; and (ii) demonstrate the greatest relative level of annual improvement in quality performance under criteria established by the Secretary. (4) Initial appropriation (A) In general The total amount of Medicaid quality performance bonuses made under this subsection for all fiscal years shall be equal to $500,000,000, to be available until expended. (B) Budget authority This paragraph constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this paragraph. (5) Use of quality performance bonus funds (A) Designation for quality improvement activities As a condition of receiving a Medicaid quality performance bonus under this subsection, a State shall agree to designate at least 75 percent of the bonus funds paid to the State under this subsection for a fiscal year for the development and operation of quality-related initiatives that will directly benefit providers or managed care entities participating in the State plan under this title or under a waiver of such plan, including— (i) pay-for-performance programs; (ii) collaboration initiatives that have been demonstrated to improve performance on quality; (iii) quality improvement initiatives, including those aimed at improving care for special and hard-to-reach populations, and those directed to managed care entities