after “1993,” in introductory provisions

    Source evidence

    Code amendment note
    Subsec. (b)(1)(C)(ii). Pub. L. 109–171, § 6021(a)(1)(A)(i), inserted “and which satisfies clause (iv), or which has a State plan amendment that provides for a qualified State long-term care insurance partnership (as defined in clause (iii))” after “1993,” in introductory provisions.

    Enacted provision · exact public law section
    (i) in clause (ii), by inserting “and which satisfies clause (iv), or which has a State plan amendment that provides for a qualified State long-term care insurance partnership (as defined in clause (iii))” after “1993,”; and

31. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6021(a)(1)(A)(ii) · 120 Stat. 4

    Added · 42 U.S.C. § 1396p(b)(1)(C)(iii)(vi)

    Pub. L. 109–171, § 6021(a)(1)(A)(ii), added cls. (iii) to (vi)

    Source evidence

    Code amendment note
    Subsec. (b)(1)(C)(iii) to (vi). Pub. L. 109–171, § 6021(a)(1)(A)(ii), added cls. (iii) to (vi).

    Enacted provision · exact public law section
    (ii) by adding at the end the following new clauses: “(iii) For purposes of this paragraph, the term ‘qualified State long-term care insurance partnership’ means an approved State plan amendment under this title that provides for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of an individual who is a beneficiary under a long-term care insurance policy if the following requirements are met: “(I) The policy covers an insured who was a resident of such State when coverage first became effective under the policy. “(II) The policy is a qualified long-term care insurance policy (as defined in section 7702B(b) of the Internal Revenue Code of 1986) issued not earlier than the effective date of the State plan amendment. “(III) The policy meets the model regulations and the requirements of the model Act specified in paragraph (5). “(IV) If the policy is sold to an individual who— “(aa) has not attained age 61 as of the date of purchase, the policy provides compound annual inflation protection; “(bb) has attained age 61 but has not attained age 76 as of such date, the policy provides some level of inflation protection; and “(cc) has attained age 76 as of such date, the policy may (but is not required to) provide some level of inflation protection. “(V) The State Medicaid agency under section 1902(a)(5) provides information and technical assistance to the State insurance department on the insurance department’s role of assuring that any individual who sells a long-term care insurance policy under the partnership receives training and demonstrates evidence of an understanding of such policies and how they relate to other public and private coverage of long-term care. “(VI) Reports. Notification. The issuer of the policy provides regular reports to the Secretary, in accordance with regulations of the Secretary, that include notification regarding when benefits provided under the policy have been paid and the amount of such benefits paid, notification regarding when the policy otherwise terminates, and such other information as the Secretary determines may be appropriate to the administration of such partnerships. “(VII) The State does not impose any requirement affecting the terms or benefits of such a policy unless the State imposes such requirement on long-term care insurance policies without regard to whether the policy is covered under the partnership or is offered in connection with such a partnership. In Applicability. the case of a long-term care insurance policy which is exchanged for another such policy, subclause (I) shall be applied based on the coverage of the first such policy that was exchanged. For purposes of this clause and paragraph (5), the term ‘long-term care insurance policy’ includes a certificate issued under a group insurance contract. “(iv) With respect to a State which had a State plan amendment approved as of May 14, 1993, such a State satisfies this clause for purposes of clause (ii) if the Secretary determines that the State plan amendment provides for consumer protection standards which are no less stringent than the consumer protection standards which applied under such State plan amendment as of December 31, 2005. “(v) The regulations of the Secretary required under clause (iii)(VI) shall be promulgated after consultation with the National Association of Insurance Commissioners, issuers of long-term care insurance policies, States with experience with long-term care insurance partnership plans, other States, and representatives of consumers of long-term care insurance policies, and shall specify the type and format of the data and information to be reported and the frequency with which such reports are to be made. Records. The Secretary, as appropriate, shall provide copies of the reports provided in accordance with that clause to the State involved. “(vi) The Secretary, in consultation with other appropriate Federal agencies, issuers of long-term care insurance, the National Association of Insurance Commissioners, State insurance commissioners, States with experience with long-term care insurance partnership plans, other States, and representatives of consumers of long-term care insurance policies, shall develop recommendations for Congress to authorize and fund a uniform minimum data set to be reported electronically by all issuers of long-term care insurance policies under qualified State long-term care insurance partnerships to a secure, centralized electronic query and report-generating mechanism that the State, the Secretary, and other Federal agencies can access.” ; and

32. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6021(a)(1)(B) · 120 Stat. 4

    Added · 42 U.S.C. § 1396p(b)(5)

    Pub. L. 109–171, § 6021(a)(1)(B), added par. (5)

    Source evidence

    Code amendment note
    Subsec. (b)(5). Pub. L. 109–171, § 6021(a)(1)(B), added par. (5).

    Enacted provision · exact public law section
    (B) by adding at the end the following: “(5) (A) For purposes of clause (iii)(III), the model regulations and the requirements of the model Act specified in this paragraph are: “(i) In the case of the model regulation, the following requirements: “(I) Section 6A (relating to guaranteed renewal or noncancellability), other than paragraph (5) thereof, and the requirements of section 6B of the model Act relating to such section 6A. “(II) Section 6B (relating to prohibitions on limitations and exclusions) other than paragraph (7) thereof. “(III) Section 6C (relating to extension of benefits). “(IV) Section 6D (relating to continuation or conversion of coverage). “(V) Section 6E (relating to discontinuance and replacement of policies). “(VI) Section 7 (relating to unintentional lapse). “(VII) Section 8 (relating to disclosure), other than sections 8F, 8G, 8H, and 8I thereof. “(VIII) Section 9 (relating to required disclosure of rating practices to consumer). “(IX) Section 11 (relating to prohibitions against post-claims underwriting). “(X) Section 12 (relating to minimum standards). “(XI) Section 14 (relating to application forms and replacement coverage). “(XII) Section 15 (relating to reporting requirements). “(XIII) Section 22 (relating to filing requirements for marketing). “(XIV) Section 23 (relating to standards for marketing), including inaccurate completion of medical histories, other than paragraphs (1), (6), and (9) of section 23C. “(XV) Section 24 (relating to suitability). “(XVI) Section 25 (relating to prohibition against preexisting conditions and probationary periods in replacement policies or certificates). “(XVII) The provisions of section 26 relating to contingent nonforfeiture benefits, if the policyholder declines the offer of a nonforfeiture provision described in paragraph (4). “(XVIII) Section 29 (relating to standard format outline of coverage). “(XIX) Section 30 (relating to requirement to deliver shopper’s guide). “(ii) In the case of the model Act, the following: “(I) Section 6C (relating to preexisting conditions). “(II) Section 6D (relating to prior hospitalization). “(III) The provisions of section 8 relating to contingent nonforfeiture benefits. “(IV) Section 6F (relating to right to return). “(V) Section 6G (relating to outline of coverage). “(VI) Section 6H (relating to requirements for certificates under group plans). “(VII) Section 6J (relating to policy summary). “(VIII) Section 6K (relating to monthly reports on accelerated death benefits). “(IX) Section 7 (relating to incontestability period). “(B) For purposes of this paragraph and paragraph (1)(C)— “(i) the terms ‘model regulation’ and ‘model Act’ mean the long-term care insurance model regulation, and the long-term care insurance model Act, respectively, promulgated by the National Association of Insurance Commissioners (as adopted as of October 2000); “(ii) any provision of the model regulation or model Act listed under subparagraph (A) shall be treated as including any other provision of such regulation or Act necessary to implement the provision; and “(iii) with respect to a long-term care insurance policy issued in a State, the policy shall be deemed to meet applicable requirements of the model regulation or the model Act if the State plan amendment under paragraph (1)(C)(iii) provides that the State insurance commissioner for the State certifies (in a manner satisfactory to the Secretary) that the policy meets such requirements. “(C) Deadline. Not later than 12 months after the National Association of Insurance Commissioners issues a revision, update, or other modification of a model regulation or model Act provision specified in subparagraph (A), or of any provision of such regulation or Act that is substantively related to a provision specified in such subparagraph, the Secretary shall review the changes made to the provision, determine whether incorporating such changes into the corresponding provision specified in such subparagraph would improve qualified State long-term care insurance partnerships, and if so, shall incorporate the changes into such provision.” .

33. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6011(a) · 120 Stat. 4

    Inserted · 42 U.S.C. § 1396p(c)(1)(B)(i)

    Pub. L. 109–171, § 6011(a), inserted “or in the case of any other disposal of assets made on or after February 8, 2006” before “, 60 months”

    Source evidence

    Code amendment note
    Subsec. (c)(1)(B)(i). Pub. L. 109–171, § 6011(a), inserted “or in the case of any other disposal of assets made on or after February 8, 2006” before “, 60 months”.

    Enacted provision · exact public law section
    (a) Lengthening Look-Back Period for All Disposals to 5 Years.— Section 1917(c)(1)(B)(i) of the Social Security Act (42 U.S.C. 1396p(c)(1)(B)(i)) is amended by inserting “or in the case of any other disposal of assets made on or after the date of the enactment of the Deficit Reduction Act of 2005” before “, 60 months”.

34. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6011(b) · 120 Stat. 4

    1. Amended · 42 U.S.C. § 1396p(c)(1)(D)

       Pub. L. 109–171, § 6011(b), designated existing provisions as cl. (i)

    2. Substituted · 42 U.S.C. § 1396p(c)(1)(D)

       Pub. L. 109–171, § 6011(b), substituted “In the case of a transfer of asset made before February 8, 2006, the date” for “The date”

    3. Added · 42 U.S.C. § 1396p(c)(1)(D)

       Pub. L. 109–171, § 6011(b), added cl. (ii)

    Source evidence

    Code amendment note
    Subsec. (c)(1)(D). Pub. L. 109–171, § 6011(b), designated existing provisions as cl. (i), substituted “In the case of a transfer of asset made before February 8, 2006, the date” for “The date”, and added cl. (ii).

    Enacted provision · exact public law section
    (b) Change in Beginning Date for Period of Ineligibility.— Section 1917(c)(1)(D) of such Act (42 U.S.C. 1396p(c)(1)(D)) is amended— (1) by striking “(D) The date” and inserting “(D)(i) In the case of a transfer of asset made before the date of the enactment of the Deficit Reduction Act of 2005, the date”; and (2) by adding at the end the following new clause: “(ii) In the case of a transfer of asset made on or after the date of the enactment of the Deficit Reduction Act of 2005, the date specified in this subparagraph is the first day of a month during or after which assets have been transferred for less than fair market value, or the date on which the individual is eligible for medical assistance under the State plan and would otherwise be receiving institutional level care described in subparagraph (C) based on an approved application for such care but for the application of the penalty period, whichever is later, and which does not occur during any other period of ineligibility under this subsection.” .

35. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6016(a) · 120 Stat. 4

    Added · 42 U.S.C. § 1396p(c)(1)(E)(iv)

    Pub. L. 109–171, § 6016(a), added cl. (iv)

    Source evidence

    Code amendment note
    Subsec. (c)(1)(E)(iv). Pub. L. 109–171, § 6016(a), added cl. (iv).

    Enacted provision · exact public law section
    (a) Requirement To Impose Partial Months of Ineligibility.— Section 1917(c)(1)(E) of the Social Security Act (42 U.S.C. 1396p(c)(1)(E)) is amended by adding at the end the following: “(iv) A State shall not round down, or otherwise disregard any fractional period of ineligibility determined under clause (i) or (ii) with respect to the disposal of assets.” .

36. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6012(b) · 120 Stat. 4

    Added · 42 U.S.C. § 1396p(c)(1)(F)

    Pub. L. 109–171, § 6012(b), added subpar. (F)

    Source evidence

    Code amendment note
    Subsec. (c)(1)(F). Pub. L. 109–171, § 6012(b), added subpar. (F).

    Enacted provision · exact public law section
    (b) Requirement for State To Be Named as a Remainder Beneficiary.— Section 1917(c)(1) of such Act (42 U.S.C. 1396p(c)(1)), is amended by adding at the end the following: “(F) For purposes of this paragraph, the purchase of an annuity shall be treated as the disposal of an asset for less than fair market value unless— “(i) the State is named as the remainder beneficiary in the first position for at least the total amount of medical assistance paid on behalf of the annuitant under this title; or “(ii) the State is named as such a beneficiary in the second position after the community spouse or minor or disabled child and is named in the first position if such spouse or a representative of such child disposes of any such remainder for less than fair market value.” .

37. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6012(c) · 120 Stat. 4

    Added · 42 U.S.C. § 1396p(c)(1)(G)

    Pub. L. 109–171, § 6012(c), added subpar. (G)

    Source evidence

    Code amendment note
    Subsec. (c)(1)(G). Pub. L. 109–171, § 6012(c), added subpar. (G).

    Enacted provision · exact public law section
    (c) Inclusion of Transfers To Purchase Balloon Annuities.— Section 1917(c)(1) of such Act (42 U.S.C. 1396p(c)(1)), as amended by subsection (b), is amended by adding at the end the following: “(G) For purposes of this paragraph with respect to a transfer of assets, the term ‘assets’ includes an annuity purchased by or on behalf of an annuitant who has applied for medical assistance with respect to nursing facility services or other long-term care services under this title unless— “(i) the annuity is— “(I) an annuity described in subsection (b) or (q) of section 408 of the Internal Revenue Code of 1986; or “(II) purchased with proceeds from— “(aa) an account or trust described in subsection (a), (c), or (p) of section 408 of such Code; “(bb) a simplified employee pension (within the meaning of section 408(k) of such Code); or “(cc) a Roth IRA described in section 408A of such Code; or “(ii) the annuity— “(I) is irrevocable and nonassignable; “(II) is actuarially sound (as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration); and “(III) provides for payments in equal amounts during the term of the annuity, with no deferral and no balloon payments made.” .

38. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6016(b) · 120 Stat. 4

    Added · 42 U.S.C. § 1396p(c)(1)(H)

    Pub. L. 109–171, § 6016(b), added subpar. (H)

    Source evidence

    Code amendment note
    Subsec. (c)(1)(H). Pub. L. 109–171, § 6016(b), added subpar. (H).

    Enacted provision · exact public law section
    (b) Authority for States To Accumulate Multiple Transfers Into One Penalty Period.— Section 1917(c)(1) of such Act (42 U.S.C. 1396p(c)(1)), as amended by subsections (b) and (c) of section 6012, is amended by adding at the end the following: “(H) Notwithstanding the preceding provisions of this paragraph, in the case of an individual (or individual’s spouse) who makes multiple fractional transfers of assets in more than 1 month for less than fair market value on or after the applicable look-back date specified in subparagraph (B), a State may determine the period of ineligibility applicable to such individual under this paragraph by— “(i) treating the total, cumulative uncompensated value of all assets transferred by the individual (or individual’s spouse) during all months on or after the look-back date specified in subparagraph (B) as 1 transfer for purposes of clause (i) or (ii) (as the case may be) of subparagraph (E); and “(ii) beginning such period on the earliest date which would apply under subparagraph (D) to any of such transfers.” .

39. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6016(c) · 120 Stat. 4

    Added · 42 U.S.C. § 1396p(c)(1)(I)

    Pub. L. 109–171, § 6016(c), added subpar. (I)

    Source evidence

    Code amendment note
    Subsec. (c)(1)(I). Pub. L. 109–171, § 6016(c), added subpar. (I).

    Enacted provision · exact public law section
    (c) Inclusion of Transfer of Certain Notes and Loans Assets.— Section 1917(c)(1) of such Act (42 U.S.C. 1396p(c)(1)), as amended by subsection (b), is amended by adding at the end the following: “(I) For purposes of this paragraph with respect to a transfer of assets, the term ‘assets’ includes funds used to purchase a promissory note, loan, or mortgage unless such note, loan, or mortgage— “(i) has a repayment term that is actuarially sound (as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration); “(ii) provides for payments to be made in equal amounts during the term of the loan, with no deferral and no balloon payments made; and “(iii) prohibits the cancellation of the balance upon the death of the lender. In the case of a promissory note, loan, or mortgage that does not satisfy the requirements of clauses (i) through (iii), the value of such note, loan, or mortgage shall be the outstanding balance due as of the date of the individual’s application for medical assistance for services described in subparagraph (C).” .

40. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6016(d) · 120 Stat. 4

    Added · 42 U.S.C. § 1396p(c)(1)(J)

    Pub. L. 109–171, § 6016(d), added subpar. (J)

    Source evidence

    Code amendment note
    Subsec. (c)(1)(J). Pub. L. 109–171, § 6016(d), added subpar. (J).

    Enacted provision · exact public law section
    (d) Inclusion of Transfers To Purchase Life Estates.— Section 1917(c)(1) of such Act (42 U.S.C. 1396p(c)(1)), as amended by subsection (c), is amended by adding at the end the following: “(J) For purposes of this paragraph with respect to a transfer of assets, the term ‘assets’ includes the purchase of a life estate interest in another individual’s home unless the purchaser resides in the home for a period of at least 1 year after the date of the purchase.” .

41. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6011(e) · 120 Stat. 4

    1. Substituted · 42 U.S.C. § 1396p(c)(2)

       Pub. L. 109–171, § 6011(e), substituted period for semicolon at end

    2. Inserted · 42 U.S.C. § 1396p(c)(2)

       Pub. L. 109–171, § 6011(e), inserted concluding provisions

    Source evidence

    Code amendment note
    Subsec. (c)(2). Pub. L. 109–171, § 6011(e), substituted period for semicolon at end and inserted concluding provisions.

    Enacted provision · exact public law section
    (e) Additional Provisions on Hardship Waivers.— (1) Application by facility.— Section 1917(c)(2) of the Social Security Act (42 U.S.C. 1396p(c)(2)) is amended— (A) by striking the semicolon at the end of subparagraph (D) and inserting a period; and (B) by adding after and below such subparagraph the following: “The procedures established under subparagraph (D) shall permit the facility in which the institutionalized individual is residing to file an undue hardship waiver application on behalf of the individual with the consent of the individual or the personal representative of the individual.” . (2) Authority to make bed hold payments for hardship applicants.— Such section is further amended by adding at the end the following: “While an application for an undue hardship waiver is pending under subparagraph (D) in the case of an individual who is a resident of a nursing facility, if the application meets such criteria as the Secretary specifies, the State may provide for payments for nursing facility services in order to hold the bed for the individual at the facility, but not in excess of payments for 30 days.”.

42. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6012(a) · 120 Stat. 4

    Redesignated · 42 U.S.C. § 1396p(e)

    Pub. L. 109–171, § 6012(a), added subsec. (e). Former subsec. (e) redesignated (f)

    Source evidence

    Code amendment note
    Subsec. (e). Pub. L. 109–171, § 6012(a), added subsec. (e). Former subsec. (e) redesignated (f).

    Enacted provision · exact public law section
    (a) In General.— Section 1917 of the Social Security Act (42 U.S.C. 1396p) is amended by redesignating subsection (e) as subsection (f) and by inserting after subsection (d) the following new subsection: “(e) (1) In order to meet the requirements of this section for purposes of section 1902(a)(18), a State shall require, as a condition for the provision of medical assistance for services described in subsection (c)(1)(C)(i) (relating to long-term care services) for an individual, the application of the individual for such assistance (including any recertification of eligibility for such assistance) shall disclose a description of any interest the individual or community spouse has in an annuity (or similar financial instrument, as may be specified by the Secretary), regardless of whether the annuity is irrevocable or is treated as an asset. Such application or recertification form shall include a statement that under paragraph (2) the State becomes a remainder beneficiary under such an annuity or similar financial instrument by virtue of the provision of such medical assistance. “(2) (A) Notification. In the case of disclosure concerning an annuity under subsection (c)(1)(F), the State shall notify the issuer of the annuity of the right of the State under such subsection as a preferred remainder beneficiary in the annuity for medical assistance furnished to the individual. Nothing in this paragraph shall be construed as preventing such an issuer from notifying persons with any other remainder interest of the State’s remainder interest under such subsection. “(B) In the case of such an issuer receiving notice under subparagraph (A), the State may require the issuer to notify the State when there is a change in the amount of income or principal being withdrawn from the amount that was being withdrawn at the time of the most recent disclosure described in paragraph (1). A State shall take such information into account in determining the amount of the State’s obligations for medical assistance or in the individual’s eligibility for such assistance. “(3) The Secretary may provide guidance to States on categories of transactions that may be treated as a transfer of asset for less than fair market value. “(4) Nothing in this subsection shall be construed as preventing a State from denying eligibility for medical assistance for an individual based on the income or resources derived from an annuity described in paragraph (1).” .

43. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6014(a) · 120 Stat. 4

    Redesignated · 42 U.S.C. § 1396p(f)

    Pub. L. 109–171, § 6014(a), added subsec. (f). Former subsec. (f) redesignated (g)

    Source evidence

    Code amendment note
    Subsec. (f). Pub. L. 109–171, § 6014(a), added subsec. (f). Former subsec. (f) redesignated (g).

    Enacted provision · exact public law section
    (a) In General.— Section 1917 of the Social Security Act, as amended by section 6012(a), is further amended by redesignating subsection (f) as subsection (g) and by inserting after subsection (e) the following new subsection: “(f) (1) (A) Notwithstanding any other provision of this title, subject to subparagraphs (B) and (C) of this paragraph and paragraph (2), in determining eligibility of an individual for medical assistance with respect to nursing facility services or other long-term care services, the individual shall not be eligible for such assistance if the individual’s equity interest in the individual’s home exceeds $500,000. “(B) A State may elect, without regard to the requirements of section 1902(a)(1) (relating to statewideness) and section 1902(a)(10)(B) (relating to comparability), to apply subparagraph (A) by substituting for ‘$500,000’, an amount that exceeds such amount, but does not exceed $750,000. “(C) The dollar amounts specified in this paragraph shall be increased, beginning with 2011, from year to year based on the percentage increase in the consumer price index for all urban consumers (all items; United States city average), rounded to the nearest $1,000. “(2) Paragraph (1) shall not apply with respect to an individual if— “(A) the spouse of such individual, or “(B) such individual’s child who is under age 21, or (with respect to States eligible to participate in the State program established under title XVI) is blind or permanently and totally disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1614, is lawfully residing in the individual’s home. “(3) Nothing in this subsection shall be construed as preventing an individual from using a reverse mortgage or home equity loan to reduce the individual’s total equity interest in the home. “(4) Procedures. The Secretary shall establish a process whereby paragraph (1) is waived in the case of a demonstrated hardship.” .

44. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6012(a) · 120 Stat. 4

    Redesignated · 42 U.S.C. § 1396p(f)

    Pub. L. 109–171, § 6012(a), redesignated subsec. (e) as (f)

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    Pub. L. 109–171, § 6012(a), redesignated subsec. (e) as (f).

    Enacted provision · exact public law section
    (a) In General.— Section 1917 of the Social Security Act (42 U.S.C. 1396p) is amended by redesignating subsection (e) as subsection (f) and by inserting after subsection (d) the following new subsection: “(e) (1) In order to meet the requirements of this section for purposes of section 1902(a)(18), a State shall require, as a condition for the provision of medical assistance for services described in subsection (c)(1)(C)(i) (relating to long-term care services) for an individual, the application of the individual for such assistance (including any recertification of eligibility for such assistance) shall disclose a description of any interest the individual or community spouse has in an annuity (or similar financial instrument, as may be specified by the Secretary), regardless of whether the annuity is irrevocable or is treated as an asset. Such application or recertification form shall include a statement that under paragraph (2) the State becomes a remainder beneficiary under such an annuity or similar financial instrument by virtue of the provision of such medical assistance. “(2) (A) Notification. In the case of disclosure concerning an annuity under subsection (c)(1)(F), the State shall notify the issuer of the annuity of the right of the State under such subsection as a preferred remainder beneficiary in the annuity for medical assistance furnished to the individual. Nothing in this paragraph shall be construed as preventing such an issuer from notifying persons with any other remainder interest of the State’s remainder interest under such subsection. “(B) In the case of such an issuer receiving notice under subparagraph (A), the State may require the issuer to notify the State when there is a change in the amount of income or principal being withdrawn from the amount that was being withdrawn at the time of the most recent disclosure described in paragraph (1). A State shall take such information into account in determining the amount of the State’s obligations for medical assistance or in the individual’s eligibility for such assistance. “(3) The Secretary may provide guidance to States on categories of transactions that may be treated as a transfer of asset for less than fair market value. “(4) Nothing in this subsection shall be construed as preventing a State from denying eligibility for medical assistance for an individual based on the income or resources derived from an annuity described in paragraph (1).” .

45. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6015(b) · 120 Stat. 4

    Redesignated · 42 U.S.C. § 1396p(g)

    Pub. L. 109–171, § 6015(b), added subsec. (g). Former subsec. (g) redesignated (h)

    Source evidence

    Code amendment note
    Subsec. (g). Pub. L. 109–171, § 6015(b), added subsec. (g). Former subsec. (g) redesignated (h).

    Enacted provision · exact public law section
    (b) Treatment of Entrance Fees.— Section 1917 of such Act (42 U.S.C. 1396p), as amended by sections 6012(a) and 6014(a), is amended by redesignating subsection (g) as subsection (h) and by inserting after subsection (f) the following new subsection: “(g) Treatment of Entrance Fees of Individuals Residing in Continuing Care Retirement Communities.— “(1) In general.— For purposes of determining an individual’s eligibility for, or amount of, benefits under a State plan under this title, the rules specified in paragraph (2) shall apply to individuals residing in continuing care retirement communities or life care communities that collect an entrance fee on admission from such individuals. “(2) Treatment of entrance fee.— For purposes of this subsection, an individual’s entrance fee in a continuing care retirement community or life care community shall be considered a resource available to the individual to the extent that— “(A) the individual has the ability to use the entrance fee, or the contract provides that the entrance fee may be used, to pay for care should other resources or income of the individual be insufficient to pay for such care; “(B) the individual is eligible for a refund of any remaining entrance fee when the individual dies or terminates the continuing care retirement community or life care community contract and leaves the community; and “(C) the entrance fee does not confer an ownership interest in the continuing care retirement community or life care community.” .

46. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6014(a) · 120 Stat. 4

    Redesignated · 42 U.S.C. § 1396p(g)

    Pub. L. 109–171, § 6014(a), redesignated subsec. (f) as (g)

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    Pub. L. 109–171, § 6014(a), redesignated subsec. (f) as (g).

    Enacted provision · exact public law section
    (a) In General.— Section 1917 of the Social Security Act, as amended by section 6012(a), is further amended by redesignating subsection (f) as subsection (g) and by inserting after subsection (e) the following new subsection: “(f) (1) (A) Notwithstanding any other provision of this title, subject to subparagraphs (B) and (C) of this paragraph and paragraph (2), in determining eligibility of an individual for medical assistance with respect to nursing facility services or other long-term care services, the individual shall not be eligible for such assistance if the individual’s equity interest in the individual’s home exceeds $500,000. “(B) A State may elect, without regard to the requirements of section 1902(a)(1) (relating to statewideness) and section 1902(a)(10)(B) (relating to comparability), to apply subparagraph (A) by substituting for ‘$500,000’, an amount that exceeds such amount, but does not exceed $750,000. “(C) The dollar amounts specified in this paragraph shall be increased, beginning with 2011, from year to year based on the percentage increase in the consumer price index for all urban consumers (all items; United States city average), rounded to the nearest $1,000. “(2) Paragraph (1) shall not apply with respect to an individual if— “(A) the spouse of such individual, or “(B) such individual’s child who is under age 21, or (with respect to States eligible to participate in the State program established under title XVI) is blind or permanently and totally disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1614, is lawfully residing in the individual’s home. “(3) Nothing in this subsection shall be construed as preventing an individual from using a reverse mortgage or home equity loan to reduce the individual’s total equity interest in the home. “(4) Procedures. The Secretary shall establish a process whereby paragraph (1) is waived in the case of a demonstrated hardship.” .

47. 2006

    Deficit Reduction Act of 2005

    Pub. L. 109–171 § 6015(b) · 120 Stat. 4

    Redesignated · 42 U.S.C. § 1396p(h)

    Pub. L. 109–171, § 6015(b), redesignated subsec. (g) as (h)

    Source evidence

    Code amendment note
    Subsec. (h). Pub. L. 109–171, § 6015(b), redesignated subsec. (g) as (h).

    Enacted provision · exact public law section
    (b) Treatment of Entrance Fees.— Section 1917 of such Act (42 U.S.C. 1396p), as amended by sections 6012(a) and 6014(a), is amended by redesignating subsection (g) as subsection (h) and by inserting after subsection (f) the following new subsection: “(g) Treatment of Entrance Fees of Individuals Residing in Continuing Care Retirement Communities.— “(1) In general.— For purposes of determining an individual’s eligibility for, or amount of, benefits under a State plan under this title, the rules specified in paragraph (2) shall apply to individuals residing in continuing care retirement communities or life care communities that collect an entrance fee on admission from such individuals. “(2) Treatment of entrance fee.— For purposes of this subsection, an individual’s entrance fee in a continuing care retirement community or life care community shall be considered a resource available to the individual to the extent that— “(A) the individual has the ability to use the entrance fee, or the contract provides that the entrance fee may be used, to pay for care should other resources or income of the individual be insufficient to pay for such care; “(B) the individual is eligible for a refund of any remaining entrance fee when the individual dies or terminates the continuing care retirement community or life care community contract and leaves the community; and “(C) the entrance fee does not confer an ownership interest in the continuing care retirement community or life care community.” .

48. 2006

    Tax Relief and Health Care Act of 2006

    Pub. L. 109–432 div. B title IV § 405(b)(1) · 120 Stat. 2922

    Substituted · 42 U.S.C. § 1396p(c)(1)(F)(i)

    Pub. L. 109–432 substituted “institutionalized individual” for “annuitant”

    Source evidence

    Code amendment note
    Subsec. (c)(1)(F)(i). Pub. L. 109–432 substituted “institutionalized individual” for “annuitant”.

    Enacted provision · exact public law section
    (b) Credit Made Part of General Business Credit.— Section 38(b) is amended by striking “and” at the end of paragraph (29), by striking the period at the end of paragraph (30) and inserting “, plus”, and by adding at the end the following new paragraph: “(31) the mine rescue team training credit determined under section 45N(a).” .

49. 2008

    Medicare Improvements for Patients and Providers Act of 2008

    Pub. L. 110–275 title I § 115(a) · 122 Stat. 2494

    Inserted · 42 U.S.C. § 1396p(b)(1)(B)(ii)

    Pub. L. 110–275 inserted “(but not including medical assistance for medicare cost-sharing or for benefits described in section 1396a(a)(10)(E) of this title)” before period at end

    Source evidence

    Code amendment note
    Subsec. (b)(1)(B)(ii). Pub. L. 110–275 inserted “(but not including medical assistance for medicare cost-sharing or for benefits described in section 1396a(a)(10)(E) of this title)” before period at end.

    Enacted provision · exact public law section
    (a) In General.— Section 1917(b)(1)(B)(ii) of the Social Security Act (42 U.S.C. 1396p(b)(1)(B)(ii)) is amended by inserting “(but not including medical assistance for medicare cost-sharing or for benefits described in section 1902(a)(10)(E))” before the period at the end.

50. 2009

    American Recovery and Reinvestment Act of 2009

    Pub. L. 111–5 div. B title V § 5006(c) · 123 Stat. 115

    1. Amended · 42 U.S.C. § 1396p(b)(3)

       Pub. L. 111–5 designated existing provisions as subpar. (A)

    2. Added · 42 U.S.C. § 1396p(b)(3)

       Pub. L. 111–5 added subpar. (B)

    Source evidence

    Code amendment note
    Subsec. (b)(3). Pub. L. 111–5 designated existing provisions as subpar. (A) and added subpar. (B).

    Enacted provision · exact public law section
    (c) Continuation of Current Law Protections of Certain Indian Property From Medicaid Estate Recovery.— Section 1917(b)(3) of the Social Security Act (42 U.S.C. 1396p(b)(3)) is amended— (1) by inserting “(A)” after “(3)”; and (2) by adding at the end the following new subparagraph: “(B) The standards specified by the Secretary under subparagraph (A) shall require that the procedures established by the State agency under subparagraph (A) exempt income, resources, and property that are exempt from the application of this subsection as of April 1, 2003, under manual instructions issued to carry out this subsection (as in effect on such date) because of the Federal responsibility for Indian Tribes and Alaska Native Villages. Nothing in this subparagraph shall be construed as preventing the Secretary from providing additional estate recovery exemptions under this title for Indians.” .

51. 2013

    Bipartisan Budget Act of 2013

    Pub. L. 113–67 § 202(b)(3) · 127 Stat. 1165

    Changed · 42 U.S.C. § 1396p(a)(1)(A)

    Pub. L. 113–67, § 202(b)(3), which directed amendment of subpar. (A) to read as follows: “pursuant to—

    Source evidence

    Code amendment note
    Subsec. (a)(1)(A). Pub. L. 113–67, § 202(b)(3), which directed amendment of subpar. (A) to read as follows: “pursuant to—

    “(i) the judgment of a court on account of benefits incorrectly paid on behalf of such individual, or “(ii) rights acquired by or assigned to the State in accordance with section 1396a(a)(25)(H) of this title or section 1396k(a)(1)(A) of this title, or”,

    Enacted provision · exact public law section
    (3) Liens.— Section 1917(a)(1)(A) of such Act (42 U.S.C. 1396p(a)(1)(A)) is amended to read as follows: “(A) pursuant to— “(i) the judgment of a court on account of benefits incorrectly paid on behalf of such individual, or “(ii) rights acquired by or assigned to the State in accordance with section 1902(a)(25)(H) or section 1912(a)(1)(A), or” .

52. 2016

    21st Century Cures Act

    Pub. L. 114–255 div. A title V § 5007(a) · 130 Stat. 1033

    Inserted · 42 U.S.C. § 1396p(d)(4)(A)

    Pub. L. 114–255 inserted “the individual,” after “for the benefit of such individual by”

    Source evidence

    Code amendment note
    Subsec. (d)(4)(A). Pub. L. 114–255 inserted “the individual,” after “for the benefit of such individual by”.

    Enacted provision · exact public law section
    (a) In General.— Section 1917(d)(4)(A) of the Social Security Act (42 U.S.C. 1396p(d)(4)(A)) is amended by inserting “the individual,” after “for the benefit of such individual by”.

53. 2018

    Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act

    Pub. L. 115–123 § 53102(b)(1) · 132 Stat. 64

    Repealed · 42 U.S.C. § 1396p(a)(1)(A)

    Pub. L. 115–123, § 53102(b)(1), repealed Pub. L. 113–67, § 202(b)(3), and provided that the provisions amended by section 202(b) shall be applied and administered as if such amendment had never been enacted. See 2013 Amendment note below

    Source evidence

    Code amendment note
    Subsec. (a)(1)(A). Pub. L. 115–123, § 53102(b)(1), repealed Pub. L. 113–67, § 202(b)(3), and provided that the provisions amended by section 202(b) shall be applied and administered as if such amendment had never been enacted. See 2013 Amendment note below.

    Enacted provision · exact public law section
    (1) Repeal.— Effective as of September 30, 2017, subsection (b) of section 202 of the Bipartisan Budget Act of 2013 (Public Law 113–67; 127 Stat. 1177; 42 U.S.C. 1396a note) (including any amendments made by such subsection) 42 USC 1396a and note, 1396k, 1396p. is repealed and the provisions amended by such subsection shall be applied and administered as if such amendments had never been enacted.

54. 2013

    Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act

    Pub. L. 115–123 § 53102(b)(1) · 132 Stat. 64

    Changed · 42 U.S.C. § 1396p(a)(1)(A)

    Pub. L. 115–123, § 53102(b)(1)

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    was repealed by Pub. L. 115–123, § 53102(b)(1).

    Enacted provision · exact public law section
    (1) Repeal.— Effective as of September 30, 2017, subsection (b) of section 202 of the Bipartisan Budget Act of 2013 (Public Law 113–67; 127 Stat. 1177; 42 U.S.C. 1396a note) (including any amendments made by such subsection) 42 USC 1396a and note, 1396k, 1396p. is repealed and the provisions amended by such subsection shall be applied and administered as if such amendments had never been enacted.

55. 2025

    Pub. L. 119–21 § 71108(a)(1) · 139 Stat. 296

    1. Amended · 42 U.S.C. § 1396p(f)(1)(B)

       Pub. L. 119–21, § 71108(a)(1), designated existing provisions as cl. (i)

    2. Inserted · 42 U.S.C. § 1396p(f)(1)(B)

       Pub. L. 119–21, § 71108(a)(1), inserted “, in the case of an individual’s home that is located on a lot that is zoned for agricultural use,” after “apply subparagraph (A)”

    3. Substituted · 42 U.S.C. § 1396p(f)(1)(B)

       Pub. L. 119–21, § 71108(a)(1), substituted “the amount specified in subparagraph (A)” for “ ‘$500,000’ ”

    4. Added · 42 U.S.C. § 1396p(f)(1)(B)

       Pub. L. 119–21, § 71108(a)(1), added cl. (ii)

    Unresolved: Pub. L. 119–21 was not found in the local Statutes at Large index.

    Source evidence

    Code amendment note
    Subsec. (f)(1)(B). Pub. L. 119–21, § 71108(a)(1), designated existing provisions as cl. (i), inserted “, in the case of an individual’s home that is located on a lot that is zoned for agricultural use,” after “apply subparagraph (A)”, substituted “the amount specified in subparagraph (A)” for “ ‘$500,000’ ”, and added cl. (ii).

    Effective date note
    Pub. L. 119–21, title VII, § 71108(c), July 4, 2025, 139 Stat. 297, provided that: “The amendments made by subsection (a) [amending this section] shall apply beginning on January 1, 2028.”

56. 2025

    Pub. L. 119–21 § 71108(a)(2) · 139 Stat. 296

    Inserted · 42 U.S.C. § 1396p(f)(1)(C)

    Pub. L. 119–21, § 71108(a)(2), inserted “(other than the amount specified in subparagraph (B)(ii) (relating to certain non-agricultural homes))” after “specified in this paragraph” and “In the case that application of the preceding sentence would result in a dollar amount (other than the amount specified in subparagraph (B)(i) (relating to certain agricultural homes)) exceeding $1,000,000, such amount shall be deemed to be equal to $1,000,000.” at end

    Unresolved: Pub. L. 119–21 was not found in the local Statutes at Large index.

    Source evidence

    Code amendment note
    Subsec. (f)(1)(C). Pub. L. 119–21, § 71108(a)(2), inserted “(other than the amount specified in subparagraph (B)(ii) (relating to certain non-agricultural homes))” after “specified in this paragraph” and “In the case that application of the preceding sentence would result in a dollar amount (other than the amount specified in subparagraph (B)(i) (relating to certain agricultural homes)) exceeding $1,000,000, such amount shall be deemed to be equal to $1,000,000.” at end.

    Effective date note
    Pub. L. 119–21, title VII, § 71108(c), July 4, 2025, 139 Stat. 297, provided that: “The amendments made by subsection (a) [amending this section] shall apply beginning on January 1, 2028.”

67 of 75 references resolved to an enrolled provision · 3 partial · 5 unresolved