Courtesy of the Committee on Energy & Commerce and the Committee on Ways & Means

MANAGER’S AMENDMENT
SECTION-BY-SECTION SUMMARY
Page number indicate pages of the Manager’s Amendment.

MANAGER’S AMENDMENT (Policy Changes)
Pages 1-4. This section of the amendment redrafts portions of the language in the underlying bill related
to changes to Medicaid expansion.
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Page 1. Terminates Obamacare’s mandatory requirement for States to expand Medicaid for certain
childless non-disabled, non-elderly, non-pregnant adults up to 133% FPL. Also sunsets the optional
ability for a State to cover adults above 133% FPL, effective December 31, 2017.

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Page 2. Preserves the ability of States to cover Medicaid expansion enrollees (childless non-disabled,
non-elderly, non-pregnant adults) at a State’s regular Federal Medical Assistance Percentage (FMAP)
by designating a new optional category in Section 1902 (nn) of the Social Security Act.

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Page 3. Medicaid expansion enrollees who were enrolled in Medicaid expansion prior to December
31, 2019 receive “grandfathered” status. States will receive the enhanced matching rate under current
law (90 % in CY2020), for grandfathered enrollees as long as such individuals remain eligible and
enrolled in the program.

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Pages 3-4. Changes Obamacare’s enhanced FMAP for Medicaid expansion by limiting the enhanced
FMAP for Medicaid expansion States that already have expanded Medicaid to cover able-bodied
adults as of March 1, 2017. Thus, any new State that might expand Medicaid to cover low nondisabled, non-elderly, non-pregnant, able-bodied adults up to 133% FPL would receive that State’s
regular FMAP and would not receive the enhanced FMAP. Makes a conforming technical change to
continue the policy in the base bill that freezes the Obamacare enhanced FMAP provided for certain
States that covered low-income adults prior to Obamacare at the State’s regular FMAP.

Pages 4-7. This section of the amendment creates a new section of the Social Security Act to give States
the option of instituting a work requirement in Medicaid for nondisabled, nonelderly, non-pregnant adults
as a condition of receiving coverage under Medicaid. The amendment adopts the language from Mr.
Griffith’s bill, H.R. 1381, which was modeled after the requirements and exemptions that exist in TANF
under current law. States could begin using this new option on October 1, 2017.
The amendment grants broad flexibility to states to implement the requirement as they see fit. However, a
few requirements are imposed. For example, the amendment defines what a work requirement entails by
using the countable TANF activities defined in section 407(d) in the Social Security Act. Countable work
activities include the following, in addition to unsubsidized employment:
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Subsidized private sector employment;
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Subsidized public sector employment;

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Work experience;
 Satisfactory attendance at secondary
On-the-job training (OJT);
school or in a course of study leading to a
Job search and job readiness assistance;
certificate of general equivalence, if a
Community service programs;
recipient has not completed secondary
Vocational educational training;
school or received such a certificate; and
Job skills training related to employment;
 Providing childcare services to an
Education directly related to employment,
individual who is participating in a
in the case of a recipient who has not
community service program.
received a high school diploma or a
certificate of high school equivalency;
Under the amendment, a state may not impose a work requirement as a condition of receiving
medical assistance under Medicaid on:
• Pregnant women;
• Children under the age of 19;
• An individual who is the only parent or caretaker of a child under the age of 6 or who is the
only paent or caretaker of a child with a disability; and,
• An individual under the age of 20 who is married or is the head of the household and
maintains satisfactory attendance at school or participates in education directly related to
employment.
To ensure that states have the tools capable to implement the work requirement, the amendment
provides a 5% administrative FMAP bump to states who choose to implement a work requirement.
Page 7. Makes technical conforming changes to clarify the per capita allotment growth rate
compounds year to year, in keeping with the intent of the underlying bill.
Page 8. Increases the annual inflation factor for the elderly and disabled from CPI-U Medical to CPIU Medical +1.
Pages 8-10. For any state that in 2016 had a DSH allotment that was more than six times the national
average and requires political subdivisions within the State to contribute funds toward Medicaid, the
amount of allowable medical assistance expenditures under the per capita allotment reform is reduced
by the amount required to be raised from the political subdivisions. The amendment provides an
exception of the State requires such funds from political subdivisions with a population that exceeds
5,000,000.
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Pages 10-18. Consistent with the vision outlined in the House Republican health care
proposal, A Better Way, the amendment creates a new option for States to opt to receive,
starting Fiscal Year 2020, a flexible block grant of funds for providing health care for their
traditional adult and children populations served in the per capita allotment. Funding for the
block grant would be determined using the same a base year calculation for the per capita
allotment reforms.

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Pages 10-11. States may choose to provide care for certain populations by receiving a block
of funds for a period of 10 years, rather than providing care through the per capita allotment.
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Pages 12-13. States choosing the block grant are required to submit a report that identifies the
conditions for eligibility under the block grant which are in lieu of eligibility in current law,
except in the case of certain low-income pregnant women and children in poverty.

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Pages 13-14. States choosing the block grant are also required to, in the submitted report,
outline the types of items and services; the amount, duration, and scope of such services; the
cost-sharing with respect to such services; and the method for delivering care. These items
and services are in lieu of those requirements in current law, except that the block grant must
provide medical assistance for hospital care; surgical care and treatment; medical care and
treatment; obstetrical and prenatal care and treatment; prescribed drugs, medicines and
prosthetics; other medical supplies and services; and health care for children under 18 years of
age.

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Pages 14. A plan shall be deemed approved by the Secretary of HHS unless the Secretary
finds within 30 days that the plan is incomplete or actuarially unsound.

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Pages 15-16. The amount of block grant funding shall be calculated by computing the per
capita cost for the eligible population, multiplied by the number of enrollees in the year prior
to adopting a block grant. The funding will increase by the growth in the consumer price
index but will not adjust for changes in population. Unused funds rollover and remain
available for expenditure so long as a State has a block grant.

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Page 17. A State may choose to provide health care to either non-expansion adults and
children, or just non-expansion adults.

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Page 18. States adopting the block grant are required to contract with an independent entity to
ensure the State is in compliance with the requirements for a block grant. Such audit reports
are required to be made available to HHS upon request.

Pages 18-20. This section of the amendment establishes Section 141 of the Social Security Act
creating an American Health Care Implementation Fund within the U.S. Department of Health and
Human Services (HHS) to carry out:
o Sec. 121. Per capita allotment for medical assistance;
o Sec. 132. Patient and State Stability Fund;
o Sec. 202. Additional modifications to premium tax credit; and,
o Sec. 214. Refundable tax credit for health insurance coverage.
A $1,000,000,000 appropriation is made to the fund.
Page 19. This section of the amendment adds an additional year of relief from Obamacare’s Cadillac
tax, moving the implementation date from 2025 to 2026.
Page 19. This section of the amendment accelerates relief from the Tax on Over-the-Counter
Medications tax by one year; repeal is effective beginning in 2017.
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 Page 19. This section of the amendment accelerates relief from the Repeal of Increase of Tax on
Health Savings Accounts by one year; repeal is effective beginning in 2017.
Page 19. This section of the amendment accelerates relief from the Repeal of Limitations on
Contributions to Flexible Spending Accounts by one year; repeal is effective beginning in 2017.
Page 19. This section of the amendment accelerates relief from the Repeal of Medical Device Excise
Tax by one year; repeal is effective beginning in 2017.
Page 19. This section of the amendment accelerates relief from the Repeal of Elimination of
Deduction for Expenses Allocable to Medicare Part D Subsidy by one year; repeal is effective
beginning in 2017.
Page 19. This section of the amendment accelerates relief from the Medical Expense Deduction by
one year (effective beginning in 2017) and makes necessary conforming changes. It also reduces the
qualifying adjusted gross income threshold from 10 percent to 5.8 percent— which is lower than the
pre-Obamacare level of 7.5 percent. The latter policy will provide additional support for Americans
with high health costs— including low- and middle-income seniors.
Page 19-20. This section of the amendment accelerates relief from the Repeal of Medicare Tax
Increase by one year (repeal is effective beginning in 2017) and includes a transition rule to
accommodate employer withholding.
Page 20. This section of the amendment accelerates relief from the Repeal of Tax on Prescription
Medications by one year; repeal is effective beginning in 2017.
Page 20-21. This section of the amendment accelerates relief from the Repeal of Health Insurance
Tax by one year; repeal is effective beginning in 2017.
Page 21. This section of the amendment accelerates relief from the Repeal of Tanning Tax by six
months; repeal is effective June 30, 2017, to reflect the quarterly nature of this collected tax.
Page 21. This section of the amendment accelerates relief from the Repeal of Remuneration from
Certain Insurers by one year; repeal is effective beginning in 2017.
Page 21. This section of the amendment accelerates relief from the Repeal of Net Investment Tax by
one year; repeal is effective beginning in 2017.

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