,i  #aac? ,,congress  #a/ ,session  ,h4 
,r4 #ahec  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,may #g1 #bjac ,mr4   
,cassidy introduc$ ! foll[+ bill2 :i* 0 
ref]r$ to ! ,committee on ,en]gy &      
,comm]ce  ,a ,,bill  ,to am5d title     
,,xix ( ! ,social ,security ,act to re=m
 paym5t to ,/ates "u ! ,m$icaid program4
  #a4 ,%ort title ,?is ,act may be cit$ 
z ! ,m$icaid ,acc\ntability & ,c>e ,act 
( #bjac4  #b4 ,m$icaid paym5t re=m  7a7 
,9 g5]al ,title ,,xix ( ! ,social       
,security ,act 7#db ,u4,s4,c4 #acif et  
seq47 is am5d$ by ins]t+ aft] section   
#aijc ! foll[+ section3  #aijc;,a4      
,re=m$ paym5t to ,/ates  7a7 ,re=m$     
paym5t sy/em  7#a7 ,9 g5]al ,= qu>t]s   
beg9n+ on or aft] ! implem5tation date  
7z def9$ 9 subsection 7k77#a771 9 lieu (
 am\nts o!rwise payable to a ,/ate "u   
?is title 7includ+ any paym5ts          
attributable to section #aibc71 except z
 o!rwise provid$ 9 ?is section1 ! am\nt 
payable to su* ,/ate %all be equal to ! 
sum ( ! foll[+3  7,a7 ,adju/$ aggregate 

b5efici>y-bas$ am\nt ,! aggregate       
b5efici>y-bas$ am\nt specifi$ 9         
subsection 7b7 = ! qu>t] & ! ,/ate1     
adju/$ "u subsection 7e74  7,b7 ,*ronic 
c>e quality bonus ,! am\nt 7if any7 ( ! 
*ronic c>e quality bonus paym5t specifi$
 9 subsection 7f7 = ! qu>t] = ! ,/ate4  
7#b7 ,requirem5t ( ,/ate %>e  7,a7 ,9   
g5]al ,a ,/ate %all make1 f non-,f$]al  
funds1 exp5ditures 9 an am\nt equal to  
its ,/ate %>e 7z det]m9$ "u subp>agraph 
7,b77 = a qu>t] = items1 s]vices1 & o!r 
co/s = :i*1 b = p>agraph 7#a71 ,f$]al   
funds w\ld h be5 payable "u ?is title4  
7,b7 ,/ate %>e ,! ,/ate %>e = a ,/ate = 
a qu>t] 9 a fiscal ye> is equal to !    
product (--  7i7 ! aggregate            
b5efici>y-bas$ am\nt specifi$ 9         
subsection 7b7 = ! qu>t] & ! ,/ate2 &   
7ii7 ! ratio (--  7,i7 ! ,/ate p]c5tage 
describ$ 9 subp>agraph 7,d77ii7 = su*   
,/ate & fiscal ye>2 to  7,,ii7 ! ,f$]al 
p]c5tage describ$ 9 subp>agraph 7,d77i7 
= su* ,/ate & fiscal ye>4  7,c7         
,nonpaym5t = failure to pay /ate %>e    

7i7 ,9 g5]al ,if a ,/ate fails to exp5d 
! am\nt requir$ "u subp>agraph 7,a7 = a 
qu>t] 9 a fiscal ye>1 ! am\nt payable to
 ! ,/ate "u p>agraph 7#a7 %all be r$uc$ 
by ! product ( ! am\nt by :i* ! ,/ate   
paym5t is less ?an ! ,/ate %>e & ! ratio
 (--  7,i7 ! ,f$]al p]c5tage describ$ 9 
subp>agraph 7,d77i7 = su* ,/ate & fiscal
 ye>2 to  7,,ii7 ! ,/ate p]c5tage       
describ$ 9 subp>agraph 7,d77ii7 = su*   
,/ate & fiscal ye>4  7ii7 ,grace p]iod  
,a ,/ate %all n be consid]$ to h fail$  
to provide paym5t ( its requir$ ,/ate   
%>e = a qu>t] "u subp>agraph 7,a7 if !  
aggregate ,/ate paym5t t[>ds ! ,/ate's  
requir$ ,/ate %>e = ! #d-qu>t] p]iod    
beg9n+ ) su* qu>t] exce$s ! requir$     
,/ate %>e am\nt = su* #d-qu>t] p]iod4   
7,d7 ,f$]al & ,/ate p]c5tages ,9 ?is    
p>agraph1 ) respect to a ,/ate & a      
fiscal ye>3  7i7 ,f$]al p]c5tage ,!     
,f$]al p]c5tage describ$ 9 ?is clause is
 #ge p]c5t or1 if high]1 ! ,f$]al m$ical
 assi/ance p]c5tage = su* ,/ate = su*   
fiscal ye>4  7ii7 ,/ate p]c5tage ,!     

,/ate p]c5tage describ$ 9 ?is clause is 
#ajj p]c5t m9us ! ,f$]al p]c5tage       
describ$ 9 clause 7i74  7,e7 ,rules =   
cr$it+ t[>d ,/ate %>e  7i7 ,g5]al       
limitation to mat*able exp5ditures ,a   
paym5t = exp5ditures %all n be c\nt$    
t[>d ! ,/ate %>e "u subp>agraph 7,a7    
unless ,f$]al paym5ts may be us$ = su*  
exp5ditures consi/5t ) p>agraph         
7#c77;,b74  7ii7 ,fur!r limitations on  
all[able exp5ditures ,a paym5t =        
exp5ditures %all n be c\nt$ t[>ds !     
,/ate %>e "u subp>agraph 7,a7 if !      
exp5diture is = any ( ! foll[+3  7,i7   
,abortion ,exp5ditures = an abortion4   
7,,ii7 ,int]gov]nm5tal transf]s ,an     
exp5diture t is attributable to an      
int]gov]nm5tal transf]4  7,,iii7        
,c]tifi$ public exp5ditures ,an         
exp5diture t is attributable to c]tifi$ 
public exp5ditures4  7iii7 ,cr$it+ fraud
 & abuse recov]ies ,am\nts recov]$ by a 
,/ate ?r\gh ! op]ation ( its ,m$icaid   
fraud & abuse control unit describ$ 9   
section #aijc7q7 %all be fully c\nt$    

t[>d ! ,/ate %>e "u subp>agraph 7,a74   
7,f7 ,con/ruction ,no?+ 9 ! p>agraph    
%all be con/ru$ z prev5t+ a ,/ate f     
exp5d+1 f non-,f$]al funds1 an am\nt "u 
?is title 9 excess ( ! am\nt ( ! ,/ate  
%>e4  7,g7 ,det]m9ation bas$ ^u submitt$
 claims ,9 apply+ ?is p>agraph ) respect
 to exp5ditures ( a ,/ate = a qu>t]1 !  
det]m9ation ( ! exp5ditures = su* ,/ate 
= su* qu>t] %all be made aft] ! end ( ! 
p]iod 7:i*1 z ( ! date ( ! enactm5t (   
?is section1 is #b ye>s7 = :i* !        
,secret>y accepts claims = paym5t "u ?is
 title ) respect to su* qu>t]4  7#c7    
,use ( ,f$]al paym5ts  7,a7 ,application
 ( ,m$icaid limitations ,a ,/ate may    
only use ,f$]al paym5ts receiv$ "u      
subsection 7a7 = exp5ditures = :i*      
,f$]al funds w\ld h be5 payable "u ?is  
title b = ?is section4  7,b7 ,limitation
 = c]ta9 eligibles  7i7 ,application (  
#ajj p]c5t f$]al pov]ty l9e limit on    
eligibility ,subject to clause 7iii71 a 
,/ate may n use su* ,f$]al paym5ts to   
provide m$ical assi/ance = an individual

 :o has an income 7z det]m9$ "u clause  
7ii77 t exce$s #ajj p]c5t ( ! pov]ty l9e
 7z def9$ 9 section #baaj7;c77#e77      
applicable to a family ( ! size involv$4
  7ii7 ,det]m9ation ( income us+ modifi$
 adju/$ gross income )\t any #e p]c5t   
increase ,9 det]m9+ income = purposes ( 
clause 7i7 "u section #aijb7;e77#ad7    
7relat+ to modifi$ adju/$ gross income71
 ! foll[+ rules %all apply3  7,i7       
,application ( sp5d d[n ,! ,/ate %all   
take into acc\nt ! co/s incurr$ = m$ical
 c>e or = any o!r type ( rem$ial c>e    
recogniz$ "u ,/ate law 9 ! same mann] & 
to ! same ext5t t su* ,/ate takes su*   
co/s into acc\nt = purposes ( section   
#aijb7;a77#ag74  7,,ii7 ,disreg>d ( #e  
p]c5t increase ,subp>agraph 7,i7 (      
section #aijb7;e77#ad7 7relat+ to a #e  
p]c5t r$uction7 %all n apply4  7iii7    
,exception ,clause 7i7 %all n apply to  
an individual :o is--  7,i7 a woman     
describ$ 9 clause 7i7 ( section         
#aijc7v77#d77;,a72  7,,ii7 a *ild :o is 
an individual describ$ 9 clause 7i7 (   

section #aije7;a72  7,,iii7 enroll$ 9 a 
,/ate plan "u ?is title z ( ! date ( !  
enactm5t ( ?is section = ! p]iod (      
cont9u\s enrollm5t2 or  7,,iv7 describ$ 
9 section #aijb7;e77#ad77;,d7 7relat+ to
 modifi$ adju/$ gross income74  7iv7    
,cl>ification relat$ to community sp\se 
,no?+ 9 ?is subp>agraph %all sup]s$e !  
application ( section #aibd 7relat$ to  
community sp\se income & assets74  7#d7 
,exceptions = pass-?r\gh paym5ts  7,a7  
,9 g5]al ,p>agraph 7#a7 %all n apply1 & 
am\nts %all cont9ue to be payable "u ?is
 title 7& n "u subsection 7a771 9 ! case
 ( ! foll[+ paym5ts 7& relat$           
adm9i/rative co/s & exp5ditures73  7i7  
,paym5ts to t]ritories ,paym5ts to a    
,/ate o!r ?an ! #ej ,/ates & ! ,di/rict 
( ,columbia4  7ii7 ,m$ic>e co/ %>+      
,paym5ts attributable to ,m$ic>e co/ %>+
 "u section #aije7p74  7iii7 ,p$iatric  
vacc9es ,paym5ts attributable to section
 #aibh4  7iv7 ,em]g5cy s]vices = c]ta9  
individuals ,paym5ts = treatm5t (       
em]g5cy m$ical conditions attributable  

to ! application ( section #aijc7v77#b74
  7v7 ,indian heal? c>e facilities      
,paym5ts = m$ical assi/ance describ$ 9 !
 ?ird s5t5ce ( section #aije7;b74  7vi7 
,employ]-sponsor$ insurance 7,,esi7     
,paym5ts = m$ical assi/ance attributable
 to paym5ts to employ]s =               
employ]-sponsor$ heal? b5efits cov]age4 
7vii7 ,o!r populations ) limit$ b5efit  
cov]age ,o!r paym5ts t are det]m9$ by ! 
,secret>y to be relat$ to a specifi$    
population = :i* ! m$ical assi/ance "u  
?is title is limit$ & does n include any
 inpati5t1 nurs+ facility1 or long-t]m  
c>e s]vices4  7,b7 ,c]ta9 exp5ses       
,p>agraph 7#a7 %all n apply1 & am\nts   
%all cont9ue to be payable "u ?is title 
7& n "u subsection 7a771 9 ! case ( !   
foll[+3  7i7 ,adm9i/ration ( m$ic>e     
prescription drug b5efit ,exp5ditures   
describ$ 9 section #aice7;b7 7relat+ to 
adm9i/ration ( ! ,m$ic>e prescription   
drug b5efit74  7ii7 ,paym5ts = ,,hit    
bonuses ,paym5ts "u section             
#aijc7;a77#c77;,f7 7relat+ to paym5ts to

 enc\rage ! adoption & use ( c]tifi$    
,,ehr te*nology74  7iii7 ,paym5ts =     
design1 developm5t1 & in/allation (     
,,mmis & eligibility sy/ems ,paym5ts "u 
subp>agraphs 7,a77i7 & 7,h77i7 ( section
 #aijc7;a77#c7 = exp5ditures = design1  
developm5t1 & in/allation ( ! ,m$icaid  
managem5t in=mation sy/ems & me*aniz$   
v]ification & in=mation retrieval sy/ems
 7relat$ to eligibility74  7#e7 ,paym5t 
( am\nts  7,a7 ,9 g5]al ,except z !     
,secret>y may o!rwise provide1 am\nts   
%all be payable to a ,/ate "u subsection
 7a7 9 ! same mann] z am\nts are payable
 "u subsection 7d7 ( section #aijc to a 
,/ate "u subsection 7a7 ( su* section4  
7,b7 ,in=mation & =ms  7i7 ,submission  
,z a condition ( receiv+ paym5t "u      
subsection 7a71 a ,/ate %all submit su* 
in=mation1 9 su* =m1 & mann]1 z !       
,secret>y %all specify1 includ+         
in=mation necess>y to make !            
computations "u subsections 7c77#b77;,c7
 & 7e74  7ii7 ,uni=m report+ ,!         
,secret>y %all develop su* =ms z may be 

ne$$ to assure a sy/em ( uni=m report+ (
 su* in=mation across ,/ates4  7,c7     
,requir$ report+ ( in=mation on m$ical  
loss ratios = manag$ c>e ,! in=mation   
requir$ to be report$ "u subp>agraph    
7,b77i7 %all include in=mation on !     
m$ical loss ratio ) respect to cov]age  
provid$ "u ea* ,m$icaid manag$ c>e plan 
) a contract ) ! ,/ate "u section       
#aijc7m7 or #aicb4  7b7 ,aggregate      
b5efici>y-,bas$ am\nt  7#a7 ,9 g5]al ,! 
aggregate b5efici>y-bas$ am\nt specifi$ 
9 ?is subsection = a ,/ate = a qu>t] is 
equal to ! sum ( ! products1 = ea* ( !  
categories ( ,m$icaid b5efici>ies       
specifi$ 9 p>agraph 7#b71 ( ! foll[+3   
7,a7 ,b5efici>y-bas$ qu>t]ly am\nt ,!   
b5efici>y-bas$ qu>t]ly am\nt = su*      
category comput$ "u subsection 7c7 = su*
 ,/ate = su* qu>t]4  7,b7 ,numb] (      
individuals 9 category ,subject to      
subsection 7d71 ! av]age numb] (        
,m$icaid b5efici>ies enroll$ 9 su*      
category 9 ! ,/ate 9 su* qu>t]4  7#b7   
,categories ,! categories specifi$ 9 ?is

 p>agraph are ! foll[+3  7,a7 ,eld]ly ,a
 category ( ,m$icaid b5efici>ies :o are 
#fe ye>s ( age or old]4  7,b7 ,bl9d or  
disabl$ ,a category ( ,m$icaid          
b5efici>ies n describ$ 9 subp>agraph    
7,a7 :o are describ$ 9 section          
#aicg7;a77#b77;,b77ii74  7,c7 ,*ildr5 ,a
 category ( ,m$icaid b5efici>ies n      
describ$ 9 subp>agraph 7,b7 :o are "u   
#ba ye>s ( age4  7,d7 ,o!r adults ,a    
category ( any ,m$icaid b5efici>ies :o  
are n describ$ 9 a previ\s subp>agraph (
 ?is p>agraph4  7c7 ,computation ( p]   
b5efici>y1 p] category qu>t]ly am\nt    
7#a7 ,9 g5]al ,= a ,/ate1 = ea* category
 ( b5efici>y = a qu>t]--  7,a7 ,fir/    
re=m ye> ,= qu>t]s 9 ! fir/ re=m ye> 7z 
def9$ 9 subsection 7k77#b771 !          
b5efici>y-bas$ qu>t]ly am\nt is equal to
 #a_/d ( ! base av]age p] b5efici>y     
,f$]al paym5ts = su* ,/ate = su*        
category det]m9$ "u p>agraph 7#b71      
increas$ by a factor t reflects ! sum ( 
! foll[+3  7i7 ,hi/orical m$ical c>e    
compon5t ( ,,cpi ?r\gh previ\s re=m ye> 

,! p]c5tage increase 9 ! hi/orical      
m$ical c>e compon5t ( ! ,consum] ,price 
,index = all urban consum]s 7,u4,s4 city
 av]age7 f ! midpo9t ( ! base fiscal ye>
 7z def9$ 9 p>agraph 7#f77 to ! midpo9t 
( ! fiscal ye> prec$+ ! fir/ re=m ye>4  
7ii7 ,project$ m$ical c>e compon5t (    
,,cpi = ! fir/ re=m ye> ,! p]c5tage     
increase 9 ! project$ m$ical c>e        
compon5t ( ! ,consum] ,price ,index =   
all urban consum]s 7,u4,s4 city av]age7 
f ! midpo9t ( ! previ\s fiscal ye>      
ref]r$ to 9 clause 7i7 to ! midpo9t ( ! 
fir/ re=m ye>4  7,b7 ,second & ?ird re=m
 ye>s ,! b5efici>y-bas$ qu>t]ly am\nt = 
a ,/ate = a category = qu>t]s 9 ! second
 re=m ye> or ! ?ird re=m ye> is equal to
 ! b5efici>y-bas$ qu>t]ly am\nt "u ?is  
p>agraph = su* ,/ate & category = !     
previ\s re=m ye> increas$ by ! p]       
b5efici>y p]c5tage increase 7z def9$ 9  
subp>agraph 7,e77 = su* category & re=m 
ye>4  7,c7 ,f\r? ?r\gh t5? re=m ye>s ,! 
b5efici>y-bas$ qu>t]ly am\nt = a ,/ate =
 a category = qu>t]s 9 a re=m ye> beg9n+

 ) ! f\r? re=m ye> & end+ ) ! t5? re=m  
ye> is--  7i7 9 ! case ( a ,/ate t is a 
high p] b5efici>y ,/ate or a l[ p]      
b5efici>y ,/ate 7z def9$ 9 p>agraph     
7#d77;,b77iii77 = ! category1 ! am\nt   
det]m9$ "u clause 7i7 or 7ii7 ( p>agraph
 7#d77;,b7 = su* ,/ate1 category1 & re=m
 ye>2 or  7ii7 9 ! case ( any o!r ,/ate1
 ! b5efici>y-bas$ qu>t]ly am\nt "u ?is  
p>agraph = su* ,/ate & category = !     
previ\s re=m ye> increas$ by ! p]       
b5efici>y p]c5tage increase = su*       
category & re=m ye>4  7,d7 ,elev5? re=m 
ye> & subsequ5t re=m ye>s ,!            
b5efici>y-bas$ qu>t]ly am\nt = a ,/ate =
 a category = qu>t]s 9 a re=m ye> beg9n+
 ) ! elev5? re=m ye> is equal to !      
b5efici>y-bas$ qu>t]ly am\nt "u ?is     
p>agraph = su* ,/ate & category = !     
previ\s re=m ye> increas$ by ! p]       
b5efici>y p]c5tage increase = su*       
category & re=m ye>4  7,e7 ,annual      
p]c5tage increase beg9n+ ) second re=m  
ye> ,= purposes ( ?is subsection1 ! t]m 
p] b5efici>y p]c5tage increase means1 = 

a re=m ye>1 ! sum (--  7i7 ! project$   
p]c5tage *ange 9 nom9al gross dome/ic   
product f ! midpo9t ( ! previ\s re=m ye>
 to ! midpo9t ( ! re=m ye> = :i* !      
p]c5tage increase is be+ appli$2 &  7ii7
 "o p]c5tage po9t4  7#b7 ,base p]       
b5efici>y1 p] category am\nt = ea* ,/ate
  7,a7 ,av]age p] category  7i7 ,9 g5]al
 ,! ,secret>y %all det]m9e1 consi/5t )  
?is p>agraph & p>agraph 7#c71 a base p] 
b5efici>y1 p] category am\nt = ea* ( !  
#ej ,/ates & ! ,di/rict ( ,columbia     
equal to ! av]age am\nt1 p] ,m$icaid    
b5efici>y1 ( ,f$]al paym5ts "u ?is      
title1 includ+ paym5ts attributable to  
disproportionate %>e hospital paym5ts "u
 section #aibc1 = ea* ( ! categories (  
b5efici>ies "u subsection 7b77#b7 = !   
base fiscal ye> = ea* ( ! #ej ,/ates & !
 ,di/rict ( ,columbia4  7ii7 ,be/       
available data ,! det]m9ation "u clause 
7i7 %all initially be e/imat$ by !      
,secret>y1 bas$ ^u ! be/ available data 
at ! "t ! det]m9ation is made4  7iii7   
,updates ,! det]m9ation "u clause 7i7   

%all be updat$ by ! ,secret>y on an     
annual basis bas$ ^u improv$ data4 ,!   
,secret>y %all adju/ ! am\nts "u        
subsection 7a77#a77;,a7 to reflect      
*anges 9 ! am\nts s det]m9$ bas$ on su* 
updates4  7,b7 ,exclusion ( pass-?r\gh  
paym5ts ,9 comput+ base p] b5efici>y1 p]
 category am\nts "u subp>agraph 7,a77i7 
! ,secret>y %all exclude paym5ts        
describ$ 9 subsection 7a77#d74  7,c7    
,/&>dization  7i7 ,9 g5]al ,9 comput+   
ea* su* am\nt1 ! ,secret>y %all /&>dize 
! am\nt 9 ord] to remove ! v>iation     
attributable to ! foll[+3  7,i7 ,risk   
factors ,su* risk factors z age1 heal? &
 disability /atus 7includ+ high co/     
m$ical conditions71 g5d]1 in/itutional  
/atus1 & su* o!r factors z ! ,secret>y  
det]m9es to be appropriate1 s z to      
ensure actu>ial equival5ce4  7,,ii7     
,geographic ,v>iations 9 co/s on a      
c\nty-by-c\nty basis4  7ii7 ,me?od (    
/&>dization  7,i7 ,consultation 9       
developm5t ( risk /&>dization ,9        
develop+ ! me?odology = risk /&>dization

 = purposes ( clause 7i77,i71 !         
,secret>y %all consult ) ! ,m$icaid &   
,,*ip ,paym5t & ,access ,commission1 !  
,m$ic>e ,paym5t ,advisory ,commission1 &
 ! ,national ,association ( ,m$icaid    
,directors4  7,,ii7 ,me?od = risk       
/&>dization ,9 c>ry+ out clause 7i77,i71
 ! ,secret>y may apply ! hi]>*al        
condition category me?odology "u section
 #ahec7;a77#a77;,c74 ,if ! ,secret>y    
uses su* me?odology1 ! ,secret>y %all   
adju/ ! application ( su* me?odology to 
take into acc\nt ! diff]5ces 9 s]vices  
provid$ "u ?is title comp>$ to title    
,,xviii1 su* z ! cov]age ( long t]m c>e1
 pregnancy1 & p$iatric s]vices4  7,,iii7
 ,me?od = geographic /&>dization ,!     
,secret>y %all apply ! /&>dization "u   
clause 7i77,,ii7 9 a mann] simil> to t  
appli$ "u section                       
#ahec7;c77#d77;,a77iii74  7iii7         
,application on a national1 budget      
neutral basis ,! /&>dization "u clause  
7i7 %all be design$ & implem5t$ on a    
uni=m national basis & %all be budget   

neutral s z to n result 9 any aggregate 
*ange 9 paym5ts "u subsection 7a74  7iv7
 ,response to new risk ,subject to      
clause 7iii71 ! ,secret>y may adju/ !   
/&>dization "u clause 7i7 to respond    
promptly to new in/ances ( communicable 
diseases & o!r public heal? haz>ds4  7v7
 ,ref]5ce to application ( risk adju/m5t
 ,= rules relat$ to ! application ( risk
 adju/m5t to am\nts "u subsection       
7a77#a77;,a71 see subsection 7e74  7,d7 
,adju/m5t = tempor>y ,,fmap increases ,9
 comput+ ea* base p] b5efici>y1 p]      
category am\nts "u subp>agraph 7,a77i7 !
 ,secret>y %all disreg>d portions (     
paym5ts t are attributable to a tempor>y
 increase 9 ! ,f$]al mat*+ rates1       
includ+ ^? attributable to ! foll[+3    
7i7 ,,ppaca disa/] ,,fmap ,section      
#aije7;aa74  7ii7 ,,arra ,section #ejja 
( ! ,am]ican ,recov]y & ,re9ve/m5t ,act 
( #bjji 7#db ,u4,s4,c4 #acif;d note74   
7iii7 ,extraord9>y employ] p5sion       
contribution ,section #fad ( ! ,*ildr5's
 ,heal? ,insurance ,program             

,reau?orization ,act ( #bjji 7#db       
,u4,s4,c4 #acif;d note74  7#c7          
,allocation ( nonm$ical assi/ance       
paym5ts ,! ,secret>y %all e/abli% rules 
= ! allocation ( paym5ts "u ?is title   
7o!r ?an ^? paym5ts describ$ 9 p>agraph 
7#a7 or 7#e7 ( section #aijc7;a7 &      
includ+ su* paym5ts attributable to     
section #aibc7--  7,a7 among diff]5t    
categories ( b5efici>ies2 &  7,b7 betwe5
 paym5ts includ$ "u subsection 7a77#a7 &
 paym5ts describ$ 9 subsection 7a77#d74 
7#d7 ,transition to a corridor ar\nd !  
national av]age  7,a7 ,det]m9ation (    
national av]age base p] b5efici>y1 p]   
category am\nt ,subject to subp>agraph  
7,c71 ! ,secret>y %all det]m9e a        
national av]age base p] b5efici>y1 p]   
category am\nt equal to ! av]age ( !    
base p] b5efici>y1 p] category am\nts = 
ea* ( ! #ej ,/ates & ! ,di/rict (       
,columbia det]m9$ "u p>agraph 7#b71     
weight$ by ! av]age numb] ( b5efici>ies 
9 ea* su* category & ,/ate z det]m9$ by 
! ,secret>y consi/5t ) subsection 7d7 = 

! base fiscal ye>4  7,b7 ,transition    
adju/m5t  7i7 ,high p] b5efici>y /ates  
,9 ! case ( a high p] b5efici>y ,/ate 7z
 def9$ 9 clause 7iii77,i77 = a category1
 ! b5efici>y-bas$ qu>t]ly am\nt = su*   
,/ate & category = a qu>t] 9 a re=m ye> 
7beg9n+ ) ! f\r? re=m ye> & end+ ) ! t5?
 re=m ye>7 is equal to ! sum (--  7,i7 !
 product ( ! ,/ate-specific factor = su*
 re=m ye> 7z def9$ 9 clause 7iv77 & !   
b5efici>y-bas$ qu>t]ly am\nt t w\ld     
o!rwise be det]m9$ "u p>agraph 7#a7 =   
su* ,/ate & category if ! ,/ate 7 a     
,/ate describ$ 9 clause 7ii7 ( p>agraph 
7#a77;,c71 in/ead ( a ,/ate describ$ 9  
clause 7i7 ( su* p>agraph2 &  7,,ii7 !  
product ( #a m9us ! ,/ate-specific      
factor = su* re=m ye> & ! b5efici>y-bas$
 qu>t]ly am\nt t w\ld o!rwise be det]m9$
 "u p>agraph 7#a7 = a ,/ate & category  
if ! base p] b5efici>y1 p] category     
am\nt det]m9$ "u p>agraph 7#b7 = ! ,/ate
 & category 7 equal to #aaj p]c5t ( !   
national av]age base p] b5efici>y1 p]   
category am\nt det]m9$ "u subp>agraph   

7,a7 = su* category4  7ii7 ,l[ p]       
b5efici>y /ates ,9 ! case ( a l[ p]     
b5efici>y ,/ate 7z def9$ 9 clause       
7iii77,,ii77 = a category1 !            
b5efici>y-bas$ qu>t]ly am\nt = su* ,/ate
 & category = a qu>t] 9 a re=m ye>      
7beg9n+ ) ! f\r? re=m ye> & end+ ) ! t5?
 re=m ye>7 is equal to ! sum (--  7,i7 !
 product ( ! ,/ate-specific factor = su*
 re=m ye> & ! b5efici>y-bas$ qu>t]ly    
am\nt t w\ld o!rwise be det]m9$ "u      
p>agraph 7#a7 = su* ,/ate & category if 
! ,/ate 7 a ,/ate describ$ 9 clause 7ii7
 ( p>agraph 7#a77;,c71 in/ead ( a ,/ate 
describ$ 9 clause 7i7 ( su* p>agraph2 & 
7,,ii7 ! product ( #a m9us !            
,/ate-specific factor = su* re=m ye> & !
 b5efici>y-bas$ qu>t]ly am\nt t w\ld    
o!rwise be det]m9$ "u p>agraph 7#a7 = a 
,/ate & category if ! base p] b5efici>y1
 p] category am\nt det]m9$ "u p>agraph  
7#b7 = ! ,/ate & category 7 equal to #ij
 p]c5t ( ! national av]age base p]      
b5efici>y1 p] category am\nt det]m9$ "u 
subp>agraph 7,a7 = su* category4  7iii7 

,high & l[ p] b5efici>y ,/ates def9$ ,9 
?is subp>agraph3  7,i7 ,high p]         
b5efici>y ,/ate ,! t]m high p] b5efici>y
 ,/ate means1 ) respect to a category1 a
 ,/ate = :i* ! base p] b5efici>y1 p]    
category am\nt det]m9$ "u p>agraph 7#b7 
= su* category is great] ?an #aaj p]c5t 
( ! national av]age base p] b5efici>y1  
p] category am\nt det]m9$ "u subp>agraph
 7,a7 = su* category4  7,,ii7 ,l[ p]    
b5efici>y ,/ate ,! t]m l[ p] b5efici>y  
,/ate means1 ) respect to a category1 a 
,/ate = :i* ! base p] b5efici>y1 p]     
category am\nt det]m9$ "u p>agraph 7#b7 
= su* category is less ?an #ij p]c5t ( !
 national av]age base p] b5efici>y1 p]  
category am\nt det]m9$ "u subp>agraph   
7,a7 = su* category4  7iv7              
,/ate-specific factor ,9 ?is            
subp>agraph1 ! t]m ,/ate-specific factor
 means--  7,i7 = ! f\r? re=m ye>1 #g_/h2
 &  7,,ii7 = a subsequ5t re=m ye>1 !    
,/ate-specific factor "u ?is clause = ! 
previ\s re=m ye> m9us #a_/h4  7,c7 ,no  
additional exp5ditures  7i7 ,det]m9ation

 ( increase 9 ,f$]al exp5ditures ,= ea* 
category = ea* re=m ye> 7beg9n+ ) ! f\r?
 re=m ye> & end+ ) ! t5? re=m ye>71 !   
,secret>y %all det]m9e :e!r !           
application ( ?is p>agraph--  7,i7 to ! 
category = ! re=m ye> w result 9 an     
aggregate increase 9 ! aggregate ,f$]al 
exp5ditures "u subsection 7a72 &  7,,ii7
 to all ! categories = ! re=m ye> w     
result 9 a net aggregate increase 9 !   
aggregate ,f$]al exp5ditures "u         
subsection 7a74  7ii7 ,adju/m5t ,if !   
,secret>y det]m9es "u clause 7i77,,ii7 t
 ! application ( ?is p>agraph to all !  
categories = a re=m ye> w result 9 a net
 aggregate increase 9 ! aggregate ,f$]al
 exp5ditures "u subsection 7a71 !       
,secret>y %all r$uce ! national av]age  
base p] b5efici>y1 p] category am\nt    
comput$ "u subp>agraph 7,a7 = ea* ( !   
categories det]m9$ "u clause 7i77,i7 =  
:i* !re w be an aggregate increase 9 !  
aggregate ,f$]al exp5ditures "u         
subsection 7a7 by su* uni=m p]c5tage z w
 ensure t !re is no net aggregate ,f$]al

 exp5diture increase describ$ 9 clause  
7i77,,ii7 = ! re=m ye>4  7#e7 ,reports  
on p] b5efici>y rates2 appeals  7,a7    
,report to /ates ,n lat] ?an #h mon?s   
aft] ! date ( ! enactm5t ( ?is section1 
! ,secret>y %all submit to ea* ,/ate !  
,secret>y's initial det]m9ation (--  7i7
 ! base p] b5efici>y1 p] category am\nts
 "u p>agraph 7#b7 = su* ,/ate2 &  7ii7 !
 national av]age base p] b5efici>y1 p]  
category am\nts "u p>agraph 7#d77;,a74  
7,b7 ,opportunity to appeal ,n lat] ?an 
#c mon?s aft] ! date a ,/ate receives   
notice ( ! ,secret>y's initial          
det]m9ation ( su* base p] b5efici>y1 p] 
category am\nts = su* ,/ate "u          
subp>agraph 7,a77i71 ! ,/ate may file ) 
! ,secret>y1 9 a =m & mann] specifi$ by 
! ,secret>y1 an appeal ( su*            
det]m9ation4  7,c7 ,det]m9ation on      
appeal ,n lat] ?an #c mon?s aft] receiv+
 su* an appeal1 ! ,secret>y %all make a 
f9al det]m9ation on su* am\nts = su*    
,/ate4 ,if no su* appeal is receiv$ = a 
,/ate1 ! ,secret>y's initial det]m9ation

 "u subp>agraph 7,a77i7 %all become     
f9al4  7#f7 ,base fiscal ye> def9$ ,9   
?is section1 ! t]m base fiscal ye> means
 ! late/ fiscal ye>1 end+ be=e ! date ( 
! enactm5t ( ?is section1 = :i* !       
,secret>y det]m9es t adequate data are  
available to make ! computations requir$
 "u ?is subsection4  7d7 ,n c\nt+       
individuals ,to acc\nt = exclud$ paym5ts
 ,"u rules specifi$ by ! ,secret>y1     
individuals %all n be c\nt$ z ,m$icaid  
b5efici>ies = purposes ( subsection     
7b77#a77;,b7 & subsection 7c77#b77;,a7 9
 proportion to ! ext5t t su* individuals
 are receiv+ m$ical assi/ance = :i*     
paym5ts describ$ "u subsection          
7a77#d77;,a7 are made4  7e7 ,risk       
,adju/m5t  7#a7 ,9 g5]al ,! am\nt "u    
subsection 7a77#a77;,a7 %all be adju/$  
"u ?is subsection 9 an appropriate      
mann]1 specifi$ by ! ,secret>y &        
consi/5t ) p>agraph 7#b71 to take into  
acc\nt--  7,a7 ! factors describ$ 9     
subsection 7c77#b77;,c77i77,i7 )9 a     
category ( b5efici>ies2 &  7,b7         

v>iations 9 co/s on a c\nty-by-c\nty    
basis = m$ical assi/ance & adm9i/rative 
exp5ses4  7#b7 ,me?od ( adju/m5t  7,a7  
,9 g5]al ,! adju/m5ts "u p>agraph 7#a7  
%all be made 9 a mann] simil> to ! mann]
 9 :i* simil> adju/m5ts are made "u     
subsection 7c77#b77;,c7 & consi/5t ) !  
requirem5ts ( clause 7iii7 ( su*        
subsection & subp>agraph 7,b74  7,b7    
,biannual update ( risk adju/m5t        
me?odology ,9 apply+ clause 7i77,i7 (   
subsection 7c77#b77;,c7 = purposes (    
subp>agraph 7,a71 ! ,secret>y %all1 9   
consultation ) ! entities describ$ 9    
clause 7ii77,i7 ( su* subsection1 update
 ! risk adju/m5t me?odology appli$ z    
appropriate n less (t5 ?an e #b ye>s4   
7f7 ,*ronic c>e quality bonus paym5ts   
7#a7 ,det]m9ation ( bonus paym5ts ,if ! 
,secret>y det]m9es t1 bas$ on ! reports 
"u p>agraph 7#e71 ) respect to          
categories ( *ronic disease = :i* *ronic
 c>e p]=mance t>gets _h be5 e/abli%$ "u 
p>agraph 7#c7 = ea* category ( ,m$icaid 
b5efici>ies specifi$ "u subsection      

7b77#b7 su* t>gets h be5 met by a ,/ate 
= a re=m ye>1 ! ,secret>y %all make an  
additional paym5t to su* ,/ate 9 ! am\nt
 specifi$ 9 p>agraph 7#f7 = ea* qu>t] 9 
! succe$+ re=m ye>4 ,su* paym5ts %all be
 made 9 a mann] specifi$ by ! ,secret>y 
& may only be us$ consi/5t ) subsection 
7a77#c74  7#b7 ,id5tification (         
categories ( *ronic disease ,! ,secret>y
 %all det]m9e ! categories ( *ronic     
disease = :i* bonus paym5ts may be      
available "u ?is subsection = ea*       
category ( ,m$icaid b5efici>ies4  7#c7  
,adoption ( quality measurem5t sy/em &  
id5tification ( p]=mance t>gets  7,a7   
,sy/em & data ,) respect to ! categories
 ( *ronic disease "u p>agraph 7#b71 !   
,secret>y %all adopt a quality          
measurem5t sy/em t uses data describ$ 9 
p>agraph 7#d7 & is simil> to ! ,five-,/>
 ,quality ,rat+ ,sy/em us$ to indicate !
 p]=mance ( ,m$ic>e ,advantage plans "u 
"p ,c ( title ,,xviii4  7,b7 ,t>gets    
,us+ su* sy/em & data1 ! ,secret>y %all 
e/abli% = ea* re=m ye> ! *ronic c>e     

p]=mance t>gets = purposes ( ! paym5ts  
"u p>agraph 7#a74 ,su* p]=mance t>gets  
%all be e/abli%$ 9 consultation )       
,/ates1 associations repres5t+          
individuals ) *ronic illnesses1 entities
 provid+ treatm5t to su* individuals =  
su* *ronic illnesses1 & o!r /akehold]s1 
includ+ ! ,national ,association (      
,m$icaid ,directors & ! ,national       
,gov]nors ,association4  7#d7 ,data to  
be us$ ,! data to be us$ "u p>agraph    
7#c7 %all include--  7,a7 data collect$ 
?r\gh me?ods su* z--  7i7 ! ,heal?c>e   
,effectiv5ess ,data & ,in=mation ,set   
7also kn[n z ,,h$is7 7or an appropriate 
successor p]=mance measurem5t tool72    
7ii7 ! ,consum] ,assessm5t ( ,heal?c>e  
,provid]s & ,sy/ems 7also kn[n z        
,,cahps7 7or an appropriate successor   
p]=mance measurem5t tool72 &  7iii7 !   
,heal? ,outcomes ,survey 7also kn[n z   
,,hos7 7or an appropriate successor     
p]=mance measurem5t tool72 &  7,b7 o!r  
data collect$ by ! ,/ate4  7#e7 ,reports
  7,a7 ,9 g5]al ,ea* ,/ate %all collect1

 analyze1 & report to ! ,secret>y1 at a 
frequ5cy & 9 a mann] to be e/abli%$ by !
 ,secret>y1 data describ$ 9 p>agraph    
7#d7 t p]mit ! ,secret>y to monitor !   
,/ate's p]=mance relative to ! *ronic   
c>e p]=mance t>gets e/abli%$ "u p>agraph
 7#c74  7,b7 ,review & v]ification ,!   
,secret>y may review ! data collect$ by 
! ,/ate "u subp>agraph 7,a7 to v]ify !  
,/ate's analysis ( su* data ) respect to
 ! p]=mance t>gets "u p>agraph 7#c74    
7#f7 ,am\nt ( bonus paym5ts  7,a7 ,9    
g5]al ,subject to subp>agraphs 7,b7 &   
7,c71 ) respect to ea* category (       
,m$icaid b5efici>ies1 9 ! case ( a ,/ate
 t ! ,secret>y det]m9es1 bas$ on !      
*ronic c>e p]=mance t>gets set "u       
p>agraph 7#c7 = a re=m ye> = su*        
category1 p]=ms--  7i7 9 ! top five     
,/ates 9 su* category1 subject to       
subp>agraph 7,c77ii71 ! am\nt ( ! bonus 
= ea* qu>t] 9 ! succe$+ re=m ye> %all be
 #aj p]c5t ( ! paym5t am\nt o!rwise paid
 to ! ,/ate "u subsection 7a7 =         
individuals enroll$ "u ! plan )9 su*    

category2  7ii7 9 ! next five ,/ates 9  
su* category1 subject to subp>agraph    
7,c77ii71 ! am\nt ( ! bonus = ea* su*   
qu>t] %all be #e p]c5t ( ! paym5t am\nt 
o!rwise paid to ! ,/ate "u subsection   
7a7 = individuals enroll$ "u ! plan )9  
su* category2  7iii7 9 ! next five      
,/ates 9 su* category1 subject to       
clauses 7i7 & 7iii7 ( subp>agraph 7,c71 
! am\nt ( ! bonus = ea* su* qu>t] %all  
be #c p]c5t ( ! paym5t am\nt o!rwise    
paid to ! ,/ate "u subsection 7a7 =     
individuals enroll$ "u ! plan )9 su*    
category2  7iv7 9 ! next five ,/ates 9  
su* category1 subject to clauses 7i7 &  
7iii7 ( subp>agraph 7,c71 ! am\nt ( !   
bonus = ea* su* qu>t] %all be #b p]c5t (
 ! paym5t am\nt o!rwise paid to ! ,/ate 
"u subsection 7a7 = individuals enroll$ 
"u ! plan )9 su* category2 &  7v7 9 !   
next five ,/ates 9 su* category1 subject
 to clauses 7i7 & 7iii7 ( subp>agraph   
7,c71 ! am\nt ( ! bonus = ea* su* qu>t] 
%all be #a p]c5t ( ! paym5t am\nt       
o!rwise paid to ! ,/ate "u subsection   

7a7 = individuals enroll$ "u ! plan )9  
su* category4  7,b7 ,aggregate annual   
limit = ea* category ( ,m$icaid         
b5efici>ies  7i7 ,9 g5]al ,9 no case may
 ! aggregate am\nt ( bonuses "u ?is     
subsection = qu>t]s 9 a re=m ye> = a    
category ( ,m$icaid b5efici>ies exce$ ! 
limit specifi$ 9 clause 7ii7 = ! re=m   
ye>4  7ii7 ,limit ,! limit specifi$ 9   
?is clause--  7,i7 = ! second re=m ye>  
is equal to #bej1jjj1jjj2 or  7,,ii7 = a
 subsequ5t re=m ye> is equal to ! limit 
specifi$ 9 ?is clause = ! previ\s re=m  
ye> increas$ by ! p] b5efici>y p]c5tage 
increase det]m9$ "u p>agraph 7#a77;,e7 (
 subsection 7c74  7,c7 ,limitation &    
proration ( bonuses bas$ on application 
( aggregate limit  7i7 ,no bonus = ?ird 
or subsequ5t ti]s unless aggregate limit
 n rea*$ on fir/ two ti]s ,no bonus %all
 be payable "u clause 7iii71 7iv71 or   
7v7 ( subp>agraph 7,a7 = a category (   
,m$icaid b5efici>ies = a qu>t] 9 a re=m 
ye> unless ! aggregate am\nt ( bonuses  
"u clauses 7i7 & 7ii7 ( su* subp>agraph 

= su* category & re=m ye> is less ?an ! 
limit specifi$ 9 subp>agraph 7,b77ii7 = 
! re=m ye>4  7ii7 ,proration = fir/ two 
ti]s ,if ! aggregate am\nt ( bonuses "u 
clauses 7i7 & 7ii7 ( subp>agraph 7,a7 = 
a category ( ,m$icaid b5efici>ies =     
qu>t]s 9 a re=m ye> exce$s ! limit      
specifi$ 9 subp>agraph 7,b77ii7 = ! re=m
 ye>1 ! am\nt ( ea* su* bonus %all be   
prorat$ 9 a mann] s ! aggregate am\nt ( 
su* bonuses is equal to su* limit4      
7iii7 ,proration = next ?ree ti]s ,if ! 
aggregate am\nt ( bonuses "u clauses 7i7
 & 7ii7 ( subp>agraph 7,a7 = a category 
( ,m$icaid b5efici>ies = qu>t]s 9 a re=m
 ye> is less ?an ! limit specifi$ 9     
subp>agraph 7,b77ii7 = ! re=m ye>1 b !  
aggregate am\nt ( bonuses "u clauses 7i7
 ?r\gh 7v7 ( subp>agraph 7,a7 = !       
category & su* qu>t]s 9 ! re=m ye>      
exce$s ! limit specifi$ 9 subp>agraph   
7,b77ii7 = ! re=m ye>1 ! am\nt ( ea*    
bonus 9 clauses 7iii71 7iv71 & 7v7 (    
subp>agraph 7,a7 %all be prorat$ 9 a    
mann] s ! aggregate am\nt ( all !       

bonuses "u subp>agraph 7,a7 is equal to 
su* limit4  7g7 ,/ate option = receiv+  
,m$ic>e paym5ts = full-,b5efit dual     
eligible individuals  7#a7 ,9 g5]al ,"u 
?is subsection a ,/ate may elect =      
qu>t]s beg9n+ on or aft] ! implem5tation
 date 9 a re=m ye> to receive paym5t f !
 ,secret>y "u p>agraph 7#c74 ,z a       
condition ( receiv+ su* paym5t1 ! ,/ate 
%all agree to provide to full-b5efit    
dual eligible individuals eligible =    
m$ical assi/ance "u ! ,/ate plan--  7,a7
 ! m$ical assi/ance to :i* su* eligible 
individuals w\ld o!rwise be entitl$ "u  
?is title2 &  7,b7 any items & s]vices  
:i* su* eligible individuals w\ld       
o!rwise receive "u title ,,xviii4  7#b7 
,provid] paym5t requirem5t  7,a7 ,9     
g5]al ,a ,/ate elect+ ! option "u ?is   
subsection %all provide paym5t to heal? 
c>e provid]s = ! items & s]vices        
describ$ "u p>agraph 7#a77;,b7 at a rate
 t is n less ?an ! rate at :i* paym5ts  
w\ld be made to su* provid]s = su* items
 & s]vices "u title ,,xviii4  7,b7      

,flexibility 9 paym5t me?ods ,no?+ 9    
subp>agraph 7,a7 %all be con/ru$ z      
prev5t+ a ,/ate f us+ alt]native paym5t 
me?odologies 7su* z bundl$ paym5ts or ! 
use ( acc\ntable c>e organizations 7z   
su* t]m is us$ 9 section #ahii77 =      
purposes ( mak+ paym5ts to heal? c>e    
provid]s = items & s]vices provid$ to   
dual eligible individuals 9 ! ,/ate "u !
 option "u ?is subsection4  7#c7        
,paym5ts to ,/ates 9 lieu ( ,m$ic>e     
paym5ts ,) respect to a full-b5efit dual
 eligible individual1 9 ! case ( a ,/ate
 t elects ! option "u p>agraph 7#a7 =   
qu>t]s 9 a re=m ye>--  7,a7 ! ,secret>y 
%all n make any paym5t "u title ,,xviii 
= items & s]vices furni%$ to su*        
individual = su* qu>t]s2 &  7,b7 !      
,secret>y %all pay to ! ,/ate1 9        
addition to ! am\nts paid to su* ,/ate  
"u subsection 7a71 ! am\nt t ! ,secret>y
 w\ld1 b = ?is subsection1 o!rwise pay  
"u title ,,xviii = items & s]vices      
furni%$ to su* an individual 9 su* ,/ate
 = su* qu>t]s4  7#d7 ,full-b5efit dual  

eligible individual def9$ ,9 ?is        
subsection1 ! t]m full-b5efit dual      
eligible individual means an individual 
:o meets ! requirem5ts ( section        
#aice7;c77#f77;,a77ii74  7h7 ,audits ,! 
,secret>y %all conduct su* audits on !  
numb] & classification ( ,m$icaid       
b5efici>ies "u su* subsections &        
exp5ditures "u ?is section z may be     
necess>y to ensure appropriate paym5ts  
"u ?is section4  7i7 ,treatm5t ( waiv]s 
7#a7 ,no impact on curr5t waiv]s ,9 !   
case ( a waiv] ( requirem5ts ( ?is title
 pursuant to section #aaae or o!r law t 
is 9 effect z ( ! date ( ! enactm5t (   
?is section1 no?+ 9 ?is section %all be 
con/ru$ to affect su* waiv] = ! p]iod ( 
! waiv] z approv$ z ( su* date4  7#b7   
,application ( budget neutrality to     
subsequ5t waiv]s & r5ewals tak+ section 
into acc\nt ,9 ! case ( a waiv] (       
requirem5ts ( ?is title pursuant to     
section #aaae or o!r law t is approv$ or
 r5ew$ aft] ! date ( ! enactm5t ( ?is   
section1 to ! ext5t t su* approval or   

r5ewal is condition$ ^u a demon/ration (
 budget neutrality1 budget neutrality   
%all be det]m9$ tak+ into acc\nt !      
application ( ?is section4  7j7 ,report 
to ,congress ,n lat] ?an ,janu>y #a ( ! 
second re=m ye>1 ! ,secret>y %all submit
 to ,congress a report on !             
implem5tation ( ?is section4  7k7       
,def9itions ,9 ?is section3  7#a7       
,implem5tation date ,! t]m implem5tation
 date means--  7,a7 ,july #a1 #bjae1 if 
?is section is enact$ on or be=e ,july  
#a1 #bjad2 or  7,b7 ,july #a1 #bjaf1 if 
?is section is enact$ aft] ,july #a1    
#bjad4  7#b7 ,re=m ye>s  7,a7 ,! t]m    
re=m ye> means a fiscal ye> beg9n+ ) !  
fir/ re=m ye>4  7,b7 ,! t]m fir/ re=m   
ye> means ! fiscal ye> 9 :i* !          
implem5tation date occurs4  7,c7 ,! t]ms
 second1 ?ird1 & successive simil> t]ms 
mean1 ) respect to a re=m ye>1 ! second1
 ?ird1 or successive re=m ye>1          
respectively1 succe$+ ! fir/ re=m ye>4  
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