add-on Section 1886(d)(5)(K)(ii)(IV) of such Act ( 42 U.S.C. 1395ww(d)(5)(K)(ii)(IV) ) is amended by striking or existing . (6) Limit on aggregate annual adjustment Section 1886(d)(5) of such Act ( 42 U.S.C. 1395ww(d)(5) ) is amended by adding at the end the following new subparagraph: (M) Limit on aggregate annual adjustment (i) In general The total of the additional payments made under subparagraphs (K) and (L) for covered services furnished for discharges in a fiscal year (as estimated by the Secretary before the beginning of the fiscal year) may not exceed the applicable percentage (specified in clause (ii)) of the total program payments estimated to be made under this subsection for all covered services furnished for discharges in that fiscal year. If this clause is first applied to less than a full fiscal year, the previous sentence shall apply only to the portion of such fiscal year. (ii) Applicable percentage For purposes of clause (i), the term ‘ applicable percentage ’ for fiscal year 2019 and each subsequent fiscal year, is a percentage specified by the Secretary up to (but not to exceed) 2.0 percent. (iii) Uniform prospective reduction if aggregate limit projected to be exceeded If the Secretary estimates before the beginning of a fiscal year that the amount of the additional payments under subparagraphs (K) and (L) for the fiscal year (or portion thereof) as determined under clause (i) without regard to this clause will exceed the limit established under such clause (i), the Secretary shall reduce pro rata the amount of each of the additional payments under this paragraph for that fiscal year (or portion thereof) in order to ensure that the aggregate additional payments under subparagraphs (K) and (L) (as so estimated) do not exceed such limit. . (7) Effective date The amendments made by paragraphs (2), (3), (4), (5), and (6) shall take effect on the date of the enactment of this Act and shall apply with respect to hospital discharges occurring on or after October 1, 2018, for inpatient hospital