,,ii  #aag? ,,congress  #a/ ,session    
,s4 #bjba  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,june #aj1 #bjba,mr4   
,rubio introduc$ ! foll[+ bill2 :i* 0   
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to am5d title ,,xix
 ( ! ,social ,security ,act to e/abli% a
 me?odology = det]m9+ ,/ate allotm5ts = 
,m$icaid disproportionate %>e hospital  
paym5ts t is bas$ on ,/ate pov]ty       
levels1 to require ,/ates to prioritize 
disproportionate %>e hospital paym5ts on
 ! basis ( ,m$icaid inpati5t utilization
 & l[-income utilization rates1 & = o!r 
purposes4  #a4 ,%ort title ,?is ,act may
 be cit$ z ! ,/ate ,acc\ntability1      
,flexibility1 & ,equity = ,hospitals    
,act ( #bjba or ! ,,safe ,hospitals ,act
 ( #bjba4  #b4 ,det]m9ation ( ,/ate ,,d%
 allotm5ts bas$ on ,/ate pov]ty levels  
,section #aibc7;f7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acifr-#d7;f77 is  
am5d$-- 7#a7 9 p>agraph 7#c7-- 7,a7 9 ! 
p>agraph head+1 by /rik+ ye> #bjjc &    
!reaft] & ins]t+ ye>s #bjjc ?r\gh #bjbc2

  7,b7 9 subp>agraph 7,a7-- 7i7 by /rik+
 1 7#g71 & 7#h7 & ins]t+ & 7#g72 &  7ii7
 by ins]t+ ?r\gh fiscal ye> #bjbc aft]  
ea* succe$+ fiscal ye>2  7,c7 9         
subp>agraph 7,c77ii71 by ins]t+ ?r\gh   
fiscal ye> #bjbc aft] ea* succe$+ fiscal
 ye>2 &  7,d7 9 subp>agraph             
7,e77i77,,iii71 by ins]t+ or p>agraph   
7#g71 z applicable1 aft] ?is p>agraph2  
7#b7 9 p>agraph 7#d77;,c71 by ins]t+ or 
p>agraph 7#g71 z applicable1 aft]       
p>agraph 7#c72  7#c7 9 p>agraph         
7#e77;,b7-- 7,a7 9 ! subp>agraph head+1 
by /rik+ & subsequ5t fiscal ye>s &      
ins]t+ ?r\gh fiscal ye> #bjbc2 &  7,b7 9
 clause 7iii71 by ins]t+ ?r\gh fiscal   
ye> #bjbc aft] any subsequ5t fiscal ye>2
  7#d7 9 p>agraph 7#f7-- 7,a7 9 clause  
7vi7 ( subp>agraph 7,a7-- 7i7 9 ! clause
 head+1 by /rik+ #bjbe & ins]t+ #bjbc2 &
  7ii7 by /rik+ fiscal ye> #bjbe &      
ins]t+ fiscal ye> #bjbc2 &  7,b7 9      
clause 7iii7 ( subp>agraph 7,b7-- 7i7 9 
! clause head+1 by ins]t+ ?r\gh fiscal  
ye> #bjbc aft] succe$+ fiscal ye>s2 &   

7ii7 9 subclause 7,,ii7-- 7,i7 9 !      
subclause head+1 by ins]t+ ?r\gh fiscal 
ye> #bjbc aft] succe$+ fiscal ye>s2 &   
7,,ii7 by ins]t+ ?r\gh fiscal ye> #bjbc 
aft] ea* fiscal ye> !reaft]2  7#e7 by   
/rik+ p>agraphs 7#g7 & 7#h7 & ins]t+ !  
foll[+3  7#g7 ,/ate ,,d% allotm5ts =    
fiscal ye>s aft] fiscal ye> #bjbc  7,a7 
,9 g5]al ,subject to subp>agraphs 7,b71 
7,c71 & 7,d71 beg9n+ ) fiscal ye> #bjbd1
 ! ,,d% allotm5t = a ,/ate & fiscal ye> 
%all be ! am\nt equal to ! product (--  
7i7 ! ,/ate pov]ty ratio 7z det]m9$ "u  
subp>agraph 7,e77ii77 = ! ,/ate & fiscal
 ye>2 &  7ii7 ! ,,d% allotm5t cap 7z    
det]m9$ "u subp>agraph 7,e77i77 = !     
fiscal ye>4  7,b7 ,phase-9 ( pov]ty-bas$
 =mula  7i7 ,9 g5]al ,dur+ ! p]iod (    
fiscal ye>s describ$ 9 clause 7ii71 !   
,secret>y %all phase 9 ! application ( !
 det]m9ation ( ,,d% allotm5ts "u        
subp>agraph 7,a7 9 a mann] t ensures t--
 7,i7 9 no case is ! ,,d% allotm5t = a  
,/ate = a fiscal ye> dur+ su* p]iod less
 ?an #ij p]c5t ( ! ,,d% allotm5t = !    

,/ate = ! previ\s fiscal ye> 7)\t reg>d 
to :e!r ! ,/ate us$ ! full am\nt ( !    
,,d% allotm5t = ! previ\s fiscal ye>72 &
  7,,ii7 ! total am\nt ( ,,d% allotm5ts 
made to all ,/ates = any fiscal ye> dur+
 su* p]iod does n exce$ ! ,,d% allotm5t 
cap det]m9$ = ! fiscal ye> "u           
subp>agraph 7,e77i74  7ii7 ,phase-9     
p]iod ,! p]iod ( fiscal ye>s describ$ 9 
?is clause is ! p]iod t beg9s ) fiscal  
ye> #bjbd & ends )-- 7,i7 fiscal ye>    
#bjcc2 or  7,,ii7 at ! ,secret>y's      
discretion1 any ( fiscal ye>s #bjcd     
?r\gh #bjch4  7iii7 ,developm5t (       
me?odology ,! ,secret>y %all promulgate 
f9al regulations t e/abli% ! me?odology 
= det]m9+ ,/ate ,,d% allotm5ts "u clause
 7i7 n lat] ?an ,janu>y #a1 #bjbc4  7,c7
 ,/ate allotm5t flexibility option  7i7 
,9 g5]al ,a ,/ate may elect to increase 
or r$uce ! am\nt ( ! ,,d% allotm5t = !  
,/ate & a fiscal ye> 7z o!rwise det]m9$ 
"u ?is p>agraph7 = ! purpose ( provid+  
c]ta9ty or m consi/5t ,,d% fund+ 9      
subsequ5t fiscal ye>s 9 accordance ) ?is

 subp>agraph4  7ii7 ,/ate option to     
res]ve allotm5t am\nts ,= any fiscal ye>
 aft] fiscal ye> #bjbc1 a ,/ate may     
reque/ t ! ,,d% allotm5t = ! ,/ate &    
fiscal ye> 7z o!rwise det]m9$ "u ?is    
p>agraph7 be r$uc$ by an am\nt t %all n 
exce$ #aj p]c5t ( ! am\nt ( ! allotm5t z
 s det]m9$4  7iii7 ,/ate option to      
increase ,,d% allotm5t f allotm5t res]ve
 ,= any fiscal ye> aft] fiscal ye>      
#bjbd1 a ,/ate may reque/ t ! ,,d%      
allotm5t = ! ,/ate & fiscal ye> 7z      
o!rwise det]m9$ "u ?is p>agraph7 be     
increas$ by an am\nt t %all n exce$ !   
,,d% res]ve am\nt = ! ,/ate & fiscal    
ye>4  7iv7 ,,d% res]ve am\nt  7,i7 ,9   
g5]al ,subject to subclause 7,,ii71 !   
,,d% res]ve am\nt = a ,/ate & fiscal ye>
 %all be equal to ! sum ( ! am\nts1 if  
any1 ( any r$uctions to ! ,/ate's ,,d%  
allotm5t 7z o!rwise det]m9$ "u ?is      
p>agraph7 made 9 ea* ( ! prec$+ #e      
fiscal ye>s pursuant to a reque/ "u     
clause 7ii74  7,,ii7 ,subtraction (     
increases f ,,d% res]ve am\nt ,! am\nt (

 any increase to a ,/ate's ,,d% allotm5t
 = a fiscal ye> made pursuant to a      
reque/ "u clause 7iii7 %all be subtract$
 f ! ,/ate's ,,d% res]ve am\nt = su* ye>
 & %all n be available to ! ,/ate 9     
subsequ5t fiscal ye>s4  7,,iii7 ,rule ( 
application ,9 ! case ( an increase to a
 ,/ate's ,,d% allotm5t = a fiscal ye> t 
is less ?an ! ,/ate's ,,d% res]ve am\nt 
= su* ye>1 ! ,secret>y %all apply       
subclause 7,,ii7 9 a mann] t maximizes !
 ,,d% res]ve am\nt t w rema9 available  
to ! ,/ate 9 subsequ5t fiscal ye>s4  7v7
 ,disreg>d ( adju/m5ts ,any increase or 
r$uction "u ?is subp>agraph to ! ,,d%   
allotm5t ( a ,/ate = a fiscal ye> %all  
be disreg>d$ :5 o!rwise det]m9+ ,/ate   
,,d% allotm5ts "u ?is p>agraph4  7,d7   
,treatm5t ( waiv]s  7i7 ,9 g5]al        
,subject to clause 7ii71 ) respect to a 
,/ate & a fiscal ye>1 if ! ,/ate has 9  
effect on ! date ( enactm5t ( ! ,,safe  
,hospitals ,act ( #bjba a /atewide waiv]
 ( requirem5ts ( ?is title "u section   
#aaae or o!r law & any "p ( ! fiscal ye>

 occurs dur+ ! p]iod ( ! waiv] 7z       
approv$ z ( su* date71 ! ,,d% allotm5t  
det]m9$ "u ?is p>agraph = su* ,/ate &   
fiscal ye> %all n be less ?an ! ,,d%    
allotm5t t w\ld h be5 det]m9$ = su*     
,/ate & fiscal ye> "u ?is section z 9   
effect on ! day be=e ! date ( enactm5t (
 ! ,,safe ,hospitals ,act ( #bjba1      
r$uc$1 9 ! case ( ea* ( fiscal ye>s     
#bjbd ?r\gh #bjbg1 by ! am\nt ( !       
,/ate's %>e ( ! r$uctions :i* w\ld h be5
 applicable = ! fiscal ye> "u p>agraph  
7#g7 ( ?is subsection 7z s 9 effect71 z 
e/imat$ by ! ,secret>y4  7ii7 ,total    
allotm5ts n to exce$ ,,d% allotm5t cap  
,! ,secret>y %all apply ?is subp>agraph 
9 su* a mann] t ! total am\nt ( ,,d%    
allotm5ts det]m9$ = all ,/ates = a      
fiscal ye> "u ?is p>agraph does n exce$ 
,,d% allotm5t cap det]m9$ = ! fiscal ye>
 "u subp>agraph 7,e77i74  7iii7         
,nonapplication ,clause 7i7 %all n      
apply-- 7,i7 ) respect to a ,/ate t has 
9 effect a waiv] describ$ 9 su* clause  
if ! ,/ate elects1 ?r\gh a revision (   

su* waiv]1 t su* clause w n apply2 or   
7,,ii7 ) respect to any "p ( a fiscal   
ye> t occurs aft] ! expiration 7det]m9$ 
)\t reg>d to any ext5sion approv$ aft] !
 date ( ! enactm5t ( ! ,/ate            
,acc\ntability1 ,flexibility1 & ,equity 
= ,hospitals ,act ( #bjba7 ( su* a      
waiv]4  7iv7 ,no effect on waiv]        
au?ority ,no?+ 9 ?is subsection %all be 
con/ru$ z prev5t+ ! ,secret>y f approv+ 
a waiv] "u section #aaae or o!r law )   
respect to requirem5ts "u ?is title     
relat$ to a ,/ate's use ( its ,,d%      
allotm5t = a fiscal ye>4  7,e7          
,def9itions ,9 ?is p>agraph3 7i7 ,,d%   
allotm5t cap ,! t]m ,,d% allotm5t cap   
means1 ) respect to a fiscal ye>1 !     
am\nt equal to ! total am\nt ( ! ,,d%   
allotm5ts t w\ld h be5 det]m9$ = all    
,/ates = ! fiscal ye> "u ?is section z 9
 effect on ! day be=e ! date ( enactm5t 
( ! ,,safe ,hospitals ,act ( #bjba1     
r$uc$1 9 ! case ( fiscal ye>s #bjbd     
?r\gh #bjbg1 by ! aggregate am\nt ( !   
r$uctions :i* w\ld h be5 applicable = ! 

fiscal ye> "u p>agraph 7#g7 ( ?is       
subsection 7z s 9 effect74  7ii7 ,/ate  
pov]ty ratio ,! t]m ,/ate pov]ty ratio  
means1 ) respect to a ,/ate & fiscal    
ye>1 ! ratio (-- 7,i7 ! numb] (         
individuals 9 ! ,/ate 9 ! mo/ rec5t     
fiscal ye> = :i* c5sus data are         
available ^: income 7z det]m9$ "u       
section #aijb7;e77#ad7 7relat+ to       
modifi$ adju/$ gross income7 & )\t reg>d
 to :e!r an individual's income         
eligibility = m$ical assi/ance is       
det]m9$ "u su* section7 0 less ?an #ajj 
p]c5t ( ! pov]ty l9e 7z def9$ 9 section 
#baaj7;c77#e77 applicable to a family ( 
! size involv$2 to  7,,ii7 ! numb] (    
individuals 9 all ,/ates 9 ! mo/ rec5t  
fiscal ye> = :i* c5sus data are         
available ^: income 7z s det]m9$7 0 less
 ?an #ajj p]c5t ( ! pov]ty l9e 7z s     
def9$7 applicable to ! family ( ! size  
involv$4  2 &  7#f7 by r$esignat+       
p>agraph 7#i7 z p>agraph 7#h74  #c4     
,prioritiz+ disproportionate %>e        
hospital paym5ts bas$ on ,m$icaid       

inpati5t utilization & l[-income        
utilization rates  7a7 ,9 g5]al ,section
 #aibc ( ! ,social ,security ,act 7#db  
,u4,s4,c4 #acifr-#d7 is am5d$-- 7#a7 9  
subsection 7a77#b77;,d71 by ins]t+ 7:i*1
 z ( ,octob] #a1 #bjbc1 %all meet !     
requirem5ts ( subsection 7k77 aft]      
me?odology2  7#b7 9 subsection 7c71 by  
/rik+ & 7g7 & ins]t+ 1 7g71 &1 beg9n+ on
 ,octob] #a1 #bjba1 7k72  7#c7 9        
subsection 7d77#b77;,a7-- 7,a7 9 clause 
7i71 by /rik+ 2 or & ins]t+ a semicolon2
  7,b7 9 clause 7ii71 by /rik+ ! p]iod  
at ! end & ins]t+ 2 or2 &  7,c7 by add+ 
at ! end ! foll[+ new clause3  7iii7 t  
is an in/itution = m5tal diseases4  2 & 
7#d7 by add+ at ! end ! foll[+ new      
subsection3  7k7 ,/ate me?odology       
requirem5ts  7#a7 ,9 g5]al ,subject to  
p>agraph 7#d71 a ,/ate me?odology =     
id5tify+ & mak+ paym5ts to              
disproportionate %>e hospitals meets !  
requirem5ts ( ?is subsection if-- 7,a7 !
 me?odology is uni=mly appli$ /atewide2 
7,b7 ! me?odology id5tifies ea* hospital

 9 ! ,/ate t is describ$ 9 a            
disproportionate %>e hospital ti] 7z    
def9$ 9 p>agraph 7#b772 &  7,c7 9 mak+  
paym5ts to disproportionate %>e         
hospitals1 ! me?odology meets !         
requirem5ts ( p>agraph 7#c74  7#b7      
,disproportionate %>e hospital ti]s ,!  
t]m disproportionate %>e hospital ti]   
means ea* ( ! foll[+3 7,a7 ,ti] #a      
hospitals ,a category ( hospitals       
7ref]r$ to 9 ?is section z ti] #a       
hospitals7 9 :i* ea* hospital           
satisfies-- 7i7 ea* ( ! crit]ia describ$
 9 clause 7ii7 ( subp>agraph 7,b72 &    
7ii7 "o or m ( ! foll[+ crit]ia3 7,i7 ,!
 hospital has a ,m$icaid inpati5t       
utilization rate 7z def9$ 9 subsection  
7b77#b77 t is n less ?an #b /&>d        
deviations above ! mean ,m$icaid        
inpati5t utilization rate = hospitals   
receiv+ ,m$icaid paym5ts 9 ! ,/ate4     
7,,ii7 ,! hospital has a l[-income      
utilization rate 7z def9$ 9 subsection  
7b77#c77 ( n less ?an #dj p]c5t4        
7,,iii7 ,m ?an #gj p]c5t ( ! inpati5t   

days = :i* paym5ts are receiv$ by !     
hospital are paid = "u ! ,m$ic>e program
 "u title ,,xviii1 ! ,m$icaid program "u
 ?is title1 or ! ,*ildr5's ,heal?       
,insurance ,program "u title ,,xxi4     
7,b7 ,ti] #b hospitals ,a category (    
hospitals 7ref]r$ to 9 ?is section z ti]
 #b hospitals7 9 :i* ea* hospital-- 7i7 
is n describ$ 9 ! previ\s subp>agraph2 &
  7ii7 satisfies "o or m ( ! foll[+     
crit]ia3 7,i7 ,! hospital has a ,m$icaid
 inpati5t utilization rate 7z def9$ 9   
subsection 7b77#b77 t is n less ?an #a4e
 /&>d deviations above ! mean ,m$icaid  
inpati5t utilization rate = hospitals   
receiv+ ,m$icaid paym5ts 9 ! ,/ate4     
7,,ii7 ,! hospital has a l[-income      
utilization rate 7z def9$ 9 subsection  
7b77#c77 ( n less ?an #ce p]c5t4        
7,,iii7 ,! hospital has ! l>ge/ numb] ( 
inpati5t days attributable to           
individuals entitl$ to b5efits "u !     
,/ate plan ( any hospital 9 su* ,/ate = 
! previ\s ,/ate fiscal ye>4  7,c7 ,ti]  
#c hospitals ,a category ( hospitals    

7ref]r$ to 9 ?is section z ti] #c       
hospitals7 9 :i* ea* hospital-- 7i7 is n
 describ$ 9 a previ\s subp>agraph2 &    
7ii7 satisfies "o or m ( ! foll[+       
crit]ia3 7,i7 ,! hospital has a ,m$icaid
 inpati5t utilization rate 7z def9$ 9   
subsection 7b77#b77 t is n less ?an !   
mean ,m$icaid inpati5t utilization rate 
= hospitals receiv+ ,m$icaid paym5ts 9 !
 ,/ate4  7,,ii7 ,! hospital has a       
l[-income utilization rate 7z def9$ 9   
subsection 7b77#c77 ( n less ?an #be    
p]c5t4  7,d7 ,ti] #d hospitals ,a       
category ( hospitals 7ref]r$ to 9 ?is   
section z ti] #d hospitals7 9 :i* ea*   
hospital-- 7i7 is n describ$ 9 a previ\s
 subp>agraph2 &  7ii7 satisfies !       
requirem5t describ$ 9 subsection        
7d77#c74  7#c7 ,paym5t me?odology       
requirem5ts  7,a7 ,prioritization (     
hospitals ,9 mak+ disproportionate %>e  
hospital paym5ts1 a ,/ate me?odology    
%all prioritize hospitals 9 ! foll[+    
ord]3 7i7 ,ti] #a hospitals %all receive
 ! highe/ priority4  7ii7 ,ti] #b       

hospitals %all receive ! second-highe/  
priority4  7iii7 ,ti] #c hospitals %all 
receive ! ?ird-highe/ priority4  7iv7   
,ti] #d hospitals %all receive !        
f\r?-highe/ priority4  7,b7 ,factors ,! 
me?odology specifies ! factors t w be   
consid]$ 9 det]m9+ ! am\nt ( a          
disproportionate %>e hospital paym5t to 
be made to a hospital1 :i* may include--
 7i7 ! hospital's net op]at+ m>g9s      
7includ+ pa/ net op]at+ m>g9s72  7ii7   
pa/ disproportionate %>e hospital       
paym5ts to ! hospital2  7iii7 :e!r !    
hospital 0 affect$ by a major disa/] 7z 
decl>$ by ! ,presid5t "u section #dja ( 
! ,rob]t ,t4 ,/af=d ,disa/] ,relief &   
,em]g5cy ,assi/ance ,act7 9 ! #ab mon?s 
prior to ! paym5t2 &  7iv7 o!r relevant 
factors1 z det]m9$ by ! ,/ate 7subject  
to ! approval ( ! ,secret>y74  7,c7     
,consid]ation ( f9ancial circum/ances ( 
high ti] hospitals  7i7 ,9 g5]al ,!     
,/ate %all c]tify t ! ,/ate me?odology  
adequately consid]s ! unique f9ancial   
circum/ances ( ti] #a hospitals & ti] #b

 hospitals1 & takes necess>y /eps to    
mitigate net op]at+ losses by su*       
hospitals4  7ii7 ,guidance  7,i7 ,9     
g5]al ,n lat] ?an #ah mon?s aft] ! date 
( enactm5t ( ! ,,safe ,hospitals ,act ( 
#bjba1 ! ,secret>y %all issue guidance  
to ,/ates outl9+ me?ods t ,/ates may use
 to satisfy ! requirem5t ( ?is          
subp>agraph4  7,,ii7 ,/ate alt]natives  
,subject to ! approval ( ! ,secret>y1 a 
,/ate may develop an alt]native me?od = 
satisfy+ ! requirem5t ( ?is subp>agraph4
  7,d7 ,treatm5t ( ,i,m,ds & ,c,a,hs ,! 
,/ate %all specify h[ ! me?odology      
prioritizes in/itutions = m5tal diseases
 & critical access hospitals 7z def9$ 9 
section #ahfa7mm77#a771 b 9 no case %all
 in/itutions = m5tal diseases or        
critical access hospitals receive a     
high] priority ?an ti] #a hospitals4    
7,e7 ,/ate au?ority to reclassify       
hospitals ,subject to ! approval ( !    
,secret>y1 = purposes ( prioritiz+      
disproportionate %>e paym5ts "u a ,/ate 
me?odology "u ?is subsection1 a ,/ate   

may treat up to #ae p]c5t ( all         
disproportionate %>e hospitals 9 !      
,/ate1 exclud+ in/itutions = m5tal      
diseases1 z belong+ to a diff]5t        
disproportionate %>e hospital ti] ?an ! 
ti] 9 :i* ! hospitals are describ$ "u   
p>agraph 7#b74  7,f7 ,rule ( con/ruction
 ,no?+ 9 ?is subsection %all be con/ru$ 
z requir+ a ,/ate to apply a uni=m      
paym5t me?odology to all hospitals )9 a 
disproportionate %>e hospital ti]4  7#d7
 ,me?odology = ,/ates ) few] ?an #ae    
disproportionate %>e hospitals  7,a7 ,9 
g5]al ,9 ! case ( a ,/ate t has few] ?an
 #ae disproportionate %>e hospitals1 !  
,/ate %all use ! me?odology = id5tify+ &
 mak+ paym5ts to disproportionate %>e   
hospitals t is develop$ by ! ,secret>y  
"u subp>agraph 7,b74  7,b7 ,developm5t (
 me?odology ,n lat] ?an #ah mon?s aft] !
 date ( enactm5t ( ! ,,safe ,hospitals  
,act ( #bjba1 ! ,secret>y %all develop a
 me?odology = id5tify+ & mak+ paym5ts to
 disproportionate %>e hospitals = ,/ates
 t h few] ?an #ae disproportionate %>e  

hospitals t prioritizes ,,d% paym5ts to 
hospitals ) disproportionately high     
volumes ( ,m$icaid pati5ts & l[-income  
pati5ts4  7#e7 ,no effect on waiv]      
au?ority ,no?+ 9 ?is subsection %all be 
con/ru$ z prev5t+ ! ,secret>y f approv+ 
a waiv] "u section #aaae or o!r law )   
respect to requirem5ts "u ?is subsection
 relat$ to ! me?odology us$ by ,/ates to
 id5tify & make paym5ts to              
disproportionate %>e hospitals4  4  7b7 
,modification ( cap on individual ,,d%  
paym5ts  7#a7 ,9 g5]al ,subp>agraph     
7,a77i7 ( section #aibc7;g77#a7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#acifr-#d7;g77#a771 z am5d$ by section  
#bjc7;a7 ( ! ,consolidat$               
,appropriations ,act1 #bjba 7,public    
,law #aaf-bfj71 is am5d$ by ins]t+      
7includ+ any co/s incurr$ by ! hospital 
dur+ ! ye> t are associat$ ) subsidiz+ a
 physician or a cl9ic or o!r heal? c5t] 
t is own$ & op]at$ by1 controll$ by1 or 
9 common control ) ! hospital = !       
purpose ( provid+ c>e to su*            

individuals7 aft] individuals describ$ 9
 subp>agraph 7,b74  7#b7 ,con=m+ am5dm5t
 ,section #aibc7;g77#b77;,a77ii7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acifr-#d7;g77#b771 z am5d$ by section  
#bjc7;a7 ( ! ,consolidat$               
,appropriations ,act1 #bjba 7,public    
,law #aaf-bfj71 is am5d$ by ins]t+      
7except t1 = purposes ( ?is clause1 su* 
p>agraph z 9 effect on su* date %all be 
appli$ by ins]t+ 1 includ+ any co/s     
incurr$ by ! hospital dur+ ! ye> t are  
associat$ ) subsidiz+ a physician or a  
cl9ic or o!r heal? c5t] t is own$ &     
op]at$ by1 controll$ by1 or 9 common    
control ) ! hospital = ! purpose (      
provid+ c>e to su* individuals at ! end 
( ! fir/ s5t5ce7 be=e ! p]iod4  7#c7    
,effective date ,! am5dm5ts made by ?is 
subsection %all take effect on ,octob]  
#a1 #bjba4  7c7 ,modification ( ,,d%    
qualification requirem5ts  7#a7 ,9 g5]al
 ,section #aibc7;d77#c7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#acifr-#d7;d77#c77 is am5d$ by /rik+    

unless ! hospital & all t foll[s ?r\gh !
 p]iod & ins]t+ ! foll[+3 8unless !     
hospital--  7,a7 has a ,m$icaid inpati5t
 utilization rate 7z def9$ 9 subsection 
7b77#b77 t is n m ?an #a /&>d deviation 
bel[ ! mean ,m$icaid inpati5t           
utilization rate = hospitals receiv+    
,m$icaid paym5ts 9 ! ,/ate2  7,b7 has a 
l[-income utilization rate 7z def9$ 9   
subsection 7b77#c77 t is n less ?an #aj 
p]c5t2 or  7,c7 is a critical access    
hospital 7z def9$ 9 section             
#ahfa7mm77#a774  4  7#b7 ,effective date
 ,! am5dm5ts made by ?is subsection %all
 take effect on ,octob] #a1 #bjbc4