42 U.S.C. § 1396r–4 | Adjustment in payment for inpatient hospital services furnished by disproportionate share hospitals

(a)

Implementation of requirement

(1)

section 1396a(a)(13)(A)(iv) of this titleJuly 1, 1988 A State plan under this subchapter shall not be considered to meet the requirement of (insofar as it requires payments to hospitals to take into account the situation of hospitals which serve a disproportionate number of low income patients with special needs), as of , unless the State has submitted to the Secretary, by not later than such date, an amendment to such plan that—

(A)

specifically defines the hospitals so described (and includes in such definition any disproportionate share hospital described in subsection (b)(1) which meets the requirements of subsection (d)), and

(B)

July 1, 1988 provides, effective for inpatient hospital services provided not later than , for an appropriate increase in the rate or amount of payment for such services provided by such hospitals, consistent with subsection (c).

(2)

(A)

section 1396a(a)(13)(A) of this titleJuly 1, 1989April 1, 1989July 1, 1989 In order to be considered to have met such requirement of as of , the State must submit to the Secretary by not later than , the State plan amendment described in paragraph (1), consistent with subsection (c), effective for inpatient hospital services provided on or after .

(B)

section 1396a(a)(13)(A) of this titleJuly 1, 1990April 1, 1990July 1, 1990 In order to be considered to have met such requirement of as of , the State must submit to the Secretary by not later than , the State plan amendment described in paragraph (1), consistent with subsections (c) and (f), effective for inpatient hospital services provided on or after .

(C)

section 1396a(a)(13)(A) of this titleJuly 1, 1989April 1, 1989July 1, 1989 If a State plan under this subchapter provides for payments for inpatient hospital services on a prospective basis (whether per diem, per case, or otherwise), in order for the plan to be considered to have met such requirement of as of , the State must submit to the Secretary by not later than , a State plan amendment that provides, in the case of hospitals defined by the State as disproportionate share hospitals under paragraph (1)(A), for an outlier adjustment in payment amounts for medically necessary inpatient hospital services provided on or after , involving exceptionally high costs or exceptionally long lengths of stay for individuals under one year of age.

(D)

section 1396a(a)(13)(A)(iv) of this titleOctober 1, 1998 A State plan under this subchapter shall not be considered to meet the requirements of (insofar as it requires payments to hospitals to take into account the situation of hospitals that serve a disproportionate number of low-income patients with special needs), as of , unless the State has submitted to the Secretary by such date a description of the methodology used by the State to identify and to make payments to disproportionate share hospitals, including children’s hospitals, on the basis of the proportion of low-income and medicaid patients (including such patients who receive benefits through a managed care entity) served by such hospitals. The State shall provide an annual report to the Secretary describing the disproportionate share payments to each such disproportionate share hospital.

(3)

The Secretary shall, not later than 90 days after the date a State submits an amendment under this subsection, review each such amendment for compliance with such requirement and by such date shall approve or disapprove each such amendment. If the Secretary disapproves such an amendment, the State shall immediately submit a revised amendment which meets such requirement.

(4)

section 1396n(b)(4) of this title The requirement of this subsection may not be waived under .

(b)

Hospitals deemed disproportionate share

(1)

For purposes of subsection (a)(1), a hospital which meets the requirements of subsection (d) is deemed to be a disproportionate share hospital if—

(A)

the hospital’s medicaid inpatient utilization rate (as defined in paragraph (2)) is at least one standard deviation above the mean medicaid inpatient utilization rate for hospitals receiving medicaid payments in the State; or

(B)

the hospital’s low-income utilization rate (as defined in paragraph (3)) exceeds 25 percent.

(2)

For purposes of paragraph (1)(A), the term “medicaid inpatient utilization rate” means, for a hospital, a fraction (expressed as a percentage), the numerator of which is the hospital’s number of inpatient days attributable to patients who (for such days) were eligible for medical assistance under a State plan approved under this subchapter in a period (regardless of whether such patients receive medical assistance on a fee-for-service basis or through a managed care entity), and the denominator of which is the total number of the hospital’s inpatient days in that period. In this paragraph, the term “inpatient day” includes each day in which an individual (including a newborn) is an inpatient in the hospital, whether or not the individual is in a specialized ward and whether or not the individual remains in the hospital for lack of suitable placement elsewhere.

(3)

For purposes of paragraph (1)(B), the term “low-income utilization rate” means, for a hospital, the sum of—

(A)

the fraction (expressed as a percentage)—

(i)

the numerator of which is the sum (for a period) of (I) the total revenues paid the hospital for patient services under a State plan under this subchapter (regardless of whether the services were furnished on a fee-for-service basis or through a managed care entity) and (II) the amount of the cash subsidies for patient services received directly from State and local governments, and

(ii)

the denominator of which is the total amount of revenues of the hospital for patient services (including the amount of such cash subsidies) in the period; and

(B)

a fraction (expressed as a percentage)—

(i)

the numerator of which is the total amount of the hospital’s charges for inpatient hospital services which are attributable to charity care in a period, less the portion of any cash subsidies described in clause (i)(II) of subparagraph (A) in the period reasonably attributable to inpatient hospital services, and

(ii)

the denominator of which is the total amount of the hospital’s charges for inpatient hospital services in the hospital in the period.

The numerator under subparagraph (B)(i) shall not include contractual allowances and discounts (other than for indigent patients not eligible for medical assistance under a State plan approved under this subchapter).

(4)

section 1396b(w)(1)(A)(iii) of this title section 1396b(w)(4) of this title The Secretary may not restrict a State’s authority to designate hospitals as disproportionate share hospitals under this section. The previous sentence shall not be construed to affect the authority of the Secretary to reduce payments pursuant to if the Secretary determines that, as a result of such designations, there is in effect a hold harmless provision described in .

(c)

Payment adjustment

Subject to subsections (f) and (g), in order to be consistent with this subsection, a payment adjustment for a disproportionate share hospital must either—

(1)

section 1395ww(a)(4) of this title section 1395ww(d)(5)(F)(iv) of this title be in an amount equal to at least the product of (A) the amount paid under the State plan to the hospital for operating costs for inpatient hospital services (of the kind described in ), and (B) the hospital’s disproportionate share adjustment percentage (established under );

(2)

1 So in original. Probably should be “subsection”.

provide for a minimum specified additional payment amount (or increased percentage payment) and (without regard to whether the hospital is described in subparagraph (A) or (B) of subsection (b)(1)) for an increase in such a payment amount (or percentage payment) in proportion to the percentage by which the hospital’s medicaid utilization rate (as defined in subsection (b)(2)) exceeds one standard deviation above the mean medicaid inpatient utilization rate for hospitals receiving medicaid payments in the State or the hospital’s low-income utilization rate (as defined in paragraph  (b)(3)); or

(3)

provide for a minimum specified additional payment amount (or increased percentage payment) that varies according to type of hospital under a methodology that—

(A)

applies equally to all hospitals of each type; and

(B)

results in an adjustment for each type of hospital that is reasonably related to the costs, volume, or proportion of services provided to patients eligible for medical assistance under a State plan approved under this subchapter or to low-income patients,

section 1395ww(d)(5)(F)(vi) of this titleexcept that, for purposes of paragraphs (1)(B) and (2)(A) of subsection (a), the payment adjustment for a disproportionate share hospital is consistent with this subsection if the appropriate increase in the rate or amount of payment is equal to at least one-third of the increase otherwise applicable under this subsection (in the case of such paragraph (1)(B)) and at least two-thirds of such increase (in the case of such paragraph (2)(A)). 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 percentage (defined in ) shall be computed by substituting for the fraction described in subclause (I) of such section the fraction described in subclause (II) of that section. If a State elects in a State plan amendment under subsection (a) to provide the 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.

(d)

Requirements to qualify as disproportionate share hospital

(1)

Except as provided in paragraph (2), no hospital may be defined or deemed as a disproportionate share hospital under a State plan under this subchapter or under subsection (b) of this section unless the hospital has at least 2 obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to individuals who are entitled to medical assistance for such services under such State plan.

(2)

(A)

Paragraph (1) shall not apply to a hospital—

(i)

the inpatients of which are predominantly individuals under 18 years of age; or

(ii)

December 22, 1987 which does not offer nonemergency obstetric services to the general population as of .

(B)

section 1395ww of this title In the case of a hospital located in a rural area (as defined for purposes of ), in paragraph (1) the term “obstetrician” includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.

(3)

No hospital may be defined or deemed as a disproportionate share hospital under a State plan under this subchapter or under subsection (b) or (e) of this section unless the hospital has a medicaid inpatient utilization rate (as defined in subsection (b)(2)) of not less than 1 percent.

(e)

Special rule

(1)

section 1396a(a)(13)(A)(iv) of this titleJanuary 1, 1984January 1, 1987 A State plan shall be considered to meet the requirement of (insofar as it requires payments to hospitals to take into account the situation of hospitals which serve a disproportionate number of low income patients with special needs) without regard to the requirement of subsection (a) if (A)(i) the plan provided for payment adjustments based on a pooling arrangement involving a majority of the hospitals participating under the plan for disproportionate share hospitals as of , or (ii) the plan as of , provided for payment adjustments based on a statewide pooling arrangement involving all acute care hospitals and the arrangement provides for reimbursement of the total amount of uncompensated care provided by each participating hospital, (B) the aggregate amount of the payment adjustments under the plan for such hospitals is not less than the aggregate amount of such adjustments otherwise required to be made under such subsection, and (C) the plan meets the requirement of subsection (d)(3) and such payment adjustments are made consistent with the last sentence of subsection (c).

(2)

January 1, 1986July 1, 1988 In the case of a State that used a health insuring organization before , to administer a portion of its plan on a statewide basis, beginning on —

(A)

the requirements of subsections (b) and (c) (other than the last sentence of subsection (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,

(B)

subsection (d)(2)(B) shall apply to hospitals located in urban areas, as well as in rural areas,

(C)

subsection (d)(3) shall apply, and

(D)

subsection (g) shall apply.

(f)

Limitation on Federal financial participation

(1)

In general

section 1396b(a) of this titlePayment under shall not be made to a State with respect to any payment adjustment made under this section for hospitals in a State for quarters in a fiscal year in excess of the disproportionate share hospital (in this subsection referred to as “DSH”) allotment for the State for the fiscal year, as specified in paragraphs (2), (3), and (7).

(2)

State DSH allotments for fiscal years 1998 through 2002

State or District	DSH Allotment (in millions of dollars)
State or District	FY 98	FY 99	FY 00	FY 01	FY 02
Alabama	293	269	248	246	246
Alaska	10	10	10	9	9
Arizona	81	81	81	81	81
Arkansas	2	2	2	2	2
California	1,085	1,068	986	931	877
Colorado	93	85	79	74	74
Connecticut	200	194	164	160	160
Delaware	4	4	4	4	4
District of Columbia	23	23	49	49	49
Florida	207	203	197	188	160
Georgia	253	248	241	228	215
Hawaii	0	0	0	0	0
Idaho	1	1	1	1	1
Illinois	203	199	193	182	172
Indiana	201	197	191	181	171
Iowa	8	8	8	8	8
Kansas	51	49	42	36	33
Kentucky	137	134	130	123	116
Louisiana	880	795	713	658	631
Maine	103	99	84	84	84
Maryland	72	70	68	64	61
Massachusetts	288	282	273	259	244
Michigan	249	244	237	224	212
Minnesota	16	16	33	33	33
Mississippi	143	141	136	129	122
Missouri	436	423	379	379	379
Montana	0.2	0.2	0.2	0.2	0.2
Nebraska	5	5	5	5	5
Nevada	37	37	37	37	37
New Hampshire	140	136	130	130	130
New Jersey	600	582	515	515	515
New Mexico	5	5	9	9	9
New York	1,512	1,482	1,436	1,361	1,285
North Carolina	278	272	264	250	236
North Dakota	1	1	1	1	1
Ohio	382	374	363	344	325
Oklahoma	16	16	16	16	16
Oregon	20	20	20	20	20
Pennsylvania	529	518	502	476	449
Rhode Island	62	60	58	55	52
South Carolina	313	303	262	262	262
South Dakota	1	1	1	1	1
Tennessee	0	0	0	0	0
Texas	979	950	806	765	765
Utah	3	3	3	3	3
Vermont	18	18	18	18	18
Virginia	70	68	66	63	59
Washington	174	171	166	157	148
West Virginia	64	63	61	58	54
Wisconsin	7	7	7	7	7
Wyoming	0	0	0.1	0.1	0.1.

Subject to paragraph (4), the DSH allotment for a State for each fiscal year during the period beginning with fiscal year 1998 and ending with fiscal year 2002 is determined in accordance with the following table:

(3)

State DSH allotments for fiscal year 2003 and thereafter

(A)

In general

Except as provided in paragraphs (6), (7), and (8) and subparagraphs (E) and (F), the DSH allotment for any State for fiscal year 2003 and each succeeding fiscal year is equal to the DSH allotment for the State for the preceding fiscal year under paragraph (2) or this paragraph, increased, subject to subparagraphs (B) and (C) and paragraph (5), by the percentage change in the consumer price index for all urban consumers (all items; U.S. city average), for the previous fiscal year.

(B)

Limitation

The DSH allotment for a State shall not be increased under subparagraph (A) for a fiscal year to the extent that such an increase would result in the DSH allotment for the year exceeding the greater of—

(i)

the DSH allotment for the previous year, or

(ii)

12 percent of the total amount of expenditures under the State plan for medical assistance during the fiscal year.

(C)

Special, temporary increase in allotments on a one-time, non-cumulative basis

The DSH allotment for any State (other than a State with a DSH allotment determined under paragraph (5))—

(i)

for fiscal year 2004 is equal to 116 percent of the DSH allotment for the State for fiscal year 2003 under this paragraph, notwithstanding subparagraph (B); and

(ii)

for each succeeding fiscal year is equal to the DSH allotment for the State for fiscal year 2004 or, in the case of fiscal years beginning with the fiscal year specified in subparagraph (D) for that State, the DSH allotment for the State for the previous fiscal year increased by the percentage change in the consumer price index for all urban consumers (all items; U.S. city average), for the previous fiscal year.

(D)

Fiscal year specified

December 8, 2003For purposes of subparagraph (C)(ii), the fiscal year specified in this subparagraph for a State is the first fiscal year for which the Secretary estimates that the DSH allotment for that State will equal (or no longer exceed) the DSH allotment for that State under the law as in effect before .

(E)

Temporary increase in allotments during recession

(i)

In general

Subject to clause (ii), the DSH allotment for any State—

(I)

for fiscal year 2009 is equal to 102.5 percent of the DSH allotment that would be determined under this paragraph for the State for fiscal year 2009 without application of this subparagraph, notwithstanding subparagraphs (B) and (C);

(II)

for fiscal year 2010 is equal to 102.5 percent of the DSH allotment for the State for fiscal year 2009, as determined under subclause (I); and

(III)

for each succeeding fiscal year is equal to the DSH allotment for the State under this paragraph determined without applying subclauses (I) and (II).

(ii)

Application

Clause (i) shall not apply to a State for a year in the case that the DSH allotment for such State for such year under this paragraph determined without applying clause (i) would grow higher than the DSH allotment specified under clause (i) for the State for such year.

(F)

Allotments during the coronavirus temporary medicaid FMAP increase

(i)

In general

Notwithstanding any other provision of this subsection, for any fiscal year for which the Federal medical assistance percentage applicable to expenditures under this section is increased pursuant to section 6008 of the Families First Coronavirus Response Act, the Secretary shall recalculate the annual DSH allotment, including the DSH allotment specified under paragraph (6)(A)(vi), to ensure that the total DSH payments (including both Federal and State shares) that a State may make related to a fiscal year is equal to the total DSH payments that the State could have made for such fiscal year without such increase to the Federal medical assistance percentage.

(ii)

No application to allotments beginning after COVID–19 emergency period

section 1320b–5(g)(1)(B) of this titleThe DSH allotment for any State for the first fiscal year beginning after the end of the emergency period described in or any succeeding fiscal year shall be determined under this paragraph without regard to the DSH allotments determined under clause (i).

(4)

Special rule for fiscal years 2001 and 2002

(A)

In general

Notwithstanding paragraph (2), the DSH allotment for any State for—

(i)

fiscal year 2001, shall be the DSH allotment determined under paragraph (2) for fiscal year 2000 increased, subject to subparagraph (B) and paragraph (5), by the percentage change in the consumer price index for all urban consumers (all items; U.S. city average) for fiscal year 2000; and

(ii)

fiscal year 2002, shall be the DSH allotment determined under clause (i) increased, subject to subparagraph (B) and paragraph (5), by the percentage change in the consumer price index for all urban consumers (all items; U.S. city average) for fiscal year 2001.

(B)

Limitation

Subparagraph (B) of paragraph (3) shall apply to subparagraph (A) of this paragraph in the same manner as that subparagraph (B) applies to paragraph (3)(A).

(C)

No application to allotments after fiscal year 2002

The DSH allotment for any State for fiscal year 2003 or any succeeding fiscal year shall be determined under paragraph (3) without regard to the DSH allotments determined under subparagraph (A) of this paragraph.

(5)

Special rule for low DSH States

(A)

For fiscal years 2001 through 2003 for extremely low DSH States

August 31, 2000In the case of a State in which the total expenditures under the State plan (including Federal and State shares) for disproportionate share hospital adjustments under this section for fiscal year 1999, as reported to the Administrator of the Health Care Financing Administration as of , is greater than 0 but less than 1 percent of the State’s total amount of expenditures under the State plan for medical assistance during the fiscal year, the DSH allotment for fiscal year 2001 shall be increased to 1 percent of the State’s total amount of expenditures under such plan for such assistance during such fiscal year. In subsequent fiscal years before fiscal year 2004, such increased allotment is subject to an increase for inflation as provided in paragraph (3)(A).

(B)

For fiscal year 2004 and subsequent fiscal years

August 31, 2003In the case of a State in which the total expenditures under the State plan (including Federal and State shares) for disproportionate share hospital adjustments under this section for fiscal year 2000, as reported to the Administrator of the Centers for Medicare & Medicaid Services as of , is greater than 0 but less than 3 percent of the State’s total amount of expenditures under the State plan for medical assistance during the fiscal year, the DSH allotment for the State with respect to—

(i)

fiscal year 2004 shall be the DSH allotment for the State for fiscal year 2003 increased by 16 percent;

(ii)

each succeeding fiscal year before fiscal year 2009 shall be the DSH allotment for the State for the previous fiscal year increased by 16 percent; and

(iii)

fiscal year 2009 and any subsequent fiscal year, shall be the DSH allotment for the State for the previous year subject to an increase for inflation as provided in paragraph (3)(A).

(6)

Allotment adjustments

(A)

Tennessee

(i)

In general

Only with respect to fiscal year 2007, the DSH allotment for Tennessee for such fiscal year, notwithstanding the table set forth in paragraph (2) or the terms of the TennCare Demonstration Project in effect for the State, shall be the greater of—

(I)

the amount that the Secretary determines is equal to the Federal medical assistance percentage component attributable to disproportionate share hospital payment adjustments for the demonstration year ending in 2006 that is reflected in the budget neutrality provision of the TennCare Demonstration Project; and

(II)

$280,000,000.

December 31, 2011 Only with respect to fiscal years 2008, 2009, 2010, and 2011, the DSH allotment for Tennessee for the fiscal year, notwithstanding such table or terms, shall be the amount specified in the previous sentence for fiscal year 2007. Only with respect to fiscal year 2012 for the period ending on , the DSH allotment for Tennessee for such portion of the fiscal year, notwithstanding such table or terms, shall be ¼ of the amount specified in the first sentence for fiscal year 2007.

(ii)

Limitation on amount of payment adjustments eligible for Federal financial participation

section 1396b(a) of this title 2

2 So in original. Probably should be preceded by “a”.

Payment under shall not be made to Tennessee with respect to the aggregate amount of any payment adjustments made under this section for hospitals in the State for fiscal year 2007, 2008, 2009, 2010, 2011, or for period  in fiscal year 2012 described in clause (i) that is in excess of 30 percent of the DSH allotment for the State for such fiscal year or period determined pursuant to clause (i).

(iii)

State plan amendment

The Secretary shall permit Tennessee to submit an amendment to its State plan under this subchapter that describes the methodology to be used by the State to identify and make payments to disproportionate share hospitals, including children’s hospitals and institutions for mental diseases or other mental health facilities. The Secretary may not approve such plan amendment unless the methodology described in the amendment is consistent with the requirements under this section for making payment adjustments to disproportionate share hospitals. For purposes of demonstrating budget neutrality under the TennCare Demonstration Project, payment adjustments made pursuant to a State plan amendment approved in accordance with this subparagraph shall be considered expenditures under such project.

(iv)

Offset of Federal share of payment adjustments for fiscal years 2007 through 2011 and the first calendar quarter of fiscal year 2012 against Essential Access Hospital supplemental pool payments under the TennCare Demonstration Project

(I)

section 1396b(a) of this title The total amount of Essential Access Hospital supplemental pool payments that may be made under the TennCare Demonstration Project for fiscal year 2007, 2008, 2009, 2010, 2011, or for a period in fiscal year 2012 described in clause (i) shall be reduced on a dollar for dollar basis by the amount of any payments made under to Tennessee with respect to payment adjustments made under this section for hospitals in the State for such fiscal year or period.

(II)

section 1396b(a) of this title The sum of the total amount of payments made under to Tennessee with respect to payment adjustments made under this section for hospitals in the State for fiscal year 2007, 2008, 2009, 2010, 2011, or for a period in fiscal year 2012 described in clause (i) and the total amount of Essential Access Hospital supplemental pool payments made under the TennCare Demonstration Project for such fiscal year or period shall not exceed the State’s DSH allotment for such fiscal year or period established under clause (i).

(v)

Allotment for 2d, 3rd, and 4th quarters of fiscal year 2012 and for fiscal year 2013

Notwithstanding the table set forth in paragraph (2):

(I)

2d, 3rd, and 4th quarters of fiscal year 2012

In the case of a State that has a DSH allotment of $0 for the 2d, 3rd, and 4th quarters of fiscal year 2012, the DSH allotment shall be $47,200,000 for such quarters.

(II)

Fiscal year 2013

In the case of a State that has a DSH allotment of $0 for fiscal year 2013, the DSH allotment shall be $53,100,000 for such fiscal year.

(vi)

Allotment for fiscal years 2015 through 2025 and a portion of fiscal year 2026

October 1, 2025January 30, 2026Notwithstanding any other provision of this subsection, any other provision of law, or the terms of the TennCare Demonstration Project in effect for the State, the DSH allotment for Tennessee for fiscal year 2015, and for each fiscal year thereafter through fiscal year 2025, shall be $53,100,000 for each such fiscal year, and the DSH allotment for Tennessee for the portion of fiscal year 2026 beginning , and ending , shall be $17,748,493, which may be claimed as fiscal year 2026 uncompensated care costs.

(B)

Hawaii

(i)

In general

December 31, 2011Only with respect to each of fiscal years 2007 through 2011, the DSH allotment for Hawaii for such fiscal year, notwithstanding the table set forth in paragraph (2), shall be $10,000,000. Only with respect to fiscal year 2012 for the period ending on , the DSH allotment for Hawaii for such portion of the fiscal year, notwithstanding the table set forth in paragraph (2), shall be $2,500,000.

(ii)

State plan amendment

The Secretary shall permit Hawaii to submit an amendment to its State plan under this subchapter that describes the methodology to be used by the State to identify and make payments to disproportionate share hospitals, including children’s hospitals and institutions for mental diseases or other mental health facilities. The Secretary may not approve such plan amendment unless the methodology described in the amendment is consistent with the requirements under this section for making payment adjustments to disproportionate share hospitals.

(iii)

Allotment for 2d, 3rd, and 4th quarter of fiscal year 2012, fiscal year 2013, and succeeding fiscal years

Notwithstanding the table set forth in paragraph (2):

(I)

2d, 3rd, and 4th quarter of fiscal year 2012

The DSH allotment for Hawaii for the 2d, 3rd, and 4th quarters of fiscal year 2012 shall be $7,500,000.

(II)

Treatment as a low-DSH State for fiscal year 2013 and succeeding fiscal years

With respect to fiscal year 2013, and each fiscal year thereafter, the DSH allotment for Hawaii shall be increased in the same manner as allotments for low DSH States are increased for such fiscal year under clause (iii) of paragraph (5)(B).

(III)

Certain hospital payments

The Secretary may not impose a limitation on the total amount of payments made to hospitals under the QUEST section 1115 Demonstration Project except to the extent that such limitation is necessary to ensure that a hospital does not receive payments in excess of the amounts described in subsection (g), or as necessary to ensure that such payments under the waiver and such payments pursuant to the allotment provided in this clause do not, in the aggregate in any year, exceed the amount that the Secretary determines is equal to the Federal medical assistance percentage component attributable to disproportionate share hospital payment adjustments for such year that is reflected in the budget neutrality provision of the QUEST Demonstration Project.

(7)

Medicaid DSH reductions

(A)

Reductions

(i)

In general

January 31, 2026September 30, 2026For the period beginning , and ending , and for each of fiscal years 2027 and 2028, the Secretary shall effect the following reductions:

(I)

Reduction in DSH allotments

The Secretary shall reduce DSH allotments to States in the amount specified under the DSH health reform methodology under subparagraph (B) for the State for the fiscal year or period.

(II)

Reductions in payments

section 1396b(a) of this titleThe Secretary shall reduce payments to States under for each calendar quarter in the fiscal year or period, in the manner specified in clause (iii), in an amount equal to ¼ of the DSH allotment reduction under subclause (I) for the State for the fiscal year.

(ii)

Aggregate reductions

January 31, 2026September 30, 2026The aggregate reductions in DSH allotments for all States under clause (i)(I) shall be equal to $8,000,000,000 for the period beginning , and ending , and for each of fiscal years 2027 and 2028.

(iii)

Manner of payment reduction

section 1396b(d)(2) of this title section 1316 of this titleThe amount of the payment reduction under clause (i)(II) for a State for a quarter shall be deemed an overpayment to the State under this subchapter to be disallowed against the State’s regular quarterly draw for all spending under . Such a disallowance is not subject to a reconsideration under subsections (d) and (e) of .

(iv)

Definition

In this paragraph, the term “State” means the 50 States and the District of Columbia.

(v)

Distribution of aggregate reductions

The Secretary shall distribute the aggregate reductions under clause (ii) among States in accordance with subparagraph (B).

(B)

DSH Health Reform methodology

The Secretary shall carry out subparagraph (A) through use of a DSH Health Reform methodology that meets the following requirements:

(i)

The methodology imposes the largest percentage reductions on the States that—

(I)

have the lowest percentages of uninsured individuals (determined on the basis of data from the Bureau of the Census, audited hospital cost reports, and other information likely to yield accurate data) during the most recent year for which such data are available; or

(II)

do not target their DSH payments on—

(aa)

hospitals with high volumes of Medicaid inpatients (as defined in subsection (b)(1)(A)); and

(bb)

hospitals that have high levels of uncompensated care (excluding bad debt).

(ii)

The methodology imposes a smaller percentage reduction on low DSH States described in paragraph (5)(B).

(iii)

section 1315 of this titleJuly 31, 2009 The methodology takes into account the extent to which the DSH allotment for a State was included in the budget neutrality calculation for a coverage expansion approved under as of .

(8)

Calculation of DSH allotments after reductions period

The DSH allotment for a State for fiscal years after fiscal year 2028 shall be calculated under paragraph (3) without regard to paragraph (7).

(9)

“State” defined

In this subsection, the term “State” means the 50 States and the District of Columbia.

(g)

Limit on amount of payment to hospital

(1)

In general

(A)

Amount of adjustment subject to uncompensated costs

A payment adjustment during a fiscal year shall not be considered to be consistent with subsection (c) with respect to a hospital (other than a hospital described in paragraph (2)(B)) if the payment adjustment exceeds an amount equal to—

(i)

the costs incurred during the year of furnishing hospital services by the hospital to individuals described in subparagraph (B) minus—

(ii)

the sum of—

(I)

payments under this subchapter (other than under this section) for such services; and

(II)

payments by uninsured patients for such services.

(B)

Individuals described

For purposes of subparagraph (A), the individuals described in this clause are the following:

(i)

Individuals who are eligible for medical assistance under the State plan or under a waiver of such plan and for whom the State plan or waiver is the primary payor for such services.

(ii)

Subject to subparagraph (C), individuals who have no health insurance (or other source of third party coverage) for services provided during the year, as determined by the Secretary.

(C)

Exclusion of certain payments

For purposes of subparagraph (B)(ii), payments made to a hospital for services provided to indigent patients made by a State or a unit of local government within a State shall not be considered to be a source of third party coverage.

(2)

Application of limits for certain hospitals

(A)

In general

A payment adjustment during a fiscal year shall not be considered to be consistent with subsection (c) with respect to a hospital described in subparagraph (B) if the payment adjustment exceeds the higher of—

(i)

the amount determined for the hospital and fiscal year under paragraph (1)(A); and

(ii)

January 1, 2020 the amount determined for the hospital under paragraph (1)(A) as in effect on .

(B)

Hospitals described

A hospital is described in this subparagraph for a fiscal year if, for the most recent cost reporting period, the hospital is in at least the 97th percentile of all hospitals with respect to—

(i)

the number of inpatient days for such period that were made up of patients who (for such days) were entitled to benefits under part A of subchapter XVIII and were entitled to supplemental security income benefits under subchapter XVI (excluding any State supplementary benefits paid with respect to such patients); or

(ii)

the percentage of total inpatient days that were made up of patients who (for such days) were described in clause (i).

(3)

Continued application of grandfathered transition rule

October 1, 2021September 30, 2021Public Law 106–113Notwithstanding paragraph (2) of this subsection (as in effect on ), paragraph (2) of this subsection (as in effect on , and as applied under section 4721(e) of the Balanced Budget Act of 1997, and amended by section 607 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 ()) shall apply in determining whether a payment adjustment for a hospital in a State referenced in section 4721(e) of the Balanced Budget Act of 1997 during a State fiscal year shall be considered consistent with subsection (c).

(h)

Limitation on certain State DSH expenditures

(1)

In general

section 1396b(a) of this titlePayment under shall not be made to a State with respect to any payment adjustments made under this section for quarters in a fiscal year (beginning with fiscal year 1998) to institutions for mental diseases or other mental health facilities, to the extent the aggregate of such adjustments in the fiscal year exceeds the lesser of the following:

(A)

1995 IMD DSH payment adjustments

The total State DSH expenditures that are attributable to fiscal year 1995 for payments to institutions for mental diseases and other mental health facilities (based on reporting data specified by the State on HCFA Form 64 as mental health DSH, and as approved by the Secretary).

(B)

Applicable percentage of 1995 total DSH payment allotment

The amount of such payment adjustments which are equal to the applicable percentage of the Federal share of payment adjustments made to hospitals in the State under subsection (c) that are attributable to the 1995 DSH allotment for the State for payments to institutions for mental diseases and other mental health facilities (based on reporting data specified by the State on HCFA Form 64 as mental health DSH, and as approved by the Secretary).

(2)

Applicable percentage

(A)

In general

For purposes of paragraph (1), the applicable percentage with respect to—

(i)

each of fiscal years 1998, 1999, and 2000, is the percentage determined under subparagraph (B); or

(ii)

a succeeding fiscal year is the lesser of the percentage determined under subparagraph (B) or the following percentage:

(I)

For fiscal year 2001, 50 percent.

(II)

For fiscal year 2002, 40 percent.

(III)

For each succeeding fiscal year, 33 percent.

(B)

1995 percentage

The percentage determined under this subparagraph is the ratio (determined as a percentage) of—

(i)

January 1, 1997 the Federal share of payment adjustments made to hospitals in the State under subsection (c) that are attributable to the 1995 DSH allotment for the State (as reported by the State not later than , on HCFA Form 64, and as approved by the Secretary) for payments to institutions for mental diseases and other mental health facilities, to

(ii)

the State 1995 DSH spending amount.

(C)

State 1995 DSH spending amount

January 1, 1997For purposes of subparagraph (B)(ii), the “State 1995 DSH spending amount”, with respect to a State, is the Federal medical assistance percentage (for fiscal year 1995) of the payment adjustments made under subsection (c) under the State plan that are attributable to the fiscal year 1995 DSH allotment for the State (as reported by the State not later than , on HCFA Form 64, and as approved by the Secretary).

(i)

Requirement for direct payment

(1)

In general

section 1396b(a)(1) of this titleOctober 1, 1997section 1396u–2(a)(1)(B) of this titleNo payment may be made under with respect to a payment adjustment made under this section, for services furnished by a hospital on or after , with respect to individuals eligible for medical assistance under the State plan who are enrolled with a managed care entity (as defined in ) or under any other managed care arrangement unless a payment, equal to the amount of the payment adjustment—

(A)

is made directly to the hospital by the State; and

(B)

is not used to determine the amount of a prepaid capitation payment under the State plan to the entity or arrangement with respect to such individuals.

(2)

Exception for current arrangements

July 1, 1997Paragraph (1) shall not apply to a payment adjustment provided pursuant to a payment arrangement in effect on .

(j)

Annual reports and other requirements regarding payment adjustments

section 1396b(a)(1) of this titleWith respect to fiscal year 2004 and each fiscal year thereafter, the Secretary shall require a State, as a condition of receiving a payment under with respect to a payment adjustment made under this section, to do the following:

(1)

Report

The State shall submit an annual report that includes the following:

(A)

An identification of each disproportionate share hospital that received a payment adjustment under this section for the preceding fiscal year and the amount of the payment adjustment made to such hospital for the preceding fiscal year.

(B)

Such other information as the Secretary determines necessary to ensure the appropriateness of the payment adjustments made under this section for the preceding fiscal year.

(2)

Independent certified audit

The State shall annually submit to the Secretary an independent certified audit that verifies each of the following:

(A)

The extent to which hospitals in the State have reduced their uncompensated care costs to reflect the total amount of claimed expenditures made under this section.

(B)

Payments under this section to hospitals that comply with the requirements of subsection (g).

(C)

Only the uncompensated care costs of providing inpatient hospital and outpatient hospital services to individuals described in paragraph (1)(A) of such subsection are included in the calculation of the hospital-specific limits under such subsection.

(D)

The State included all payments under this subchapter, including supplemental payments, in the calculation of such hospital-specific limits.

(E)

The State has separately documented and retained a record of all of its costs under this subchapter, claimed expenditures under this subchapter, uninsured costs in determining payment adjustments under this section, and any payments made on behalf of the uninsured from payment adjustments under this section.

Aug. 14, 1935, ch. 531 Pub. L. 100–203, title IV, § 4112Dec. 22, 1987101 Stat. 1330–148Aug. 14, 1935Pub. L. 100–360, title III, § 302(b)(2)July 1, 1988102 Stat. 752 Pub. L. 100–485, title VI, § 608(d)(15)(C)Oct. 13, 1988102 Stat. 2417 Pub. L. 101–239, title VI, § 6411(c)(1)Dec. 19, 1989103 Stat. 2270 Pub. L. 101–508, title IVNov. 5, 1990104 Stat. 1388–171 Pub. L. 102–234Dec. 12, 1991105 Stat. 1799 Pub. L. 103–66, title XIII, § 13621(a)(1)Aug. 10, 1993107 Stat. 629–631 Pub. L. 105–33, title IVAug. 5, 1997111 Stat. 508 Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, §§ 601(a), 608(s)]Nov. 29, 1999113 Stat. 1536 Pub. L. 106–554, § 1(a)(6) [title VII, § 701(a)(1), (2), (b)(2)]Dec. 21, 2000114 Stat. 2763 Pub. L. 108–173, title X, § 1001(a)Dec. 8, 2003117 Stat. 2428–2430 Pub. L. 109–171, title VI, § 6054(a)Feb. 8, 2006120 Stat. 96 Pub. L. 109–432, div. B, title IV, § 404Dec. 20, 2006120 Stat. 2995 Pub. L. 110–173, title II, § 204Dec. 29, 2007121 Stat. 2513 Pub. L. 110–275, title II, § 202July 15, 2008122 Stat. 2591 Pub. L. 111–3, title VI, § 616Feb. 4, 2009123 Stat. 103 Pub. L. 111–5, div. B, title V, § 5002Feb. 17, 2009123 Stat. 502 Pub. L. 111–148, title II, § 2551(a)Mar. 23, 2010124 Stat. 312 Pub. L. 111–152, title I, § 1203Mar. 30, 2010124 Stat. 1053 Pub. L. 112–96, title III, § 3203Feb. 22, 2012126 Stat. 193 Pub. L. 112–240, title VI, § 641Jan. 2, 2013126 Stat. 2357 Pub. L. 113–67, div. B, title II, § 1204(a)Dec. 26, 2013127 Stat. 1199 Pub. L. 113–93, title II, § 221(a)Apr. 1, 2014128 Stat. 1076 Pub. L. 114–10, title II, § 219Apr. 16, 2015129 Stat. 153 Pub. L. 115–123, div. E, title XII, § 53101Feb. 9, 2018132 Stat. 298 Pub. L. 116–59, div. B, title III, § 1303Sept. 27, 2019133 Stat. 1105 Pub. L. 116–69, div. B, title III, § 1303Nov. 21, 2019133 Stat. 1137 Pub. L. 116–94, div. N, title I, § 203Dec. 20, 2019133 Stat. 3111 Pub. L. 116–136, div. A, title III, § 3813Mar. 27, 2020134 Stat. 429 Pub. L. 116–159, div. C, title III, § 2303Oct. 1, 2020134 Stat. 732 Pub. L. 116–215, div. B, title I, § 1106Dec. 11, 2020134 Stat. 1043 Pub. L. 116–260, div. CC, title IIDec. 27, 2020134 Stat. 2977 Pub. L. 117–2, title IX, § 9819(a)Mar. 11, 2021135 Stat. 218 Pub. L. 117–7, § 2(b)Apr. 14, 2021135 Stat. 252 Pub. L. 118–15, div. B, title III, § 2341Sept. 30, 2023137 Stat. 96 Pub. L. 118–22, div. B, title II, § 301Nov. 17, 2023137 Stat. 121 Pub. L. 118–35, div. B, title I, § 121Jan. 19, 2024138 Stat. 6 Pub. L. 118–42, div. G, title I, § 210Mar. 9, 2024138 Stat. 414 Pub. L. 118–158, div. C, title IV, § 3401Dec. 21, 2024138 Stat. 1767 Pub. L. 119–4, div. B, title IV, § 2401Mar. 15, 2025139 Stat. 45 Pub. L. 119–37, div. F, title IV, § 6401Nov. 12, 2025139 Stat. 636(, title XIX, § 1923, formerly , , ; renumbered § 1923 of act , and amended , title IV, § 411(k)(6)(A)–(B)(ix), , , 792–794; , (26)(A)–(F), , , 2421, 2422; , , ; , §§ 4702(a), 4703(a)–(c), , ; , §§ 3(b)(1), (2)(A), (c), , , 1802, 1803; , (b)(1), (2), , ; , §§ 4711(c)(2), 4721(a)(1), (b)–(d), , , 511, 513, 514; , , , 1501A–394, 1501A–397; , , , 2763A–569, 2763A–570; –(d), , ; , , ; , , ; , , ; , , ; , , ; , , ; , title X, § 10201(e), , , 920; , , ; , , ; , , ; , , ; , , ; , title IV, § 412, , , 162; , , ; , , ; , , ; , , ; , , ; , , ; , , ; , §§ 201, 203(a), , , 2978; , , ; , , ; , , ; , , ; , , ; , , ; , , ; , , ; , , .)

Editorial Notes

References in Text

section 6008 of Pub. L. 116–127 section 1396d of this title section 1396d of this titleSection 6008 of the Families First Coronavirus Response Act, referred to in subsec. (f)(3)(F), is , which amended and enacted provisions set out as a note under .

Public Law 106–113 Pub. L. 105–33, title IV, § 4721(e)Aug. 5, 1997111 Stat. 514 Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, § 607(a)]Nov. 29, 1999113 Stat. 1536Section 4721(e) of the Balanced Budget Act of 1997, and amended by section 607 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (), referred to in subsec. (g)(3), is , , , as amended by , , , 1501A–396, which is set out as a note under this section.

Codification

Pub. L. 100–360 section 4112 of Pub. L. 100–203 section 1396a of this titlePrior to redesignation by , , cited in the credits to this section, was classified as a note under .

Prior Provisions

Aug. 14, 1935section 1396v of this titleA prior section 1923 of act , was renumbered section 1939 and is classified to .

Amendments

Pub. L. 119–37, § 6401(a)October 1, 2025January 30, 20262025—Subsec. (f)(6)(A)(vi). , inserted “and a portion of fiscal year 2026” after “2025” in heading and, in text, inserted “, and the DSH allotment for Tennessee for the portion of fiscal year 2026 beginning , and ending , shall be $17,748,493, which may be claimed as fiscal year 2026 uncompensated care costs” before period at end.

Pub. L. 119–37, § 6401(b)(1)(A)(i)January 31, 2026September 30, 2026Subsec. (f)(7)(A)(i). , substituted “For the period beginning , and ending , and for each of fiscal years 2027 and 2028” for “For each of fiscal years 2026 through 2028” in introductory provisions.

Pub. L. 119–4, § 2401(1)(A)April 1, 2025September 30, 2025, substituted “For” for “For the period beginning , and ending , and for” and “through 2028” for “through 2027” in introductory provisions.

Pub. L. 119–37, § 6401(b)(1)(A)(ii)Subsec. (f)(7)(A)(i)(I). , inserted “or period” after “the fiscal year”.

Pub. L. 119–4, § 2401(1)(B), struck out “or period” after “fiscal year”.

Pub. L. 119–37, § 6401(b)(1)(A)(iii)Subsec. (f)(7)(A)(i)(II). , inserted “or period” after “in the fiscal year”.

Pub. L. 119–4, § 2401(1)(C), which directed amendment of subcl. (II) by striking out “or period” without specifying the location of such amendment, was executed by striking out “or period” after “fiscal year” both places appearing, to reflect the probable intent of Congress.

Pub. L. 119–37, § 6401(b)(1)(B)January 31, 2026September 30, 2026Subsec. (f)(7)(A)(ii). , substituted “for the period beginning , and ending , and for each of fiscal years 2027 and 2028” for “for each of fiscal years 2026 through 2028”.

Pub. L. 119–4, § 2401(2)April 1, 2025September 30, 2025, struck out “for the period beginning , and ending , and” after “$8,000,000,000” and substituted “through 2028” for “through 2027”.

Pub. L. 119–37, § 6401(b)(2)Subsec. (f)(8). , substituted “2028” for “2027”.

Pub. L. 118–1582024—Subsec. (f)(7)(A). substituted “April 1” for “January 1” in introductory provisions of cl. (i) and in cl. (ii).

Pub. L. 118–42January 1, 2025September 30, 2025March 9, 2024September 30, 2024January 1, 2025September 30, 2025March 9, 2024September 30, 2024, in introductory provisions of cl. (i), substituted “For the period beginning , and ending , and for each of fiscal years 2026” for “For the period beginning , and ending , and for each of fiscal years 2025” and, in cl. (ii), substituted “, and ending , and for each of fiscal years 2026” for “, and ending , and for each of fiscal years 2025”.

Pub. L. 118–35March 9, 2024January 20, 2024 substituted “” for “” in introductory provisions of cl. (i) and in cl. (ii).

Pub. L. 118–22, § 301(1)January 20, 2024November 18, 20232023—Subsec. (f)(7)(A)(i). , substituted “” for “” in introductory provisions.

Pub. L. 118–15, § 2341(1)November 18, 2023September 30, 2024, substituted “For the period beginning , and ending , and for each of fiscal years 2025 through 2027” for “For each of fiscal years 2024 through 2027” in introductory provisions and inserted “or period” after “the fiscal year” wherever appearing in subcls. (I) and (II).

Pub. L. 118–22, § 301(2)January 20, 2024November 18, 2023Subsec. (f)(7)(A)(ii). , substituted “” for “”.

Pub. L. 118–15, § 2341(2)November 18, 2023September 30, 2024, substituted “for the period beginning , and ending , and for each of fiscal years 2025 through 2027.” for “for each of fiscal years 2024 through 2027”.

Pub. L. 117–2, § 9819(a)(1)2021—Subsec. (f)(3)(A). , substituted “subparagraphs (E) and (F)” for “subparagraph (E)”.

Pub. L. 117–2, § 9819(a)(2)Subsec. (f)(3)(F). , added subpar. (F).

Pub. L. 117–7Subsec. (g)(3). added par. (3).

Pub. L. 116–260, § 201(1)(A)December 19, 2020September 30, 20212020—Subsec. (f)(7)(A)(i). , substituted “For each of fiscal years 2024 through 2027,” for “For the period beginning , and ending , and for each of fiscal years 2022 through 2025” in introductory provisions.

Pub. L. 116–215December 19, 2020December 12, 2020 substituted “” for “” in introductory provisions.

Pub. L. 116–159, § 2303(1)December 12, 2020December 1, 2020, substituted “” for “” in introductory provisions.

Pub. L. 116–136, § 3813(1)December 1, 2020September 30, 2021May 23, 2020September 30, 2020, substituted “, and ending , and for each of fiscal years 2022” for “, and ending , and for each of fiscal years 2021” in introductory provisions.

Pub. L. 116–260, § 201(1)(B)Subsec. (f)(7)(A)(ii). , substituted “equal to $8,000,000,000 for each of fiscal years 2024 through 2027” for “equal to—

December 19, 2020September 30, 2021“(I) $4,000,000,000 for the period beginning , and ending ; and

“(II) $8,000,000,000 for each of fiscal years 2022 through 2025.”

Pub. L. 116–215December 19, 2020December 12, 2020Subsec. (f)(7)(A)(ii)(I). substituted “” for “”.

Pub. L. 116–159, § 2303(2)December 12, 2020December 1, 2020, substituted “” for “”.

Pub. L. 116–136, § 3813(2)(A)December 1, 2020September 30, 2021May 23, 2020September 30, 2020, substituted “, and ending ” for “, and ending ”.

Pub. L. 116–136, § 3813(2)(B)Subsec. (f)(7)(A)(ii)(II). , substituted “2022” for “2021”.

Pub. L. 116–260, § 201(2)Subsec. (f)(8). , substituted “2027” for “2025”.

Pub. L. 116–260, § 203(a)Subsec. (g). , amended subsec. (g) generally. Prior to amendment, subsec. (g) related to limit on amount of payment to hospital.

Pub. L. 116–94May 23, 2020December 21, 20192019—Subsec. (f)(7)(A). substituted “” for “” in cls. (i) and (ii)(I).

Pub. L. 116–69December 21, 2019November 22, 2019 substituted “” for “” in cls. (i) and (ii)(I).

Pub. L. 116–59, § 1303(1)November 22, 2019September 30, 2020Subsec. (f)(7)(A)(i). , in introductory provisions, substituted “For the period beginning , and ending , and for each of fiscal years 2021 through 2025” for “For each of fiscal years 2020 through 2025”.

Pub. L. 116–59, § 1303(2)November 22, 2019September 30, 2020Subsec. (f)(7)(A)(ii)(I). , substituted “for the period beginning , and ending ” for “for fiscal year 2020”.

Pub. L. 115–123, § 53101(1)2018—Subsec. (f)(7)(A)(i). , substituted “2020” for “2018” in introductory provisions.

Pub. L. 115–123, § 53101(2)Subsec. (f)(7)(A)(ii)(I) to (VIII). , added subcls. (I) and (II) and struck out former subcls. (I) to (VIII) which related to fiscal years 2018 to 2025, respectively.

Pub. L. 114–10, § 2192015—Subsec. (f)(6)(A)(vi). , added cl. (vi).

Pub. L. 114–10, § 412(1)(A)Subsec. (f)(7)(A)(i). , substituted “2018 through 2025” for “2017 through 2024” in introductory provisions.

Pub. L. 114–10, § 412(1)(B)Subsec. (f)(7)(A)(ii). , added cl. (ii) and struck out former cl. (ii) which related to aggregate reductions for fiscal years 2017 to 2024.

Pub. L. 114–10, § 412(1)(C)Subsec. (f)(7)(A)(v). , added cl. (v).

Pub. L. 114–10, § 412(2)Subsec. (f)(8). , substituted “2025” for “2024”.

Pub. L. 113–93, § 221(a)(1)(A)2014—Subsec. (f)(7)(A)(i). , substituted “2017 through 2024” for “2016 through 2020” in introductory provisions.

Pub. L. 113–93, § 221(a)(1)(B)Subsec. (f)(7)(A)(ii)(I) to (VIII). , added subcls. (I) to (VIII) and struck out former subcls. (I) to (IV) which related to amounts for fiscal years 2016 to 2019.

Pub. L. 113–93, § 221(a)(2)Subsec. (f)(8). , added par. (8) and struck out former par. (8) which related to special rules for calculating DSH allotments for certain fiscal years.

Pub. L. 113–67, § 1204(a)(1)(A)2013—Subsec. (f)(7)(A)(i). , substituted “2016” for “2014” in introductory provisions.

Pub. L. 113–67, § 1204(a)(1)(B)Subsec. (f)(7)(A)(ii). , redesignated subcls. (III) to (VII) as subcls. (I) to (V), respectively, in subcl. (I), substituted “$1,200,000,000” for “$600,000,000”, and struck out former subcls. (I) and (II) which read as follows:

“(I) $500,000,000 for fiscal year 2014;

“(II) $600,000,000 for fiscal year 2015;”.

Pub. L. 112–240Subsec. (f)(8). amended par. (8) generally. Prior to amendment, text read as follows: “With respect to fiscal year 2021, for purposes of applying paragraph (3)(A) to determine the DSH allotment for a State, the amount of the DSH allotment for the State under paragraph (3) for fiscal year 2020 shall be equal to the DSH allotment as reduced under paragraph (7).”

Pub. L. 113–67, § 1204(a)(2)Subsec. (f)(8)(C), (D). , added subpar. (C) and redesignated former subpar. (C) as (D), and in subpar. (D), substituted “fiscal year 2023” for “fiscal year 2022”.

Pub. L. 112–96, § 3203(2)2012—Subsec. (f)(3)(A). , substituted “paragraphs (6), (7), and (8)” for “paragraphs (6) and (7)”.

Pub. L. 112–96, § 3203(1)Subsec. (f)(8), (9). , (3), added par. (8) and redesignated former par. (8) as (9).

Pub. L. 111–148, § 2551(a)(1)2010—Subsec. (f)(1). , substituted “, (3), and (7)” for “and (3)”.

Pub. L. 111–148, § 2551(a)(2)Subsec. (f)(3)(A). , substituted “paragraphs (6) and (7)” for “paragraph (6)”.

Pub. L. 111–148, § 10201(e)(1)(A)(i)Subsec. (f)(6). , substituted “Allotment adjustments” for “Allotment adjustments for fiscal years 2007 through 2011 and the first calendar quarter of fiscal year 2012” in heading.

Pub. L. 111–152, § 1203(b)Subsec. (f)(6)(A)(v). , added cl. (v).

Pub. L. 111–152, § 1203(a)(1)Subsec. (f)(6)(B)(iii). , struck out “or paragraph (7)” after “paragraph (2)” in introductory provisions.

Pub. L. 111–148, § 10201(e)(1)(A)(ii), added cl. (iii).

Pub. L. 111–152, § 1203(a)(2)Subsec. (f)(7). , added par. (7) and struck out former par. (7) which related to reduction of State DSH allotments once reduction in uninsured threshold reached.

Pub. L. 111–148, § 2551(a)(4), added par. (7). Former par. (7) redesignated (8).

Pub. L. 111–148, § 10201(e)(1)(B)(i)Subsec. (f)(7)(A). , substituted “subparagraphs (E) and (G)” for “subparagraph (E)” in introductory provisions.

Pub. L. 111–148, § 10201(e)(1)(B)(ii)(I)Subsec. (f)(7)(B)(i). , added subcls. (I) to (IV) and struck out former subcls. (I) and (II) which read as follows:

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

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

Pub. L. 111–148, § 10201(e)(1)(B)(ii)(II)Subsec. (f)(7)(B)(ii). , added subcls. (I) to (IV) and struck out former subcls. (I) and (II) which read as follows:

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

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

Pub. L. 111–148, § 10201(e)(1)(B)(ii)(III)Subsec. (f)(7)(E). , which directed amendment of par. (7)(B) by substituting “50 percent” for “35 percent” in subpar. (E), was executed by making the substitution in par. (7)(E) to reflect the probable intent of Congress.

Pub. L. 111–148, § 10201(e)(1)(B)(ii)(IV)Subsec. (f)(7)(G). , which directed amendment of par. (7)(B) by adding subpar. (G) at the end, was executed by adding subpar. (G) at end of par. (7) to reflect the probable intent of Congress.

Pub. L. 111–148, § 2551(a)(3)Subsec. (f)(8). , redesignated par. (7) as (8).

Pub. L. 111–5, § 5002(1)2009—Subsec. (f)(3)(A). , substituted “paragraph (6) and subparagraph (E)” for “paragraph (6)”.

Pub. L. 111–5, § 5002(2)Subsec. (f)(3)(E). , added subpar. (E).

Pub. L. 111–3, § 616(1)Subsec. (f)(6). , substituted “2011 and the first calendar quarter of fiscal year 2012” for “2009 and the first calendar quarter of fiscal year 2010” in heading.

Pub. L. 111–3, § 616(2)(A)December 31, 2011December 31, 2009Subsec. (f)(6)(A)(i). , in concluding provisions, substituted “fiscal years 2008, 2009, 2010, and 2011, the DSH allotment for Tennessee for” for “fiscal years 2008 and 2009, the DSH allotment for Tennessee for such portion of” and “2012 for the period ending on ” for “2010 for the period ending on ”.

Pub. L. 111–3, § 616(2)(B)Subsec. (f)(6)(A)(ii). , substituted “2010, 2011, or for period in fiscal year 2012” for “or for a period in fiscal year 2010”.

Pub. L. 111–3, § 616(2)(C)(i)Subsec. (f)(6)(A)(iv). , substituted “2011 and the first calendar quarter of fiscal year 2012” for “2009 and the first calendar quarter of fiscal year 2010” in heading.

Pub. L. 111–3, § 616(2)(C)(ii)Subsec. (f)(6)(A)(iv)(I), (II). , substituted “2010, 2011, or for a period in fiscal year 2012” for “or for a period in fiscal year 2010”.

Pub. L. 111–3, § 616(3)(A)December 31, 2011December 31, 2009Subsec. (f)(6)(B)(i). , substituted “2007 through 2011” for “2007 through 2009” and “2012 for the period ending on ” for “2010 for the period ending on ”.

Pub. L. 110–275, § 202(1)2008—Subsec. (f)(6). , substituted “fiscal years 2007 through 2009 and the first calendar quarter of fiscal year 2010” for “for fiscal year 2007 and portions of fiscal year 2008” in heading.

Pub. L. 110–275, § 202(2)(A)June 30, 2008December 31, 2009Subsec. (f)(6)(A)(i). , in concluding provisions, substituted “fiscal years 2008 and 2009” for “fiscal year 2008 for the period ending on ”, struck out “¾ of” before “the amount specified in the previous sentence”, and inserted “Only with respect to fiscal year 2010 for the period ending on , the DSH allotment for Tennessee for such portion of the fiscal year, notwithstanding such table or terms, shall be ¼ of the amount specified in the first sentence for fiscal year 2007.” at end.

Pub. L. 110–275, § 202(2)(B)Subsec. (f)(6)(A)(ii). , substituted “, 2008, 2009, or for a period in fiscal year 2010” for “or for a period in fiscal year 2008”.

Pub. L. 110–275, § 202(2)(C)Subsec. (f)(6)(A)(iv). , substituted “fiscal years 2007 through 2009 and the first calendar quarter of fiscal year 2010” for “fiscal year 2007 and fiscal year 2008” in heading and “, 2008, 2009, or for a period in fiscal year 2010” for “or for a period in fiscal year 2008” in subcls. (I) and (II).

Pub. L. 110–275, § 202(3)June 30, 2008Subsec. (f)(6)(B)(i). , substituted “each of fiscal years 2007 through 2009” for “fiscal year 2007” in first sentence, inserted last sentence, and struck out former last sentence which read as follows: “Only with respect to fiscal year 2008 for the period ending on , the DSH allotment for Hawaii for such portion of the fiscal year, notwithstanding the table set forth in paragraph (2), shall be $7,500,000.”

Pub. L. 110–173, § 204(1)2007—Subsec. (f)(6). , inserted “and portions of fiscal year 2008” after “fiscal year 2007” in heading.

Pub. L. 110–173, § 204(2)(A)Subsec. (f)(6)(A)(i). , inserted concluding provisions.

Pub. L. 110–173, § 204(2)(B)Subsec. (f)(6)(A)(ii). , inserted “or for a period in fiscal year 2008 described in clause (i)” after “fiscal year 2007” and “or period” after “such fiscal year”.

Pub. L. 110–173, § 204(2)(C)Subsec. (f)(6)(A)(iv). , inserted “and fiscal year 2008” after “fiscal year 2007” in heading, “or for a period in fiscal year 2008 described in clause (i)” after “fiscal year 2007” in subcls. (I) and (II), “or period” after “for such fiscal year” in subcl. (I), and “or period” after “such fiscal year” in two places in subcl. (II).

Pub. L. 110–173, § 204(3)June 30, 2008Subsec. (f)(6)(B)(i). , inserted at end “Only with respect to fiscal year 2008 for the period ending on , the DSH allotment for Hawaii for such portion of the fiscal year, notwithstanding the table set forth in paragraph (2), shall be $7,500,000.”

Pub. L. 109–1712006—Subsec. (f)(2). under each of the columns for FY 00, FY 01, and FY 02, substituted “49” for “32” in the entry for the District of Columbia.

Pub. L. 109–432Subsec. (f)(6). amended heading and text of par. (6) generally, substituting provisions relating to allotment adjustments for fiscal year 2007 in Tennessee and Hawaii for provisions relating to allotment adjustments with respect to fiscal year 2004 or 2005 in any State if a statewide waiver had been revoked or terminated before the end of either such fiscal year and there had been no DSH allotment for the State.

Pub. L. 108–173, § 1001(a)(1)2003—Subsec. (f)(3)(A). , (c)(1), substituted “Except as provided in paragraph (6), the DSH” for “The DSH” and “subparagraphs (B) and (C)” for “subparagraph (B)”.

Pub. L. 108–173, § 1001(a)(2)Subsec. (f)(3)(C), (D). , added subpars. (C) and (D).

Pub. L. 108–173, § 1001(b)(1)Subsec. (f)(5). , (2), (4), struck out “extremely” before “low DSH States” in heading, designated existing provisions as subpar. (A) and inserted subpar. heading, and added subpar. (B).

Pub. L. 108–173, § 1001(b)(3)Subsec. (f)(5)(A). , which directed insertion of “before fiscal year 2004” after “In subsequent years”, was executed by making the insertion after “In subsequent fiscal years” to reflect the probable intent of Congress.

Pub. L. 108–173, § 1001(c)(2)Subsec. (f)(6), (7). , (3), added par. (6) and redesignated former par. (6) as (7).

Pub. L. 108–173, § 1001(d)Subsec. (j). , added subsec. (j).

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(b)(2)(A)]2000—Subsec. (a)(2)(D). , inserted “(including such patients who receive benefits through a managed care entity)” after “the proportion of low-income and medicaid patients”.

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(b)(2)(B)]Subsec. (b)(2). , inserted “(regardless of whether such patients receive medical assistance on a fee-for-service basis or through a managed care entity)” after “a State plan approved under this subchapter in a period”.

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(b)(2)(C)]Subsec. (b)(3)(A)(i)(I). , inserted “(regardless of whether the services were furnished on a fee-for-service basis or through a managed care entity)” after “under a State plan under this subchapter”.

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(a)(1)(A)(i)]Subsec. (f)(2). , substituted “Subject to paragraph (4), the DSH allotment” for “The DSH allotment” in introductory provisions.

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(a)(2)(B)]Subsec. (f)(3)(A). , inserted “and paragraph (5)” after “subparagraph (B)”.

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(a)(1)(A)(iii)]Subsec. (f)(4). , added par. (4). Former par. (4) redesignated (6).

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(a)(2)(A)]Subsec. (f)(5). , added par. (5).

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(a)(1)(A)(ii)]Subsec. (f)(6). , redesignated par. (4) as (6).

Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(s)]1999—Subsec. (c)(3)(B). , substituted comma for period at end.

Pub. L. 106–113, § 1000(a)(6) [title VI, § 601(a)]Subsec. (f)(2). , under each of the columns for FY 00, FY 01, and FY 02, substituted “32” for “23” in the entry for the District of Columbia, “33” for “16” in the entry for Minnesota, “9” for “5” in the entry for New Mexico, and “0.1” for “0” in the entry for Wyoming.

Pub. L. 105–33, § 4711(c)(2)1997—Subsec. (a)(1). , substituted “1396a(a)(13)(A)(iv)” for “1396a(a)(13)(A)”.

Pub. L. 105–33, § 4721(c)Subsec. (a)(2)(D). , added subpar. (D).

Pub. L. 105–33, § 4711(c)(2)Subsec. (e)(1). , substituted “1396a(a)(13)(A)(iv)” for “1396a(a)(13)(A)”.

Pub. L. 105–33, § 4721(a)(1)Subsec. (f). , amended heading and text of subsec. (f) generally. Prior to amendment, subsec. (f) related to denial of Federal financial participation for payments in excess of certain limits.

Pub. L. 105–33, § 4721(b)Subsec. (h). , added subsec. (h).

Pub. L. 105–33, § 4721(d)Subsec. (i). , added subsec. (i).

Pub. L. 103–66, § 13621(a)(1)(A)1993—Subsec. (a)(1)(A). , substituted “requirements” for “requirement”.

Pub. L. 103–66, § 13621(a)(1)(B)Subsec. (b)(1). , substituted “requirements” for “requirement” in introductory provisions.

Pub. L. 103–66, § 13621(b)(2)(A)Subsec. (c). , substituted “subsections (f) and (g)” for “subsection (f)” in introductory provisions.

Pub. L. 103–66, § 13621(a)(1)(C)Subsec. (d). , substituted “Requirements” for “Requirement” in heading.

Pub. L. 103–66, § 13621(a)(1)(D)Subsec. (d)(3). , added par. (3).

Pub. L. 103–66, § 13621(a)(1)(E)Subsec. (e)(1)(C). , added cl. (C).

Pub. L. 103–66, § 13621(a)(1)(F)(i)Subsec. (e)(2)(A). , inserted “(other than the last sentence of subsection (c))” before “shall not apply”.

Pub. L. 103–66, § 13621(a)(1)(F)(ii)Subsec. (e)(2)(C). –(iv), added subpar. (C).

Pub. L. 103–66, § 13621(b)(2)(B)Subsec. (e)(2)(D). , added subpar. (D).

Pub. L. 103–66, § 13621(b)(1)Subsec. (g). , added subsec. (g).

Pub. L. 102–234, § 3(b)(2)(A)(i)1991—Subsec. (a)(2)(B). , substituted “subsections (c) and (f)” for “subsection (c)”.

Pub. L. 102–234, § 3(c)Subsec. (b)(4). , added par. (4).

Pub. L. 102–234, § 3(b)(2)(A)(ii)Subsec. (c). , substituted “Subject to subsection (f), in order” for “In order”.

Pub. L. 102–234, § 3(b)(1)Subsec. (f). , added subsec. (f).

Pub. L. 101–508, § 4702(a)1990—Subsec. (b)(2). , inserted at end “In this paragraph, the term ‘inpatient day’ includes each day in which an individual (including a newborn) is an inpatient in the hospital, whether or not the individual is in a specialized ward and whether or not the individual remains in the hospital for lack of suitable placement elsewhere.”

Pub. L. 101–508, § 4703(c)Subsec. (c)(2). , inserted before semicolon at end “or the hospital’s low-income utilization rate (as defined in paragraph (b)(3))”.

Pub. L. 101–508, § 4703(a)Subsec. (c)(3). , added par. (3).

Pub. L. 101–508, § 4703(b)Subsec. (e)(2). , struck out “during the 3-year period” before “beginning on”.

Pub. L. 101–2391989—Subsec. (e)(1). designated portion of existing provisions as cls. (A) and (B), and in cl. (A) designated existing provisions as subcl. (i) and added subcl. (ii).

Pub. L. 100–360, § 411(k)(6)(A)Pub. L. 100–485, § 608(d)(26)(F)Pub. L. 100–203, § 4112 section 4112 of Pub. L. 100–2031988—–(B)(ix), as amended by , amended , so as to redesignate as this section.

Pub. L. 100–360, § 411(k)(6)(B)(iv)Subsec. (a). , struck out “of Health and Human Services” after “to the Secretary” wherever appearing in pars. (1) and (2).

Pub. L. 100–360, § 411(k)(6)(B)(ii)section 1396a(a)(13)(A) of this titleSubsec. (a)(1). , (iii), substituted “A State plan under this subchapter” for “A State’s plan under title XIX of the Social Security Act”, and made technical amendment to reference to involving underlying provisions of original act.

Pub. L. 100–360, § 411(k)(6)(A)(i)April 1, 1989July 1, 1989Subsec. (a)(2)(A). , substituted “” for “such date” and inserted before period at end “, effective for inpatient hospital services provided on or after ”.

Pub. L. 100–360, § 411(k)(6)(A)(ii)April 1, 1990July 1, 1990Subsec. (a)(2)(B). , substituted “” for “such date” and inserted before period at end “, effective for inpatient hospital services provided on or after ”.

Pub. L. 100–485, § 608(d)(15)(C)Subsec. (a)(2)(C). , realigned the margin of subpar. (C).

Pub. L. 100–360, § 302(b)(2), added subpar. (C).

Pub. L. 100–360, § 411(k)(6)(A)(iii)Subsec. (a)(3). , inserted par. (3) designation and substituted “90 days after the date a State submits an amendment” for “June 30 of each year in which the State is required to submit an amendment”.

Pub. L. 100–360, § 411(k)(6)(A)(iii)(II)section 1396n(b)(4) of this titleSubsec. (a)(4). , (III), (B)(v), inserted par. (4) designation and made technical amendment to reference to involving underlying provisions of original act.

Pub. L. 100–360, § 411(k)(6)(A)(iv)Subsec. (b)(2). , substituted “a State plan” for “the State plan”.

Pub. L. 100–360, § 411(k)(6)(B)(vi)Pub. L. 100–485, § 608(d)(26)(F), as amended by , substituted “under this subchapter” for “under subchapter XIX of this chapter”.

Pub. L. 100–360, § 411(k)(6)(B)(vi)Pub. L. 100–485, § 608(d)(26)(F)Subsec. (b)(3). , as amended by , substituted “under this subchapter” for “under subchapter XIX of this chapter” in last sentence.

Pub. L. 100–360, § 411(k)(6)(B)(vi)Pub. L. 100–485, § 608(d)(26)(F)Subsec. (b)(3)(A)(i). , as amended by , substituted “under this subchapter” for “under subchapter XIX of this chapter”.

Pub. L. 100–485, § 608(d)(26)(D)Subsec. (b)(3)(B)(i). , inserted “of subparagraph (A)” after “clause (i)(II)”.

Pub. L. 100–360, § 411(k)(6)(A)(v), inserted “, 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”.

Pub. L. 100–485, § 608(d)(26)(E)Subsec. (c). , substituted “this subsection” for “subsection (c)” in concluding provisions.

Pub. L. 100–360, § 411(k)(6)(A)(vi)(I), (II), (V), in concluding provisions, substituted “paragraphs (1)(B) and (2)(A) of subsection (a)” for “paragraphs (2)(A) and (2)(B)”, “such paragraph (1)(B)” for “paragraph (2)(A)”, and “such paragraph (2)(A)” for “paragraph (2)(B)” and inserted “at least” before “one-third” and “two-thirds”.

Pub. L. 100–360, § 411(k)(6)(A)(vi)(VI)section 1395ww(d)(5)(F)(vi) of this title, inserted at end “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 percentage (defined in ) shall be computed by substituting for the fraction described in subclause (I) of such section the fraction described in subclause (II) of that section. If a State elects in a State plan amendment under subsection (a) to provide the 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.”

Pub. L. 100–360, § 411(k)(6)(A)(vi)(III)Subsec. (c)(1). , inserted “at least” after “equal to”.

Pub. L. 100–360, § 411(k)(6)(A)(vi)(IV)Pub. L. 100–485, § 608(d)(26)(A)Subsec. (c)(2). , as amended by , inserted “(without regard to whether the hospital is described in subparagraph (A) or (B) of subsection (b)(1))” after “payment) and”.

Pub. L. 100–360, § 411(k)(6)(B)(vi)Pub. L. 100–485, § 608(d)(26)(F)Subsec. (d)(1). , as amended by , substituted “under this subchapter” for “under subchapter XIX of this chapter”.

Pub. L. 100–360, § 411(k)(6)(B)(vii)section 1395ww of this titleSubsec. (d)(2)(B). , made technical amendment to reference to involving underlying provisions of original Act.

Pub. L. 100–360, § 411(k)(6)(A)(vii)Pub. L. 100–485, § 608(d)(26)(B)Subsec. (e). , as amended by , (C), designated existing provisions as par. (1), inserted “based on a pooling arrangement involving a majority of the hospitals participating under the plan” after first reference to “payment adjustments”, added par. (2) and substituted “statewide” for “Statewide” in par. (2).

Statutory Notes and Related Subsidiaries

Effective Date of 2021 Amendment

Pub. L. 117–7, § 2(b)Apr. 14, 2021135 Stat. 252 Public Law 116–260, , , provided that the amendment made by section 2(b) is effective as if included in the enactment of section 203(a) of title II of division CC of .

Pub. L. 117–2, title IX, § 9819(b)Mar. 11, 2021135 Stat. 218

Public Law 116–127“The amendment made by subsection (a) [amending this section] shall take effect and apply as if included in the enactment of the Families First Coronavirus Response Act ().”

, , , provided that:

Effective Date of 2020 Amendment

Pub. L. 116–260, div. CC, title II, § 203(b)Dec. 27, 2020134 Stat. 2979

October 1, 202142 U.S.C. 1396r–4“The amendment made by this section [amending this section] shall take effect on , and shall apply to payment adjustments made under section 1923 of the Social Security Act () during fiscal years beginning on or after such date.”

, , , provided that:

Effective Date of 2013 Amendment

Pub. L. 113–67, div. B, title II, § 1204(b)Dec. 26, 2013127 Stat. 1199

October 1, 2013“The amendments made by subsection (a) [amending this section] shall be effective as of .”

, , , provided that:

Effective Date of 2010 Amendment

Pub. L. 111–148, title II, § 2551(b)Mar. 23, 2010124 Stat. 314Oct. 1, 2011Pub. L. 111–148, title X, § 10201(f)Mar. 23, 2010124 Stat. 922, , , which provided that the amendments made by subsection (a), amending this section, were effective on , was repealed by , , .

Effective Date of 2009 Amendment

Pub. L. 111–3Apr. 1, 2009section 3 of Pub. L. 111–3 section 1396 of this titleAmendment by effective , and applicable to child health assistance and medical assistance provided on or after that date, with certain exceptions, see , set out as an Effective Date note under .

Effective Date of 2006 Amendment

Pub. L. 109–171, title VI, § 6054(b)Feb. 8, 2006120 Stat. 96

October 1, 2005“The amendments made by subsection (a) [amending this section] shall take effect as if enacted on , and shall only apply to disproportionate share hospital adjustment expenditures applicable to fiscal year 2006 and subsequent fiscal years made on or after that date.”

, , , provided that:

Effective Date of 2000 Amendment

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(a)(3)]Dec. 21, 2000114 Stat. 2763

114 Stat. 2763“The amendments made by paragraphs (1) and (2) [amending this section] take effect on the date the final regulation required under section 705(a) [A–575] (relating to the application of an aggregate upper payment limit test for State medicaid spending for inpatient hospital services, outpatient hospital services, nursing facility services, intermediate care facility services for the mentally retarded, and clinic services provided by government facilities that are not State-owned or operated facilities) is published in the Federal Register.”

Jan. 12, 2001, , , 2763A–570, provided that: [The final regulation was published , 66 Fed. Reg. 3147.]

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(b)(3)(B)]Dec. 21, 2000114 Stat. 2763

January 1, 2001“The amendments made by paragraph (2) [amending this section] shall apply to payments made on or after .”

, , , 2763A–571, provided that:

Effective Date of 1999 Amendment

Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, § 601(b)]Nov. 29, 1999113 Stat. 1536

October 1, 1999“The amendments made by subsection (a) [amending this section] take effect on , and applies [sic] to expenditures made on or after such date.”

, , , 1501A–394, provided that:

Pub. L. 106–113Nov. 29, 1999Pub. L. 106–113 section 1396a of this titleAmendment by section 1000(a)(6) [title VI, § 608(s)] of effective , see section 1000(a)(6) [title VI, § 608(bb)] of , set out as a note under .

Effective Date of 1997 Amendment

section 4711(c)(2) of Pub. L. 105–33Aug. 5, 1997Oct. 1, 1997section 4711(d) of Pub. L. 105–33Amendment by effective , and applicable to payment for items and services furnished on or after , see , set out as a note under 1396a of this title.

Pub. L. 105–33, title IV, § 4721(a)(2)Aug. 5, 1997111 Stat. 512

“The amendment made by paragraph (1) [amending this section] shall apply to payment adjustments attributable to DSH allotments for fiscal years beginning with fiscal year 1998.”

, , , provided that:

Effective Date of 1993 Amendment

Pub. L. 103–66, title XIII, § 13621(a)(2)Aug. 10, 1993107 Stat. 629

42 U.S.C. 1396b(a)“The amendments made by this subsection [amending this section] shall apply to payments to States under section 1903(a) of the Social Security Act [] for payments to hospitals made under State plans after—

“(A)

the end of the State fiscal year that ends during 1994, or

“(B)

in the case of a State with a State legislature which is not scheduled to have a regular legislative session in 1994, the end of the State fiscal year that ends during 1995;

without regard to whether or not final regulations to carry out such amendments have been promulgated by either such date.”

, , , provided that:

Pub. L. 103–66, title XIII, § 13621(b)(3)Aug. 10, 1993107 Stat. 631

“(A)

In general .—

42 U.S.C. 1396b(a)Except as provided in subparagraph (B), the amendments made by this subsection [amending this section] shall apply to payments to States under section 1903(a) of the Social Security Act [] for payments to hospitals made under State plans after—

“(i)

the end of the State fiscal year that ends during 1994, or

“(ii)

in the case of a State with a State legislature which is not scheduled to have a regular legislative session in 1994, the end of the State fiscal year that ends during 1995;

without regard to whether or not final regulations to carry out such amendments have been promulgated by either such date.

“(B)

Delay in implementation for private hospitals .—

With respect to a hospital that is not owned or operated by a State (or by an instrumentality or a unit of government within a State), the amendments made by this subsection shall apply to payments to States under section 1903(a) for payments to hospitals made under State plans for State fiscal years that begin during or after 1995, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date.”

, , , provided that:

Effective Date of 1991 Amendment

Pub. L. 102–234Jan. 1, 1992section 3(e)(1) of Pub. L. 102–234 section 1396a of this titleAmendments by effective , see , set out as a note under .

Effective Date of 1990 Amendment

Pub. L. 101–508, title IV, § 4702(b)Nov. 5, 1990104 Stat. 1388–171

July 1, 1990“The amendment made by subsection (a) [amending this section] shall take effect on .”

, , , provided that:

Pub. L. 101–508, title IV, § 4703(d)Nov. 5, 1990104 Stat. 1388–171

Pub. L. 100–203“The amendments made by this section [amending this section] shall take effect as if included in the enactment of section 412(a)(2)[4112(a)(2)] of the Omnibus Budget Reconciliation Act of 1987 [, enacting this section].”

, , , provided that:

Effective Date of 1988 Amendment

Pub. L. 100–485 Pub. L. 100–360 section 608(g)(1) of Pub. L. 100–485 section 704 of this titleAmendment by effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, , see , set out as a note under .

section 302(b)(2) of Pub. L. 100–360July 1, 1988section 302(f)(2) of Pub. L. 100–360 section 1396a of this titleAmendment by effective , see , set out as a note under .

section 411 of Pub. L. 100–360 Pub. L. 100–360 Pub. L. 100–203 Pub. L. 100–203 section 411(a) of Pub. L. 100–360 section 106 of Title 1Except as specifically provided in , amendment by section 411(k)(6)(A)–(B)(ix) of , as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, , effective as if included in the enactment of that provision in , see , set out as a Reference to OBRA; Effective Date note under , General Provisions.

Application of Medicaid DSH Transition Rule to Public Hospitals in All States

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(c)]Dec. 21, 2000114 Stat. 2763

“(1)

In general .—

Public Law 105–33 111 Stat. 514 Pub. L. 106–113, § 1000(a)(6) [title VI, § 607(a)]113 Stat. 1501During the period described in paragraph (3), with respect to a State, section 4721(e) of the Balanced Budget Act of 1997 (; ) [set out as a note below], as amended by section 607 of BBRA [] (A–396), shall be applied as though—

“(A)

September 30, 2002July 1, 1997 ‘’ were substituted for ‘’ each place it appears;

“(B)

42 U.S.C. 1396 ‘hospitals owned or operated by a State (as defined for purposes of title XIX of such Act [ et seq.]), or by an instrumentality or a unit of government within a State (as so defined)’ were substituted for ‘the State of California’;

“(C)

paragraph (3) were redesignated as paragraph (4);

“(D)

‘and’ were omitted from the end of paragraph (2); and

“(E)

the following new paragraph were inserted after paragraph (2):

, , , 2763A–571, provided that:

‘(3) “(as defined in subparagraph (B) but without regard to clause (ii) of that subparagraph and subject to subsection (d))” were substituted for “(as defined in subparagraph (B))” in subparagraph (A) of such section; and’.

Special rulePublic Law 105–33 111 Stat. 514“(2) .—With respect to California, section 4721(e) of the Balanced Budget Act of 1997 (; ), as so amended, shall be applied without regard to paragraph (1).

Period describedSeptember 30, 2002“(3) .—The period described in this paragraph is the period that begins, with respect to a State, on the first day of the first State fiscal year that begins after , and ends on the last day of the succeeding State fiscal year.

Application to waivers42 U.S.C. 1396 42 U.S.C. 1315 42 U.S.C. 1396“(4) .—With respect to a State operating under a waiver of the requirements of title XIX of the Social Security Act ( et seq.) under section 1115 of such Act (), the amount by which any payment adjustment made by the State under title XIX of such Act ( et seq.), after the application of section 4721(e) of the Balanced Budget Act of 1997 under paragraph (1) to such State, exceeds the costs of furnishing hospital services provided by hospitals described in such section shall be fully reflected as an increase in the baseline expenditure limit for such waiver.”

Assistance for Certain Public Hospitals

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(d)]Dec. 21, 2000114 Stat. 2763

“(1)

In general .—

42 U.S.C. 1396r–4(f)42 U.S.C. 1396 42 U.S.C. 1396r–4(f)Beginning with fiscal year 2002, notwithstanding section 1923(f) of the Social Security Act () and subject to paragraph (3), with respect to a State, payment adjustments made under title XIX of the Social Security Act ( et seq.) to a hospital described in paragraph (2) shall be made without regard to the DSH allotment limitation for the State determined under section 1923(f) of that Act ().

“(2)

Hospital described .—

A hospital is described in this paragraph if the hospital—

“(A)

42 U.S.C. 1396 is owned or operated by a State (as defined for purposes of title XIX of the Social Security Act [ et seq.]), or by an instrumentality or a unit of government within a State (as so defined);

“(B)

October 1, 2000 as of —

“(i)

is in existence and operating as a hospital described in subparagraph (A); and

“(ii)

42 U.S.C. 1396 is not receiving disproportionate share hospital payments from the State in which it is located under title XIX of such Act [ et seq.]; and

“(C)

42 U.S.C. 1396r–4(b)(3) has a low-income utilization rate (as defined in section 1923(b)(3) of the Social Security Act ()) in excess of 65 percent.

“(3)

Limitation on expenditures.—

“(A)

In general .—

With respect to any fiscal year, the aggregate amount of Federal financial participation that may be provided for payment adjustments described in paragraph (1) for that fiscal year for all States may not exceed the amount described in subparagraph (B) for the fiscal year.

“(B)

Amount described .—

The amount described in this subparagraph for a fiscal year is as follows:

“(i)

For fiscal year 2002, $15,000,000.

“(ii)

For fiscal year 2003, $176,000,000.

“(iii)

For fiscal year 2004, $269,000,000.

“(iv)

For fiscal year 2005, $330,000,000.

“(v)

For fiscal year 2006 and each fiscal year thereafter, $375,000,000.”

, , , 2763A–571, provided that:

DSH Payment Accountability Standards

Pub. L. 106–554, § 1(a)(6) [title VII, § 701(e)]Dec. 21, 2000114 Stat. 2763

September 30, 200242 U.S.C. 1396r–4“Not later than , the Secretary of Health and Human Services shall implement accountability standards to ensure that Federal funds provided with respect to disproportionate share hospital adjustments made under section 1923 of the Social Security Act () are used to reimburse States and hospitals eligible for such payment adjustments for providing uncompensated health care to low-income patients and are otherwise made in accordance with the requirements of section 1923 of that Act.”

, , , 2763A–572, provided that:

DSH Allotments for Specific Years

Pub. L. 105–277, div. A, § 101(f) [title VII, § 702]Oct. 21, 1998112 Stat. 2681–337

42 U.S.C. 1396r–4(f)(2)section 4721(a)(1) of Public Law 105–33“The amount of the DSH allotment for the State of Minnesota for fiscal year 1999, specified in the table under section 1923(f)(2) of the Social Security Act [] (as amended by ) is deemed to be $33,000,000.”

, , , 2681–389, provided that:

Similar provisions were contained in the following prior appropriations act:

Pub. L. 105–78, title VI, § 601Nov. 13, 1997111 Stat. 1519, , .

Pub. L. 105–277, div. A, § 101(f) [title VII, § 703]Oct. 21, 1998112 Stat. 2681–337

42 U.S.C. 1396r–4(f)(2)section 4721(a)(1) of Public Law 105–33“The amount of the DSH allotment for the State of New Mexico for fiscal year 1999, specified in the table under section 1923(f)(2) of the Social Security Act [] (as amended by ) is deemed to be $9,000,000.”

, , , 2681–389, provided that:

Pub. L. 105–277, div. A, § 101(f) [title VII, § 704]Oct. 21, 1998112 Stat. 2681–337

42 U.S.C. 1396r–4(f)(2)Public Law 105–33 111 Stat. 511“Notwithstanding section 1923(f)(2) of the Social Security Act () (as amended by section 4721(a)(1) of the Balanced Budget Act of 1997 (; )[)], the amount of the DSH allotment for Wyoming for fiscal year 1999 is deemed to be $95,000.”

, , , 2681–389, provided that:

Similar provisions were contained in the following prior appropriations act:

Pub. L. 105–78, title VI, § 602Nov. 13, 1997111 Stat. 1519, , .

California Transition Rule

Pub. L. 105–33, title IV, § 4721(e)Aug. 5, 1997111 Stat. 514 Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, § 607(a)]Nov. 29, 1999113 Stat. 1536

July 1, 199742 U.S.C. 1396r–4(g)(2)“Effective , section 1923(g)(2) of the Social Security Act () shall be applied to the State of California as though—

“(1)

July 1, 1997January 1, 1995 ‘(or that begins on or after )’ were inserted in subparagraph (A) of such section after ‘,’;

“(2)

July 1, 1997 ‘(or 175 percent in the case of a State fiscal year that begins on or after )’ were inserted in subparagraph (A) of such section after ‘200 percent’; and

“(3)

July 1, 1999 effective for State fiscal years that begin on or after , ‘or (b)(1)(B)’ were inserted in section 1923(g)(2)(B)(ii)(I) after ‘(b)(1)(A)’.”

, , , as amended by , , , 1501A–396, provided that:

Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, § 607(b)]Nov. 29, 1999113 Stat. 1536

section 4721(e) of Pub. L. 105–33 Pub. L. 105–33“The amendments made by subsection (a) [amending , set out above] shall take effect as if included in the enactment of section 4721(e) of BBA [the Balanced Budget Act of 1997, ].”

[, , , 1501A–396, provided that: ]

Study of DSH Payment Adjustments

Pub. L. 102–234, § 3(d)Dec. 12, 1991105 Stat. 1803Jan. 1, 1994, , , directed Prospective Payment Assessment Commission to conduct a study concerning feasibility and desirability of establishing maximum and minimum payment adjustments under subsec. (c) of this section for hospitals deemed disproportionate share hospitals under State medicaid plans, and criteria (other than criteria described in clause (i) or (ii) of subsec. (f)(1)(D)) that are appropriate for the designation of disproportionate share hospitals under this section, specified items to be included in study, and directed that, not later than , Commission submit a report on the study to Committee on Finance of Senate and Committee on Energy and Commerce of House of Representatives, such report to include such recommendations respecting designation of disproportionate share hospitals and the establishment of maximum and minimum payment adjustments for such hospitals under this section as may be appropriate.